William Osler at 150

Michael Bliss, PhD

CMAJ 1999;161(7):831-4

Osler's career

The Reverend Featherstone Osler was the Church of England's equivalent of a circuit-riding preacher, sent out from England in 1837 to serve a huge territory in backwoods Canada just north of Toronto. His wife, Ellen, bore him 9 children, of whom 8 reached adulthood. Three of the Osler boys attained high positions in the Canadian judiciary, the bar and investment banking. The youngest, Willie, was influenced by a love of natural history and the microscope to enter medicine. After 2 years of training at the Toronto School of Medicine he transferred to McGill, graduating with a medical degree in 1872.

Osler spent about 18 months doing graduate studies in physiological and clinical subjects in London, Berlin and Vienna. He then returned to Canada, where in 1874 he was offered an appointment at McGill as lecturer in, then professor of, the "institutes" (fundamentals) of medicine. During 10 years in Montreal he established himself as one of the most promising researchers and medical educators in the English-speaking world. He published at a furious rate on a vast range of diseases, concentrating on the presentation of pathological data but increasingly drawing correlations with clinical conditions. He became extremely popular with McGill students and the Montreal medical community and, as an educational reformer, was active in the renewal of the McGill Faculty of Medicine as one of the best and most progressive in North America.

Osler moved to the United States in 1884 to become professor of clinical medicine at America's oldest and largest medical school, at the University of Pennsylvania. While continuing his pathology work in the "dead house" through his Philadelphia years, Osler began to focus on clinical practice; he continued to publish at an astonishing rate and was in the forefront of a profession finally coming into its own. In 1889 Osler leapt at the opportunity to become physician-in-chief of the showpiece Johns Hopkins Hospital in Baltimore and professor of medicine at Johns Hopkins University's School of Medicine (the opening of which was delayed until 1893). While Osler was underemployed waiting for the medical school to open, he pulled together a vast body of knowledge in readable form in what instantly became the dominant textbook of the age, The Principles and Practice of Medicine, first published in 1892.

By virtue of Johns Hopkins' resources and its commitment to excellence in care and advanced research, and because of the high standards of admission to its medical school and the quality of its staff, the Baltimore institution was by a considerable margin the most important medical facility in North America in the 1890s. Both its hospital and its school were the gold standard on this continent and throughout the English-speaking world. William Osler was the most glittering of the Hopkins group. One hundred years ago he had attained the zenith of his reputation as a clinician of exquisite diagnostic capacity and human warmth, and a charismatic teacher who inspired a generation of students with a passion for the medical calling. "We all worship him," one of the Hopkins students observed.

Pedagogically, Osler brought to Johns Hopkins the institution of the clinical clerkship, which McGill had copied from Edinburgh. This was an extraordinarily important innovation in American medical education, not because of the introduction of bedside teaching per se, which was common enough in many hospitals, but because it represented the incorporation of students into hospital and medical life as budding professionals.

Remarkably, there was virtually no dissent from the view that William Osler was an outstanding clinician, teacher and human being. He was effectively canonized by the North American profession while still in his middle years. The pressures of maintaining his position as the greatest American physician — his private practice, which required frequent travel, threatened to overwhelm him — gradually wore Osler down to the point where, seriously concerned about his health, he left Johns Hopkins at age 55 in 1905 to become Regius Professor of Medicine at Oxford.

Osler's duties were very light at Oxford, and although he continued to see private patients and give ward rounds at the Radcliffe Infirmary he had much more time for his growing interests in book-collecting, medical history and writing about the medical life. He was happily married to Grace, a great-granddaughter of Paul Revere. They became Sir William and Lady Osler when he was awarded a baronetcy in 1911. The death of their only son, Revere, on the Western Front in 1917 was the tragedy of their lives. Sir William Osler died at age 70 on December 29, 1919, of empyema and other infections secondary to influenza.

Osler worship

The outpouring of adulation after Osler's death affected his reputation in contradictory ways. By some of his friends he was proclaimed to have been the greatest physician in history. Osler clubs, plaques, cairns, portraits, lectureships, medals and other commemorations multiplied. In 1925 his protege, the great neurosurgeon Harvey Cushing, published a 2-volume, 1400-page Life of Sir William Osler, written to commemorate "one of the most greatly beloved physicians of all time." Cushing's biography was hailed by friendly reviewers as a masterpiece; it won a Pulitzer prize and for more than 70 years has served as the guide to Osler's life and good works. Many thousands of North American medical students have been given copies of Cushing or of editions of Osler's essays to inspire them.

