Part 2

Holmes apparently was slightly annoyed at this frank but somewhat insensate disquisition, and remarked, “You are an enthusiast in your line of thought, I perceive, sir, as I am in mine.”

On another occasion when Dr. Mortimer was speaking of Sir Henry Baskerville, he stated: “A glance at our friend here reveals the rounded head of the Celt, which carries inside it the Celtic enthusiasm and power of attachment. Poor Charles’ head was of a very rare type, half-Gaelic, half-Ivernian in its characteristics.”

Dr. Mortimer obviously was a keen observer, a person of scholarly tastes and “a most learned man in his own line.” When he was telling Sherlock Holmes and Dr. Watson of his friendship with Sir Charles Baskerville, he remarked, “... and many a charming evening we have spent together discussing the comparative anatomy of the Bushman and the Hottentot.”

Interest in anthropology is evinced further by mention of prehistoric man. One day, while Dr. Watson was walking on the moor, he met the naturalist Stapleton, the villain in _The Hound of the Baskervilles_. Watson’s attention was attracted to the circular rings of stone on a hillside. He asked his companion whether they were the ruins of ancient sheep pens. Stapleton replied, “Prehistoric man lived thickly on the moor....” When Watson questioned him as to when the moor was inhabited; the answer was, “Neolithic man--no date.”

Another allusion to ancient man may be cited. In the house of Garrideb, as mentioned, Holmes and Watson noticed above a cupboard a series of plaster skulls; the names “Neanderthal,” “Heidelberg,” and “Cromagnon” were printed underneath them (_The Adventure of the Three Garridebs_). Not only the anthropologist but the trained biologist as well is, of course, quite familiar with the names of our early ancestors.

Once Holmes’ knowledge of anthropology helped him solve an important case. A maiden lady had received in the mail a small cardboard box containing two human ears--one that of a woman. Holmes was called in, and during the course of his investigations visited the receiver of the gruesome package. He noted the resemblance of one of the severed ears to those of the lady upon whom he was calling. Because of the striking likeness, he felt certain that the person whose ear had been dismembered was a close relative of the lady he had come to interview.

Somewhat later, he gave a lecture--a thing he was prone to do--to Dr. Watson on the surface anatomy of the ear:

... there is no part of the body which varies so much as the human ear. Each ear is as a rule quite distinctive and differs from all others.... I ... examined the ears in the box with the eyes of an expert and had carefully noted their anatomical peculiarities.... I perceived that her [Miss Cushing’s] ear corresponded exactly with the female ear I had just inspected. The matter was entirely beyond coincidence. There was the same shortening of the pinna, the same broad curve of the upper lobe, the same convolution of the inner cartilage. In all essentials it was the same ear.

Of course, I at once saw the enormous importance of the observation. It was evident that the victim was a blood relative, and probably a very close one.

_The Adventure of the Cardboard Box_

This was an exceedingly astute observation on Holmes’ part. He was right when he remarked that as a rule each ear is quite distinctive, and cleverly pointed out the important anatomical features. In any event, the study he made of Miss Cushing’s ear aided him greatly in solving the mystery of the cardboard box, and we know that the murderer was promptly apprehended.

In the story just related, a newspaper of the day was supposed to have suggested that the preserved ears had been sent by medical students as a joke. It appears that the maiden lady at one time had had unpleasant dealings with medical students: “... she let her apartments in her house to three young medical students, whom she was obliged to get rid of on account of their noisy and irregular habits.... [The ears were sent] by those students who owed her a grudge and who hoped to frighten her by sending her those relics of the dissecting rooms.”

Although this theory was later proved to be false, it was not too farfetched. Indeed, many, many stories can be told about the behavior of medical students in the anatomy laboratory. A favorite minor prank, for example, is to cut off a finger or an ear and slip it into the pocket of an unsuspecting visitor. This bit of horseplay probably discourages future visits to the anatomical laboratory. Although anatomy instructors deplore such practices, they are likely to overlook them, because laymen are not encouraged to visit dissecting rooms.

In the opening of one of the stories, we find Holmes stooping over a low-power microscope (_The Adventure of Shoscombe Old Place_). He explained to Watson that there were epithelial cells in the microscopic field. As far as I am aware, this is the only reference to individual body cells to be found in the tales. It appears, then, that Holmes was much more interested in gross structures of the body, especially osteology, than in microscopic structures.

We have seen that many pertinent allusions to anatomical science may be found in the tales. In one instance, at least, Holmes’ intimate knowledge of surface anatomy--that is, the configuration of the external ear--enabled him to solve handily a perplexing mystery. The allusions made to anatomical matters are of especial delight to those of us in the field of biology.

“BRAIN FEVER” AND SHERLOCK HOLMES

“I have only just recovered from nine weeks of brain fever and am still exceedingly weak.”

