For twenty years I wanted to write about the world I knew as a medical resident, but I could never find the way to do so. There have been plenty of bildungsromans and medical memoirs, but the canvas seemed so rich with possibility I knew I wanted to reach a little further outside myself. When the answer finally came to me, I could only laugh at how long it had taken to realize that my medical book should be a crime novel.
The reason I should have thought of it long ago, is that I have always considered medical diagnosis and criminal investigation as being a pair of conjoined twins. After all, at their most urgent, they come down to exactly the same thing: an attempt to identify a killer before they claim another victim. Beyond that, I may even have a special personal claim to crime-writing, for I was born in the same hospital as Sherlock Holmes.
I understand that sounds implausible. A century separates my birth from that of the world’s only consulting detective, and then there is the small matter of Sherlock Holmes being a fictional character. Nonetheless, it was Holmes himself – via the medium of his creator, Arthur Conan Doyle – who declared that ‘once you have eliminated all which is impossible, then whatever remains, however improbable, must be the truth.’
Like generations of my fellow Edinburgh citizens before me, I was born in the old Royal Infirmary on Lauriston Place. The Infirmary was built in the grandiose Scottish baronial style and still stands today, tall and proud between the green fields of the Meadows and the sandstone tenements of the old town. Alas the infirmary is no longer a hospital, for in the early part of the twenty-first century, the premises were sold to a property developer who planned to turn the whole thing into luxury flats. Much of the planned development has not materialized: just as so many of us were born there, an equal number of us have died there, and few locals turned out to want to live in bespoke modern splendor where Grandma passed. A few parts of the original hospital building were converted to flats and restaurants, and even a gym, but the refurbished crow-stepped gables and conical bartizans belie the fact that the old wards and operating theatres inside have largely simply been abandoned. The Scottish term for this kind of situation – an ostentatious appearance that conceals something lacking – is, ‘All fur coat and nae knickers.’
In the early 1880s, Arthur Conan Doyle was first a medical student, and then a newly-qualified clerk at the Royal Infirmary. His teacher there, the surgeon Joseph Bell, was world-renowned for his diagnostic ability. Bell termed his diagnostic process ‘The Method’ and characterized it as ‘observe carefully, deduce shrewdly, and confirm with evidence’. On his rounds each morning, Bell liked to impress his junior colleagues by announcing the occupation and diagnosis of each newly-admitted patient before he had asked them even a single question. The place where a suntan ended on the arms, the erectness of a bearing, whether or not a man removed his hat at the doctor’s approach; each of these were clues which could lead Dr Bell to correctly deduce that a patient was a former soldier, recently returned from the Tropics – Barbados, to be precise – and was suffering from elephantitis.
If one of a clerk’s jobs is to take notes, Conan Doyle surely did that, for Dr Bell became the model for his Sherlock Holmes. The opening chapter of the second Holmes book, The Sign Of Four, is titled ‘The Science of Deduction’. In it, Dr Watson offers Holmes a wristwatch and asks him to guess at its provenance. In a scene that could have come from one of Bell’s ward rounds, Holmes notes the scratches near the watch’s bezel and surmises that it belonged to Watson’s father, who passed it on to Watson’s brother, and that this unfortunate late brother was an alcoholic who had trouble winding it. Holmes is, of course, entirely correct.
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Medical and criminal cases generally commence in more or less the same way: with a complaint. A patient or victim has experienced something unwanted, and the doctor or detective interrogates them about the details: what, when, where, how. In each field, this first consultation can set the investigator up for success or failure. ‘Listen to the patient’ Hippocrates counseled, ‘He is telling you the diagnosis’. Likewise, the importance of this initial exchange – and its vast potential for self-incrimination – is why suspects are routinely read their Miranda rights on arrest.
The report taken or the interview completed, the search for physical clues now commences. At the crime scene, the detective looks carefully for signs of forced entry, of violence, of theft, of an escape route. Meantime, the physician’s crime scene is the patient’s own body: here she looks for anaemia, a fast heart rate, finger clubbing, surgical scars, or swollen lymph nodes. No single finding can solve a case or make a diagnosis, but to both the detective and the doctor, every new piece of information that can be gleaned by observation helps narrow down the range of potential suspects.
Finally, in both disciplines, laboratory science is ultimately used to confirm or refute an investigator’s suspicions. In medicine, the gold standard is what is called a ‘tissue diagnosis’: a sample is inspected under a microscope, and dividing cells or invading parasites are caught red-handed. In detective work, forensic evidence – a fingerprint, a DNA match – likewise serves an equally final and inarguable function.
