Why do doctors love Sherlock Holmes so much? In this episode, we’ll explore this endearing, nerdy obsession with the good detective, from Holmes’ medical origins and influences, the parallels with medical reasoning, and how the Holmes stories still influence medicine to this day. Plus a new #AdamAnswers about the origin of the white coat. All this and more in Episode 35 of Bedside Rounds, a tiny podcast about fascinating stories in clinical medicine!

Sources:

• Blumhagen DW, “The Doctor’s White Coat,” Annals of Internal Medicine, Vol 91, No. 1, July 1979.
• Conan Doyle A, “The Adventure of the Speckled Band,”  retrieved from https://sherlock-holm.es/stories/pdf/a4/1-sided/spec.pdf
• Hochberg MS, “The Doctor’s White Coat — an Historical Perspective,” Virtual Mentor. April 2007, Volume 9, Number 4: 310-314.
• Levine D, Revalidating Sherlock Holmes for a role in medical education.Clin Med April 1, 2012 vol. 12
• McDaniels, AK, “In change in tradition, Johns Hopkins interns will no longer wear short white coats,” Baltimore Sun, retrieved from http://www.baltimoresun.com/health/bs-hs-short-white-coat-20180328-story.html
• Oderwald AK, Sebus JH. The physician and Sherlock Holmes. Journal of the Royal Society of Medicine 1991;84:151–2.
• Perry S, “It takes a medical Sherlock Holmes to solve complex neurological mysteries,” MinnPost, retrieved from https://www.minnpost.com/second-opinion/2013/09/it-takes-medical-sherlock-holmes-solve-complex-neurological-mysteries
• Peschel RE, Peschel E. What physicians have in common with Sherlock Holmes: discussion paper. Journal of the Royal Society of Medicine 1989;82:33–6.
• Rapezzi C, Ferrari R, Branzi A. White coats and fingerprints: diagnostic reasoning in medicine and investigative methods of fictional detectives. BMJ 2005;331:1491–4 FREE Full Textno. 2 146-149.
• Reed J, A medical perspective on the adventures of Sherlock Holmes, BMJ Medical Humanities, Volume 27, Issue 2. http://mh.bmj.com/content/27/2/76
• Snyder LJ, “Sherlock Holmes: scientific detective,” Endeavor, Vol. 28 No.3 September 2004.
• Whitaker P, “Had Sherlock Holmes gone into medicine, he’d have been a dermatologist,” New Statesman, retrieved from https://www.newstatesman.com/politics/health/2018/03/had-sherlock-holmes-gone-medicine-he-d-have-been-dermatologist

Transcript

This is Adam Rodman, and you’re listening to Bedside Rounds, a tiny podcast about fascinating stories in clinical medicine. This episode is called “Sherlock,” and it’s about the strange, endearing, and somewhat obsessive love affair between doctors and Sherlock Holmes, from the medical origins of the good detective, the parallels with medical reasoning, and how the Holmes stories still influence medicine to this day.

Doctors love Sherlock Holmes, though that shouldn’t be surprising since pretty much everyone loves Sherlock Holmes. Holmes isn’t the first literary detective — that honor belongs to Edgar Allan Poe’s C. Auguste Dupin — but he’s definitely the most famous. Since Arthur Conan Doyle first introduced the detective in the 1887 short story A Study in Scarlet in 1887 Holmes has appeared in four novels and 56 short stories, and that’s only if you count those penned by Conan Doyle himself. He’s been in inumerous other derivative works. The Guiness Book of World Records awarded Sherlock the coveted title “most portrayed movie character” — more than 70 different actors in over 200 films. Just a sampling — he was first portrayed in stage plays, which cemented his famous look of his overcoat and deerhunter hat. Then he was in a mutoscope film — a silent reel that played into an eyeset; think late 19th century boardwalks. And after that, movies, both silent, talkies, and animated. He was in a Japanese anime series where he’s a talking dog, in a famous Soviet television series (with Riga doubling as Baker street), and he’s fought Nazis. And if I have this right, there are currently two English-language Sherlock Holmes series currently on television — one set in London, and one in New York City. 

So yeah, everyone loves Sherlock. But still, doctors are at an especially high level. I am willing to bet that he is quoted at least daily on the wards somewhere in the English-speaking world. I even bungled this Holmes quote last week in the workup of a fever of unknown origin:

“When you have eliminated all which is impossible, then whatever remains, however improbable, must be the truth”

Except I said something more like, “You know, it’s like Sherlock Holmes — once you’ve gotten rid of the main possibilities, whatever remains, no matter how unlikely — well, you get the picture.”

