Childhood's deadly scourge: the campaign to control diphtheria in New York City, 1880–1930

English combines the roles of clinician and medical historian in his presentation of rheumatic fever as a "moving target" for doctors, epidemiologists, laboratory scientists and public health officials who struggled to understand and treat a disease that changed rapidly and dramatically with each generation of patients. In the eighteenth century, acute rheumatism, characterized by fever and arthritis, was a trivial disease which remitted spontaneously. At the century's end, it assumed a more sinister form, attacking the heart and subjecting its adolescent casualties to severe chest pain and distressing palpitations before they succumbed to pericarditis. During the nineteenth century, endocarditis surpassed pericarditis as the primary cardiac injury, and its association with chorea showed the brain to be an additional target. The skin and connective tissue also became involved, and tonsillitis frequently preceded the fever, joint pains, skin rashes and heart symptoms. In the twentieth century, myocarditis turned rheumatic heart disease into a chronic, debilitating illness because it smouldered silently, often for decades. By the 1930s, up to two per cent of school age children in Britain and the USA had perceptible cardiac scars but there was already a decline in the mortality from rheumatic fever. By 1944, patients experienced mildly sore throats with minimal joint swelling, which melted away over the next decades to insignificant aches and pains. Chorea disappeared, and by the 1970s rheumatic fever was largely extinct. During the course of its dynamic history, rheumatic fever taught bacteriologists and immunologists much about the Group A beta-hemolytic streptococcus (GABS) and the body's immunological response to infection. It taught physicians how to detect endocardial damage with the stethoscope and cardiologists how to interpret electrocardiographs in order to gauge myocardial injury during a patient's lifetime. It taught pharmacologists the benefits of treatment with aspirin, antibiotics and cardiac glycosides. Rheumatic fever made tonsillectomy the most common operation in the United States after circumcision, and produced a generation of postwar cardiac surgeons who became adept at first repairing and then replacing mitral and aortic valves. Rheumatic fever was diminishing in prevalence before the discoveries of sulphonamide and penicillin. It paralleled similar declines in other streptococcal-related illnesses such as scarlet fever, erysipelas and puerperal sepsis. By the 1950s, only one per cent of streptococcal throat infections progressed to rheumatic fever whether or not antibiotics were given. English believes that the streptococcus contained components which cross-reacted with different parts of the body at different times during …