The Chain that Links the Heart to the Throat

N OWHERE HAVE THE POWER-and the limitations-of antimicrobial agents been more clearly revealed than in the control of rheumatic heart disease. On the one hand, we have an organism which in the test tube is exquisitely and uniformly sensitive to penicillin. And we can point with pride to the remarkable prophylactic record of antimicrobials in reducing the frequency of rheumatic recurrences. On the other hand, we must be cautious in attributing our currently favorable position exclusively or even primarily to the use of antimicrobials. A close examination of the statistics reveals that the rheumatic fever problem was declining before these agents were available.1 The reasons for the beginning decline before the antibiotic era are obscure-possibly due to socioeconomic improvements such as changes in housing or even in nutrition. Since the reasons for this are obscure we must be guarded in our optimism that this trend will continue forever downward. Above all, we must not become mesmerized into believing that antibiotics are the final answer to the rheumatic fever problem, that all we have to do is improve our delivery of health care-spread enough penicillin widely and judiciously-and the disease will disappear completely and permanently. We still have problems. Even with throat