Part 10

John H. Watson, M.D., practiced medicine in the city of London in the early eighties of this past century. This was a long time ago--nearly seventy-five years. At the time of which we write, Roentgen had not as yet discovered the X-ray, and Ehrlich’s “606” (salvarsan) was not available for the treatment of syphilis. Banting and Best, the Canadian physiologists, had not given insulin to the world, nor had Minot and Murphy of Harvard discovered that liver extract was an efficient agent in the treatment of pernicious anemia, a heretofore fatal blood disease. The sulfonamide drugs and the antibiotics, such as penicillin and streptomycin, presumably were only a dream.

From what has been related, it appears that Dr. Watson’s therapeutic armamentarium, insofar as efficacious drugs are concerned, was sadly limited. But the fact must not be forgotten that he had at his command a number of powerful medicines: morphine, cocaine, belladonna, and strychnine, to name a few.

Let us turn to the stories and see what medicines Dr. Watson used in his practice and under what conditions they were employed.

It appears that iodoform and silver nitrate were well known drugs, for Holmes on one occasion remarked to him: “... if a gentleman walks into my rooms smelling of iodoform, with a black mark of nitrate of silver upon his right forefinger.... I would be dull indeed if I do not pronounce him to be an active member of the medical profession” (_A Scandal in Bohemia_).

Iodoform was introduced as an antiseptic about the year 1879. For many years it was widely employed as a dusting powder, especially to diminish infection of open wounds and to promote granulation. Its persistent and penetrating odor, as well as its relative ineffectiveness, gradually brought it into disfavor. This is probably just as well, for its use is not entirely without danger, especially when iodoform is applied over an extensive area where a good deal of it can be absorbed.

Silver nitrate still enjoys a wide usage. It is employed to produce astringent, antiseptic, and caustic effects. Even many laymen know that silver nitrate will remove “proud flesh.” Unfortunately, it has the property of staining the skin “with a black mark” (as Holmes remarked), which incidentally is often difficult to remove. It may persist until it is virtually worn off, although recent and superficial stains can be removed by painting the area with a ten per cent solution of potassium iodide.

As might be expected, Dr. Watson found it necessary on several occasions to resort to morphine to alleviate pain. We find, for example, that when Kitty Winter, the cast-off mistress of the infamous Baron Gruner, threw vitriol in the Baron’s face, Dr. Watson administered a hypodermic of morphine to the wretched Baron to ease the intense suffering (_The Adventure of the Illustrious Client_). On another occasion, when Professor Presbury was savagely attacked by his wolfhound, Watson immediately gave morphine to the unfortunate professor (_The Adventure of the Creeping Man_). In still another instance, when Carlos, the mastiff, had attacked Rucastle, Watson probably would have used morphine had he had it in his possession. He wrote: “I did what I could to relieve the pain” (_The Adventure of the Copper Beeches_). He did not state, however, what agent he employed.

On one occasion, at least, it was necessary to administer morphine to Sherlock Holmes. He had been attacked and beaten severely by two ruffians. Sir Leslie Oakshott, the eminent London surgeon, had been called in on the case. He later tersely remarked to Watson that Holmes suffered from lacerated scalp wounds, and there were also some bruises. It had been necessary to take several stitches. Morphine had been administered (_The Adventure of the Illustrious Client_). Morphine, because it is a dangerous habit-forming drug, should be used only when absolutely indicated. It is noteworthy that Dr. Watson administered morphine only when the patient had suffered a grave physical injury. He is to be commended for his conservative attitude.

On many occasions, when assisting Sherlock Holmes with his cases, Dr. Watson found it necessary to administer a stimulant to those individuals who had suffered a physical injury or had been under great emotional stress. His favorite remedy for such conditions was brandy. Numerous instances may be cited when this agent was employed as an emergency measure. Dr. Watson obviously believed firmly in the efficacy of brandy as a stimulant, and, indeed, claimed to have saved the life of an individual by its use:

Mr. Melas, however, still lived, and in less than an hour, with the aid of ammonia and brandy I had the satisfaction of seeing him open his eyes, and of knowing that my hand had drawn him back from that dark valley in which all paths meet.

