Arthur Conan A
Doyle, Joseph Bell, and Sherlock Holmes
Neurologic Connection
Barbara F. Westmoreland, MD, Jack D. Key, MS
\s=b\ Neurologists, like physicians in several other medical specialties, can lay claim to Sherlock Holmes as one of their own. This assertion is validated by the number of neurologic conditions, such as seizures, stroke, syncope, encephalopathies, and head trauma, that are mentioned in the stories and novels. In addition, the article reviews the powers of observation and the deductive approach utilized by Conan Doyle and Joseph Bell, the models for Sherlock Holmes, and how these skills can be applied to medical
problems. (Arch Neurol. 1991;48:325-329)
rthur Conan Doyle was born in Ed-
inburgh, Scotland, on May 22, graduated from the Edin¬ burgh University in 1881 with degrees 1859. He
of Bachelor of Medicine and Master of Surgery. Two brief sea voyages as a ship's surgeon, first to the Arctic on a whaler and later to the west coast of Africa, and several short tours of duty as an assistant to physicians in En¬ gland, contributed to his reservoir of experience, much of which was subse¬ quently incorporated into novels and short stories. After a disappointing interval as assistant to George Budd, a medical school colleague, Conan Doyle Accepted for publication July 20,1990. From the Section of Electroencephalography (Dr Westmoreland) and the Medical Library (Mr Key), Mayo Clinic and Mayo Foundation, Rochester, Minn.
Presented, in part, at the Hans Berger Day Clinical Neurophysiology Symposium, Richmond,
Va, May 23,1989. Reprint requests to Mayo Clinic, 200 First St SW, Rochester, MN 55905 (Dr Westmoreland).
put up his own brass plate at Southsea, England. In 1885, he qualified for the
degree awarded by Edinburgh University for his thesis on tabes dor¬ salis. His modest practice left him with sufficient free time for writing (Fig 1). As this medical practice did not provide enough challenge, Conan Doyle decided to become an eye spe¬ cialist and, in December 1890, he left for Vienna, Austria, to study. Return¬ ing from the Continent after a few short months, he set up an office in London, England, among the fashion¬ able practitioners at Devonshire Place—but saw no patients. While sur¬ viving a severe bout of influenza, Co¬ nan Doyle made up his mind to give full time to writing. It was evident to him that what had started modestly MD
with the sale of his first story in 1879 had subsequently, with many other
publications,
grown to
an
enjoyable
and comfortable business. He turned to medicine again only while treating British soldiers in the Boer War in South Africa. He died on July 7,1930.1 During his lifetime, few men were better known than Arthur Conan Doyle. He possessed a boundless en¬ thusiasm and energy, was involved in and supported diverse interests and causes, was imbued with a keen sense of history, country, and personal dig¬ nity, and had a propensity for imagi¬ native writing. He was a man often in the public eye. His most popular liter¬ ary creation is, of course, the worldfamous scientific detective, Sherlock Holmes. Over the years, this creation has been metamorphosed from a fic¬ tional character into a very popular living person, but one who has greatly
overshadowed and obscured his tor.2·3
crea¬
Conan Doyle's writings, especially the science fiction and the Sherlock Holmes adventures, were greatly in¬ fluenced by his medical training and
experiences.
These writings have vivid characteriza¬ tions, intensely drawn human events and a significant amount of medical allusion. It is the extensiveness and variety of the medi¬ cal content that is not generally appreci¬ ated. Included within the 60 Holmes adven¬ tures are references to 68 diseases, 32 med¬ ical terms, 38 doctors, 22 drugs, twelve medical specialties, six hospitals, and even three medical journals and two medical schools. Conan Doyle often patterned char¬ acters in his writings after medical school professors and friends. Also on record are 42 of his real patients with the nature of the illness available for 31 of them. Many of the real patients have their fictional counter¬ parts in the Holmes adventures. This all contributes to the compelling realism of Conan Doyle's literary writings.2
Many factors contribute to the pop¬ ularity of the Sherlock Holmes canon¬ ical stories. Among them is the unique
character of Holmes himself—an in¬ dividual with marked aloofness from commonplace affairs, his dedication to deductive reasoning, his general dis¬ dain for the opposite sex (with one en¬ thralling exception), the hard edge to his character, and his knowledge of medicine, which exceeded in some areas even that of Doctor John Wat¬ son. There is also the very compelling sense of realism provided by graphic descriptions of real world geography and climate, by references to actual events of the day, and, in the medical area, by the mention of diseases, med-
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ical terms, instruments, hospitals, soci¬ eties, and so on. Perhaps the greatest appeal for the modern-day reader lies in the atmosphere that permeates the*
adventures—the rich ambience of the Victorian period in England.4 While a medical student at Edin¬ burgh University, Conan Doyle did some of his training at the Royal Infirmary, where he was greatly influ¬ enced by one of his teachers—Dr Jo¬ seph Bell. Later, he used this teacher as his model for Sherlock Holmes.5·6 Joseph Bell, born in Edinburgh in 1837, was one of a distinguished fam¬ ily of physicians who had occupied prominent positions in medicine in Edinburgh. One of his ancestors was Dr Charles Bell who was famous for describing Bell's palsy. After gradua¬ tion from the Edinburgh University in 1859, Joseph Bell became house physi¬ cian to Professor James Syme at the Royal Infirmary. (Dr Syme was Lis¬ ter's father-in-law.) After being ap¬ pointed to the Royal Infirmary at an early age, Bell became highly esteemed as a physician and a surgeon.6 On one occasion Dr Bell gave a pre¬ sentation of a neurologic condition, diphtheritic paralysis, before the So¬ ciety of Doctors of Edinburgh. It was an excellent case presentation with detailed observations of various as¬ pects of the condition. The most im¬ pressive feature of the presentation, however, was that the patient was Bell himself, and he gave a detailed and graphic description of his symptoms. He had received the infection from a patient on whom he had performed a tracheotomy. Later, Bell developed a sore throat, nasal voice, unintelligible speech, double vision, difficulty with swallowing, and progressive weakness. His strength gradually returned, and he recovered with the only residuals being a limp in one leg and a lisp in
speech.7
Bell was recognized as an excellent teacher. His keenness of observation and skills in diagnosis were phenome¬ nal. One of his students, Dr . E. Jones, recalls his methods.6 "What is the matter with this man, eh?" Then flashing a signal to one particular student with those piercing eyes, Dr Bell would indicate he should pronounce the di¬ agnosis. "No, you mustn't touch him. Use
your eyes, sir, use your ears, use your brain, your bump of perception, and use your powers of deduction."
taught his art of diagnosis, stressing the necessity of noting the environment, the appearance, and the personal characteristics of the patient. Dr Douglas Guthrie, a colleague, noted that he would sit and Thus, Bell
Fig 2.—Dr Joseph Bell.
