Did Osler suffer from "paranoia antitherapeuticum baltimorensis"?

A comparative content analysis of The Principles and Practice of Medicine and Harrison's Principles of Internal Medicine, 11th edition

David B. Hogan, MD

CMAJ 1999;161(7):842-5

• Abstract
• Introduction
• Methods
• Results
• Interpretation
• References

One of the most important legacies of Sir William Osler was his textbook The Principles and Practice of Medicine. A common criticism of the book when it was first published was its deficiency in the area of therapeutics. In this article, the 1st edition of The Principles and Practice of Medicine is compared with the 11th edition of Harrison's Principles of Internal Medicine. The analysis focuses on the treatment recommendations for 4 conditions that were covered in both books (diabetes mellitus, ischemic heart disease, pneumonia and typhoid fever). Osler's textbook dealt with typhoid fever and pneumonia at greater length, whereas Harrison's placed more emphasis on diabetes mellitus and ischemic heart disease. Notwithstanding Osler's reputation as a therapeutic nihilist, the 2 books devoted equivalent space to treatment (in terms of proportion of total sentences for the conditions). For all conditions except ischemic heart disease, Osler concentrated on general measures and symptomatic care. Throughout Osler's textbook numerous negative comments are made about the medicinal treatment of various conditions. A more accurate statement about Osler's therapeutic approach was that he was a "medicinal nihilist." His demand for proof of efficacy before use of a medication remains relevant.

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I performed a comparative content analysis of the first edition of Osler's The Principles and Practice of Medicine, published in 1892,¹ and the 11th edition of Harrison's Principles of Internal Medicine.¹⁶ This edition, published in 1987, was selected because it came out more than 10 years ago (which gives it some distance from current practice) and approximately 100 years after the first edition of Osler's text. Because of Osler's reputation as a therapeutic nihilist^6,13,14 the comparison is based on the management of 4 specific conditions.

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The organization and emphasis of the 2 volumes was examined by listing chapter titles and calculating the percentage of the total number of pages for specific chapters.

The content analysis was performed for 4 disease states by means of sentence counts. The disease states selected for analysis were diabetes mellitus, ischemic heart disease, pneumonia and typhoid fever. These conditions were selected because they were all discussed in both books, because typhoid and pneumonia were major health issues in the late 19th century, and because diabetes mellitus and ischemic heart disease are significant health problems in our era. Chi² testing was used to examine the statistical significance of any differences in proportions. Further analysis of the treatment recommendations for these conditions was undertaken, again by means of sentence counts. Chi² testing was not performed for this analysis, because for a number of the comparisons more than 20% of the cells had expected counts of less than 5. Finally, Osler's textbook was reviewed for "negative" comments about drug therapies.

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The chapter comparisons are presented in Table 1. Approximately one-fifth of Harrison's textbook is given over to a general consideration of the basis of internal medicine. There is no equivalent discussion in Osler's book. Although Osler's organization is not foreign to a "modern" reader, some of the chapter headings do seem unusual. For example, the grouping of intoxications, sunstroke and obesity appears idiosyncratic.

Table 2 shows the content analysis for diabetes mellitus, ischemic heart disease, pneumonia and typhoid fever. The proportions for the subject headings were significantly different (p < 0.001) for all 4 conditions. In particular, Osler gave more space to pathology and clinical manifestations. However, equivalent proportions were allocated to treatment for diabetes mellitus (chi² = 0.047, p = 0.82), pneumonia (chi² = 0.86, p = 0.35) and typhoid fever (chi² = 0.71, p = 0.39) when we reduced the contingency tables to 2 × 2 tables. For treatment of ischemic heart disease the difference in proportions was significant (chi² = 8.44, p = 0.004).

Table 3 presents the analysis of treatment recommendations. Most of Osler's recommendations dealt with general care, diet or relief of symptoms, except for ischemic heart disease, for which he advocated various drugs (nitrates, chloroform, morphine and iodides). Drug treatment for diabetes was characterized as "most unsatisfactory, and no one drug appears to have a directly curative influence" (p. 304). Pneumonia was described as a "self-limited disease, and runs its course uninfluenced in any way by medicine" (p. 529). Concerning typhoid fever, Osler wrote that "[it] is not a disease to be treated by medicines" and that "Careful nursing and a regulated diet are the essentials in the majority of cases" (p. 33).

Osler specifically stated that drugs were ineffective in the treatment of 45 diseases. His comments were definitive, incorporating words and phrases such as "unsatisfactory," "futility [of treatment]," "no measures have been found to be of the slightest avail," "of little service" and "useless."

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Osler's grounding as a pathologist and his keen interest in clinical medicine are reflected by his emphasis on both of these subjects in his textbook. Our era has seen a diminution of the emphasis on pathology and clinical manifestations. However, the 2 textbooks devoted equivalent space to treatment for 3 of the 4 disease states examined. Further analysis of Osler's discussion of treatment revealed that most of his recommendations dealt with general measures or symptomatic relief. He made a number of harsh yet generally true statements about the futility of then-available medications.

According to Golden and Roland,^13,14 the major criticism of The Principles and Practice of Medicine when it was first published was Osler's therapeutic conservatism. One critic characterized his approach as "paranoia antitherapeuticum baltimorensis."¹⁴ Some have stated that his cautious approach arose from an awareness of the lack of efficacy of most available drugs and his belief in the importance of treating the whole patient.¹⁴ Yet it would be wrong to accuse him of being a therapeutic nihilist — it is more accurate to call him a "medicinal nihilist."^17,18,19 That is not to say that he considered all medications useless. He prescribed ergot, nitroglycerine and potassium iodide¹⁷ and referred to morphine as "G.O.M." ("God's own medicine").¹³ Osler emphasized general supportive measures.⁶ While his suggestions were not beyond reproach, he did deal better than most current medical authors with end-of-life care.²⁰

Osler's conservative approach to drugs helped in making his book widely accepted.¹⁵ He did not ally himself to a particular therapeutic approach. The book helped to shape the evolving concept of the physician less as a therapist and more as a diagnostician.¹⁵ His frank appraisal of the futility of much of the medical therapy available at the time had the direct beneficial impact of instigating the Rockefeller philanthropic efforts in health.²¹ His comments about drugs were surprisingly strong in tone. Osler felt that "no class of men need friction so much as physicians."^22,23 On occasion he chose to speak out strongly, trying to shake his audience out of its complacency. Although this approach may have contributed to the strength and colour of his comments, it may also have led to some of the controversial episodes in his life.^23,24

The literature of medicine is shaped by the social and intellectual climate of the time in which it is written. The particular content of medical textbooks decays rapidly with the years. To get a truer picture of the merit of a medical textbook, it is important to acknowledge the context of its era. By this criterion, Osler's work deserves its high reputation. In addition, we can still find practical advice in this textbook. Recent Canadian studies have shown an alarming degree of overprescribing by Canadian physicians.^25,26,27 Osler's demand for proof of efficacy before using a medication thus remains relevant to today's medical practice.

Competing interests: None declared.

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Reprint requests to: Dr. David B. Hogan, Department of Medicine, Health Sciences Centre, 3330 Hospital Dr. NW, Calgary AB T2N 4N1; fax 403 283-1089; dhogan@ucalgary.ca

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