The Wisdom of Sir William Osier Marvin J. Stone, MD

William Osier (1849-1919) was generally regarded as the greatest and most respected physician of his time. He is still considered by many in these terms. Others have questioned the relevance of Osler's teachings in recent years. This paper describes Osler's lifo and gives his philosophy and views in his own words. An out- standing clinician who emphasized bedside teaching and observation, he possessed extraordinary charm that inspired many disciples. As Professor of Medicine at 4 institutions in 3 countries, he exerted a profound influence on medical education. He was a prolific writer and his textbook became the most papular and wide-

ly read treatise on medicine in the wodd. He also was a medical historian, a classical scholar, and an avid bibliophile. He emphasized the value of hard work and ongoing education. His compassion and concern for patients and colleagues reflected his personality. Osler's wisdom is as relevant now as in his era. It is likely that he would be in the forefront of medical science if he were alive today. Osier blended the art and s~ience of medicine perhaps better than anyone else and remains a valuable role model for students and physicians more than 75 years after his death.

(Am J Cardiol 1995;75:269-276)

l lhe year 1994 marked the 75th anniversary of Sir William Osler's death. Osier occupies a umque posi-

tion in the hmtory of medicine. He was generally acknowledged as the greatest and best-loved physician of has time. 1-4 Many of Osler's writings 5-13 have msptred and been cherished by medical students and physicians throughout the world. His close personal relationship w]th students and colleagues has been amply docu- mented. 14-17 Commemorative issues of several journals have appeared in his honor, J8-2° a number of b~bliogra- phles of Ins writings have been pubhshed, 21-24 and his ltkeness has been preserved on many portraits, busts, and medals. 25 The Osier Society of McGdl Unwerslty was founded m 1921, the Osier Club of London m 1928, and the American Osier Society in 1970. 26,27 Recently, an organizaUon honoring Osler's memory was estabhshed m Japan. In May 1994, a joint meeting of the American Osier Society and the Osier Club of London was held m the Umted Kingdom

What are the reasons for the enormous and enduring influence of this man? I wdl try to address this quesUon in 2 ways: fist, by providing a brief description of his hfe; and second, by letting Osier speak for himself.

In 1889 Osier gave the valedictory address to grad- uates m medicme at The University of Pennsylvania. His speech became the title essay m the book, Aequammt- tas wtth Other Addresses to Medwal Students, Nurses and Practztloners of Medwme, 5 which has been revered by generaUons of medical students and phys]clans.

Equammlty has been defined as evenness of mind or calmness. Synonyms include composure and self-pos- session.

"In the physician or surgeon no quahty takes rank with lmperturbablhty-28

"One of the fist essentials in secunng a good-natured equanlrmty is not to expect too much of the people amongst whom you dwell. ''29

From the Departments of Internal Medicine and Oncology and the Charles A Sammons Cancer Center, Baylor University Medical Cen- let, Dallas, Texas Manuscnpt rec)eved and accepted October 6, 1994

Address for repr)nts MarvmJ Stone, MD, Baylor Unlvers)t',/Med- ical Center, 3500 Gaston Avenue, Dallas, Texas 75246

Sixteen years later Osier stud, "I have had three per- sonal 1deals. One, to do the day's work well and not to bother about tomorrow... The second ideal has been to act the Golden Rule, as far as m me lay, towards my pro- fesslonal brethren and towards the patients committed to my care. And the third has been to cultivate such a mea- sure of equanimity as would enable me to bear success with humlhty, the affection of my friends without pride, and to be ready when the day of sorrow and grief came to meet it with the courage befitting a man. ''3°

William Osier was born in Bond Head near Toronto m 1849. 31,32 His mother lived past the age of 100 years; his father was an Anghcan clergyman. William attend- ed private school where he met Reverend W. A. John- son, who introduced him to biology and the microscope This interest m m~croscopy was to become one of the dominant features of h~s career. He enrolled in Trinity College at Toronto and originally planned to follow his father into the clergy. After being influenced by a physi- cian, Dr. James Bovell, Osier switched to medicine. 33 He transferred to McGill for his final 2 years of medical school. There he came in contact with the famous clin- ician and teacher, R. Palmer Howard. Johnson, Bovell, and Howard were the 3 teachers to whom Osier later dedicated his textbook. He recewed his MD degree m 1872 and then traveled to England and Continental Europe. Osler's experience abroad made him a propo- nent of postgraduate travel. His trip was the fist of what later became known as "bram-dustmg excursions." He spent a year in Burdon-Sanderson's laboratory m Eng- land, during which time he became one of the first to recogmze the platelet as the third formed element in the blood and documented the importance of platelets in thrombus formation. 34 He also visited Germany and came m brief contact with the great Rudolph Virchow. On returning to Canada, he worked briefly as a general practitioner A few months later, he was invited to join the medical faculty at McGII1.

