Of the fictional characters who have attained immortality, none has
acquired as faithful a following of admirers as has Sherlock Holmes, described
as "the greatest detective who never lived." At least 5 "biographies" have
been written on the famous man with the deerstalker hat and pipe, and he has
been featured in several stage, movie, and television performances. While
other fictional persons are revered or despised for the roles they have played,
their fame is relegated to the past. Holmes and his worthy colleague, John
H. Watson, MD, are likely to live forever.
Given the medical background of Sir Arthur Conan Doyle, it is not surprising
that various aspects of clinical medicine appear in his writings. Most of
these have been described by Holmes' companion Watson, but written as they
are for a nonmedical reading public, clinical detail is scanty. Diseases of
the cardiovascular system do not play a prominent part in the adventures of
this dynamic duo. The largest series so far describes in some detail 4 incidents:
Arthur Morstan's sudden death and Thaddeus Sholto's cardiac neurosis take
place in The Sign of Four, Sir Charles Baskerville
dies in The Hound of the Baskervilles, and the dramatic
description of Jefferson Hope's aortic aneurysm is related in A Study in Scarlet. Abnormalities of the pulse are briefly mentioned
in "The Adventure of the Priory School" and "The Adventure of the Stockbroker's
Clerk," and a passing reference is made to dropsy in "The Adventure of Shoscombe
Old Place."1 Four more incidents are identified,
and all 11 events are analyzed in greater detail in what I believe to be the
most complete description of cardiovascular diseases in The Adventures of Sherlock Holmes.
Palpation of the pulse is the classic first step in evaluation of the
cardiovascular system and, indeed, in the examination of any critically ill
patient. Watson makes 2 references to an abnormal pulse. In "The Adventure
of the Stockbroker's Clerk," an attempt at duplicity by the manager of the
Franco-Midland Hardware Company resulted in dismal failure. Disguising himself
as his own brother, this worthy gentleman attempted to swindle a large investment
firm. Unfortunately, his broad smile in both guises revealed an identical
gold filling, an astute observation made by the stockbroker's clerk. To avoid
prosecution and shame, Harry Pinner attempted to hang himself, and was rescued
"just in time" by Holmes and Watson. "What do you think of him?" asks Holmes,
in response to which Watson relates: "I stooped over him and examined him.
His pulse was feeble and intermittent, but his breathing grew longer. . .
.‘It has been touch and go with him' I said, ‘but he'll live now.'"2(p371)
In judicial hanging, the placement of the knot on the noose and the
degree of drop are designed to cause instant death by compression of the spinal
cord.3 This technique not being familiar to
the inexperienced, suicidal hanging often results in failure. Cerebral hypoxemia
is followed by acidosis and hypoxia of the myocardium. Neck traction produces
automatic reflex activity, stimulating the carotid sinus and parasympathetic
network in the pericarotid area. Irregular bradycardia that follows leads
to asystole and cardiac arrest.4 This fatal
outcome was averted by Watson's rapid resuscitative efforts. The second instance
of an abnormal pulse is seen in "The Adventure of the Priory School." In this
saga, the dignified headmaster, Thorneycroft Huxtable, MA, PhD, collapses
immediately on entering Holmes' living room. Watson's examination revealed
a "thready pulse." "‘What is it, Watson?' asked Holmes. ‘Absolute
exhaustion—possibly mere hunger and fatigue,' said I [Watson], with
my finger on the thready pulse, where the stream of life trickled thin and
small."2(p539)
There seems little doubt that this scholar had experienced great physical
stress. Having run to the point of exhaustion, he was probably dehydrated,
a diagnosis in which I concur with Watson. The ensuing hypovolemia accounted
for his thready pulse. Having had a glass of milk and a biscuit, Huxtable
made a rapid recovery.
The most dramatic cardiac illness in Watson's experience was that of
the Mormon, Jefferson Hope. Having followed his quarry over 3 continents for
more than 2 decades, Hope tracks down his adversaries and murders them. When
apprehended by the law, the following scene, as related by Watson, ensues:
"I've got a good deal to say," said our prisoner slowly, "I want
to tell you gentlemen all about it."
"Hadn't you better reserve that for your trial?" asked the inspector.
"I may never be tried." He answered. "You needn't look startled. It
isn't suicide I am thinking of. Are you a doctor?" He turned his dark, fierce
eyes upon me as he asked this last question.
"Yes, I am," I answered. "Then put your hand here," he said with a smile,
motioning with his manacled wrists towards his chest. I did so; and became
at once conscious of an extraordinary throbbing and commotion which was going
on inside. The walls of his 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.
