Rheumatic Fever in America and Britain: A Biological, Epidemiological, and Medical History (review)

Peter C. English. Rheumatic Fever in America and Britain: A Biological, Epidemiological, and Medical History. New Brunswick, NJ: Rutgers University Press, 1999. 320 pp. $50.00 cloth.

Rheumatic fever, a feared and deadly disease in Britain and the United States in the not-too-distant past, has all but disappeared. A constantly changing entity that has undergone several transformations during its biological lifetime, it represents a historical moving target that defies easy description or analysis. Historian and pediatrician Peter C. English keeps this shifting illness well within his sights and has written a rich, instructive book for those seeking an understanding of this disease over the course of two centuries.

In Rheumatic Fever in America and Britain, English's chronology begins in the late eighteenth century and ends in the mid-twentieth. The earliest descriptions of "acute rheumatism" detailed a seasonal affliction that appeared in the fall, winter, and spring. After prolonged exposure to the cold, a susceptible patient might develop fever and chills, then swelling, redness, and tenderness of the knees, ankles, and wrists. These symptoms would wane but often recur during multiple relapses. By the start of the nineteenth century, this illness became more virulent. A number of patients developed palpitations and "oppression in the chest"—signs of ominous cardiac complications—and sometimes died, while others suffered from chorea, an involuntary twitching of the muscles. Physicians recommended bed rest to prevent damage to affected joints and relied on opium, and later salicylates, to relieve the pain. Those with pericarditis or endocarditis required bleeding or the application of medicines to the chest wall for proper treatment.

By the mid-1900s, patients with rheumatic fever manifested even more signs, including tonsillitis, subcutaneous nodules, and erythematous rashes. This posed new challenges for physicians intent on diagnosing and treating the disease and prompted new strategies for classifying it. Younger patients were affected, and more were treated in hospitals. The presence of patients in an institutional setting allowed epidemiologists to study and describe the disease in greater detail, and technological tools like the stethoscope proved useful in diagnosis. British physician Walter Cheadle's classification scheme codified the idea of a "typical case" of rheumatic fever and helped medical practitioners to recognize the illness more readily.

By the twentieth century, investigations shifted to the laboratory and shaped physicians' perceptions of the disease. Bacteriologists hypothesized that microorganisms triggered rheumatic fever. After infecting the tonsils, it used the bloodstream to travel to other parts of the body—the heart, skin, central nervous system, joints, and tendons—to wreak its own special havoc. Ludwig Aschoff identified degenerated collections of cells, or "Aschoff bodies," which indicated myocardial damage. Physicians ordered white blood cell counts to monitor the presence and severity of infection and embraced the tonsillectomy as both a curative and preventive measure. Public health officials directed campaigns against the villainous streptococcus. Sulfanilamide and penicillin joined the therapeutic armamentarium and were used with gusto. Even before these antibiotics became available, physicians noted a decline in the incidence of rheumatic fever. Its cardinal symptoms lessened in intensity, and T. Duckett Jones crafted new criteria for diagnosis. Once a purely acute disease, it now emerged as a chronic illness. It ultimately faded from the hospital and clinic by midcentury in Britain and the United States.

English has delved deeply into the many clinical sources on rheumatic fever, and his book is superbly documented. His narrative reveals how the character of a complex disease can change radically over time. He has shown how this particular illness was shaped and altered by biological, technological, and institutional factors within the universe of physicians and patients. He has avoided casting this tale as a medical triumph and instead tells a story of constant striving to solve a medical mystery. The book is well organized, and the chapters flow from start to finish. He has chosen several...