William Osler's Legacy and his Contribution to Haematology

William Osler (1849–1919) is generally regarded as one of the greatest and most admired physicians in the history of medicine. An outstanding clinician, he possessed extraordinary charm which inspired many pupils. Osler stressed bedside teaching, hard work, medical history and lifelong learning. As Professor of Medicine at four institutions in three countries, he exerted a profound influence on medical education. A prolific writer, his textbook became the most popular and widely read treatise on medicine in the world. His humanistic philosophy was reflected in all aspects of his life. Osler blended the art and science of medicine perhaps better than anyone else and remains a valuable role model for students and physicians. Osler's early experience with the microscope as a schoolboy led to important contributions to haematology. He was among the first to recognize platelets as the third formed element of the blood; he documented their importance in thrombosis. His early studies on pernicious anaemia have been largely neglected, but his thorough descriptions of polycythaemia vera and hereditary haemorrhagic telangiectasia popularized both entities. Most significant of all, Osler brought the microscope to the clinic and emphasized the value of examination of the blood in clinical diagnosis. Osler occupies a unique position in the history of medicine. He is generally acknowledged as one of the most outstanding clinicians and teachers of all time (Dana, 1919; Cushing, 1925; Abbott, 1926; Reid, 1931; Bailey, 1993; Stone, 1995). Many of Osler's writings (Osler, 1904a, 1907a, 1908a, 1913, 1921; Camac, 1906; Verney, 1960; McGovern & Roland, 1969, 1985; Roland, 1982; Nation, 1987; Hinohara & Niki, 2001; Silverman et al, 2003) have inspired and been cherished by medical students and physicians throughout the world. His close personal relationship with students and colleagues has been amply documented (Pratt, 1949; Nation & McGovern, 1980; Howard, 1983; Golden, 1992a). Commemorative issues of several journals have appeared in his honour (Osler Memorial Issue, 1949; William Osler Anniversary Issue, 1949; Roland, 1969), a number of bibliographies of his writings have been published (Blogg, 1921; Abbott, 1939; Nation et al, 1976; Golden & Roland, 1988), and his likeness has been preserved on many portraits, busts and medals (Sakula, 1991). A new biography appeared in the sesquicentennial year of his birth (Bliss, 1999), the first full-length account of Osler's life since Cushing's Pulitzer prize-winning treatise published in 1925. The Osler Society of McGill University was founded in 1921, the Osler Club of London in 1928, the American Osler Society in 1970 (Barondess et al, 1985; Barondess & Roland, 1994, 2002) and the Japanese Osler Society in 1983. In May 2003, a joint meeting of the American, London and Japanese Osler organizations was held in Edinburgh, UK. Thus, Osler remains one of the most revered physicians of modern times (Golden, 1999a). William Osler was born in Bond Head near Toronto in 1849, the eighth of nine children (Table I) (Talbott, 1969; Roland, 1984; Bliss, 1999). His mother lived past the age of 100 years; his father was an Anglican clergyman. As a bright, high-spirited youngster, Willie got into his fair share of trouble – he was expelled from grammar school for abusive language and once filled a schoolroom with geese after moving the desks to an attic. At private school, he met Reverend W. A. Johnson, who introduced him to biology and the microscope. This interest in microscopy was to become one of the dominant themes of his career. He enrolled in Trinity College at Toronto and originally planned to follow his father into the clergy. After being influenced by a physician, Dr James Bovell, Osler switched to medicine (Silverman, 1993). He entered Toronto Medical School and transferred to McGill for his final 2 years. There, he came into contact with the well-known clinician and teacher, R. Palmer Howard. Johnson, Bovell and Howard were the three teachers to whom Osler later dedicated his textbook. He received his MD degree in 1872 from McGill and then travelled to England and continental Europe. Osler's experience abroad made him a proponent of postgraduate travel. His trip was the first of what later became known as ‘brain-dusting excursions’. He spent 17 months in London at University College Hospital in the physiology laboratory of John Burdon Sanderson (whom he would succeed as Regius Professor of Medicine at Oxford 33 years later), during which time he became one of the first to recognize the platelet as the third formed element in the blood and documented the importance of platelets in thrombus formation (Osler, 1886a). He also visited Germany and came into brief contact with the great Rudolph Virchow. On returning to Canada, he began working as a general practitioner. A few months later, he was invited to join the medical faculty at McGill. ‘ No bubble is so iridescent or floats longer than that blown by the successful teacher ’ (Osler, 1911) During his 10 years on the McGill faculty (1874–1884), Osler rose to the rank of professor. He was quickly recognized as an outstanding clinician and stimulating teacher, always emphasizing the role of bedside teaching and observation. He also served as a pathologist to a smallpox hospital, maintained a small private practice and published many papers dealing with various clinical, pathological and veterinary subjects. During this decade, Osler organized medical clubs and achieved unusual popularity engendered by his exemplary conduct and generosity. ‘ Medicine is learned by the bedside and not in the classroom ’ (Thayer, 1931) Osler performed nearly 1000 autopsies; this experience, combined with his knowledge of microscopy, made him well grounded in morbid anatomy and contributed much to his understanding of the natural history of disease and the importance of clinicopathological correlation (Robb-Smith, 1981; Rodin, 1981). ‘ 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 