"Why," I cried, "You have an aortic aneurism!"2(p77)
It is not surprising that Watson, who obtained his doctor of medicine
degree from the University of London, London, England, and received his clinical
training at Saint Bartholomew's Hospital, London, was able to make the clinical
diagnosis instantly. But then again, given Hope's clinical presentation, there
was really no other tenable diagnosis. Osler's description of the physical
findings in aortic aneurysm is not much different from that of Watson:
An external tumor is present in many cases, projecting through
the upper part of the sternum . . . the impulse is as a rule, forcible, slow,
heaving, and expansile. The hand upon the sac, or on the region in which it
is in contact with the vessel wall, feels in many cases a diastolic shock,
often of great intensity, which forms one of the valuable physical signs of
aneurysm.5(pp673-674)
The cause of Hope's aortic aneurysm remains to be considered. Hope attributed
his illness to "over-exposure and under-feeding among the Salt Lake Mountains,"2(p77) but Ziegler observes, rather cynically, "Though
under-feeding had nothing to do with it, over-exposure certainly did, namely,
over-exposure to the spirochete, though this is not what Hope meant to imply."6(p224)
Syphilis is the major cause of aneurysms of the ascending aorta and
the aortic arch. An autopsy study7 of 100 cases
of syphilitic aortitis showed that changes were invariably found in the ascending
aorta. In a review of aneurysm of the aorta, Osler states, "There is only
one infection of any moment with which aneurysm is connected, namely syphilis."8(p535) There seems little doubt, therefore, that syphilis
was the cause of Hope's aortic aneurysm. Hope later observes, "I am on the
brink of the grave. . . . "2(p77) (a prognosis
rapidly confirmed when his aneurysm ruptured in the next 24 hours).
Intractable heart failure and 2 episodes of sudden death occur in the
adventures of Holmes and his indefatigable partner. In "The Adventure of Shoscombe
Old Place," John Mason, head trainer of the Shoscombe stables, tells Holmes:
"Of course, with her [Lady Beatrice Falder] weak heart and dropsy, one couldn't
expect that she could get about without him."2(p1104)
Later, when Sir Robert is brought to book, he says: "My sister died
of dropsy which had long afflicted her.. . . Her doctor would certify that
for months her symptoms have threatened such an end."2(pp1111-1112)
(He was referring to Lady Beatrice's demise a week earlier.)
Dropsy, or fluid retention, was a common diagnosis at the time. That
Falder's dropsy was of cardiac origin is substantiated by Mason's observation
that she had a "weak heart." The deceased is never seen or heard in the tale
related, and given the paucity of clinical information provided, no more can
be said. There seems little doubt, however, that she had intractable heart
failure, a fact recognized by her physician and voiced as a poor prognosis.
In The Hound of the Baskervilles, some aspects
of Sir Charles Baskerville's illness, being provided by a physician, are more
complete than in other narratives. The opinion of James Mortimer, as reported
in the Devon County Chronicle, reads as follows:
The evidence . . . points especially to some affection of the
heart. Doctor James Mortimer, the friend and medical attendant of the deceased,
has given evidence to the same effect. . . . The doctor's evidence pointed
to an almost incredible facial distortion—it was explained that that
is a symptom which is not unusual in cases of dyspnea and death from cardiac
exhaustion. This explanation was borne out by the postmortem examination.2(pp676-677)
Mortimer confirms this report when he tells Holmes, "His heart was,
I knew, affected."2(p678)
Baskerville's body was found with "features convulsed with some strong
emotion."2(p679) One assumes that Baskerville
was running away from someone or something—perhaps a hound—and
succumbed to a terminal cardiac event.
The Sign of Four provides 3 incidents of interest.
Major John Sholto reveals to his son Thaddeus (who had a problem of his own,
to be described later) a secret that he had harbored for many years. We are
told that the major had "suffered for many years from an enlarged spleen."2(p102) On his deathbed, he expressed a wish to make
a last communication to his son. "When we entered his room, he was propped
up with pillows and breathing heavily."2(p102)
The picture presented is suggestive of a patient with advanced left
ventricular failure; but what might have been the antecedent illness? We know
that much of John Sholto's life was spent in India, where kala azar (visceral
leishmaniasis) and malaria were endemic. Acute anemia is characteristic of
visceral leishmaniasis,9 and pulmonary edema
may develop in patients with malaria who develop intravascular hemolysis.10 Either condition could well have been the cause for
the heart failure manifesting as orthopnea.
John Sholto's account included some details of the illness and the death
of a colleague, Captain Arthur Morstan.