His views on travel are exemplified by the followmg statements: "The all-important matter is to get a breadth of view as early as possible, and this is dlflicult without travel. ''35

"To walk the wards of Guy's or St. Bartholomew's, to see the work at the St. Louis and at the Salp&n~re,

HISTORICAL STUDIES/THE WISDOM OF SIR WILLIAM OSLER 269

to put in a few quiet months of study at one of the Ger- man university towns will store the young man's mind with priceless treasures. I assume that he has a mind. I am not heedless of the truth of the sharp taunt-- How much the fool that hath been sent to Rome, Exceeds the fool that hath been kept at home. ''36

"At any rate, whether he goes abroad or not, let him early escape from the besetting sin of the young physi- cian, Chauvmtsm, that intolerant attitude of mind, which brooks no regard for anything outside his own circle and his own school. ''36

Dunng his 10 years on the McGlll faculty (1874--1884), Osier rose to the rank of professor He was recognized as an outstanding clinician and stimulating teacher. He also served as pathologist to a smallpox hos- pital, had a small private practice, and pubhshed many papers dealing with various chnical, pathologic, and vet- erinary subjects. Dunng this decade, Osier orgamzed medical clubs and achieved unusual popularity engen- dered by his exemplary conduct and generosity.

Osier performed nearly 1,000 autopsies; this experi- ence, combined with his knowledge of microscopy, made him well grounded in morbid anatomy and contributed much to his understanding of the natural history of dis- ease and importance of chnlcopathologlc correla- tion. 37,38

FIGURE 1. William Osier in 1905. From a photograph by William Nolman, Montreal. Reproduced from A b b o t t ME, ed. Sir William Osier Memorial Number. Appreciations and Remi- niscences. Bulletin No. IX of the International Association of Medical Museums. Privately printed at 836 University St., Mon- treal, Canada; 1926:320. 4

Af ter 4 years at the University of Pennsylvania as Professor of Chnical Medicine, Osier became Chief of Medicine at the new Johns Hopkins Hospital and med- ical school where he remamed from 1889 to 1905 (Fig- ure 1).

Dr. Robert B. Bean, the father of Dr. William B. Bean, was a student of Osler's at The Johns Hopkins between 1903 and 1905. The younger Dr Bean, a renowned Oslerlan Scholar, complied numerous epi- grams of Osier from Ins father's notes. 39,40 Many of Osler's clinical aphorisms collected by Dr. Bean and oth- ers still nng true:

"Medicine is learned by the bedside and not in the clas sroom."41

"In taking histories follow each line of thought; ask no leading questions; never suggest. Give the patient's

• " - ,42 own words m the complaint. "Record what you have seen; make a note at the time;

do not walt -43 "Half of us are blind, few of us feel, and we are all

deaf."4z "Pneumoma is the captam of the men of death and

tuberculosis is the handmaid. ''45 "A patient with a written list of symptoms--neuras-

thenia. ''46 "Adhesions are the refuge of the diagnosUcally des-

titute -47 "There is no disease more conducive to clinical

humility than aneurysm of the aorta. ''48 "One swallow does not make a summer, but one

tophus makes gout and one crescent malaria. ''48 "Angina pectorls may be precipitated by: muscular

exertion, violent mental states, stomach upsets, or cold weather. ''45

"A physician who treats himself has a fool for a patient. ''49

"The chief function of the consultant is to make a rectal examination that you have omitted. ''5°

"Advice Is sought to confirm a position already tak- en."51

Osier was instrumental m estabhshmg The Johns Hopkins as the outstandmg restitution of medical edu- cation m the United States. 52-55 He helped start the new school and was 1 of 4 doctors commemorated in the famous Sargent portrait. 56 He introduced the clinical clerkship and created the template of graded responsi- bility among students and house officers that survwes to the present. 54,55 He stressed the importance of medical history and wrote many inspirational essays.

Dunng his tenure at Hopkms, Osier acqutred an mtematlonal reputation and became one of the most respected chnlclans in the world (Figure 2).

"The practice of medicine is an art, based on sci- ence."57

"Variability is the law of life, and as no two faces are the same, so no two bodies are alike, and no two indi- viduals react alike and behave ahke under the abnormal conditions which we know as disease -58

"Start out with the conviction that absolute truth is hard to reach in matters relating to our fellow creatures, healthy or diseased, that slips m observation are inevitable even with the best-trained faculties, that errors

270 THE AMERICAN JOURNAL OF CARDIOLOGY ~ VOL 75 FEB 1, 1995

in judgn tent must occur m the practice of an art which consists largely in balancing probabilities. "'59

"We the doctors, are so falhble, ever beset with the common and fatal facdity of reaching conclusions from superficial observations, and constantly misled by the ease w~t h which our mmds fall into the ruts of one or two experiences. ''6°

"The Art of Detachment, the Vtrtue of Method, and the Quahty of Thoroughness may make you students, m the true sense of the word, successful practitioners, or even great investigators; but your characters may still lack that which can alone give permanence to powers-- the Grace of Humdtty-6]

In 1892, Osler pubhshed the first edition of his text- book, The Princzples and Practtce of Medtcine, which became the leading treatise on general medicine in the world for the next 40 years. 62-69 He personally revised the book through 7 ediUons

Two quotations appear m the front of the book: "Experience is fallacious and judgment difficult" Hip- pocrates

"And I said of medicine, that this is an art which con- siders the const]tuuon of the patient, and has prmclples of acUon and reasons in each case" Plato.

