At the end of 2019, William Osler’s legacy is stronger than ever; he has been called the “Father of Modern Medicine” and held up as the paragon of the modern physician. In this episode, I’m going to explore the historical Osler — just who was William Osler in the context of rapidly changing scientific medicine at the dawn of the 20th century, and how did he become so influential? But I’m also going to explore Osler the myth — what does the 21st century obsession with the man say about us, a century after his death?
- Bliss M, William Osler: A Life in Medicine.
- Bryan CS, Osler goes viral: “The Fixed Period” revisited, Proc (Bayl Univ Med Cent). 2018 Oct; 31(4): 550–553.
- Cooper B, Osler’s role in defining the third corpuscle, or “blood plates”, Proc (Bayl Univ Med Cent). 2005 Oct; 18(4): 376–378.
- Davis E, Vaginismus, The medical news, 1884. Retrieved online from: https://archive.org/details/medicalnews45philuoft/page/672
- Flint AF, A Treatise on the Principles and Practice of Medicine. Retrieved from: https://books.google.com/books?id=1mvmA1ajwfUC&printsec=frontcover&source=gbs_ge_summary_r&cad=0#v=onepage&q&f=false
- Justin MS, “The Entry of Women into Medicine in America: Education and Obstacles 1847-1910”. Retrieved from: https://www.hws.edu/about/blackwell/articles/womenmedicine.aspx
- Ludmerer KM, Cultural origins of residency training, OUP Blog, retrieved from https://blog.oup.com/2015/05/cultural-origins-residency-training/.
- Ludmerer KM, Learning to Heal: The Development of American Medical Education (New York: Basic, 1985).
- National Library of Medicine, The William Osler Papers, retrieved from: https://profiles.nlm.nih.gov/spotlight/gf/feature/biographical-overview
- Osler W, Aequanamitas. Retrieved from: https://medicalarchives.jhmi.edu:8443/osler/aequessay.htm
- Osler W, An Alabama Student and Other Biographical Essays, retrieved from: https://medicalarchives.jhmi.edu:8443/osler/alabacontents.htm
- Periyakoil VS, What Would Osler Do? J Palliat Med. 2013 Feb; 16(2): 118–119.
- Rezaie S, From Hippocrates to Osler to FOAM, retrieved from: https://rebelem.com/hippocrates-osler-foam/.
- Sokol D, Doctors: use social media with restraint, STAT 2019 Jun 10. Retrieved from: https://www.statnews.com/2019/06/10/doctors-social-media-restraint/
- Warner JH, The Therapeutic Perspective: Medical Practice, Knowledge, and Identity in America, 1783-1784.
Please note that this transcript is made from the editorial copy and is different than the broadcast version.
This is Adam Rodman, and you’re listening to Bedside Rounds, a monthly podcast on the weird, wonderful, and intensely human stories that have shaped modern medicine, brought to you in partnership with the American College of Physicians. This episode is called “Hero Worship,” and it’s about a subject I’m perineally asked about — the life and legacy of William Osler, and how we should understand and contextualize him 100 years after his death. Some of you may know I have a sister podcast with the ACP called Origins, available now for resident members of #IMPower. The third episode was about William Osler’s life, and I had a great time going down to Hopkins and talking to people who were still affected by his legacy.
But as someone interested in history and context, a lot of writing about Osler comes up remarkably disappointing. These days, writing about Osler is usually more similar to hagiography than history. He is the “Father of Modern Medicine.” Numerous articles breathlessly speculate on his opinions on any matter, oftentimes contradictory. Daniel Sokol argues that Osler would have been aghast at doctors using social media, while Salim Rezaie (rez-ay) from REBELEM and the REBEL Cast feels that Osler would have embraced the Free and Open Access Medical Education movement. Vyjeyanthi Periyakoil passionately exclaims, “I like to believe that Sir William Osler would have found the magic formula for the ever elusive life-work balance and he would teach it to us all. Osler would work hard to make palliative academia a more faculty-friendly environment. He would insist that educational Relative Value Units (RVUs) be tracked and reimbursed exactly like clinical RVUs so that teaching would never be a gratis effort.” That is, by the way, from a piece called, “What Would Osler Do?” presumably modeled after the Christian phrase and bracelet, “What would Jesus do?”
As someone deeply interested in history and how past contingencies continue to shape and constrain our practice today, these articles really are closer to describing a saint rather than a flesh-and-blood doctor. So in this episode, I want to do two things — the first is to explore the historical William Osler in the context of his own age. Who was Osler, and why was he important in his own time, and how has he influenced ours? And then I want to look at 2019 — why has Osler been sainted? Why do we insist on such hero worship? And what does this say about us? That’s a lot to cover — so let’s get started!
