Part 3

In conclusion, let us turn to the tales. _The Adventure of the Sussex Vampire_ could have been written only by an individual quite familiar with the action of curare, and with a good understanding of clinical medicine. This story is of especial interest to physicians. Not only is curare used in the plot in an interesting and unusual manner, but certain psychosomatic problems are presented: The estrangement of the husband and wife; and a clear portrayal of how the mind of a physically handicapped youngster may become warped, even though reared in an excellent environment.

SHERLOCK HOLMES AND THE PORTUGUESE MAN-OF-WAR

“I did what I could to relieve his pain.”

_The Adventure of the Copper Beeches_

_The Adventure of the Lion’s Mane_ has always appealed to me, although I am mindful that this story is not universally popular with Holmesian enthusiasts. The story was written by Sherlock Holmes himself. The title alone arrests one’s attention. Immediately, one thinks of a magnificently maned lion at bay, or, as one artist pictures him, standing in the moonlight on the shore of the ocean, roaring defiantly at the incoming waves.

As the adventure unfolds, however, we learn that while the story does deal with the ocean, a lion is not mentioned, but rather a huge jellyfish, _Cyanea capillata_. It is also called the “Lion’s Mane,” for as Holmes wrote, the jellyfish resembled a mass of tangled hair which looked as if it might have been procured from a lion’s mane.

Let us recall that in this story the death of a person, as well as that of a dog, was produced by the poisonous sting of the Lion’s Mane. The victim of this catastrophe was Fitzroy McPherson, a young scientist who had suffered from rheumatic fever, and whose heart had been damaged. In spite of his cardiac ailment, he was portrayed as a fine athlete and an expert swimmer. It was his custom to take a daily dip in the ocean in and out of season.

At the time of which we write, Sherlock Holmes was living in retirement on the Sussex Downs, not far from the place where McPherson often swam. One fine morning in July, following a severe storm, Holmes and his neighbor Stackhurst, who kept a preparatory school, were taking a bracing walk. To their intense surprise and dismay, they discovered the figure of McPherson, a science master of Stackhurst’s establishment, coming up the path staggering as if drunk. As they came nearer, he uttered a terrible cry and fell upon his face. They rushed to his side and turned him on his back. He was _in extremis_. Just before he expired, he indistinctly uttered words that sounded like “lion’s mane.” The cause of his death was a mystery even to Holmes.

A few days later, Ian Murdoch, a colleague and close friend of the late McPherson, went swimming in the exact spot where the latter had met his untimely death. Holmes dramatically describes how Ian Murdoch lurched in the room, extremely pale, and with his clothes all rumpled. It was an effort for him to stand; finally, he staggered to the sofa and collapsed from the excruciating pain. He experienced great difficulty in getting his breath, his face appeared livid, and beads of cold sweat stood on his brow. It appeared that he was also _in extremis_.

It is not necessary to relate here the steps which Holmes took in solving this baffling mystery. Suffice it to say that he came to the conclusion that both McPherson and Murdoch had come into contact with a huge jellyfish. He became absolutely convinced of this when he discovered in the attic of his home a book by J. G. Wood entitled, _Out of Doors_. Holmes found in this book a description of a patient who had been in contact with a jellyfish. The victim complained that while the local pain was severe, it was nothing compared to the pangs which surged through his chest. It was impossible for him to stand up. The cardiac beat became quite irregular; the heart would virtually stop, and then several violent pulsations would occur.

Admittedly, Holmes’ story is a thrilling one. The criticism to be made, however, is that although _Cyanea capillata_ can produce a nasty sting, it probably could not produce death, especially in a healthy person. There is no question but that it would be an unpleasant experience for a swimmer to come into contact with _Cyanea_. In a standard textbook of biology, _Cyanea arctica_, another species of the same genus, is described as a creature which may measure six feet in diameter and bear tentacles reaching the astonishing length of one hundred and thirty feet! It can readily be seen that a swimmer could easily be stung by such a jellyfish before recognizing the danger.