Fig 1.—Dr Arthur Conan Doyle in his study No. 1 Bush Villas, Southsea, England.
at
study with close interest all the manner¬ isms, features, expressions, and personal traits of the patient. Then, turning to the assembled students, he would discuss the
method which enabled him to tell the as¬ tonished company where the man came from, what was his occupation, and various details of his family life. He showed how the hands and finger-nails revealed the nature of various crafts, how the color of mud on a boot might indicate a certain part of the town, and how an accent or dialect might be a clue to the birthplace of the patient.8
In A Study in Scarlet, Holmes states, Like all other arts, the science of Deduction and Analysis is one which can only be acquired by long and patient study on
meeting a fellow-mortal, learn at a glance to distinguish the history of the man, and the trade or profession to which he belongs. ...
Puerile
as
such
an
exercise may seem, it
sharpens the faculties of observation and
teaches one where to look and what to look a man's fingernails, by his coat-
for. By
sleeve, by his boot, by his trouser-knees, by the callosities of his forefinger and thumb, by his expression, by his shirt-cuffs—by each of these things a man's calling is
plainly revealed.9
As Holmes noted, "You know my method." "It is founded upon the ob¬ servation of trifles." Bell, himself, could have spoken these words, ob¬ served Doctor Guthrie.8 Conan Doyle, once an outpatient clerk for Dr Bell, later said in his Memories and Adventures,10 "I had ample chance of studying his methods and of noticing that he often learned more of the patient by a few quick glances than I had done by my questions." Conan Doyle also speaks of his debt to his old teacher and writes,
"He would sit in his receiving room, with a face like a red Indian, and diag¬ nose people as they came in, before they even opened their mouths. He would tell them their symptoms, and even give them details of their past life; and hardly ever make a mistake." Conan Doyle wrote to Bell "My dear Doctor Bell, it is most certainly to you that I owe Sherlock Holmes"11 (Fig 2). In his autobiography, he said that when he was developing his masterful
detective,
thought of my old teacher, Joe Bell, of his eagle face, of his curious way, of his eerie trick of spotting details. If he were a detec¬ tive, he would surely reduce this fascinat¬ ing, but unorganized business into some¬ thing nearer to an exact science It is all very well to say that a man is clever, but the reader wants to see examples of it... such examples as Bell gave us every day in the I
...
wards. The idea amused me. What shall I call the fellow? First it was Sherringford Holmes; then it was Sherlock Holmes.10 ...
Doctor Bell was initially taken aback by the publicity, but he obvi¬ ously was secretly pleased about this and contributed several suggestions for further adventures. He also wrote a foreword to one of the Sherlock Holmes books, in which he emphasized the importance of appreciating details and learning all the features of disease and injury. He said
precise and intelligent recognition and appreciation of minor differences is the real The
essential factor in all successful medical diagnoses Eyes and ears which can see and hear, memory to record at once and to recall at pleasure the impression of the senses, and an imagination capable of weaving a theory or piecing together a bro¬ ken chain or unravelling a tangled clue, such are implements of his trade to a suc¬ cessful diagnostician.10
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...
On one occasion, when Bell was asked about Conan Doyle and his lit¬ erary creation,8 he responded "... I always regarded him as one of the best students I ever had. He was exceed¬ ingly interested in anything connected with diagnosis, and was never tired of trying to discover all those little de¬ tails which one looks for." Then Bell went
on to say With regard to the doctors, I think every good teacher, if he is to make his men good doctors, must get them to cultivate the habit of noticing the little apparent trifles. Any really good doctor ought to be able to tell, before a patient has really sat down, a good deal of what is the matter with him or her... I should like to say this about my friend Doyle's stories, that I believe they have inculcated in the general public a new source of interest. They make many a fel¬ low think that, after all, there may be much more in life if he keeps his eyes open There is a problem, a whole game of chess, in many a little street incident or trifling occurrence if one once learns the ...
...
moves.8
Holmes' powers of deduction and were based on the didactic methods of Dr Bell who emphasized 'the practiced eye,' the importance of close examination and attention to physical details, the empirical obser¬ vation of the patient, and the legiti¬ mate inferences which might be drawn therefrom."12 Bell emphasized in his teaching the methods of observation, intuition, and deductive reasoning that are of importance for neurolo¬ gists, or any physician involved with the art of diagnosis, and which Conan Doyle personified in Sherlock Holmes. These methods are similar to those used by neurologists as noted by Cherington13 and are illustrated in the various statements made by Sherlock Holmes.9
reasoning "
In A
Study in Scarlet—"It is
a
capital
mistake to theorize before you have all the
evidence." In The Adventure of Black Peter—"We all learn by experience, and your lesson this time is that you should never lose sight of the alternative." In The Reigate Squires— "It is of the highest importance in the art of detection to be able to recognize out of a number of facts which are incidental and which vital." In TheFive Orange Pips—" k man should keep his little brain attic stocked with all the furniture that he is likely to use, and the rest he can put away in the lumber-room of his library, where he can get it if he wants it." Finally, one of his most famous sayings, in The Sign of the Four—"when you have eliminated the impossible, whatever re¬ mains, however improbable, must be the truth."
The acclaim accorded the canonical
writings by the public at large has spilled over into the realm of medicine,
manifested there in the form of arti¬ cles and commentary in books, pam¬ phlets, and professional journals.4 The narrations of some of these treat Holmes and Watson as real-life his¬ torical figures14; others focus on the medical content15; and several stress the applicability to modern day medi¬ cine of some of the Holmesian
techniques.16
Just as other medical specialties like dermatology, ophthalmology, and pa¬ thology identify with and lay claim to Sherlock Holmes, so, too, can neurol¬
the number of stories reference to neurologic conditions that primarily or second¬ arily involve the brain or nervous sys¬ tem and the methods used in the ob¬ servation and diagnosis of patients it may well be that neurology's claim to such an association is as, or even more, valid than the others. In reviewing the Sherlock Holmes stories, we found a total of 41 (73% ) of the 56 short stories and all four of the novels made some ogy. Based
making
on
some
reference condition
or
comment to
or
a
neurologic
symptom. Described—
specifically mentioned—or some refer¬ made to are some 104 examples in the canonical writings that a neurolo¬ gist and Sherlock Holmes aficionado might make a case for to include in such a listing (Table).3·11·17 Among the neurologic conditions ence
mentioned in the Sherlock Holmes sto¬ ries are the following interesting ex¬
briefly noted. Scott, Mr Trevor describes the following condi¬ amples, which
are
In the story The Gloria
tion:
A letter arrived for my father yesterday evening... My father read it, clapped both his hands to his head, and began running
round the room in little circles like a man who has been driven out of his senses. When I at last drew him down onto the sofa, his mouth and eyelids were all puckered on one side, and I saw that he had a stroke we put him to bed; but the paralysis has spread, and he has shown no signs of returning consciousness.' ...