William Osler was born on July 12, 1849 in the tiny village of Bonds Head in Canada West, now Ontario, the son of a minister. His childhood appears to have been happy and unremarkable, though the young Willie was taken up with the microscopy craze that was sweeping the British Empire, and he spent many an afternoon studying pond water. He started his studies at the University of Toronto, where his mentors convinced him to study medicine.
This was a time of great — and exciting — change for North American medicine. The medical world across the Americas at the beginning of the nineteenth century looked very similar to how traditional Western medicine had operated for the past 2,000 years. Both physicians and patients shared a similar understanding of disease — that of an organism in balance, or of “flows” and “blockages” that needed to be relieved. Therapeutics were largely the same as well — bloodletting, purgatives, laxatives, and irritants like blisters of cantharides. Patients were understood to be unique cases — there were largely not specific treatments for specific diseases, but constitutions that needed to be understood, and treatments that might work differently in different climates, different genders, or different ages. By the end of the nineteenth century, a far different model had become dominant — diseases were understood as discrete entities, pathophysiologic in basis; it was understood that many diseases were “self-limited” and that patients often got better on their own with only support from physicians.
Unsurprisingly, many traditional therapeutics had been abandoned, an idea often derided as “therapeutic nihilism.” Oliver Wendell Holmes probably best summed this up this sentiment in his famous quote: “I firmly believe that if the whole materia medica as now used could be sunk to the bottom of the sea, it would be all the better for mankind-and all the worse for the fishes.”
Why the change? The traditional story is of increasing European — and scientific — influence. American physicians increasingly traveled to Europe through the nineteenth century. In the first several decades, Paris was the most popular, and in the Paris Clinical School students would be exposed to a number of heretical ideas: first, that of pathological anatomy, that diseases lived somewhere in the body where they could be detected on autopsy, and living equivalent of that idea, the physical exam, that these same diseases, which were now discrete entities, could be detected by tools and exam maneuvers. The second is the idea of efficacy and medical statistics — that studies could and should be done to actually determine if medical therapeutics worked. I’ve discussed this at great length before on Bedside Rounds, but the classic example is Pierre Louis using his numerical method in bloodletting for pneumonia. The final heretical idea was the “healing power of nature” — that many diseases are self-limited, and rather than try potentially harmful interventions, physicians should support the patient while their body healed themselves, and failing this, ease the pain of the dying.
Later on students would increasingly travel to the German states, the so-called German school, where further iconoclastic ideas were advanced — that laboratory science and microscopy could help define disease even further (and that even the cell, rather than the tissues, were the seat of disease), that new scientific tools like thermometers could come out of the laboratory directly to the bedside, and that new industrial processes could invent a new class of therapeutics unknown to the ancients. And in the German states (and later Empire), a new model of a medical university was starting to come into existence — a model that we’d recognize today, with a high concentration of sick patients, bedside teaching by experienced ward physicians, and the latest in medical science increasingly finding its way on the wards, along with a state apparatus to license and regulate doctors.
So that’s the traditional story, where change in the structure of medicine is driven by increasing skepticism about traditional forms of medicine, increased belief in the healing power of nature leading to less drastic therapeutics, and eventually laboratory science being melded with medicine and providing powerful new diagnostic tools and treatments.
Of course, reality is far more nuanced. Licensing laws were always less drastic in the New World, and a series of sectarians or “irregular” physicians had risen up. These included some that we know today — homeopaths believed that “like cures like” and would prescribe extremely dilute concoctions of substances. Chiropractors believed in a vitalistic theory of energy flow through nerves, where disease could be treated by correcting “subluxations” to relieve blockages. Both homeopathy and chiropractic are running strong in 2019; others have long since died. Samuel Thomson practiced a form of herablism with native American plants; these “Thomsonian” or “Thomsonite” physicians were quite popular in the middle of the 19th century and rejected whole swaths of traditional medicine. Hydropathic physicians felt that they could use warm and cold baths to help drain toxins out of the body. And one of my favorite movements, the Eclectic School, merged traditional medicine and physiology with Thomsonian botany. Fun fact — the last school lasted until 1939 in the US! Many of these defunct sects are still practiced in one way or another by naturopaths to this day.
