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Me<5Il6l-^/4/' "' f I "' r {Reprinted from the Montreal Mbdxoa^ Journal, Janvary, 1891.) I SOME CAEDIAC PHENOMENA OBSERVED IN TYPHOID FEVER* By Robert E. McKbchnie, M.D., House Physician, Montreal General Hospital. Mr. President and Gtentlemen : — Through the kindness of Dr. MacDonnell, I am permitted to bring before your notice the two following cases, which were admitted into his wards in the Montreal General Hospital, and so came under my immediate observation as his House Physician. They are two cases of typhoid fever, which would be classed as mild and uninterest- ing, were it not for certain cardiac phenomena which they presented. Their histories are as follows : — Case I — Mary M., aged 23, a servant, came into hospital on the Yth day of her illness. With the exception of an attack of smallpox at 2 years of age, she had always enjoyed good health. On admission, her temperature was 102°; pulse, 100; and fespirations, 28. Examination of lungs and heart yielded negative results. The abdomen was tumid with marked ten- derness, with gurgling in the right iliac fossa. No typhoid spots were seen and the spleen was not enlarged. On the nth day of the fever, typhoid spots appeared. There was no tympanites, and bowels moved only by enemata. Up to the 18th day the case progressed favorably ; the tern, perature for the previous week rarely going above 102° ; the bowels s^ill moving only by enemata; and there being no tympanices or excessive abdominal pain. * Read before the Medioo-Chirurgioal Society of Montreal. On this 18th day, at 6 a.m., the nurso took the temperature as usual, and found it 100°. Half an hour later, notin: a great change iu the patient, the temperature v^as again taken and found to he but 98°. The patient was then extremely pale, as though blanched by a haemorrhage; the pulse about 150 and very weak ; the face and extremities cold, and bathed by a profuse cold perspiration. HaBmorrhage being at once thought of, the usual remedies were applied. By noon the extremities were warmer, and the pulse, although still weak and fast, somewhat stronger. From this time on to the 28th day (ten days), the patient steadily grew stronger ; a slight degree of color returned to the cheeks ; appetite was returning, and the temperature had been normal for five days. The bowels still moved only by enemata, and a close watch was kept on the stools for signs of hsemorrhuge ; but none appeared, although three large motions had been passed in the interval. But on this 28th day a fresh syncopal attack occurred. At 7.30 p.m., just after having been made comfortable in bed for the night, which process necessitated a certain amount of dis- turbance to the patient, she again became suddenly faint, very pale, broke out into a profuse perspiration, and pulse became rapid and feeble. In fact, the pulse was so feeble that the stethescope was applied over the heart to get the rate. There was then heard over the left ventricle, at the apex, and propa- gated into the axilla, a loud blowing systolic murmur. Ex- amination failed to find any cardiac enlargement. Hot applications were applied and stimulants oi'dered. Two days afterwards she was much stronger. The murmur, as above noted, still persisted, and in addition a loud systolic murmur was heard at the aortic cartilage, propagated upwards along the vessels of the neck, and also heard across the upper part of the chest, from the aortic cartilage to the left axilla. A slight trace cf blood was seen in a stool passed this day, which was the only blood passe^i throughout the case. Ten days afterwards fciie patient had so advanced in conval- escence that she was out of bed every afternoon. At this time the mui'mur could not be heard at the apex at all. A week later, two days before her discharge, the note in the %>f ' *>.• ease book reads : " The murmur is heard with difficulty at the aortic cartilage, and not at all in the axilla or at the apex." The second case is entirely different to the preceding, bu t still presents a similar problem to be solved. Case II. — Annie M., aged 21 ; a general servant, lately out from Ireland, was admitted to hospital on the 6th day of the fever. When a child she had had measles, scarlet fever, chicken pox, and whooping cough ; since when she had always had good health. But the past four months she had found herself breathless on exertion ; dizzy at times; and troubled with palpitation. On admission, she was found to be in a good state of nutri- tion. Her face, the mucous membranes of