Reminiscence
SHERLOCK HOLMES AND DERMATOLOGY >
Few persons, either real or fictional, have captured the public imagination in quite such a manner as the great consulting detective of Victorian and Edwardian England, Sherlock Holmes. At the beginning of this century, accounts of the adventures of Holmes and his physician companion Dr. John H. Watson made Arthur Conan Doyle one of the first literary millionaires. Recent months have seen a revival of popularity for Holmes and Watson with best-selling new adventures, several new motion pictures and television shows, and the successful return to the stage of the William Gillette play, Sherlock Holmes. The world's first consulting detective was born in 1854, the scion of a family of country squires that also contained a distinct artistic strain.' After attending one of England's great universities (authorities still disagree whether it was Oxford or Cambridge), he moved to London and began a long and distinguished career. From 1874 until his retirement in 1903, he aided victims of crime from all walks of life, including statesmen and nobility of several nations, quietly assisted his "professional" colleagues of Scotland Yard, and soundly placed the art of detection on a logical and scientific basis. He was an expert boxer, fencer, musician, and despite Dr. John Watson's early as-
EDGAR B. SMITH, M.D. AND HERMAN BEERMAN, M.D.
Erom the Division of Dermatology, Department of Medicine, University of New Mexico School of Medicine, Albuquerque, New Mexico, and the Department of Dermatology, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
sessment of his knowledge, a well-read scholar in many fields.^ From the records of Watson, Arthur Conan Doyle and himself, we have details of 60 cases solved by Holmes, including 2 after his retirement to Sussex. In addition, many other cases are briefly mentioned in the original stories (known as the Canon) and recent years have seen the appearance of a number of newly discovered adventures. For a person widely thought to be fictitious, Sherlock Holmes has achieved a rare state of reality. His biographies are still being written and have appeared in "books of facts" such as The People's Almanac. The late Vincent Starrett remarked, "The plain fact is that Sherlock Holmes is still a more commanding figure in the world than most of the warriors and statesmen in whose present existence we are invited to believe."^ Three Physicians Three physicians were closely involved with the life and works of the great detective. The most important of them is, of course, his first biographer and some-
Address for reprints: Edgar B. Smith, M.D., Division of Dermatology, University of New Mexico Scbool of Medicine, Albuquerque, NM 87131.
433
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INTERNATIONAL JOURNAL OF DERMATOLOGY
time sharer of lodgings. Dr. John H. Watson. Watson v.'as born in 1852 and is believed to have traveled widely throughout the world in his early life. He studied medicine at the University of Edinburgh and probably received his Bachelor of Medicine and Baccalaureate of Surgery degree there before taking advanced studies for the Doctor of Medicine degree at the University of London. While serving as a medical officer in the British Army in Afghanistan, he received a wound which abruptly ended his military career. He returned to London, a poor and discouraged pensioner, where fate and one of his former surgical assistants (another doctor named Stamford) led him to his historic meeting with Mr. Sherlock Holmes in the Pathology Laboratory of Saint Bartholomew's Hospital. From their meeting in 1881 until Holmes' retirement. Dr. Watson was the master detective's loyal companion, able (usually) assistant, and most important, the recorder of 56 of his most notable cases. Skeptics who maintain that Holmes and Watson are indeed fictional characters give credit for their creation to another physician. Dr. Arthur Conan Doyle.5 Doyle was born in Edinburgh in 1889. He studied medicine at the University of Edinburgh from 1876 to 1881 and after a brief stint as a ship's surgeon, he entered practice at Plymouth. He never achieved success as a physician, neither as a general practitioner at Plymouth and Southsea nor as an ophthalmologist in London. Then he turned to writing. In addition to the Sherlock Holmes stories, he wrote a number of popular historical and science fiction novels and many short stories. For his service to Britain in the Boer War, he was knighted in 1902 (an honor which Holmes declined the same year). Doyle in his later years developed
June 1977
Vol. 16