I’m not a very quotable man. Of course, I was actually wrong, but we’ll talk more about that later. 

A Pubmed search for “Sherlock Holmes” returns 160 articles, a good portion of which I have now read. Doctors even like to compete in the absurdly hypothetical contest of, if Sherlock Holmes had gone to medical school and then decided to subspecialize, which medical subspecialty would he pick? Take, for example, the headline, “Had Sherlock Holmes gone into medicine, he’d have been a dermatologist.” Or another one, which asks the question we’ve all been dying to know, “Is Sherlock Holmes the neurologist’s alter ego?” (the article concludes, unsurpisingly, yes). Though I happen to know for a fact that he’d be an internist. Come on guys!

This geeky and honestly quite endearing love is actually quite understandable — Arthur Conan Doyle was one of us, a trained and practising physician, and he imbued the Holmes stories with multiple references to medicine. A BMJ review looked in the entire canon, and there are references to “68 diseases, 32 medical terms, 38 doctors, 22 drugs, 12 medical specialties, 6 hospitals, and even three medical journals and 2 medical schools.”  And many of the characters in his books were modeled after his real patients, as well as friends and medical school professors. 

Let’s talk about Arthur Conan Doyle the man. Arthur Conan Doyle was born in 1859 in Edinburgh, and attended medical school at the University of Edinburgh, graduating in 1881. He was apparently a sharp student and published his first academic article as a second year medical student, “Gelsemium as a Poison,” in the BMJ — as impressive a feat for a second year medical student then as it is today. Conan Doyle self ingested the drug in increasing amounts for seven days and reported the effects on his own body. And this is neither here nor there, but his study was actually cited in the 2013 murder of a Russian spy in France, which was initially thought to be a death of natural causes, until traces of gelsemium was found in his stomach.  

After graduation, Doyle joined on as a ship’s doctor and traveled to the Arctic and the West African Coast. After returning, he attempted to go into practice with a colleague but it didn’t go well, so he went to Portsmouth and set up his own practice. Patients were not initially forthcoming, so he took to writing short stories. He had started to do this in medical school, but it was in this period that he first wrote A Study in Scarlet, his first Sherlock Holmes adventure. After a dermatologist friend recommended ophthalmology as field in which Conan Doyle would have plenty of leisure time in which to write, he traveled to Vienna for two months to take classes, and then Paris for a weekend to shadow a famous opthalmologist. Medical training was much shorter back then. His dream apparently came true. In his autobiography, he wrote:

“I reached my consulting room at ten and sat there until three or four, with never a ring to disturb my serenity.., so long as I was thoroughly unsuccessful in my professional venture there was every chance of improvement in my literary prospects. ‘

In those four months, he wrote a number of short stories and finally published A Study in Scarlet  in The Strand. As money started to pour in from his writing, he closed his London office, though continued to practice for another nine years. 

One final biographic point — during the second Anglo-Boer War, he volunteered as a medic, and wrote a pamphlet defending the British position, which got him knighted as “Sir Arthur Conan Doyle,” which is how most people refer to him today.

I mentioned that Conan Doyle based characters on people he knew in real life. And most notably, Sherlock Holmes himself is based on Conan Doyle’s mentor from medical school, the famous surgeon Dr. Joe Bell. 

When Conan Doyle clerked in his clinic at the Royal Infirmary, Dr. Joe Bell was already a prominent surgeon in his 40s. In Episode 34, I spoke about how the physical exam rapidly developed at the turn on the 19th century as a way to discern illness inside the human body. By the late 19th century — just two generations later — the idea of the pathognomonic sign — that each disease had characteristic hints that could be discerned by an observant physician — was probably at its height. Medicine, and the popular press, showered praise on these physicians and their eponyms. You had Trousseau and his description of tetany of the hand in low calcium, described in 1861. That was just the first of two prominent Trousseau sign; the other was a description of migrating superficial blood clots in patients with an underlying malignancy, which he actually used to diagnose gastric cancer in himself. You had Cheyne and Stokes, who described an unusual breathing pattern seen in brain damage and heart failure. And you have the Austin Flint heart murmur, a sign of aortic regurgitation. I love this one, because Austin Flint hated the idea of eponyms, and wrote: “So long as signs are determined from fancied analogies, and named from these or after the person who describes them, there cannot but be obscurity and confusion.”