subsequently died within the next day. This is probably an example of a cerebrovascular hemorrhage that was brought on by stress.17·18 In The Valley of Fear, Holmes uses the expression "brain wave."17 Watson places the case as having occurred in January 1888. The first description of He
brain waves or the "currents of the brain" was given by Richard Caton in the British Medical Journal in 1875, and, therefore, Conan Doyle could have been aware of the report in which Caton described the presence of "elee-
trie currents in the brains of a rabbit and monkey."3·17·19 In the story, how¬ ever, the term is used as follows: "One more coruscation [flash of light], my dear Watson—yet another brain¬ wave."9 In The Sign ofthe Four, Holmes and Watson come upon the body of Bar¬ tholomew Sholto whose features were set... in a horrible smile, a fixed and unnatural grin, which, in that still and moonlit room, was more jarring to the nerves than any scowl or contortion. On further examining the body, Holmes says to Watson "Put your hand here on this poor fellow's arm, and here on his leg. What do you feel?" "The muscles are as hard as a board," Watson answered. "Quite so" Holmes replied. "They are in a state of extreme contraction, far exceed¬ ing the usual 'rigor mortis.' Coupled with this distortion of the face, this Hippocratic smile, or 'risus sardonicus,' as the old writ¬ ers called it, what conclusion would it sug¬ gest to your mind?" "Death from some powerful vegetable alkaloid," I answered; "some strychnine¬ like substance which would produce tetanus." "That was the idea which occurred to me the instant I saw the drawn muscles of the face," Holmes replied.'
In The Adventure ofthe Devil's Foot, toxic encephalopathy is produced by an unidentified poison, in which sev¬ eral people were driven mad or died of fright. Sherlock Holmes decides to expériment with the drug, and the fol¬ lowing is a description by Dr Watson of what happened to them: a
was conscious of a thick, musky odour, subtle and nauseous. At the very first whiff of it, my brain and my imagination were beyond all control. A thick black cloud swirled before my eyes, and my mind told me that in this cloud, unseen as yet, but about to spring out upon my appalled senses, lurked all that was vaguely horrible, all that was monstrous and inconceivably wicked in the universe. Vague shapes swirled and swam amid the dark cloudbank, each a menace and a warning of something coming, the advent of some un¬ speakable dweller upon the threshold, whose very shadow would blast my soul. A freezing horror took possession of The turmoil within my brain was me
I
such that something must surely snap. I tried to scream, and was vaguely aware of some hoarse croak which was my own voice, but distant and detached from myself. At the same moment, in some effort of escape, I broke through that cloud of despair, and had a glimpse of Holmes's face, white, rigid, and drawn with horror—the very look which I had seen upon the features of the dead. It was that vision which gave me an instant of sanity and of strength. I dashed from my chair, threw my arms round Holmes, and together we lurched through the door, and an instant afterwards had ...
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'
we carried him into the kitchen, where he lay back in a large chair and breathed heavily for some minutes. Finally, with a shamefaced apology for his weak¬ ness, he rose once more and said "I am lia¬ ble to these sudden nervous attacks." Later Holmes confesses that when the Inspector in the case was going to reveal something important to the villains, "I tumbled down in a sort of fit and so changed the conversation."'
attack,
Neurologie Conditions Mentioned in the Sherlock Holmes Stories
Neurologic Connections Drugs and toxins Syncope Head trauma Brain fever
Spinal deformities, injuries, diseases
Alcohol Seizures Cerebrovascular accidents,
injuries,
No. 30 21 11 7
and 6 6 5 4
etc
Movement disorders Simulated condition
Hydrocephalus (possible) Carbon monoxide
Cataplexy
Nervous breakdown Delirium Brain waves Total
3 3 2 2 1 1 1 1
104
thrown ourselves down upon the grass plot and were lying side by side, conscious only of the glorious sunshine which was bursting its way through the hellish cloud of terror which had girt us in. Slowly it rose from our souls like the mists from a landscape, until peace and reason had returned, and we were sitting up on the grass, wiping our clammy foreheads, and looking with apprehension at each other to mark the last traces of that terrific experience which we had undergone. "Upon my word, Watson!" said Holmes at last, with an unsteady voice, "I owe you both my thanks and an apology. It was an unjus¬ tifiable experiment even for oneself, and doubly so for a friend. I am really very
sorry."'
central
system stimula¬ tion or depression with symptoms of fear, anxiety, terror, color flashes, feel¬ nervous
ing cold, nausea or vomiting, and even¬ tually respiratory failure. It can also induce hallucinations and psychoticlike change similar to those produced by lysergic acid diethylamide (LSD).3·20·21 In The Adventure of the Dying De¬ tective, Holmes is thought by Dr Wat¬ son to be delirious, thus simulating a metabolic encephalopathy (Fig 3). As described by Dr Watson, He [Sherlock Holmes] was indeed a deplor¬ His eyes had the bright¬ able spectacle ness of fever, there was a hectic flush upon either cheek and dark crusts clung to his lips He spoke with a feverish energy, the long hands twitching and jerking as he motioned me away. ...
...
...
Later, when Watson was looking at little box on the mantle, Holmes let out a dreadful cry. Watson a
caught
a glimpse of a convulsed face and frantic eyes... Holmes said "Put it down I hate to have my things touched You are enough to drive a patient into ...
asylum" The violent and causeless excitement... so far removed from his usual suavity, showed me how deep was the disorganization of his mind. Of all ruins, that of a noble mind is the most deplorable. an
...
Holmes then started talking with a feverish animation about half crowns and oysters.
raving insanity," thought Wat¬ "I left him full of the image of this magnificent intellect babbling like a foolish child Behind me as I passed from the flat I heard Holmes's high thin voice in some delirious chant."9 "this
son
There is some speculation that the drug may be related to calabar, an Af¬ rican poison, or mescaline, which can cause
Fig 3.—Drawing by Frederic Dorr Steele of an emaciated Sherlock Holmes for Conan Doyle's The Dying Detective (from The Dying Detective. Strand Magazine. December 1893). After the original (courtesy Philip S. and Mary K. Hench Collection of the Special Collections Library, University of Minnesota).
was
...
...
Later, Holmes confessed that he was
simulating a terminal illness. He said
The best way of successfully acting a part is to be it... I give you my word that for three days I have tasted neither food nor drinkThree days of absolute fast does not improve one's beauty For the rest, there is nothing which a sponge may not cure. With vaseline upon one's forehead, bella¬ donna in one's eyes, rouge over the cheek¬ bones, and crusts of beeswax round one's lips, a very satisfying effect can be pro¬ duced. Malingering is a subject upon which I have sometimes thought of writing a monograph. A little occasional talk about half crowns, oysters, or any other extrane¬ ous subjects produces a pleasing effect of delirium.' ...
