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Osler Centenary Papers: Osler the clinician and scientist: a personal and historical perspective
  1. Terence Ryan
  1. Green Templeton College, University of Oxford, Oxford, UK
  1. Correspondence to Dr Terence Ryan, Green Templeton College, University of Oxford, Oxford, UK; terence.ryan2020{at}gmail.com

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Introduction

Osler demonstrated two cultures in his practice, in accordance with the conventions of his time: humanity and science. He was aware that ill health is best managed by one who is both ‘a scientist and a humanist in one’. (This was the title of seminars that took place at 13 Norham Gardens Oxford, his former home, to celebrate the Osler centenary. See figure 1.) In terms of humanity, his friendliness was itself therapeutic. As for science, his accurate observations of symptoms in the living, and of signs in both the living and dead, were more numerous. well described and analysed than ever before. Those who state nowadays that there are two separate cultures that do not speak to each other should recall Osler’s last communication to be published in the British Medical Journal: ‘The old humanities and the new science’.1 Here, he complained himself that the culture of humanities in Oxford, while embracing the philosophy of ancient Greeks, was giving too little attention to their contributions to science. Later, CP Snow2 and others such as the American philanthropist John McGovern3 discussed how these two cultures should both be embraced by practicing physicians I will reinterpret these as the ‘attitude of care’ and the ‘technology of care’. Osler was the greatest exponent of both in his time, deserving the claim that he was both a bringer of cheer and a scientist in what he brought to the bedside, rather more than most of his contemporaries.

Figure 1

13 Norham Gardens, built in 1870.

Much has been written about Osler the clinician and it is no longer easy to find something new to say. One such attempt was in a recent article by a contemporary student of ethics and his supervisor in Melbourne, Fiddes and Komesaroff was entitled ‘An emperor unclothed: the virtuous Osler’.4 The main charge that Fiddes and Komesaroff make is that Osler insisted too much on having the dead bodies of his patients available for his postmortem studies. Leach and Coleman in this issue quote Bliss in stating that this was McGill University policy.5 Osler is criticised specifically by Fiddes and Komesaroff for insisting on a postmortem on the Canadian Alexis St Martin whose stomach wound had allowed in-depth studies of gastric juices. That story was one of the most dominant more than 70 years later in my own days of student instruction. Yet one thing is certain: when criticising belief and practice, one must be aware of changes in convention resulting from the passage of time. I cannot imagine any of the medical and surgical professions that later tutored myself, not also going to extreme lengths to obtain such a patient’s stomach for postmortem study. Applying pressure to make the bodies available also reminds me of my days as a houseman in the 1950s when we largely left such persuasion to the head hospital porter but reimbursed him for his successes. To write, as Fiddes and Komesaroff do, that the religions in Osler’s time were clearly not so in favour of asking relatives for the bodies of their loved ones also reminds me that the early 19th century Regius professor of medicine (Kidd), stated not all that long before Osler was born that what was seen under the microscope God would not want you to know.

Time changes people’s perspectives. When I was a student at Worcester College Oxford in 1950, for example, it had only a few years back appointed a medical tutor. He asked the college librarian to purchase some books on science. After a long pause the librarian said: ‘yes you can purchase some books on science, but you cannot put them into my library’. Nowadays, ways to see into the body are numerous and usually by the time of death the body will have been fully explored. Today I sympathise with the view that a postmortem is less essential after every hospital death. I also have doubts now about the hundreds of frogs we used to pith and the class of 100 decerebrate cats that would await us in the pharmacology laboratory in the 1950s. All over Oxford there were displays of pickled body parts and we had not the current possibility of examining such on our lap tops at home. I have similar views on the passage of time when considering the practical jokes that Osler enjoyed. Apple pie beds are rarer now. I am old enough to remember a great uncle making me laugh with some quite cruel practical jokes on visitors. I do not laugh any longer at the comic strip of Desperate Dan slipping on a banana skin.

I was taught in my younger days by family physicians and surgeons, some of whom—like Mallam, Hobson, Cooke and Abernethy—wrote for the student magazine, the Medical School Gazette about their experience of knowing Osler. Later, as a fellow of Green College attending tropical medicine seminars, I sat next to Cicely Williams, the authority on Kwashiorkor (see figure 2). As the only woman she slipped into Osler’s bedside teaching sessions and, perhaps woman-like, fainted at what she heard and saw. Osler believed women should become laboratory members of medicine and did not stop her attending his class. But as she describes it, others did not approve. Beliefs about the place of women in medicine were dissimilar to the thinking and practice of today.

Figure 2

Cicely Williams who identified Kwashiokor.

Osler has also been judged as a therapeutic nihilist. He wrote that ‘one of the first duties of the physician is to advise the masses not to take any medicines’.6 Yet in order to discourage the prescription of the majority of remedies advertised at his time, the BMA published ‘Secret Remedies’.7 It is one of several books that Osler would have read about medicaments with adverse reactions. ‘All are poisons’ he said. With so many medicaments today, it is difficult to judge what it was like with few. When I was a dermatologist in the Royal Army Medical Corps in 1958 the armed services had not yet purchased steroids, but I was still frequently able to prescribe topicals containing lead and mercury, or rarely Fowler’s solution containing arsenic by mouth.