The sectarian argument for change goes like this — virtually every single alternative therapy preached far more gentle therapies than traditional medicine. Homeopaths essentially gave placebos; chiropractors realigned spines; Thomsonites and Eclectic prescribed herbs, and hydropaths prescribed baths. A regular physician who prescribed drastic amounts of bloodletting and emetics now had to compete with a whole suite of presumably equally efficacious but milder therapies. There’s a finite amount of patient attention and money — it’s no wonder that regular physicians felt an economic pressure to moderate their therapies.
Regardless of the causes, all of this is to say that Osler was entering a period of intense change in North American medicine when he started at the Toronto School of Medicine in 1868. Toronto had not adapted many of the changes coming in from France and Germany, and was in dire financial straits. The school had no money — the disinterested faculty were mostly working in private jobs to make ends meet. And more importantly, there were no patients as the charity hospital had recently closed — again, for lack of funds. Osler quickly transferred to McGill in Montreal, which was in the process of reforming itself in the style of the great Scottish medical University of Edinburgh. Osler excelled in his studies. After graduating in 1872, he traveled to London — a bit unusual for physicians, though as a proud Brit perhaps not surprising — and then Austria and Germany to study for almost a year. Here he was exposed to the latest German methods in pathology and histology, but also medical education, and he had the opportunity to learn from greats like Virchow and Rokitansky.
After returning home, he became the youngest Professor of Medicine that McGill had seen. In particular, he was passionate about anatomy and histology. He began to adopt his frenetic pace of writing that would define his later life. It was during this time that he probably made his most significant scientific contribution — becoming one of the first physicians to see and describe platelets in the blood — what he called blood plates. Red blood cells, as we’ve previously discussed, had been recognized since the 17th century as the major component of blood; white blood cells (or colorless blood corpuscles) were identified in the 18th. But platelets are an order of magnitude smaller. By the 1840s, some microscopists had started to theorize about a “third corpuscle” in blood; you can see an image from the British physician William Addison that shows a platelet and fibrin clot from this period on Twitter. Osler first observed “globoid bodies” during his studies in London, and continued his studies in Germany. When he had returned to McGill, he published, “An Account of Certain Organisms Occurring in the Liquor Sanguinis,” and yes, liquor sanguinis was a normal — and awesome — way to say “blood,” where he described platelets, and a follow up article, where he asserted that these “blood plates” were in fact a fundamental component of blood rather than a bacteria, the third corpuscle.
Osler quickly distinguished himself with his teaching style. Lecturing at McGill and Toronto had largely been comprised of reading notes directly off a sheet of paper, and Osler’s initial lectures, which we still have, largely followed in the same vein. However, he quickly became one of the most popular professors at McGill, largely because of interactive and engaging teaching around anatomy and histology. We need to talk about Osler’s, shall we say, graverobbing, which is usually omitted from popular histories. In order to supply cadavers and interesting specimens for his classes, Osler accepted bodies from so-called resurrectionists. To be clear, this wasn’t that unusual during this time period, but it also was not socially acceptable and led to a spate of reactionary laws. The most famous example is probably Alexis St. Martin, the man who developed a fistula in his stomach from an accidental shotgun discharge, who would help revolutionize our understanding of digestion in his famous experiments with William Beaumont, which I talked about way back in Episode 33. After Alexis died, his family got word that Osler had his eyes on the famous stomach. To combat this, his family intentionally allowed his body to putrefy, and then buried him 8 feet deep in the ground so Osler would not be able to get his hands on him.
Osler was a rising star, and was soon recruited to the University of Pennsylvania, which at the time was the most “modern” American medical university. He continued his teaching and his writing, and was a cofounder of the American Association of Physicians, a professional society that still exists today. But he would not stay long in Philadelphia. The late 1870s and early 1880s were an exciting and energetic time in American medicine. Young physicians were looking to modernize American medical universities on a German model — and suddenly a new class of wealthy philanthropists was flush with cash to help this happen.
Osler was lured away to the thriving port city of Baltimore with the opportunity to not just reform an older institution, but to build a new one from scratch. The wealthy banker Johns Hopkins had recently died, and left his considerable wealth — the largest gift in the US at that time — to founding a new medical school and hospital based on scientific medicine. This opportunity was far too exciting for Osler to turn down, and Osler left the University of Pennsylvania after only 5 years for Baltimore.
At Hopkins, Osler continued to work like an insane person. He rounded on his patients on the medical wards with teams of trainees who would travel far and wide to study with him; he taught medical students and developed new ways of education at the medical school; he continued to write prodigiously; he saw private patients, sometimes traveling days via train and steamship to see some of the most prominent patients in America; and somehow he found time to get married and have a son.