...
In The Reigate Squires, Holmes sim¬ ulates a seizure, which Watson de¬ scribes as poor friend's face had suddenly as¬ sumed the most dreadful appearance. His eyes rolled upwards, his features writhed in an agony, and with a suppressed groan, he dropped on his face upon the ground. Hor¬ rified at the suddenness and severity of the
My
In The Resident Patient, interest in the diseases of the nervous system is expressed through a comment made by Dr Percy Trevelyan who says "My own hobby has always been nervous dis¬ ease. I should wish to make it an abso¬ lute specialty, but, of course, a man must take what he can get at first." He also did some research on the pathol¬ ogy of catalepsy and is noted in the story to have won a "prize and medal by the monograph on nervous le¬ sions."9·21 In reality, Conan Doyle himself wrote a thesis on a neurologic condi¬ tion, tabes dorsalis. It was the custom that a graduate for the Doctor of Med¬ icine write a thesis for the MD degree. The thesis was completed in April 1885, two years before the first Sher¬ lock Holmes story, A Study in Scarlet. In the thesis, Doyle acknowledged Duchenne's contribution of the rela¬ tion of syphilis to tabes dorsalis, which was a new concept for the time. He also presented the various anatomic, phys¬ iologic, and clinical aspects of tabes dorsalis in a literary style that was as "graphic as the fiction stories." Of note, tabes is mentioned in several stories by Conan Doyle, but not in any of the Sherlock Holmes stories.22·23 From this brief review it is evident that Arthur Conan Doyle's medical training and experience had a major impact on his fiction—in fact, it per¬ meated his writings and especially the chronicles of the adventures of Sher¬ lock Holmes. The medical content of Conan Doyle's fiction contributed much to its success. There were strik¬ ing depictions of characters with med¬ ical problems; plot manipulations en¬ hanced by medically related descrip¬ tions; and various emotions like pity, horror, sympathy, and even humor were engendered for many of the liter¬ ary figures as a result of their afflic¬ tions or circumstances.21 The popular¬ ity of the canonical writings is cer¬ tainly due in part to the large amount of realistic detail, including the medi¬ cal. Perhaps more surprising is the fact that Holmes and Watson and var¬ ious elements of their adventures have spilled over into the realms of legiti¬ mate medicine. In the medical litera¬ ture, there are many references to the
...
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famous duo, their adventures, and modus operandi.24 The stories that we have referred to in this article illustrate a few of the examples of neurologic conditions de¬ scribed in the Sherlock Holmes adven¬ tures. There are many others that could have been referred to plus those
that appear in Conan Doyle's nonSherlockian writings. Several medical specialties have nominated Sherlock Holmes as one of their own. It would seem that neurology also has a claim to the master detective that is as valid— and, perhaps, even more so, based on sheer numbers of neurologic-related
references. As a final word on this matter, it was Holmes in The Adventure ofthe Mazarin Stone,9 who said, "I am a brain, Watson. The rest of me is a mere
appendix."
References 1. Key JD. Hench's Triumph\p=m-\AFixed Point in Changing World: Dr. Philip S. Hench's Contributions to Keeping the Holmes Fires Burning. Rochester, Minn: Davies; 1981. 2. Key JD, Rodin AE. Medical reputation and literary creation: An essay on Arthur Conan Doyle versus Sherlock Holmes 1887-1987. Adler Museum Bull. 1987;13:21-25. 3. Rodin AE, Key JD. Medical Casebook of Doctor Arthur Conan Doyle: From Practitioner to Sherlock Holmes and Beyond. Malabar, Fla: Krieger; 1984. 4. Key JD, Rodin AE. Permeation of medicine by a literary legend: Arthur Conan Doyle's consulting detective, Mister Sherlock Holmes. Baker Street Misc. 1985;42:11-17. 5. Harnagel EE. Joseph Bell, M.D.: the real Sherlock Holmes. N Engl J Med. 1958;258:1158\x=req-\ a
1159. 6. Liebow E. Dr Joe Bell: Model for Sherlock Holmes. Bowling Green, Ohio: Bowling Green University Popular Press; 1982. 7. Mann RJ, Key JD. Joseph Bell, M.D.,
F.R.C.S.: 'notes on a case of paralysis following diphtheria.' Pharos. 1982;45:27-29. 8. Scarlett EP. Doctor out of Zebulun. Arch Intern Med. 1964;114:696-701. 9. Doyle AC. The Complete Sherlock Holmes. New York, NY: Doubleday & Co; 1930. 10. Doyle AC. Memories and Adventures. London, England: Hodder & Stoughton; 1924. 11. Baring-Gould WS, ed. The Annotated Sherlock Holmes. The Four Novels and the Fifty-six Short Stories Completed by Sir Arthur Conan Doyle. 2nd ed. New York, NY: Clarkson N. Potter
Inc; 1967.
12. Ober WB. Conan Doyle's dying detective. N Y State J Med. 1967;67:2141-2145. 13. Cherington M. Sherlock Holmes: neurolo-
gist. Neurology. 1987;37:824-825.
14. Bates DM. Dr. Watson and the Jezail bullet. Va Med Bull. 1976;163:828-829. 15. Campbell M. Sherlock Holmes and Dr Watson: a medical digression. Guy's Hosp Gazette. 1935:56. 16. Fitzgerald FT, Tierney LM. The bedside
Sherlock Holmes. West J Med. 1982;137:169-175. 17. Brenner RP. Holmes, Watson, and neurology. J Clin Psychiatry. 1980;41:202-205. 18. Van Liere EJ. Dr Watson and nervous maladies. Baker Street J. 1954;4:100-108. 19. Caton R. The electric currents of the brain. BMJ. 1875;2:278. 20. Goetz CG. Neurotoxins in Medical Practice. New York, NY: Spectrum; 1985. 21. Rodin AE, Key JD. Doctor Arthur Conan Doyle's patients in fact and fiction. Med Heritage.
1985;1:80-98. 22. Doyle AC. An Essay Upon the Vaseomotor
Changes in Tabes Dorsalis and on the Influence Which Is Exerted by the Sympathetic Nervous System in That Disease. University of Edinburgh; April 1885. Unpublished thesis. 23. Rodin AE, Key JD. Arthur Conan Doyle's thesis on tabes dorsalis. JAMA. 1982;247:646-650. 24. Rodin AE, Key JD. The influence of literary legends on medicine. Y-The Med Inquirer. 1985; 1:8-11.
