[Decline of acute rheumatism].

The purpose of this communication is to present the statistics of acute rheumatism in school children as they have appeared in the records of the local rheumatism service in one large city (Cardiff) during the 20-year period 1931-50. The particular circumstance which gives point to the study is the wellknown change which community experience of the disease has undergone in recent times: a progressive fall in mortality at ages 5-15 in England and Wales, and a reduction in the clinical severity of the acute manifestations. Glover (1946) described rheumatic fever as an obsolescent disease as far back as the early 1930s and has referred subsequently (Glover, 1952) to the remarkable fall in mortality. For rheumatic heart disease, however, the trend of mortality has been somewhat less clear-cut. Knowelden (1949) studied mortality from rheumatic fever and heart disease in England and Wales during the years 1920-38, distinguishing separately the experience of three age groups, 5-14, 15-24, and 25-34. Rheumatic fever showed a steady decline at all ages and in both sexes, but for heart disease the trend was not uniform. In the adult age group, for men an improvement was apparent only in the early part of the period, and for women there was virtually no improvement at all. In children, the death rates declined, but the trend showed a slight setback in 1933-35 with a sharper fall thereafter. In the context of its decline, many epidemiological features of acute rheumatism raise points of considerable interest. The association with streptococcal infection relates rheumatism to the problem of infectious diseases generally and of other streptococcal infections in particular, and the disease has a notable association with inferior living standards. Explanations of the declining mortality have been sought particularly in relation to these facts, and it is