The BBC series Sherlock has hit the Philippines, and although I think the plots are stupid, the dialogue and characters are quirky enough to keep my interest.
But as a doc, I got very annoyed with the Dr. Watson limp in story number one.

Quick: What’s wrong with this picture?

watsonstick_300

The answer is that he is limping with his right leg and also holding his cane with his right arm.

This is commonly how people use a single crutch or cane, but it is wrong.

If you watch the series, you see how his body rocks back and forth when he uses the cane to walk. The problem? After a short while, he’s going to have a very sore back.

The second problem is that his cane is too short: He has to lean over to the side when he puts the cane down.

Since this is basic medicine, one wonders who his physical therapist is, or why the producers didn’t catch this medical mistake in the program.

So how does one use a cane? MobilityTraining website is one on many that tells you how.

The first thing is proper cane measurement: you have to be measured using the shoes you usually wear to get the length right, And the measurement has to be done when you are standing straight, not leaning over.

The livestrong website has this picture on how canes are supposed to be used:Ihaveahip dearie

Photo Credit Apple Tree House/Lifesize/Getty Images

Notice that grandmom in this photo is standing straight, not leaning to the side.

The site then goes on to explain how to walk with the cane:

Step One:

  The cane should be level with your wrist.
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Step 2

Grasp the grip of the cane with the hand that is on the opposite side of your injured or weak leg. To properly grasp the grip, your thumb should be facing your body and the back of your hand should be facing away from you.
Step 3

Swing the cane forward as you simultaneously step forward with your opposing leg. Both the cane and your foot should touch the ground at the same time. Take small steps as the cane and your leg work together in unison. Small steps help you maintain balance.

Which brings us back to Dr. Watson. Did the producers make a major medical gaffe, or will a perusal of the original stories show why he doesn’t put the cane in his left hand?

At the end of the first episode of the BBC series, Watson admits that his wound that got him sent home from Afghanistan was in the left shoulder, not the leg.

This is what happened in the original stories too: From A Study in Scarlet:

I served at the fatal battle of Maiwand. There I was struck on the shoulder by a Jezail bullet, which shattered the bone and grazed the subclavian artery. I should have fallen into the hands of the murderous Ghazis had it not been for the devotion and courage shown by Murray, my orderly, who threw me across a pack-horse, and succeeded in bringing me safely to the British lines.

Worn with pain, and weak from the prolonged hardships which I had undergone, I was removed, with a great train of wounded sufferers, to the base hospital at Peshawar.

The wound in the left shoulder, so he is unable to use the cane with his left hand.

This was a serious wound: in the days before antibiotics, could have been fatal.

The bullet, if left inside, could lead to infection, yet the presence of vital organs nearby (including a major artery and a lung) made removing the bullet dangerous, yet letting it behind could lead to other problems, including empyema, collapsed lung, or an abcess that would eat a hole into the Subclavian artery. Shoulder wounds are only “minor” in TV and film: in reality they are quite serious, as the writer of the Sherlock Holmes series, who was a physician, knew very well.
But what about the leg wound? Is the pain really “psychosomatic”?

In The Sign of the Four, we read:

More than once during the years that I had lived with him in Baker Street I had observed that a small vanity underlay my companion’s quiet and didactic manner. I made no remark, however, but sat nursing my wounded leg. I had a Jezail bullet through it some time before, and, though it did not prevent me from walking, it ached wearily at every change of the weather.

Some Sherlock geeks see the two wounds as a problem, but a graze to the lower leg (the bullet went through the muscle, and did not hit bone nor stay embedded) is not a serious wound: even in the days before antibiotics, it was considered a “clean” wound since the bullet and the accompanying clothing and dirt came out and was not left behind as a seed to cause a major infection.

The Jezail rifle was either a musket or a rifled hunting rifle, and often used for sniping at great distances.  But whether or not it caused as much soft tissue trauma as modern combat weapons using specialized ammunition. This is outside my area of expertise: in Watson’s case, this wound sound more like what the average inner city doc sees on a Saturday night.
In the TV show, Watson’s therapist calls his limp “psychosomatic”, but actually what it would be is what we docs see all the time: When someone is depressed, often minor pain problems exacerbate. So I suspect Watson’s leg wound/limp  probably aches him on and off (like Mrs Watson’s Hip) but was something he was “fixated” on during his convalescence, making it “hurt” more; after he had an occupation, the pain could be tolerated or ignored (and merely taking an ibuprofen or paracetamol when it ached too much).

As for all those websites trying to figure out how he could get two wounds from one bullet: Uh, it doesn’t work that way. It was two wounds: One minor, treated on the battle line, one major, needing evacuation, and from which he was lucky to survive.

But the reason Dr. Watson was sent home (in the books) was not the wound, or the 18th century version of “shell shock”: He was sent home after a bout with “enteric fever” (usually this meant typhoid), not the wound.

Again, from a Study in Scarlet:

Here I rallied, and had already improved so far as to be able to walk about the wards, and even to bask a little upon the verandah, when I was struck down by enteric fever, that curse of our Indian possessions. For months my life was despaired of, and when at last I came to myself and became convalescent, I was so weak and emaciated that a medical board determined that not a day should be lost in sending me back to England.

In today’s world with antibiotics, we sometimes forget that disease probably kills as many soldiers in war as bullets and other weapons. This link discusses typhoid in soldiers during the First World War. 

This problem continues today, mainly because Afghanistan lacks a civilian infrastructure with clean water and sewage disposal, but now we can treat it with antibiotics, prevent with vaccines, and stop it’s spread by proper sewage desposal, handwashing and using using bottled water.

The Soviet Army in Afghanistan had over half their troops developing diseases like malaria, typhoid, hepatitis B or other more common illnesses like TB or influenza, although only one thousand of their fatalities were from disease. The US military probably has a similar problem with infectious disease LINK but the statistics are not yet clear (the anti war sites exaggerate, the pentagon sites only see the severe problems).

But luckily, due to modern sanitation, vaccines, and antibiotics, the problems once seen from typhoid or other “enteric” fevers is something that only those of us with third world experience have seen.

____________________________

Nancy Reyes is a retired physician living in the rural Philippines.

A longer version of this essay was posted at heyDoc Xanga blog

 

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