_The Greek Interpreter_

Dr. Watson in this beautiful passage expresses the wish of every physician.

Brandy and whiskey were not the only stimulants used by Dr. Watson; in point of fact, he employed several others. We have noted previously that ammonia was administered along with brandy to Mr. Melas, the Greek interpreter. Physicians will recall that ammonia is the principal ingredient in so-called smelling salts. The vapors of ammonia when inhaled stimulate the medullary centers, causing an increase in respiration, and by action on the vasomotor center produce a rise in blood pressure.

In his heroic efforts to save the life of a woman who had been chloroformed nearly to death, Dr. Watson gave ether intravenously with successful results (_The Disappearance of Lady Frances Carfax_). At any rate, he records that the patient regained consciousness. Ether is not often given in this manner as a stimulant, and the question could be raised whether it was indicated under the condition which faced Dr. Watson. I am afraid that this was an instance in which the patient lived in spite of the treatment.

A popular and effective stimulant, namely, caffeine, was used to bring a young woman out of a stuporous state produced by opium. Dr. Watson relates that a couple of cups of very strong coffee brought her out of this state (_The Adventure of Wisteria Lodge_). Dr. Watson used the classical agent. Strong coffee is still used today in morphine poisoning, although relatively new preparations, such as metrazol, nikethamide, and amphetamine are at present the drugs of choice. Coffee is, of course, easy to obtain, is a relatively harmless stimulant, and has the pleasing virtue of not producing disagreeable aftereffects.

On one occasion, the nature of the stimulant administered was not disclosed. We find the following: “... while his nurse poured him out a glass of some stimulating medicine” (_The Naval Treaty_). We can only guess at the contents of the glass, but more than likely it contained either brandy or whiskey. We have previously pointed out that these agents were frequently prescribed as stimulants.

Dr. Watson, strangely enough, administered amyl nitrite to a patient who presumably was suffering from catalepsy. He writes, “I had obtained good results in such cases by the inhalation of nitrite of amyl....” (_The Resident Patient_). It will be recalled that this rather rare condition is characterized by a rigidity of all the skeletal muscles; the patient, as a consequence, tends to remain in any position in which he is placed. The reason Dr. Watson used amyl nitrite in this instance is not clear. The nitrites are frequently prescribed to reduce systemic blood pressure or to relieve angina pectoris. Surely there is no evidence in the literature that the nitrites are of aid in cataleptic states. We can dismiss the matter by assuming that in this instance Dr. Watson used amyl nitrite empirically.

Oil is mentioned as a therapeutic agent in at least two of the stories. Both Dr. Watson and Sherlock Holmes had occasion for its use. When Baron Gruner had vitriol thrown in his face, Dr. Watson tried to alleviate the poor wretch’s pain by bathing his face in oil and applying cotton to the raw areas (_The Adventure of the Illustrious Client_).

On another occasion, Holmes relates how he treated Murdoch, who had come into contact with the giant jellyfish. He used cotton-wool which had been soaked in salad oil; and he related that this application greatly relieved the pain (_The Adventure of the Lion’s Mane_). This adventure took place in the country, and we may assume that there was little, if any, medication on hand. The patient was suffering intensely, and Holmes did what he could to assuage the pain with the material he had at his disposal. He showed real ingenuity by making use of a homely preparation. Morphine obviously was badly needed, and it is a pity that Dr. Watson was not there to administer it. But it must be remembered that, at the time this happened, Holmes had retired to the Sussex Downs and Dr. Watson was in London. A perusal of the story shows, however, that the patient had been given liberal quantities of brandy, so perhaps he got along fairly well without morphine after all.

