“Marsten had sprung out of his chair in a paroxysm of anger, when he
suddenly pressed his hand to his side, his face turned a dusky hue,
and he fell backward....”
_The Sign of the Four_
Dr. Watson did not profess to be a cardiologist, but rather a general
practitioner of medicine. There are more allusions to minor surgery
and to nervous disorders in the tales than there are to diseases of
the heart or circulation. There are, however, several references to
the latter which are of historical interest to medical students and
practicing physicians.
Let us examine some of the references to cardiovascular conditions. In
_The Sign of the Four_, a sudden cardiac death already cited above
is described:
Marsten had sprung out of his chair in a paroxysm of anger, when he
suddenly pressed his hand to his side, his face turned a dusky hue,
and he fell backward, cutting his head against the corner of the
treasure-chest. When I stooped over him, I found to my horror that he
was dead.
The cause of death in this instance, so dramatically described,
presumably was produced by a coronary occlusion. It is noteworthy that
the patient was “in a paroxysm of anger” at the time he was stricken.
One is reminded of John Hunter, the famous English anatomist, who in
later life suffered from severe angina pectoris. He is reputed to have
said that he was at the mercy of any rascal who saw fit to make him
angry. Any intense emotion, of course, is capable of producing profound
effects on the cardiovascular system.
It will be remembered in the novel, _The Hound of the Baskervilles_,
that Sir Charles Baskerville had a cardiac disorder. His friend and
physician, Dr. James Mortimer, had concurred that “Sir Charles’
health has for some time been impaired, and points especially to
some affection of the heart manifesting itself in changes in colour,
breathlessness, and acute attacks of nervous depression.” One evening,
when Sir Charles was taking his customary walk between the rows of
yew trees, he saw the awesome hound; he became greatly frightened and
ran as fast as he could toward Baskerville Hall. He fell dead before
he reached the house. In this instance, the intense mental excitement
and the tremendous physical effort caused heart failure--perhaps
ventricular failure produced by a diseased myocardium rather than a
coronary occlusion.
Physical exertion does not necessarily produce a coronary occlusion. It
was once thought that patients suffering from angina pectoris, or who
actually had coronary disease, should not exert themselves physically.
They were warned, for example, not to run to catch a streetcar. A
more liberal view is held today; most patients are urged to exercise
themselves. In point of fact, many coronary occlusions occur when the
patient is at complete rest or performing some slight task.
An interesting allusion to cardiac neurosis may be found in _The Sign
of the Four_. When Dr. Watson was introduced to Thaddeus Sholto,
the latter became greatly excited and said: “A doctor, eh?... Have
you your stethoscope? Might I ask you--would you have the kindness?
I have grave doubts as to my mitral valve, if you would be so very
good. The aortic I may rely upon, but I would value your opinion upon
the mitral.” After Dr. Watson had listened to Sholto’s heart, and had
assured him that he had no cause for uneasiness, the patient turned to
Miss Morstan and said: “You will excuse my anxiety, Miss Morstan ... I
am a great sufferer, and I have long had suspicions as to that valve. I
am delighted to hear that they are unwarranted.”
The above clearly depicts a man who is unduly, and probably needlessly,
alarmed about the condition of his heart; the diagnosis of cardiac
neurosis can obviously be made. This could have been brought about by
some physician who, in an ill-advised moment, had hinted to the patient
that he might be suffering from a cardiac disorder. Such a condition
is spoken of as “iatrogenic heart disease.” Unfortunately, a good many
people suffer from cardioneurosis, and the majority probably would be
benefited by consulting a psychiatrist. The doctor might be able to
ascertain the underlying cause for the patient’s fear.
These passages from _The Sign of the Four_ show that Dr. Watson
was acquainted with valvular heart disease; they are, however, rather
farfetched, if not ludicrous, and probably could not be appreciated
by the nonmedical reader. Watson does not often attempt to show his
erudition or weary his readers by employing technical terms. A good
example of this matter-of-factness may be found in _The Crooked
Man_: “The injury from which this unfortunate veteran was suffering
was found to be a jagged cut some two inches long at the back part
of his head, which had evidently been caused by a violent blow from
a blunt weapon.” The above is written in a language that anyone can
understand.
