“I had obtained good results in such cases by the inhalation of
nitrite of amyl....”
_The Resident Patient_
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.