Osler: The saint of Baltimore

Osler: The saint of Baltimore

He "may have been the greatest clinical teacher of any day, and any country," says the author, in this review of a new biography.

By Sherwin B. Nuland, MD

On a brilliantly clear day in early May 1889, six young physicians and scientists looked on in eager but apprehensive anticipation as the opening ceremonies were held in Baltimore for a new kind of hospital, on which they had staked their careers. Ranging in age from 31 to 39, each of the men was riding the upward arc of a brilliant academic trajectory; each of them had been recruited away from a university position that would have assured him the facilities and the support for a productive career. But each of them wanted more than mere professional success. These rising medical stars were risking a great deal in order to take part in an incompletely formed project that would succeed or fail on the basis of their individual and collective abilities to create a novel and quite independent atmosphere of research, teaching, and patient care. On that spring day, however, the entire enterprise was still only a dream in the minds of its planners.

The Johns Hopkins Hospital and the associated medical school that was to be founded four years later held the promise of launching American medicine on excitingly novel adventures, in which each of the new professors would essentially create from scratch the conditions that he considered ideal for his work and for the development of his specialty. But it also held the threat of failing in a welter of poor planning, pedagogical squabbles, and inadequate financing. Franklin P. Mall in anatomy, John Jacob Abel in pharmacology, Ira Remsen in chemistry, William Welch in pathology, Howard Kelly in gynecology, and William Osler in medicine formed the vanguard of a potential revolution in medical science and education, and they knew it.

They also knew that the entire bubble of fantasy might explode in their faces. Even four years later, when the 33-year-old William Howell joined them to be professor of physiology at the opening of the medical school, a great deal was still uncertain. The only sure thing was the conviction of those who observed them that they were all caught up in what one commentator called "the contagion of excellence."

In spite of a bundle of obstacles—not excluding their own philosophical differences and the inevitable personality clashes that might have undone lesser men—the seven 30-somethings did succeed. Soon they would be the envy of the world. One of the seven would become, as Michael Bliss calls him in his eminently readable new biography, "the high priest of his emerging profession." William Osler is remembered as the greatest clinical teacher of his day; a judgment so universal that it needs no modifying by such trendy adverbs as "arguably." In fact, he may have been the greatest clinical teacher of any day, and any country, too.

Primarily by means of Osler's great textbook, The Principles and Practice of Medicine (which went through 16 editions, the last being published in 1947, 26 years after his death), but also by means of Osler's widely circulated lectures and many published articles, English displaced German as the language of medical discourse, the language that one had to know in order to comprehend the new advances beginning to appear so rapidly near the end of the 19th century. An immensely well-liked man and a catalyst to the accomplishments of others, he became the most sought-after medical speaker in America. He served as president, and often founder, of so many cultural and scientific organizations that even an Osler addict like myself is constantly surprised to come across yet another one not previously known to him.

Bliss writes: "His was a life that stands up almost too well to critical dissection, even microscopic scrutiny. In an age when biographers make their reputation by claiming to have discovered hidden internal derangements in their subjects, this project has been an unusual intellectual autopsy, at times something of a modern biographer's nightmare. Try as I might, I could not find a cause to justify the death of Osler's reputation. He lived a magnificent, epic, important, and more than slightly saintly life."

There is that word: saintly. Does it mean that Bliss has written a hagiography, whether in the classical sense of its being the life of a saint or in its current usage, carrying the implication of memorializing an exemplary subject whose flaws are minor? The answer to both questions is Yes, for William Osler really was a kind of medical saint; and it is reassuring to those of us who have long worshiped at his figurative shrine that no amount of scratching at his holiness has marred the sheen of the halo under which he stands. In fact, thanks to Bliss's uncompromising search, it shines more brightly than ever. Sometimes hagiography is only truth.

Like all saints, Osler was a living, breathing human being before being canonized, and a colorful one at that. He played outrageous practical jokes, invented an alter ego with a bawdy sense of humor, charged enormous fees (but only to the very wealthy among his patients, of whom there were many), was rumored to have fathered an illegitimate child by his cousin, and offended an entire generation by advising, in a widely reported address, that men beyond the age of 60 should be chloroformed until dead.