a deep interest in spiritualism, a paradox in view of his creation of such logical and scientific minds as Sherlock Holmes and Professor Challenger. His death in 1930 ended one of the most successful literary careers of all time. Those who hold that Arthur Conan Doyle rather than John Watson was the actual author of the Holmesian Canon point to a third doctor of importance. Dr. Joseph Bell was for many years Professor of Surgery at the University of Edinburgh. He was an outstanding teacher and journalist who excelled in accurately deducing not only medical problems but personal characteristics and occupations of his patients by observation of such trifles as the calluses on their hands and the type of mud on their shoes. Bell taught Doyle and immensely impressed him. His gift for observation of details and amazingly accurate deductions made him an excellent model for the character of Holmes and his role in the creation of the great detective was acknowledged by Doyle many times. Because of the influence of Dr. Joseph Bell, the important role of Dr. Arthur Conan Doyle as either the creator of the Holmes tales or, as some maintain, the literary agent responsible for the distribution of the stories, and the even more important role of Dr. John H. Watson, it is not surprising that the Canon contains much of medical interest. As a result, physicians have been prominent members of such Holmes admiring clubs as the Baker Street Irregulars and its many scion societies; also, articles on various medical aspects of the stories have appeared in many professional journals. Dermatologists are particularly attracted to the Holmes stories. The most important reason for this attraction is the fact that the specialist in skin diseases follows the methods and teachings of Holmes more closely than any other
No. 5
SHERLOCK HOLMES
medical specialist. As pointed out by the late Dr. Joseph V. Klauder, "Keen observation, intense inspection of the subject, attention to details and apparent trifles so much emphasized by Sherlock Holmes are particularly pertinent to the dermatologist.""^ The dermatologist is also drawn to the Canon by the numerous references to dermatologic problems and allusions to physiological changes in the skin. Excellent clinical descriptions are sprinkled throughout the stories and any dermatologist can find great enjoyment in seeking these. We would like to draw particular attention to several dermatologic aspects of the Holmesian Canon. Among these are Sherlock Holmes' scientific and scholarly interests as they relate to the skin, the master detective's own dermatological problems, and Holmes' use of his knowledge of the skin and its abnormalities in solving 2 most puzzling mysteries. Sherlock Holmes had no desire to accumulate vast knowledge of all dermatologic problems. He quite readily sought help in reference textbooks or expert consultation when such help was needed. In those areas which contributed to his success as a consulting detective, however, his knowledge of the skin and its abnormalities was unsurpassed. For example, we know from the comments of Stamford to Watson in The Study in Scarlet that Holmes carried on basic research into the nature of postmortem bruising.2 He was also an expert on the various dyes and techniques of tattooing and wrote a monograph on the subject.' He wrote a most important monograph on the effects of trades on the form of the hands which, unfortunately, is not available today.8 This monograph was no doubt the model for Ronchese's book. Occupational Marks, which was published in 1948.«
Smith and Beerman
435
Holmes was also an authority on malingering and was quite familiar with selfinflicted or "factitious" lesions with which patients sometimes perplex their physicians.'" He considered writing a monograph on this subject, but never completed i t , " to our regret.
Skin Diseases Almost every person has at least one problem relating to his skin and the great detective was no exception. At their first meeting. Dr. Watson noted the chemical staining on Sherlock Holmes' fingers and emphasized them because of their importance in documenting Holmes' scientific interests and abilities.'-' In The Sign of the Four we learn that Holmes, during periods of boredom due to inactivity, resorted to the use of cocaine. As he injected the drug intravenously, it is quite likely that he had a series of small punctate scars over the veins of the arms such as are frequently seen in the users of addictive drugs.'^ As reported in the Adventure of the Dying Detective, Holmes, in 1887, faked an attack of Tapanuli fever or the Black Formosa corruption in order to trap the evil expert in tropical diseases, Culverton Smith. As part of his feigned illness, he used bees' wax to produce a crust on his lip typical of infection with the herpes simplex virus.*'' The great detective had another very common skin problem which is documented in the Ac^venture of the Stockbroker's Clerk. In periods of great anxiety, he chewed his nails.^^ The most important dermatologic references in the Canon are in the 2 stories related to us by Holmes himself. In 1903 in the Adventure of the Blanched Soldier, he was employed by James M. Dodd to solve the mystery of the disappearance of his companion of the wars in South Africa, young Godfrey Emsworth.^* Holmes noted a smell of disinfectant
436
INTERNATIONAL JOURNAL OF DERMATOLOGY