This late 19th century fascination with medical signs still lives on today. We still glowingly teach our medical students about pathognomonic signs, even as their use has become increasingly suspect. My personal bugaboo is the Reynold’s Pentad, which is an extension of the Charcot Triad for ascending cholangitis, an infection of the biliary system. The Charcot Triad is pain over the liver, jaundice and fever — and why we need an eponym for this I don’t even know. It’s not even accurate; plenty of cholangitis presents without jaundice. But then we add on low blood pressure and altered mental status to get the Pentad — which is essentially saying severe sepsis. This annoys me to now end, because I could do this with any disease. Take, for example, the humble pneumonia. Well, if you get pneumonia, and now shock and altered mental status, we’ll call in the Rodman Quatrad. If you have a urinary tract infection and get those symptoms, just call it Rodman Heptad. I can do this with pretty much everything, with increasingly convoluted names. Sepsis can be caused by any infection, and basically adding it onto a Pentad for a specific disease obscures disease etiology, especially for new learners, and it’s just not clinically useful in a world of “early goal directed therapy” for sepsis, regardless of the cause. It should be stricken from medical education. I told you this was a bugaboo of mine.

But back to Joe Bell. He was steeped in this exciting new trend of pathognomonic signs, and he combined this with his astute powers of observation of pretty much everything. Stories about his abilities on rounds with his students have become legends, even in the 21st century. 

To recount probably the most famous story about Bell, which so impressed Conan Doyle:

A stranger is brought into his outpatient clinic. After studying him for a moment, Dr. Bell spoke, “Well, my man, you’ve served in the army.”

“Aye, sir”

“Not long discharged?

“No sir.

A highland regiment?

Aye sir

“Stationed in Barbados?

Aye sir

Turning to his students, Dr Bell explained, you see, gentlemen, the man was a respectful man, but he did not remove his hat. They do not do so in the army, but he would have learned civilian ways had he been long discharged. He had an air of authority and was obviously Scottish. As to Barbados, his complaint is elephantiasis, which is West Indian and not British.”

And like true legends, this story has been retold in many different, and often bawdier, iterations. One doctor who trained in the 1970s at the University of Edinburgh recounts the same story, with the conclusion, “And his diagnosis is syphilis, because everyone in the Army has syphilis.”

The narrator of the vast majority of the stories is Dr. Watson, a surgeon himself, and you can see the Joe Bell influence the first time that Watson meets Holmes in A Study in Scarlet:

He says to Watson, “You have been in Afghanistan I perceive… Here is a gentleman of a medical type, but with the air of a military man. Clearly an army doctor then. He has just come from the tropics, because his face is dark and that is not the natural tint of his skin for his wrists are fair. He has undergone hardships and sickness, as his haggard face says clearly. His left arm has been injured. He holds it in a stiff and unnatural manner. Where in the tropics could an English army doctor have seen much hardship and got his arm wounded? Clearly in Afghanistan.”

Conan Doyle was openly thankful to Joe Bell for his influence and mentoring, and years later wrote to the man, “My dear Doctor Bell, it is most certainly to you that I owe Sherlock Holmes.” For his part, Bell “took a keen interest” in Sherlock Holmes, and would even suggest ideas for further adventures to Conan Doyle. I wish I knew what those adventures were, because Conan Doyle dismissed them in his autobiography as “not very practical,” which I have to imagine is a polite way of saying they were terrible.

So I hope I’ve convinced you that Conan Doyle imbued his Holmes stories with the medical milieu of the day, especially influenced by his mentor Joe Bell. And since the way we practiced medicine in 19th and early 20th century still greatly (and I’d argue absurdly) influences us today, Holmes’ style feels remarkably contemporary. But I’d also argue that the way that Sherlock Holmes solves crimes is essentially medical diagnosis, and that his method of reasoning has important lessons for doctors today.

Okay, so here’s the past where I assign my first ever Bedside Rounds homework. I’m going to use the Adventure of the Speckled Band as an example here. This is my favorite Sherlock Holmes story of all time; I first read it when I was around 10, and I’ve loved the story ever since. I am going to spoil the story here, and I don’t feel that I need a #spoileralert for a story that’s 130 years old. However, I have a link in the shownotes to the story, and I also recorded an audio version, if you just can’t get enough of my voice. I actually literally recorded it on a dark and stormy night here in Boston. So if you’ve never read it, I highly suggest you do before we go any further. 