Osler's personal library, donated to McGill, became the basis of a shrine to the man and his books. Several of his apostles, including the first Osler Librarian, W.W. Francis, worked to create a virtual Osler cult, replete with relics, sacred texts, censorship, hymns and holy days. The value his admirers place on Osler's work is quantified in the catalogues of antiquarian book dealers. A first edition of The Principles and Practice of Medicine sells for about US$850; an original Osler letter will go at US$1000­$3000.

But, as the generation who had known Osler died and the great man's image faded into history, those who bothered to think of him at all began to wonder who this man really was. Had Osler been oversold by Cushing, Francis and other admirers? Had he been turned into a plaster saint by a kind of "Osler industry"? Could any human have been as perfect as Osler was said to have been? After all, what did he discover? Nothing much. How relevant are his clinical studies today? With a very few exceptions, they are of historical interest only. How readable are his inspirational essays today? They're ponderous and cluttered and it's not clear they are inspirational, either. What was William Osler really like? Hard to tell. Cushing's Life is also ponderous and cluttered and, like most writing about Osler, anything but objective.

What is to be said, then, about Osler at the sesquicentennial of his birth? Does he have any significance for our time, or should he be allowed to fade into history — another long-dead physician, albeit one with a cult of antiquarian idolators, a still-famous name and an obvious place in the pantheon of high-achieving Canadians?

Osler R.I.P.

By any standards Osler's achievements were remarkable. The man who brought the clinical clerkship to medical education in the US will always have a high place in any medical historian's esteem. The historical Osler was a brilliant and innovative medical teacher. Some "Oslerians" go on to suggest that he was essentially a medical humanist whose concern for having students learn to treat patients and for putting patient care at the centre of medicine is still relevant — indeed, more relevant than ever in an era of impersonal, high-tech diagnosis and treatment.

In point of fact, Osler's medical humanism is somewhat time bound, with little direct relevance for us. No one who reads The Principles and Practice of Medicine, or who compares it with modern texts (including the revived editions written primarily by Johns Hopkins faculty) would find Oslerian medicine particularly patient centred. Osler wrote mostly about the clinicopathological manifestations of disease. As others have noted, he was a natural historian of disease. As a clinician and consultant his forte was diagnosis, achieved not through careful, sensitive regard to patients' histories and narratives, but as a result of careful examination of their bodies in light of his encyclopedic knowledge of the manifestations of disease. Uncompromisingly committed to scientific medicine, Osler welcomed all useful technological advances, from x-rays to electrocardiography to blood pressure monitoring. He was not the doctrinaire "therapeutic nihilist" some have claimed, and certainly not a medical "holist" in today's elastic use of the term. (Osler wrote and said so much, often aphoristically, that he can be quoted to support almost any present therapeutic or educational position.) The rise of patient autonomy and patient-centredness in medicine in the past 30 years would, I believe, astonish Osler and might even leave him anxious about declining levels of confidence in medical authority.

Nor does the Osler of history offer us guidance about the way we organize health care. He lived most of his life in pre-insurance times, when physicians collected from those who could pay their bills and gave their services free of charge to those without means. Osler had little to say about the beginnings of state health insurance. What he did say, in a speech delivered to Canadian medical officers at the end of the Great War, suggests that he might have been deeply conservative:

Personally I do not see that in Canada it would be a feasible thing if any Ministry organised the taking over both the Health and the Disease of the entire community ... . I am afraid that even under the most favourable circumstances if the general practitioners were made State officials no matter how carefully graded the services would be, there would be that absence of competition and that sense of independence which after all is the most important factor in a man's individuality in his professional career....

I really do not think that any of the Provinces of Canada would ever be likely to have a complete State control of the profession. I do not believe it would be good for the profession or good for the Public. I think the profession must stand on the individual work of the Doctors ... .

Osler also was off the mark in his understanding of what has become one of modern medicine's greatest triumphs and ongoing challenges: the extension of our life expectancy. He was nowhere more a man of the 19th century than in his view that the human lifespan is effectively a "fixed period," with intellectual performance peaking before 40 and serious deterioration virtually inevitable after 60. Osler was rightly criticized in the medical and lay press for some of his flippant views on the uselessness of the aged. In his serious writing he completely missed the possibility that new discoveries, therapies and approaches to lifestyle would significantly extend our useful lives and culminate in an assault on the aging process itself.

