Chapter 2

It was relegated to the same limbo as the old expression
“typhoid malaria.”

In order that I may develop my thesis, a brief review of Cassamajor’s
article is in order. The author points out that, in the early part of
the past century, considerable literature appeared describing a disease
known as “brain fever” (called also “hydrocephalic fever” and sometimes
“encephalitis”). For the main part, it occurred in children. The
illness subsided after a few days to a couple of weeks, and the patient
usually recovered.

The author brings out further that, although the disease was apparently
accompanied by fever, there are no recorded temperatures, for the
modern clinical thermometer was not invented until 1868. It is
emphasized, also, that no neurological signs appeared in the case
reports. It was only after the writings of Erb and of Westphal in 1875
that neurological examination, as we now know it, began to develop.
For some unknown reason, about 1850 mention of the disease disappeared
from medical literature. The author, however, makes the statement:
“Undoubtedly the condition does exist today.”

Following a brief historical introduction, the author gives in some
detail the case histories of four children, the youngest six and
one-half and the oldest eleven years of age, whom he had rather
recently diagnosed as suffering from “brain fever.” It is highly
gratifying that they all made a complete recovery. The disease is
characterized by signs and symptoms indicating a considerable brain
involvement, “including convulsions, comas, paralyses, cerebellar
asynergy and a sort of bulbar palsy.” The onset is irregular, except
when head trauma has been previously sustained, when it may be sudden.

One reason, among others, why this stimulating article especially
interested me was that the term “brain fever” called to my mind the
immortal stories of Sherlock Holmes. In them several individuals are
described as suffering from this condition. It is of nostalgic interest
to examine the circumstances which surrounded these victims when they
were stricken.

We find in one of the stories that a housemaid, with an unstable
Celtic temperament, “had a sharp touch of brain fever.” She had had
a violent love affair with a handsome but perfidious butler, who had
thrown her over for another girl. Following her partial recovery, she
had taken a terrible vengeance and was directly responsible for her
faithless lover’s death. When questioned about him by the master of the
household, she became hysterical and unmanageable: “For two days [she]
had been so ill, sometimes delirious, sometimes hysterical...” (_The
Musgrave Ritual_). She evidently made a rapid recovery, for on the
third night she disappeared and her whereabouts were never discovered.

In another story, a young girl whose mother had died was treated
cruelly by her father, who had remarried. She had an income of her
own which she generously allowed her father to use. When she fell in
love with a young man, her father tried desperately to make her sign
a contract providing that, in the event of marriage, he could still
use her money. This she refused to do. He placed her in solitary
confinement so that she could not see her lover, and treated her
inhumanly in other ways: “... he kept on worrying her until she got
brain fever, and for several weeks was at death’s door” (_The
Adventure of the Copper Beeches_). It is pleasant to relate that she
recovered and succeeded in eloping with her lover and presumably lived
happily ever after.

In still another story, in which Sherlock Holmes attempted to gain an
audience with a middle-aged spinster, he was informed that she was
too ill to be interviewed. Her doctor said: “She has been suffering
since yesterday from brain symptoms of great severity. As her medical
adviser, I cannot possibly take the responsibility of allowing anyone
to see her. I should recommend you to call again in ten days” (_The
Adventure of the Cardboard Box_). This illness, somewhat later in
the story, is referred to specifically as “brain fever.”

The illness had developed when this spinster heard that conscientious
diplomat. Through his own carelessness, how-her younger sister had been
foully murdered by her husband. It was the spinster who, by wicked
machinations, had been largely responsible for her sister’s death. It
is noteworthy that Holmes was advised to come back ten days later. This
indicates that the disease was not of long duration.

One of Dr. Watson’s former schoolfellows, Percy Phelps, wrote him, “I
have only just recovered from nine weeks of brain fever and am still
exceedingly weak.” In his letter, he further informed Dr. Watson that
he wished to consult with Sherlock Holmes, and asked his friend to
bring him, since he was in deep trouble. This able young man was an
earnest and ever, he had lost an important state document. In
narrating his story to Sherlock Holmes and Dr. Watson, the patient gave
a vivid description of his distressing illness: “Here I have lain, Mr.
Holmes, for over nine weeks, unconscious, and raving with brain fever
... in my mad fits I was capable of anything. Slowly my reason has
cleared, but it is only during the last three days that my memory has
quite returned” (_The Naval Treaty_).

This poor fellow had an illness of long duration and, according to the
story, his strength came back but slowly. It will be recalled that
Sherlock Holmes solved the mystery and was able to place the important
state document again in the patient’s hands. As far as we know, he
eventually made a complete recovery in spite of the severity of the
attack.

In _The Hound of the Baskervilles_, it will be remembered that the
heir, Sir Henry Baskerville, narrowly escaped death on the moor. The
shock of the adventure with the hound, coupled with the fact that
the woman with whom the heir was in love was actually the wife of
the villainous Stapleton, his would-be murderer, was too much for
our hero. Watson writes: “But the shock of the night’s adventure had
shattered his nerves, and before morning he lay delirious in a high
fever under the care of Dr. Mortimer. The two of them were destined to
travel together round the world before Sir Henry had become once more
the hale, hearty man that he had been before he became master of that
ill-omened estate.”