The Adventure of the Speckled Band plays out like a medical report — Holmes takes a thorough history, performs a “physical,” and then finally performing some diagnostic tests, before finally laying out his conclusion. So let’s get started.

Holmes and Watson are now bachelor roomies at Baker Street hoping to sleep in, when they’re awoken early one morning by a knock on the door — a young lady named Helen Stoner. 

Holmes ushers her in, and starts off by wowing her with some good old identification of pathognomonic signs: 

You have come in by train this morning, I see.” 

“You know me, then?” 

“No, but I observe the second half of a return ticket in the palm of your left glove. You must have started early, and yet you had a good drive in a dog-cart, along heavy roads, before you reached the station.” The lady gave a violent start and stared in bewilderment at my companion. “There is no mystery, my dear madam,” said he, smiling. “The left arm of your jacket is spattered with mud in no less than seven places. The marks are perfectly fresh. There is no vehicle save a dog-cart which throws up mud in that way, and then only when you sit on the left-hand side of the driver.”

After that interlude, Holmes starts by essentially taking an open-ended history: “And now I beg that you will lay before us everything that may help us in forming an opinion upon the matter.” 

Stoner tells Holmes that she feels her stepfather, a medical doctor who practiced in India named Dr. Roylott, murdered her sister two years ago to prevent her from marrying and collecting her inheritance. The last thing her sister uttered before dying was, “The speckled band!” Now she is engaged to be married, and inexplicably Roylott moved her into her sister’s old room. She has been hearing strange noises around their estate, and she is worried that she is next. 

Holmes listens to her Stoner speak her piece, and then asks directed follow up questions — about a strange whistling and metallic sound in the night, about a band on gypsies that lives on the plantation, and about a cheetah and baboon that Roylott has collected, that roam around the plantation.

I should mention that this history takes up almost half the story — like any good doctor, Holmes knows that the patient will tell you the cause of his disease.

After a brief interlude in which he is threatened by Dr. Roylott, Holmes and Watson take off on their physical exam. First Holmes reviews Stoner’s late mother’s will, and then the two of them set off the Stoke Moran, the decaying and heavily mortgaged countryside estate of Roylott and Stoner.

Holmes performs a detailed exam of the manor, especially of Helen’s sister’s room, where Helen is now sleeping. He notes some odd findings — the bed is anchored to the floor, and there is a bell cord in the room, but it’s not attached to any bell. There’s a mysterious ventilation hole running to Dr. Roylott’s room, rather than running to the outside. And finally, in Roylott’s room, they find a mysterious iron safe with a saucer of milk in front of it. 

Holmes has now concluded his history and physical, and he’s ready to run some investigations. He tells Helen that when she goes to bed, she should open her window and escape to a local inn. Holmes and Watson will then sneak in and spend the night in the room. 

As the two friends sit in the dark room that evening, Holmes gives Watson a presentation of the case, summarizing the history and then the results of their observations. Holmes doesn’t give everything away of course, the grimly foreshadows:

“Subtle enough and horrible enough. When a doctor does go wrong he is the first of criminals.
He has nerve and he has knowledge. … We shall have horrors enough before the night is over”

That’s an awesome quote about doctors if I’ve ever heard one.

Suddenly, past midnight they hear a metallic creaking noise, and Holmes quickly strikes a match and lights a candle. He beats at the bell rope with his cane — where a venomous “swamp adder” is slithering down. A low whistling noise is heard, and the panicked snake retreats back up the rope. The two men hear a loud scream, and then burst into Roylott’s room, Watson’s revolver drawn, where they find Roylott dead on the floor, “the deadliest snake in India,” the swamp adder, coiled around his head, looking indeed like a speckled band.

The next day, as Holmes and Watson are travelling back to London, Holmes revealed his reasoning, which I’ll quote in its entirety:

“I had come to an entirely erroneous conclusion which shows, my dear Watson, how
dangerous it always is to reason from insufficient data. The presence of the gipsies, and the use of the word ‘band,’ .., were sufficient to put me upon an entirely wrong scent. … I instantly reconsidered my position when, however, it became clear to me that whatever danger threatened an occupant of the room could not come either from the window or the door. My attention was speedily drawn, as I have already remarked to you, to this ventilator, and to the bell-rope which hung down to the bed. … The idea of a snake instantly occurred to me, and when I coupled it with my knowledge that the doctor was furnished with a supply of creatures from India, I felt that I was probably on the right track. The idea of using a form of poison which could not possibly be discovered by any chemical test was just such a one as would occur to a clever and ruthless man who had had an Eastern training. … Then I thought of the whistle. Of course he must recall the snake before the morning light revealed it to the victim. He had trained it, probably by the use of the milk which we saw, to return to him when summoned. …

