Medicine and Literature Sherlock Holmes and the Art of Dermatologic Diagnosis JOHN H. DIRCKX, M.D.
W h e r e v e r t h e E n g l i s h l a n g u a g e i s s p o k e n , the name of Sherlock Holmes is current coin and his legend thrives. It has been suggested that the re nowned detective of Baker Street is the best-known character in all of English literature, more famous than Hamlet, Frankenstein, Scrooge or James Bond. Trans lations of his adventures into dozens of languages have, of course, contributed to the global extent of his renown. One indication of Holmes’ enduring popularity is the fact that for nearly a century his most ardent admirers have refused to admit that he is a myth. Hundreds of letters are still addressed to him each year, asking for help or advice. Innumerable organizations of “ Sherlockians” flourish in all quarters of the world— harmless lunatics pretending to believe that Holmes once lived as a man of flesh and blood (unless, indeed, he is still knocking around somewhere at the age of about 130). His goings and comings are commemorated by more brass tablets in and near London than those of many a real-life Englishman with a stronger title to the admira tion and respect of his fellow-countrymen. So perva sive a legend is Holmes that probably the great ma jority of those who recognize his name have never read a single one of the stories in which his adventures are recounted. There must be thousands who glibly utter the expression, “ Elementary, my dear Watson,” for every true adept who knows that no such sentence appears in any authentic Holmes story. Holmes’ deerstalker cap and Inverness cape, his magnifying glass and calabash pipe have become international symbols for systematic investigation, the unraveling of puzzles and the elucidation of mysteries. These props also appear rather often in commercial advertising as mere eyecatchers. Within the past five years, various combinations of them have been used to D r. D irc k x is M e d ical D ir e c to r o f th e S tu d e n t H e a lth C e n te r, U n iv e rsity o f D a y to n , D a y to n , O hio. A d d ress r e p rin t re q u e s ts to D r. Jo h n H . D irc k x , 300 C o llege P a rk A ven ue, D a y to n , O h io 45469.
exploit the persona of Holmes in major promotional campaigns for Aldomet®, Omade®, and Synthroid®. It is not surprising that Sherlock Holmes has always held a special fascination for physicians, for his ties to medicine are numerous. He was created in 1886 by an impecunious young physician, Dr. Arthur Conan Doyle of Southsea (a suburb of Portsmouth, England); modeled upon another physician, Dr. Joseph Bell of Edinburgh; and named for a third, Dr. Oliver Wendell Holmes of Boston. His fictitious companion, col laborator and chronicler, almost as well known as Holmes himself, is yet another doctor, the warm hearted but thick-headed Dr. John H. Watson (who was, in turn, named after a real-life Dr. James Watson). Parallels are often drawn in the medical literature between the investigative methods of Sherlock Holmes and those of the physician in search of a diag nosis. Though the physician makes use of scientific facts and instruments, and may establish hypotheses that can be put to experimental proof, he is not, in his role of healer, a scientist in the strict sense, interested in the abstraction or induction of general principles. Like the detective, the practicing physician is princi pally a deductive reasoner, gathering clues and pro ceeding from effect to cause. Cooperman1, Bardana2, Hussey3, and Vaisrub4, among others, have recently written of the similarity between Holmes’ viewpoint and technique and those of medical practice. So too, a symposium on subtle clues to the diagnosis of skin diseases, conducted in October, 1978, at the New York University School of Medicine, was entitled “ Sherlockian Dermatopathology.” Is the comparison apt? Is the famous Holmes really a worthy standard and exemplar for the modem dermatologist? One who is unfamiliar with the Holmes tales might judge, from a list of their titles, that skin disease is one of their dominant themes. A Study in Scarlet refers, though, to the color of shed blood, not to a case of erysipelas. The unnatural hue of “ The Yellow Face”
J. Dermatol. Surg. Oncol. 5:3 March 1979
