The Background To The Medical Casebook

 

Background

The primary part of this week’s blog page is going to be the introductory chapter of the book. This overlaps a bit with last week’s post, but explains in more detail why I decided to write the book, along with an explanation of how I approached the academic aspects of the project.

Progress Report

This week’s exciting news is that the book exists as a real thing. MX Publishing sent out the very first paperback copy, which arrived yesterday. Quite an emotional moment for a first-time author.

This Week’s Illustration

Alex Holt has drawn me 8 original illustrations for the book, as well as the cover drawing.

The scene at the start of this post is from “The Resident Patient”. A young doctor, Percy Trevelyan, is set up in practice by a mysterious benefactor called Blessington. Trevelyan is an expert in an obscure medical condition – catalepsy. He is approached by a Russian count who suffers from the condition. During their first consultation, he suddenly has an attack. 

“The patient and I then plunged into a discussion of his case, of which I took exhaustive notes. He was not remarkable for intelligence, and his answers were frequently obscure, which I attributed to his limited acquaintance with our language. Suddenly, however, as I sat writing, he ceased to give any answer at all to my inquiries, and on my turning towards him I was shocked to see that he was sitting bolt upright in his chair, staring at me with a perfectly blank and rigid face. He was again in the grip of the mysterious malady”. 

However, the Russian count is only pretending to have the disease, in order to get access to Blessington, who is murdered.

 

Introductory Chapter

I first encountered Sherlock Holmes through the Basil Rathbone movies. Filmed during the Second World War, they were a regular feature of BBC weekend afternoon TV when I was aged maybe 11 or 12. They captivated me straight away. Wonderful characters in wonderful stories. Most were set in a mysterious, foggy, Victorian England. But in some, Holmes battles Nazi agents, which, for a Victor comic loving kid, made them even more exciting.

I then moved onto the Sherlock Holmes stories themselves, of which I discovered there were many. Again I thought they were brilliant – thrilling plots in great settings. But above all I was fascinated by Holmes’s deductive technique – partly how he solved the mysteries, but particularly how he was able to tell so much about a person at a mere inspection, when they walked through the door of 221B Baker Street. At the time I was starting to think about becoming a doctor. I wouldn’t then have been aware that doctors use very similar techniques with patients, but the concept of what I would now call hypotheticodeductive reasoning was just so intriguing. Sherlock even had a sidekick who was a doctor, and Dr Watson became a further role-model for me.

Somewhere along the line I learnt that the author of the stories, Arthur Conan-Doyle, had also been a doctor. Likely by this point I had fully decided on my goal of getting to medical school. I then found out that Conan Doyle had been a GP in Southsea, with a practice in Elm Grove. Wow – that was so close. I was living in Milton – Conan Doyle had been practising less than 2 miles from where I grew up.

My obsession with Conan Doyle and Sherlock Holmes was then fully entrenched when I discovered that Conan Doyle was one of the founders of Portsmouth Amateur Football Club [in 1884]. At the time I would have been standing on the terraces for all home matches. Fratton Park is in Milton, and the roar from the ground on a Saturday is one of my earliest memories [along with 1970’s football violence, which often played out along my road]. Conan Doyle even played for my team, both as goalkeeper and full-back.

I safely got the A Level grades needed to get to medical school, and headed north to the lovely city of Sheffield. It was very deprived and rundown at the time, with the closure of a lot of the steelworks, but was very friendly and welcoming, and so beautiful, with its many parks, and easy access to the Peak District.

After qualification I took on House Officer posts in Sheffield and Whitehaven, and, with the latter post, discovered the wonders of the Lake District. I decided to follow Conan Doyle into becoming a General Practitioner, and completed my 3 years GP training in Lancaster and Kendal. I then became an itinerant GP, working in such diverse places as Ipswich, Seascale [the village next to Sellafield Nuclear Power Station], Hampshire [for the RAF], Germany [for the British Army], Tasmania [providing overnight GP cover for the city of Hobart] and Chile [working for Raleigh International].

Eventually I decided to settle down, and joined a practice in High Bentham, North Yorkshire, in 2000. It is a beautiful spot on the edge of the Yorkshire Dales National Park, and my practice area includes 2 of the Yorkshire Three Peaks [Ingleborough and Whernside].

And amazingly Conan Doyle’s presence was still to be found. Conan Doyle’s father, Charles Altamount Doyle, sadly suffered from depression and alcoholism, and spent spells in Montrose Royal Mental Hospital. Conan Doyle’s mother, Mary [“the Mam”] , left Charles in 1884, and moved to the tiny village of Masongill, which is a pleasant 2 mile walk across the fields from where I live. She was likely having an affair with the owner of Masongill Hall, Bryan Waller, though ostensibly was living in a cottage on the estate. Conan Doyle’s first marriage, to Louise Hawkins [“Touie”], took place in St Oswald’s Church, Thornton In Lonsdale, which was the nearest Anglican church to Masongill. Mary lived at Masongill until 1917, when she moved to Sussex [she died in 1920]. It is uncertain how much time Conan Doyle spent in my practice area. Though he did write a short story which is set in the area – “The Surgeon of Gaster Fell” [1] – “In my frequent walks I had learned to know well the wild and desolate region where Yorkshire borders on both Lancashire and Westmorland.” Sadly this is not, however, a Sherlock Holmes story.