Bliss tells a good story, and there are plenty of good stories to be recounted, as he follows his peripatetic subject from the backwoods Canadian parsonage where he was born until his death as Sir William Osler, the Regius Professor of Medicine at Oxford and the most famous doctor in the world. In fact, the stories go well beyond Osler's physical death, to the memorializations of his life that have taken various forms over the past eight decades, not neglecting such vignettes as the author's personal experience of the ultimate shrine, in the Osler Library at McGill: "I was working on this biography in the Osler Library, sitting at Osler's desk, one day in September 1997, when a freshman student at McGill quietly slipped into the inner sanctum and, in an act of secular worship, placed at the foot of the Osler plaque a bouquet of flowers and a card asking for Osler's blessing."

The decade of the 1880s was perhaps the most exciting brief period that had ever occurred in the 2,300-year history of Western medicine. The germ theory of Louis Pasteur, Robert Koch, and Joseph Lister gained acceptance during that time, and one disease after another was shown to be caused by some specific organism. Medical thinking was transformed. William Osler was one of very few men on this continent equipped fully to comprehend the magnitude of the changes about to take place in research and later in practice. His unique expertness with the microscope, his studies with leading scientists in Vienna and Berlin, his focus on the study of pathological tissues as guides to the understanding of disease processes, his youthful energies and enthusiasms: All of these combined to guarantee that the new discoveries so rapidly emerging from European laboratories would find practical use in his hands, not only in the study of sickness but also in the teaching of students.

In 1884 the medical school of the University of Pennsylvania, America's oldest and one of its best, called Osler to the chair of medicine. Osler's departure was a devastating blow to McGill. Their finest teacher was escorted to the train station by the entire student body. He was on his way to the next phase of the journey that would lead inevitably to Baltimore. The geographic progression southward was partnered with the academic progression upward.

In Philadelphia, Osler gave free rein to his determination that autopsy and microscopic study were the keys to understanding the evolution of disease. He conducted so many postmortem examinations that complaints inevitably arose about what must have been his sometimes cavalier attitude about permissions and the formal protocols required by the hospital authorities. Even in the flood of new scientific information he was discovering, however, Osler never neglected the humanity of his patients. The medical statistics and massing of cases into groups that were necessary to elucidate clinical conditions did not mislead him into forgetting the distinctiveness of each person who came under his care.

In 1886, Osler wrote of the necessity that a doctor have a profound knowledge of human nature, and stressed "the careful consideration which is given to every circumstance in the life and condition of the individual." Two years later, thinking about a visit he had just made to his famous patient Walt Whitman, he penned a note in his commonplace book: "A doctor does not treat typhoid fever, but he treats the man with typhoid, and it is the man with his peculiarities—his bodily idiosyncrasies we have to consider." These were themes that Osler would reiterate for the rest of his life.

Osler was doing clinical research, writing journal articles, taking on a huge load of teaching, and lecturing to his medical colleagues in Philadelphia and elsewhere. In 1884, he was invited to London to follow centuries of distinguished British physicians by giving the Goulstonian Lectures, choosing to describe the pathological and clinical findings in 200 cases of endocarditis and the role of bacteria in the disease. He described the inflammation that occurs in the inner lining membrane and valves of the heart and the streptococcal, staphylococcal, or other bacterial invaders that cause it. The three lectures were characteristic of Osler's approach in all his research writings: detailed clinical and pathological descriptions of distinct disease processes so accurate and so lucid that even in later years they could barely be improved upon. Osler would never become known for presenting grand conceptual notions or overriding theories of disease. His great gift was the presentation of material so finely and comprehensively observed that it was of enormous value to bedside physicians, pathologists, and even students.