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is that of a mask and does not indicate chrysoderma of hypercarotenemia or the jaundice of hyper bilirubinemia. What would the heroine of “ The Ad venture of the Veiled Lodger” be hiding? A lupoid condition? Scars of smallpox? A photodermatitis? None of them. She seeks to conceal scars resulting from an encounter with a lion. “ The Adventure of the Engineer’s Thumb” concerns neither contact der matitis nor verrucae vulgares, and “ The Adventure of the Blue Carbuncle” is about a precious stone, not a much loculated pyoderma due to Pseudomonas aeruginosa. Joking aside, it happens that the four novels and 56 short stories written about Holmes by Dr. Doyle con tain an adequate body of evidence on which to judge how appropriate the comparison is between the fic tional detective and a real-life dermatologist. Doyle endowed his character with a fund of medical knowl edge rather unusual in a layman, and it might be well to form some estimate of that first. Before introducing Watson to Holmes, their friend “ young Stanhope” warns the doctor (A Study in Scar let) that Holmes goes in for some peculiar kinds of scientific research. Employed in the chemical labora tory at St. Bartholomew’s Hospital, he has often been seen hanging about the dissecting rooms. He is not, however, a regularly enrolled medical student seeking to sharpen his knowledge of anatomy; instead, his purpose has been to study the effects of post-mortem injury by beating cadavers with a stick. Here, as usual, Holmes’ medical interests have a strong forensic tinge. When the famous introduction takes place, Holmes has just developed a highly sensi tive and specific test for hemoglobin—a test whose application he foresees in criminal detection rather than in clinical medicine. A lifelong dabbler in chemi cal experimentation, he is specially skilled in tox icology. Musto5 has commented in detail on Holmes’ knowledge of biometrics and medical genetics. Con siderable knowledge of clinical medicine is implied by his interest in the “ art” of malingering, in which he gives a brilliant performance in “ The Adventure of the Dying Detective,” deceiving even Watson. In “ The Reigate Puzzle” he feigns an epileptiform seizure, and in “ The Resident Patient” he claims to have imitated catalepsy. In A Study in Scarlet he says, “ By a man’s finger nails, by his coat-sleeve, by his boots, by his trouser knees, by the callosities of his forefinger and thumb, by his shirtcuffs—by each of these things a man’s call ing is plainly revealed. That all united should fail to enlighten the competent inquirer in any case is almost inconceivable.” Warshaw6 quotes these remarks to in troduce an article on occupational medicine. Holmes
192
J. Dermatol. Surg. Oncol. 5:3 March 1979
tells Watson in The Sign o f Four that he has written a monograph on the influence of a trade on the hand. A book on occupational markings by a dermatologist, Dr. Francesco Ronchese7, is cited in this connection by Baring-Gould8 in The Annotated Sherlock Holmes. Holmes reveals other skills of a dermatologic charac ter when he mentions to Jabez Wilson in “ The RedHeaded League’’ that he has made a special study of tattoo marks. Two of his later cases hinge directly on dermatologic diagnosis. In “ The Adventure of the Blanched Sol dier” Holmes deduces from indirect evidence that a Boer War veteran has gone into isolation with the diagnosis of leprosy. He further speculates that the diagnosis is erroneous and brings in an eminent dermatologist, who confirms that the patient has ichthyosis. After retiring to Sussex, Holmes solves the apparent murder of a local schoolmaster in “ The Ad venture of the Lion’s Mane.” The victim’s dying ref erence to “ the lion’s mane” and the appearance of the dark red lines on his back tell Holmes that he has been fatally stung by Cyanea capillata, the largest of the jellyfish, whose tentacles may exceed 20 m in length. These two dermatologic cases are the only Sherlock Holmes stories narrated in the first person by the de tective himself, a fact whose possibilities for fantastic interpretation seem to have been overlooked by Sherlockians. Clearly the circumstances of these cases are too specific and particular for our present purpose: we are comparing Holmes with the dermatologist, not try ing to prove that he was a dermatologist. Let us review some of the canons of dermatologic diagnosis and judge whether Holmes’ methods, and his frequent asides to Watson and others on the subject of those methods, justify the comparisons so frequently made. Authorities on the art of diagnosis always lay great stress on the importance of beginning the investigation with a careful and thorough review of the patient’s history. In virtually all of his criminal investigations, Holmes begins by extracting from his client—private citizen or bewildered police detective—a detailed, ac curate, chronologic statement of the case. The only exceptions are those few stories in which Holmes acts on his own initiative and therefore has no client to question. His manner of gathering historical facts is thorough, perceptive and discreet. He is a keen psychologist, able to inspire confidence and convey compassion, and not often taken in by informants who gild or distort the truth. In “ The Problem of Thor Bridge” he states that the investigator must look for consistency in the data, and when it is lacking, suspect deception. The physi cian, too, must often thresh out apparent contradic tions in medical history, distinguishing facts from mis-