I have now been a GP at High Bentham for over 20 years. As a rural GP, I have become an integral part of my fantastic Yorkshire farming community. Like many modern GP’s I have what is called a portfolio career. I train GP’s, and there are now a good number of local GP’s that I have taught to use similar diagnostic techniques to Sherlock Holmes. I sub-specialise in dermatology [skin disease], and have a tutoring post on a postgraduate course run by Cardiff University. I am also one of the medics for the local cave and mountain rescue team [the “Cave Rescue Organisation”].

I am passionate about being a GP. It is a brilliant role that provides a brilliant service for our patients. Sadly what is great about general practice is gradually being eroded, and we are becoming less effective [both in terms of what we achieve, and also financially for the NHS as a whole].

This book is an attempt to bring together much of the above. I started the project with two main goals. Firstly to look at how Dr Arthur Conan Doyle used his medical knowledge when writing the Sherlock Holmes stories, via a study of the diseases that feature in the tales. Secondly I wanted to take a historical look at the understanding of these diseases at the time Conan Doyle was at medical school and practising as a GP. Along the way I decided to include some personal commentary based on a modern understanding of these diseases. 

My first task was to re-read the Sherlock Holmes canon [“canon” is the slightly pretentious term us Conan Doyle groupies call the collected Sherlock stories]. I used my battered copy of “The Penguin Complete Sherlock Holmes” [2]. I pulled out all the medical references. My self-imposed rule was to include all references to medical diseases, whether referring to the disease directly, or using the term as a metaphor. I decided to exclude deaths by other human hands, such as shooting, stabbing, or poisoning. My eventual list of Sherlockian diseases is inevitably open to interpretation, as some of the Victorian medical terminology is quite tricky.

I thus ended up with a list of 52 diseases referenced in the canon. I was amazed, and delighted, by the spread – my list included a large proportion of what I see today as a modern GP.

The bulk of the book is then a chapter on each of these 52 diseases.

My second task was to research Victorian medical knowledge. I want the book to reflect how Conan Doyle would have practised as a GP. I therefore endeavoured to locate the textbooks that he would likely have used, either when at medical school, or when he was practising as a GP. Conan Doyle attended Edinburgh Medical School between 1876 and 1881. Sadly he didn’t write a huge amount about his time as a GP [one gets the impression that he wasn’t very successful, or happy, as a GP], but he was a practising doctor until 1891, when he became a full-time writer. I therefore decided to confine my research to medical books published between 1870 and 1890.

Most of my sources are the general medical textbooks of the time. These yielded plenty of information for the majority of the conditions, but for a few areas I had to look a bit further, and use more specialised texts and collections of essays. The majority of the texts were written by British doctors. I have used one American text [by Da Costa], as it produced a wealth of interesting information, and was co-published in London and Philadelphia [3]. You will notice that the text was not rewritten in British English for UK publication, so contains American spellings. I also used a German textbook for the subject of psychiatry [by Griesinger], as there were no comparable British texts at the time [4].

I used the Wellcome Library to find the medical works I needed. This is an incredible resource of medical knowledge. They have digitised, and made freely available, all the medical books in their library. So, despite COVID striking just as I started my research, I could pore over the texts without leaving my study. They even introduced some new digitisation software just as I was starting, allowing me to search the texts for specific words, saving me loads of time battling with book content pages and indexes. My huge thanks go to the Wellcome organisation for providing this fantastic resource.

So how are my disease-based chapters going to work? They are all going to follow a similar format.

Firstly I am going to look at how the diseases feature in the Sherlock Holmes stories. I’ll provide the relevant quotes, and discuss how Conan Doyle uses his medical knowledge in his writing. A note here that I have decided not to provide references for the individual stories.   

Next we’ll take a look at a Victorian perspective of the disease. This will largely consist of transcriptions of the relevant sections of the medical texts, as they are so fascinating. I’ll add some personal commentary.

These chapters will generally break down the disease information in a set pattern [though with a little variation dependant on the information I was able to find]:-

[1] Background – providing assorted interesting facts about the disease.

[2] Aetiology – this section looks at the causes and triggers of disease.

[3] Diagnosis – looking at symptoms, clinical signs and investigation.

[4] Treatment – looks at some of the incredible ways Victorian doctors managed disease.

The order of the chapters is simply chosen by me as an interesting mix. I considered sorting the chapters alphabetically by disease, or alternatively in the order the diseases appear in the Sherlock canon, but neither worked very well. So we’ll start with diabetes and end with lumbago.

 

Next Week

 

My post next week will be a look at one of my disease chapters. We’re going to go with my diabetes chapter – a hugely important condition in modern General Practice, and in the case of type 1 diabetes, an inevitably rapidly fatal disease in Victorian times.

 

My Kickstarter Project

A reminder that I have a Kickstarter project in progress. This can be found at:-

https://www.kickstarter.com/projects/1263265994/the-medical-casebook-of-sherlock-holmes-and-doctor-watson