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

Doctors and patients all too often think of disease as a predictable process. Nevertheless, we are often confronted with the unpredictability of disease—the way it fluctuates over time, increasing in virulence and then lapsing into quiescence. Peter English’s new book explores one of the most intensely studied of these mercurial diseases, rheumatic fever. The story of rheumatic fever contains all the features of great drama: emotional heartache, scientific discoveries, mysterious appearances and disappearances, and the pathos of childhood disability and death. It was a disease that did not yield to the dominant explanatory models of the time, a disease that provoked scientists to better understand the intricate ways that diseases interact with the human body.

The medical students and residents of today are unlikely to encounter rheumatic fever except on the exam page, where they will be asked to recount the Jones criteria used to make the diagnosis. This set of clinical criteria exemplifies old-fashioned diagnosis, applying often subtle clues from the history, physical exam, and laboratory tests to create a clinical picture. When T. Duckett Jones created these criteria in 1944, rheumatic fever was disabling and killing hundreds of children a year, and yet the force of the disease was already waning. Jones and others had already recognized the central role the streptococcus played in rheumatic fever—though why the body responded to the disease the way it did, and why so many different organ systems were affected, remained elusive. The Jones criteria were important not only because they helped diagnose a serious and often fatal disease, but also because they symbolized a revered form of medical investigation based on the century-old concept of grouping similar patients together and looking for commonalities.

English clearly and carefully describes the shifting scientific and medical features of the disease and its complex relationship with race, socioeconomic status, and age. From the early search for a bacterial cause of the disease to the elucidation of the role of M-proteins, he weaves a masterful tale of medical investigation, replete with triumphs and pitfalls.

What I liked about this book is the way English addressed many of the mysteries that have plagued this disease. For instance, English sheds light on why the hallmarks of the disease—St. Vitus’ Dance or subcutaneous nodules—are rarely seen by today’s physicians. He places the unfolding understanding of the pathophysiology of the disease within the context of the changing understandings of infectious and autoimmune diseases. English shows how the rise of bacteriology and the emergence of sophisticated understandings of infection allowed major steps forward in the understanding of the infectious etiology of rheumatic fever, and yet continued to stymie doctors because fundamental questions about the disease remained elusive. Research done in the twentieth century on immunology laid the groundwork for understanding the role of autoimmunity in rheumatic disease. This juxtaposition between scientific breakthroughs on the one hand and continued inability to develop an overarching explanatory model of the disease on the other is all too familiar in scientific process. English expertly dissects this case using the lens of the historian.

Indeed, rheumatic fever and rheumatic heart disease played key roles in an emerging understanding of the complex ways that the body interacts with infection. Through research on how and why rheumatic fever exacted its damage on various organs in the human body, a more complex picture of the relationship between disease and health emerged. English is acutely aware of the streptococcus’ biological mutability and deftly demonstrates how change over time on the microscopic level led to macroscopic changes, both at the level of the individual patient and at the societal level. All too often, historians of disease ignore the scientific aspects of disease, but English reveals his medical...