Osler and science

Osler wrote of Science:

A devotion to science, a saturation with its spirit, will give you that most precious of all faculties—a sane, cool reason which enables you to sift the true from the false in life and at the same time keeps you in the van of progress.8

Accurate observation is the first attribute of a scientist. The claim that Osler was one of the greatest physicians of all time was based on his being a writer of a very important and widely distributed textbook The Principles and Practice of Medicine.9 It was based on his accurate observations of many patients both alive and when dead. Becker, remembering Osler’s legacy in the Lancet 100 years after his death, wrote:

Osler sets medicine’s primary task in becoming scientific as confirming and reconfirming the validity of one’s sources for gaining or using knowledge. His textbook cleared out the dead wood to make way for the advent of scientific medicine.10

Osler’s textbook had more observations than any other previous medical text and observing is the first attribute of science. As Osler’s skills evolved in Montreal, he was making advances as a scientist.

The second of Osler’s skills that is most praised and currently the most quoted is as a teacher at the bedside. Today, in an era when care in hospitals and in care homes sometimes is completely lacking, he is perhaps the most quoted when seeking to identify and teach best practice. It is half a century since I learnt from Sir George Pickering, who emulated Osler at the bedside and was another great observer who wished to be thought of as a great scientist. He was the first Regius Professor of Medicine to have research facilities built into his department within the Radcliffe Infirmary. He demanded accurate observation. He was capable of making a hypothesis too, as described above on his thoughts on high blood pressure. Yet when I was responsible for a Christmas pantomime in which he was featured as a scientist with a lesser degree of humanity, he was upset by it.

In 1976, I wrote my publications for the Oxford University senior degree of Doctor of Medicine, on observations on the blood vessels of the skin. I was initially aware of publications by Pickering and his mentor Sir Thomas Lewis. My later book Microvascular Injury 11 turned to Osler to quote from his observations on vasculitis, seen in his patients in Oxfordshire. First, he had commented on what urticaria, purpura and erythema looked like and then on his hypothesis that ‘all are exudative, in which the blood elements—the red blood corpuscles alone, the serum alone or both combined—pass out of the vessels’.12 I was at that time intrigued that the rash could vary in different regions of the body from day to day, the idiosyncrasies of the local vascular constitution and reasons for localisation I believed were more important than the triggers such as immune complexes in determining the patterns of rashes.

Today, we know that contributions to ‘physical’ signs in the skin depend on the molecules manipulated both by epithelia, blood vessels and lymphatic. Osler would have read Unna’s Textbook of Histopathology.13

It discusses these organs, but both Unna and Osler would have been ignorant, just as was I ignorant even in 1976, of 99% of the molecules we now know to be involved in the inflammatory and immunological states we were observing as purpura. These explain the triggers rather than the patterns of disease, and it is the latter that Osler was best at identifying. Similarly, there are not many physicians using a microscope, like Osler in his younger days, who can claim to have seen and recorded the clusters of ‘debris’ which were later identified as platelets,14 or to have been one of the first to see the parasite causing malaria.15

As president of Osler House, the centre for Oxford’s clinical students in 1956, I was engaged with those who thought that Lord Nuffield, who was still alive, was by this time seriously unappreciated (see figure 3). We wrote about it in the Medical School Gazette. It was during a brief period when the Nuffield professors were thinking of giving up training medical students and being a centre for advanced research only. This they debated in our journal. Some students wanted teachers who would cheer them on the rugby field, but this was not the habit of the Nuffield professors. Nuffield himself, as Mr Morris repairing Osler’s cars, had long conversations with Osler. He had a copy of The Principles and Practice of Medicine by his bedside. Later, as chairman of the governing body of the Radcliffe Infirmary, he thought the consultants did too little research and he bought the Radcliffe Observatory so they had a place to do this. He probably knew that Osler in 1917 was rallying support for a new school of medicine in Cardiff and said he had said at that time ‘pick your men … for their enthusiasm and for their work as researchers’.16

Figure 3

Lord Nuffield, October 1938.

The family practitioners later appointed as consultants to the Radcliffe Infirmary were not interested in research. Nuffield therefore created the clinical medical school with Nuffield professors. The story is well known and oft repeated. What is less well known is that on his golf course at Huntercombe, he had Guys and St Thomas’s Hospital consultants as regular visitors, whom he believed were more interested in research. They would tease him as being a hypochondriac when he wanted to discuss unknown causes of disease. One of these, Conybeare, was born in 13 Norham Gardens. Nuffield asked that he be appointed outside assessor to his scheme.

Another of his London based golfers was the anaesthetist Macintosh, whom Nuffield insisted should be appointed as Nuffield professor. All of this occurred within a few years of Osler’s death. Another of the golf course consultants was the doyen of British dermatology, Geoffrey Dowling. His daughter Jane Dowling remembered, even as a mid-90-years olds in recent conversations with myself, the debates on the golf course and the teasing of Nuffield because of his health concerns. She remembers why Guys Hospital was well endowed by Nuffield because of its willingness to do research into the illnesses of Nuffield’s concern. Although Nuffield was indeed a well-known hypochondriac, he was a passionate inventor. He learnt from Osler the passion to advance medicine by research.