_The Naval Treaty_

Several years ago, there appeared in the _Journal of the American Medical Association_ a provocative article with the arresting title, “Brain Fever,” written by Louis Cassamajor.[1] The author is to be commended for his courage in choosing this unusual title, and the _Journal_ to be congratulated for publishing it. Although I welcome the term “brain fever,” I did rub my eyes, because I had not seen it employed for a long time. In my youth the term was used commonly, but was dismissed from my mind when I commenced the study of medicine. It was relegated to the same limbo as the old expression “typhoid malaria.”

In order that I may develop my thesis, a brief review of Cassamajor’s article is in order. The author points out that, in the early part of the past century, considerable literature appeared describing a disease known as “brain fever” (called also “hydrocephalic fever” and sometimes “encephalitis”). For the main part, it occurred in children. The illness subsided after a few days to a couple of weeks, and the patient usually recovered.

The author brings out further that, although the disease was apparently accompanied by fever, there are no recorded temperatures, for the modern clinical thermometer was not invented until 1868. It is emphasized, also, that no neurological signs appeared in the case reports. It was only after the writings of Erb and of Westphal in 1875 that neurological examination, as we now know it, began to develop. For some unknown reason, about 1850 mention of the disease disappeared from medical literature. The author, however, makes the statement: “Undoubtedly the condition does exist today.”

Following a brief historical introduction, the author gives in some detail the case histories of four children, the youngest six and one-half and the oldest eleven years of age, whom he had rather recently diagnosed as suffering from “brain fever.” It is highly gratifying that they all made a complete recovery. The disease is characterized by signs and symptoms indicating a considerable brain involvement, “including convulsions, comas, paralyses, cerebellar asynergy and a sort of bulbar palsy.” The onset is irregular, except when head trauma has been previously sustained, when it may be sudden.

One reason, among others, why this stimulating article especially interested me was that the term “brain fever” called to my mind the immortal stories of Sherlock Holmes. In them several individuals are described as suffering from this condition. It is of nostalgic interest to examine the circumstances which surrounded these victims when they were stricken.

We find in one of the stories that a housemaid, with an unstable Celtic temperament, “had a sharp touch of brain fever.” She had had a violent love affair with a handsome but perfidious butler, who had thrown her over for another girl. Following her partial recovery, she had taken a terrible vengeance and was directly responsible for her faithless lover’s death. When questioned about him by the master of the household, she became hysterical and unmanageable: “For two days [she] had been so ill, sometimes delirious, sometimes hysterical...” (_The Musgrave Ritual_). She evidently made a rapid recovery, for on the third night she disappeared and her whereabouts were never discovered.

In another story, a young girl whose mother had died was treated cruelly by her father, who had remarried. She had an income of her own which she generously allowed her father to use. When she fell in love with a young man, her father tried desperately to make her sign a contract providing that, in the event of marriage, he could still use her money. This she refused to do. He placed her in solitary confinement so that she could not see her lover, and treated her inhumanly in other ways: “... he kept on worrying her until she got brain fever, and for several weeks was at death’s door” (_The Adventure of the Copper Beeches_). It is pleasant to relate that she recovered and succeeded in eloping with her lover and presumably lived happily ever after.

In still another story, in which Sherlock Holmes attempted to gain an audience with a middle-aged spinster, he was informed that she was too ill to be interviewed. Her doctor said: “She has been suffering since yesterday from brain symptoms of great severity. As her medical adviser, I cannot possibly take the responsibility of allowing anyone to see her. I should recommend you to call again in ten days” (_The Adventure of the Cardboard Box_). This illness, somewhat later in the story, is referred to specifically as “brain fever.”

The illness had developed when this spinster heard that conscientious diplomat. Through his own carelessness, how-her younger sister had been foully murdered by her husband. It was the spinster who, by wicked machinations, had been largely responsible for her sister’s death. It is noteworthy that Holmes was advised to come back ten days later. This indicates that the disease was not of long duration.

One of Dr. Watson’s former schoolfellows, Percy Phelps, wrote him, “I have only just recovered from nine weeks of brain fever and am still exceedingly weak.” In his letter, he further informed Dr. Watson that he wished to consult with Sherlock Holmes, and asked his friend to bring him, since he was in deep trouble. This able young man was an earnest and ever, he had lost an important state document. In narrating his story to Sherlock Holmes and Dr. Watson, the patient gave a vivid description of his distressing illness: “Here I have lain, Mr. Holmes, for over nine weeks, unconscious, and raving with brain fever ... in my mad fits I was capable of anything. Slowly my reason has cleared, but it is only during the last three days that my memory has quite returned” (_The Naval Treaty_).

This poor fellow had an illness of long duration and, according to the story, his strength came back but slowly. It will be recalled that Sherlock Holmes solved the mystery and was able to place the important state document again in the patient’s hands. As far as we know, he eventually made a complete recovery in spite of the severity of the attack.