The enormous influence and popularity of the text- book were evident from its sales and its translation into French, German, Spamsh, and Chinese editions. It also was indirectly responsible for the formation of the Rock- efeller InsUtute for Medical Research. 65,67,69,70 The text- book emphasized euology, pathogenesls, and dmgnosis, and reflected Osler's great clmical and morphologic knowledge. It was said that Osier "succeeded in making a sc]enufic treatise literature." However, he became known as a therapeutic nihd]st. 65,71 On balance, one should recall that not many effectwe medical treatments existed m the latter part of the 19th century.

"But know also, man has an mborn craving for med- icine. Heroic dosing for several generalaons has gwen his Ussues athtrst for drugs. The destre to take medicine is one feature which distinguishes man, the ammal, from his fellow creatures. ''72

"Remember how much you do not know. Do not pour strange medicines into your patients -73

"Do not rashly use every new product of which the penpateUc siren smgs. Consider what surprising reac- tions may occur m the laboratory from the careless mix- mg of l mknown substances. Be as considerate of your patient and yourself as you are of the test-tube. ''73

"The young physicmn starts hfe with twenty drugs for each disease, and the old physician ends life with one drug for twenty diseases. ''74

Osler's philosophy of medical education might be best dlustrated by a passage from his farewell address to The Johns Hopkins Hospital m 1905. 75

"By far the greatest work of the Johns Hopkins Hos- pital has been the demonstraUon to the profession of the Umted States and to the pubhc of this country of how medical students should be instructed m thetr art. I place it first because it was the most needed lesson, I place it first because ~t has done the most good as a stimulating example, and I place it first because never before m the history of this country have medical students hved and

worked in a hospital as part of its machinery, as an essen- tml part of the work of the wards. In saying this, Heav- en forbid that I should obliquely disparage the good and faithful work of my colleagues elsewhere. But the amphitheater clinic, the ward and dispensary classes, are but bastard substitutes for a system which makes the medical student hmaself help in the work of the hospi- tal as part of Its human machinery. He does not see the pneumoma case m the amphitheater from the benches, but he follows it day by day, hour by hour; he has tus Ume arranged so that he can follow it; he sees and stud- ]es similar cases and the disease itself becomes his chief teacher, and he knows its phases and variations as depict- ed in the lwing, he learns under skdled direction when to act and when to refrain, he learns insensibly pnncl- pies of practice and he possibly escapes a "nickel-in-the- slot" attitude of mind which has been the curse of the physician m the treatment of disease. And the same with other branches of his art; he gets a first hand knowledge, which, if he has any sense, may make him wise unto the salvation of his fellows. And all this has come about through the wise provision that the hospital was to be part of the medical school, and it has become for the

. . . . ' , ~ , ~ m ' ~ ' ,

FIGURE 2. Osier at the bedside. Snaps.hob taken by T. W. Clarke. Reproduced from Cushing H. The Life of Sir William Osier, Volume 1. Oxford: Claren~don Press, 1925:552.1

HISTORICAL STUDIES/THE WISDOM OF SIR WILLIAM OSLER 271

senior students, as it should be, their college Moreover they are not in it upon sufferance and admitted through side-doors, but they are welcomed as important aids without which the work could not be done efficiently The whole question of the practical education of the medical student is one in which the public is vitally inter- ested. Sane, intelligent physicians and surgeons with cul- ture, science, and art, are worth much in a community, and they are worth paying for in rich endowments of our medical schools and hospitals. Personally, there is noth- ing in life in which I take greater pride than m my con- nection with the organization of the medical clinic of the Johns Hopkins Hospital and with the introduction of the old-fashioned methods of practical mstruction I desire no other epitaph--no hurry about it, I may say--than the statement that I taught medical students m the wards, as I regard this as by far the most useful and important work I have been called upon to do."

Grace Revere Osler was the great granddaughter of Paul Revere and the widow of Osler's friend, Doctor Samuel W. Gross, the Philadelphia surgeon who helped recruit Osier to the University of Pennsylvania. 76-79 Grace and William were mamed in May 1892, shortly after publication of the first edition of the textbook They had 2 children, Paul Revere who survived only briefly, and in 1895, Edward Revere

When Osier was appointed Regius Professor of Med- icine at Oxford, he was busy with professional activities and testimonial d iners . He departed for England in advance of his family, leaving Grace to oversee the pack- ing and shipping of their household goods and books. She remarked, "Wilhe's motto may well be Aequanim- ltas because he always files when things like this are going on. ''77

Osier left Baltimore m 1905 to assume his new posi- tion at Oxford where he lived the remainder of his life. 8°,81 He thought that Oxford would offer a more relaxmg atmosphere so that he could retire gradually, but he was soon as busy as he had been m Baltimore. 31 The Osier home at 13 Norham Gardens became known as the "Open Arms" to students, colleagues, and friends. Osier con- tmued to found medical organizations and journals. In the pattern of Virchow, Osler vigorously supported pub- lic health and sanitary measures He contmued clinical teaching, collected books, published papers, and prac- ticed medicine. 81-83 He was kmghted in 1911. The tragedy of his hfe occurred m 1917 when his son, Edward was lolled m Flanders m World War I. Osler never recovered from this loss, and m 1919, he developed pneumonia and died on December 29th. 84 His last formal presentation was the inaugural address as President of the British Clas- sical Association 6 months before his death. 85