Since it is generally believed that _Cyanea capillata_ cannot cause the death of an individual, and since the symptoms described in _The Adventure of the Lion’s Mane_ were so grave, the coelenterate which Holmes had in mind probably was no other than _Physalia_, commonly known as the Portuguese man-of-war. Exposure to the tentacles of this creature is apt to produce a chain of alarming symptoms.

Owing to my warm interest in Holmes’ story I read with profit and keen enjoyment a case history reported by Klein and Bradshaw.[2] A twenty-year-old man, while swimming about twenty feet off North Miami Beach, Florida, came into contact with a Portuguese man-of-war. His attention was drawn to a purple object floating near him, which he thought to be a balloon. He swam up and touched it. Immediately, he became aware of a sharp stinging sensation on his arm and shoulder. Noting several strands which he could not brush off, he left the water at once, and a companion removed them with a towel. Underneath each strand could be seen a “painful fiery red welt.” Soon he found it difficult to breathe, and shortly suffered from severe abdominal cramps. A little later, he showed signs of shock and mental confusion.

A swimmer exposed to the tentacles of these large jellyfish may, according to Klein and Bradshaw, suffer pain, swelling, and redness in the affected part. In a few minutes to an hour following exposure, systemic effects may appear, such as anxiety, muscular pains and cramps, dyspnea, constriction of the throat, cardiac symptoms, and prostration. The authors stress that the alarming symptoms which often follow stings from coelenterates suggest the action of a powerful neurotoxin.

Waite,[3] writing in the same year, stresses the fact that contact with a Portuguese man-of-war produces symptoms indicative of anaphylactic shock, such as pallor, sweating, faintness, fall in blood pressure, and the like. He mentions that although there have been no authenticated medical reports of death as a result of the sting of a Portuguese man-of-war, it could happen if complicated by anaphylactic shock.

One wonders, of course, what would have happened if the patient described by Klein and Bradshaw had been some distance from shore. If anaphylactic shock had occurred within a few minutes, the patient no doubt would have drowned if no one had been in the vicinity to help him. A swimmer who experiences difficulty in breathing, who is afflicted with severe abdominal cramps, who shows signs of shock, and who is mentally confused, will certainly drown. Indeed, any one of these four symptoms could provoke disaster in deep water.

The treatment instituted by Klein and Bradshaw is worthy of our attention. The patient was hospitalized and given calcium gluconate and benadryl intravenously. Epinephrine and atropine were administered intramuscularly, and ammonia applied locally. I might add that a purist could raise the question whether all this medication was necessary. The next day, the itching areas were treated with tetracaine. The patient made an uneventful recovery, although it took about three weeks before the lesions were healed. Waite emphasizes that, in case of anaphylactic shock, epinephrine or benadryl should be given immediately. He warns further that if angioneurotic edema appears, the air passageways should be cleared, oxygen supplied, and, if necessary, a tracheotomy performed. The latter constitutes heroic treatment, but may, of course, save a person’s life.

Let us return to _The Adventure of the Lion’s Mane_, in an attempt to ascertain what medical agents were used fifty years ago to treat the sting of coelenterates. As previously mentioned, Sherlock Holmes was in retirement and living alone, so unfortunately he could not call upon his friend Dr. Watson to prescribe for Ian Murdoch.

Holmes, however, rose to the occasion and made an earnest attempt to help the patient, for he writes that he soaked cotton in salad oil and applied it to the wounds. He felt that this greatly alleviated the pain. The famous detective showed real ingenuity in making use of such a homely remedy. He also gave the suffering man liberal quantities of brandy, which doubtless had a narcotizing effect. There is considerable evidence that brandy was widely used for medicinal purposes at the turn of the century, when this adventure is supposed to have occurred.