on the butler's gloves and the presence of a physician residing on the Emsworth estate, and correctly deduced that young Emsworth thought he was the victim of leprosy. Emsworth confirmed this when he told how he wandered into a leprosarium in South Africa and inadvertently spent the night in a bed of one of the patients. It is now widely recognized that leprosy is not a very contagious disease and could hardly have been contracted in such a manner. However, when Emsworth developed white spots on his face, he naturally concluded that they were the result of his misadventure. Holmes saved Emsworth from a life of anxiety and solitude by prevailing upon his friend Sir James Saunders, the most eminent specialist in skin diseases of the Edwardian period, to travel with him to the Emsworth estate and examine Godfrey. Sir James, who was also an expert in tropical diseases, changed the course of the patient's life on pronouncing that he had "a well-marked case of pseudoleprosy or ichthyosis." Emsworth's anxiety was based, no doubt, upon his knowledge that one type of leprosy, the tuberculoid form, is characterized by depigmented patches of skin which are anesthetic or have diminished sensation. It is interesting to consider what Emsworth's diagnosis really was." The eminent dermatologist must have used the term ichthyosis only in a general sense to describe a scaly condition of the skin. There are several specific diseases identified with this term, but none result in scaling and loss of pigmentation on the face such as troubled his patient. Tuberculoid leprosy would not be likely to cause scaling and would be unlikely to result in many blotches over the face. It is possible that Godfrey had pityriasis alba, a condition characterized by slight scaling and loss of pigmentation which occurs on the cheeks of children and
June 1977
Vol. 16
young adults. This condition is much more apparent in those who are tanned or darkly pigmented as Godfrey was from exposure to the South African sun. Although usually not associated with scaling, vitiligo is also a diagnostic possibility. Why Sir James Saunders used the terms pseudoleprosy and ichthyosis is not clear. It is possible that Holmes, being unfamiliar with dermatologic jargon, inaccurately reported Saunders' words. This theory is inconsistent with what we know of the master detective's passion for accuracy and it is more likely that the specialist was more sure of what the condition wasn't than what it was. In other words, he used these terms with the primary intention of reassuring young Emsworth that he did not have the disease he so feared. Another interesting question that arises in the study of the Adventure of tbe Btancbed Soldier relates to the identity of Sir James Saunders. We know that both Watson and Holmes frequently used aliases when discussing cases. In this particular case "Sir James Saunders" was likely a pseudonym for Sir Jonathan Hutchinson.18 Hutchinson was the bestknown English specialist in skin diseases of the time. He was also widely known as a surgeon, which explains why the Emsworth surgeon. Dr. Kent, held him in such respect. In addition, he was a most knowledgeable expert in the field of tropical diseases and had a special interest in leprosy. Holmes showed great wisdom in his selection of a consultant in this case. In the Adventure of tbe Lion's Mane, Holmes related how he solved the mystery of the deaths of Fitzroy McPherson and his dog, and the subsequent attack on Ian Murdoch, by observing the peculiar marks inflicted on the skin.^^ The series of punctate lesions arranged in a linear fashion are characteristic of the
No. 5
SHERLOCK HOLMES
Smith and Beerman
437
injury produced by the nematocysts of certain marine animals. Holmes again showed great wisdom by seeking out an appropriate reference, J. D. Woods' Out of Doors, to aid him in identifying the murderer. Holmes believed the creature to be Cyanea capillata, a species of jellyfish. However, one fact makes this identification unlikely. Deaths from the sting of Cyanea species are very rare except in persons who have been previously exposed to such stings and have developed an allergy to the injected toxin. However, the culprit in The Lion's Mane caused the death of both McPherson and his dog and it is unlikely that they both had been previously sensitized.
Dermatology Annual Meeting to honor the great detective and to discuss the medical and dermatological aspects of the Canon.
Another marine animal, a member of the genus Physalia, or the Portuguese man of war, produces a much more potent toxin and is a more likely candidate for the role of the creature described in this story. Both have long tentacles armed with stinging nematocysts and would produce an identical picture on the skin of the victims. This minor error in identifying the species does not detract at all from Holmes' accomplishment in recognizing the peculiar patterns produced on the victim's skin, thus both solving the mystery and removing the shadow of suspicion from Ian Murdoch.
References
Sir James Saunders Society Sherlock Holmes developed to the highest degree the powers of observation and the ability to reason analytically which are so important to the practitioner of dermatology. It is not surprising that a number of dermatologists are among the more dedicated students ot Holmes. In 1974, a group of dermatologic Sherlockians formed one of the newest Scion Societies of the Baker Street Irregulars. This group, known as the Sir James Saunders Society, meets for lunch each year at the American Academy of
Summation We have tried to show in this brief report that there is much material in the Holmes stories as reported by Drs. Doyle and Watson, and Holmes himself, which relates to the skin. The study of this material is a delightful hobby for the dermatologist and a stimulus to continually develop the ability to observe accurately and think logically.