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Doyle, Joseph Bell, and Sherlock Holmes
Neurologic Connection
Barbara F. Westmoreland, MD, Jack D. Key, MS
\s=b\ Neurologists, like physicians in several other medical specialties, can lay claim to Sherlock Holmes as one of their own. This assertion is validated by the number of neurologic conditions, such as seizures, stroke, syncope, encephalopathies, and head trauma, that are mentioned in the stories and novels. In addition, the article reviews the powers of observation and the deductive approach utilized by Conan Doyle and Joseph Bell, the models for Sherlock Holmes, and how these skills can be applied to medical
problems. (Arch Neurol. 1991;48:325-329)
rthur Conan Doyle was born in Ed-
inburgh, Scotland, on May 22, graduated from the Edin¬ burgh University in 1881 with degrees 1859. He
of Bachelor of Medicine and Master of Surgery. Two brief sea voyages as a ship's surgeon, first to the Arctic on a whaler and later to the west coast of Africa, and several short tours of duty as an assistant to physicians in En¬ gland, contributed to his reservoir of experience, much of which was subse¬ quently incorporated into novels and short stories. After a disappointing interval as assistant to George Budd, a medical school colleague, Conan Doyle Accepted for publication July 20,1990. From the Section of Electroencephalography (Dr Westmoreland) and the Medical Library (Mr Key), Mayo Clinic and Mayo Foundation, Rochester, Minn.
Presented, in part, at the Hans Berger Day Clinical Neurophysiology Symposium, Richmond,
Va, May 23,1989. Reprint requests to Mayo Clinic, 200 First St SW, Rochester, MN 55905 (Dr Westmoreland).
put up his own brass plate at Southsea, England. In 1885, he qualified for the
degree awarded by Edinburgh University for his thesis on tabes dor¬ salis. His modest practice left him with sufficient free time for writing (Fig 1). As this medical practice did not provide enough challenge, Conan Doyle decided to become an eye spe¬ cialist and, in December 1890, he left for Vienna, Austria, to study. Return¬ ing from the Continent after a few short months, he set up an office in London, England, among the fashion¬ able practitioners at Devonshire Place—but saw no patients. While sur¬ viving a severe bout of influenza, Co¬ nan Doyle made up his mind to give full time to writing. It was evident to him that what had started modestly MD
with the sale of his first story in 1879 had subsequently, with many other
publications,
grown to
an
enjoyable
and comfortable business. He turned to medicine again only while treating British soldiers in the Boer War in South Africa. He died on July 7,1930.1 During his lifetime, few men were better known than Arthur Conan Doyle. He possessed a boundless en¬ thusiasm and energy, was involved in and supported diverse interests and causes, was imbued with a keen sense of history, country, and personal dig¬ nity, and had a propensity for imagi¬ native writing. He was a man often in the public eye. His most popular liter¬ ary creation is, of course, the worldfamous scientific detective, Sherlock Holmes. Over the years, this creation has been metamorphosed from a fic¬ tional character into a very popular living person, but one who has greatly
overshadowed and obscured his tor.2·3
crea¬
Conan Doyle's writings, especially the science fiction and the Sherlock Holmes adventures, were greatly in¬ fluenced by his medical training and
experiences.
These writings have vivid characteriza¬ tions, intensely drawn human events and a significant amount of medical allusion. It is the extensiveness and variety of the medi¬ cal content that is not generally appreci¬ ated. Included within the 60 Holmes adven¬ tures are references to 68 diseases, 32 med¬ ical terms, 38 doctors, 22 drugs, twelve medical specialties, six hospitals, and even three medical journals and two medical schools. Conan Doyle often patterned char¬ acters in his writings after medical school professors and friends. Also on record are 42 of his real patients with the nature of the illness available for 31 of them. Many of the real patients have their fictional counter¬ parts in the Holmes adventures. This all contributes to the compelling realism of Conan Doyle's literary writings.2
Many factors contribute to the pop¬ ularity of the Sherlock Holmes canon¬ ical stories. Among them is the unique
character of Holmes himself—an in¬ dividual with marked aloofness from commonplace affairs, his dedication to deductive reasoning, his general dis¬ dain for the opposite sex (with one en¬ thralling exception), the hard edge to his character, and his knowledge of medicine, which exceeded in some areas even that of Doctor John Wat¬ son. There is also the very compelling sense of realism provided by graphic descriptions of real world geography and climate, by references to actual events of the day, and, in the medical area, by the mention of diseases, med-
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ical terms, instruments, hospitals, soci¬ eties, and so on. Perhaps the greatest appeal for the modern-day reader lies in the atmosphere that permeates the*
adventures—the rich ambience of the Victorian period in England.4 While a medical student at Edin¬ burgh University, Conan Doyle did some of his training at the Royal Infirmary, where he was greatly influ¬ enced by one of his teachers—Dr Jo¬ seph Bell. Later, he used this teacher as his model for Sherlock Holmes.5·6 Joseph Bell, born in Edinburgh in 1837, was one of a distinguished fam¬ ily of physicians who had occupied prominent positions in medicine in Edinburgh. One of his ancestors was Dr Charles Bell who was famous for describing Bell's palsy. After gradua¬ tion from the Edinburgh University in 1859, Joseph Bell became house physi¬ cian to Professor James Syme at the Royal Infirmary. (Dr Syme was Lis¬ ter's father-in-law.) After being ap¬ pointed to the Royal Infirmary at an early age, Bell became highly esteemed as a physician and a surgeon.6 On one occasion Dr Bell gave a pre¬ sentation of a neurologic condition, diphtheritic paralysis, before the So¬ ciety of Doctors of Edinburgh. It was an excellent case presentation with detailed observations of various as¬ pects of the condition. The most im¬ pressive feature of the presentation, however, was that the patient was Bell himself, and he gave a detailed and graphic description of his symptoms. He had received the infection from a patient on whom he had performed a tracheotomy. Later, Bell developed a sore throat, nasal voice, unintelligible speech, double vision, difficulty with swallowing, and progressive weakness. His strength gradually returned, and he recovered with the only residuals being a limp in one leg and a lisp in
speech.7
Bell was recognized as an excellent teacher. His keenness of observation and skills in diagnosis were phenome¬ nal. One of his students, Dr . E. Jones, recalls his methods.6 "What is the matter with this man, eh?" Then flashing a signal to one particular student with those piercing eyes, Dr Bell would indicate he should pronounce the di¬ agnosis. "No, you mustn't touch him. Use
your eyes, sir, use your ears, use your brain, your bump of perception, and use your powers of deduction."
taught his art of diagnosis, stressing the necessity of noting the environment, the appearance, and the personal characteristics of the patient. Dr Douglas Guthrie, a colleague, noted that he would sit and Thus, Bell
Fig 2.—Dr Joseph Bell.