the mouth, and the surface of tho body generally, were very pale. There was visible pulsation of the carotids ; and under the finger nails, and through the mucous membrane of the lips, could be seen a capillary pulse. The abdomen was tumid, with no complaint of pain on palpation ; the bowels constipated ; the tongue of the ordinary typhoid tj'^pe. No spots were visible. The super- ficial ai'ea of cardiac dulness was enlarged, measuring 3J inches transversely, with the apex beating ^ inch inside and under the nipple. Over the upper part of the sternum could be heard a systolic blowing murmur, propagated up the neck, and across the upper part of the chest to the left axilla ; but not heard at the apex. The pulse was semi-collapsing, 102 to the minute, regular in volume and rhythm ; temperature, 103" ; respirations, 24. Examination of lungs found them normal. The liver measured 3 inches vertically in the right mammillary line. The spleen was not enlarged. Three days later, characteristic typhoid spots began to appear ; and the next day the spleen was noted as enlarged. But, on the third day after admission (the 9th of the fever), a faint s^'stolic murmur was heard at the heart's apex. It increased in strength for a day or so, becoming quite marked, and coexisting with the original murmur. This persisted for some days. The fii-st sound of the heart was also dlmost inaudible. The case ran a favorable course and normal tem- perature was reached on the 20th day. 6 On the 26th day, the patient convalescing rapidly, I find this note : "Area of cardiac dulness remains an on admission ; the apex also where then found. But the systolic murmur then described as being heard over the upper part of the sternum, across into the axilla, up the neck, and the addi- tional one, discovered three days later, at the apex ; now at times cannot be heard at all, sometimes can be heard faintly at the aortic cartilage, sometimes at the apex." Three weeks later, the patient was still in the hospital, having been detained by an abnormal temperature, which appeared after she had been given solid food. At this date, no trace of a murmur could be heard in any of the areas where it had been formerly heard. While these two cases are different in many important points, they possess this feature in common, that, there was a progressive development of some cardial affection in each. This was shewn, in the first case, by the presence of a murmur where none existed before and an addition in a few days of another mai'ked murmur. In the second case, a murmur was present when the patient first came under observation, but an additional one was developed during the course of the disease. And in each, as the fevei' ran its course, these cardiac mani- festations became less marked, entirely ceasing in one. If the two cases cited were not typhoid, the infeiences and conclusions to be drawn from them would be erroneous ; hence, it will be necessary to brieflv exclude those diseases which might be mistaken for it, especially those with cardiac compli- cations. Murchison says that "the various manifestations of tubercu- losis constitute the maladies most difficult to distinguish from enteric fever." Fagge qualifies this by saying that " miliary tuberculosis of the lungs may be mistaken for typhoid with bronchitis." As there was no pulmonary involvement this can be at once excluded. Spots, closely resembling those found in typhoid, are described as being found in acute tuberculosis J Dut Murchison met with only one such case. It was diagnosed typhoid and died, the autopsy revealing the error. The strongest proof that our cases were not tuberculosis is, that both recovered. The same fact will exclude ulcerative endocarditis, and pernicious aneemia with febrile symptoms. Il »^« I ;, m^< On the other hand, we have the Btrongest proofs that our eaees wei'e typhoid, in a sequence of typical symptoms, completed ov the finding of the characteristic typhoid spots. Murchison says : " When after febrile symptoms of about a week's duration, lenticular rose spots appear in sncoeslKVtt crops, the diagnosis of enteric fever is certain, whatever he the other symptoms. Two or three characteristic spots will be sufficient." Acknowledging the cases to be typhoid fever, the que&tion arises, what, then, was the nature of the cardiac phenomena? We have in the production of cardiac murmurato take account of the factors engaged ; namely, of the blood, of the endocar- dium, of the myocardium, and of the' pericardium. There were no symptoms at all suggestive of a pericarditis, nor