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If that all seems too tenuous or abstract, a real world case from my own annals. A few years ago, my mother suffered a catastrophic complication after what should have been a routine operation. A large amount of her bowel had to be removed, and after a rockily uncertain first night that I passed at her bedside in the intensive care unit, she spent several further weeks on a ventilator. Eventually, she was stepped down to the ordinary ward to begin the slow process of rehabilitation.
By visiting time on the first afternoon in the regular ward, the nurses had got my mother sitting out of bed. From a distance she was a glorious sight: weak but awake, sitting in the sunlight in her robe, her breathing tube and many of her lines now removed. If she was not yet well, she was finally on the way to being so. But when she turned to look up at me, I stopped dead: one of my mother’s pupils was noticeably and strikingly far bigger than the other.
In medicine, a difference in the size of the pupils is termed ‘anisocoria’. Anisocoria can be a normal finding if present from birth, but in most people a reflex mediated through the third cranial nerve keeps the pupils symmetrical. The new onset of anisocoria is therefore a clue that something is afoot in the brain, and requires thorough investigation.
I called over the nurse, who confirmed the difference between the pupils, agreed it was odd, and hurried off to summon the doctor. The doctor who arrived was very junior – the twenty-first century equivalent of a clerk – and he suggested hopefully that perhaps my mother’s pupils had simply always been different sizes. I could prove they had not been, because in the ICU pupil size is regularly checked. The young doctor fetched my mother’s charts and sure enough, her pupils had been recorded as perfectly equal at six hourly intervals for the entire preceding month. The puzzled young doctor took some bloods, ordered a CT scan, and promised a more senior colleague would come to review my mother with the results.
It took until the evening for the scan to be arranged, and during this time my mother’s pupils remained stubbornly unequal. By now I had also discovered that she was subtly confused: on a few occasions during the afternoon she had forgotten we were awaiting a scan and attempted to send me home, and once she had even asked if I would be driving back to the United States that same night. I did not think too much of any of this, for some confusion is common in patients recently discharged from the ICU, and it usually resolves without intervention.
Sometime after 8pm, I followed as two porters wheeled my mother through long corridors, into various elevators and finally into the scanner itself. By the time we made it back to the ward, evening visiting hours had long since finished and the overhead lights had been turned off for the night. When the more senior doctor arrived he informed us that my mother’s bloods had been normal and her scan had shown no sign of a developing stroke or a bleed. He admitted that he could not provide an explanation for her unequal pupils, but reassured me the tests they had performed had ruled out anything serious.
To stretch the metaphor, this doctor was a police sergeant informing me that he could not explain why I had returned home to find my front door open and the furniture rearranged, but nothing seemed to have been taken and we could therefore assume that nothing serious had occurred. I was uneasy about this – I had the feeling we had simply not yet discovered the true nature of the crime – but there is a good reason why doctors are not supposed to treat family members, and that good reason is that it is impossible to be objective when it comes to our own loved ones. I accepted the doctor’s opinion and returned home to a restless night.
The next day was Saturday, and I went in mid-morning to find that my mother had gotten a little worse. She had fallen in her shower that morning, and was now more obviously confused. Nonetheless, the nurse said the doctors had reviewed her on the ward round, and were confident her current issues were all simply due to her recent ICU stay.
But when I looked closely at my mother, I saw that as well as her still uneven pupils, the left side of her mouth had begun to subtly droop, and when I asked her to look to the side, her eyes flickered for a few beats in the horizontal plane. I recorded this all on my phone, and showed it to the young clerk, who grudgingly agreed to ask a neurologist to come and review her. He made it clear that he did not think this was necessary, and that he was doing it only to humor me.
The neurologist did not arrive on the ward until late afternoon, and he had clearly been forewarned that I was an over-anxious relative. He examined my mother brusquely, and then declared that there were no issues whatsoever with her nervous system. By now certain that this could not be true, I protested.
The neurologist sighed wearily, and told me that my mother had been reviewed by a senior neurologist – himself – who had found no evidence of a neurological problem. Anyway, she had already been bled and scanned and none of it had shown anything, so what did I even want him to do at five pm on a Saturday? What I wanted him to do, of course, was to solve the crime, but that required him to first agree that a crime was in progress. Instead, when I showed him what I considered the prima facie evidence on my phone, he shrugged and told that he could not see what I was talking about, so my findings were not pronounced enough to be clinically significant.