Dr. Watson used carbolized bandages to dress the hand of the unfortunate hydraulic engineer who had, a few hours previously, lost his thumb in an adventure which nearly cost him his life. “I sponged the wound, cleansed it, dressed it, and finally covered it over with cotton wadding and carbolized bandages” (_The Adventure of the Engineer’s Thumb_). Carbolized bandages are no longer used in present-day surgery. Historically, it is of interest to record that carbolic acid became widely known as an antiseptic through its introduction by Lister in 1867.

Dr. Watson does not often mention hypnotics. We find in one of his stories that it was the custom of an invalid, Mr. Percy Phelps, to take some sleeping potion: “... you did not take your usual draught that night” (_The Naval Treaty_). We shall never know what the “usual draught” contained. The barbiturates which are so widely used today were unknown when Dr. Watson practiced medicine. Bromides were employed not only for sedation but for inducing sleep as well. The draught of which Watson spoke might have contained chloral hydrate, for it once enjoyed wide usage as a hypnotic. It is a potent and dangerous drug and, as generally known, is used by gangsters (among others) in what are inelegantly but expressively referred to as “knockout drops.”

An interesting reference is found to an alterative in one of the stories (_The Disappearance of Lady Frances Carfax_). Holmes, meeting Watson in an establishment which specialized in Turkish baths, asked his friend why he insisted upon this type of therapy. The latter replied that a Turkish bath is actually an alterative in medicine. He explained further that an alterative was a cleanser of the system. An “alterative” is defined in _Webster’s Unabridged Dictionary_ as: “A medicine or treatment which gradually induces a change, and restores healthy functions without sensible evacuations.” A modern medical dictionary states: “An obsolete term originally used for drugs said to reestablish healthy functions of the system.” (_Dorland’s Illustrated Medical Dictionary_. Philadelphia: W. B. Saunders Company, 1947).

Present-day medical students probably never heard of alteratives. Many middle-aged physicians, however, will remember them well, for formerly alteratives were used extensively in therapeutics, and included the following preparations: iodine, arsenic, iron, and the compounds of mercury. Nowadays, a more scientific attitude is taken toward these agents, and they are prescribed only if there is a specific need for them: for example, iron for certain anemias, mercury for syphilis, and so on. If one considers the esteem in which alteratives were held in the latter part of this past century--and, for that matter, in the early part of the present one--it is surprising that Dr. Watson did not mention alteratives more frequently.

One wishes that Dr. Watson had mentioned other drugs used in his practice. In the early part of the twentieth century, a survey in England showed that physicians considered that from thirty to thirty-five drugs were necessary to practice medicine satisfactorily. In the stories of Sherlock Holmes, the names of about a dozen occur. Dr. Watson probably mentioned only those which for the main part are familiar to the layman.

Drugs are, of course, an important part of the armamentarium of doctors, especially those engaged in general practice. From the evidence at hand, obviously Dr. Watson was not a therapeutic nihilist, but neither can he be accused of prescribing drugs loosely or in excessive doses.

The matter of overdosing with drugs calls for a brief comment. The famous poet-physician, Oliver Wendell Holmes, wrote: “If the whole _materia medica_ (excepting opium and ether) as now used, could be sunk to the bottom of the sea, it would be all the better for mankind--and all the worse for the fishes.” These were harsh words; but when written, timely. The indiscriminate use of drugs was directly responsible for the genesis of the ill-conceived homeopathic system of medicine founded by Hahnemann. The followers of this school used drugs in such minute doses that they were virtually ineffectual. It is, indeed, an ill wind which blows no good, for the rise of homeopathy had a sobering influence on many physicians of the allopathic school who were using drugs lavishly, but not well. Let us not forget, however, that the prescribing of drugs plays only a part--albeit an important one--in the successful practice of medicine.

In conclusion, we may think of Dr. Watson briskly setting out to answer the call, carrying his trusty bag filled with the recognized and popular drugs of that period. He undoubtedly prescribed these fairly liberally, and firmly believed in their curative powers. Most of Dr. Watson’s patients probably got well with the aid of, or perhaps in spite of, his prescriptions. Those who were not helped by his medication were undoubtedly benefited by his kindliness and his sympathetic understanding of their ailments.