Lady Osler selected Doctor Harvey Cushmg to write her husband's biography after reading Cushing's tribute to Osler in January 1920. 86,87 It began: "in the first shock of grief at the news of Sir William Osler's death it is dif- ficult for anyone who felt close to hun to say what is in his heart And the strange thing about this unusually gift- ed and versatde man is that everyone fortunate enough to have been brought in contact with him shares in this feehng of devotion, for he gave of himself much to all

This was true of his patients as might be expected, and he was sought far and wide not only because of his wide knowledge of medicine and great wisdom, but because of his generosity, sympathy and great personal charm. It was true als(y--and this is more rare--of the members of his profession, for whom, tugh or low, he showed a spirit of brotherly helpfulness untlnctured by those pet- ty jealousies which sometimes mar these relationships. Never believe what a patient may tell you to the detri- ment of another physician--even though you may fear it is true, was one of his sayings to students. He was pre- emmently the physician to physicians ~md their families, and would go out of his way unsolicited and unspanng- ly to help them when he learned that they were 111 or m distress of any kind."

Harvey Cushing was a me&cal immortal in his own right. 86,88 The father of neurosurgery, he was the man about whom Osier said, "[he] had opened the book of surgery in a new place." They had been long-time friends and next-door neighbors m Baltimore Cushing was one of Edward Revere Osler's physicians after he was wounded in World War 1 89 When Osler's wife asked Cushing to write the biography, he accepted, but planned to spend only a year. It took 5 years Notably, Cushing omitted himself from the book Cushmg's Ltfe of Osier won the Pulitzer Prize in 1926 1

A prolific writer, Osler had approximately 1,500 items in 24 his bibliography. His first publication dealt with the microscope.9°His important origmal observa- tions on blood platelets were made in 1873 when he was 24 years old. Nearly one third of his scientific papers dealt with cardiovascular disease, particularly infective endocarditis. 91.92 He described hereditary hemorrhagic telangiectasia (Osler-Weber-Rendu disease) 93 and wrote an excellent clinical description of polycythemia vera (Osler-Vaquez disease). 94 Osler's clinical mvestigatlve and research background provided him with an insight- ful perspective:

"By the historical method alone can many problems in medicine be approached profitably. ''95

"The philosophies of one age have become the absur- dities of the next, and the foohshness of yesterday has become the wisdom of tomorrow. ''96

'q'he greater the ignorance the greater the dogma- tism. ''97

"In science the credit goes to the man who convmces the world, not to the man to whom the idea first occurs' ,98

"Should your assistant make an important observa- tion, let him pubhsh it. Through your students and your disciples will come your greatest honor ,,9

"Men will not take tune to get to the heart of a mat- ter After all, concentration is the price the modem stu- dent pays for success. Thoroughness is the most difficult habit to acquire, but it is the pearl of great price, worth all the worry and trouble of the search. The dilettante hves an easy, butterfly life, knowmg nothmg of the toll and labor with which the treasures of knowledge are dug out of the past, or wrung by patient research m the laboratories. ''1°°

Osler's delightful sense of humor, practical approach to the job at hand, and insplnng advice to students are exemplified by the following quotations:

272 THE AMERICAN JOURNAL OF CARDIOLOGY ® VOL 75 FEB 1, 1995

"A cheerful man at the breakfast table is a great annoyance to his grouchy neighbor. ''i°l

"Look wise, say nothing and grunt Speech was giv- en to conceal thought. ''1°2

"Things cannot always go your way. Learn to accept m silence the minor aggravations, cultivate the gift of tac- ittmuty and consume your own smoke with an extra draught of hard work, so that those about you may not be annoyed with the dust and soot of your complamts ,,103

"Practically there should be for each of you a busy, useful, and happy life; more you cannot expect; a greater blessing the world cannot bestow. ''1°4

"Throw away, in the first place, all ambition beyond that of domg the day's work well. ''1°5

"Now the way of life that I preach is a habit to be acquired gradually by long and steady repetition It is the practice of livmg for the day only, and for the day's work. Ltfe tn day-ttght compartments ,,106

"To know just what has to be done, then to do it, comprises the whole philosophy of practical life -107

"To many of a somber and sour disposition it is hard to mmntaan good spirits amid the trials and tribulations of the day, and yet it is an unpardonable mistake to go about among patients with a long face. ''1°8

"Nothing will sustain you more potently than the power to recognize in your humdrum routine, as perhaps it may be thought, the true poetry of life--the poetry of the commonplace, of the ordinary man, of the plain toll- worn woman, with their loves and their joys, their sor- rows and their griefs. ''1°9

"We are here to add what we can to, not get what we can from, hfe. ''1°4

"Nothing in life is more wonderful than faith--the one great moving force which we can neither weigh m the balance nor test in the crucible. ''u°

"Faith in the gods or in the samts cures one, faith m little pills another, hypnotic suggestion a third, faith m a plato common doctor a fourth. ''m

Osier continually emphasized the importance of bed- side teaching and clinical laboratory microscopy, the ongoing necessity to read throughout one's career, and the acknowledgment of contributions of previous physi- cians. He was always in direct contact with students, and often hosted informal meetings with them on Saturday evenings in his home. Many were given keys to his front door so that they could take advantage of his outstand- ing library and were known as the "Latch Keyers."