In my favorite of all the Sherlock Holmes stories, “The Red-Headed League”, a flame-haired pawnbroker named Jabez Wilson answers an advertisement seeking a red-haired man for an unspecified but highly lucrative position. Wilson attends for interview and, among thousands of queueing redheads, is decreed by the delighted panel to have hair of the precise shade of red they require. Wilson is then set to his new work, which turns out to be copying out the Encyclopedia Britannica by hand. After two months at this, Wilson arrives at the offices of the Red-Headed League one morning to find that the entire organization has disappeared. Convinced that something untoward is afoot but having no idea exactly what, Wilson consults Sherlock Holmes.
That Saturday afternoon at the hospital in Edinburgh, I felt like Jabez Wilson: certain that malfeasance was occurring, but baffled as to what it might be.That Saturday afternoon at the hospital in Edinburgh, I felt like Jabez Wilson: certain that malfeasance was occurring, but baffled as to what it might be. When Sherlock Holmes needs to think deeply, he smokes his pipe; difficult cases are referred to as ‘three-pipe problems’. Pipe-smoking is not for me, but in medical school I had made the unfortunate discovery that I do my own best thinking while exercising. Perhaps it is the increased blood flow, or simply the lack of oxygen, but when I am going flat out, things often seem to occur to me that otherwise would not. The hardest exercise for me is running, and I knew that what faced me that evening was at least a five-mile problem.
In The Red-Headed League, Sherlock Holmes answers Wilson’s plea by visiting his pawnshop. He strikes the pavement outside with his walking stick, and thereby observes that the shop’s cellar extends towards the street. On meeting Wilson’s assistant, he notes that the knees of his trousers are dusty. From these two observations, Holmes deduces that a nearby bank is to be robbed that night. After a stakeout, and the capture of Wilson’s assistant and his accomplice, Holmes explains his deductions to Watson: Wilson’s assistant – in fact a wanted criminal by the name of John Clay – created the Red-Headed League as a ruse to get Wilson out of the shop each day so that he and his accomplice could tunnel to the vault of the bank and there steal a shipment of coins. Wilson, then, had been entirely correct to suspect a crime was afoot, but it had required the mind of Sherlock Holmes to solve it.
In February, Edinburgh is already cold and dark by late afternoon, so I when I left the hospital I headed not for the park or canal, but a treadmill. My gym at that time was the one housed in the old Royal Infirmary building, the place where both Sherlock Holmes and I had been born. Logically I knew this coincidence was merely a reflection of how contained a city Edinburgh is but, as I had a major crime to solve, it seemed a good omen.
Nonetheless, for the first mile, I had monkey-brain: racing thoughts that leapt into my mind unbidden and prevented me from following a train of thought anywhere useful. Perhaps this was understandable, for I had the unshakeable feeling that if I did not crack the case soon, some irreparable harm would befall my mother. As I pounded the rubber belt, I grasped at possible diagnoses: a medication side effect, a stroke that had been too early for a scan to show, a brain tumor that had been unmasked by her current illness. As my heart rate increased and I became breathless, I sensed my head begin to clear and my feet fall into a steadier rhythm. At this point I remembered Dr Bell’s Method, and tried to apply it to our predicament.
The patient being my mother, I did not have to attempt to glean any basic facts about her by observation. I already knew she was a 68-year-old retired elementary school headteacher, and until these recent troubles she had been in good health. I could therefore cut straight to the far trickier part of Dr Bell’s exhortation: the Method now required me to ‘deduce shrewdly.’
The brain is the most complex of all the organs, and it can malfunction in myriad ways. The key to diagnosing these is often anatomy: the composition of speech, for instance, occurs in one area of the brain, its comprehension in another. With adequate anatomical knowledge, a patient’s signs and symptoms can therefore be used to locate where in the brain a lesion has occurred. Just as housebreakers and serial killers have their preferred stalking grounds, so to do individual maladies; if we can pinpoint where in the brain a crime is taking place, we can usually glean a good idea of the likely culprit.
I ran through my mother’s symptoms: anisocoria mapped to the third cranial nerve, the drooping mouth to the seventh, and the horizontal flickering in her eyes to the cerebellum at the back of the brain. No single anatomical location could account for all these symptoms, so the pathology was therefore not a single lesion, a fact that effectively ruled out the usual suspects of an ischemic stroke, a bleed, or a tumor. Instead, we were dealing with something more insidious that had been able to affect several parts of her brain at once: a Napoleon of crime.
I increased the pace on the treadmill, hoping the exertion would keep me focused. What kind of a process, I asked myself, could affect the whole brain, or at least several distinct locations within it? An infection could do it, but my mother did not have a fever, and her blood tests had been normal. Perhaps a rarer vasculitis then, an inflammation of the blood vessels themselves, but the blood tests likewise went against that.
