ever, as
stated in the AAN
these
report,
guidelines refer to "cases of hypoxic-ischemic encephalopathy. As Levin and colleagues1 have indi¬ cated, the clinical and pathophysio¬ logic characteristics of hypoxia/ "
ischemia are distinct from those of traumatic brain injuries, illustrated by the contrast between the TCDB find¬ ings and the results of earlier studies3 with broader inclusion criteria. For the same reasons, the results of positronemission data collected primarily on hypoxic-ischemic patients in VS, al¬ luded to in the AAN statement, may not be generalizable to the traumatically brain-injured population. Sec¬ ond, in the TCDB study, neither clin¬ ical observation nor laboratory studies, the primary bases for diagnosis recom¬ mended in the AAN statement, pre¬ dicted which of the patients in VS at discharge would recover the ability to follow commands on the long term. Third, the majority of the AAN state¬ ment concerns the ethical, moral, and medical issues related to the with¬ drawal of nutrition/hydration from VS patients of all causes, based on as¬ sumptions that may be called into question by the TCDB report, eg, that patient status at 1 to 2 months predicts status at 1 to 3 years. The incorporation of the TCDB data into the AAN Posi¬ tion Statement would provide more in¬ formative guidelines for the assess¬ ment and treatment of severely brain-
injured patients.
Lyn S. Turkstra, MA Department of Speech and Sciences University of Arizona Tucson, AZ 85721
Hearing
al.
1. Levin HS,
Saydjari C, Eisenberg HM, et after closed head injury: a Vegetative state
Traumatic Coma Data Bank
report. Arch Neu¬ rol. 1991;48:580-585. of the 2. Position American Academy of Neu¬ rology on certain aspects of the care and man¬ agement of the persistent vegetative state pa¬ tient: adopted by the Executive Board of the American Academy of Neurology, April 21,1988, Cincinnati, Ohio. Neurology. 1989;39:125-126. 3. Higashi K, Sakata Y, Hitano M, et al. Ep¬ idemiological studies on patients with a per¬ sistent vegetative state. ] Neurol Neurosurg
Psychiatry. 1977;40:876-885.
The Meaning of Sherlock Holmes To the Editor.— The case of Mr Sher¬ lock Holmes, recently re-reported in the ARCHIVES,1 can rightfully be re¬ garded as part of general medical
lore.2"4 The very nature of Holmes' mythical immortality forever pre¬
cludes completeness of the second¬ ary literature. We, therefore, feel jus¬ tified to add a note to the contribution of Westmoreland and Key.1 They re¬ stated the special relationship of the great detective to neurology by point¬ ing out the many nervous affections in his cases (see also Cherington3). Still, in our opinion, it is Holmes' method, his "science of deduction,"5 that deserves the most interest. Like Voltaire's Zadig, Poe's Dupin, Eco's William of Baskerville, and, of course, Drs Joseph Bell and Charles S. Peirce (calling the method "abduction"6), Holmes belongs to those who "read the book of nature." A remarkable amount of thinking has been devoted to this modus operandi by semiotics, the science of sign reading.6 Yet the signs of nature need to be recognized as such before they can be deciphered (com¬ pare Klawans7). As Holmes explains to Watson (and Baskerville to Adson), "You have not observed. And yet you have seen. That is just my point."5 What is it that physicians have in common with Holmes4 as he tackles this central question of how data turn into "signs"? His magnifying lens symbolizes the seemingly unbiased,
systematic scrutiny. Also, encyclope¬ dic knowledge and past experience
fundamental—Holmes' mono¬ graphs and his collections, eg, of crim¬ inal cases: "I have made a special study I flatter myself that of cigar ashes I can distinguish at a glance the ash of any known brand either of cigar or of tobacco."5 On the other hand, there is also the permanent readiness to accept seem
...
