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, N.J.: Rutgers University Press, 1999. xx + 257 pp. Ill. $50.00.

"Biology matters" (p. xx)! In this book Peter C. English attacks social historians for privileging perceptions of disease over biology, and for ignoring the role of the latter in shaping the knowledge and management of disease. He claims that it is possible to identify, in the past, evidence of actual biological change in the nature of rheumatic fever. His argument is that the disease has provided a moving target for clinicians, and that its changing nature has informed their attempts to manage and to make sense of it over the last two hundred years. He is not alone among historians in urging a return to biology, but he has used it to reinstate an older form of medical history focused on the intellectual and practical accomplishments of physicians.

English grounds his account in an extensive review of the published medical literature on rheumatic fever. He argues that the disease began its life buried in the general category of rheumatism, a broadly defined group of ills characterized by fevers, arthritis, aches, pains, and general debility. It began to separate out in the late eighteenth century when inflammations of the heart (especially the pericardium and endocardium) joined the list of symptoms--followed a short time later by chorea, a disorder characterized by jerky, involuntary movements especially of the head, face, and limbs. From the 1880s and 1890s the clinical picture--of fever, arthritis, pericarditis, endocarditis, and chorea--was joined by tonsillitis (probably always there but unnoticed due to its ubiquity), subcutaneous nodules, various rashes, and pleurisy (the last a late complication of mitral valve injury, often regarded by contemporaries as the end-stage of endocarditis). English argues that of these changes probably only the inflammations of the heart, the chorea, and perhaps the rashes were really new.

If English builds his survey of the changing clinical picture on a literature review, he bases his argument about "real" changes on a knowledge of current biomedical understandings of the disease, especially its molecular biology. His claim is that in the eighteenth century the causative agent, the Group A beta-hemolytic streptococcus (GABS), contained elements that cross-reacted with human joints to produce arthritis. Later mutations cross-reacted with the pericardium and endocardium, resulting in the heart problems in these tissues, and still later it also cross-reacted with the brain, skin, and connective tissue to generate chorea. In the twentieth century, English claims, further mutations account for the disappearance of all rashes except erythematous ones, and the emergence of the myocardium as the primary cardiac target. In contrast to pericarditis and endocarditis, myocarditis seldom caused death acutely, smoldering away instead to cause a chronic debility. The result was that mortality from rheumatic fever began to decline, and the disease turned into a chronic condition. Decades after the onset of the disease the myocardium could still be inflamed. People no longer died of rheumatic fever in childhood or as young adults, but carried the damage into middle and old age. The clinical picture also changed in other ways. Migratory polyarthritis became less prevalent, as did subcutaneous nodules and chorea. Eventually even myocardial injury declined, and--except for a brief recurrence in the 1980s--rheumatic fever ceased to be a cause of death or debility in the West. The streptococcus had lost its earlier provocative components. English concludes that clinicians can claim little credit for such changes, and they are unable to prevent its continued mutation and possible reemergence.

Whatever the truth of the claim that rheumatic fever has changed biologically, it is unfortunate that English chooses to see this book as an attack on social history. First, social historians are not as dismissive of biology as he suggests: many portray social...