MEDICINE AND LITERATURE
understandings, wishful thinking and deliberate lies. History taken, the physician subjects his patient to a careful physical examination. In dermatology this de mands, before all else, good light. In “ The Adventure of the Blanched Soldier” Holmes affirms that it is his habit to sit with his back to the window and to place his visitors in the opposite chair where the light falls fully upon them. In the gaslight era this was of course exactly the practice of dermatologists (who dreaded gloomy weather and never held evening consulta tions). Besides proper illumination the dermatologist must have adequate exposure of the skin, not taking on faith the patient’s assurances that lesions are or are not present in a given area, or that they are like or unlike ones that have been displayed. “ There is nothing like first-hand evidence,” says Holmes in A Study in Scar let. He condemns the practice of theorizing on insuffi cient data in The Valley o f Fear. The dermatologic examination requires the utmost alertness. Pillsbury, Shelley and Kligman9 assert, not without considerable plausibility, that under the condi tions prevailing in some clinics even a green monkey tattooed on the patient’s chin might escape notice. Much the same sentiment was voiced by Holmes in The Hound o f the Baskervilles when he remarked, “ The world is full of obvious things that nobody by any chance ever observes.” In seeking to interpret and identify abnormal signs in the skin, the specialist must focus his attention on the most characteristic lesions. Holmes counsels Watson in “ A Case of Identity,” “ Never trust to general im pressions, but concentrate yourself upon details.” Thoroughness is the mark of the competent diagnosti cian, in dermatology and in other branches of medi cine; no feature of the history or the examination should be considered a priori as trivial or irrelevant. “ The little things,” says Holmes in the story just quoted, “ are infinitely the most important.” The physician, and particularly the dermatologist, does not perceive with his senses alone; his is an in formed, a prepared observation, concerned with the recognition of shapes, colors, textures and patterns already known. Holmes observes in A Study in Scarlet that like other arts, the technique of investigation is one which can only be acquired by long and patient study, “ nor is life long enough to allow any mortal to attain the highest possible perfection in it.” Perhaps here the physician-author unwittingly echoed the well-known aphorism of Hippocrates, “ Life is so short, and the art takes so long to learn.” The astute clinician recognizes a disorder of the skin not only when it appears in its classic manifesta tion but also when it takes a forme fruste or plays the role of “ great impersonator.” “ It is the first quality of
194
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the criminal investigator,” says Holmes in The Hound o f the Baskervilles, “ that he should see through a dis guise.” Moreover, thorough competence in der matologic diagnosis implies a knowledge of many sci entific disciplines, including anatomy, chemistry, physiology, physics, pathology, immunology, mi crobiology, pharmacology, internal medicine, and psy chiatry. Sherlock Holmes, who brought to his work an astounding range of information, remarked in The Val ley o f Fear that breadth of view is essential for the detective, and that the interplay of ideas and the oblique uses of knowledge are often of crucial importance. Diagnosis is not, of course, mere recognition; it is an intellectual process. When the nature of the disease is not immediately apparent, the faculty of analytic or deductive reasoning comes into play. Holmes de scribes the reasoning process at some length in A Study in Scarlet, and in “ The Five Orange Pips” he says, “ The ideal reasoner would, when he had once been shown a single fact in all its bearings, deduce from it not only all the chain of events which led up to it but also all the results which would follow from it.” Physicians who are inclined to look for esoteric dis eases are