“I had come to these conclusions before ever I had entered his room. … The sight of the safe, the saucer of milk, and the loop of whipcord were enough to finally dispel any doubts which may have remained. The metallic clang heard by Miss Stoner was obviously caused by her stepfather hastily closing the door of his safe upon its terrible occupant.”

Essentially, Holmes took a detailed history — by initially asking open-ended questions, then more pointed clarifying questions. Based on this history, and this history alone, he developed a working hypothesis, a differential diagnosis — in typical nineteenth century fashion, the gypsies did it. He then performed a detailed “physical examination” of the premises. With this additional information, he refined his differential diagnosis. And though at this point, he pretty much had his diagnosis, he performed one final diagnostic test — with deadly consequences. You might think that these similarities to medical diagnosis are just superficial, and that this is a quirk of the detective genre. But contrast Conan Doyle to Agatha Christia. Miss Marple and Hercule Poirot, as talented detectives as they are, chase down red herrings, have chance occurrences.  Holmes is methodical — he needs no lucky break. He solves his cases with detailed observation, and then force of reason alone. And tellingly, this history – exam – diagnostic test format is followed almost exclusively throughout the Holmes’ stories. 

And I think this is fundamentally why Holmes remains popular with doctors over 100 years later — he’s probably the most prominent example of how doctors think, despite not being a doctor. Now I want to seriously consider, was Conan Doyle onto something? Is the Holmesian method really how doctors think? Holmes calls the way he thinks “deduction”. But he’s really using the word deduction in a more general sense that means inference. Formal deductive reasoning dates back to Aristotle, and means moving from a general premise to a specific conclusion. You can imagine a medical example, tying this back to pathognomonic signs. All patients with Trousseau’s sign of malignancy have an abdominal cancer. My patient had a blood clot in the peripheral veins of the thighs, and then of the arms the next day. Therefore, my patient has an abdominal cancer. 

Holmes does not start from any general principles. What he does is collect as much information as possible — some of it seemingly trivial — and then tries to fit a hypothesis to this data. As he collects more data, he refines his hypothesis. This is more consistent with what is called abductive reasoning, which was first described in the late 19th century as a way to explain hypothesis testing in science. In the late 19th century, of course, people were not really thinking about how doctors thought. But by the 1970s, scholars started to become more interested in medical decision making, for two reasons — the first, so it could be better taught to students, who were just placed in clinical situations and made to, essentially, figure it out. But a secondary goal was to teach computers how to think like doctors. The primary model that was developed was called the hypothethico-deductive model of clinical reasoning, essentially abduction applied to the medical encounter. When doctors encounter a new case, they build a differential, and then start to collect data — through the history, through the exam, and through investigations. They then test their hypotheses against this data set. Sound familiar? It’s basically the Holmesian way. 

Take, for example, the quote that I bungled on my wards:

“When you have eliminated all which is impossible, then whatever remains, however improbable, must be the truth”

This is the hypothetico-deductive model of clinical reasoning at its most extreme. I mentioned I used this is a fever of unknown origin. A lot of things can cause a fever. We “collect data” — taking an obscenely detailed history (ever been in jail? Swimming in fresh water? Any spleunking lately?), a detailed exam, and diagnostic tests. Each data point helps us cross another thing off the list. Eventually we’ll get to more obscure causes — in my case, a rare cause of drug fever, though like I mentioned earlier, I was wrong.

So I also mentioned that doctors were interested in formal medical reasoning to program computers that could theoretically diagnose patients. The 1970s were the beginning of the use of expert systems — essentially branching “choose your own adventures” that would collect data, and then provide a diagnosis. The first was MYCIN, developed at Stanford to identify bacteria and antibiotic treatments, followed by INTERNIST-I, use to diagnose any sort of medical problem. These expert systems worked by different methods, which I’m not really qualified to get into, but they both essentially used the principle of the hypothetico-deductive method — essentially a computerized Sherlock Holmes.

So that’s great, then, right? Holmes is basically one of us!