"The-tralnmg of the medical school gwes a man his direction, points him the way, and furnishes him with a chart, fairly incomplete, for the voyage, but nothing more."ll2

"We expect too much of the student and we try to teach him too much. Give him good methods and a prop- er point of view, and all other things will be added as his experience grows ,,H3

"No bubble is so mdescent or floats longer than that blown by the successful teacher. ''114

"When a simple, earnest spirit animates a college, there is no appreciable interval between the teacher and the taught--both are m the same class, the one a little more advanced than the other. ''uS

"The very best Instructor for students may have no conception of the higher lmes of work in his branch, and contrariwise, how many brilliant investigators have been wretched teachers? ''u6

"It is astonishing with how little reading a doctor can practice medicine, but it is not astonishing how badly he may do it. ''u7

Osier cultivated a lifelong interest m the history of medicine and the humanities, u8-121 He emphasized the importance of the classics and of regular reading at bed- time 122 He collected over 7,000 books, which Lady Osler donated to McGlll University. 123,124 He humor- ously wrote under a pseudonym, Egerton Yordck Davis, sometimes cnticlzmg his own (i.e., Osier's) writ- lngs.24,125-127 Perhaps one of the best examples of Osler's literary style as well as his knowledge of medical history comes from The Master-Word m Medtcme 128. "It seems a bounden duty on such an occasion to be honest and frank, so I propose to tell you the secret of life as I have seen the game played, and as I have tried to play it myself You remember in one of the Jungle Stones that when Mowgh wished to be avenged on the villagers he could only get the help of Hathi and his sons by send- mg them the master-word. This I propose to gwe you m the hope, yes, in the full assurance, that some of you at least will lay hold upon it to your profit. Though a little one, the master-word looms large m meaning. It is the open sesame to every portal, the great equalizer in the world, the true philosopher's stone, which transmutes all the base metal of humanity into gold. The stupid man among you it will make bright, the bright man bnlhant, and the bnlhant student steady. With the magic word in your heart all things are possible, and without it all study is vanity and vexation. The miracles of life are with it; the blmd see by touch, the deaf hear with eyes, the dumb speak with fingers. To the youth it brings hope, to the middle-aged confidence, to the aged repose. True balm of hurt mmds, in its presence the heart of the sorrowful is lightened and consoled. It is directly responsible for all advances m medicine during the past twenty-five cen- turies Laying hold upon it Hippocrates made observa- tion and science the warp and woof of our art. Galen so read its meaning that fifteen centuries stopped thinking, and slept until awakened by the De Fabrwa of Vesal- ius, which IS the very incarnation of the master-word. With its inspiration Harvey gave an impulse to a larger circulation than he wot of, an impulse which we feel to- day. Hunter sounded all its heights and depths, and stands out m our history as one of the great exemplars of its virtue. With it Virchow smote the rock, and the waters of progress gushed out; while In the hands of Pasteur it proved a very tahsman to open to us a new heaven in medicine and a new earth in surgery. Not only has it been the touchstone of progress, but it is the measure of success m everyday life. Not a man before you but is be- holden to it for his position here, while he who address- es you has that honor directly in consequence of having had it graven on his heart when he was as you are to- day. And the master-word is Work..."

Osler's love of books and classical literature equaled his love of teaching 13,129

HISTORICAL STUDIES/THE WISDOM OF SIR WILLIAM OS!.ER 273

"It is easier to buy books than to read them and eas- ier to read them than to absorb them. ''I30

"With half an hour's reading m bed every night as a steady practice, the busiest man can get a fatr education before the plasma sets in the penganghonic spaces of his grey cortex. ''13°

"To study the phenomena of disease without books is to sail an uncharted sea, while to study books with- out patients is not to go to sea at all. ''131

"But by the neglect of the study of the humanities, which has been far too general, the profession loses a very precious quality. ''132

"You secrete materials which do for society at large what the thyroid gland does for the individual. The Humamties are the hormones .... The humanities bring the student into contact with the minds who gave us the pinlosopines, the models of our literature, the ideals of democratic freedom, the fine and technical arts, the fun- damentals of science, the basis of our law...into contact with the dead who never die, with those immortal lives not of now, nor of yesterday, but who always were. ''133

Osler constantly remmded students of the human side of patient care and the high ideals of the medical pro- fession:

"Care more particularly for the indwldual patient than for the special features of the disease -134

"Not that we all live up to the highest ideals, far from i t - -we are only men. But we have ideals, which mean much, and they are realizable, which means more. ''135