It’s worth spending time on his Hopkins innovations, since these are more or less what his legacy is based on. So let’s take them in pieces to put them in appropriate context. First, his changes to undergraduate medical education. When Osler arrived at Hopkins, the medical school had yet to open — it would take an additional four years to matriculate the first class. This gave Osler and the other founders at Hopkins — the pathologist Welch, the surgeon Halstead, and the gynecologist Kelly — the chance to design a new medical school curricula from scratch. Traditional American medical schools in the nineteenth century were more akin to trade schools. Almost anyone could be admitted after high school, as long as you could pay the course tuition. They were generally not associated with universities, and certainly not with university hospitals. Teaching was largely classroom based, by part-time instructors of varying quality who, like during Osler’s time at Toronto, would supplement their meager teaching income with private practice, though anatomy, and later histology became increasingly studied. Bedside teaching was spotty; in many schools you could complete your education without truly touching a living patient.
Hopkins instituted strict admission requirements to their new medical school — matriculants would need a bachelor’s degree equivalent before starting study. The curriculum was rebuilt in a German model to focus on the latest scientific innovations — courses would focus not only on anatomy and histology but basic sciences, hematology, and bacteriology; no more would anyone memorize the materia medica, or study the classics. Medical school was standardized at four years, which was becoming increasingly common, though many schools were still two. And probably the biggest innovation was the development of clinical clerkships; after a period studying in the classroom, students would leave for the wards where they would “clerk” — essentially performing all the bedside tasks, and learn directly from patients.
The other innovation was that Hopkins was a co-educational institution — it admitted both men and women on an equal footing. Hopkins was not the first formally co-educational institution — the first policy came from the University of Michigan, but Hopkins was certainly the most prominent. Throughout the middle of the 19th century in Europe, more women started to obtain medical training, especially in Switzerland. The British physician Elizabeth Blackwell was the first woman who completed a medical degree in the United States at Geneva Medical College in NY — though her sister was denied admission the next year. Soon after, a women’s only medical college opened in Boston, the first in the US. Spurred by these new graduates and Elizabeth Blackwell’s advocacy, several women apply to start courses at Harvard Medical School in 1850. The faculty voted overwhelmingly to admit them, but the male students protested and the faculty convinced the women to withdraw. Several decades later the mood had changed considerably, and in the late 1860s when Susan Dimock applied to Harvard, she was rejected out of hand, and the university adopted an official no-women policy. The new Johns Hopkins was originally going to deny women admission based on the Harvard model; in fact, they formally asked for the justification for the ban from Harvard’s president, who gave four reasons: “students might fall in love, which could produce disastrous, socially unequal marriages; women would have trouble keeping up with the academic pace and hold up instruction for the men; the stress could prove so severe that the women might fall ill and destroy their chances of good marriages; and finally, a woman’s future was so different from a man’s that there was no point in educating them together.” This would likely have been the end of it, but Hopkins had run out of money to complete the medical school and the university had to fundraise. A group of prominent Baltimore women — unmarried, wealthy, well-educated, and decidedly feminist — came to Hopkins’ assistance. And their biggest demand was that the new medical school would have to admit both men and women equally.
Welch, the pathologist, was famously against women being trained as physicians. Osler’s views were more complicated. He was a progressive and a suffragist — but also felt society had little use for female doctors. In 1885, he gave a speech in which he proclaimed,
|It is useless manufacturing articles for which there is no market, and in Canada the people have not yet reached the condition in which the lady doctor finds a suitable environment y Do not understand from these remarks that I am in any way hostile to the admission of women to our ranks; on the contrary, my sympathies are entirely with them in the attempt to work out the problem as to how far they can succeed in such an arduous profession as that of medicine”
This was in 1885. By 1890 at Hopkins, with half a million dollars on the line, he was more supportive and felt that women physicians could have a role, “‘in hospital practice among women, in penal institutions in which women were prisoners, in charitable institutions in which women were cared for, and in private life when women are to be attended,” though this meant unmarried women; if a woman married she would be expected to stop her training and return home to raise a family. He would later discuss his evolution frankly, “while on principle I am poosed to co-education, guided by the Apocrypha and my preceptor, I was warmly in favour of it particularly when the ladies came forward with half a million dollars,” and when called out on his changing position years later by the Hopkins president he wrote, “We are all for sale, dear Remsen.”
We also know that Osler’s female students respected him despite his views on women physicians — Dorothy Reed, who shares in the eponym for Reed-Sternberg cells, commented how Osler was initially dismissive of her at Hopkins:
‘‘Are you entering the medical school?’’. I managed to gasp out that I intended to. ‘‘Don’t,’’ said he, ‘‘go home.’