Not quite. Decades of study on the hypothetico-deductive model have shown that it actually IS not how doctors approach medical problems, at least not most of the time. Other models have been proposed, but they don’t pan out either. Nor has teaching these methods been helpful to students. Our current understanding of medical decision making is that there’s a lot of pattern recognition — or “gut feelings” as Holmes would likely deride. We try to fit presentations to patterns that we’ve been before, or read about. And it’s only when this breaks down that we use other methods of clinical reasoning — the Holmesian hypothetico-deduction chief among them — to get our diagnosis.

With this understanding, a Holmes story is less like the process of diagnosing an actual medical problem in real life, and more like reading a medical case report in a journal. Because real medicine is much messier — it involves human connection, hunches, gut feelings, but also keen observation, a good intellect, and solid clinical reasoning. Still, there’s much to admire in Conan Doyle’s Sherlock Holmes, and with any luck, medicine’s nerdy love affair with the detective can continue for another 130 years.

That’s it for the show! But wait, it’s time for a #AdamAnswers.

#AdamAnswers is the segment where I answer whatever burning medical questions you have, no matter how trivial or profound!

This month’s question comes from Dr. Tony Breu, who asks via Twitter: Partly related to @HopkinsMedicine changing their policy on white coats): When did the white cost become the uniform of the doctor? Has the length of the coat always indicated level of training?

I love this question! But first let’s address the Hopkins change — so, like Tony mentions, this year, Johns Hopkins university will no longer require its residents to wear short white coats. I’ve linked to the Baltimore Sun story in the shownotes if you want to read it. There’s a tradition in medicine that the length of your white coat matches your seniority, at least in the United States. Students wear a short white coat, and doctors wear a long white coat. Johns Hopkins had a well-known tradition of having their interns — first year residents — wear a short white coat as well. From the article, it seems the residents were not too happy about this. Sanjay Desai, the Hopkins program director, is quoted as writing of the short white coat:

“Today, it does not promote the values which it was intended to promote,” Desai wrote. “Instead, it represents a physical symbol of the past, and of an excessive rigidity and hierarchy. This is unfortunate, but it is real. All institutions have to adapt to stay relevant and to ensure their traditions continue to uphold their core values. It would be a mistake for us not to.”

Feelings about white coats run deep. I waste enough time on reddit to know that ever six months or so, some student or doctor will complain about the “watering down” of the symbolism of the white coat — usually because a non-MD is wearing it.  So like Tony asks — where did the tradition of the white coat come from? It’s a far more recent tradition than you’d expect. Prior to the end of the nineteenth century, doctors would wear formal attire, similar to other professionals in their social class. This effectively meant a black suit, with either a tie or cravat. Take, for example, Thomas Eakins’ portrait of Dr. Samuel Gross, from 1875. I’ve posted it to my Twitter. Dr. Gross, his assistants, and his nurse are all dressed in black formal dress. Even the piece of artwork I use for a logo — the Anatomy Lesson of Dr. Nicolaes Tulp — which is FAR older, from 1632, shows the physicians gathered around the executed criminal in formal blacks.

So where did the white coat come from? Let’s just say the people who call it a lab coat are 100% correct. Two trends intersected in the late 19th century to bring us the white coat. The first is the German research university, a union of laboratory research with medical education. This model was wholeheartedly adopted in the United States, the primary example being Johns Hopkins, but also around the world. The second is Joseph Lister and the invention and widespread adoption of antisepsis in surgery, with a new focus on cleanliness in the operating room. Doctors had long used aprons in surgery to keep themselves clean. But now the focus was on not spreading microorganisms to patients on the surgical table. At some point, the lab coat jumped from the lab into the operating room. There were practical reasons, of course — it was light colored (tan or beige, initially, then white) so contamination could easily be seen. But the symbolism also proved powerful. With the recent invention of anesthesia, and now antisepsis, surgery had dramatically improved, and the color white was associated with the new cleanliness of scientific surgery. It proliferated throughout the operating theaters — the sheets, the gowns (white coats were abandoned by surgeons rather quickly), and even the nursing uniforms. Take a look at the Agnew Clinic, also painted by Thomas Eakins, in 1889. This is the same artist only 14 years later, but it’s a dramatic difference. The room is brightly lit, with Dr. Agnew clad in a white gown, as are his two assistants. His nurse, Mary Clymer, is also wearing a white uniform. And quite interestingly, the anesthesiologist, Dr. Ellwood Kirby, is wearing what we would today identify as a short white coat. 

