Ischaemic Heart Disease In The Medical Casebook

 

This Week

We are having a second week looking at Victorian heart disease, looking at Ischaemic Heart Disease. This is a more modern disease term, comprising myocardial infarctions [heart attacks] and angina pectoris. Strangely Victorian physicians had a clear understanding of angina, but not of myocardial infarctions.

 

The Illustrator

Our sample chapter features an incredibly detailed illustration by Alex Holt.

Alex Holt is an artist specialising in original ink illustrations. He has a special interest in Comic Art, single image illustrations and covers. Alex is a student of the Edinburgh Atelier of Fine Art. He works in private commissions and commercial projects. More of his work can be found in Instagram @alexholtart.

 

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.

 

Ischaemic Heart Disease

Ischaemic Heart Disease + Sherlock

As we discussed in our chapter on heart failure, there are many references in the canon to heart problems. This chapter looks at ischaemic heart disease. We’ll look at the exact definition of this condition later, but in this chapter I have included what I feel are references to either angina or myocardial infarctions [heart attacks].

Firstly we are heading back to “A Study In Scarlet”. In the style of many works of detective fiction that followed Conan Doyle, Holmes is explaining to Watson his processes of deduction that allowed him to solve the case.

“On entering the house this last inference was confirmed. My well-booted man lay before me. The tall one, then, had done the murder, if murder there was. There was no wound upon the dead man’s person, but the agitated expression upon his face assured me that he had foreseen his fate before it came upon him. Men who die from heart disease, or any sudden natural cause, never by any chance exhibit agitation upon their features.”

Holmes is alluding to myocardial infarctions being a very sudden event, giving the victim no warning. 

We then head to the next novel, “The Sign Of Four”, which contains a description of a likely fatal myocardial infarction [probably in someone with pre-existing heart failure]. Thaddeus Sholto relates to Holmes, Watson, and Mary Morstan, what his father, Major John Sholto, had told him regarding the death of Captain Morstan.

“I will tell you how Morstan died”, he continued. “He had suffered for years from a weak heart, but he concealed it from every one. I alone knew it. When in India, he and I, through a remarkable chain of circumstances, came into possession of a considerable treasure. I brought it over to England, and on the night of Morstan’s arrival he came straight over here to claim his share. He walked over from the station and was admitted by my faithful old Lal Chowder, who is now dead. Morstan and I had a difference of opinion as to the division of the treasure, and we came to heated words. 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.” 

Our third and final references are in “The Hound Of The Baskervilles”, the most famous of the Sherlock Holmes stories. Published in 1901, 10 years after Conan Doyle stopped practising medicine, it sadly contains fewer medical references than the earlier novels. However, ischaemic heart disease plays a crucial part in the plot, causing the death of Sir Charles Baskerville.

A probable reference to angina is first encountered in an article in the Devon County Chronicle, detailing his death.

“Their evidence, corroborated by several friends, tend to show that Sir Charles’s health has for some time been impaired, and points especially to some affection of the heart, manifesting itself in changes of colour, breathlessness, and acute attacks of nervous depression. Dr James Mortimer, the friend and medical attendant of the deceased, has given evidence to the same effect.”

Later in the same article, the circumstances of his death are described.

“No signs of violence were to be discovered upon Sir Charles’s person, and though the doctor’s evidence pointed to an almost incredible facial distortion – so great that Dr Mortimer refused at first to believe that it was indeed his friend and patient who lay before him – it was explained that that is a symptom which is not unusual in cases of dyspnoea and death from cardiac exhaustion. This explanation was borne out by the post-mortem examination, which showed long-standing organic disease, and the coroner’s jury returned a verdict in accordance with the medical evidence.”

Holmes gives us a further description of the sudden cardiac death, whilst analysing the footprints found at the scene of Baskerville’s death.

“What do you make of it?”

“It is very bewildering.”

“It has certainly a character of its own. There are points of distinction about it. That change in the footprints, for example. What do you make of that?”

“Mortimer said that the man had walked on tiptoe down that portion of the alley.”

“He only repeated what some fool had said at the inquest. Why should a man walk on tiptoe down the alley?”

“What then?”

“He was running, Watson—running desperately, running for his life, running until he burst his heart and fell dead upon his face.”

“Running from what?”

“There lies our problem. There are indications that the man was crazed with fear before ever he began to run.”

One of Baskerville’s neighbours, Jack Stapleton, has a theory as to the trigger for the heart attack.

“His nerves were so worked up that the appearance of any dog might have had a fatal effect upon his diseased heart. I fancy that he really did see something of the kind upon that last night in the yew alley. I feared that some disaster might occur, for I was very fond of the old man, and I knew that his heart was weak.” 

And we finish with Sherlock’s eventual explanation as to the true circumstances surrounding the death of Sir Charles Baskerville.

“Driving back in the evening from Coombe Tracey he was in time to get his hound, to treat it with his infernal paint, and to bring the beast round to the gate at which he had reason to expect that he would find the old gentleman waiting. The dog, incited by its master, sprang over the wicket-gate and pursued the unfortunate baronet, who fled screaming down the yew alley. In that gloomy tunnel it must indeed have been a dreadful sight to see that huge black creature, with its flaming jaws and blazing eyes, bounding after its victim. He fell dead at the end of the alley from heart disease and terror.”

 

 

The death of Charles Baskerville.

“Charles Baskerville has a myocardial infection, triggered by the sight of the fearsome hound.” © Alex Holt

 

Ischaemic Heart Disease In Victorian Times

I would define ischaemic heart disease as narrowing of the heart arteries by atheroma, causing symptoms. Broadly this manifests in two ways.