1. Baring-Could, W. S.: Sherlock Holmes of Baker Street. New York, Bramhall House, 1962. 2. Watson, ]. H.: A Study in Scarlet. In The Annotated Sherlock Holmes. Vol. 1. Edited by Baring-Could, W. S. New York, Clarkson N. Potter, Inc. 1967, p. 149. 3. Wallechinsky, D., and Wallace, I.: The Peoples Almanac. Carden City, NY, Doubleday, 1975, pp. 1235-1237. 4. Scott, B.: The doctor did it. Todays Health October, p. 57, 1970. 5. Carr, ). D.: The Life of Sir Arthur Conan Doyle. London, John Murray, 1949. 6. Klauder, ). V.: Sherlock Holmes as a dermatologist. Arch. Dermatol. Syphilol. 68:373, 1953. 7. Watson, ). H.: The Red Headed League. In The Annotated Sherlock Holmes. Vol. 1. Edited by Baring-Could, W. S. New York, Clarkson N. Potter, Inc. 1967, p. 149. 8. Watson, J. H.: The Sign of the Four. In The Annotated Sherlock Holmes. Vol. 1, Edited by Baring-Could, W. S. New York, Clarkson N. Potter, Inc. 1967, p. 420. 9. Ronchese, F.: Occupational Marks. New York, Crunc and Stratton, 1948. 10. Beerman, H.: Malingering: What hath man wrought! In More Leaves from the Copper Beeches. Edited by Starr, H. W., Jewell, J. C , Anderson, C, et al. Liditz, PA, Sutter House, 1976, pp. 181-192. 11. Watson, J. H.: The Adventure of the Dying Detective. In The Annotated Sheriock Holmes. Vol. 1, Edited by Baring-Could, W.
438
12,
13,
14,
15,
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S, New York, Clarkson N, Potter, Inc, 1967, p, 450, Watson, ], H,: A Study in Scarlet, In The Annotated Sherlock Holmes, Vol, 2, Edited by Baring-Could, W, S, New York, Clarkson N, Potter, Inc, 1967, p, 776-789, Watson, j , H,: The Sign of the Four, In The Annotated Sherlock Holmes, Vol, 1, Edited by Baring-Gould, W, S, New York, Clarkson N, Potter, Inc, 1967, p, 610. Watson, J, H,, The Adventure of the Dying Detective, In The Annotated Sherlock Holmes, Vol, 1, Edited by Baring-Gould, W, S, New York, Clarkson N, Potter, Inc, 1967, p, 450, Watson, J, H,: Tbe Adventure of the Stockbrokers Clerk, In The Annotated Sherlock Holmes, Edited by Baring-Gould, W, S, Vol,
16,
17,
18,
19,
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2, New York, Clarkson N, Potter, Inc, 1967, p, 161, Holmes, S,: "Tbe Adventure of the Blanched Soldier," In The Annotated Sherlock Holmes, Vol, 2, Edited by Baring-Gould, W, S, New York, Clarkson N, Potter, Inc, 1967, p. 707721, Beerman, H,: A few remarks about tbe Blanched Soldier, Baker Street Journal 23:148, 155, 1973, Talbott, J, H,: A Biographical History of Medicine, New York, Grune and Stratton, 1970, p, 697-700, Holmes, S,: The Adventure of the Lion's Mane, In The Annotated Sherlock Holmes. Vol, 2, Edited by Baring-Gould, W, S, New York, Clarkson N, Potter, Inc, 1967, p, 707721.
An Approach to Cancer Therapy Skin cancers serve as excellent examples of how studies of skin lesions lead to medical knowledge and techniques which are quite generally useful and, conversely, how diagnostic and therapeutic procedures derived from many disciplines are required for the management of skin lesions. To illustrate these points I shall draw upon my knowledge of the history, the people, and the workings of the institution witb which I was associated for the major part of my medical life. The New York Skin and Cancer Hospital was established in 1882. It was, therefore, one of the first multidisciplinary hospitals in the United States — and perhaps in the world — devoted to the study, prevention, and treatment of cancer. The rather unusual emphasis upon skin tumors, in a hospital devoted to the management of all cancer, could not fail to produce great benefits, perhaps unexpected by the founders. For skin cancers are so numerous, so accessible, and so varied (ranging from basal cell epithelioma, which is usually almost entirely benign, to that often most malignant of all human tumors, the malignant melanoma) that their study has yielded valuable information about almost every type of cancer. Moreover, the approaches required for the optimal management of skin tumors are so diverse (ranging from minor, major, and plastic surgery to radiation therapy, immunotherapy, chemotherapy, and cryosurgery) that many different skills and disciplines must be brought to focus in order to achieve the greatest success. In addition, many skin diseases are the outer signs of inner tumors; and still other skin lesions (the precanccroses) are the earliest forewarnings of malignancy to follow. — Sulzberger, M. B.: Observations on tbe Treatment of Skin Cancer, in Cancer of tbe Skin, edited by Andrade, R. et al. Pbiladelpbia, VV. B. Saunders, 1976, p. 3.