data as enigmatic, as meaningful, as in¬ dicative of other realities, and in need
of interpretation. It is quite difficult here to draw a clear boundary to the realms of para¬ noid divination. Holmes' use of co¬ caine now seems much less surpris¬ ing. Some authors have spoken of mere guesswork and have even called the detective's method a "mythod."2 Do the approaches of Holmes and Bell to criminal, respec¬ tively medical detection then really deserve the attribute of "scientific"? In fact, Holmes does validate the conclusions that he arrives at. He makes use of educated guesses and of chances that his prepared mind seizes. The criminals whose charac¬ ter and identity he has reconstructed
Downloaded From: http://archneur.jamanetwork.com/ by a Western University User on 06/09/2015
signs are lured into his office at 221B Baker Street by clever newspa¬ per advertisements. Similarly, how¬ ever biased and preoccupied, in a strict sense, our reading of neuro¬ from
logic signs may be, we often seem to detect responsible culprits. In concluding, we would like to
point out that the "deductions" pro¬ vided in the March 1991 issue of the Archives should be complemented by the "observation" thatMay 4,1991, has marked the hundredth anniversary of Sherlock Holmes' lethal fight with Pro¬ fessor Moriarty, "the Napoleon of crime" (see also Wiggins8). Adrian Danek, MD Christoph Helmchen, MD Kai Bötzel, MD Department of Neurology
Ludwig-MaximiliansUniversität PO Box 701260 D-W-8000 Munich,
Germany
1, Westmoreland BF, KeyJD. Arthur Conan Doyle, Joseph Bell, and Sherlock Holmes. Arch Neurol. 1991;48:325-329. 2. Shepherd M. Sherlock Holmes and the Case of Dr Freud. London, United Kingdom: Tavistock; 1986. 3. Cherington M. Sherlock Holmes: neu¬
rologist? Neurology. 1985;37:824-825. 4. Peschel RE, Peschel E. What physicians
have in common with Sherlock Holmes: dis¬ cussion paper. J R Soc Med. 1989;82:33-36. 5. Doyle CA; Morley C, ed. The Complete Sherlock Holmes. Garden City, NY: Doubleday; 1988. 6. Eco U, Sebeok TA. The Sign of Three: Dupin, Holmes, Peirce. Bloomington, Ind: Indiana University Press; 1983. 7. Klawans HL. Toscanini's Fumble. Lon¬ don, England: Headline; 1990:73-85. 8. Wiggins E. Struggle to death at Reichen¬ bach Falls. The Sherlock Holmes Gazette. 1991:1:19.
Reply. —We thank Danek and col¬ leagues for their comments regarding In
Sherlock Holmes, and we agree that the Holmes method of deduction is one of the most important features of the Holmes story. As mentioned in the article "The Scientific Holmes" by Ro¬ din and Key,1 part of the "Holmesian reasoning" is "not only looking, but actually consciously observing and thinking about what one is seeing" and "stressing the relationship between the patience to observe minutely and the knowledge to interpret such findings. Barbara F. Westmoreland, MD Jack D. Key, MS Department of Neurology Mayo Clinic Rochester, MN 55905 "
1. Rodin A, Key J. The scientific Holmes. The Sherlock Holmes Rev. 1987;1:81-122.
stated in the AAN
these
report,
guidelines refer to "cases of hypoxic-ischemic encephalopathy. As Levin and colleagues1 have indi¬ cated, the clinical and pathophysio¬ logic characteristics of hypoxia/ "
ischemia are distinct from those of traumatic brain injuries, illustrated by the contrast between the TCDB find¬ ings and the results of earlier studies3 with broader inclusion criteria. For the same reasons, the results of positronemission data collected primarily on hypoxic-ischemic patients in VS, al¬ luded to in the AAN statement, may not be generalizable to the traumatically brain-injured population. Sec¬ ond, in the TCDB study, neither clin¬ ical observation nor laboratory studies, the primary bases for diagnosis recom¬ mended in the AAN statement, pre¬ dicted which of the patients in VS at discharge would recover the ability to follow commands on the long term. Third, the majority of the AAN state¬ ment concerns the ethical, moral, and medical issues related to the with¬ drawal of nutrition/hydration from VS patients of all causes, based on as¬ sumptions that may be called into question by the TCDB report, eg, that patient status at 1 to 2 months predicts status at 1 to 3 years. The incorporation of the TCDB data into the AAN Posi¬ tion Statement would provide more in¬ formative guidelines for the assess¬ ment and treatment of severely brain-
injured patients.
Lyn S. Turkstra, MA Department of Speech and Sciences University of Arizona Tucson, AZ 85721
Hearing
al.
1. Levin HS,
Saydjari C, Eisenberg HM, et after closed head injury: a Vegetative state
Traumatic Coma Data Bank
report. Arch Neu¬ rol. 1991;48:580-585. of the 2. Position American Academy of Neu¬ rology on certain aspects of the care and man¬ agement of the persistent vegetative state pa¬ tient: adopted by the Executive Board of the American Academy of Neurology, April 21,1988, Cincinnati, Ohio. Neurology. 1989;39:125-126. 3. Higashi K, Sakata Y, Hitano M, et al. Ep¬ idemiological studies on patients with a per¬ sistent vegetative state. ] Neurol Neurosurg
Psychiatry. 1977;40:876-885.