Those normal blood tests, I now realized, were key. The vast majority of whole-brain pathologies would be expected to provoke at least inflammation that would have shown up on them. My question therefore now became: what could affect the whole brain, but do so without triggering the body’s intruder alarms? The answer, I deduced as I passed mile four, was not something that should not have been present – a bacteria, say, or a virus – but rather some kind of deficiency.
But a deficiency of what? The two most common culprits are a lack of oxygen, or sugar, but my mother’s saturations had been normal, and I had watched the nurse repeatedly check her sugars at the bedside.
Once again, I returned to the Method. Even if I did not require to deduce anything about my mother, perhaps there was something I could deduce from her experiences. Her previous good health offered no clues: she was a lifelong vegetarian, but that had never caused her any problems. Likewise, the routine operation she had undergone had little obvious connection to her brain, and the subsequent removal of her intestine-
I hit pause on the treadmill, stopped running too soon, and found myself thrown off the back of it. Much of my mother’s small intestine had been removed; as the small intestines absorb nutrients, it would make perfect sense that the thing she was most likely deficient in was a dietary nutrient. The question now was which one.
A deficiency of thiamine – vitamin B1 – is well known to cause neurological problems, but this usually occurs in alcoholics. Moreover, the risk is so well understood and so easily ameliorated, that anybody suspected of alcohol misuse – and anybody admitted to an ICU – is routinely supplemented with parenteral thiamine. – is prescribed a thiamine infusion on admission. If ever you have ever spent an hour in an Emergency Room you have almost certainly seen someone being given a thiamine infusion, and may even recall it, for the bags are an unforgettable bright yellow color.
My prime suspect, then, was Vitamin B12. B12 is often reduced in vegetarians, and low levels can trigger a serious condition called Subacute Degeneration of the Spinal Cord. That put us at least in the ballpark of a deficiency causing a neurological problem, but the primary symptoms of Subacute Degeneration are classically issues with peripheral sensation, so the diagnosis was by no means an ideal fit. Nonetheless, I wondered if my mother’s symptoms might still be an unusual manifestation of vitamin B12 deficiency. I certainly did not have any better ideas.
If Conan Doyle himself had been unsure about a diagnosis during his clerkship, he would have no doubt asked Dr Bell. Likewise, when Sherlock Holmes is faced with a puzzling case that even three pipes can’t solve, he will occasionally seek the help of his brother, Mycroft. (Mycroft Holmes is even better at deductive reasoning than Sherlock, but cursed with laziness and so must work running the British government instead of solving cases.)
But I was not a Sherlock Holmes, nor even a Conan Doyle. At best, I was a Dr Watson: logical enough, but apparently incapable of the necessary leap of deductive brilliance to make the required diagnosis. I therefore now collected my phone from the changing room and called my own Dr Bell, my own Sherlock Holmes, my own Mycroft: a friend who has spent the last twenty years honing his own deductive skills at the coal face of acute internal medicine.
He listened patiently as I explained my mother’s history and symptoms. I then asked him if he agreed this could be an unusual manifestation of vitamin B12 deficiency? He paused and thought for some time – in the way Holmes himself frequently does – before replying. My friend acknowledged that he could not fault my logic and Method, but said he had never heard of B12 deficiency causing such symptoms. If anything, he mused, it sounded far more like a thiamine deficiency, except of course it could not possibly be a thiamine deficiency, as my mother had spent the last month in ICU where she would have been reviewed daily by a dietician.
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A vitamin is a substance that the body requires but is incapable of synthesizing itself. As thiamine is essential for the Krebs Cycle, the biochemical reaction that produces the intracellular energy that powers our bodies, our brains require an uninterrupted supply of it. In health, the human body is capable of storing only about 25mg of thiamine, equivalent to around three weeks’ supply.
In medical school, the disastrous effects of untreated thiamine deficiency are drilled into students. It commences with a condition called Wernicke’s Encephalopathy, traditionally described as the triad of confusion, unsteadiness, and eye muscle paralysis, but increasingly recognized to present with a wider array of symptoms. If treated immediately with high dose parenteral thiamine, Wernicke’s Encephalopathy is reversible. Left untreated, it will rapidly progress into its feared older sibling, Korsakoff Syndrome. Patients with Korsakoff Syndrome develop a profound and devastating amnesia; unlike Wernicke’s, Korsakoff Syndrome is generally not reversible.