It is of interest to speculate upon what medication Dr. Watson would have administered to Ian Murdoch had he been in attendance. At that time, neither benadryl nor calcium gluconate nor, for that matter, tetracaine was available. On the other hand, epinephrine, atropine, and ammonia were even then widely used. Dr. Watson presumably would have given a hypodermic injection of morphine and offered the patient brandy, as did Sherlock Holmes. He, too, doubtless would have applied some soothing ointment to the painful lesions, or, like Klein and Bradshaw, might have used ammonia. It is even possible that he would have employed epinephrine. The latter certainly was indicated, for the symptoms described by Holmes were those of anaphylactic shock. This syndrome (anaphylactic shock) was not well understood fifty years ago. In point of fact, the word “anaphylaxis” was coined in 1907 by Richet. This, as mentioned earlier, was the year when the adventure was supposed to have taken place. Holmes, however, wrote _The Adventure of the Lion’s Mane_ probably in 1925, since it was first published in 1926. At that time, the significance of anaphylactic shock in man was pretty well understood, and it is possible that he was familiar with this condition.

It is a pity that we have to resort to speculation, and that Dr. Watson was not in attendance instead of Holmes, a nonmedical man. If such had been the case, Watson probably would have mentioned the agents medical men used at that time. This would not only have satisfied our sympathetic curiosity but, what is more important, these facts would have been of historical interest. We then could actually have compared the medical agents which were prescribed fifty years ago with those currently employed for the grave symptoms of shock produced by the excruciatingly painful stings of coelenterates.

DOCTOR WATSON AND NERVOUS MALADIES

“... the shock of the night’s adventures had shattered his nerves.”

_The Hound of the Baskervilles_

The harrowing adventures experienced by some of the characters in the stories of Sherlock Holmes, and the great shocks they sustained, often induced in them a state of high nervous tension. References to such individuals are numerous.

Sherlock Holmes himself possessed an iron constitution, and was favored with an especially well-balanced mind. His biographer, John H. Watson, M.D., writes, “All emotions ... were abhorrent to his cold, precise but admirably balanced mind” (_A Scandal in Bohemia_). But even Holmes, on one occasion at least, was on the verge of a serious nervous breakdown. In the spring of 1897, Dr. Watson became concerned about the health of his distinguished friend: “... I found him a prey to the blackest depression ... [even his realization of his worldly fame] was insufficient to rouse him from his nervous prostration” (_The Reigate Puzzle_).

Watson felt that Holmes needed a complete rest in a quiet and soothing atmosphere, and finally persuaded the great detective to take a holiday in the country. Arrangements were made to stay at the home of one of Dr. Watson’s old friends. On the evening of their arrival, their host, Colonel Hayter, in the course of a conversation following dinner, told them of an unusual burglary which had occurred a few nights before in the neighborhood. When Holmes manifested too warm an interest in this event, Watson became alarmed and cautioned him: “You are here for a rest, my dear fellow. For Heaven’s sake don’t get started on a new problem when your nerves are all in shreds” (_The Reigate Puzzle_). Watson’s admonition proved of no avail. The next morning, while at breakfast, they were informed that a dastardly murder had been committed at the home of a nearby neighbor. Inspector Forrester, knowing that Sherlock Holmes was in the vicinity, asked for his help. Holmes answered the call, and after a rather painful experience, solved the mystery brilliantly in the course of a few hours.

The neat solution of this case, together with the concomitant excitement which it afforded, apparently caused Holmes to recover quickly from his “blackest depression,” for that afternoon he remarked to his faithful friend, “Watson, I think our quiet rest in the country has been a distinct success, and I shall certainly return much invigorated to Baker Street tomorrow” (_The Reigate Puzzle_). This episode demonstrates the man’s superb constitution. Most people would have required several weeks, or even months, to recover their normal health following a severe nervous breakdown. But not Holmes.

In several instances, the characters described by Dr. Watson showed clear-cut signs of hysteria. When the well-known banker Alexander Holden found that the “Beryl Coronet,” which had been intrusted to his care, had been mutilated and three of its jewels stolen, he became greatly agitated and called on Sherlock Holmes:

For a while he could not get his words out, but swayed his body and plucked at his hair like one who has been driven to the extreme limits of his reason. Then suddenly springing to his feet, he beat his head against the wall with such force that we both rushed upon him and tore him away to the centre of the room.