often admonished, “ When you hear hoofbeats, think first of a horse, not a zebra.” Holmes admits, in “ The Adventure of the Abbey Grange,” “ When a man has special knowledge and special pow ers like my own, it rather encourages him to seek a complex explanation when a simple one is at hand.” Yet it is essential too for the diagnostician to be on his guard against the uncritical acceptance of too evident and facile an explanation. As Holmes puts it in “ The Boscombe Valley Mystery,” “ There is nothing so de ceptive as an obvious fact.” Despite the temptation to explain all abnormal find ings by a unitary cause, the analytic reasoner must always be open to the possibility that several causes are operative, either independently or in series. Dis tinguishing these causes and assigning to each its prop er significance demands not only clinical acumen but a certain measure of imagination. In “ The Disappear ance of Lady Frances Carfax” Holmes discourses on the process whereby two separate chains of thought can be made to intersect and yield an approximation to the truth. More often than not, even when deductive reasoning has been exploited to the utmost, dermatologic diag nosis resolves itself into the matching of the case at hand with a known pattern or stereotype. In this mode of diagnosis we follow the principle of detection that is perhaps most closely associated with the name of Holmes, a principle that he enunciated several times throughout the stories, but nowhere more lucidly or
MEDICINE AND LITERATURE
succinctly than in “ The Adventure of the Blanched Soldier” : “ When you have eliminated all that is im possible, whatever remains, however improbable, must be the truth.” The cynic who objects that in der matology nothing is impossible will feel little kinship with the detective when he remarks, in The Hound o f the Baskervilles, “ There is nothing more stimulating than a case where everything goes against you.” In drawing parallels between Holmes and the der matologist I have perhaps allowed my enthusiasm for the subject to blur the distinction between reality and fantasy. Though the facts may not support the fiction that Holmes was a competent dermatologist, it is surely not too much to say that every dermatologist should be a Sherlock Holmes. REFERENCES 1. Cooperman, E. M. Marfan’s syndrome and Sherlock Holmes (letter). Can. Med. Assoc. J. 112:423, 1975. 2. Bardana, E. J., Jr. Looking at SLE: a case of identity. Consul tant. June: 139-144, 1975. 3. Hussey, H. H. Diagnosis by deduction from a few observations (editorial). J.A.M.A. 235:1884, 1976. 4. Vaisrub, S. Holmes or Spade? (editorial) J.A.M.A. 238:27212722, 1977. 5. Musto, D. F. Sherlock Holmes and heredity. J.A.M.A. 196:4549, 1966. 6. Warshaw, L. J. Clues to illness from the patient’s occupation. Consultant. November: 107-113, 1976. 7. Rónchese, F. Occupational Marks. New York, Grune & Strat ton, 1948. 8. Baring-Gould, W. S. The Annotated Sherlock Holmes. New York, Clarkson N. Potter, 1967, Vol. 1, p. 613. 9. Pillsbury, D. M., Shelley, W. B., and Kligman, A. M. A Manual of Cutaneous Medicine. Philadelphia, W. B. Saunders Com pany, 1961, p. 52.
Professional Meetings MARCH 1979________________________ March 2-4 Postgraduate Seminar in Dermatology. Miami Beach, Florida. Information: Dr. William H. Eaglstein, 6614 Miami Lakes Drive East, Miami Lakes, Fla 33014. March 2-4 Fourth Annual Conference on Skin Diseases for the Nurse. Miami Beach, Florida. Information: Dr. William H. Eaglstein, 6614 Miami Lakes Drive East, Miami Lakes, Fla 33014. March 3-6 Seminar on Rhinoplasty. Birmingham, Alabama. Sponsored by the American Academy of Facial Plastic and Reconstructive Surgery. Information: E. Gaylon McCollough, M.D., 1516 South 20th Street, Birmingham, Al 35205. March 4-9 Eighteenth Annual Conference on Detection and Treatment of Breast Cancer. Atlanta, Georgia. Sponsored by the American College of Radiology. Information: Robert W. Harrington, Ph.D., American College of Radiology, 20 North Wacker Drive, Chicago, III 60606. March 6-10 Seventh Annual Consultant’s Course. San Fran cisco, California. Information: Extended Programs in Medical Education, University of California, San Francisco, Ca 94143. March 13-16 First International Congress of Hair Research. Sponsored by German Society of Cosmetic Chemists, GKC, Frankfurt. Hamburg, Germany. In formation: Dralle Work Shop Group, “Scientific Hair Research,” P.O. Box 600469, D 2000 Hamburg 60, West Germany. March 26-28 Occupational Dermatology Symposium. San Fran cisco, California. Information: Extended Programs in Medical Education, University of California Hos pital, San Francisco, Ca 94143.