In this last instance, Watson does not specifically state that the
patient was afflicted with “brain fever,” but the implication is
plainly there. It is, moreover, worthy of note that it took the victim
a long time to regain his health.

The individuals whom Dr. Watson described as suffering from “brain
fever” obviously had all passed through a terrific mental storm--in
modern parlance, they had sustained “severe psychic traumata.” Whether
this alone could cause “brain fever” is a moot question. The condition
presumably is caused by a virus. That a severe brain storm could cause
the lurking virus to become active seems unlikely.

Previously it has been mentioned that a head injury apparently is
capable of hastening the onset of brain fever in children. (We will
waive the fact that the cases Dr. Watson described are adults.) A
physical injury presumably produces certain organic changes in the
brain or in its meninges, which perhaps could precipitate an attack
of encephalitis, assuming that the virus was present. There is no
particular evidence that the patients mentioned in the tales had
suffered a head injury.

It is true, of course, that great emotional upsets are often
accompanied by marked vascular disturbances. These may manifest
themselves in the brain as well as in other parts of the body. It is
not conceivable that encephalitis would follow an emotional storm.
Be that as it may, this can be said: It is generally agreed that
anything which lowers the resistance of an individual may make him more
susceptible to disease. In the cases described by Dr. Watson, the virus
may have been present, and the shock produced by the emotional storm,
which all these people experienced, might have precipitated an attack
of encephalitis (brain fever).

If this seems too farfetched, and the reader cannot go along with me,
I can say only that I am sorry. I will have to use the argument that
one should allow a talented and imaginative writer like Dr. Watson a
liberal degree of poetic license.

Dr. Watson may have used the term “brain fever” loosely, and perhaps as
synonymous with extreme nervous exhaustion. He does, however, mention
that some of the sufferers became delirious. This symptom is suggestive
of encephalitis. Also, in one or two instances the victim recovered
rather quickly, which points to an acute condition such as encephalitis
rather than nervous exhaustion. I am cognizant that some may regard
this as a specious argument.

The question could be raised whether the patients described by Dr.
Watson suffered from hysteria. This condition cannot entirely be ruled
out. Hysteria has protean manifestations, and may even be accompanied
by fever. The great mental storms through which these patients passed
are conducive to hysterical attacks. The fact, however, that these
individuals ran a high fever and were dangerously ill would militate
against a diagnosis of hysteria. It seems fairly safe to assume that
the disease from which they suffered probably had an organic basis.

The reader should be reminded that Dr. Watson began the study of
medicine only a short time after the researches of Erb and of Westphal
on the nervous system had been published. Neurology had not yet come
into its own, and it is likely that the medical profession did not
make fine distinctions when dealing with diseases of the brain or its
meninges. It probably is not charitable for me to suggest that the
professors who taught the young Watson about nervous diseases in the
year 1876 or thereabouts had not kept up with the literature in their
field--a fault of which we are all more or less guilty.

Dr. Watson has been taken to task by some critics in the medical
profession for using the term “brain fever,” and the implication has
been made that his employment of a meaningless term was unworthy
of a medically trained man. Now it appears that this criticism is
unjustified. We might quarrel with Dr. Watson as to what brought on
the attacks of “brain fever,” or whether the victims actually had the
disease in the cases he so vividly described, but the term itself is
acceptable.

The Holmesian enthusiast will rejoice that the term “brain fever”
is again in good repute and is accepted by the medical fraternity.
The very fact that the staid _Journal of the American Medical
Association_ has published an article bearing the title “Brain
Fever” has stripped criticism of all weapons. The loyal Holmesian no
longer needs to feel apologetic for the nomenclature Dr. Watson used to
describe a rather unusual and fortunately rare clinical entity.

CURARE AND SHERLOCK HOLMES

“... for the action of the alkaloid is rapid.”

_A Study in Scarlet_

Curare is used as a lethal agent in two of the Sherlock Holmes stories.
In the novel _A Study in Scarlet_, liberties are taken with the
pharmacologic properties of curare, for actions are ascribed to this
agent which it could not possibly have had. But in _The Adventure
of the Sussex Vampire_, curare is employed scientifically and with
telling effect; and indeed, an interesting plot is built around this
agent.

Let us first examine the role curare played in _A Study in Scarlet_.
Holmes, it will be remembered, wished to determine the toxicity of
certain pills and instructed Dr. Watson to fetch a little dog, which
already was _in extremis_: “... that poor little devil of a terrier
which has been bad so long, and which the landlady wanted you to put
out of its pain yesterday.” Watson commented on the state of the
animal: “Its laboured breathing and glazing eye showed that it was not
far from its end. Indeed, its snow-white muzzle proclaimed that it had
already exceeded the usual term of its existence.” Then, according to
Dr. Watson, some of the pills which were thought to contain curare
were dissolved in milk and offered to the sick dog: “The unfortunate
creature’s tongue seemed hardly to have been moistened in it before it
gave a convulsive shiver in every limb and lay as rigid and lifeless as
if it had been struck by lightning.”

