Editor’s note: The Bulletin occasionally publishes articles based on winning entries in the History of Surgery Poster Competition, which occurs in conjunction with Clinical Congress. The following article is based on the 2021 third-place entry. An article based on the first-place entry will be published in the April Bulletin.
Sir Arthur Conan Doyle, MD, is famous for introducing the world to the character of Sherlock Holmes, but less well known are his contributions to medicine, some of which remain relevant to this day. From the original books to blockbuster movies, to widely watched television shows, and even a videogame—Sherlock Holmes is pervasive in our society. He is a symbol of intelligence, mastery, and truth. But who exactly was the creator of this legendary character, and what were Dr. Doyle’s contributions to, of all specialties, surgery?
Dr. Doyle’s Upbringing and Education
Dr. Doyle was born in Edinburgh, Scotland, in 1859, the second of 10 children. His father, Charles Altamont Doyle, was an artist but suffered from alcohol use disorder. In fact, addiction would later play a role in Dr. Doyle’s creation of Sherlock, who struggled with substance abuse himself. Dr. Doyle was raised primarily by his mother, Mary Foley Doyle, who was a great storyteller and influenced Sir Arthur’s writing style. Dr. Doyle recalled, “In my early childhood, as far as I can remember anything at all, the vivid stories she would tell me stand out so clearly that they obscure the real facts of my life.” Mary’s family friend, Dr. Bryan Charles Waller, originally a young lodger that the Doyle family took in to make ends meet, became another influential part of young Doyle’s life, spurring his interest in problem-solving, technical skills, great narrative, and medicine.
Dr. Doyle’s education was strict. At age 9, he was sent to Hodder Place, a Jesuit boarding school in England. He was bullied and suffered corporal punishment from teachers. Through these challenges, he discovered a talent and passion for storytelling, often drawing in younger students to regale them with gripping tales.
In 1869, he attended Stonyhurst College, Lancashire, England, and remained there until 1875. After leaving a desk carving of his name as one of his marks on the institution, he left Stonyhurst to attend Stella Matutina in Austria from 1875 to 1876, where he studied German.
From 1876 to 1881, Dr. Doyle studied medicine at the University of Edinburgh Medical School. In his third year of medical school, he worked as an assistant to Reginald Hoare, MD, a general practitioner in Aston. At the University of Edinburgh, Dr. Doyle studied the toxic effects of a plant—on himself. Dr. Doyle’s toxin of choice was tincture of gelsemium, which was used for medicinal purposes until 1906. The active ingredients include alkaloids, with one alkaloid related to strychnine; death from respiratory arrest previously had been reported at a dose of 75 minims. Dr. Doyle ingested the substance in doses exceeding the recommendation, which helped with neuralgia but caused intense diarrhea. He documented these experiences and published them in the British Medical Journal in 1879.
Self-experimentation was relatively common among physicians at the time, and Dr. Doyle continued the practice throughout medical school. In his doctorate of medicine thesis, which he finalized four years after graduation, Dr. Doyle described the effect of self-administering nitroglycerin in 1885 before administering it to his patients. Specifically, he delineated the medication in relation to the vasomotor changes observed in tabes dorsalis, with syphilis being a common infectious disease at the time. Other examples of physicians engaging in self-experimentation include Sigmund Freud, who self-experimented with cocaine in the 1880s. More recently, Barry James Marshall, MD, won the 1984 Nobel Prize in Medicine for demonstrating the link between Helicobacter pylori and gastric ulcers on himself. Poisons became a theme in many of Doyle’s later mysteries.
In terms of his academic success in medical training, Dr. Doyle was considered to be an average student. He stated, “I won no distinction in the race. I was always one of the ruck, neither lingering nor gaining—a 60% man at examinations.” Part of his academic struggles were related to financial constraints. He would “compress the classes for a year into half a year” in order to have time to work as a medical assistant. At this time, only about half of matriculated medical students graduated.
Despite his lackluster transcript, his kindness, especially to indigent patients, was noted among his classmates. One of his colleagues wrote that Dr. Doyle “[I]mpressed me chiefly by his very kind and considerate manner towards the poor people who came to the outpatient department, whom I’m afraid some of us were in the habit of treating somewhat cavalierly.” His compassionate nature would later become evident in his humanitarian and public health interests.