APRIL 1979 April 19-21 Cutaneous Vulvar and Vaginal Disease. New York, New York. Sponsored by the Columbia University College of Physicians and Surgeons. Information: Jose M. Ferrer, M.D., 630 West 168th St., New York, N.Y. 10032. 0Continued on page 199) 196
J. Dermatol. Surg. Oncol. 5:3 March 1979
W h e r e v e r t h e E n g l i s h l a n g u a g e i s s p o k e n , the name of Sherlock Holmes is current coin and his legend thrives. It has been suggested that the re nowned detective of Baker Street is the best-known character in all of English literature, more famous than Hamlet, Frankenstein, Scrooge or James Bond. Trans lations of his adventures into dozens of languages have, of course, contributed to the global extent of his renown. One indication of Holmes’ enduring popularity is the fact that for nearly a century his most ardent admirers have refused to admit that he is a myth. Hundreds of letters are still addressed to him each year, asking for help or advice. Innumerable organizations of “ Sherlockians” flourish in all quarters of the world— harmless lunatics pretending to believe that Holmes once lived as a man of flesh and blood (unless, indeed, he is still knocking around somewhere at the age of about 130). His goings and comings are commemorated by more brass tablets in and near London than those of many a real-life Englishman with a stronger title to the admira tion and respect of his fellow-countrymen. So perva sive a legend is Holmes that probably the great ma jority of those who recognize his name have never read a single one of the stories in which his adventures are recounted. There must be thousands who glibly utter the expression, “ Elementary, my dear Watson,” for every true adept who knows that no such sentence appears in any authentic Holmes story. Holmes’ deerstalker cap and Inverness cape, his magnifying glass and calabash pipe have become international symbols for systematic investigation, the unraveling of puzzles and the elucidation of mysteries. These props also appear rather often in commercial advertising as mere eyecatchers. Within the past five years, various combinations of them have been used to D r. D irc k x is M e d ical D ir e c to r o f th e S tu d e n t H e a lth C e n te r, U n iv e rsity o f D a y to n , D a y to n , O hio. A d d ress r e p rin t re q u e s ts to D r. Jo h n H . D irc k x , 300 C o llege P a rk A ven ue, D a y to n , O h io 45469.
exploit the persona of Holmes in major promotional campaigns for Aldomet®, Omade®, and Synthroid®. It is not surprising that Sherlock Holmes has always held a special fascination for physicians, for his ties to medicine are numerous. He was created in 1886 by an impecunious young physician, Dr. Arthur Conan Doyle of Southsea (a suburb of Portsmouth, England); modeled upon another physician, Dr. Joseph Bell of Edinburgh; and named for a third, Dr. Oliver Wendell Holmes of Boston. His fictitious companion, col laborator and chronicler, almost as well known as Holmes himself, is yet another doctor, the warm hearted but thick-headed Dr. John H. Watson (who was, in turn, named after a real-life Dr. James Watson). Parallels are often drawn in the medical literature between the investigative methods of Sherlock Holmes and those of the physician in search of a diag nosis. Though the physician makes use of scientific facts and instruments, and may establish hypotheses that can be put to experimental proof, he is not, in his role of healer, a scientist in the strict sense, interested in the abstraction or induction of general principles. Like the detective, the practicing physician is princi pally a deductive reasoner, gathering clues and pro ceeding from effect to cause. Cooperman1, Bardana2, Hussey3, and Vaisrub4, among others, have recently written of the similarity between Holmes’ viewpoint and technique and those of medical practice. So too, a symposium on subtle clues to the diagnosis of skin diseases, conducted in October, 1978, at the New York University School of Medicine, was entitled “ Sherlockian Dermatopathology.” Is the comparison apt? Is the famous Holmes really a worthy standard and exemplar for the modem dermatologist? One who is unfamiliar with the Holmes tales might judge, from a list of their titles, that skin disease is one of their dominant themes. A Study in Scarlet refers, though, to the color of shed blood, not to a case of erysipelas. The unnatural hue of “ The Yellow Face”
J. Dermatol. Surg. Oncol. 5:3 March 1979
191
MEDICINE AND LITERATURE
