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Sir Arthur Conan Doyle created Sherlock Holmes during exciting times. He graduated from Edinburgh University Medical College in 1881, and Sherlock Holmes made his appearance (in The Study in Scarlet) in 1886. This was the golden age of microbiology, with landmark discoveries by Koch, Ehrlich and Pasteur amongst others, and the British Empire was at its height. It is not surprising that the Sherlock Holmes stories contain numerous references to infectious diseases, either local or imported from the farflung colonies. In the course of his adventures Sherlock Holmes became acquainted with bioterrorism.
In The Adventure of the Dying Detective1 an esoteric fatal infectious disease called the Tapanuli fever is used as a biological weapon by a criminal named Culverton Smith. Holmes speaks of him thus to his friend Dr Watson:
‘It may surprise you to know that the man upon earth who is best versed in this disease is not a medical man, but a planter. Mr. Culverton Smith is a well known resident of Sumatra, now visiting London. An outbreak of the disease upon his plantation, which was distant from medical aid, caused him to study it himself, with some rather far-reaching consequences’.
Smith cultured the bacteria on gelatin, brought the specimens back to London and infected his nephew, who died within four days. Sherlock Holmes suspected homicide. Culverton Smith then attempts to infect Holmes, but Holmes anticipates and avoids the booby trap. He fakes the illness very cleverly, deceiving even Watson, who describes him with clinical precision!
‘He was indeed a deplorable spectacle. In the dim light of a foggy November day the sick room was a gloomy spot, but it was that gaunt, wasted face staring at me from the bed which sent a chill to my heart. His eyes had the brightness of fever, there was a hectic flush upon either cheek, and dark crusts clung to his lips; the thin hands upon the coverlet twitched incessantly, his voice was croaking and spasmodic.’
Convinced that Holmes is dying, Watson is sent to persuade Culverton Smith to come and treat him. Dr Watson narrates his meeting with Smith.
‘ “Have you come from Holmes?” he [Smith] asked.
“I have just left him.”
“What about Holmes? How is he?”
“He is desperately ill. That is why I have come.”
The man motioned me to a chair, and turned to resume his own. As he did so I caught a glimpse of his face in the mirror over the mantelpiece. I could have sworn that it was set in a malicious and abominable smile. Yet I persuaded myself that it must have been some nervous contraction which I had surprised, for he turned to me an instant later with genuine concern upon his features. “I am sorry to hear this,” said he. “I only know Mr Holmes through some business dealings which we have had, but I have every respect for his talents and his character. He is an amateur of crime, as I am of disease. For him the villain, for me the microbe. There are my prisons,” he continued, pointing to a row of bottles and jars which stood upon a side table. “Among those gelatine cultivations some of the very worst offenders in the world are now doing time.” ’
Smith is convinced that his plan to infect and kill Holmes is working. He behaves as predicted by Holmes. By allowing Smith to gloat over him, Holmes draws him to confess and also reveal the modus operandi. Watson secretly witnesses the conversation:
“Listen now! Can you remember any unusual incident in your life just about the time your symptoms began?”
“No, no: nothing.”
“I'm too ill to think.”
“Well, then, I'll help you. Did anything come by post?”
“A box by chance?”
“I'm fainting—I'm gone!”
“Listen, Holmes!” There was a sound as if he was shaking the dying man, and it was all that I could do to hold myself quiet in my hiding-place. ‘You must hear me. You shall hear me. Do you remember a box—an ivory box? It came on Wednesday. You opened it—do you remember?”
“Yes, yes, I opened it. There was a sharp spring inside it. Some joke...”
“It was no joke, as you will find to your cost. You fool, you would have it and you have got it. Who asked you to cross my path? if you had left me alone I would not have hurt you.” ’
Sherlock Holmes gets Culverton Smith arrested on the charges of murder and attempted murder, and after the arrest Holmes takes Watson into his confidence:
‘ “No, Watson, I would not touch that box. You can just see if you look at it sideways where the sharp spring like a viper's tooth emerges as you open it. I dare say it was by some such device that poor Savage, who stood between this monster and a reversion, was done to death. My correspondence, however is, as you know, a varied one, and I am somewhat upon my guard against any packages which reach me...” ’
What can be deduced about ‘Tapanuli fever’ or ‘the black corruption of Formosa’? This infectious disease must be prevalent in South-East Asia and should have outbreaks among plantation workers in Sumatra—Indonesia. It should have a short incubation period and a high case fatality rate. The organism should be easily cultured and transmissible by needlestick injury. Holmes avoids examination by telling Watson that disease is ‘highly contagious by touch’. This, it emerges, was only a ruse to prevent Watson from finding out about the faked illness. The disease expert Culverton Smith shakes Holmes and touches him without any concern for his own safety.
