by Michael Sims
Arthur and other efficient clerks interviewed patients in a side room and herded them quickly in and out of Bell’s examination. He sorted as many as seventy or eighty per day, noted details about their complaint or injury, and then brought them in one by one for a consultation—during which he often thought Bell learned more with a glance than had Arthur with his queries. When Arthur began working as clerk, Bell warned him that outpatient interviews required familiarity with the uniquely Scottish slang employed by uneducated locals. Although his parents were Irish, Arthur had been born in Edinburgh—on Picardy Place, in a three-story house of modest but handsome flats near the Gothic Revival parapets of St. Paul’s and St. George’s Episcopal Church. He assured Bell that he was fluent in the local vernacular. Inevitably, one of the first patients Arthur asked about his ailment proved incomprehensible: he complained of a bealin’ in his oxter. Bell was amused to have to explain to Arthur that the location of the pain was the armpit and the problem was an abscess.
“From close observation and deduction, gentlemen,” Bell would declaim confidently, “you can make a correct diagnosis of any and every case.” He was proud of his reputation as an intelligent observer. “However,” he would add, “never neglect to ratify your deductions, to substantiate your diagnosis with the stethoscope—and by other recognized and everyday methods of diagnosis.”
Bell would look over a patient and remark casually, “Cobbler, I see.” Then came the explanation to students, the leap from a detail that not one of the young men had observed: a worn place on the inside of the knee of a patient’s trousers. It was where a cobbler rested his lapstone, across which stretched the leather that was to be hammered into greater strength.
He pointed out to students other clues of profession that he insisted they ought to observe at a glance. Once he immediately identified a patient as either a slater or a cork-cutter: “If you will only use your eyes a moment you will be able to define a slight hardening—a regular callus, gentlemen—on one side of his forefinger, and a thickening on the outside of his thumb—a sure sign that he follows the one occupation or the other.”
Once Bell’s clerk brought in a mother and child. The doctor exchanged greetings with her and asked casually, “What sort o’ crossing did ye have from Burntisland?”—a town in Fife, on the Firth.
“It was good,” she answered.
“And had ye a good walk up Inverleith Row?”
“Yes.”
“And what did ye do with the other wain?”
“I left him with my sister in Leith.”
“And would ye still be working at the linoleum factory?”
“Yes, I am.”
To students Bell explained his mutually supporting surmises: that the woman had a Fife accent, that Burntisland was the closest town in Fife, and that the fingers of the woman’s right hand bore a dermatitis peculiar to workers in the Burntisland linoleum factory. “You notice the red clay on the edges of the soles of her shoes,” he added pointedly, “and the only such clay within twenty miles of Edinburgh is the Botanical Gardens. Inverleith Row borders the gardens and is her nearest way here from Leith.” And although she was carrying a coat with her, it was obviously too large for the boy accompanying her, so he must have an older sibling.
“Quite easy, gentlemen,” remarked Bell on another occasion, “if you will only observe and put two and two together.”
One of Arthur’s predecessors as Bell’s assistant, a student named A. L. Curor, had idolized Bell as Arthur did, and later called him “a super-man.” Bell’s family agreed with such students. When he traveled by train with his family, he entertained his children by observing details about their fellow passengers and, once the strangers had departed, by deducing their private lives from such clues. He would tell his children the occupations and habits of the strangers with whom he had exchanged nary a word, as well as their likely destination. Later his daughter remembered, “We thought him a magician.”
CHAPTER 2
Your Powers of Deduction
It is no wonder that after the study of such a character, I used and amplified his methods when in later life I tried to build up a scientific detective who solved cases on his own merits and not through the folly of the criminal.