would such a disease account for the signs found ; so we n^ay dismins a lesion of the pericardium at once. A hsemic origin of the murmurs is not so easily Siec aside. In our 2nd case we have a girl of 21, probably a hard-worked servant, very anaemic, and with a history of having suffered from breathlessness, dizziness and palpitation for four monlths previously. No recent cause had occurred to bring on these symptoms, unless it were an anaemic state. But, there is Strong evidence that there was long-standing valvular disease in her case. She hud had scarlet fever as well as me&sles when a child, and it i::^ quite possible that an endocarditis had com- plicated one of these diseases, leaving permanent damage. Compensation had been good from that time till perhaps four months ago, when she tirst noticed shortness of breath and palpitation. At this date, also, she left home and went to service, hence bard work may have lessened the perfection of compensation. Or mero ansemia may have given these symp- toms irrespective of cardiac disease. At any rate, when > the patient came under our observation, she had every evidence of long-standing disease of the aortic valves, in an enlarged heart, with pallor of the surface of .he body, pulsation of the vessels in the neck, a capillary pulse, a systolic murmur heard at the aortic cartilage, and propagated up the great vessels of the neck. If it were not that fresh cardiac symptoms were added to the foregoing, this case would not present the interest it does. 8 Why an ansBmic state of the blood, Buporaddod to the changes which take place in the blood in all fevers, would not ewpo'iiaily predispoHC to the development of cardiac murmurH, without any actual cardiac diwease, may well be asked. According to Bristowe, in his article on Aniumia, "the development of abnormal sounds in the heart and bloodvessels, independent of organic lesions, is of common occuironco and highly characteristic, a soft systolic murmur is to bo heard frequently over the situation of the aortic and pulmonary valvo, and along the course of the ascending arch and innominate artery, occasionally at the apex ;" while Fagge, in descibing dif- lerentformsof aniumic murmurs, says : "An aneemic murmur of another kind is systolic in rhythm, and is heard over the heart and main arteries. It is usually loudest at the base, and it often seems to be traceable along the pulmonary artery, rather than along the aorta Whether an anaemic murmur is ever localized at the apex, I am not sure The basic systolic murmur often has a rough, harsh quality, sugges- tive of anything rather than a functional origin." Fagge, therefore, doubts an aneemic murmur ever being localized at the apex. But in both our cases this occurred. In this 2nd case which we have been discussing, the murmur was developed under observation, and the characters of it suggested regurgitation, rather than that it had a htemic origin. In the 1st case, the onset of the cardiac manifestations was too sudden to be from a heemic cause. In ooth cases, the distribution of the murmurs, together with their intensity of sound, pointed to an incompetency of the valves from some cause. " For an ansemic murmur is usually loudest at the base, and it often seems to be traceable along the pulmonary arterj'' rather than along the aorta." So, while anaemia itself cannot be excluded from the cases, \t of itself is not sufficient to account for the collapse in the one case, or the physical signs in either. That an endocarditis may have been the cause also needs investigation. It is a complication which may be looked for in auy of the specific fevers, and slight degrees of it are found in typhoid oftener than commonly supposed. Jennei- noted it in throe cases out of sixteen, while, according to Hoffman, the endocardium is often opaque and thickened, owing to a fatty degeneration of its lining epithelium ; and in several instances \ V- 9 I V- 1) ho found rocetit oudocui'ditiu, with vugot4itionH on the aortic and mitral vulve8. < . Bristowe savH a Hubjeiuwf endocarditis reraaitiH liai)ie to fresh attacks of the inflammation, and there is every probability to suppoHO that Caso 2 was a former Hubjoct of endocarditis. I think there is some proof, that not only wore the aortic valves then art'ected, but also the mitral, for a contracted liver of three inches vei'tical dulness wiis noted, which would be ac- counted for by chronic mitral incompetency. If this be the correct view, then compensation had later on improved, so as to be about perfect, but was again lost