Firstly there are myocardial infarctions, commonly called heart attacks. This is where the artery blockage becomes severe enough that a section of heart muscle is permanently damaged. The classic presentation is left sided tight chest pain, radiating to the left arm, accompanied by breathlessness and sweating.

Secondly there is angina, which is a when the blocked artery causes reversible damage. Patients get the same sort of pain as in a myocardial infarction, typically when exerting themselves, but resting produces complete relief of the pain.

I was interested to find that the Victorian medical textbooks make no reference to myocardial infarctions. All the references below are concerning angina, though they recognised this could be fatal.

The most typical forms of angina pectoris may exist without any lesion recognizable during life, and the dissections often show merely certain changes in the structure of the walls, especially fatty degeneration of the fibres and atheroma of the coronary arteries. [15]

Victorian pathologists were starting to understand that the key cause of angina was coronary artery atheroma. Though they had no understanding of what caused atheroma.

The typical cases occur in people over 40 years of age and with gouty constitutions, but similar pains not ending fatally may be felt by young men and bloodless women [pseudo-angina]. [5]

There was almost nothing in the texts concerning the aetiology of angina. As far as I can work out a bloodless woman in Victorian times was seen as a woman lacking in human feeling.

Angina pectoris is a name reserved for pain obviously of cardiac origin and of a very special and alarming character; all forms of cardiac anguish, although not presenting the features of this complaint in its most typical form, have a certain resemblance to this peculiar suffering. “The subjects of angina pectoris report that it is a suffering as sharp as anything that can be conceived in the nature of pain, and that it includes, moreover, something which is beyond the nature of pain, a sense of dying.” [Latham] [15]

These paroxysms come on suddenly, and pass off as suddenly. Their main feature is an agonizing pain in the praecordia, as if the heart were being firmly grasped by an invisible hand, or as if it were being torn to pieces. The pain is, however, not limited to the cardiac region; it radiates in various directions, shooting to the back, the neck, and especially down the left arm. But this is not all: worse than the pain are the intense anxiety and the feeling of impending death. [3]

The duration of the fits is as uncertain as are the causes which excite them. They may cease in a few minutes; they may last upward of an hour. They come on rapidly, without any assignable reason; they are reproduced by bodily ailment, or by exertion, by fatigue, by exposure to cold, or by mental irritation. However provoked, they are always dangerous. The heart may stop beating during the paroxysm. “My life is in the hands of any rascal who chooses to annoy and tease me,” was a saying of John Hunter. And in truth, after he had suffered for years from these seizures, his ungovernable temper brought on one in which is expired. [3]

So they had a clear understanding of the symptoms of angina, as usual embellished with some splendid Victorian descriptions and terminology.

John Hunter was a pioneering 18th century surgeon, who was presumably famous enough to be mentioned in a textbook written over 80 years after his death.  He was perhaps remembered as he was notoriously bad-tempered, and indeed dropped dead during an argument about the admission of students to St George’s Hospital.

The patient instinctively remains at rest in the sitting position, and seems to dread the slightest muscular exertion. He should not be disturbed until the pain has completely passed away, as any movement is apt to give rise to a recurrence of the attack. [6]

If you can discover any exciting cause, such as a recent meal of indigestible food, you had better act briskly on the bowels with a dose of calomel and colocynth or an enema. Where flatulence or acidity are prominent symptoms you may prescribe magnesia, soda, or potash, along with chloroform or peppermint water. [6]

Relief of the agonizing pain that accompanies the attacks is the most important indication, and opium is superior to any other drug for this purpose. In severe cases, or where the attacks recur frequently, the inhalation of chloroform and ether may be employed, but bear in mind that the former of these is very apt to depress the action of the heart. Of late years the nitrite of amyl has been had recourse to, and generally with benefit. Hermetically closed gelatine envelopes are manufactured, containing a proper dose of this valuable remedy. As soon as the symptoms of an attack are felt a perle may be broken and the drug inhaled at once. [6]

Nitrite of amyl and nitroglycerine are the best remedies, they are antispasmodic and though they dilate the arterioles, it does not prove that spasm of the arterioles is the pathology of all cases, for they may relieve spasm of the heart. Rest and careful regulation of the diet should be enjoined. [5]

Sinapisms, fomentations, turpentine stupes and hypodermic injections of morphia may be used locally; brandy, ammonia, belladonna and opium are other internal remedies. [5]

A long course of arsenic in small doses is often of great value in warding off the attacks of angina pectoris. [6]

There are 2 drugs mentioned here that are still used for managing ischaemic heart disease today.

Morphine is still given when we suspect someone is having a myocardial infarction, as it remains the most effective drug for severe, acute pain, and it also reduces the strain on the heart.

And nitroglycerine remains the key ingredient in the sprays that patients with angina are given to treat or prevent attacks [usually called GTN sprays]. It is a fascinating compound, as it is also a highly volatile explosive. Alfred Nobel, of prize fame, made his name, and money, from the manufacture of such explosives. The drug’s use as a vasodilator started during our research period – it's efficacy being first outlined in a Lancet article in 1879 [34] [the Fenwick textbook mentioning it’s use was from 1881, so was impressively up-to-date]. Rather splendidly it is known that Alfred Nobel used the drug to treat his angina.

The textbooks contain nothing regarding the prevention of angina, bar the one short reference to using arsenic.

 

Next Week 

Let’s venture into some of the shorter [but still interesting] chapters, and take a look at leprosy – a disease everyone will have heard of, but possibly know little about.

 

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.