is that of a mask and does not indicate chrysoderma of hypercarotenemia or the jaundice of hyper bilirubinemia. What would the heroine of “ The Ad venture of the Veiled Lodger” be hiding? A lupoid condition? Scars of smallpox? A photodermatitis? None of them. She seeks to conceal scars resulting from an encounter with a lion. “ The Adventure of the Engineer’s Thumb” concerns neither contact der matitis nor verrucae vulgares, and “ The Adventure of the Blue Carbuncle” is about a precious stone, not a much loculated pyoderma due to Pseudomonas aeruginosa. Joking aside, it happens that the four novels and 56 short stories written about Holmes by Dr. Doyle con tain an adequate body of evidence on which to judge how appropriate the comparison is between the fic tional detective and a real-life dermatologist. Doyle endowed his character with a fund of medical knowl edge rather unusual in a layman, and it might be well to form some estimate of that first. Before introducing Watson to Holmes, their friend “ young Stanhope” warns the doctor (A Study in Scar let) that Holmes goes in for some peculiar kinds of scientific research. Employed in the chemical labora tory at St. Bartholomew’s Hospital, he has often been seen hanging about the dissecting rooms. He is not, however, a regularly enrolled medical student seeking to sharpen his knowledge of anatomy; instead, his purpose has been to study the effects of post-mortem injury by beating cadavers with a stick. Here, as usual, Holmes’ medical interests have a strong forensic tinge. When the famous introduction takes place, Holmes has just developed a highly sensi tive and specific test for hemoglobin—a test whose application he foresees in criminal detection rather than in clinical medicine. A lifelong dabbler in chemi cal experimentation, he is specially skilled in tox icology. Musto5 has commented in detail on Holmes’ knowledge of biometrics and medical genetics. Con siderable knowledge of clinical medicine is implied by his interest in the “ art” of malingering, in which he gives a brilliant performance in “ The Adventure of the Dying Detective,” deceiving even Watson. In “ The Reigate Puzzle” he feigns an epileptiform seizure, and in “ The Resident Patient” he claims to have imitated catalepsy. In A Study in Scarlet he says, “ By a man’s finger nails, by his coat-sleeve, by his boots, by his trouser knees, by the callosities of his forefinger and thumb, by his shirtcuffs—by each of these things a man’s call ing is plainly revealed. That all united should fail to enlighten the competent inquirer in any case is almost inconceivable.” Warshaw6 quotes these remarks to in troduce an article on occupational medicine. Holmes
192
J. Dermatol. Surg. Oncol. 5:3 March 1979
tells Watson in The Sign o f Four that he has written a monograph on the influence of a trade on the hand. A book on occupational markings by a dermatologist, Dr. Francesco Ronchese7, is cited in this connection by Baring-Gould8 in The Annotated Sherlock Holmes. Holmes reveals other skills of a dermatologic charac ter when he mentions to Jabez Wilson in “ The RedHeaded League’’ that he has made a special study of tattoo marks. Two of his later cases hinge directly on dermatologic diagnosis. In “ The Adventure of the Blanched Sol dier” Holmes deduces from indirect evidence that a Boer War veteran has gone into isolation with the diagnosis of leprosy. He further speculates that the diagnosis is erroneous and brings in an eminent dermatologist, who confirms that the patient has ichthyosis. After retiring to Sussex, Holmes solves the apparent murder of a local schoolmaster in “ The Ad venture of the Lion’s Mane.” The victim’s dying ref erence to “ the lion’s mane” and the appearance of the dark red lines on his back tell Holmes that he has been fatally stung by Cyanea capillata, the largest of the jellyfish, whose tentacles may exceed 20 m in length. These two dermatologic cases are the only Sherlock Holmes stories narrated in the first person by the de tective himself, a fact whose possibilities for fantastic interpretation seem to have been overlooked by Sherlockians. Clearly the circumstances of these cases are too specific and particular for our present purpose: we are comparing Holmes with the dermatologist, not try ing to prove that he was a dermatologist. Let us review some of the canons of dermatologic diagnosis and judge whether Holmes’ methods, and his frequent asides to Watson and others on the subject of those methods, justify the comparisons so frequently made. Authorities on the art of diagnosis always lay great stress on the importance of beginning the investigation with a careful and thorough review of the patient’s history. In virtually all of his criminal investigations, Holmes begins by extracting from his client—private citizen or bewildered police detective—a detailed, ac curate, chronologic statement of the case. The only exceptions are those few stories in which Holmes acts on his own initiative and therefore has no client to question. His manner of gathering historical facts is thorough, perceptive and discreet. He is a keen psychologist, able to inspire confidence and convey compassion, and not often taken in by informants who gild or distort the truth. In “ The Problem of Thor Bridge” he states that the investigator must look for consistency in the data, and when it is lacking, suspect deception. The physi cian, too, must often thresh out apparent contradic tions in medical history, distinguishing facts from mis-