In the novel _A Study in Scarlet_, may be found an interesting
reference to an aortic aneurism. Jefferson Hope told Dr. Watson to put
his hand over his heart. Watson writes:
I did so, and became at once conscious of an extraordinary throbbing
and commotion which was going on inside. The walls of the chest seemed
to thrill and quiver as a frail building would do inside when some
powerful engine was at work. In the silence of the room I could hear
a dull humming and buzzing noise which proceeded from the same source.
Dr. Watson promptly diagnosed it as an aortic aneurism. Just before
Watson made his examination, Jefferson Hope had put up a terrific
struggle to escape capture, and it had taken four men to subdue him:
So powerful and fierce was he that the four of us were shaken off
again and again. He appeared to have the convulsive strength of a man
in an epileptic fit. It was not until Lestrade succeeded in getting
his hand inside his neckcloth and half strangling him that we made him
realize that his struggles were of no avail.
The remarkable thing is that this man was suffering from an aortic
aneurism which was on the point of bursting. Why the aneurism did not
burst during the terrific struggle will always be a mystery. We find
later in the story that it subsequently did burst.
Several references to the pulse may be found in the tales. When
the pompous if dignified Thorney Huxtable, M.A., Ph.D., collapsed
in Holmes’ living room, Dr. Watson attended him, and described the
condition as one of severe exhaustion; he spoke of the pulse as being
thready in character (_The Adventure of the Priory School_). In
_The Adventure of the Stock Broker’s Clerk_, a man had tried
to hang himself, but Dr. Watson helped rescue him just in time. The
patient was placed on the floor, and the good doctor immediately felt
his pulse; he reported that it was feeble and intermittent.
At the time Dr. Watson practiced medicine, more attention was probably
paid to the study of the pulse than now obtains. The experienced
physician knows that considerable information can be obtained by
studying the pulse. Not only can the rate be ascertained, but the
character of the beat as well: whether it is full or bounding, or
thready or feeble, and the like. By digital pressure on the radial
artery, a rough idea can be obtained of the systemic blood pressure,
and at the same time some information can be gained as to whether the
artery shows any sclerosis.
Some physicians of the older school feel that the younger generation
of physicians neglects the pulse, and its study is becoming a lost
art. The more recently trained physicians are more apt to depend upon
certain instruments of precision. Be that as it may, we have already
seen that Dr. Watson attempted to gain as much information as he could
by feeling the pulse.
On one occasion (_The Adventure of Shoscombe Old Place_), Dr. Watson
speaks of a failing heart; he describes a patient who had a dropsical
condition. When reading about a failing heart in English medical
literature, one cannot but think of William Withering (1741-99), who
was the first physician to employ digitalis therapeutically as a
single pharmacologic agent. He reported his findings many years before
Dr. Watson practiced medicine. It is singular that Dr. Watson never
mentioned any digitalis preparation in the Sherlock Holmes stories.
He does mention amyl nitrite, but not in connection with any heart
condition; he also mentions morphine as a drug to assuage pain, but
again not in connection with the heart.
Since the time Dr. Watson practiced medicine in London, great strides
have been made in the diagnosis and treatment of cardiovascular
disorders. The electrocardiogram and other instruments have been
developed for diagnosing disorders of the heart and vessels. Methods of
treatment, such as the use of antibiotic drugs, and agents for reducing
high blood pressure, have been of inestimable value.
In this country during the past few years, the citizens have become
increasingly aware of the value of research in cardiovascular disease.
It is noteworthy that a part of this interest was stimulated by the
fact that President Dwight D. Eisenhower suffered a coronary occlusion
and later a mild cerebral accident.
In conclusion, when Dr. Watson practiced medicine, he did not have any
effective drugs at his disposal to combat hypertension, or any drugs,
such as dicumarol, to lessen the danger of further coronary occlusions.
We may be assured, however, that those agents he did have were used to
the best of his ability, and he did all he could to restore the patient
to health. No man could do more.