during the course of the fever to an appreciable extent, and regained as convalescence advanced. The cause of thiH slight loss of compensation and recoveiy will be discussed later or , and is not an endocarditis. But endocardiiirt cannot bo thus easily dismissed, for certain points are strongly in its favor. Thus Bristowe says : ** If in the progress of anj' one of those diseases of which endocarditis is a common complication, we detect a cardiac murmur which had not pieviously existed ; or if further observation proves this to be a permanent phenomenon; or if changes in it w^'- caiive oi" increasing mischief take place ; or if additional mu; murs become developed, we cannot reasonably doubt that endocarditis is present." And as further support he says: " We must not forget that direct murmurs due to granulations occasionally disappear." Now, in regard to these statements, we must note that Bristowe speaks of those diseases in which enJocaiditis is a common complication, which statement lessens the value of the observation when we try to apply it to typhoid ; for endo carditis is not a common complication of it. Bristowe, in making this statement, was carefully weighing evidences and probabilities, which were of value only in the class of cases he was thinking of, so that having taken typhoid out of that class, the probabilities of endocarditis being present are reduced, unless new evidence is forthcoming. The fact that our murmurs lessened and disappeared is, of course, not at all contrary to the view that endocarditis was their cause ; but the fact that they lesseneii and disappeared coincidently with the return of strength, as convalescence advanced, strongly suggests another cause, which either will so account for the phenomena under discussion, or will act as a factor, in conjunction with the causes ah-eady discussed, to account for them. This is disease of the myocardium. 'Degeneration of the muscle cells of the heai't walls is common to many different fevers. According to Murchison, " Louis found marked softening, sometimes associated with thinning of the walls, in 15 out of 47 cases of typhoid. Jenner found the heart soft and flabby in 6 out of 11 c&ca ; . . . and Hoffman has fon.nd either waxy or granular degeneration of the muscular tissue of the heart in lOH out of 159 cases." Hutchinson, in Pepper's System, observes that *' the heart, in common with the other muscles of the body, 8dffert+ from both forms of degeneration, but the granular foi-m appears to be more common than the waxy. In protracted cases it is usually much softened. . . Upon minute examination, the degeneration is found to have taken place in patches, the diseased fibres being found alongside of others which have scarcely undergone any alteration. These patches are espe- cially common in the papillary muscles of the mitral valve, a f^ct which explains the occasional presence of systolic murmurs in typhoid fever." In another place he also says : " Degeneration of the muscu- lar tissue of the heart is probably present in some degree in eveiy case of typhoid fever, being^ of course, most marked in the severest cases." Pi'om the fwegoing, it is evident that a weakening of the cardiac wall must be looked for in every case of typhoid, and is a factor too important to be overlooked in hunting for an explanation of the signs found in our cases. That we have evidence that this parenchymatous degeneration may occur early in the disease, is seen in the tremors of the tongue, an early observable fact. These tremors, according to Fagge, are due to this cause. Now, ansemia itself is a common cause of parenchymatous degeneration of the muscle wall of the heart, and may lead to so much weakening, with dilatation, as to give cardiac mur- murs which are not heemic. Both our cases wore antemic on admission, hard-worked servants. So we have a two-fold reason for supposing the heart-walls weakened, fever and aneemia. S 11 According to Osier, " impaired nutrition of the heart-walls, from degeneration or inflammation, may lead to such a diminu- tion of the reslHting power that dilatation readily occurs. In fevers, t^** loss of tone due to parenchymatous degeneration or myocardiuH, may lead to a condition of acute dilatation which may prove fatal. It is a well recognized cause of death in scarlatinal dropsy, and may occur in rheumatic fever, typhus, typhoid, erysipelas, etc. . . .In ansemia, leuka)mia and chlorosis, the dilatation of the chambers may be considerable. Under any of these circumstances, the walls may yield with normal blood pressure,