But she later consider Osler a friend, “to all of us an unfailing guide, who treated his women students, once they had arrived at Hopkins, with scrupulous integrity”
That’s medical school. Osler also had a huge influence on formalizing post-graduate medical education, what we would today call “residency.” Informal post-graduate training stretched back hundreds of years, and was essentially an apprenticeship. A new graduate would work with an experienced physician for no pay, learning his skills. But the end of the nineteenth century, this was called an “internship” taken from the French word intern, and operated similar to how internships in non-medical fields work (which is why there’s so much confusion about what a medical internship actually is among lay people). In Europe, this had become increasingly formalized, but was still ad hoc in the Americas. Osler developed a formal process, appointing house officers or residents to staff the medical wards. As the name suggests, these residents “lived” in the house, and essentially worked around the clock for anywhere between 2-5 years.
Osler — who himself didn’t marry until the age of 42 — advised his trainees to push off marrying and starting a family. And if they had made the mistake of having children early, his advice was simple:
“What about the wife and babies, if you have them? Leave them. Heavy as are your responsibilities to those nearest and dearest, they are outweighed by the responsibilities to
yourself, to the profession, and to the public . . . Your wife will be glad to bear
her share in the sacrifice you make.”
Even though it’s over 100 years later, I think these words still sound familiar — residency training does have heavy responsibilities and takes an increasing toll of everyone involved, including exhaustion, burnout, and yes, putting off life milestones like marrying, buying a house, and having a family. In fact, one reason that I started working on this episode is because a friend of mine (who wants to not use his name, given that this is still such a sensitive subject), asked me a question for a #AdamAnswers segment — why did Osler hate his family? At this point, I’ve read thousands of pages of Osleria, and I think I can confidently say that Osler most certainly did not hate his family; he was devoted to his wife Grace, and absolutely doted on his son Revere. Osler also loved children in general, and served as a surrogate father both to his nephews and to countless young medical students and physicians.
So I asked my friend — what do you mean? And my friend, a devoted father and husband himself responded, “If he loved his family so much, why did he set up this system that basically makes it impossible to dedicate enough time to your family.”
In order to answer this question — how did Osler set up such a brutal of postgraduate medical education that still affects us all today, we need to understand the cultural context of the 1890s. The labor movement in the US was in its infancy; Samuel Gompers and the American Federation of Labor were organizing and striking, but brutally long working conditions were still the standard, and the five-day workweek wouldn’t exist for several decades more. And there were strict gendered expectations — a man would be expected to solely work, while a woman would be in control of the household and raising children. That partially explains why women physicians would stay unmarried — society could accept a spinster working as a physician, but not a wife.
So when Osler designed the Hopkins residency, the expectations on work would be completely in line with society-at-large. Osler’s ideal career trajectory still gets bandied about: “Study until 25, investigate until 40, profession until 60, at which age I would have him retired on a double allowance,” but unspoken in all of this is that it requires essentially a late 19th century social order, with the work of the home purely placed on women, in order to function; it also explains Osler’s late marriage and child-rearing.
So Osler most certainly did not hate his family — nor did he want anyone else to be denied a family. However, he was a creature of his of his own time and the assumptions that colored it. I think a better question is, why have we in 2019 hewn so closely to a structure that was developed about the same time as street cars and electric lights, that was made long before women were able to vote? Is residency as currently construed really the best way forward in a far different and far more egalitarian society? The answer is clearly a resounding “no,” and it’s a great example of how historical contingencies constraint our ability to look at other ways of doing things, but that’s a conversation for a future episode.
We probably recognize Osler’s influences in education, but during his lifetime, his writing bought him the most influence and wealth. In retrospect, his scientific contributions were minimal beyond describing platelets; Osler was far too interested in histology in a medical world devoted more and more to laboratory science. But he made important contributions in the burgeoning field of internal medicine, and at least 7 eponyms named after him today, including Osler’s nodules, painful areas on the fingertips seen during bacterial endocarditis, and Rendu-Osler-Weber syndrome, or hereditary hemorrhagic telangiectasias. Osler wrote over 1300 medical articles in his career with topics including “infectious diseases like typhoid, malaria, tuberculosis, and pneumonia; heart diseases, cancers, nervous system diseases, Addison’s disease, diabetes,” and that’s just the beginning. By the early 1890s, Osler turned his attention to something that would seem insane to any other man — writing a new medical textbook that included the whole of the newly evolving scientific medicine. Textbooks, or at least some sort of compedia, have existed for thousands of years. The most famous of all time, by the Persian polymath Ibn Sina, the Canon of Medicine, was used for almost a millennium. The late 19th century had seen several attempts at prominent English-language medical textbooks; Austin Flint’s final edition of his textbook was published shortly after his death in 1886. But these books were hardly up to the task of a rapidly changing medicine.
