ST. Shulman, editor Pharyngitis - Management in an Era of Declining Rheumatic Fever New York; Praeger, 1984
This book may provide an important service if it succeeds in reducing the level of "streptomania" (Sydney Gellis) which still afflicts medical and lay circles in North America. The basic theme of the volume is that rheumatic fever (RF) has become an increasingly and even disappearingly rare disease, especially among those social classes able to afford private medical care. The book attempts to explain what has happened and why: its contents were assembled from papers presented at a Ross Conference on Medical Research held in February 1983 and already summarized and published earlier by the sponsor. The verbatim transcripts of discussions among the participants are included: these occasionally offer new insights, ask fresh questions, or suggest different interpretations of the data. As is the case in many conference proceedings, the quality of the chapters varies, some are truly excellent, others quite pedestrian, with little useful information. What is offered is a description of the state of the art in our knowledge of the streptococcus and its relationship to RF.
One might ask what took so long, why wasn't this conference held a decade or more ago when it was already abundantly clear that RF had become a disease of the past in most population groups? It has been obvious for many years that much money and effort was being wasted to hunt down the streptococcus and thus "prevent rheumatic fever" in populations where the disease had virtually disappeared. An almost paranoid search for the . streptococcus continues, carriers of the organism are sought, schoolchildren are cultured en masse and even the family pet is not exempt. Children unfortunate enough to be chronic carriers of the bacterium often receive one antibiotic course after another, which more often than not include painful injections of benzathine penicillin. Is all of this really necessary? Wasn't much of what was recommended based on data from the Warren Air Force Base studies whose relevance to middle class American children is and always has been questionable?
Did any of our efforts actually prevent RF and lead to its disappearance? Undoubtedly some cases were prevented, but as the disease vanished from middle class populations in the 1960s, it became increasingly difficult to determine the degree of risk for an individual child. Furthermore, the available evidence, including a recent study from Hong Kong, indicates that the disappearance of the disease in a population could not be related to any antistreptococcal measures. Along with its decline, the clinical course of RF became milder and the disease more difficult to diagnose: patients demonstrated illnesses that did not satisfy the "revised" or the "revised and modified" Jones Criteria. What factors caused RF virtually to disappear in most segments of our society but allow it to continue to affect children amongst the successive waves of immigrants to North America?
The present volume addresses these and related questions from several different perspectives: the data are interesting, some even fascinating but no hypothesis emerges to explain all of the known facts.
Some of the authors sound a little sad, even melancholy, as they write about the past, when the streptococcus was king. A vaccine eluded us and RF slipped away, probably not as a result of our medical efforts but because of a greatly improved standard of living, better nutrition, more fresh air, and a general healthier population.
The time is long overdue for a re-examination of our approaches to children with streptococcal pharyngitis: this book allows us to do so without bogging down in the debris and biases of the past.