Fig 1.—Dr Arthur Conan Doyle in his study No. 1 Bush Villas, Southsea, England.
at
study with close interest all the manner¬ isms, features, expressions, and personal traits of the patient. Then, turning to the assembled students, he would discuss the
method which enabled him to tell the as¬ tonished company where the man came from, what was his occupation, and various details of his family life. He showed how the hands and finger-nails revealed the nature of various crafts, how the color of mud on a boot might indicate a certain part of the town, and how an accent or dialect might be a clue to the birthplace of the patient.8
In A Study in Scarlet, Holmes states, Like all other arts, the science of Deduction and Analysis is one which can only be acquired by long and patient study on
meeting a fellow-mortal, learn at a glance to distinguish the history of the man, and the trade or profession to which he belongs. ...
Puerile
as
such
an
exercise may seem, it
sharpens the faculties of observation and
teaches one where to look and what to look a man's fingernails, by his coat-
for. By
sleeve, by his boot, by his trouser-knees, by the callosities of his forefinger and thumb, by his expression, by his shirt-cuffs—by each of these things a man's calling is
plainly revealed.9
As Holmes noted, "You know my method." "It is founded upon the ob¬ servation of trifles." Bell, himself, could have spoken these words, ob¬ served Doctor Guthrie.8 Conan Doyle, once an outpatient clerk for Dr Bell, later said in his Memories and Adventures,10 "I had ample chance of studying his methods and of noticing that he often learned more of the patient by a few quick glances than I had done by my questions." Conan Doyle also speaks of his debt to his old teacher and writes,
"He would sit in his receiving room, with a face like a red Indian, and diag¬ nose people as they came in, before they even opened their mouths. He would tell them their symptoms, and even give them details of their past life; and hardly ever make a mistake." Conan Doyle wrote to Bell "My dear Doctor Bell, it is most certainly to you that I owe Sherlock Holmes"11 (Fig 2). In his autobiography, he said that when he was developing his masterful
detective,
thought of my old teacher, Joe Bell, of his eagle face, of his curious way, of his eerie trick of spotting details. If he were a detec¬ tive, he would surely reduce this fascinat¬ ing, but unorganized business into some¬ thing nearer to an exact science It is all very well to say that a man is clever, but the reader wants to see examples of it... such examples as Bell gave us every day in the I
...
wards. The idea amused me. What shall I call the fellow? First it was Sherringford Holmes; then it was Sherlock Holmes.10 ...
Doctor Bell was initially taken aback by the publicity, but he obvi¬ ously was secretly pleased about this and contributed several suggestions for further adventures. He also wrote a foreword to one of the Sherlock Holmes books, in which he emphasized the importance of appreciating details and learning all the features of disease and injury. He said
precise and intelligent recognition and appreciation of minor differences is the real The
essential factor in all successful medical diagnoses Eyes and ears which can see and hear, memory to record at once and to recall at pleasure the impression of the senses, and an imagination capable of weaving a theory or piecing together a bro¬ ken chain or unravelling a tangled clue, such are implements of his trade to a suc¬ cessful diagnostician.10
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...
On one occasion, when Bell was asked about Conan Doyle and his lit¬ erary creation,8 he responded "... I always regarded him as one of the best students I ever had. He was exceed¬ ingly interested in anything connected with diagnosis, and was never tired of trying to discover all those little de¬ tails which one looks for." Then Bell went
on to say With regard to the doctors, I think every good teacher, if he is to make his men good doctors, must get them to cultivate the habit of noticing the little apparent trifles. Any really good doctor ought to be able to tell, before a patient has really sat down, a good deal of what is the matter with him or her... I should like to say this about my friend Doyle's stories, that I believe they have inculcated in the general public a new source of interest. They make many a fel¬ low think that, after all, there may be much more in life if he keeps his eyes open There is a problem, a whole game of chess, in many a little street incident or trifling occurrence if one once learns the ...
...
moves.8
Holmes' powers of deduction and were based on the didactic methods of Dr Bell who emphasized 'the practiced eye,' the importance of close examination and attention to physical details, the empirical obser¬ vation of the patient, and the legiti¬ mate inferences which might be drawn therefrom."12 Bell emphasized in his teaching the methods of observation, intuition, and deductive reasoning that are of importance for neurolo¬ gists, or any physician involved with the art of diagnosis, and which Conan Doyle personified in Sherlock Holmes. These methods are similar to those used by neurologists as noted by Cherington13 and are illustrated in the various statements made by Sherlock Holmes.9
reasoning "
In A
Study in Scarlet—"It is
a
capital
mistake to theorize before you have all the
evidence." In The Adventure of Black Peter—"We all learn by experience, and your lesson this time is that you should never lose sight of the alternative." In The Reigate Squires— "It is of the highest importance in the art of detection to be able to recognize out of a number of facts which are incidental and which vital." In TheFive Orange Pips—" k man should keep his little brain attic stocked with all the furniture that he is likely to use, and the rest he can put away in the lumber-room of his library, where he can get it if he wants it." Finally, one of his most famous sayings, in The Sign of the Four—"when you have eliminated the impossible, whatever re¬ mains, however improbable, must be the truth."
The acclaim accorded the canonical
writings by the public at large has spilled over into the realm of medicine,
manifested there in the form of arti¬ cles and commentary in books, pam¬ phlets, and professional journals.4 The narrations of some of these treat Holmes and Watson as real-life his¬ torical figures14; others focus on the medical content15; and several stress the applicability to modern day medi¬ cine of some of the Holmesian
techniques.16
Just as other medical specialties like dermatology, ophthalmology, and pa¬ thology identify with and lay claim to Sherlock Holmes, so, too, can neurol¬
the number of stories reference to neurologic conditions that primarily or second¬ arily involve the brain or nervous sys¬ tem and the methods used in the ob¬ servation and diagnosis of patients it may well be that neurology's claim to such an association is as, or even more, valid than the others. In reviewing the Sherlock Holmes stories, we found a total of 41 (73% ) of the 56 short stories and all four of the novels made some ogy. Based
making
on
some
reference condition
or
comment to
or
a
neurologic
symptom. Described—
specifically mentioned—or some refer¬ made to are some 104 examples in the canonical writings that a neurolo¬ gist and Sherlock Holmes aficionado might make a case for to include in such a listing (Table).3·11·17 Among the neurologic conditions ence
mentioned in the Sherlock Holmes sto¬ ries are the following interesting ex¬
briefly noted. Scott, Mr Trevor describes the following condi¬ amples, which
are
In the story The Gloria
tion:
A letter arrived for my father yesterday evening... My father read it, clapped both his hands to his head, and began running
round the room in little circles like a man who has been driven out of his senses. When I at last drew him down onto the sofa, his mouth and eyelids were all puckered on one side, and I saw that he had a stroke we put him to bed; but the paralysis has spread, and he has shown no signs of returning consciousness.' ...
