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16
I have discussed this question with doctors in practice who
are the first to see cases of rheumatic infection in children.
They are unanimous that "rheumatic fever" is becoming a very
rare disease. In certain metropolitan boroughs the disease has
been notifiable for a number of years. The numbers notified
have diminished each year.
What is the explanation of this decline in the incidence of
juvenile rheumatism in recent years? Various answers have
been offered, e.g., it may be that the phenomenon is a phase
in the natural periodicity of the disease. We know that some
diseases occur in cycles. During one generation or century a
disease may appear to increase in numbers and severity, and in
a subsequent period gradually decline without any obvious
reason. Juvenile rheumatism may be a "periodic disease."
On the other hand, it has been claimed by the advocates of
tonsillectomy that the recent decline in juvenile rheumatism is
a direct result of the common practice of removing children's
tonsils.
The explanation which I favour is that rheumatic infection,
like tuberculosis, is a disease in which the general resistance of
the child to infection is the most important factor in determining
not only the frequency of infection, but also the severity of the
disease and the incidence of complications. If this is correct,
then it can be claimed that the decline in juvenile rheumatism
is just one of the results of the vastly-improved conditions of
child-life to-day as compared with a generation ago—better care
during infancy and childhood, better habits of rest and exercise,
better economic circumstances, better housing, better nutrition,
All of these improved conditions of life are closely related
to better education and general enlightenment, and as these
are progressive, there is reason to hope that juvenile rheumatic
infection may be entirely eliminated, or, at any rate, cease to
be a grave menace to the health of the juvenile population.
It would therefore seem that the incidence of juvenile
rheumatism may be taken as an inverse index of the efficiency
of preventive medicine in an area; a means of estimating the
social and environmental conditions of a community; a measure
of the effectiveness of the agencies of social amelioration within
its boundaries.