Here, then, is a physician whose writings are no longer widely read, whose views on many of the issues that concern us are seriously dated and who perhaps is most appropriately dealt with when honoured as a great man of a different era. Why suggest that at 150 Osler might still speak to medicine in our time?

The persisting Osler

No one has ever loved the medical life more than William Osler did. From the day he decided to become a doctor until the day of his death he lived, breathed, ate, slept, talked and wrote medicine. Osler preached that medicine was the greatest of all professions and that medical men and women were doing more than any others to relieve the sufferings of poor fragile humans. He was a doctor without borders or bigotry, who believed that the brotherhood of physicians (including women, although they usually entered the sisterhood of nurses), rather like the holy catholic Church, rose above all localisms and chauvinism.

Osler was committed to excellence in the practice of medicine in a way that dazzled both his students and his colleagues. He wanted every institution he served to aspire to being the best it could become: hire the best people wherever they can be found, practise the best possible medicine at all times, never cut corners, never avoid confronting your mistakes, never become set in your ways. Osler became mentor and role model for several generations of Anglo-American physicians partly because of this passion for excellence. Most of the students and colleagues who observed Osler with patients thought he was the best they had ever seen. Most of the patients thought so too. Only in Britain was there a sense that Osler's clinical skills were not quite as singular as the Americans liked to think — but even the English thought his charismatic bedside manner more than compensated for any technical rustiness.

Osler understood and taught that the essence of medicine was the confrontation between a physician and a sick person. He became a great hero to students at McGill, Pennsylvania, Hopkins and Oxford because he taught them not the sciences of medicine but the art of medicine in the light of science. Already in Osler's day the mystique of research was elevating laboratory investigators such as Pasteur, Koch and Ehrlich into great prominence and public acclaim. But, as all students understand, outstanding scientists, even great discoverers, could not and cannot be the mentors who show anxious young men and women how to cope with suffering patients. Osler was a general who lived and fought and slept in the trenches. Here, perhaps, was the enduring aspect of his medical humanism. But it had another important dimension in Osler's belief that physicians should also be persons of learning and culture. Every day they were to retire from battle, however briefly, and savour the intellectual riches of the world around them.

To a modern biographer looking for a subject's warts and failings it is disconcerting to find that the Osler of history was a man who for the most part lived up to his shining image. Trying to commit "pathography" on Osler, I was unable to find anything that would justify the death of his reputation. Granted, he was uneasy about the entry of women into medicine, worrying that women physicians would find it extremely difficult to make a living — as indeed they did during his lifetime. But Osler was unusual among his colleagues in supporting medical coeducation, and all the evidence, including their own testimony, suggests that medical women found him the most inspiring of their teachers. Except for a penchant for harmless but occasionally tasteless practical jokes and a somewhat scatological sense of humour — the latter perhaps not uncommon among male doctors in his and other times — the real Osler was a man of extraordinary self-discipline and productivity combined with charm, equanimity, poise, good cheer and magnetic affection for children. He was probably celibate until his marriage; his marriage and family life were intensely happy until Revere's death. Osler lived a beautiful life. Someone has said that the real trouble with Osler as a role model is that he never had a bad day, and no one can come close to matching him.

Osler's Canadian upbringing stood him in good stead. Like many of the young medical men Canada produced in abundance in the late 19th century, he combined in his personality the best of British culture and American energy and so was at home everywhere in the English-speaking world. He rose from a parsonage on the fringes of the wilderness to become one of the transmitters of the heritage of the Old World to the New and retired as one of the ornaments of Oxford at the height of the Empire's glory. The son of a minister who deeply believed in human immortality, Osler as physician came to understand the terrible brevity of the human lifespan and resolved to make the most of the time he had. Few of us are as fortunate or as gifted in our strivings to take the good of every hour and contribute to human betterment.

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Reprint requests to: Dr. Michael Bliss, History of Medicine Program, University of Toronto, 207­88 College St., Toronto ON M5G 1L4; fax 416 978-2160; history.medicine@utoronto.ca

1. Bliss M. William Osler: a life in medicine. Toronto: University of Toronto Press; 1999.

© 1999 Canadian Medical Association or its licensors