Heart fever

BMJ 2005; 330 doi: (Published 24 March 2005) Cite this as: BMJ 2005;330:737
  1. George Dunea, attending physician
  1. Cook County Hospital, Chicago, USA

“Oh God, why do we have to watch all these autopsies,” said a bored medical student perched high up in the amphitheatre as the pathologist was dissecting a patient supposed to have died from mixed essential cryoglobulinaemia.

This was decades ago, when autopsies had not yet gone the way of the horse and buggy. But, surprise—there were large vegetations on the aortic and mitral valves. What had blown out life's little candle, in the parlance of William Boyd's memorable textbook, was bacterial endocarditis, unrecognised and unchecked during the patient's life.

In the past there was something romantic about this horrible disease, and its ravages were linked eponymously to the great clinicians of the times—Osler nodes, Roth spots, Janeway lesions. The diagnosis depended on that old platitude “a high index of suspicion,” and at the bedside clinician teachers would cast valuable pearls before credulous (or bored) students. They said (probably wrongly) that endocarditis never occurred in the absence of red cells in the urine, nor in the face of a normal sedimentation rate (also gone the way of the horse and buggy but curiously resuscitated as the C reactive protein). Now we have guidelines or algorithms and order transoesophageal echocardiograms to make the diagnosis and meet targets.

One of the victims of this disease in the pre-penicillin era was the composer Gustav Mahler. Known to have a leaking valve and while on a conducting tour in the United States, he developed a sore throat that just would not go away, then fever and profound weakness.

As a last resort his wife, Alma, took him to a celebrated bacteriologist in Paris. There for a moment a miracle seemed to have happened. Highly excited the doctor rushed into the room carrying a microscope and beamed: “Come and look, Madame Mahler. Even I have not seen streptococci in such a marvellous state of development. Look at these threads. Just like seaweed.”

Mahler soon grew too weak even to hold up a book and would tear out the pages to read them. He died in 1911, some eight months after the triumphant premiere of his eighth symphony. Conducting with one finger, his last words were “Mozart.”

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