"To have striven, to have made an effort, to have been true to certain ideals--this alone is worth the strug- gle."136

What application does Osier have to the pres- ent? 137-14° Is he obsolete in the late twentieth century? Much has been written about the "Oslerian tradition" and its decline or lack of relevance m today's world.141-146 An "antl-Oslenan" attitude has been voiced by some. 31 The focus on equanlrmty and detachment as desirable qualities has been connected with a lack of empathy in medical students and physicians 147 Osier anticipated such a reaction:

"From its very nature this precious quahty (imper- turbablhty) is hable to be misinterpreted, and the gen- eral accusation of hardness, so often brought agmnst the profession, has here its foundation. ''148

I maintain that Osler's teachings are as important now as they were during his life. He was not just a kindly old clirnclan who liked to teach and write. He recognized the need to be critical of colleagues.149 He applied the latest advances in medicine to the care of his patients-- whether it was the use of newly described stmns in Inter- pretation of blood smears or urging the Board of The Johns Hoplons Hospital to acqutre an x-ray machine within a few months of Roentgen's first publication announcing its discovery, l~ It seems likely Osier would be squarely m the forefront of advances in medical sci- ence if he were alive today. 138,151 He also would contin- ue to emphasize the value of bedside observation in diag- nosis 152

"To wrest from nature the secrets winch have per- plexed philosophers m all ages, to track to thetr sources

the causes of &sease, to correlate the vast stores of knowl- edge, that they may be quickly available for the preven- tion and cure of &sease--these are our ambitions. ''is3

Much evidence indicates that Osier remains acknowl- edged as one of the greatest physicians who ever hved. His precepts and teachings continue to be cited fre- quently.65,121,138-140,146,151,15,:1--167 His approach to patients and recognition that medicine is an art as well as a sci- ence are touchstones m teaching the ethics and ethos of medicine. 155,165,166 His thesis that "humanities are the hormones" may be more important now than in 1919, as we cope with the moral and humanitarian dilemmas of care associated with intense pressures to reduce cost and define "cost-effectiveness."

Patients are cared for indwidually; the doctor-patient relationship is a one-on-one encounter. Whether in an office, clinic, hospital, or--as we were recently remind- ed during the ceremonies commemorating the 50th anniversary of D-Day---on a battlefield, doctors take care of patients one at a tune. A physician must obtain a Ins- tory, elicit pertment positive and negative physical find- rags, and order appropriate laboratory tests. ~67 He or she must analyze these data m the context of an ever-expand- ing galaxy of scientific knowledge. What is the dtagno- szs? What constitutes the best treatment for this patient? What can be done to return this individual to as close to normal daily actwlties for him or her as possible? These goals of accurate inductive reasoning are sought every time a doctor sees a patient.

Medical knowledge advances faster than anyone can keep up with, medicine and society encounter new chal- lenges on a continuing basis, and medical school orga- mzatlon and curricula become ever more complicated-- year by year, let alone decade to decade, or from one century to another.

However, some things do not change--at least not very much. In this era of ongoing debate on health care reform and delwery, it is essential to keep in mind how patients are cared for, how medical students are taught, and how medical science advances through carefully conducted research. In flats context, Osler's wisdom is everlasting. Its universality and timeless relevance are guideposts. Osler's emphasis on the importance of hard work, close observation, ongoing education, and practi- cal approach to the day's activities build the foundation for effective application of scientific knowledge in diag- nosis and treatment. His wit, humor, warmth, compas- sion, and humane concern for patients and colleagues are trmts we strive to emulate. His example and precepts provide the core quahtles that define what it means to be a physician. In the words of composer Stephen Sond- helm, "the art of malong art is putting it together. ''16s Osier said, "the old art cannot possibly be replaced by, but must be absorbed in, the new science. ''169 He put the art and science of medicine together as well as anyone ever has. Osier remains a role model for us all.

kknowledgnlen~ I thank Jill Stone, Nancy Stone, and Rob Stone for editorial assistance and support. Pamela Shortmo provided expert help with manuscript preparation.