But even all of those obligations did not consume his vast energies. Handsome and witty, the young bachelor became a favorite at Philadelphia social evenings. And he never could resist an opportunity to tease anyone in his vicinity. As the usually stern Hopkins nurse, Miss Nutting, put it after he grabbed a grapefruit off a basket one day and bowled it down a hospital hallway, "It was Dr. Osler, you know, and his behavior cannot be predicted."

Osler traveled frequently during the Philadelphia years, either to visit other hospitals and schools, to lecture, or to see patients in his rapidly expanding consultation practice; he was setting a pattern that would never be abandoned, though it did lessen considerably during his last years at Oxford. In 1886, he went to Baltimore to visit the campus of the new Johns Hopkins University. "It is the university of the future," Osler wrote to an Ontario friend, "& when the Medical school is organized all others will be distanced in the country." At that time, rumors were already flying around Philadelphia that their best medical teacher was soon to be offered the chair at Hopkins. The rumors were well founded. Osler traveled to Baltimore in September 1888 to accept the appointment.

And so the heady days began. The next 16 years would be a period of immense productivity, during which the Hopkins experiment was successful beyond even Osler's predictions. And so was he. His international fame grew, his clinical research flourished, and he was more popular a teacher than ever, if it is possible to imagine such a thing. The atmosphere of joy that he brought to everything he did, and the sense of high purpose that he conveyed, infected students with a love of medicine and an appreciation for the nobility of the calling they had chosen.

Osler introduced a number of pedagogical innovations, the most important and enduring of which was to bring students out of the lecture halls and on to the wards, as so-called clinical clerks, partners in the care of the sick. He called this "the natural method" of teaching. It had never been attempted in an American hospital, and it became the precedent upon which every teaching service would thereafter be based. Its purpose was clearly stated by Osler: "The student begins with the patient, continues with the patient, and ends with the patient. . . . [T]each him how to observe, give him plenty of facts to observe, and the lessons will come out of the facts themselves. . . . [T]he best teaching is that taught by the patient himself."

In 1890 Osler married the 37-year-old Grace Revere Gross, the widow of a prominent Philadelphia surgeon and a direct descendant of the famous Revolutionary War courier. A son born nine months almost to the day after their wedding died shortly after birth, but within two years Mrs. Osler had given birth to a boy they named Revere, who would become the adored only child of his parents as they aged.

By the turn of the century, Osler's various sources of income—salary, book royalties, and consultation fees—were bringing him a huge income, in 1903 amounting to $47,000, or $1.4 million in today's money, some $9,000 of which he gave away. But the huge prosperity was coming at a huge price. His patients included the president, members of the cabinet, and many public officials and wealthy men and women, and such consultations often demanded travel over considerable distances. Between these and his visits to various medical facilities and universities he was out of town 33 times in 1901.

He began to complain about the pressures of it all. This was the busiest period of his life, and even his seemingly limitless energies were being severely tested: "The racket of my present life is too much for me. I am going downhill physically and mentally."

When a letter arrived in June 1904 inviting Osler to become the Regius Professor of Medicine at Oxford, a position whose responsibilities were largely honorary, he gave it serious consideration. But Grace, who had become increasingly concerned about her husband's overwork, did more than that. She was determined that he should accept, and right away. On May 19, 1905, the Oslers sailed for England, and what was meant to serve as semiretirement for the 56-year-old Chief.

Oxford proved to be all that was hoped for, though there was still plenty of demand for consultations, and the writing and the speech-making continued unabated; and there were too many meetings to attend. But the Regius professorship proved a welcome relief from the unsustainable burdens of Baltimore. There was much more time for the beloved books and for the history of medicine, which Osler now began to study avidly after many years of intermittent attention.

The rewards for all the years of dedication began to pour in. The baronetcy conferred in 1911 was the highest of the honors, but offers of memberships, degrees, and presidencies aplenty came Osler's way. The applause never seemed to die down. The Oslers' home in Oxford was the center, as it had been in Baltimore, of a constant celebration of life. They watched in awe as Revere, at first a callow and unambitious youth, began to develop into a serious young man dedicated to books and devoted to his father. Willie and Grace loved England, and the years seemed charmed.