MEDICINE AND LITERATURE
understandings, wishful thinking and deliberate lies. History taken, the physician subjects his patient to a careful physical examination. In dermatology this de mands, before all else, good light. In “ The Adventure of the Blanched Soldier” Holmes affirms that it is his habit to sit with his back to the window and to place his visitors in the opposite chair where the light falls fully upon them. In the gaslight era this was of course exactly the practice of dermatologists (who dreaded gloomy weather and never held evening consulta tions). Besides proper illumination the dermatologist must have adequate exposure of the skin, not taking on faith the patient’s assurances that lesions are or are not present in a given area, or that they are like or unlike ones that have been displayed. “ There is nothing like first-hand evidence,” says Holmes in A Study in Scar let. He condemns the practice of theorizing on insuffi cient data in The Valley o f Fear. The dermatologic examination requires the utmost alertness. Pillsbury, Shelley and Kligman9 assert, not without considerable plausibility, that under the condi tions prevailing in some clinics even a green monkey tattooed on the patient’s chin might escape notice. Much the same sentiment was voiced by Holmes in The Hound o f the Baskervilles when he remarked, “ The world is full of obvious things that nobody by any chance ever observes.” In seeking to interpret and identify abnormal signs in the skin, the specialist must focus his attention on the most characteristic lesions. Holmes counsels Watson in “ A Case of Identity,” “ Never trust to general im pressions, but concentrate yourself upon details.” Thoroughness is the mark of the competent diagnosti cian, in dermatology and in other branches of medi cine; no feature of the history or the examination should be considered a priori as trivial or irrelevant. “ The little things,” says Holmes in the story just quoted, “ are infinitely the most important.” The physician, and particularly the dermatologist, does not perceive with his senses alone; his is an in formed, a prepared observation, concerned with the recognition of shapes, colors, textures and patterns already known. Holmes observes in A Study in Scarlet that like other arts, the technique of investigation is one which can only be acquired by long and patient study, “ nor is life long enough to allow any mortal to attain the highest possible perfection in it.” Perhaps here the physician-author unwittingly echoed the well-known aphorism of Hippocrates, “ Life is so short, and the art takes so long to learn.” The astute clinician recognizes a disorder of the skin not only when it appears in its classic manifesta tion but also when it takes a forme fruste or plays the role of “ great impersonator.” “ It is the first quality of
194
J. Dermatol. Surg. Oncol. 5:3 March 1979
the criminal investigator,” says Holmes in The Hound o f the Baskervilles, “ that he should see through a dis guise.” Moreover, thorough competence in der matologic diagnosis implies a knowledge of many sci entific disciplines, including anatomy, chemistry, physiology, physics, pathology, immunology, mi crobiology, pharmacology, internal medicine, and psy chiatry. Sherlock Holmes, who brought to his work an astounding range of information, remarked in The Val ley o f Fear that breadth of view is essential for the detective, and that the interplay of ideas and the oblique uses of knowledge are often of crucial importance. Diagnosis is not, of course, mere recognition; it is an intellectual process. When the nature of the disease is not immediately apparent, the faculty of analytic or deductive reasoning comes into play. Holmes de scribes the reasoning process at some length in A Study in Scarlet, and in “ The Five Orange Pips” he says, “ The ideal reasoner would, when he had once been shown a single fact in all its bearings, deduce from it not only all the chain of events which led up to it but also all the results which would follow from it.” Physicians who are inclined to look for esoteric dis eases are often admonished, “ When you hear hoofbeats, think first of a horse, not a zebra.” Holmes admits, in “ The Adventure of the Abbey Grange,” “ When a man has special knowledge and special