As a fourth-year medical student in 1880, Dr. Doyle spent 7 months on an arctic whaler as the ship’s surgeon. After graduation, he held a similar position for three months on an African steamer. In 1883, Dr. Doyle published a collection of short stories titled The Captain of the Polestar and Other Tales, inspired by his adventures at sea.
After his maritime expeditions, Dr. Doyle settled down to practice and partnered with a former classmate, George Turnavine Budd, MD, in Plymouth. This venture would prove unsuccessful, and Dr. Doyle left the practice after only a month. He would later write a novel, The Stark Munro Letters, closely based on his experiences during this time. It features a young doctor struggling to work with an eccentric partner. He then moved on to general practice for 8 years and ultimately settled on ophthalmology as his surgical subspecialty.
Dr. Doyle’s interests were diverse, with the unifying theme of problem-solving and analysis that would be beneficial to humankind. Unlike his infallible Sherlock Holmes character, however, Dr. Doyle made an error in reasoning in a March 1882 article in The Lancet, “Notes on case of leucocythaemia.” In it, Dr. Doyle described a patient in whom leukemia had developed several years after a malaria infection and erroneously suggested a causal relationship.
The following year, Dr. Doyle published an article in the weekly magazine Good Words summarizing the understanding of microbiology, including leukocytes, viruses, and vaccines. Referring to microbes, he wrote: “I propose to glance at some of the work done of late in this direction—work which has opened up a romance world of living creatures so minute as to be hardly detected by our highest lenses, yet many of them endowed with such fearful properties that the savage tiger or venomous cobra have not inflicted one fiftieth part of the damage upon the human race.” Particularly in our COVID-19 era, this statement rings harrowingly true.
The next year, in November of 1884, he wrote a letter to The Lancet describing various manifestations of gout, including eye disease, psoriasis, and arthritis across three generations of one family. Psoriasis and gout are indeed linked. Gout causes arthritis and eye disease from surface tophi deposition, and susceptibility to gout is inherited. This analysis was certainly more accurate than his older malaria observation. His courage and outspoken manner would serve him well in other matters, particularly regarding social justice issues later in life.
Creation of Sherlock Holmes
Dr. Doyle established his ophthalmological surgery practice in London, UK, in 1891 after finishing his subspecialty training in Vienna, Austria, and Paris, France. He had relatively few patients, and in his spare time he wrote. In fact, for one 4-month span, he had no patients at all. After suffering a health crisis of severe influenza later in 1891, he gained clarity about his life priorities, saying, “I remember in my delight taking the handkerchief which lay upon the coverlet in my enfeebled hand, and tossing it up to the ceiling in my exultation—I should be my own master.” And only 1 year later, the first compendium of 12 stories, The Adventures of Sherlock Holmes, was published. Nonetheless, the spirit of surgery was always with him and permeated his literary and advocacy career.
His model for Sherlock Holmes was Joseph Bell, MD, FRCSE, a renowned surgeon who worked at the royal infirmary and attended to Queen Victoria during her visits to Scotland. Dr. Doyle considered Dr. Bell the most important person whom he encountered during his own medical training. Dr. Bell was known for his inductive reasoning skills, observations, and clinical judgment—not to mention his timeless sense of style. Even today, more than a century later, one witnesses the classic deerstalker hat and tweed coat available as a Halloween costume for all ages. Dr. Bell recognized potential in Dr. Doyle during his medical training and selected him for an outpatient clerkship. It is here that the character study of Dr. Bell began.
Dr. Bell was not only a master diagnostician, but also was known to make extraordinary observations about patients. He could discern where a sailor had traveled based on his tattoos, was able to determine patients’ specific regional origins by their accent, and could detect their profession by looking at their hands. He was reported to have noted that a man was a cobbler by the particular way the inside of the knee of the trousers was worn. He could also tell, by observing behavior and mannerisms, if someone had lied to him.