And then the lamps went out all over Europe. On Aug. 14, 1914, Great Britain went to war. Less than six months later, Revere joined the army. The carnage of the war was beyond anyone's imagination. Scarcely a family among the Oslers' acquaintance had not lost a son or sons, and the house was always full of Oxford men recovering from wounds. After Revere returned to the front, Grace wrote to a friend: "It broke my heart to look at him & to think I may never see him again—One stroke and all may be over." The stroke came on Aug. 29, 1917. Revere was hit by shrapnel and died a few hours later, after surgery in an attempt to stop internal bleeding.

The enchanted life of the Oslers was over. "We have been preparing for the blow," Osler wrote to the surgeon Harvey Cushing, who had been with Revere at the end. "I felt sure the fates would hit me through him. I have escaped all these years without a great sorrow, and have had so much in life, so much more, really, than I have deserved that I have all along felt we could not escape. . . . Poor Grace! It hit her hard; but we are both going to be brave, and take up what is left of life as though he were with us." They faced their loss with courage, at least externally, but Osler was a broken man. Another year passed before a semblance of normality returned to their lives, and even then they lived with the awareness that everything had changed, and their happiness would never return.

Seasonal upper-respiratory infections that had plagued Osler over the course of many years now began to be more common, and harder to shake off. He returned from a visit to Edinburgh in late September 1920 with the beginnings of what appeared to be influenza, and his condition gradually worsened during the next few weeks. He developed pneumonia and then pleurisy, and after a time it became obvious that there was pus in his chest cavity. He suffered through several weeks of pain, needling of his chest, and finally a small operation done in his bed, in an attempt to remove the pus. But nothing helped. On the afternoon of Dec. 29, he died following an intestinal hemorrhage. True to form, he had requested an autopsy, which was done in his own home on the following day. Bliss tells us that "Osler had said that he wished he could be present, having taken such a lifelong interest in the case."

Osler was dead, but Osler lived on. Although the numbers are now becoming small, medical students and grizzled physicians still occasionally seek inspiration by reading the many essays that he wrote on the medical life. Some are dated, but others are as fresh as the day he put pen to paper. Among many examples that may be quoted is the following, from an address to students at the University of Toronto in 1903:

"To you the silent workers of the ranks, in villages and country districts, in the slums of our large cities, in the mining camps and factory towns, in the homes of the rich, and in the hovels of the poor, to you is given the harder task of illustrating with your lives the Hippocratic standards of Learning, of Sagacity, of Humanity, and of Probity. Of learning, that you may apply in your practice the best that is known in our art, and that with the increase in your knowledge there may be an increase in that priceless endowment of sagacity, so that to all, everywhere, skilled succour may come in the hour of need. Of a humanity, that will show in your daily life tenderness and consideration to the weak, infinite pity to the suffering, and broad charity to all. Of a probity, that will make you under all circumstances true to yourselves, true to your high calling, and true to your fellow man."

William Osler is a fascinating man whom we need nowadays. In this time of cynicism, it is good to know that the earth can be inherited by those who have faith and trust in the improvability if not the perfectibility of humankind; in this time of bioethical conundrums, it is good to know that patience, goodwill, and personal morality will untie far more intellectual knots than the disarray of rancor, conflict, and special interests; in this time of great medical miracles it is good, and properly humbling too, to know that there have been other periods of miracles, and yet the ancient problems of health and human happiness remain, bringing new challenges to each succeeding generation. William Osler's life and his writings tell us of these things, but they are beginning to fade from the experience of all but a few men and women who seek them out. They need to be revived, and he needs to be heard again.

The author, a general surgeon, teaches at Yale University in New Haven, CT.

This is an excerpt from a review of William Osler: A Life in Medicine, by Michael Bliss (Oxford University Press, 581 pp., $35). Reprinted by permission of THE NEW REPUBLIC, © 1999, The New Republic, Inc.

 

Carol Pincus, ed. Sherwin Nuland. Osler: The saint of Baltimore. Medical Economics 2000;8:137.