The candidate infectious disease should also explain the clinical features that Holmes simulated so cleverly. Tapanuli fever should cause fever, anorexia, severe fatigue and sweating. The patient would also have cramping body ache, dyspnoea, cough and a croaking and feeble voice. Lips would have dark crusts and pupils would be dilated. Delirium usually heralds imminent death in this disease. Readers are referred to the definitive report on this matter by Sodeman2. Among the possible causes are scrub typhus, anthrax, typhoid fever and primary septicaemic plague. Sodeman rightly remarks that Conan Doyle is unlikely to have selected a commonplace disease such as typhoid fever or anthrax as the ‘deadly Asiatic infection’ for use in murder. Typhus endemic in South-East Asia, including Sumatra, is an attractive possibility. It is caused by Rickettsia tsutsugamushi transmitted by mites or chiggers. It could account for an earlier reference made by Sherlock Holmes to ‘the giant rat of Sumatra’. Holmes was involved in the investigation of the ship Matilda Briggs which seems to have carried a cargo of rats from Sumatra3. Culverton Smith might have imported these rats. Holmes was probably aware of the role of Sumatran rats as a natural host of the vector for the disease—hence his familiarity with the Tapanuli fever. However, scrub typhus is unlikely to be Tapanuli fever, because rickettsia would be difficult to culture on gelatin. And although it is a serious infection, case fatality is not very high, making it a poor choice as a murder weapon.
The presence of dysphonia suggests the possibility of diphtheria. There are reports of non-toxigenic strains of Corynebacterium diphtheriae that cause severe systemic disease with aggressive course and high mortality. An outbreak of severe invasive infection by non-toxigenic C. diphtheriae among Swiss intravenous drug users4 suggests that needle-stick injury could be a mode of transmission. But once again, diphtheria was a well-known local disease in England and therefore unlikely to have been chosen by Conan Doyle.
New evidence strongly supports the case for acute septicaemic melioidosis, as suggested by Sodeman. Whitmore and Krishnaswami first reported melioidosis in 1912 among the morphine addicts in Rangoon, Burma. They described acute septicaemic melioidosis with rapid onset, a short course and high mortality. Melioidosis, also known as Whitmore's disease, is caused by Berkholderia pseudomallei infection. Conan Doyle could have come across Whitmore and Krishnaswami's report in his medical readings before writing this particular story in 1913. In 1987 melioidosis was responsible for 20% of all cases of community-acquired septicaemia in a large study in Thailand5, which is geographically similar to Sumatra—Indonesia. B. pseudomallei was the single most common organism isolated in the monsoon months from July to September, and in August it caused 50% of all documented cases of community-acquired septicaemia. The disease commonly affects rice paddy farmers, and Culverton Smith could have studied septicaemic melioidosis among his plantation workers in Sumatra. In 1987, even with the availability of potent antibiotics, mortality from septicaemic melioidosis was very high at 68%. Over 50% of deaths occurred within 48 hours. Melioidosis can cause the clinical features simulated by Sherlock Holmes. In the study of septicaemic melioidosis reported from Thailand, most of the patients became profoundly ill soon after the onset of fever. Metabolic acidosis and blood-borne pneumonia was found to be common, which could explain why Holmes was ‘struggling for breath’ and coughing. A patient with such a severe septic illness is likely to have a ‘feeble’ croaking voice. Septic shock would explain the severe fatigue, anorexia, cold sweats and delirium. Dark crusts on the lips could be from the subcutaneous abscesses seen with melioidosis or activation of herpes labialis. B. pseudomallei is culturable in gelatin agar and could easily have been imported to England from the plantations of Sumatra. To this day, according to a research letter published in The Lancet, almost all cases of melioidosis in England are imported from South-East Asia and tropical Australia6. Even more fascinating is a Lancet letter7 entitled ‘A deadly thorn’, describing the case of a 61-year-old man who returned to England after a 2-week holiday in Thailand. While gardening the next day he stood on a large thorn which penetrated his left heel through the sole of the shoes that he had worn throughout his vacation in Thailand. He developed melioidosis and died. The skin and shoes were probably colonized with B. pseudomallei in Thailand, and the thorn then inoculated the bacteria. This case provides modern evidence to strengthen the case for melioidosis as the ‘deadly Asiatic disease’ described by Conan Doyle.
If B. pseudomallei was indeed the murder weapon, Culverton Smith chose well. Should his victim escape death from acute septicaemic melioidosis, there was always a strong possibility of late relapse or rupture of a visceral abscess. Delayed death from melioidosis has earned it the name of ‘the Vietnamese time bomb’8. The Centers for Disease Control and Prevention have identified B. pseudomallei as a potential agent for bioterrorism9. Culverton Smith's use of the postal service to deliver the lethal infection has an echo today. Life, sometimes regrettably, does imitate art.