DOCTOR WATSON, GENERAL PRACTITIONER

One night ... there came a ring to my bell, about the hour when a man gives his first yawn and glances at the clock. I sat up in my chair.... I groaned for I was newly back from a weary day.

_The Man with the Twisted Lip_

John H. Watson, M.D., was born in England in 1852. He was graduated from the University of London Medical School in 1878 (_A Study in Scarlet_), and took his internship at St. Bartholomew’s Hospital.

Since England was then engaged in a war on the Afghan frontier, Dr. Watson became attached as a military surgeon to the Fifth Northumberland Fusiliers. The English were badly defeated on July 27, 1880 by a large Afghan force at Maiwand. Dr. Watson received a painful wound--a Jezail bullet hit him in the shoulder. Later he contracted typhoid fever in a base hospital at Peshawar. He was eventually discharged from the army and returned to London with a very modest disability pension.

Not long after this, he met Sherlock Holmes through a mutual acquaintance, and they obtained comfortable living quarters at 221B Baker Street. While living with Holmes, Dr. Watson, as we know, assisted him in many of his cases and served as his chronicler.

After a time, Dr. Watson married and set up as a general practitioner in London. Doubtless, many of his experiences in his practice are reflected in his writing. It is in order to consider some of the references made to the general practice of medicine in the tales.

In one of Watson’s early stories, _A Scandal in Bohemia_ (written about seventy years ago), we find Holmes saying to Dr. Watson:

As to your practice, if a gentleman walks into my rooms smelling of iodoform, with a black mark of nitrate of silver upon his right forefinger and a bulge on the side of his top-hat to show where he has secreted his stethoscope, I must be dull indeed, if I do not pronounce him to be an active member of the medical profession.

As Holmes stated, if an individual smelled of iodoform, had silver nitrate stains on his fingers, and carried his stethoscope in his hat, it would not be difficult to pronounce him a medical man. Iodoform, which was once widely used, is employed but little today, and it would be poor taste for a physician making professional calls to carry its odor with him. Silver nitrate is still widely used, but most physicians make an earnest effort to keep their hands looking neat and free of stains.

Dr. Watson had an appropriate sense of the fitness of things, and appreciated the fact that a physician should comport himself with dignity both in manner and in dress. Dr. Watson writes: “The rough-and-tumble work in Afghanistan, coming on the top of a natural Bohemianism of disposition, has made me rather more lax than befits a medical man” (_The Musgrave Ritual_). In speaking of dress, Watson states: “His dress was quiet and sober--a black frock coat, dark trousers, and a touch of color about his necktie” (_The Resident Patient_).

It is hardly necessary to say that the modern physician no longer carries his stethoscope in his hat. An interesting reference is found in the story just mentioned concerning how the general practitioner carried his instruments. One evening, Holmes and Watson returned from a walk and found a brougham waiting at their door. Holmes remarked that it belonged to a general practitioner. Watson writes: “I was sufficiently conversant with Holmes’ methods to be able to follow his reasoning, and to see the nature and state of the various medical instruments in the wicker basket which hung in the lamplight inside the brougham....”

A fact not generally known in this country is that a red lamp was once the sign of the general practitioner. Reference is made to this in _The Adventure of the Six Napoleons_. Watson writes that a bust of Napoleon, owned by a Dr. Barnicott, was found broken near his red lamp.

A pleasing manner is surely a desirable trait in a physician. There are doctors whose mere presence in the sickroom makes a patient feel better. Dr. Watson is depicted as a person not only eager to help his patients but also as a kind and sympathetic individual--attributes that are most commendable in all physicians. Once when Dr. Watson was speaking of a lady who was emotionally upset, he writes: “We soothed and comforted her by such words as we could find.” Somewhat later, he states: “I am an old campaigner.... If I can be of any assistance, either to you or my friend here, I should be indeed happy” (_The Man with the Twisted Lip_). In _The Adventure of the Sussex Vampire_, Dr. Watson again states that he would be glad to be of any service. Later, when he was asked to see a lady who had suffered a great nervous shock, he explains how he stepped up to the bed on which she was lying and spoke a few reassuring words to her, while he took her pulse and temperature.