—ARTHUR CONAN DOYLE, MEMORIES AND ADVENTURES
The kind of diagnostic clairvoyance that so impressed Arthur was not limited to Joseph Bell. He was a member of a generation of observant, insightful European physicians who—with few diagnostic tools and tests available beyond a talent for quick observation—were in demand and lauded. Around the turn of the nineteenth century, medical professionals began to emphasize careful observation of patients and to reject traditional non-medical notions of the genesis of disease. Seldom since the Hippocratics of the fifth century B.C.E., who sought to discover the mechanistic processes by which disease invades a body—rather than to divine which deity or spirit to blame for the attack—had medicine focused more on careful observation as the key to diagnosis and treatment.
The Austrian physician and dermatologist Ferdinand von Hebra, founder in the 1840s of the renowned Vienna School of Dermatology, demonstrated similar perception, especially in observing bodily traces of profession and personal history. To diagnostics he brought experience in postmortem pathology and extensive work on scabies and eczema. Hebra’s mentor, the Bohemian clinician and pathologist Joseph Škoda—the first professor to lecture in German rather than Latin at the University of Vienna—guided Hebra into this formerly neglected and even disdained specialty. He thought the young man’s aptitude for diagnostic observation and extrapolation, as well as his talent for lively fact-based lecturing, could contribute greatly.
Often Hebra asked not a single question before stating a patient’s ailment, age, weight, region of birth, and recent activities. He advised students, when examining a skin eruption, to look for scratch marks rather than to merely ask the patient if the eruption itched. A callus on the ball of a thumb would tell Hebra that the patient was a hatter. Velvety skin and a pink nose signaled a drinker of brandy or beer. In grasping a patient’s hands he would notice a pinprick-scarred forefinger and tell his students, “This man is a tailor.”
Like Joseph Bell, Hebra was considered an entertaining professor as well as a knowledgeable one. One student not studying medicine remarked that he didn’t “care a rap about dermatology” but that he found Hebra’s lectures more entertaining than a show at Vienna’s famed Theater an der Wien.
Once a patient limped in and sat down to unwind a bandage he had tied around his leg. Hebra announced to his students, “This man is a Croat, fifty-five years of age, has pulmonary tuberculosis—and is a tailor by occupation.”
Students who recalled their professor’s previous recognition of a tailor from finger scars knew that he had not yet touched this man’s hands. They were skeptical this time.
“Wouldn’t you know he was a tailor?” Hebra demanded. “Look at that little strip of drab cloth he has tied around the bandage. Tailors use that stuff for vest linings.”
In an era in which tradesmen and laborers tended to wear predictable, almost uniform-like clothing and to work repetitively with their hands, such assessments required educated scrutiny but not second sight. In the early 1750s, in The Rambler, Samuel Johnson—one of Arthur Doyle’s favorite historical figures, thanks to James Boswell’s quirky biography—had employed this well-known characteristic in a beautiful analogy:
As any action or posture, long continued, will distort and disfigure the limbs; so the mind likewise is crippled and contracted by perpetual application to the same set of ideas. It is easy to guess the trade of an artizan by his knees, his fingers, or his shoulders: and there are few among men of the more liberal professions, whose minds do not carry the brand of their calling, or whose conversation does not quickly discover to what class of the community they belong.
Johnson’s observational skills were not entirely literary. He personally investigated the notorious Cock Lane Ghost,
helping expose what Boswell called “the imposture” behind the scenes. A century after Johnson’s remarks, and a decade after Arthur’s birth, a Frenchman published an influential survey of the diagnostic value of stigma (visible characteristics of disease) resulting from occupational labor. Auguste Ambroise Tardieu, a French specialist in forensic medicine and toxicology, explored the topic at length in A Study of the Physical and Chemical Changes Caused in Certain Parts of the Body by the Practice of Diverse Professions, to Assist in Medical-Legal Research of Identity. Tardieu described other such perceptive diagnosticians. They included the Frenchman Jean-Nicolas Corvisart, a cardiology pioneer and personal physician to Napoleon; Corvisart’s pupil Guillaume Dupuytren, an openly freethinking surgeon and anatomist so renowned that he inspired Honoré de Balzac’s story “The Atheist’s Mass” and was mentioned in Gustave Flaubert’s novel Madame Bovary; and Armand Trousseau, a French internist who defined what came to be called Trousseau’s early signs of malignancy from cancer—and who later diagnosed them in himself and soon died.