pow ers like my own, it rather encourages him to seek a complex explanation when a simple one is at hand.” Yet it is essential too for the diagnostician to be on his guard against the uncritical acceptance of too evident and facile an explanation. As Holmes puts it in “ The Boscombe Valley Mystery,” “ There is nothing so de ceptive as an obvious fact.” Despite the temptation to explain all abnormal find ings by a unitary cause, the analytic reasoner must always be open to the possibility that several causes are operative, either independently or in series. Dis tinguishing these causes and assigning to each its prop er significance demands not only clinical acumen but a certain measure of imagination. In “ The Disappear ance of Lady Frances Carfax” Holmes discourses on the process whereby two separate chains of thought can be made to intersect and yield an approximation to the truth. More often than not, even when deductive reasoning has been exploited to the utmost, dermatologic diag nosis resolves itself into the matching of the case at hand with a known pattern or stereotype. In this mode of diagnosis we follow the principle of detection that is perhaps most closely associated with the name of Holmes, a principle that he enunciated several times throughout the stories, but nowhere more lucidly or
MEDICINE AND LITERATURE
succinctly than in “ The Adventure of the Blanched Soldier” : “ When you have eliminated all that is im possible, whatever remains, however improbable, must be the truth.” The cynic who objects that in der matology nothing is impossible will feel little kinship with the detective when he remarks, in The Hound o f the Baskervilles, “ There is nothing more stimulating than a case where everything goes against you.” In drawing parallels between Holmes and the der matologist I have perhaps allowed my enthusiasm for the subject to blur the distinction between reality and fantasy. Though the facts may not support the fiction that Holmes was a competent dermatologist, it is surely not too much to say that every dermatologist should be a Sherlock Holmes. REFERENCES 1. Cooperman, E. M. Marfan’s syndrome and Sherlock Holmes (letter). Can. Med. Assoc. J. 112:423, 1975. 2. Bardana, E. J., Jr. Looking at SLE: a case of identity. Consul tant. June: 139-144, 1975. 3. Hussey, H. H. Diagnosis by deduction from a few observations (editorial). J.A.M.A. 235:1884, 1976. 4. Vaisrub, S. Holmes or Spade? (editorial) J.A.M.A. 238:27212722, 1977. 5. Musto, D. F. Sherlock Holmes and heredity. J.A.M.A. 196:4549, 1966. 6. Warshaw, L. J. Clues to illness from the patient’s occupation. Consultant. November: 107-113, 1976. 7. Rónchese, F. Occupational Marks. New York, Grune & Strat ton, 1948. 8. Baring-Gould, W. S. The Annotated Sherlock Holmes. New York, Clarkson N. Potter, 1967, Vol. 1, p. 613. 9. Pillsbury, D. M., Shelley, W. B., and Kligman, A. M. A Manual of Cutaneous Medicine. Philadelphia, W. B. Saunders Com pany, 1961, p. 52.
Professional Meetings MARCH 1979________________________ March 2-4 Postgraduate Seminar in Dermatology. Miami Beach, Florida. Information: Dr. William H. Eaglstein, 6614 Miami Lakes Drive East, Miami Lakes, Fla 33014. March 2-4 Fourth Annual Conference on Skin Diseases for the Nurse. Miami Beach, Florida. Information: Dr. William H. Eaglstein, 6614 Miami Lakes Drive East, Miami Lakes, Fla 33014. March 3-6 Seminar on Rhinoplasty. Birmingham, Alabama. Sponsored by the American Academy of Facial Plastic and Reconstructive Surgery. Information: E. Gaylon McCollough, M.D., 1516 South 20th Street, Birmingham, Al 35205. March 4-9 Eighteenth Annual Conference on Detection and Treatment of Breast Cancer. Atlanta, Georgia. Sponsored by the American College of Radiology. Information: Robert W. Harrington, Ph.D., American College of Radiology, 20 North Wacker Drive, Chicago, III 60606. March 6-10 Seventh Annual Consultant’s Course. San Fran cisco, California. Information: Extended Programs in Medical Education, University of California, San Francisco, Ca 94143. March 13-16 First International Congress of Hair Research. Sponsored by German Society of Cosmetic Chemists, GKC, Frankfurt. Hamburg, Germany. In formation: Dralle Work Shop Group, “Scientific Hair Research,” P.O. Box 600469, D 2000 Hamburg 60, West Germany. March 26-28 Occupational Dermatology Symposium. San Fran cisco, California. Information: Extended Programs in Medical Education, University of California Hos pital, San Francisco, Ca 94143.
APRIL 1979 April 19-21 Cutaneous Vulvar and Vaginal Disease. New York, New York. Sponsored by the Columbia University College of Physicians and Surgeons. Information: Jose M. Ferrer, M.D., 630 West 168th St., New York, N.Y. 10032. 0Continued on page 199) 196
J. Dermatol. Surg. Oncol. 5:3 March 1979