Dr. Bell’s manner of interview shows the basis for Sherlock’s incisive questioning style. This type of deduction is instantly recognizable as the way Holmes conducts his investigations. One may speculate that the Doyle-Bell relationship was analogous to the Watson-Holmes dynamic. Dr. Doyle wrote to Dr. Bell after A Study in Scarlet was published in 1887, thanking him for serving as a model for his leading character. “It is to you that I owe Sherlock Holmes,” he wrote.
The character of Sherlock Holmes was created 6 years after Dr. Doyle graduated from medical school. The mysteries Dr. Doyle authored manage to tie in medical expertise in some way.
The character of Sherlock Holmes was created 6 years after Dr. Doyle graduated from medical school. The mysteries Dr. Doyle authored manage to tie in medical expertise in some way. A Study in Scarlet centers on medical knowledge of how a body decomposes after death. In addition to dedicating the book to Dr. Bell, he also wrote to him personally. For example, on May 4, 1892, he wrote, “Though in the stories I have the advantage of being able to place [Sherlock] in all sorts of dramatic positions, I do not think that his analytical work is in the least an exaggeration of some effects which I have seen you produce in the outpatient ward.”
Several years later, Dr. Doyle returned to physician duty during the Boer War, joining the medical staff in South Africa. The wider context of this world event included expanding spheres of influence and the drive of global imperialism. The British Empire conflicted with the Boers of the South African Republic and Orange Free State, an event precipitated by the discovery of gold. When the Anglo-Boer War broke out in 1899, Dr. Doyle volunteered to treat British soldiers out of a sense of patriotism and adventure. He had tried to enlist in the Army first but was rejected for being too old (41 years) and too heavy (225 pounds). He was stationed at the Langman Hospital in Bloemfontein, South Africa. Dr. Doyle was knighted for his service in 1902, the same year the war ended.
After his wartime experiences in South Africa, he advocated for vaccination of the military against typhoid fever, which had reached epidemic proportions, resulting in 57,684 cases and 8,022 deaths. Twice as many British soldiers died from the disease as from bullets, and typhoid accounted for 75% of deaths from disease. Dr. Doyle wrote a letter to the editor of the British Medical Journal describing the terrible conditions. He argued that inoculation should have been mandatory and would have lessened the disease burden; 95% of the soldiers refused immunization because of the side effects. In the midst of the COVID-19 pandemic, the epidemiologic effects of vaccine mandates stand out as all the more relevant.
After time in the Congo, he wrote about the human rights abuses to bring about attention to the matter and inspire change. His 1909 exposé, The Crime of the Congo, about the human rights abuses in the Congo Free State (today, the Democratic Republic of the Congo) highlighted these tragedies. The Congo Free State was a colony under the personal control of Leopold II of Belgium. Dr. Doyle was “strongly of the opinion” that the crimes committed in the Congo were the “greatest to be ever known.” The atrocities were a result of a booming rubber export with forced labor by the civilian population. The severing of workers’ hands achieved particular international notoriety. Eventually, growing international pressure emanating from the UK and the US forced Belgium to officially annex the territory, and conditions significantly improved.
Another public health issue he tackled was safer uniforms for the military, to guard against traumatic injuries from shrapnel and gunfire. In 1914, he volunteered again to join the British Army in World War I but was rejected because of his age (he was 55). However, Dr. Doyle was invited to join His Majesty’s Government’s secret War Propaganda Board. Appalled by the British casualties, he wrote to The Times and proposed that helmets and body armor would reduce the number of wounds caused by shrapnel and gunfire.
Although he was restricted from serving in the military during the Great War, he contributed to the cause by authoring a propaganda piece that was a spy story rather than detective novel, with Holmes as the central character. It was intended to boost morale for British readers. In the story “His Last Bow, The War Service of Sherlock Holmes,” Sherlock tricks a German spy preparing to leave England for Germany with a rich treasure of intelligence, preventing him from stealing the information. The year 1917 was a pivotal one in World War I, with Russia surrendering to the Germans and the US entering the conflict. Dr. Doyle attempted to do his part with the creative tools at his disposal.