"I will tell you how Morstan died" he continued. "He had suffered
for years from a weak heart . . . I alone knew it. . . . Morstan 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."2(p103)
Morstan's antecedent cardiac history and his pressing his hand to his
side suggest that sudden coronary occlusion was the terminal event. An increase
in blood pressure brought on by his paroxysm of anger could have been the
precipitating event. John Hunter, the English anatomist who had angina pectoris,
is reported to have said that he was at the mercy of any rascal who saw fit
to make him angry. And so it was with Morstan.
Thaddeus Sholto, John Sholto's son, was perhaps the only person to have
sought Watson's professional opinion outside his consulting rooms:
"A doctor eh!" he cried, much excited. "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 can rely upon,
but I should value your opinion upon the mitral."
I listened to his heart as requested, but was unable to find anything
amiss, save, indeed, that he was in an ecstasy of fear. . . . "It appears
to be normal," I said. "You have no cause for uneasiness."
"You will excuse my anxiety, Miss Morstan," he remarked airily. "I am
a great sufferer, and I have long had suspicions as to that valve. I am delighted
to hear that they are unwarranted."2(pp100-101)
Thaddeus Sholto clearly manifested the features of cardiac neurosis.
This condition, most often associated with a fear of coronary artery disease,
has also been reported in persons with valvular disease of the heart. Rheumatic
fever was widely prevalent in India, and involvement of the mitral and aortic
valves is a common late consequence of the disease. Perhaps Thaddeus Sholto
had a febrile illness and his knowledge of the valve complications of some
types of fever induced in him a fear of heart disease. Neuroses associated
with rheumatic valvular heart disease have been reviewed by Viko.11 The type of anxiety Thaddeus Sholto manifested is
that described as introspective neurosis, a condition in which the patient
has a fear of having diseased heart valves in the absence of any signs of
such an illness. Thaddeus Sholto was probably well aware of his unjustified
concern, as reflected in his comment to Miss Morstan. One suspects that his
delight on learning that his heart valves were unaffected will be short-lived.
Whether 1 or 2 bullets injured Watson while serving in India has perplexed
Holmesian scholars for more than a century. Sovine12
believes that a single bullet entered Watson's left shoulder, exited anteriorly,
reentered his left leg, and came to rest in the calf muscle. Van Liere13 also subscribes to the single-bullet hypothesis,
but regards Sovine's argument as specious. He believes that transient episodes
of amnesia account for the differing sites of the wound described by Watson,
and ascribes this intermittent loss of memory to a subclavian steal effect
caused by the injury to that vessel.
The 2-bullet theory, which I believe is correct, states that Watson
sustained 2 distinct injuries, for the trajectory of the single bullet as
described by Sovine12 is highly unlikely. By
his own accounts, Watson sustained at least 2 wounds. In A Study in Scarlet, he relates, "There I was struck on the shoulder
by a Jezail bullet which . . . grazed the subclavian artery."2(p15)
The Jezail rifle was a heavy, long-barreled musket with a swiveling
muzzle manufactured by a tribe of the same name located on the India-Afghanistan
border. It was here, in the battle of Maiwand, that Watson sustained his injuries.
Inclement weather appears to have affected Watson, for in The Sign of Four he says, "I had had a Jezail bullet through it [leg]
some time before, and though it did not prevent me from walking, it ached
wearily at every change of the weather."2(p90)
Later in the same narrative, Holmes expresses much concern
about his companion's leg.
"Are you game for a six-mile trudge, Watson?"
"Certainly." I answered.
"Your leg will stand it?"
"Oh, yes."2(pp118-119)
On another occasion, in "The Adventure of the Noble Bachelor," Watson
observes, "I had remained indoors all day, for the weather had taken a sudden
turn to rain, with high autumnal winds, and the Jezail bullet which I had
brought back in one of my limbs as a relic of my Afghan campaign throbbed
with dull persistence."2(p287)
Other lapses in Watson's memory are evident. Although a meticulous chronicler
of Holmes' adventures, he seems to have forgotten the dates of key events
in his own life. It is clear that he married Mary Morstan in 1888, ie, 6 years
after she answered an advertisement in the Times
of May 4, 1882. Yet, in "The Five Orange Pips," which took place in 1887,
Watson indicates that his wife was "on a visit to her mother's."2(p218)
Mary Morstan's mother was not alive at the time of her engagement to Watson,
so she could not have been visiting her mother. Can Watson's episodes of amnesia
(or confusion) be explained by the injury to his subclavian artery, as suggested
by Van Liere?13 I think they can. Thirty years
after Van Liere's proposal, Blasco et al14
describe a patient with transient global amnesia caused by subclavian steal.
This episodic symptom complex is manifested by confusion and amnesia, with
preservation of consciousness and higher cognitive functions. Amnesia was
the probable cause of Watson's inability to remember dates and events in his
personal life, and that amnesia was a consequence of a bullet having "grazed"
his left subclavian artery.