subsequently died within the next day. This is probably an example of a cerebrovascular hemorrhage that was brought on by stress.17·18 In The Valley of Fear, Holmes uses the expression "brain wave."17 Watson places the case as having occurred in January 1888. The first description of He
brain waves or the "currents of the brain" was given by Richard Caton in the British Medical Journal in 1875, and, therefore, Conan Doyle could have been aware of the report in which Caton described the presence of "elee-
trie currents in the brains of a rabbit and monkey."3·17·19 In the story, how¬ ever, the term is used as follows: "One more coruscation [flash of light], my dear Watson—yet another brain¬ wave."9 In The Sign ofthe Four, Holmes and Watson come upon the body of Bar¬ tholomew Sholto whose features were set... in a horrible smile, a fixed and unnatural grin, which, in that still and moonlit room, was more jarring to the nerves than any scowl or contortion. On further examining the body, Holmes says to Watson "Put your hand here on this poor fellow's arm, and here on his leg. What do you feel?" "The muscles are as hard as a board," Watson answered. "Quite so" Holmes replied. "They are in a state of extreme contraction, far exceed¬ ing the usual 'rigor mortis.' Coupled with this distortion of the face, this Hippocratic smile, or 'risus sardonicus,' as the old writ¬ ers called it, what conclusion would it sug¬ gest to your mind?" "Death from some powerful vegetable alkaloid," I answered; "some strychnine¬ like substance which would produce tetanus." "That was the idea which occurred to me the instant I saw the drawn muscles of the face," Holmes replied.'
In The Adventure ofthe Devil's Foot, toxic encephalopathy is produced by an unidentified poison, in which sev¬ eral people were driven mad or died of fright. Sherlock Holmes decides to expériment with the drug, and the fol¬ lowing is a description by Dr Watson of what happened to them: a
was conscious of a thick, musky odour, subtle and nauseous. At the very first whiff of it, my brain and my imagination were beyond all control. A thick black cloud swirled before my eyes, and my mind told me that in this cloud, unseen as yet, but about to spring out upon my appalled senses, lurked all that was vaguely horrible, all that was monstrous and inconceivably wicked in the universe. Vague shapes swirled and swam amid the dark cloudbank, each a menace and a warning of something coming, the advent of some un¬ speakable dweller upon the threshold, whose very shadow would blast my soul. A freezing horror took possession of The turmoil within my brain was me
I
such that something must surely snap. I tried to scream, and was vaguely aware of some hoarse croak which was my own voice, but distant and detached from myself. At the same moment, in some effort of escape, I broke through that cloud of despair, and had a glimpse of Holmes's face, white, rigid, and drawn with horror—the very look which I had seen upon the features of the dead. It was that vision which gave me an instant of sanity and of strength. I dashed from my chair, threw my arms round Holmes, and together we lurched through the door, and an instant afterwards had ...
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'
we carried him into the kitchen, where he lay back in a large chair and breathed heavily for some minutes. Finally, with a shamefaced apology for his weak¬ ness, he rose once more and said "I am lia¬ ble to these sudden nervous attacks." Later Holmes confesses that when the Inspector in the case was going to reveal something important to the villains, "I tumbled down in a sort of fit and so changed the conversation."'
attack,
Neurologie Conditions Mentioned in the Sherlock Holmes Stories
Neurologic Connections Drugs and toxins Syncope Head trauma Brain fever
Spinal deformities, injuries, diseases
Alcohol Seizures Cerebrovascular accidents,
injuries,
No. 30 21 11 7
and 6 6 5 4
etc
Movement disorders Simulated condition
Hydrocephalus (possible) Carbon monoxide
Cataplexy
Nervous breakdown Delirium Brain waves Total
3 3 2 2 1 1 1 1
104
thrown ourselves down upon the grass plot and were lying side by side, conscious only of the glorious sunshine which was bursting its way through the hellish cloud of terror which had girt us in. Slowly it rose from our souls like the mists from a landscape, until peace and reason had returned, and we were sitting up on the grass, wiping our clammy foreheads, and looking with apprehension at each other to mark the last traces of that terrific experience which we had undergone. "Upon my word, Watson!" said Holmes at last, with an unsteady voice, "I owe you both my thanks and an apology. It was an unjus¬ tifiable experiment even for oneself, and doubly so for a friend. I am really very
sorry."'
central
system stimula¬ tion or depression with symptoms of fear, anxiety, terror, color flashes, feel¬ nervous
ing cold, nausea or vomiting, and even¬ tually respiratory failure. It can also induce hallucinations and psychoticlike change similar to those produced by lysergic acid diethylamide (LSD).3·20·21 In The Adventure of the Dying De¬ tective, Holmes is thought by Dr Wat¬ son to be delirious, thus simulating a metabolic encephalopathy (Fig 3). As described by Dr Watson, He [Sherlock Holmes] was indeed a deplor¬ His eyes had the bright¬ able spectacle ness of fever, there was a hectic flush upon either cheek and dark crusts clung to his lips He spoke with a feverish energy, the long hands twitching and jerking as he motioned me away. ...
...
...
Later, when Watson was looking at little box on the mantle, Holmes let out a dreadful cry. Watson a
caught
a glimpse of a convulsed face and frantic eyes... Holmes said "Put it down I hate to have my things touched You are enough to drive a patient into ...
asylum" The violent and causeless excitement... so far removed from his usual suavity, showed me how deep was the disorganization of his mind. Of all ruins, that of a noble mind is the most deplorable. an
...
Holmes then started talking with a feverish animation about half crowns and oysters.
raving insanity," thought Wat¬ "I left him full of the image of this magnificent intellect babbling like a foolish child Behind me as I passed from the flat I heard Holmes's high thin voice in some delirious chant."9 "this
son
There is some speculation that the drug may be related to calabar, an Af¬ rican poison, or mescaline, which can cause
Fig 3.—Drawing by Frederic Dorr Steele of an emaciated Sherlock Holmes for Conan Doyle's The Dying Detective (from The Dying Detective. Strand Magazine. December 1893). After the original (courtesy Philip S. and Mary K. Hench Collection of the Special Collections Library, University of Minnesota).
was
...
...
Later, Holmes confessed that he was
simulating a terminal illness. He said
The best way of successfully acting a part is to be it... I give you my word that for three days I have tasted neither food nor drinkThree days of absolute fast does not improve one's beauty For the rest, there is nothing which a sponge may not cure. With vaseline upon one's forehead, bella¬ donna in one's eyes, rouge over the cheek¬ bones, and crusts of beeswax round one's lips, a very satisfying effect can be pro¬ duced. Malingering is a subject upon which I have sometimes thought of writing a monograph. A little occasional talk about half crowns, oysters, or any other extrane¬ ous subjects produces a pleasing effect of delirium.' ...