The Meaning of Sherlock Holmes To the Editor.— The case of Mr Sher¬ lock Holmes, recently re-reported in the ARCHIVES,1 can rightfully be re¬ garded as part of general medical
lore.2"4 The very nature of Holmes' mythical immortality forever pre¬
cludes completeness of the second¬ ary literature. We, therefore, feel jus¬ tified to add a note to the contribution of Westmoreland and Key.1 They re¬ stated the special relationship of the great detective to neurology by point¬ ing out the many nervous affections in his cases (see also Cherington3). Still, in our opinion, it is Holmes' method, his "science of deduction,"5 that deserves the most interest. Like Voltaire's Zadig, Poe's Dupin, Eco's William of Baskerville, and, of course, Drs Joseph Bell and Charles S. Peirce (calling the method "abduction"6), Holmes belongs to those who "read the book of nature." A remarkable amount of thinking has been devoted to this modus operandi by semiotics, the science of sign reading.6 Yet the signs of nature need to be recognized as such before they can be deciphered (com¬ pare Klawans7). As Holmes explains to Watson (and Baskerville to Adson), "You have not observed. And yet you have seen. That is just my point."5 What is it that physicians have in common with Holmes4 as he tackles this central question of how data turn into "signs"? His magnifying lens symbolizes the seemingly unbiased,
systematic scrutiny. Also, encyclope¬ dic knowledge and past experience
fundamental—Holmes' mono¬ graphs and his collections, eg, of crim¬ inal cases: "I have made a special study I flatter myself that of cigar ashes I can distinguish at a glance the ash of any known brand either of cigar or of tobacco."5 On the other hand, there is also the permanent readiness to accept seem
...
data as enigmatic, as meaningful, as in¬ dicative of other realities, and in need
of interpretation. It is quite difficult here to draw a clear boundary to the realms of para¬ noid divination. Holmes' use of co¬ caine now seems much less surpris¬ ing. Some authors have spoken of mere guesswork and have even called the detective's method a "mythod."2 Do the approaches of Holmes and Bell to criminal, respec¬ tively medical detection then really deserve the attribute of "scientific"? In fact, Holmes does validate the conclusions that he arrives at. He makes use of educated guesses and of chances that his prepared mind seizes. The criminals whose charac¬ ter and identity he has reconstructed
Downloaded From: http://archneur.jamanetwork.com/ by a Western University User on 06/09/2015
signs are lured into his office at 221B Baker Street by clever newspa¬ per advertisements. Similarly, how¬ ever biased and preoccupied, in a strict sense, our reading of neuro¬ from
logic signs may be, we often seem to detect responsible culprits. In concluding, we would like to
point out that the "deductions" pro¬ vided in the March 1991 issue of the Archives should be complemented by the "observation" thatMay 4,1991, has marked the hundredth anniversary of Sherlock Holmes' lethal fight with Pro¬ fessor Moriarty, "the Napoleon of crime" (see also Wiggins8). Adrian Danek, MD Christoph Helmchen, MD Kai Bötzel, MD Department of Neurology
Ludwig-MaximiliansUniversität PO Box 701260 D-W-8000 Munich,
Germany
1, Westmoreland BF, KeyJD. Arthur Conan Doyle, Joseph Bell, and Sherlock Holmes. Arch Neurol. 1991;48:325-329. 2. Shepherd M. Sherlock Holmes and the Case of Dr Freud. London, United Kingdom: Tavistock; 1986. 3. Cherington M. Sherlock Holmes: neu¬
rologist? Neurology. 1985;37:824-825. 4. Peschel RE, Peschel E. What physicians
have in common with Sherlock Holmes: dis¬ cussion paper. J R Soc Med. 1989;82:33-36. 5. Doyle CA; Morley C, ed. The Complete Sherlock Holmes. Garden City, NY: Doubleday; 1988. 6. Eco U, Sebeok TA. The Sign of Three: Dupin, Holmes, Peirce. Bloomington, Ind: Indiana University Press; 1983. 7. Klawans HL. Toscanini's Fumble. Lon¬ don, England: Headline; 1990:73-85. 8. Wiggins E. Struggle to death at Reichen¬ bach Falls. The Sherlock Holmes Gazette. 1991:1:19.
Reply. —We thank Danek and col¬ leagues for their comments regarding In
Sherlock Holmes, and we agree that the Holmes method of deduction is one of the most important features of the Holmes story. As mentioned in the article "The Scientific Holmes" by Ro¬ din and Key,1 part of the "Holmesian reasoning" is "not only looking, but actually consciously observing and thinking about what one is seeing" and "stressing the relationship between the patience to observe minutely and the knowledge to interpret such findings. Barbara F. Westmoreland, MD Jack D. Key, MS Department of Neurology Mayo Clinic Rochester, MN 55905 "
1. Rodin A, Key J. The scientific Holmes. The Sherlock Holmes Rev. 1987;1:81-122.