Watson's last meeting with Holmes was near the falls of Reichenbach
(near the village of Meiringer in Switzerland), which the former describes
in vivid detail.
It is indeed a fearful place. The torrent, swollen by the melting
snow, plunges into a tremendous abyss, from which the spray rolls up like
the smoke from a burning house. The shaft into which the river hurls itself
is an immense chasm, lined by glistening coal-black rock, and narrowing into
a creaming, boiling pit of incalculable depth, which brims over and shoots
the stream onward over its jagged lip.2(p478)
Into this maelstrom Doyle murderously consigned Holmes and James Moriarty.
In response to outcries from his reading public, Doyle, with much reluctance,
resurrects Holmes. No longer residing at 221B Baker Street, Watson returns
to his home in Kensington, England, when the maid announces a visitor, an
elderly deformed bookseller who sought audience with the physician.
"Well, Sir, if it isn't too great a liberty, I am a neighbor
of yours, for you'll find my little bookshop at the corner of Church Street.
Maybe you collect yourself, sir. . . . With five volumes, you could just fill
that gap on the second shelf. It looks untidy, does it not, sir?"
I moved my head to look at the cabinet behind me. When I turned again
Holmes was smiling at me across my study table. I rose to my feet and stared
at him . . . and then it appears I must have fainted for the first and last
time in my life.2(p485)
There seems little doubt that neurocardiogenic syncope was the cause
of Watson's transient loss of consciousness. Emotional stress is a common
precipitating cause, and certainly seeing a man presumed dead come alive was
more than sufficient reason to unsettle the nerves of even a war veteran.
Inappropriate peripheral vasodilation and relative bradycardia brought about
by depressed sympathetic activity with augmentation of the parasympathetic
receptors lead to progressive hypotension and syncope.15
In "The Adventure of the Lion's Mane," we learn that Holmes was on the
scene of a mystery after retirement: "It occurred after my withdrawal to my
little Sussex home, when I had given myself up entirely to that soothing life
of Nature for which I had so often yearned during the long years spent amid
the gloom of London."2(p1083)
This is one of the few tales in which Holmes is his own chronicler,
for "the good Watson had passed almost beyond my ken."2(p1083)
Fitzroy McPherson was "A science master whose life had been crippled
by heart trouble following rheumatic fever."2(p1084) Soon after a swim—or so it appeared—McPherson was found "staggering
like a drunken man,"2(p1084) and in a few minutes
he was dead. The science master's colleague, Ian Murdoch, was similarly afflicted
a few days later, but not having preexisting heart disease, he was revived
with half a tumbler of brandy. Physical examination revealed Murdoch to have
"Crisscrossed upon the man's naked shoulder, the same reticulated pattern
of red, inflammed lines which had been the death-mark of Fitzroy McPherson."2(p1092)
On inspection of the "deadly lagoon," Holmes detected the coelenterate Cyanea capillata, and deemed the toxin of this marine animal
to be the cause of death of one person and near death of another. While most Cyanea species are small, they can be large, with tentacles
that can extend to 120 feet.16 Holmes' suspicion
of the cause of death was raised by the study of a book in his own library,
in which J. G. Wood gives a true account of his untoward experience with this
fearsome creature:
Both the respiration and the action of the heart became affected,
while at short intervals sharp pangs shot through the chest. Then the pulsation
of the heart would cease for a time that seemed an age, and then it would
give six or seven leaps, as if it would force its way through the chest.17(pp141-142)
Studies18-19 on biologically
occurring histamine releasers have shown that the infusion of as little as
0.1 mg of extract of C capillata can produce a histamine
response. It is likely that the release of such factors caused anaphylaxis
through activation of histamine1 and histamine2 receptors,
resulting in vascular permeability leading to a decrease in systolic blood
pressure.20
Cardiac arrhythmias, including supraventricular tachycardia and ventricular
fibrillation, occur in patients with cardiovascular collapse, and in a series21 of 227 patients, 7 did not respond to resuscitation.
One patient with severe preexisting cardiac disease was found at autopsy to
have massive myocardial infarction.21 These
pathophysiologic changes are the likely cause for the symptoms described by
Wood.17 They were also probably responsible
for the death of McPherson, who was "crippled by heart trouble," although
Murdoch, who was not so affected, recovered from his misadventure.
I have attempted to critically analyze incidents of cardiovascular interest
in The Adventures of Sherlock Holmes. In doing so,
I have correlated clinical presentations with the illnesses extant at the
time and treatments then available, and interpreted them in light of pathophysiologic
concepts of disease known today.