Before we comment on the sudden death of the terrier, let us see what
befell Enoch Drebber, who was forced by Jefferson Hope to swallow
a pill containing curare. The wretched Drebber met the same fate as
the aged terrier, for we find Watson writing: “... the action of the
alkaloid is rapid. A spasm of pain contorted his features; he threw his
hands out in front of him, staggered, and then with a hoarse cry, fell
heavily upon the floor. I turned him over with my foot, and placed my
hand upon his heart. There was no movement. He was dead.”

The deaths of Drebber and the terrier were dramatically portrayed, and
Dr. Watson is to be congratulated on the vivid picture he presented.
The trained scientist however, could not entirely accept the events
as he outlined them. The difficulty lies in the fact that curare is
relatively harmless if taken by mouth. If extremely large doses are
administered on an empty stomach, sufficient curare may be absorbed
to cause grave symptoms, but death would not be instantaneous, for
absorption is slow from mucous surfaces. If, on the other hand, there
were an open lesion in the stomach or the upper part of the small
intestine, such as an ulcer, then rapid absorption could take place,
and death would ensue in a relatively short time, although not as
rapidly as portrayed in the story. The action of curare is rapidly
lethal only if injected directly into the blood stream. It would
stretch our credulity too far to assume that both the dog and the man
had either a gastric or a duodenal ulcer.

Let us now consider how curare was employed in the story _The Adventure
of the Sussex Vampire_. It will be recalled that Sherlock Holmes was
asked by Mr. Robert Ferguson to investigate certain irregularities in
his household. Ferguson, a fine gentleman, was very much in love with
his beautiful Peruvian wife; but one day, to his infinite horror, he
had actually seen her sucking blood from a wound on the neck of their
year-old baby. She refused to make any explanation, and the husband
and wife became estranged. There was another child in the family, an
invalid boy of fifteen, Ferguson’s son by a previous marriage.

Dr. Watson accompanied Sherlock Holmes to Ferguson’s country home on a
dreary autumn day. One of the rooms of the old house contained a fine
collection of South American utensils and weapons which presumably had
been brought from Peru by the mistress of the house. As Holmes was
examining this interesting collection, the movements of a dog attracted
his attention. Holmes noted that the dog experienced difficulty in
walking. The astute detective asked Ferguson what ailed the dog. His
host replied that the thing had also puzzled the veterinarian. The
latter had thought it might be spinal meningitis. Holmes asked a few
more questions about the dog, and finally remarked that the picture the
dog presented was very suggestive.

The frantic husband insisted that Holmes tell all he knew or suspected.
Holmes then gently explained to the indulgent father that his
fifteen-year-old invalid boy was so insanely jealous of his healthy
baby half-brother that he had tried to do away with him by wounding
him with an arrow treated with curare. The boy had first tried out the
poison on the dog. Ferguson’s wife, in an heroic effort to save her
baby, had sucked the site of the arrow wound. The mystery was solved,
and Holmes and Watson had the keen satisfaction of clearing up the
grave misunderstanding between Ferguson and his lovely Peruvian wife.

In this story, curare was handled in an expert manner. It is known, of
course, that the South American Indians dipped their arrowheads into a
curare solution before using them to kill birds. The curare was rapidly
absorbed from the wound made by the arrow; the wing muscles became
paralyzed; and the bird plummeted to earth--an airplane without wings.

_The Adventure of the Sussex Vampire_ was written many years ago. What
is the status of curare today? This interesting compound has actually
insinuated itself from the jungle not only into the experimental
laboratory but into the surgical amphitheater as well. This is not
the place to take up in detail the clinical use of curare, but a few
remarks are in order.

Relaxation of the muscles is often highly desirable in surgical
procedures; it is not surprising, therefore, that the anesthetists have
added curare to their armamentarium. Although curare has no anesthetic
action _per se_, it has been found to serve as a useful adjuvant to
certain anesthetic agents. It has been used also for the convulsions
of strychnine poisoning, tetanus, and hydrophobia, as well as certain
spastic contractures. It could furthermore be of help in the management
of dislocations, especially in heavily muscled individuals.

Curare should be employed only by experienced workers, for the muscles
of respiration may become paralyzed, and unless mechanical respiration
is given immediately, the patient will die of asphyxia. Fortunately,
curare is quickly excreted by the body, and the patient will soon start
voluntary breathing movements.

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

SHERLOCK HOLMES AND THE PORTUGUESE MAN-OF-WAR

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

_The Adventure of the Copper Beeches_

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

DOCTOR WATSON AND NERVOUS MALADIES

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

_The Hound of the Baskervilles_

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

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

Watson felt that Holmes needed a complete rest in a quiet and soothing
atmosphere, and finally persuaded the great detective to take a holiday
in the country. Arrangements were made to stay at the home of one of
Dr. Watson’s old friends. On the evening of their arrival, their host,
Colonel Hayter, in the course of a conversation following dinner, told
them of an unusual burglary which had occurred a few nights before
in the neighborhood. When Holmes manifested too warm an interest in
this event, Watson became alarmed and cautioned him: “You are here
for a rest, my dear fellow.