In medical school, Arthur attended the Friday clinics held in the infirmary’s surgical amphitheater, in the attic of the main building. Semicircular tiers of benches surrounded the polished deal operating table, below which stood a tin tub filled with sawdust that could absorb blood. Not surprisingly, uncertain students cowered before Dr. Bell’s authority and confident presence. They had witnessed his absolute control over both students and patients. When a prospective patient made it clear that he was unwilling to fraternize with common students while awaiting a chance to consult Bell, the doctor simply threw him out of the clinic.
Once, after a patient limped in and stood before the gathered students without taking off his coat, Bell turned to a nervous young man in the lecture audience and demanded, “What is the matter with this man, sir? Come down, sir, and look at him!”
The student walked hesitantly down to the patient.
“No!” squawked Bell. “You mustn’t touch him!” He commanded the cowering student firmly, “Use your eyes, sir! Use your ears. Use your brain, your bump of perception,” he added, invoking the already debunked “science” of phrenology. He returned to his usual theme: “And use your powers of deduction.”
The young man warily looked the patient over and finally volunteered a diagnosis: “Hip-joint disease, sir!”
Bell leaned back in his chair and steepled his long, delicate fingers under his chin. “Hip-nothing!” he snorted derisively. “The man’s limp is not from his hip, but from his foot—or rather from his feet. Were you to observe closely,” he continued, “you would see that there are slits, cut by a knife, in those parts of the shoes where the pressure of the shoe is greatest against the foot. The man is a sufferer from corns, gentlemen, and has no hip trouble at all.”
Then Bell went on to reveal that his first diagnosis was trivial compared to what else he had observed: “He has not come here to be treated for corns, gentlemen. We are not chiropodists. His trouble is of a much more serious nature. This is a case of chronic alcoholism, gentlemen.” The patient must have been mortified as Bell enumerated details of his appearance: “The rubicund nose, the puffed, bloated face, the bloodshot eyes, the tremulous hands and twitching face muscles, with the quick, pulsating temporal arteries—all show this.”
Slyly Bell reiterated his point about confirmation: “These deductions, gentlemen, must, however, be confirmed by absolute and concrete evidence.” He pointed out that poking from the patient’s right-hand coat pocket was the top of a whiskey bottle.
On another occasion, Bell read—and revealed to the class—the life of a student instead of a patient. A young man had failed dismally in his efforts to diagnose a patient’s illness under the fierce eye of Dr. Bell, who then snapped, “Get out your notebook, man, and see whether you can’t express your thoughts that way.”
He turned to the amused class and invoked the biblical Isaiah and Matthew: “The gentleman has ears and he hears not, eyes and he sees not!”
Bell turned back to the student, who, in nervously taking a notebook from his pocket, had dislodged a letter. He tried and failed to hide it.
“You come from Wales, don’t you, sir?” demanded Bell, a Scot himself, Edinburgh born and raised. “I thought so! A man who says silling for shilling, who rattles his R’s, who has a peculiar, rough, broad accent like yours, sir, is not a Scotchman. You are not an Irishman; you are not an Englishman. Your speech smacks of Wales.”
He turned away from the squirming and blushing young man for a moment and addressed the other students, explaining that he had further confirmation of his deductions beyond the man’s enunciation. He had observed that the dropped letter was addressed in a feminine hand to “Mr. Edward Jones—that is his name, gentlemen”—and postmarked the day before at Cardiff. “Cardiff is in South Wales, and the name Jones proclaims our friend a Welshman.”
To Arthur and his fellow students, Joe Bell seemed irresistibly colorful. He would roll up to a university entrance in his low barouche, with its double facing seats—behind them a half roof folded like a bellows, in front an elevated driver in livery calling to Bell’s paired bay horses, whom his children had named Major and Minor. Old-timers at the hospital realized that, whether deliberately or unwittingly, Bell mimicked his own revered mentor, Professor James Syme, an innovative surgeon and renowned professor who had died in 1870. Bell stopped, however, before copying his teacher’s yellow carriage with its gaudily painted C-spring suspension.