All of Dr. Doyle’s personal experiences fed into the creation of John H. Watson, MD, Holmes’s beloved sidekick. Dr. Watson, a surgeon, studied at St. Bartholomew’s Hospital in London and received his medical degree from the University of London. Subsequently, he trained at the Royal Victoria Hospital as an assistant surgeon in the British Army. He joined the British Indian Army, served in the Second Anglo-Afghan War, and was injured in the Battle of Maiwand. He suffered from enteric fever, also known as typhoid fever, and was sent home to recover. It is then that Watson encounters Sherlock, and their journeys begin. Like his creator, the character Dr. Watson was a war veteran, a physician, and fought typhoid fever. His compassionate disposition was similar to Dr. Doyle’s and in stark contrast to the character of Sherlock.
Holmes and Watson can be compared to two sides of the same coin. Holmes is a character with a reputation of intellect and rationality. At times, he insults people unintentionally and is known to be a loner, with the exception of his friendship with Dr. Watson. Watson, on the other hand, is a character with morality and sympathy. He is highly educated and intelligent but does not attempt to match Holmes in problem-solving and analysis. He also is more emotionally accessible, frequently providing support to the victims and clients in the mysteries. Holmes and Watson complement each other’s strengths while compensating for each other’s weaknesses.
Doyle the Defender
But it is Dr. Doyle’s contribution to society, not just the world of literature, that secured his spot in the history of surgery. A champion of the underdog, he used his medical knowledge to take on cases in which he believed the individual was wrongly imprisoned. The first case involved George Edalji, a solicitor in the British law system who was wrongly accused of vicious abuse of horses and cattle. After learning of Edalji’s case, Dr. Doyle publicly defended the man, citing his visual deficits, including astigmatism, as reasons Edalji could not have committed the crimes. With Dr. Doyle’s advocacy, including letters to The Lancet and the British Medical Journal, Mr. Edalji was released from prison after serving three of his 7-year sentence. Public upset over the case eventually led to the creation of the Court of Criminal Appeal. The case still has popular appeal today, described not only in texts but on a Public Broadcasting Service special Arthur & George.
But it is Dr. Doyle’s contribution to society, not just the world of literature, that secured his spot in the history of surgery. A champion of the underdog, he used his medical knowledge to take on cases in which he believed the individual was wrongly imprisoned.
The second criminal case in which Dr. Doyle played an active role also involved his medical expertise and took place 2 years later. In the case of Oscar Slater, an immigrant accused of murder, Dr. Doyle argued that the alleged murder weapon was incompatible with the extent of the victim’s head and eye trauma. Subsequently, two witnesses recanted their testimony against Slater, and he, too, was released from prison. Mr. Slater had served nearly 19 years in prison and had been sentenced to death, but with Dr. Doyle’s advocacy he became a free man.
Later in life, Dr. Doyle retired the Holmes character and shifted his attention to spiritualism. He suffered from depression after the loss of family members and friends. At 71 years old, a myocardial infarction claimed his life. But his overarching legacy was rooted in medicine and society. In 1910, Dr. Doyle gave a talk titled The Romance of Medicine to the entering medical school class at St. Mary’s Hospital in London. He posited that medical training was a valuable and worthwhile background for any profession, stating, “Medicine tinges the whole philosophy of life and furnishes the whole basis of thought.” Dr. Doyle’s full-time medical career lasted only about 15 years, but he was proud of it. Despite all of his literary successes, Dr. Doyle honored his medical degree above all. Even after obtaining knighthood, he said to his mother, “The title I value most is that of ‘Doctor,’ which was conferred by your self-sacrifice and determination.”
Dr. Doyle was a surgeon, a man of the people, and a man of society. His translation of medical knowledge to serve the public has ramifications today. Like Dr. Doyle, who was influenced by his mother’s storytelling skills, Eleanor Fallon, MD, lead author of this article, was influenced by her mother, Ann C. Fallon, a mystery writer. Dr. Fallon believes it is important to always stay interested in patients’ stories, hear their narratives, and use that knowledge to take the best care of patients both inside and outside the operating room.
Finally, as an example of Dr. Doyle’s medical training and cultural influence coming full circle, there is now a real-life medical detective in the Netflix series Diagnosis, adapted from a column in The New York Times and subsequent book by Lisa Sanders, MD, Every Patient Tells a Story.
Dr. Doyle told stories of fictional characters, he defended the narratives of those wrongly accused, and fought for better future stories for all of us.
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