Heart Failure In The Medical Casebook

 

Heart anatomy:-

“Illustration of left side heart anatomy from Gray’s Anatomy.” [7]

This Week

We’ll start 2 weeks looking at heart disease. The book has 3 chapters on heart disease – looking at Heart Failure [which is the subject this week], Ischaemic Heart Disease and Valvular Heart Disease. As you might expect, developing any heart disease would have been very serious in Victorian times.

 

Sherlock Holmes And The Adventure Of The Ordered Occupations

Another story to accompany publication of The Medical Casebook Of Sherlock Holmes And Dr John Watson.

Dr Watson attends a hansom cab accident on Kensington High Street, in which a fellow general practitioner is seriously injured. Acting as a locum for his colleague, Watson is called to a mysterious death. Sherlock Holmes is asked for help, and discovers another similar death. Unravelling the mystery makes full use of Watson’s medical knowledge, but can our heroes prevent further deaths?

Available from the Amazon Kindle Store.

 

Heart Failure

Heart Failure + Sherlock

Heart disease is the area of medicine that makes the most appearances in the Sherlock Holmes books. I have chosen to divide heart disease into 3 chapters – heart failure, ischaemic heart disease, and valvular heart disease. Though these conditions overlap, both in patients, and in the stories, all three merit a chapter of their own. 

Let’s start with a definition. Heart failure primarily refers to loss of the pumping ability of the left ventricle, which is the largest of the four heart chambers. This leads to impaired ability of the heart to pump blood, and hence oxygen, around the body.

In Victorian times they didn’t use the term heart failure. Instead they used the terms “weak heart”, or the rather wonderful “cardiac dropsy”. 

I’m going to tackle this chapter in a slightly different way to my previous chapters, which aimed to cover every single reference to the disease in question. This approach is unmanageable for a few of the chapters. A quick internet PDF word search tells me that the word “heart”, or related words like “heartfelt” or “hearty” appear 328 times in the stories.

Thus I am only going to look at 3 stories that I feel portray heart failure as a clear clinical problem. Some references better fit in the other 2 heart-based chapters. As I am not looking at injuries caused by deliberate human intervention, stabbings and poisonings affecting the heart are excluded. And for this chapter I am going to ignore heart-related metaphors, so there are no “broken hearts” or “guilty hearts” included.

Firstly let’s return to “The Resident Patient”, which we encountered a few chapters back when looking at Catalepsy. Blessington tries to hide from his co-conspirator bank robbers by setting up a medical practice, with Percy Trevalyan at its helm.

“This was the strange proposal, Mr Holmes, with which the man Blessington approached me. I won’t weary you with the account of how we bargained, and negotiated. It ended in my moving into the house next Lady Day, and starting in practice on very much the same conditions as he had suggested. He came himself  to live with me in the character of a resident patient. His heart was weak, it appears, and he needed constant medical supervision. He turned the two best rooms of the first floor into a sitting-room and bedroom for himself. He was a man of singular habits, shunning company and very seldom going out. His life was irregular, but in one respect he was regularity itself. Every evening, at the same hour, he walked into the consulting-room, examined the books, put down five and three-pence for every guinea that I had earned, and carried the rest off to the strong-box in his own room.”

Our next story is a return visit to “The Gloria Scott”. Holmes befriends a fellow student, Victor Trevor, after he is bitten by Trevor’s dog. During their long vacation, Holmes is invited to stay at the Trevor family seat in Norfolk. There he meets Victor Trevor senior. Over a glass of port, Trevor senior encourages Holmes to deduce what he can about him. Sherlock makes some astute observations, culminating in a reference to a past acquaintance, the shock of which causes Old Trevor to collapse [an event we will cover in our Faint chapter]. Luckily he comes round quickly.

“Ah, boys,” said he, forcing a smile, “I hope I haven’t frightened you. Strong as I look, there is a weak place in my heart, and it does not take much to knock me over. I don’t know how you manage this, Mr. Holmes, but it seems to me that all the detectives of fact and of fancy would be children in your hands. That’s your line of life, sir, and you may take the word of a man who has seen something of the world.”

“And that recommendation, with the exaggerated estimate of my ability with which he prefaced it, was, if you will believe me, Watson, the very first thing which ever made me feel that a profession might be made out of what had up to that time been the merest hobby. At the moment, however, I was too much concerned at the sudden illness of my host to think of anything else.”

“I hope that I have said nothing to pain you?” said I.

“Well, you certainly touched upon rather a tender point. Might I ask how you know, and how much you know?” He spoke now in a half-jesting fashion, but a look of terror still lurked at the back of his eyes.

Later, we learn the back-story of Victor Trevor senior in a letter sent to his son, to be read after his death.