274 THE AMERICAN JOURNAl OF CARDIOLOGY ® VOI. 75 FEB 1, 1995

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HISTORICAL STUDIES/THE WISDOM OF SIR WILLIAM OSLER 275

tim, 1920 1--64 86. Fulton .IF Literary pursuits The Osier biography 1920-1924 In Harvey Cush- ing A Biography Spnngfield, IL Charles C Thomas, 1946 456-513 8 7 . Cushing H Wflham Osier, the man In Cushing H Consecratlo Medici and Other Papers Boston Little, Brown, 1928,97-117 88. Thompson Eli Harvey Cushing Surgeon, Author, Artist New York Henry Schuman, 1950 1-347 89. Cushing H From a Surgeon's Journal Boston Little, Brown, 1936 197-198 90 Osier W Ctmstmas and the microscope Hardwlcke's Science- Gossip An Illustrated Medmm of Interchange and Gossip for Students and Lovers of Nature 1869,5 44 91. Fye WB, ed Wflham Osler's Collected Papers on the Cardrovascular System Btmungham, AL Classics of Cardiology Llbrury, 1985 1-919 9"2. Prmtt RE) Wllham Osier and his Gulstoman lectures on malignant endocarth- tls Mayo Chn Proc 1982,57 4-9 93. Osier W On multiple herexhtary telanglectases with recurring hemorrhages Quart J Med 1907,1 53-58 94. Osier W Chronic cyanosm with polycythemia and enlarged spleen a new chn- lcal emay Am J Med Scl 1903,126 187-201 95. Osier W Books and men In Osier W, ed AequanlmJtas with Other Address- es to Medical Students, Nurses and Practmoners of Medicine 3rd ed New York Blaktston, 1932 212-213 96. Osier W Chauvinism m medicine In Osier W, ed Aequanimitas with Other Addresses to Medical Students, Nurses and Pmcuttoners of Medicine 3rd ed New York Blalaston, 1932 266 97. Osier W Chauvinism m medrcme In Osier W, ed Aequammltas with Other Addresses to Medical Students, Nurses and Pmcttuoners of Medicine 3rd ed New York Blalaston, 1932 284 98. Bean RB, Bean WB, eds Sir Wdham Osier Aphorisms from His Bedside Teach- rags and Writings Springfield, IL Charles C Thomas, 1961 112 99 Bean RB, Bean WB, eds Sir Wdham Osier Aphorisms from His Bedside Teach- rags and Writings Springfield, IL Charles C Thomas, 1961 71-72 100. Osier W The student life In Osier W, ed AequanlmJtas with Other Address- es to Medical Students, Nurses and Practmoners of Medicine 3rd ed New York Blalast~n, 1932 400--401 101. Bean RB, Bean WB, eds Su" William Osier Aphorisms from His Bedside Teachings and Writings Spnngfield. IL Charles C Thomas. 1961 85 102. Bean RB, Bean WB, eds Sir William Osier Aphorisms from His Bedside Teachings and Writings Spnngfield, IL Charles C Thomas, 1961 130 103. Osier W The master-wurd in medicine In Osier W, ed Aequamm~tas with Other Addresses to Me&cal Students, Nurses and Practitioners of Medicine 3rd ed New York Blalaston, 1932 368 104 Osier W Doctor and nurse In Osier W, ed Aequanimltas with Other Address- es to Medical Students, Nurses and Pmctmoners of Medicine 3rd ed New York Blakaston, 1932 19 105. Osier W The army surgeon In Osier W, ed Aequanmutas with Other Addresses to Mechcal Students, Nurses and Practltaoners of Medicine 3rd ed New York Blakiston, 1932 104 106, Osier W A way of life In A Way of Life and Selected Writings of Sir Wdham Osier New York Dover, 1958 239 107. Osier W British medicine in greater Britain In Osier W, ed Aequammltas with Other Addresses to Medical Students, Nurses and Practtuoners of Medicine 3rd ed New York Blaklston. 1932 171 101L Osler W The student life In Osler W. ed Aequammltas with Other Address- es to Medical Students. Nurses and Practmoners of Me&cme 3rd ed New York Blaklston, 1932 405 109. Osler W The student hfe In Osier W. ed Aequammitas with Other Address- es to Medrcal Students, Nurses and Practitioners of Medicine 3rd ed New York Blaklston, 1932 404--405 110. Cushing H The Life of Sir William Osier vol 2 Oxford Clarendon Press, 1925 222 l l 1. Osier W Me&cme in the nineteenth century In Osier W, ed Aequanlmltas with Other Addresses to Me&cal Students, Nurses and Practmoners of Medicine 3rd ed New York Blaksston, 1932 259 112. Bean RB, Bean WB, ads Sir Wflham Osier Aphorisms from His Bedside Teachings and Wntmgs Spnngfield. 1L Charles C Thomas. 1951 40 | 13. Osier W The hospital as a college In Osier W, ed Aequanlmaas with Oth- er Addresses to Medical Students, Nurses and Practationers of Me&one 3rd ed