He also credited Syme with diagnostic acumen greater than his own, although few of Syme’s other students later emphasized this trait. Bell liked to quote Syme’s motto: “Try to learn the features of disease or injury as precisely as you know the features, the gait, the tricks of manner of your most intimate friend.”
After graduating from Edinburgh University in 1859, the year of Arthur’s birth, Bell had served as house physician under Syme at the Royal Infirmary. Syme had been a legend at the university, an exemplar of the genius and commitment of which the medical school liked to boast. Interested in chemistry from childhood, he discovered in his late teens that coal tar, the oily sludge resulting from coal processing, could be used to produce a solution of caoutchouc or india-rubber—and thus could be employed to waterproof textiles such as silk. Glasgow chemist Charles Macintosh patented a variation of this method and went on to produce a new kind of waterproof coat soon named after him.
Bell’s positions at the university had included Hospital Surgeon, Demonstrator of Anatomy, and Surgeon to the Eye Infirmary, but he was acclaimed beyond Edinburgh. For several years, he had been editor of the respected Edinburgh Medical Journal, which was known throughout Europe and America. He was known for his influential textbook, A Manual of the Operations of Surgery for the Use of Senior Students, House Surgeons, and Junior Practitioners (“My aim has been to describe as simply as possible those operations which are most likely to prove useful, and especially those which, from their nature, admit of being practised on the dead body”). He came from a long line of Edinburgh physicians, including his grandfather Charles Bell, who described what came to be called Bell’s palsy. The Bell generations of sons alternated the names Benjamin and Joseph.
Nor had it taken Bell long to build this impressive résumé. At the age of twenty-one, he read a brilliant paper on epithelial cancer to the usually skeptical and contentious Royal Medical Society of Edinburgh, who responded with a standing ovation. William Turner, who had been a distinguished professor of anatomy since 1865, said of Bell’s two-year tenure as Demonstrator of Anatomy early in his career, “Whilst discharging his duties he acted as my junior, and acquired a well-deserved popularity amongst the students from his powers of observation, his clearness of exposition, his capacity for taking trouble to help them in their difficulties, and by his words of encouragement.”
Arthur too considered Bell kind and admirably conscientious with students and patients. The professor was sincere in his claim that he asked nothing of st
udents that he had not already accomplished himself, and he taught compassion as much as diagnosis. Bell felt that commitment to his fellow human beings was a religious duty. A passionate naturalist, hunter, and gardener, he traced both his love of the world and his yearning to help humanity to his faith. Upon his marriage in 1865, his mother told his wife that he had been “dedicated to God in his cradle,” and the newlyweds committed a tithe of their income to the church. His wife died in 1874. When Arthur met him two years later, Bell was still a silently grieving man with two young daughters and a son to raise. Despite his many commitments, he seldom missed a Sunday in church with them.
He had long been demonstrating his faith through deeds; both his high-pitched voice and his halting gait resulted from his own courage. In the early 1860s, as an overworked medical assistant, young Joe Bell had tended agonized and dying patients during numerous epidemics. The serpentine Water of Leith, which lazily bisected Edinburgh, might as well have been a sewer for all the filth it carried. During the preceding few years, Edinburghers had been brought down by cholera, typhoid, and smallpox, and early 1864 saw the exhausted city reeling from an even more devastating outbreak of diphtheria. Fate spared Arthur, who was not yet five years old.
Diphtheria was named from the Greek word for leather. Its effect was sadly memorialized in the nickname for Spain’s epidemic year of 1613—El Año de los Garrotillos, “The Year of Strangulations.” The disease produced gray mucus and a leathery membrane in the throat, resulting in choking as well as sore throat, swollen and inflamed tonsils, fever, and usually inflammation of the heart.