Dr. Watson, like many practitioners, presumably had patients whom he felt he was not helping, and who were taking an inordinate amount of his time and energy. It is likely that he persuaded them to seek the aid of some other physician. Holmes probably sensed this, for on one occasion Dr. Watson asked whether a certain individual was Holmes’ client. The detective remarked that he supposed so, since Scotland Yard had sent this individual to him on the same principle that some doctors refer their incurable patients to quacks, with the idea that nothing can be done for them anyway, and that whatever happens they are no worse off than they were formerly. Dr. Watson made no reply. One does not like to think that an ethical practitioner would knowingly send any patient to a quack. Holmes probably was in a facetious mood when he made this remark, and was simply teasing Watson, who was not known for his sense of humor.

Dr. Watson clearly recognized a doctor’s responsibility to his patient, because in _The Sign of the Four_ he writes: “Remember that I speak not only as one comrade to another but as a medical man to one for whose constitution he is to some extent answerable.” In _The Dying Detective_, Holmes twitted Watson by reminding him that he was after all only a general practitioner with rather mediocre qualifications. This hurt Dr. Watson, and his comment was that Holmes might be his master elsewhere, but not in the sickroom. Here undeniably Watson was his master.

Like other general practitioners, Dr. Watson undoubtedly had hard days, but presumably he answered night calls. The following occurs in _The Man with the Twisted Lip_:

One night ... there came a ring to my bell, about the hour when a man gives his first yawn and glances at the clock. I sat up in my chair, and my wife ... made a little face of disappointment.... I groaned, for I was newly back from a weary day.

Obviously, Dr. Watson had never had a lucrative practice, for he states: “Everyone was out of town, and I yearned for the glades of the New Forest or the shingle of Southsea. A depleted bank account had caused me to postpone my holiday....” (_The Resident Patient_). In a similar vein, “I have nothing to do today. My practice is never very absorbing” (_The Red-Haired League_). In _A Scandal in Bohemia_ occurs a reference which further indicates that Dr. Watson was not a busy practitioner: “At three o’clock precisely I was at Baker Street, but Holmes had not yet returned.... I sat down beside the fire, however, with the intention of awaiting him however long he might be.” This shows that Dr. Watson was not loath to be absent from his practice in the middle of the day for an indeterminate length of time. Apparently, he thought nothing of this, but sat down calmly out of reach of his patients to wait for his friend.

We must not infer, however, that his practice was always dull, for on one occasion he explains that he had pressing professional business of his own, and it was not possible for him to accompany Holmes (_The Adventure of the Illustrious Client_). And again: “A professional case of great gravity was engaging my attention at the time, and the whole of next day I was busy at the bedside of the sufferer” (_The Red-Haired League_). Also, once when Holmes suggested that he and Watson go out of town, the latter writes that although it was easy for Holmes to go almost any time, he (Watson) had to do a certain amount of planning and hurrying because his practice was not inconsiderable. Holmes was cognizant of the fact that Watson had definite obligations, for once Holmes told a client that not only was he a busy man but that Dr. Watson had his patients to consider (_The Adventure of the Creeping Man_).

Apparently, at the time Watson wrote, it was common for physicians to buy and sell their practice. Several references are made to this custom. Watson describes how he had purchased his practice:

I had bought a connection.... Old Mr. ... from whom I purchased it, had at one time an excellent practice, but his age, and an affliction ... had very much thinned it.... Until when I purchased it from him it had sunk from twelve hundred to a little more than three hundred a year.

_The Stock Broker’s Clerk_

It must be remembered that at that time the English pound was worth almost five dollars; so the practice described by Dr. Watson had been bringing in about $6,000 per year, but had sunk to $1,500. In those days, of course, money went much further than it does now, and $6,000 a year was a splendid income.