William Dock (1898-1990) was an American cardiologist.
Renowned for his skills in bedside physical examination he is considered a leading cardiologist of his generation. He was integral in establishing the link between high-fat diets and atherosclerosis, other notable work included championing ‘bed to chair‘ movement within the first 48 hours of acute myocardial infarct.
Although extensively published he is best known for an eponymously named diastolic murmur indicating severe stenosis of the left anterior descending coronary artery and ‘Sutton’s Law‘ (Dock’s Law) stating; if ‘the money‘ resides in a specific diagnostic test, then that test should be conducted immediately instead of several steps into a general algorithm.
- Born 1898 in Ann Arbor, Michigan. Son of Dr George Dock former professor of medicine at the University of Michigan and Washington University.
- Interrupted medical studies to volunteer as an ambulance driver for the French army during World War I; awarded Croix de Guerre for his service
- 1923 – Graduated from Rush Medical College in Chicago; Internship/residency at Peter Bent Brigham Hospital in Boston
- 1924 – Postgraduate work in Vienna where he studied under Karel Frederik Wenckebach
- 1925 – Additional residency at Stanford
- 1930 – Joined the department of medicine at the Stanford University School of Medicine while practicing in San Francisco
- 1936 – Professor of Pathology at Stanford
- 1941 – Professor of Pathology at Cornell
- 1942 – 1945 Served as an Army major in World War II
- 1946 – 1962 After WWII became head of the department of medicine at the Long Island College of Medicine in Brooklyn, NY now SUNY Downstate Medical Center
- 1963 -1969 Retired from teaching; became chief of medical services at Brooklyn Veterans Hospital
- 1970-1979 Chief of the cardiology laboratory at the Lutheran Medical Center
- 1980 – Retired to Paris
- Died October 17, 1990 on Guadaloupe
Dock’s murmur (1967)
Early diastolic murmur similar to that of aortic regurgitation and is heard at the left second or third intercostal space. Similar to that of aortic regurgitation with an additional presystolic accentuation.
Associated with severe stenosis of the left anterior descending coronary artery. The murmur produced is diastolic since the coronary arteries fill in diastole. It is described as early diastolic and decrescendo sounding similar to the murmur of aortic regurgitation.
…when he [the patient] is erect, one can record a continuous, high-pitched diastolic murmur, with striking early and late (presystolic) accentuation…a decrescendo early diastolic murmur and diamond-shaped high pitched presystolic murmur.
In this area (left of midline, third interspace), but only when he is erect, one can record a continuous, high-pitched diastolic murmur, with striking early and late (presystolic) accentuation. It seems likely this is due to a coronary A-V (atrioventricular) fistula, or a coronary anomaly with one vessel entering the pulmonary artery and retrograde flow from collaterals connecting with the normal artery.Dock W, Zoneraich S. 1967
Dock’s murmur occurs when there is a severe stenosis of the left anterior descending coronary artery. The murmur produced is diastolic since the coronary arteries fill in diastole. It is described as early diastolic and decrescendo sounding similar to the murmur of aortic regurgitation with a late accentuation.
Sutton’s Law (Dock’s Law) (1961)
Sutton’s law: When making a diagnosis one should first consider the obvious, and initially conduct those tests which could confirm (or rule out) the most likely diagnosis.
Go to the patient, because that’s where the diagnosis is.Dock’s Law
Dr. Dock recalled the reply when, as a professor of medicine at what is now Downstate, he was visiting the Yale Medical School in New Haven and found doctors there puzzled by a mysterious liver ailment in a young girl from Puerto Rico.
Taking note of where she had lived, Dr. Dock suspected that she was afflicted with schistosomiasis, a parasitic disease common in Puerto Rico. Instead of the usual diagnostic routine of expensive blood tests and special X-rays that might have pointed to bad liver function in the patient but still not have pinpointed the cause, he recommended that a small sample of liver tissue be taken for examination.
The biopsy disclosed no abnormalities in the liver, but a medical student who examined the tissue detected the tiny eggs of a schistosome parasite, confirming Dr. Dock’s diagnosis. Thus was written Sutton’s Law, which tells diagnosticians to use the single test most likely to bear fruit before undertaking a series of routine examinations that may do little more than produce red herrings.