_The Adventure of the Beryl Coronet_

This highly respected citizen must have been an emotionally unstable person. One wonders how he could have been a successful banker, with such a sensitive nervous system. The poor man must have lain awake many a weary night worrying about his investments. We do not know his subsequent history, but I suspect that he eventually developed hypertension or suffered from gastric ulcers.

When Rachel Howells was questioned by the master of the house about the disappearance of her perfidious lover Brunton, she showed pronounced signs of hysteria:

She looked at me with so strange an expression that I began to suspect that her brain was affected.... She fell back against the wall with shriek after shriek of laughter, while I, horrified at this sudden hysterical attack, rushed to the bell to summon help. The girl was taken to her room still screaming and sobbing....

_The Musgrave Ritual_

There was a real reason for the girl’s behavior; she had been directly responsible for her lover’s horrible death. It is small wonder that she suffered a violent hysterical attack.

Once Dr. Watson was asked to see the wife of his boyhood friend Robert Ferguson. It was a tragic situation. She had been observed on several occasions sucking blood from her infant son. The sympathetic doctor stated that she appeared only half conscious, and had a frightened expression. Her pulse and temperature were both high, but he felt that this was due to her highly emotional state (_The Adventure of the Sussex Vampire_). Mrs. Ferguson was probably suffering from hysteria. The attack cleared up promptly when Sherlock Holmes sat down at the patient’s bedside and, in the presence of her husband, analyzed the situation, explaining why it was necessary for Mrs. Ferguson to suck the baby’s wounds. They had been made by arrows dipped in curare. The baby’s insanely jealous half-brother had committed this atrocious deed. Truly, a shocking episode!

In _The Greek Interpreter_, reference is made to a man who showed symptoms of St. Vitus’ dance. Mr. Melas described his unpleasant companion: “... his lips and eyelids were continually twitching like a man with St. Vitus’ dance. I could not help thinking that his strange, catchy little laugh was also a symptom of some nervous malady.”

The term “St. Vitus’ dance” is seldom used nowadays; it is presently called “acute chorea.” This condition is characterized by irregular involuntary contractions of the muscles and is associated with a variable amount of psychic disturbance. The name (St. Vitus’ dance) has been handed down from the Middle Ages. Epidemics characterized by excitement, gesticulations, and dancing brought about mainly by religious fervor were in those days not uncommon. Whenever these symptoms became excessive, the people in the Rhenish province frequently made pilgrimages to the Chapel of St. Vitus in Zebern.

Another reference to twitching muscles may be cited. Sherlock Holmes called on Mr. Sidney Johnson, senior clerk and draughtsman, in an office from which extremely important secret papers had disappeared. Watson writes that the clerk had haggard cheeks, and that his hands were twitching from the nervous strain he had undergone (_The Adventure of the Bruce-Partington Plans_).

In the tales, other references may be found to shattered nerves and states of nervous exhaustion. In describing the condition of her father, Alice Turner tells Sherlock Holmes: “... Dr. Willow says that he is a wreck and that his nervous system is shattered” (_The Boscombe Valley Mystery_). The real reason for his pitiful state, which his daughter did not know, was that he had recently murdered an old acquaintance.

When Don Murillo, Tiger of San Pedro, tried to kidnap Miss Burnett, she broke away from him, and with the help of a friend got into a cab. Here Holmes saw her, and observed that she was in a state of collapse from nervous exhaustion (_The Adventure of Wisteria Lodge_). This brave lady had been locked in a room for a number of days with insufficient food, and had undergone other traumatic experiences. It is no wonder that Holmes found her in such a pitiful state.

After Sir Henry Baskerville had narrowly escaped death on the moor from the savage hound, he suffered a nervous collapse, “... the shock of the night’s adventure had shattered his nerves.” Sir Henry assuredly was not a weak man, but the victim of a concatenation of unfortunate circumstances. The family history of the hound, Sir Henry’s love for a married woman, his isolation and loneliness, and the somber landscape of the bleak moor doubtless all preyed on his mind. When the hound actually sprang upon him, his nervous system finally reached the breaking point. Stronger men than he would have quailed.

