DOCTOR WATSON, CARDIOLOGIST
“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.