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122. Rakel RE Modem version of Osler's bedside hbrary Perspect Btol Med 1988,31 577-585 123. Osier W Btbhotheca Oslenana Kingston, Ontario McGdl-Queen's Umver- slty Press, 1969 1-792 124. The Osier Library Montreal MEG111, 1979'1-64 125 . Natron EF Osler's alter ego Dis Chest 1969,56 531-537 126 Bean WB Osier, the legend, the man and the influence Can MedAssoc J 1966,95 1031-1037 127. Tergen PM, Bensley EH An Egerton Y Davis Checkhst Osier Labrary Newsletter, 1981,no 38 1-5 128. Osier W The master-word m medicine In Osier W, od Aequanmaltas with Other Addresses to Medical Students, Nurses and Practaaoners of Medicine 3rd ed New York Blalast~n, 1932 356-357 129 Bean WB The Fourth Annual Guthne Lecture Some phystoans and books Guthrie Chn Bull 1962,32 9-20 130. Osier W The medical library m post-graduate work Br Med J 1909,2 925-928 131. Osier W Books and men In Osier W, ed Aequammitas with Other Address- es to Medical Students, Nurses and Practitioners of Me&cme 3rd ed New York Blakdston, 1932 210 132. Osier W Bntash me&cme m greater Britain In Osier W, ed Aequantmitas with Other Addresses to Medical Students, Nurses and Pract~tioners of Medicine 3rd ed New York Blakiston, 1932 168 133. Osier W The Old Humanities and the New Science Boston Houghton Msf- tim, 1920,26-29 134. Bean RB, Bean WB, eds Sir Wflham Osier Aphorisms from His Bedside Teachings and Writings Spnngfield, IL Charles C Thomas 1951 97 135. Osier W Teaching and thmkmg In Osier W, ed Aequamrmtas with Other Addresses to Medical Students, Nurses and Practmoners of Medicme 3rd ed New York Blaktston, 1932 119 136. Osier W An Alabama student In osier W, ed An Alabama student and Oth- er Blograph,cal Essays London Oxford University Press, 1926 18 137. Bondy PK What's so special about Osier9 Yale JBiol Med 1980.53 213-217 138. Joy M Wdham Osier then and now Am J Med 1985,79 5-9 139. Berk SL An interview with Sir Wdham Osier on the GPEP report Am J Med 1987,82 295-297 140. Berk SL International medical graduates m the Umted States An interview with Sir William Osier JAMA 1991,266 1760-1761 141. Keynes G The Oslenan tra&tton Br Med J 1968,4 5 9 9 ~ 4 142. Kampmeler RH "The Oslenan tradition "South Med J 1970,63 345-349 143. Regelson W The weakening of the Oslenan tradition JAMA 1978,239 317-319 1,44 Stevens R Issues for American internal medicine through the last century Ann Intern Med 1986,105 595-602 145. King LS Transformataons m American Me&cme from BenJamin Rush to Wdham Osier Baltimore John Hoplons, 1991 4 146. Bryan CS What is the Oslenan tradtuon 9 Ann Intern Med 1994,120 682~87 147. Splro H What is empathy and can it be taugh& Ann Intern Med 1992, 116 843--846 148 Osier W Aequanlmttas In Osier W, ed Aequanimltas with Other Address- es to Medical Students Nurses and Pmctumners of Medicine 3rd ed Philadelphia Blakaston, 1932 5 147. Roland CG Osler's rough edge Ann Intern Med 1974,81 690-692 150. Conn RB Osier and laboratory medicine In Barondess JA, McGovem JP, Roland CG, eds The Persisting Osier Baltimore Umverslty Park Press, 1985 173-178 151. Hurst JW Osier as wslttng professor house pupils plus six skills Ann Intern Med 1984,101 546-549 152 Bellan BM, Feelon FA The art of observation Wilham Osier and the method of Zadlg Ann Intern Med 1992,116 863-866 153. Osier W Chauvinism m medlcme In Osier W, ed Aequanlmaas with Oth- er Addresses to Medical Students, Nurses and Practataoners of Medicine 3rd ed New York Blaklston, 1932 267 154. Coope R The Qmet Art Edinburgh E & S Livingstone, 1958 8, 12, 226, 250 155 Radwany SM, Adelson BH The use of hterary classics in teaching medrcal ethics to physicians JAMA 1987,257 1629-1631 156. Mannmg PR, DeBakey L Methcme Preservmg the Passion New York Spnnger-Vedag, 1987 32, 35, 73, 164, 222-223 1,57. McHugh PR William Osier and the new psychiatry Ann Intern Med 1987, 107 914-918 158. Reynolds R, Stone J On Doctoring New York Simon & Schuster;. 1991 32-37 I$?. Hurst JW The Bench and Me Teaching and learning Medicine New York Igaku-Shom, 1992 32 160 Barley I Sir William Osier (1849-1919) physician, teacher, Instonan, biog- rapher, bibliophile J Med Biography 1993,1 2-10 161 Gordon BS The masks of mexhclne Am J Med 1994,96 88-89 162. Reynolds PP Reaflirrmng professlonahsm through the edueanon commtmay Ann Intern Med 1994,120 ~ 1 4 163 lsselbacher K J, Braunwald E, Wdson JD, Marian JB, Fauo AS, Kasper DL, eds Hamson's Pnnciples of Internal Me&cme 13th ed New York McGraw-Hall, 19945 164. Pandya SK Osler's neurology J Neurol Sct 1994,124 99-112 165. Slegler M A legacy of Osier Teaching chmcal ethics at the bedside JAMA 1978,239 951-958 166. Jonsen AR The New Medicine & the Old Ethics Cambridge, MA Harvard University Press, 1990 61-79,141-158 167. Hunter KM Doctors' Stones The Narrative Structure of Medacal Knowledge Pnnceton Pnnceton University Press, 1991 27-28 168, Gottfned M Sondheim New York Harry N Abrams, 1993 155-166 169, Osier W The reserves of hfe St Mary's Hospital Gazette 1907,13 95-98

276 THE AMERICAN JOURNAL OF CARDIOLOGY ® VOL 75 FEB 1, 1995