SHERLOCK HOLMES AND DERMATOLOGY >
Few persons, either real or fictional, have captured the public imagination in quite such a manner as the great consulting detective of Victorian and Edwardian England, Sherlock Holmes. At the beginning of this century, accounts of the adventures of Holmes and his physician companion Dr. John H. Watson made Arthur Conan Doyle one of the first literary millionaires. Recent months have seen a revival of popularity for Holmes and Watson with best-selling new adventures, several new motion pictures and television shows, and the successful return to the stage of the William Gillette play, Sherlock Holmes. The world's first consulting detective was born in 1854, the scion of a family of country squires that also contained a distinct artistic strain.' After attending one of England's great universities (authorities still disagree whether it was Oxford or Cambridge), he moved to London and began a long and distinguished career. From 1874 until his retirement in 1903, he aided victims of crime from all walks of life, including statesmen and nobility of several nations, quietly assisted his "professional" colleagues of Scotland Yard, and soundly placed the art of detection on a logical and scientific basis. He was an expert boxer, fencer, musician, and despite Dr. John Watson's early as-
EDGAR B. SMITH, M.D. AND HERMAN BEERMAN, M.D.
Erom the Division of Dermatology, Department of Medicine, University of New Mexico School of Medicine, Albuquerque, New Mexico, and the Department of Dermatology, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
sessment of his knowledge, a well-read scholar in many fields.^ From the records of Watson, Arthur Conan Doyle and himself, we have details of 60 cases solved by Holmes, including 2 after his retirement to Sussex. In addition, many other cases are briefly mentioned in the original stories (known as the Canon) and recent years have seen the appearance of a number of newly discovered adventures. For a person widely thought to be fictitious, Sherlock Holmes has achieved a rare state of reality. His biographies are still being written and have appeared in "books of facts" such as The People's Almanac. The late Vincent Starrett remarked, "The plain fact is that Sherlock Holmes is still a more commanding figure in the world than most of the warriors and statesmen in whose present existence we are invited to believe."^ Three Physicians Three physicians were closely involved with the life and works of the great detective. The most important of them is, of course, his first biographer and some-
Address for reprints: Edgar B. Smith, M.D., Division of Dermatology, University of New Mexico Scbool of Medicine, Albuquerque, NM 87131.
433
434
INTERNATIONAL JOURNAL OF DERMATOLOGY
time sharer of lodgings. Dr. John H. Watson. Watson v.'as born in 1852 and is believed to have traveled widely throughout the world in his early life. He studied medicine at the University of Edinburgh and probably received his Bachelor of Medicine and Baccalaureate of Surgery degree there before taking advanced studies for the Doctor of Medicine degree at the University of London. While serving as a medical officer in the British Army in Afghanistan, he received a wound which abruptly ended his military career. He returned to London, a poor and discouraged pensioner, where fate and one of his former surgical assistants (another doctor named Stamford) led him to his historic meeting with Mr. Sherlock Holmes in the Pathology Laboratory of Saint Bartholomew's Hospital. From their meeting in 1881 until Holmes' retirement. Dr. Watson was the master detective's loyal companion, able (usually) assistant, and most important, the recorder of 56 of his most notable cases. Skeptics who maintain that Holmes and Watson are indeed fictional characters give credit for their creation to another physician. Dr. Arthur Conan Doyle.5 Doyle was born in Edinburgh in 1889. He studied medicine at the University of Edinburgh from 1876 to 1881 and after a brief stint as a ship's surgeon, he entered practice at Plymouth. He never achieved success as a physician, neither as a general practitioner at Plymouth and Southsea nor as an ophthalmologist in London. Then he turned to writing. In addition to the Sherlock Holmes stories, he wrote a number of popular historical and science fiction novels and many short stories. For his service to Britain in the Boer War, he was knighted in 1902 (an honor which Holmes declined the same year). Doyle in his later years developed
June 1977
Vol. 16