Compare the language on treatment of pneumonia, or acute “acute pneumonitis” as Flint calls it, not fully attributing it to an infectious disease.
He recommends bloodletting, but then expounds:
“The efficiency of this measure as a palliative is due in part to its effect on the general circulation and to the dimunition of the functional labor of the lungs; but the relief can be in part explained by the effect in diminishing congestion of the portal and pulmonary organs not inflamed (the collateral fluxion of Virchow) and also by the effect in lessening the accumulation of blood in the cavities of the right side of the heart”
But if bloodletting is not used other therapies could be used. “These consist of depletion by saline purgatives, and sedative remedies. After the administration of a saline purgative, if the skin be hot and pulse frequent, tartar-emetic or some antimonial preparation may be given as a nauseant sedative.”
Contrast this to Osler’s description of pneumonia: “Pneumonia is a self-limited disease and even under the most unfavorable circumstances it may terminate abruptly and naturally.” He then describes the importance of good nursing, diet, and hydration. “Morgenroth and Levy claim for optochin, a quinine derivative, a specific action on the pneumococcus. It has a well-marked protective action against experimental infection in mice; encouraging, but scarcely good enough results to see the term specific have been reported clinically.” Osler also advocates bloodletting: “To bleed at the very onset in robust, healthy individuals in whom the disease sets in with great intensity and high fever is good practice.”
Flint is still referencing age-old therapies like purgatives and emetics that rely on a traditional Western understanding of disease. His language is formal and stilted. Osler’s text, published only six years later, has a description of pneumonia and its treatments that is recognizable to us. Pneumonia is an infection, and he clearly recognizes that it is self-limited, with good nursing care and nutrition probably being the most important. He is skeptical about therapeutics; he references animal studies, but recognizes that doesn’t necessarily mean they will work in humans. Of course, he still has an affinity for bloodletting.
So it should be no surprise that when Osler’s 1050-page Principles and Practice of Medicine was published in 1892, it was an immediate hit. It would go through eight editions in his lifetime — and eight more after that, until the 1940s, getting translated into a multitude of languages, and making Osler a very rich man. His textbook was even read by the lay public, it was so approachable — something hard to imagine from, say, Harrisons or UptoDate today.
Osler was also a bibliophile, and in particular was interested in medical history. He bought and consumed many rare books through his in Europe, leaving them both to the Maryland medical society and McGill. His work on history is very much in the vein of the late 19th century — great men on a march towards scientific medicine, and historiography would move on fairly rapidly. But Osler certainly provided an impetus to the study of history of medicine in the United States, and Hopkins is still a major center (and in fact, I’m taking a class there right now, so feel free to send me a message if you’re interested). And Osler shared my affection for the traditionally overlooked Pierre Louis; in fact, when he attended a conference in Paris, he hosted a memorial in Montparnasse cemetery and ceremonially laid a bouquet on his grave.
Osler had always believed that elder doctors should step out of the way for the young, and in 1905 he followed his own advice and departed Hopkins for a quasi-retirement as the regius chair of medicine at Oxford. Osler gave a famous departing speech called the Fixed Period, where he opined that most breakthroughs are made by the young: “Take the sum of human achievement in action, in science, in art, in literature—subtract the work of the men above forty, and while we should miss great treasures, even priceless treasures, we would practically be where we are to-day.” More controversially, he felt that professors should retire at the age of 60 so make way for the young — and he made a humorous literary allusion that perhaps they should be chloroformed. The press went crazy with his address: one characteristic headline read, “Osler recommends chloroform at sixty,” and “Oslerize” began to be used as a synonym for “euthanize.” I’ve posted some of these pictures to Twitter if you’re interested.
In any event, Osler settled into a slower pace of life in the last few decades of his life, spending time mentoring students, lecturing, and spending time with his wife and son. Unfortunately, his time in England would end in tragedy — his beloved son Revere was killed in 1917 in World War I; Osler was crushed, and died two years later of pneumonia and empyema.
