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Emergence of rheumatic fever in the nineteenth century.

How do we make sense of the process of disease definition when the tools for "framing" a pathophysiologic reality and the reality to be framed may have both been changing? The sudden emergence of rheumatic fever at the end of the eighteenth century was the result of distinct biological changes that led to cardiac damage. But the identification of the disease also depended on the ability of clinicians to diagnose it in the absence of easily observable cardiac symptoms. Clinicians were able to appreciate the alteration of rheumatism into rheumatic fever through assimilation of technological changes (the stethoscope and autopsy), refinements in clinical thinking (the "typical case"), and the concentration of patients in hospitals where they were treated by physicians who were medical leaders and educators.