a deep interest in spiritualism, a paradox in view of his creation of such logical and scientific minds as Sherlock Holmes and Professor Challenger. His death in 1930 ended one of the most successful literary careers of all time. Those who hold that Arthur Conan Doyle rather than John Watson was the actual author of the Holmesian Canon point to a third doctor of importance. Dr. Joseph Bell was for many years Professor of Surgery at the University of Edinburgh. He was an outstanding teacher and journalist who excelled in accurately deducing not only medical problems but personal characteristics and occupations of his patients by observation of such trifles as the calluses on their hands and the type of mud on their shoes. Bell taught Doyle and immensely impressed him. His gift for observation of details and amazingly accurate deductions made him an excellent model for the character of Holmes and his role in the creation of the great detective was acknowledged by Doyle many times. Because of the influence of Dr. Joseph Bell, the important role of Dr. Arthur Conan Doyle as either the creator of the Holmes tales or, as some maintain, the literary agent responsible for the distribution of the stories, and the even more important role of Dr. John H. Watson, it is not surprising that the Canon contains much of medical interest. As a result, physicians have been prominent members of such Holmes admiring clubs as the Baker Street Irregulars and its many scion societies; also, articles on various medical aspects of the stories have appeared in many professional journals. Dermatologists are particularly attracted to the Holmes stories. The most important reason for this attraction is the fact that the specialist in skin diseases follows the methods and teachings of Holmes more closely than any other
No. 5
SHERLOCK HOLMES
medical specialist. As pointed out by the late Dr. Joseph V. Klauder, "Keen observation, intense inspection of the subject, attention to details and apparent trifles so much emphasized by Sherlock Holmes are particularly pertinent to the dermatologist.""^ The dermatologist is also drawn to the Canon by the numerous references to dermatologic problems and allusions to physiological changes in the skin. Excellent clinical descriptions are sprinkled throughout the stories and any dermatologist can find great enjoyment in seeking these. We would like to draw particular attention to several dermatologic aspects of the Holmesian Canon. Among these are Sherlock Holmes' scientific and scholarly interests as they relate to the skin, the master detective's own dermatological problems, and Holmes' use of his knowledge of the skin and its abnormalities in solving 2 most puzzling mysteries. Sherlock Holmes had no desire to accumulate vast knowledge of all dermatologic problems. He quite readily sought help in reference textbooks or expert consultation when such help was needed. In those areas which contributed to his success as a consulting detective, however, his knowledge of the skin and its abnormalities was unsurpassed. For example, we know from the comments of Stamford to Watson in The Study in Scarlet that Holmes carried on basic research into the nature of postmortem bruising.2 He was also an expert on the various dyes and techniques of tattooing and wrote a monograph on the subject.' He wrote a most important monograph on the effects of trades on the form of the hands which, unfortunately, is not available today.8 This monograph was no doubt the model for Ronchese's book. Occupational Marks, which was published in 1948.«
Smith and Beerman
435
Holmes was also an authority on malingering and was quite familiar with selfinflicted or "factitious" lesions with which patients sometimes perplex their physicians.'" He considered writing a monograph on this subject, but never completed i t , " to our regret.
Skin Diseases Almost every person has at least one problem relating to his skin and the great detective was no exception. At their first meeting. Dr. Watson noted the chemical staining on Sherlock Holmes' fingers and emphasized them because of their importance in documenting Holmes' scientific interests and abilities.'-' In The Sign of the Four we learn that Holmes, during periods of boredom due to inactivity, resorted to the use of cocaine. As he injected the drug intravenously, it is quite likely that he had a series of small punctate scars over the veins of the arms such as are frequently seen in the users of addictive drugs.'^ As reported in the Adventure of the Dying Detective, Holmes, in 1887, faked an attack of Tapanuli fever or the Black Formosa corruption in order to trap the evil expert in tropical diseases, Culverton Smith. As part of his feigned illness, he used bees' wax to produce a crust on his lip typical of infection with the herpes simplex virus.*'' The great detective had another very common skin problem which is documented in the Ac^venture of the Stockbroker's Clerk. In periods of great anxiety, he chewed his nails.^^ The most important dermatologic references in the Canon are in the 2 stories related to us by Holmes himself. In 1903 in the Adventure of the Blanched Soldier, he was employed by James M. Dodd to solve the mystery of the disappearance of his companion of the wars in South Africa, young Godfrey Emsworth.^* Holmes noted a smell of disinfectant
436
INTERNATIONAL JOURNAL OF DERMATOLOGY