“If then your eye goes on to read this line, I know that I shall already have been exposed and dragged from my home, or as is more likely, for you know that my heart is weak, by lying with my tongue sealed forever in death. In either case the time for suppression is past, and every word which I tell you is the naked truth, and this I swear as I hope for mercy.

My name, dear lad, is not Trevor. I was James Armitage in my younger days, and you can understand now the shock that it was to me a few weeks ago when your college friend addressed me in words which seemed to imply that he had surprised my secret.” 

We then move to “The Adventure Of Shoscombe Old Place”. The order of the Sherlock stories varies between editions, but this is generally considered to be the last of the 60 tales, published in 1927 [Conan Doyle died 3 years later].

Holmes is visited by John Mason, a horse trainer. He works for Sir Robert Norberton, master of Shoscombe Old Place. He is concerned that Sir Robert’s sister, Lady Beatrice, has been murdered, and the act concealed.

“Of course with her weak heart and dropsy one couldn’t expect that she could get about with him, but he spent two hours every evening in her room. He might well do what he could, for she has been a rare good friend to him. But that’s all over, too. He never goes near her. And she takes it to heart. She is brooding and sulky and drinking, Mr Holmes – drinking like a fish.”

“Did she drink before this estrangement?”

“Well, she took her glass, but now it is often a whole bottle of an evening.”

It transpires that Lady Beatrice’s maid has become entangled with Sir Robert, who is a noted “lover of fair ladies”.

“I quite understand, Mr. Mason. Of course, the situation is clear enough. From Dr. Watson’s description of Sir Robert I can realize that no woman is safe from him. Don’t you think the quarrel between brother and sister may lie there?” “Well, the scandal has been pretty clear for a long time.”

“But she may not have seen it before. Let us suppose that she has suddenly found it out. She wants to get rid of the woman. Her brother will not permit it. The invalid, with her weak heart and inability to get about, has no means of enforcing her will. The hated maid is still tied to her. The lady refuses to speak, sulks, takes to drink.” 

Sherlock discovers that Lady Beatrice has in fact died of natural causes. But Sir Robert conceals the fact, using an actor, as she owned the house, and his fancied racehorse Shoscombe Prince. He plans to hide the death until the horse wins the Derby.

“What could I do? Absolute ruin faced me. If I could stave things off for three weeks all would be well. Her maid’s husband – this man here – is an actor. It come into our heads – it came into my head – that he could for that short period personate my sister. It was but a case of appearing daily in the carriage, for no one need enter her room save the maid. It was not difficult to arrange. My sister died of the dropsy, which had long afflicted her.”

Unlike in other stories, Holmes does decide to report Sir Robert to the police. The police, however, let him off with a mild censure for the delay in reporting his sister’s death. The horse wins the Derby, netting him £80,000, and clearing his debts. Which is quite an odd ending to the final Sherlock tale.

  

Heart Failure In Victorian Times

The shape of the heart is more square than when healthy, and the capacity of one or more cavities is increased, so that the whole organ seems enlarged. Dilatation may be caused by any circumstance that prevents the complete emptying of one of the heart’s cavities; thus it affects the left ventricle when an imperfect closure of the aortic valves allows the blood which had been just expelled to flow back again into the cavity; or it may be caused by loss of tone resulting from myocarditis or general debility, or from fatty or other degenerations of the muscular structure of the heart. [10]

Pure dilatation of the myocardium may occur in acute diseases, or as the result of sudden effort, and sometimes from blood poisoning including tobacco and alcoholism. [5] 

Heart failure most commonly occurs in older patients, typically as an aftermath of having a myocardial infarction [heart attack]. A range of other heart conditions can lead to heart failure. Probably the most important are cardiomyopathies, which are a complex group of conditions, potentially genetic, which can lead to failure of heart function. These can present in teenagers and young adults, and are usually present in sportspeople who have sudden cardiac events. Heart failure is also a potential consequence of having undetected or untreated high blood pressure [hypertension]. Assorted other heart diseases can lead to heart failure – problems with heart valves; problems with heart rhythm [typically atrial fibrillation]; infections of the heart [myocarditis]. A final important cause of heart failure is alcoholism.

The Victorians thus had a fairly good understanding of the causes of heart failure. Although I couldn’t find a recognition that myocardial infarctions are a common cause. They also had no concept of hypertension [high blood pressure], though the first sphygmomanometer was invented during the period we are looking at [by an Austrian doctor, Samuel Siegfried Karl Ritter von Basch, in 1881]. I was intrigued that they had recognised that tobacco could cause heart disease, though I think this was acute tobacco poisoning, rather than regular use of tobacco.