On the phone, after raising and excluding several other remote possibilities, my friend was circling back again to thiamine deficiency, the notion clearly nagging at him. Perhaps, he said, it would be a good idea just to double-check that my mother had been given thiamine. He could not conceive of a situation where she had not, but once you have excluded every other possibility, whatever remains, however improbable, is the answer. As he spoke, I thought back to that first night at my mother’s bedside. I had spent long hours staring at her beeping pumps, her monitors, her syringe drivers, her infusions. And at no point during that time had I ever seen a yellow bag.
In the Sherlock Holmes story, ‘The Adventure of Silver Blaze’, Holmes is asked to investigate the disappearance of a race horse and the apparent murder of its trainer, John Straker. A bookmaker is suspected of the crime, but Holmes makes a key deduction from what he describes as the ‘curious incident of the dog in the night-time’, the curious incident being the dog’s failure to bark. From this fact, Holmes deducts that the dog must have known the intruder, and that it was Stryker himself, who subsequently became an accidental victim of his own plot to throw a race.
The yellow IV bag, I realized, was my own dog that did not bark in the night: I should have encountered it, but I had not. I thanked my friend, called the ward, and spoke to my mother’s nurse. Like us, she was certain that my mother would have been given thiamine on admission, but agreed to confirm this by reading through her notes. Five minutes later, she called me back to say there was no record of my mother ever having received thiamine, and she would now arrange for it to be given as an immediate infusion.
When I returned to the hospital the next day, my mothers’ pupils had returned to equal size, her eyes no longer flickered, her mouth no longer drooped and her confusion had evaporated. Unaware of events overnight, the clerk told me that he was pleased with her progress and a good night’s sleep had obviously done her the world of good. I told him what had really happened, not to gloat, but because she would need more thiamine in the coming days. It would later be explained to me that my mother had been so sick that first night that her thiamine had simply been forgotten amid the confusion. Like me, her dietician had then failed to notice the dog that had not barked in the night.
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My mother is fully recovered now, and lives with her husband on the remote west coast of Scotland, a wild and ruggedly beautiful place. I keep a bicycle there, and when I visit them I often ride a ten-mile loop that takes me past both sides of a peninsula, a golf course, and several small farms. The ride also takes me through an estate that was the site of one of Scotland’s most infamous killings, the Ardlamont Murder.
In 1883, a wealthy young heir by the name of Cecil Hambrough was shot dead while hunting in the grounds of Ardlamont House with his hired tutor, John Monson. Monson claimed it had been a tragic accident, with Hambrough accidentally shooting himself while climbing over a wall. The Procurator Fiscal – the Scottish equivalent of a coroner – initially accepted this explanation, but two weeks later, Monson attempted to claim a £20,000 life insurance policy that he said Hambrough had taken out six days before he died. The named beneficiary of the policy was Monson’s wife.
Monson was arrested and put on trial at the High Court in Edinburgh. As well as the murder itself, Monson was also charged with an earlier attempt. A few days prior to Hambrough’s death, Monson allegedly sought to drown his non-swimming pupil by rowing him out into Ardlamont bay and scuttling their boat.
At his trial, Monson stuck to his original story, that Cecil Hambrough had accidentally shot himself. To refute this, the prosecution called a special witness. His appearance at the trial made national news, and The Leeds Mercury reported it thus:
‘The next witness was the veritable Sherlock Holmes, Dr Joseph Bell. A clean-cut intellectual face, piercing eyes and thoughtful expression somewhat recalled the pictures of Dr Doyle’s celebrated detective.’
Dr Bell did not perform the post-mortem on Cecil Hambrough, so was not in court to report those findings as a doctor, but rather as an expert at the science of deduction – that is, as a doctor whose deductive methods could be applied to crime. Asked for his opinion of the death, Dr Bell stated:
‘I have not been able to make out any way by which the injury could have been done either designedly or accidentally by My Hambrough himself.’
Despite the testimony of the veritable Sherlock Holmes, the jury was not entirely persuaded. The case ended with Scotland’s unique third verdict: Not Proven. Sitting somewhere between ‘guilty’ and ‘not guilty’, ‘Not proven’ carries with it a shame, for it implies that the accused likely committed the crime but there was simply insufficient evidence to convict them. Perhaps this stigma is best illustrated by a lawsuit that Monson subsequently brought against Madame Tussauds, who had placed a waxwork of him with a gun on display in a room filled with likenesses of murderers. Monson sued for libel by innuendo; he won the case, but was awarded only a single shilling in compensation.
Briefly tempted though I was, I did not write my own crime novel about Monson, Hambrough, or even Dr Bell. Instead, I wrote about a fictional crime in a world I had once known, but sought to bring to it some of the deductive skills that were instilled in me by my own medical teachers. Readers can decide for themselves how successful I was, but in a struggling East London hospital, the game is most certainly afoot.
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