In _The Hound of the Baskervilles_, it will be remembered that the heir, Sir Henry Baskerville, narrowly escaped death on the moor. The shock of the adventure with the hound, coupled with the fact that the woman with whom the heir was in love was actually the wife of the villainous Stapleton, his would-be murderer, was too much for our hero. Watson writes: “But the shock of the night’s adventure had shattered his nerves, and before morning he lay delirious in a high fever under the care of Dr. Mortimer. The two of them were destined to travel together round the world before Sir Henry had become once more the hale, hearty man that he had been before he became master of that ill-omened estate.”

In this last instance, Watson does not specifically state that the patient was afflicted with “brain fever,” but the implication is plainly there. It is, moreover, worthy of note that it took the victim a long time to regain his health.

The individuals whom Dr. Watson described as suffering from “brain fever” obviously had all passed through a terrific mental storm--in modern parlance, they had sustained “severe psychic traumata.” Whether this alone could cause “brain fever” is a moot question. The condition presumably is caused by a virus. That a severe brain storm could cause the lurking virus to become active seems unlikely.

Previously it has been mentioned that a head injury apparently is capable of hastening the onset of brain fever in children. (We will waive the fact that the cases Dr. Watson described are adults.) A physical injury presumably produces certain organic changes in the brain or in its meninges, which perhaps could precipitate an attack of encephalitis, assuming that the virus was present. There is no particular evidence that the patients mentioned in the tales had suffered a head injury.

It is true, of course, that great emotional upsets are often accompanied by marked vascular disturbances. These may manifest themselves in the brain as well as in other parts of the body. It is not conceivable that encephalitis would follow an emotional storm. Be that as it may, this can be said: It is generally agreed that anything which lowers the resistance of an individual may make him more susceptible to disease. In the cases described by Dr. Watson, the virus may have been present, and the shock produced by the emotional storm, which all these people experienced, might have precipitated an attack of encephalitis (brain fever).

If this seems too farfetched, and the reader cannot go along with me, I can say only that I am sorry. I will have to use the argument that one should allow a talented and imaginative writer like Dr. Watson a liberal degree of poetic license.

Dr. Watson may have used the term “brain fever” loosely, and perhaps as synonymous with extreme nervous exhaustion. He does, however, mention that some of the sufferers became delirious. This symptom is suggestive of encephalitis. Also, in one or two instances the victim recovered rather quickly, which points to an acute condition such as encephalitis rather than nervous exhaustion. I am cognizant that some may regard this as a specious argument.

The question could be raised whether the patients described by Dr. Watson suffered from hysteria. This condition cannot entirely be ruled out. Hysteria has protean manifestations, and may even be accompanied by fever. The great mental storms through which these patients passed are conducive to hysterical attacks. The fact, however, that these individuals ran a high fever and were dangerously ill would militate against a diagnosis of hysteria. It seems fairly safe to assume that the disease from which they suffered probably had an organic basis.

The reader should be reminded that Dr. Watson began the study of medicine only a short time after the researches of Erb and of Westphal on the nervous system had been published. Neurology had not yet come into its own, and it is likely that the medical profession did not make fine distinctions when dealing with diseases of the brain or its meninges. It probably is not charitable for me to suggest that the professors who taught the young Watson about nervous diseases in the year 1876 or thereabouts had not kept up with the literature in their field--a fault of which we are all more or less guilty.

Dr. Watson has been taken to task by some critics in the medical profession for using the term “brain fever,” and the implication has been made that his employment of a meaningless term was unworthy of a medically trained man. Now it appears that this criticism is unjustified. We might quarrel with Dr. Watson as to what brought on the attacks of “brain fever,” or whether the victims actually had the disease in the cases he so vividly described, but the term itself is acceptable.

The Holmesian enthusiast will rejoice that the term “brain fever” is again in good repute and is accepted by the medical fraternity. The very fact that the staid _Journal of the American Medical Association_ has published an article bearing the title “Brain Fever” has stripped criticism of all weapons. The loyal Holmesian no longer needs to feel apologetic for the nomenclature Dr. Watson used to describe a rather unusual and fortunately rare clinical entity.

CURARE AND SHERLOCK HOLMES

“... for the action of the alkaloid is rapid.”

_A Study in Scarlet_

Curare is used as a lethal agent in two of the Sherlock Holmes stories. In the novel _A Study in Scarlet_, liberties are taken with the pharmacologic properties of curare, for actions are ascribed to this agent which it could not possibly have had. But in _The Adventure of the Sussex Vampire_, curare is employed scientifically and with telling effect; and indeed, an interesting plot is built around this agent.