on the butler's gloves and the presence of a physician residing on the Emsworth estate, and correctly deduced that young Emsworth thought he was the victim of leprosy. Emsworth confirmed this when he told how he wandered into a leprosarium in South Africa and inadvertently spent the night in a bed of one of the patients. It is now widely recognized that leprosy is not a very contagious disease and could hardly have been contracted in such a manner. However, when Emsworth developed white spots on his face, he naturally concluded that they were the result of his misadventure. Holmes saved Emsworth from a life of anxiety and solitude by prevailing upon his friend Sir James Saunders, the most eminent specialist in skin diseases of the Edwardian period, to travel with him to the Emsworth estate and examine Godfrey. Sir James, who was also an expert in tropical diseases, changed the course of the patient's life on pronouncing that he had "a well-marked case of pseudoleprosy or ichthyosis." Emsworth's anxiety was based, no doubt, upon his knowledge that one type of leprosy, the tuberculoid form, is characterized by depigmented patches of skin which are anesthetic or have diminished sensation. It is interesting to consider what Emsworth's diagnosis really was." The eminent dermatologist must have used the term ichthyosis only in a general sense to describe a scaly condition of the skin. There are several specific diseases identified with this term, but none result in scaling and loss of pigmentation on the face such as troubled his patient. Tuberculoid leprosy would not be likely to cause scaling and would be unlikely to result in many blotches over the face. It is possible that Godfrey had pityriasis alba, a condition characterized by slight scaling and loss of pigmentation which occurs on the cheeks of children and
June 1977
Vol. 16
young adults. This condition is much more apparent in those who are tanned or darkly pigmented as Godfrey was from exposure to the South African sun. Although usually not associated with scaling, vitiligo is also a diagnostic possibility. Why Sir James Saunders used the terms pseudoleprosy and ichthyosis is not clear. It is possible that Holmes, being unfamiliar with dermatologic jargon, inaccurately reported Saunders' words. This theory is inconsistent with what we know of the master detective's passion for accuracy and it is more likely that the specialist was more sure of what the condition wasn't than what it was. In other words, he used these terms with the primary intention of reassuring young Emsworth that he did not have the disease he so feared. Another interesting question that arises in the study of the Adventure of tbe Btancbed Soldier relates to the identity of Sir James Saunders. We know that both Watson and Holmes frequently used aliases when discussing cases. In this particular case "Sir James Saunders" was likely a pseudonym for Sir Jonathan Hutchinson.18 Hutchinson was the bestknown English specialist in skin diseases of the time. He was also widely known as a surgeon, which explains why the Emsworth surgeon. Dr. Kent, held him in such respect. In addition, he was a most knowledgeable expert in the field of tropical diseases and had a special interest in leprosy. Holmes showed great wisdom in his selection of a consultant in this case. In the Adventure of tbe Lion's Mane, Holmes related how he solved the mystery of the deaths of Fitzroy McPherson and his dog, and the subsequent attack on Ian Murdoch, by observing the peculiar marks inflicted on the skin.^^ The series of punctate lesions arranged in a linear fashion are characteristic of the
No. 5
SHERLOCK HOLMES
Smith and Beerman
437
injury produced by the nematocysts of certain marine animals. Holmes again showed great wisdom by seeking out an appropriate reference, J. D. Woods' Out of Doors, to aid him in identifying the murderer. Holmes believed the creature to be Cyanea capillata, a species of jellyfish. However, one fact makes this identification unlikely. Deaths from the sting of Cyanea species are very rare except in persons who have been previously exposed to such stings and have developed an allergy to the injected toxin. However, the culprit in The Lion's Mane caused the death of both McPherson and his dog and it is unlikely that they both had been previously sensitized.
Dermatology Annual Meeting to honor the great detective and to discuss the medical and dermatological aspects of the Canon.
Another marine animal, a member of the genus Physalia, or the Portuguese man of war, produces a much more potent toxin and is a more likely candidate for the role of the creature described in this story. Both have long tentacles armed with stinging nematocysts and would produce an identical picture on the skin of the victims. This minor error in identifying the species does not detract at all from Holmes' accomplishment in recognizing the peculiar patterns produced on the victim's skin, thus both solving the mystery and removing the shadow of suspicion from Ian Murdoch.
References
Sir James Saunders Society Sherlock Holmes developed to the highest degree the powers of observation and the ability to reason analytically which are so important to the practitioner of dermatology. It is not surprising that a number of dermatologists are among the more dedicated students ot Holmes. In 1974, a group of dermatologic Sherlockians formed one of the newest Scion Societies of the Baker Street Irregulars. This group, known as the Sir James Saunders Society, meets for lunch each year at the American Academy of
Summation We have tried to show in this brief report that there is much material in the Holmes stories as reported by Drs. Doyle and Watson, and Holmes himself, which relates to the skin. The study of this material is a delightful hobby for the dermatologist and a stimulus to continually develop the ability to observe accurately and think logically.