Understanding the constraints of a less-than-hour long podcast, this is the historical Osler. An important figure to be sure — he helped to import a German model of medical education and research universities to the United States, helped to formalize undergraduate and postgraduate medical education, and set a model of a thoughtful physician to the new field of internal medicine. In fact, Osler would agree with this assessment; in yet another farewell speech, he assessed his time at Hopkins:
“I have had but two ambitions in the profession: first, to make of myself a good clinical physician, to be ranked with the men who have done so much for the profession of this country . . . My second ambition has been to build up a great clinic on Teutonic lines, not on those previously followed here and in England, but on lines which have proved so successful on the Continent, and which have placed the scientific medicine of Germany in the forefront of the world.”
Osler in this sense is certainly important in the history of medicine, but mostly as a bridge between Continental scientific medicine and a newly reforming and flush-with-money American medicine. How did he come, then, to be considered the “Father of Modern Medicine?”
There are a couple of historical reasons. The first is that Osler’s reforms were spread far and wide. In the early 20th century, the Carnegie Foundation sponsored Abraham Flexner, who trained at Hopkins with Osler and the other greats, to produce a report on a reform of the American medical educational system. This Flexner Report, as it’s known now, became the model of the American medical university, and the Hopkins model was adopted throughout the country. As American medicine became increasingly dominant throughout the 20th century, this model was emulated all over the world, greatly expanding Osler’s legacy. It should be noted that Osler actually disagreed with many of Flexner’s ideas — in particular, he was concerned about the increasing focus on laboratory medicine over spending time at the bedside. The second is that Osler was genuinely a kind and supportive man, and many of the people he inspired sought to carry on his legacy. Harvey Cushing, for example, wrote a three volume biography of Osler for which he won a Pulitzer Prize.
But even many generations after his death, Osler continues to be deified. In 1970, the American Osler Society was formed as, “a group of physicians, medical historians, and members of related professions united by the common purpose of keeping alive the memory of William Osler, and keeping its members vigilantly attentive to the lessons found in his life and teachings.” At the ACPs centennial meeting there was a life-size cutout of Osler. More attuned to the needs of younger physicians, the excellent blog CLOSLER by Hopkins wants to move physicians “Closer to Osler.” If you’re in the United States, I suspect you hear his name frequently — maybe in talking about the importance of physical examination, or in having close relationship with his patients, or of bedside rounding. Many of these sentiments are blatantly ahistorical; while his rounds were legendary for his clinical prowess, not nearly as much time was actually spent talking with the patient. As for those exam skills — well, the wards of the late 19th century were filled with poor patients who had no choice but to submit to detailed examinations that upper class patients would never agree to. They also presented much later in their illnesses than any patient does in 2019. And those bedside rounds could have dozens of people in them, all examining a supplicant patient — hardly the model we want to emulate today. The focus on the exam is ahistorical as well — Osler was deeply interested in all sorts of new diagnostics, and made his house staff do urinalyses on all patients. Even that legendary sense of humor would get him deeply in trouble with human resources today — one of his famous “jokes” was mixing up all the medications that a poor nurse had laid out to give patients. Maybe funny to the doctors there — but deeply abusive to the nursing staff.
We are getting into my opinion here, but I think the Osler of 2019 — the Osler we breathlessly speak about, pose next to cardboard cutouts of, write humanistic blog posts about — says more about us than about William Osler. We have some innate need to imagine a mythical time before our current broken system, a time when physicians cared deeply about their patients, when education took the forefront, and time when physicians were erudite bibliophiles and had great senses of humor. Osler himself understood this need. In his famous speech Aequenamitas, he wrote, “It helps a man immensely to be a bit of a hero worshipper, and the stories of the lives of the masters of medicine do much to stimulate our ambition and arouse our sympathies,” though I doubt that he ever saw himself in that role.
The problem is, that time never existed. The Hopkins of Osler’s time was strictly segregated by race. Poor patients largely served for the learning of elite young men (and a few women). Osler would lavish attention to private patients who would pay astronomical fees to see him. Sexism was baked into the system — Osler’s most famous joke article, published under the pseudonym Eggerton Y. Davis, was about “penis captivus.” You can read it in the shownotes if you want; it’s quite gross (and very sexist).
I don’t want us to judge Osler by the standards of 2019; I want to understand his historical context, in which he was certainly an important figure, and mostly a genuinely nice person. But I would argue that Osler’s thesis about hero worship is fundamentally wrong — I think a focus on the lives of the “masters” of medicine focuses us on the wrong things, in particular on an elite history that has excluded vast proportions of the population until very recently. I’ll give an example.