Let us first examine the role curare played in _A Study in Scarlet_. Holmes, it will be remembered, wished to determine the toxicity of certain pills and instructed Dr. Watson to fetch a little dog, which already was _in extremis_: “... that poor little devil of a terrier which has been bad so long, and which the landlady wanted you to put out of its pain yesterday.” Watson commented on the state of the animal: “Its laboured breathing and glazing eye showed that it was not far from its end. Indeed, its snow-white muzzle proclaimed that it had already exceeded the usual term of its existence.” Then, according to Dr. Watson, some of the pills which were thought to contain curare were dissolved in milk and offered to the sick dog: “The unfortunate creature’s tongue seemed hardly to have been moistened in it before it gave a convulsive shiver in every limb and lay as rigid and lifeless as if it had been struck by lightning.”

Before we comment on the sudden death of the terrier, let us see what befell Enoch Drebber, who was forced by Jefferson Hope to swallow a pill containing curare. The wretched Drebber met the same fate as the aged terrier, for we find Watson writing: “... the action of the alkaloid is rapid. A spasm of pain contorted his features; he threw his hands out in front of him, staggered, and then with a hoarse cry, fell heavily upon the floor. I turned him over with my foot, and placed my hand upon his heart. There was no movement. He was dead.”

The deaths of Drebber and the terrier were dramatically portrayed, and Dr. Watson is to be congratulated on the vivid picture he presented. The trained scientist however, could not entirely accept the events as he outlined them. The difficulty lies in the fact that curare is relatively harmless if taken by mouth. If extremely large doses are administered on an empty stomach, sufficient curare may be absorbed to cause grave symptoms, but death would not be instantaneous, for absorption is slow from mucous surfaces. If, on the other hand, there were an open lesion in the stomach or the upper part of the small intestine, such as an ulcer, then rapid absorption could take place, and death would ensue in a relatively short time, although not as rapidly as portrayed in the story. The action of curare is rapidly lethal only if injected directly into the blood stream. It would stretch our credulity too far to assume that both the dog and the man had either a gastric or a duodenal ulcer.

Let us now consider how curare was employed in the story _The Adventure of the Sussex Vampire_. It will be recalled that Sherlock Holmes was asked by Mr. Robert Ferguson to investigate certain irregularities in his household. Ferguson, a fine gentleman, was very much in love with his beautiful Peruvian wife; but one day, to his infinite horror, he had actually seen her sucking blood from a wound on the neck of their year-old baby. She refused to make any explanation, and the husband and wife became estranged. There was another child in the family, an invalid boy of fifteen, Ferguson’s son by a previous marriage.

Dr. Watson accompanied Sherlock Holmes to Ferguson’s country home on a dreary autumn day. One of the rooms of the old house contained a fine collection of South American utensils and weapons which presumably had been brought from Peru by the mistress of the house. As Holmes was examining this interesting collection, the movements of a dog attracted his attention. Holmes noted that the dog experienced difficulty in walking. The astute detective asked Ferguson what ailed the dog. His host replied that the thing had also puzzled the veterinarian. The latter had thought it might be spinal meningitis. Holmes asked a few more questions about the dog, and finally remarked that the picture the dog presented was very suggestive.

The frantic husband insisted that Holmes tell all he knew or suspected. Holmes then gently explained to the indulgent father that his fifteen-year-old invalid boy was so insanely jealous of his healthy baby half-brother that he had tried to do away with him by wounding him with an arrow treated with curare. The boy had first tried out the poison on the dog. Ferguson’s wife, in an heroic effort to save her baby, had sucked the site of the arrow wound. The mystery was solved, and Holmes and Watson had the keen satisfaction of clearing up the grave misunderstanding between Ferguson and his lovely Peruvian wife.

In this story, curare was handled in an expert manner. It is known, of course, that the South American Indians dipped their arrowheads into a curare solution before using them to kill birds. The curare was rapidly absorbed from the wound made by the arrow; the wing muscles became paralyzed; and the bird plummeted to earth--an airplane without wings.

_The Adventure of the Sussex Vampire_ was written many years ago. What is the status of curare today? This interesting compound has actually insinuated itself from the jungle not only into the experimental laboratory but into the surgical amphitheater as well. This is not the place to take up in detail the clinical use of curare, but a few remarks are in order.

Relaxation of the muscles is often highly desirable in surgical procedures; it is not surprising, therefore, that the anesthetists have added curare to their armamentarium. Although curare has no anesthetic action _per se_, it has been found to serve as a useful adjuvant to certain anesthetic agents. It has been used also for the convulsions of strychnine poisoning, tetanus, and hydrophobia, as well as certain spastic contractures. It could furthermore be of help in the management of dislocations, especially in heavily muscled individuals.

Curare should be employed only by experienced workers, for the muscles of respiration may become paralyzed, and unless mechanical respiration is given immediately, the patient will die of asphyxia. Fortunately, curare is quickly excreted by the body, and the patient will soon start voluntary breathing movements.