...
In The Reigate Squires, Holmes sim¬ ulates a seizure, which Watson de¬ scribes as poor friend's face had suddenly as¬ sumed the most dreadful appearance. His eyes rolled upwards, his features writhed in an agony, and with a suppressed groan, he dropped on his face upon the ground. Hor¬ rified at the suddenness and severity of the
My
In The Resident Patient, interest in the diseases of the nervous system is expressed through a comment made by Dr Percy Trevelyan who says "My own hobby has always been nervous dis¬ ease. I should wish to make it an abso¬ lute specialty, but, of course, a man must take what he can get at first." He also did some research on the pathol¬ ogy of catalepsy and is noted in the story to have won a "prize and medal by the monograph on nervous le¬ sions."9·21 In reality, Conan Doyle himself wrote a thesis on a neurologic condi¬ tion, tabes dorsalis. It was the custom that a graduate for the Doctor of Med¬ icine write a thesis for the MD degree. The thesis was completed in April 1885, two years before the first Sher¬ lock Holmes story, A Study in Scarlet. In the thesis, Doyle acknowledged Duchenne's contribution of the rela¬ tion of syphilis to tabes dorsalis, which was a new concept for the time. He also presented the various anatomic, phys¬ iologic, and clinical aspects of tabes dorsalis in a literary style that was as "graphic as the fiction stories." Of note, tabes is mentioned in several stories by Conan Doyle, but not in any of the Sherlock Holmes stories.22·23 From this brief review it is evident that Arthur Conan Doyle's medical training and experience had a major impact on his fiction—in fact, it per¬ meated his writings and especially the chronicles of the adventures of Sher¬ lock Holmes. The medical content of Conan Doyle's fiction contributed much to its success. There were strik¬ ing depictions of characters with med¬ ical problems; plot manipulations en¬ hanced by medically related descrip¬ tions; and various emotions like pity, horror, sympathy, and even humor were engendered for many of the liter¬ ary figures as a result of their afflic¬ tions or circumstances.21 The popular¬ ity of the canonical writings is cer¬ tainly due in part to the large amount of realistic detail, including the medi¬ cal. Perhaps more surprising is the fact that Holmes and Watson and var¬ ious elements of their adventures have spilled over into the realms of legiti¬ mate medicine. In the medical litera¬ ture, there are many references to the
...
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famous duo, their adventures, and modus operandi.24 The stories that we have referred to in this article illustrate a few of the examples of neurologic conditions de¬ scribed in the Sherlock Holmes adven¬ tures. There are many others that could have been referred to plus those
that appear in Conan Doyle's nonSherlockian writings. Several medical specialties have nominated Sherlock Holmes as one of their own. It would seem that neurology also has a claim to the master detective that is as valid— and, perhaps, even more so, based on sheer numbers of neurologic-related
references. As a final word on this matter, it was Holmes in The Adventure ofthe Mazarin Stone,9 who said, "I am a brain, Watson. The rest of me is a mere
appendix."
References 1. Key JD. Hench's Triumph\p=m-\AFixed Point in Changing World: Dr. Philip S. Hench's Contributions to Keeping the Holmes Fires Burning. Rochester, Minn: Davies; 1981. 2. Key JD, Rodin AE. Medical reputation and literary creation: An essay on Arthur Conan Doyle versus Sherlock Holmes 1887-1987. Adler Museum Bull. 1987;13:21-25. 3. Rodin AE, Key JD. Medical Casebook of Doctor Arthur Conan Doyle: From Practitioner to Sherlock Holmes and Beyond. Malabar, Fla: Krieger; 1984. 4. Key JD, Rodin AE. Permeation of medicine by a literary legend: Arthur Conan Doyle's consulting detective, Mister Sherlock Holmes. Baker Street Misc. 1985;42:11-17. 5. Harnagel EE. Joseph Bell, M.D.: the real Sherlock Holmes. N Engl J Med. 1958;258:1158\x=req-\ a
1159. 6. Liebow E. Dr Joe Bell: Model for Sherlock Holmes. Bowling Green, Ohio: Bowling Green University Popular Press; 1982. 7. Mann RJ, Key JD. Joseph Bell, M.D.,
F.R.C.S.: 'notes on a case of paralysis following diphtheria.' Pharos. 1982;45:27-29. 8. Scarlett EP. Doctor out of Zebulun. Arch Intern Med. 1964;114:696-701. 9. Doyle AC. The Complete Sherlock Holmes. New York, NY: Doubleday & Co; 1930. 10. Doyle AC. Memories and Adventures. London, England: Hodder & Stoughton; 1924. 11. Baring-Gould WS, ed. The Annotated Sherlock Holmes. The Four Novels and the Fifty-six Short Stories Completed by Sir Arthur Conan Doyle. 2nd ed. New York, NY: Clarkson N. Potter
Inc; 1967.
12. Ober WB. Conan Doyle's dying detective. N Y State J Med. 1967;67:2141-2145. 13. Cherington M. Sherlock Holmes: neurolo-
gist. Neurology. 1987;37:824-825.
14. Bates DM. Dr. Watson and the Jezail bullet. Va Med Bull. 1976;163:828-829. 15. Campbell M. Sherlock Holmes and Dr Watson: a medical digression. Guy's Hosp Gazette. 1935:56. 16. Fitzgerald FT, Tierney LM. The bedside
Sherlock Holmes. West J Med. 1982;137:169-175. 17. Brenner RP. Holmes, Watson, and neurology. J Clin Psychiatry. 1980;41:202-205. 18. Van Liere EJ. Dr Watson and nervous maladies. Baker Street J. 1954;4:100-108. 19. Caton R. The electric currents of the brain. BMJ. 1875;2:278. 20. Goetz CG. Neurotoxins in Medical Practice. New York, NY: Spectrum; 1985. 21. Rodin AE, Key JD. Doctor Arthur Conan Doyle's patients in fact and fiction. Med Heritage.
1985;1:80-98. 22. Doyle AC. An Essay Upon the Vaseomotor
Changes in Tabes Dorsalis and on the Influence Which Is Exerted by the Sympathetic Nervous System in That Disease. University of Edinburgh; April 1885. Unpublished thesis. 23. Rodin AE, Key JD. Arthur Conan Doyle's thesis on tabes dorsalis. JAMA. 1982;247:646-650. 24. Rodin AE, Key JD. The influence of literary legends on medicine. Y-The Med Inquirer. 1985; 1:8-11.
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