Dock explains the 99 diphthong misnomer (1973)
Tactile fremitus has been used to describe precordial vibrations perceived in a tactile, rather than acoustic, manner. Students have been taught to instruct the patient to utter the number ‘99‘ to best elicit these vibrations.
However this is a literal translation error from the original German “neun und neunzig.” This term uses a diphthong not found in “ninety nine” but similar to “toy boat.” Research has shown this diphthong is essential to the characteristic of the sound useful for diagnostics.
When our medical ancestors studied in Austria or Germany, they observed that physicians asked patients to say neun und neunzig to evoke fremitus over the thorax. When they came home they taught their patients to say ninety-nine, thus translating literally, but not phonetically, what they had heard.
This was a serious error, since their teachers would have asked patients to say: nein, nein, if that was the sound they had wanted. Nein, nein was what every girl had been taught to say to overeager swains, and men said it to friends who wanted a loan. Neun und neunzig is pronounced noyn unt noynzig and the oy is what it takes to evoke palpable, low-pitched vibrations, most effectively transmitted from the larynx to the rib-cage.
“Nein, nein” and ninety-nine are high-pitched sounds, useless for evoking fremitus. We continue to translate the one phrase we should have left in German, while leaving untranslated, or mistranslated and mispronounced, bruits and rales. We should use “boy boy”, or “boogy woogy”, as equivalents of “neun und neunzig”Dock 1973
I really envy the newer generation for having at its disposal so many new techniques which supplement, complete, and confirm clinical data. In my time we had to rely on our clinical experience and on some graphic techniques. You should consider yourself a lucky generationWilliam Dock 1985 – said in his latter years while reportedly reflecting on the future of medicine.
- Dock W. Mode of production of the first heart sound. Arch lntern Med, 1933; 737-746
- Dock W. The evil sequelae of complete bed rest. JAMA. 1944; 125(16): 1083-1085
- Dock W. Presbycardia, or aging of the myocardium. NY State J Med 1945 45,983-986
- Dock W. The mechanism and management of circulatory failure. Bull N Y Acad Med. 1951 Nov;27(11):645-52
- Dock W. Hypercholesteremia; its clinical significance and management. Med Clin North Am. 1952 May;36(3):865-74
- Dock W, Zoneraich S. A diastolic murmur arising in a stenosed coronary artery. Am J Med. 1967 Apr;42(4):617-9
- Dock W. Atherosclerosis: the facts and the mysteries. Bull N Y Acad Med. 1967 Sep;43(9):792-7.
- Dock W. Examination of the chest: advantages of conducting and reporting it in English. Bull NY Acad Med 1973;49: 575-582
- Dock W. Proteinuria: the story of 280 years of trials, errors, and rectifications. Bull N Y Acad Med. 1974 Jun;50(6):659-66
- Zoneraich S. William Dock as I knew him. American Journal of Cardiology. 1986 Feb 15;57(6):467-70.
- Weisse AB. William Dock, M.D. Hosp Pract (Off Ed). 1987 Aug 15;22(8):43-5, 49, 52-6.
- Fowler G. Dr. William Dock, 91, innovator who questioned medical beliefs. New York Times. October 23, 1990.
- Zoneraich S. The legacy of William dock, a giant of American cardiology. Clin. Cardiol. 1994; 17,95-97
- Altman LK. A Law Named for Willie Sutton Assists Physician. The New York Times. Jan 3 1970
- Sangster JF, Oakley CM. Diastolic murmur of coronary artery stenosis. Br Heart J. 1973 Aug; 35(8): 840–844.
- Rytand DA. Sutton’s or Dock’s law? N Engl J Med. 1980; 302(17): 972.
- Cheng O. William Dock, Willie Sutton and Sutton’s Law. Int J Cardiol. 2010 Jun 11;141(3):209-13
- Mark N. Tactile Fremitus: Lost in Translation. ICU OnePager 2020
- Robbins A, Zhang G, Cadogan M. Name that murmur. LITFL 2022
BA MA (Oxon) MBChB (Edin) FACEM FFSEM. Associate Professor Curtin Medical School, Curtin University. Emergency physician, Sir Charles Gairdner Hospital. Passion for rugby; medical history; medical education; and asynchronous learning #FOAMed evangelist. Co-founder and CTO of Life in the Fast lane | Eponyms | Books | Twitter |