Mr. Marlow Bates, the manager of the estates of the wealthy “Gold King” Mr. Gibson (whose wife had been found dead), called on Sherlock Holmes. Watson describes him as a small, thin, fidgety man, who appeared to be on the brink of a serious nervous breakdown. Although in great fear of his vicious employer, Bates detested him so heartily that he hurried to Baker Street and told Holmes that Gibson was an “infernal villain.” In view of the circumstances, this was indeed a grave accusation. The reader will recall that the “Gold King” had not murdered his wife; she had died by her own hand (_The Problem of Thor Bridge_).

The eyes often show a characteristic expression under emotional strain. Referring to Colonel Valentine Walther, whose brother had suddenly died, Watson observes that he had wild eyes and presented a worried and disheveled appearance (_The Adventure of the Bruce-Partington Plans_). It was discovered that it was the colonel who had stolen an extremely important state document. His older brother, Sir James, suspected Valentine’s guilt. The shock was too much for the older man and caused his death; there was a question as to whether he took his own life. Be that as it may, his younger brother was responsible for the tragedy. We are not surprised to learn that the eyes of the colonel had a wild expression.

People under great emotional strain often break out in a cold sweat. Nearly everyone has, at one time or another, experienced this phenomenon. It is caused by violent stimulation of the sympathetic nervous system. When John Openshaw’s uncle Elias received a letter containing five orange pips, a great change came over him. At times he acted like a madman. His nephew told Holmes, “At such times I have seen his face, even on a cold day, glisten with moisture, as though it were new raised from a basin” (_The Five Orange Pips_).

A cold sweat is more apt to manifest itself on the forehead, but it is not necessarily limited to the face, for any portion, or all, of the body may be involved. The cold, clammy sweat produced under conditions of intense mental stress is different, of course, from the normal healthy sweat brought about by a warm environment or by physical exertion, or by both. The physiologic explanation of a cold sweat is that it is a condition brought about by pain or fear as a reaction anticipatory of the strenuous muscle movements that may ensue.

Victor Trevor’s father was also the recipient of a letter which led to tragedy:

My father read it, clapped both hands to his head and began running round the room in little circles like a man who has been driven out of his senses.... I saw that he had a stroke.

_The “Gloria Scott”_

Apparently, this individual became so agitated, and his blood pressure rose so high, that he was stricken with a fatal cerebral hemorrhage. It is well known that emotions may produce a pronounced rise in blood pressure even in healthy people.

Most of the nervous maladies described by Dr. Watson were in the nature of acute episodes, and more or less transient in character. The individuals he depicted were high-strung, nervous people, overwhelmed by the traumatic experiences to which they had been subjected. Some of these were unable to suppress their emotions and either became hysterical or suffered a nervous collapse.

As a rule, we do not think of the English people as giving way to their feelings, but as governing them strictly. It is the Latins who are supposed to manifest hysterical reactions. However, it would take extraordinarily strong men, regardless of their nationality, to maintain normal mental equilibrium under some of the situations described in the spine-tingling tales; even the stolid Britishers cracked under the mental strain. The nervous system of man can withstand just so much and no more. It is given to but few to possess nerves of steel, and even such rare individuals finally reach a breaking point. Man is not a machine, but a human being.

If Dr. Watson were writing his adventurous stories today, he probably would stress the fact that long-continued nervous strain is likely to produce ulcers of the stomach or of the duodenum. The modern view is that mental worry may lead to hypertension and to diseases of the arteries, especially those which supply the heart muscles, namely, the coronaries--although it is true, as previously mentioned, that most of the characters depicted in the tales suffered mental strain for a substantial length of time.

It is noteworthy that both Sherlock Holmes and Dr. Watson maintained a nice mental balance even during periods of tremendous excitement and danger. A striking characteristic about both was their extraordinary fearlessness and mental poise. Although people around them often manifested signs of abject fear, or were given to hysterical outbursts, our heroes never faltered, but maintained a calm demeanor and dispatched neatly and efficiently the task before them.

DOGS AND SHERLOCK HOLMES