So, by the late 19th century, white garb had become standard gear in operating rooms. But take a look at that painting again — all of the observers, who are presumably students and other doctors, are wearing formal black attire. There’s a photograph I want you to look at now, from May 1, 1908, in the Bigelow Amphitheater at Mass Gen. In this picture, the surgeons and anesthesiologists are all dressed in white gowns, including caps. They also have what appears to be leather gloves on as well, another innovation. There are some surgeons in the audience who are also dressed in the same white surgical gowns. But most of the audience is still wearing formal suits — except one gentleman in the far left corner, dressed in a remarkably modern-looking white coat. So when did this spread happen? Dr. Blumhagen, who wrote pretty much THE article on the history of the white coat, looked at house officer photos at the Mass General Hospital in Boston — and it was about in this period, between 1905 to 1915, when residents started to shed the formal black for the white coat. The reason appeared to be the symbolism, rather than any sort of practicality — apparently the coats were cleaned by hand by the hospital, and stains were hard to get out. Nursing uniforms were also made white in this period, associated with further professionalizing the field away from its religious roots. It’s no coincidence that this period saw the white coat start to metastasize from the operating room. The Flexner Report was published in 1910, and soon after scientific medicine became the formal curriculum in new medical schools modeled after the German research universities. The association with science, cleanliness, and purity of the color white was too powerful to pass up. A guide to running a hospital from 1912 actually dictated that all people connected with the healing process were to wear white — and all non-clinical personnel were forbidden from wearing it. 

So by the 1930s, you pretty much have the white coat as it is currently used today — but mostly on physicians working in a hospital. Doctors in private practice largely continued to wear professional street clothes, and surgeons switched to light blue or light green colored scrubs as the glare from new electric lights on white cloth made operating too difficult. Over the ensuing decades, it continued to spread beyond the hospital, and became so associated with the entire field of medicine, that in 1993 the first “white coat ceremony” was held, in which first year medical students are ceremonially cloaked in their short white coats. 

Now to Dr. Breu’s second part of his question, I’m not quite certain where the different lengths of coats come from. I’ve been looking through collections of old photos from Mass General and Beth Israel, and even as late as the 1950s, you see a variety of coat lengths being worn by attending physicians. To this day, there are some physicians in my department who still wear the short white coat as a testament to lifelong learning. Unfortunately, I can’t find more than circumstantial evidence about when the short-long divide started — but if any of my listeners are able to, please let me know!

Thank you for the question Dr. Breu, and I’m sorry I couldn’t fully answer your question. And to my listeners, if you have a question that you want to submit to #AdamAnswers, please tweet at me @AdamRodmanMD! 

Thank you so much for listening! This episode is a long time in the making. I first read about Sherlock Holmes and medicine five years ago, when I took a medical humanities class run by Chad Miller and Ben Rothwell, and I’ve been putzing around with an episode for about a year and a half now. So thank you Drs. Miller and Rothwell for running a wonderful medical humanities class back in the day. Believe it or not, I restrained myself this episode. I was ready to discuss the birth of medical forensics and the part that Holmes stories played in popularizing that in the lay public — essentially a 19th century “CSI effect” — but then I had to remind myself I have a full time job other than this podcast. So perhaps another time!

It’s been a period of intense and exciting growth for Bedside Rounds. If you don’t follow me on Twitter, the podcast was recently written up in Internal Medicine News as a top 3 medical podcast, just behind UptoDate. Listenership is waaay up. Needless to say, this was unexpected. I never planned for this when I started this as a resident. I don’t know where it will lead,but I’m excited for the journey. So thank you so much to all my listeners, new and old If you’ve never done it before, please consider writing me a review on iTunes or whatever platform you use for podcasts. It’s a great way of getting the word out. Or even better, tell your friends!

You can listen to all previous episodes on the website at www.bedside-rounds.org, or on iTunes, Stitcher, Spotify, or the podcast retrieval method of your choice. I’m on  Facebook at /BedsideRounds and Twitter as AdamRodmanMD, where I tweet mostly about medical history and evidence based medicine. And increasingly on Reddit, where I spend way too much time on r/askhistorians. I’ll be in the askhistorians podcast this month, so check it out at:

All of the sources are in the show notes.

And finally, while I am actually a doctor and I don’t just play one on the internet, this podcast is intended to be purely for entertainment and informational purposes, and should not be construed as medical advice. If you have any medical concerns, please see your primary care provider.