The pulse is small, feeble, or irregular and intermitting. The most prominent symptoms are distressing palpitation, dyspnoea, cough, expectoration, blueness of face or lips, dropsy, disordered digestion, and scanty urine. All these symptoms result from enfeebled action in the heart. Murmurs are often present from co-existing affections of the valves. [10]

In anasarca dependent upon a cardiac lesion, the dropsical swelling begins about the ankles and feet; hence oedema starting in this situation is regarded as among the surest of the symptoms of a disease of the heart. The accumulation is much influenced by position: the feet are more puffy toward evening, when the patient has been all day in the erect posture, and least so when he gets up in the morning. The dropsy begins in the feet and ankle, being much influenced by position, and gradually extends upward; but it is rarely very obvious in the face or upper extremities. The thighs and scrotum are sometimes greatly swollen, and there is a watery effusion into the pleural cavities or into the pulmonary parenchyma. [3]

These descriptions would fit very well with our modern knowledge of how heart failure presents. To clarify the terminology they used, heart enlargement was called cardiac dilatation. If it progressed to the development of fluid retention, it was then termed cardiac dropsy. Dropsy, as such, was just a term for fluid retention, which could have a range of other causes. Today we would call it oedema. Anasarca is another little used term for the same thing.

In order to reduce the vascular contents it is better that you should direct your patient to eat sparingly and to avoid much liquid food, such as soup, milk, malt liquors etc. As regards exercise, if there be no contraindicating circumstance, let the patient take it regularly and systematically, carefully avoiding all fatigue, hurry, or excitement. [6]

Digitalis is the best tonic in all cases of dilated heart, and at the same time, by its diuretic action it assists in reducing the amount of fluid in the vascular system. If there are no dangerous symptoms you may prescribe it in moderate doses for a week or two at a time, merely as a heart tonic, but when any complications arise it must be used more freely. The greater the feebleness of the heart then more useful is this invaluable medicine. [6]

In almost every case, therefore, you will find it an advantage to prescribe iron, strychnia, quinine, or some other tonic, with or without digitalis, in order to improve the nutrition of the organ. When iron is unsuitable arsenic is often of great value, but it should be given in small doses and for a length of time. [6]

Where the kidneys are not greatly implicated digitalis is by far the best diuretic. It may be combined with the acetate or acid titrate of potash, or other remedies. Where a stimulating diuretic is required copaiba will be found useful. The compound powder of jalap, with or without gamboge, is one of the most reliable, but in other cases you may employ elaterium. [6]

It is in the severe cases of this nature that you may expect benefit from venesection. Blood should be taken if the dyspnoea is very severe, the face of the patient blue, and the whole venous system greatly engorged.  You should, however, abstract no more than is requisite to afford belief; generally six or eight ounces are sufficient. At the same time as you withdraw blood you may stimulate the heart by means of alcohol, ammonia, or ether. In children or feeble persons you may apply leeches, and if bloodletting seems not to be desirable you may try to give relief by dry cupping. [6]

Where diuretics and purgatives are insufficient to relieve, you may puncture the skin of a dropsical limb to allow the fluid to escape. The punctures may be made with a common needle, the surface being previously smeared over with oil containing carbolic acid, and the limb being afterwards laid upon flannels, into which the fluid is allowed to soak. [6]

This is one of the few instances in this book where the Victorian doctors used a drug that we still use today. Digitalis [digoxin] is still occasionally used to treat heart failure, though usually only where the patient has atrial fibrillation as the cause of the heart failure. In Victorian times it would have been directly obtained from the dried leaves of the common foxglove [Digitalis purpurea]. It works via slowing the heart rate, and improving the contractility of the heart muscle, but not as a diuretic as the Victorians thought. It had been used as a treatment for heart disease as long ago as the 18th century. “An account of the foxglove, and some of its medical uses” [21] was published in 1785, by William Withering, an English physician and botanist.

Thereafter, and we will see this repeatedly through the book, the Victorians were using a range of poisonous substances for medical treatment – so in this section we have arsenic and strychnine. They had no system for pharmacological [drug] research, and most of their treatments would have been based on anecdotal reports of improvement in the patient after use of a particular drug.

They were then using a range of amazingly exotic remedies. Copaiba was a resin obtained from a South American tree, and is today mainly used as biodiesel. Jalap was derived from the roots of a Mexican climbing plant. Gamboge was also a resin, but this time from trees growing in East Africa [also used to dye Buddhist monks’ robes]. Finally, elaterium was extracted from the brilliantly named squirting or exploding cucumber, which grew in Africa and Asia.

We then finish with a range of remedies which, I would have assumed that, by Victorian times, would have been a thing of the medieval past. Indeed, bleeding and leeching were being used less and less as we progress through the Victorian era.

 

Next Week

We’ll have a look at Ischaemic Heart Disease next, which is heart attacks and angina. The chapter features a quite amazing original illustration from The Hound Of The Baskervilles, by Alex Holt.

 

Buying The Book

The Medical Casebook of Sherlock Holmes and Dr John Watson is available from all good bookstores including Amazon USA, Barnes and Noble, Amazon UK and additional formats like Kindle.