Earlier this year, Brigham and Women’s Hospital in Boston removed 31 portraits of former department heads from an auditorium — including Harvey Cushing — in order to improve efforts at diversity on campus; all 31 were men, and 30 of them were white, in an institution that increasingly reflects the broader society. If you hadn’t heard about this, I’ll let you know that reactions via Twitter and the opinion pages of the Boston Globe were varied and occasionally hyperbolic, with some detractors of the decision accusing the hospital of historical dishonesty, akin to using petroleum jelly to erase Trotsky from Soviet photos.
This is the hero worshipping argument. Looking at the portraits of those great masters, their defenders argue, arouses our sympathy and gives us something to aspire to. Removing them is to ignore that grand history. But really, is the history of Brigham and Women’s tied up in a succession of department heads? A hospital is a complex ecosystem, with its history equally comprising the work of nurses, laboratory technicians, architects — and yes, the patients. A series of portraits is an intentional narrative that we’re crafting, and to pretend otherwise is historical dishonesty.
One of the responses to this is to develop a new pantheon of heroes, more relevant to the modern day. The ACP, for example, had not only a cutout of William Osler, but a cutout of Elizabeth Blackwell, the first female doctor trained in the United States. Maybe what we need is a pantheon of heroes that better represent modern society — a medical Avengers that includes the “Greats” like Hippocrates, Avicenna, and Osler, but also Elizabeth Blackwell, Rebecca Lee Crumpler, the first black woman physician in the US who dedicated her career to treating freed slaves, Ogino Gingko, the first female Japanese obstetrician, or William Anderson Soga, the first black doctor in South Africa… I could go on for a long time here, because the history of medicine involves any number of women and men who broke barriers and “stimulate our ambition and arouse our sympathies.”
But I would argue for something completely different, something that I think would make us all better doctors — a conception of our history not driven by hero worship, but by complex relationships: relationships between doctors, patients, nurses, politicians, popular culture, pharmaceutical companies, scientists — basically all of society. Physicians are not the heroes of this story, but part of a complex web in which we try to make people’s lives better. Men like William Osler are certainly part of this story — but so are the nurses on his wards, the publishers of his textbook, the scandalized public talking about “oslerizing” the elderly, and, importantly, his patients. What would a portrait wall of this sort of history look like? There probably would be a portrait of Harvey Cushing — but also photos of holiday parties and mundane hospital life, portraits of the nursing matrons, the blueprints of the hospital, birth registers from the NICU, od uniforms of “candy stripers,” press coverage of hospital scandals, and maybe even some fine oil paintings of patients who have benefited. .
We are but a small part in a vast historical tapestry dedicated to trying to make our patients’ lives a little bit better. Reminding ourselves of this and having a little humility for the role of the physician, I think, would do much to “arouse of sympathies,” as Osler might put it.
That’s it for the show! This episode has been three years or so in development, but only really took shape over the past several months. I’m familiar with Osler of course — I have a later edition copy of Practice and Principles that I refer to frequently for contemporaneous treatment, and an Alabama Student is a wonderful little biographic essay collection on medical history that I re-read from time to time. But what really inspired me was when I visited Hopkins and talked to physicians of all ages who were still deeply influenced by his legacy. I of course love medical history — and by now you’ve heard me opine about many of the people that I think had a large influence in medicine, like Louis, Farr, Koch, Goldberger, and Bradford Hill. I mean, there’s a common thread here — I’m interested in epistemology and knowledge generation, probably because as a nerdy internist so many of my clinical questions about my patients come down to some version of, “but how do I really know how to best help this person?” But while I’d love to know, for example, how much Pierre Louis was influenced by Laplace, I’ve never wondered what he’d think of RVUs, or work hour restrictions, or the electronic medical record. I mean, I think he’d just have a hard time wrapping his head around the electronic part. ButI realized that for many people, William Osler, almost 100 years dead, is viscerally ALIVE for people. And that I found far more interesting than any mere biography. So let me know what you thought of the episode — I’m thankful to have had a lot of input from both my amazing editorial board and other friends for what can be a very sensitive subject.
And thanks to YOU dear listeners, because the last few months have been very challenging for me. I’ve never been busier in my life, with my full time job actually practicing medicine, the masters class I’m taking at Hopkins, my public speaking, my research, exciting professional developments, and a very active and very adorable 11-month old, all on top of this podcast. I mean, it’s all stuff to be excited about, though sometimes I do think I’ve bit off more than I can chew. So if you’ve sent me an e-mail or Tweet and I haven’t responded, I sincerely apologize! It was not intentional, and please reach out again, because talking to you guys is one of my favorite things!