1. Baring-Could, W. S.: Sherlock Holmes of Baker Street. New York, Bramhall House, 1962. 2. Watson, ]. H.: A Study in Scarlet. In The Annotated Sherlock Holmes. Vol. 1. Edited by Baring-Could, W. S. New York, Clarkson N. Potter, Inc. 1967, p. 149. 3. Wallechinsky, D., and Wallace, I.: The Peoples Almanac. Carden City, NY, Doubleday, 1975, pp. 1235-1237. 4. Scott, B.: The doctor did it. Todays Health October, p. 57, 1970. 5. Carr, ). D.: The Life of Sir Arthur Conan Doyle. London, John Murray, 1949. 6. Klauder, ). V.: Sherlock Holmes as a dermatologist. Arch. Dermatol. Syphilol. 68:373, 1953. 7. Watson, ). H.: The Red Headed League. In The Annotated Sherlock Holmes. Vol. 1. Edited by Baring-Could, W. S. New York, Clarkson N. Potter, Inc. 1967, p. 149. 8. Watson, J. H.: The Sign of the Four. In The Annotated Sherlock Holmes. Vol. 1, Edited by Baring-Could, W. S. New York, Clarkson N. Potter, Inc. 1967, p. 420. 9. Ronchese, F.: Occupational Marks. New York, Crunc and Stratton, 1948. 10. Beerman, H.: Malingering: What hath man wrought! In More Leaves from the Copper Beeches. Edited by Starr, H. W., Jewell, J. C , Anderson, C, et al. Liditz, PA, Sutter House, 1976, pp. 181-192. 11. Watson, J. H.: The Adventure of the Dying Detective. In The Annotated Sheriock Holmes. Vol. 1, Edited by Baring-Could, W.
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S, New York, Clarkson N, Potter, Inc, 1967, p, 450, Watson, ], H,: A Study in Scarlet, In The Annotated Sherlock Holmes, Vol, 2, Edited by Baring-Could, W, S, New York, Clarkson N, Potter, Inc, 1967, p, 776-789, Watson, j , H,: The Sign of the Four, In The Annotated Sherlock Holmes, Vol, 1, Edited by Baring-Gould, W, S, New York, Clarkson N, Potter, Inc, 1967, p, 610. Watson, J, H,, The Adventure of the Dying Detective, In The Annotated Sherlock Holmes, Vol, 1, Edited by Baring-Gould, W, S, New York, Clarkson N, Potter, Inc, 1967, p, 450, Watson, J, H,: Tbe Adventure of the Stockbrokers Clerk, In The Annotated Sherlock Holmes, Edited by Baring-Gould, W, S, Vol,
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2, New York, Clarkson N, Potter, Inc, 1967, p, 161, Holmes, S,: "Tbe Adventure of the Blanched Soldier," In The Annotated Sherlock Holmes, Vol, 2, Edited by Baring-Gould, W, S, New York, Clarkson N, Potter, Inc, 1967, p. 707721, Beerman, H,: A few remarks about tbe Blanched Soldier, Baker Street Journal 23:148, 155, 1973, Talbott, J, H,: A Biographical History of Medicine, New York, Grune and Stratton, 1970, p, 697-700, Holmes, S,: The Adventure of the Lion's Mane, In The Annotated Sherlock Holmes. Vol, 2, Edited by Baring-Gould, W, S, New York, Clarkson N, Potter, Inc, 1967, p, 707721.
An Approach to Cancer Therapy Skin cancers serve as excellent examples of how studies of skin lesions lead to medical knowledge and techniques which are quite generally useful and, conversely, how diagnostic and therapeutic procedures derived from many disciplines are required for the management of skin lesions. To illustrate these points I shall draw upon my knowledge of the history, the people, and the workings of the institution witb which I was associated for the major part of my medical life. The New York Skin and Cancer Hospital was established in 1882. It was, therefore, one of the first multidisciplinary hospitals in the United States — and perhaps in the world — devoted to the study, prevention, and treatment of cancer. The rather unusual emphasis upon skin tumors, in a hospital devoted to the management of all cancer, could not fail to produce great benefits, perhaps unexpected by the founders. For skin cancers are so numerous, so accessible, and so varied (ranging from basal cell epithelioma, which is usually almost entirely benign, to that often most malignant of all human tumors, the malignant melanoma) that their study has yielded valuable information about almost every type of cancer. Moreover, the approaches required for the optimal management of skin tumors are so diverse (ranging from minor, major, and plastic surgery to radiation therapy, immunotherapy, chemotherapy, and cryosurgery) that many different skills and disciplines must be brought to focus in order to achieve the greatest success. In addition, many skin diseases are the outer signs of inner tumors; and still other skin lesions (the precanccroses) are the earliest forewarnings of malignancy to follow. — Sulzberger, M. B.: Observations on tbe Treatment of Skin Cancer, in Cancer of tbe Skin, edited by Andrade, R. et al. Pbiladelpbia, VV. B. Saunders, 1976, p. 3.