Osler and humanity, the role of equanimity and friendliness

What I now find most intriguing is Osler’s views on humaneness. This too has undergone changes with the mores of the times. Interestingly, probably the changes are greatest in very recent years, perhaps the more so because of the contributions of the humanities as a controlling factor in science which, according to Bertrand Russell,17 the Astronomer Royal18 and Townsend19 has a dark side. I would guess that Osler, were he alive today, would wish that there were more controls on science in space or for climate change and even in medicine.

Osler might well be most excited by advances in today’s neurosciences. This has much to do with our recent exploration of the brain’s control of the emotions. I have always found Cannon’s studies of flight and fright or of Selye’s on stress very intriguing. Today’s studies on the limbic system of the brain explain so much about how emotion can cause disease. Osler’s views on science and the control of the emotions was as follows.

The man of science is in a sad quandary today. He cannot but feel that the emotional side to which faith leans makes for all that is bright and joyous in life. Fed on dry husks of facts, the human heart has a hidden want which science cannot supply; as a steady diet it is too strong and meaty, and hinders rather than promotes harmonious mental metabolism … Science is organised knowledge, and knowledge is of things we see. Now the things that are seen are temporal; of the things that are unseen science knows nothing, and has at present no means of knowing anything.20

Magic and religion control the uncharted sphere—the supernatural, the superhuman: science seeks to know the world and through knowing it, to control it.21

Today we know much more how the limbic regions of the brain can control inflammatory processes, and we can credit with evidence a role for the release of endorphins or determining a balance between the vagal and parasympathetic versus the sympathetic nervous system in ‘flight and fright’. Similarly, recent discussions of care refer to a range or spectrum of emotions—sympathy, empathy, compassion, kindness, the preservation of dignity and spiritual beliefs and friendliness with the bringing of cheer.

This brings us back to Osler and his own humanity as a clinician. MacNalty, the Minister of Health in the UK in Osler’s time wrote of him: ‘He advanced the science of medicine, he enriched literature and the humanities: yet individually he had a greater power’.22 This ‘greater power’ was in fact friendship and the bringing of cheer, sympathy, empathy, humaneness, kindness, concern for spiritual beliefs, preservation of dignity, friendliness and the bringing of cheer are part of the spectrum under the control of the limbic system of the brain.23 24 Each one now has a voluminous literature in the field of neuroscience. At one end of the spectrum, we have an inclination to weep and take flight and fright with the patient. This releases epinephrine and stimulates the sympathetic nervous system. At the other end of the spectrum, there is more pleasure with an inclination towards social laughter with its effect one may read about in Dunbar et al 25 and Manninen et al.26 To bring cheer, to take pleasure in, to groom, to give time and to employ mindfulness, yoga and religious contemplation is essentially vagal and parasympathetic balancing and endorphin releasing. This is relevant to Osler’s conduct as a clinician because, contrary to Fiddes and Komesaroff’s argument, equanimity is not a lack of sympathy. Instead, within the spectrum of care it avoids crying with the patient. Osler wrote

Hilarity and good humour, a breezy cheerfulness …help enormously both in the study and in the practice of medicine

It is an unpardonable mistake to go about among patients with a long face.27

Even in the context of terminal care he wrote that we should not depress patients in any way whatsoever.

The science of care itself now applauds the bringing of cheer and the accompanying stimulus to endorphin release leading to laughter. Like mindfulness and yoga, it avoids discomfort and encourages the vagal powers of the parasympathetic system.

When in this centenary year, I have seen First World War films of the bullying of recruits to the armed forces when forcing them to the trenches of the Somme, I see extraordinary effect of esprit de corps—so that they are laughing together before going to their death, clearly partially protected from pain and fear. Dunbar et al 25 demonstrated a rise in pain threshold as a result of social laughter which is similar to esprit de corps. I also think of the role of cheer provided by most of the British Royal Family when making contact with their public and by Prince Harry in the Paralympic Games. I watch chimpanzees on television, who cannot laugh but they can bring good cheer as they practice the grooming of their mates which releases endorphins.MacNalty in emphasising Osler’s friendliness was right. Osler’s power has a scientific explanation: his good cheer released endorphins and stimulated a vagal response. It is my belief that science and humanity in Osler were one. His equanimity prevented him from a practice of care which could have ended in flight or tears. He was a clinician in whom the practice of science and humanity were united. Recent research in Oxford points to friendship as the key to this unification. As Professor RLM Dunbar, from the Department of Experimental Psychology in Oxford has written, following studies of the amygdala as the emotional centre of the brain: “Friendship is the single most important factor influencing our health, well being and happiness."28

References

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Footnotes

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Provenance and peer review Commissioned; externally peer reviewed.

  • Author note Terence Ryan is Emeritus Professor of Dermatology at the University of Oxford and Oxford Brookes University, Emeritus Fellow of Green Templeton College, Oxford, and archivist of the History of Medicine at the home of Sir William Osler at 13 Norham Gardens, Oxford.

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