living for the day only, and for the day's work. Life in day-tight compartments' (Osler, 1913) Osler left Montreal in 1884 to become Professor of Clinical Medicine at the University of Pennsylvania. His reputation and productivity continued to grow in Philadelphia. He gave his famous address, Aequanimitas, to the University of Pennsylvania graduating class in 1889. That year, he became Chief of Medicine at the new Johns Hopkins Hospital and Medical School, where he remained until 1905 (Fig 1). William Osler in 1905. From a photograph by William Notman, Montreal. Reproduced (with permission from the Secretary-Treasurer of the US and Canadian Academy of Pathology) from Abbott (1926). ‘In the physician or surgeon no quality takes rank with imperturbability ’ (Osler, 1904b) Osler was instrumental in establishing Johns Hopkins as the outstanding institution of medical education in the United States (Starr, 1982; Ludmerer, 1985, 1999; Harvey et al, He to the new school and was one of the of Hopkins with and He introduced the clinical and the of among students and that to the day 1985, 1999; & He continued to the importance of with and clinical observation. He stressed the value of medical history and many the in medicine was (Osler, During his at Osler acquired an reputation and became one of the most clinicians in the (Fig Osler at the From with the permission of Oxford University ‘ is the of and as no the so no and no and the which as disease ’ (Osler, ‘ with the that is hard to in to or that in with the that in in the practice of an art which largely in ’ (Osler, In Osler's The and of appeared and became the treatise on general medicine in the for the years (Osler, Harvey & 1987; Golden, He the in the of the ‘ is and ’ – I ‘ I of that this is an art which the of the and has of and in ’ – The of the first of the the was in the and The influence and popularity of the textbook were from and into and It was also for the formation of the for Medical Golden, The textbook emphasized and and reflected Osler's great knowledge of clinical medicine and with many was that Osler in a treatise he became known as a 1983; & On one that not many medical in the of the ‘ not new of which the what in the laboratory from the of as of and as of the ’ (Thayer, 1931) Osler was the great of and the of Osler's W. the surgeon who Osler to the University of Pennsylvania 1931; 1985; and William were in May after of the textbook. who and born in Osler left in 1905 to his new position as Regius Professor of Medicine at Oxford his Burdon where he lived for the of his life 1921; Cushing, 1925; Bliss, 1999). He that Oxford would a so that he but he was as as he been in The Osler at became known as the to colleagues and Osler continued to medical organizations and journals the of He served as of the In the of Osler and He continued clinical teaching, published papers and medicine. A was on him in The of his life in his was in in In Osler and on 1993). His was the as of the months his (Osler, A prolific writer, Osler in his & Roland, Golden, 1999a). His first the of the microscope (Osler, His important on blood platelets were made in he was years of his with or the microscope. of his papers were to on disease 1982; Osler's clinical and him with an ‘ The the the the ’ (Osler, ‘ The of one age have become the of the and the of has become the of ’ (Osler, ‘ of with the the blood from the and and and of the and the blood but all in in a few the of was ’ (Osler, 1911) Osler emphasized the importance of bedside teaching and clinical laboratory microscopy, the to read throughout and the of contributions by physicians. He was always in contact with students was medical students on the and with on at his In and many were to his so that of his outstanding students became known as the ‘ as the life of in the – the the – so the of the medical the of the knowledge that has made the most of all to ’ (Osler, 1911) ‘ the of disease is to an to is not to to at all ’ (Osler, Osler a lifelong interest in the history of medicine and the (Osler, 1921; 1949; & 1976; His humanistic philosophy and conduct were reflected in all aspects of his life. He emphasized the importance of the and of at (Osler, His personal which he to McGill University (Osler, The Osler a he a his writings Nation, 1969; Golden & Roland, Golden, Osler students of the of the medical and the of ‘ for the than for the of the disease ’ & ‘ have to have made an to have been to – this is the ’ (Osler, Osler was not a clinician who to and He recognized the to be of colleagues He the in medicine to the of his – was the of in the of blood or the of The Johns Hopkins Hospital to an a few months of first Osler that in medicine the in and he (Osler, It that Osler would be in the of in medical science he were ‘ It is with a practice but is not he ’ (Osler, ‘ from the which have in all to to their the of to the of that be quickly for the and of disease – ’ (Osler, In this of on and is to in medical students and medical science In this Osler's is and Osler's on the importance of hard work, close education and a to the day's the for of knowledge in and His and for and colleagues to His and the that what to be a Osler art be but be the new (Osler, He the art and science of medicine as well as anyone Osler remains a role model for Osler was introduced to the as a by his Reverend Johnson, and his interest the influence of Dr Osler's first age was and the microscope (Osler, In the he has on and most of which in and so A for one would a the microscope I I the of and as were in a Reverend and Dr Bovell, Osler acquired a of to with the in after Willie to become a than a of the clergy. After 2 years at the Toronto medical school, he to McGill. His first clinical a medical the and of a with (Osler, Osler's in 1872 with the time he received the MD Osler was an He this to great in his postgraduate and became a of the value of microscopy in medicine. Osler microscopy to students at brought the first microscope to the University of Pennsylvania Hospital and the Clinical at Johns A meeting of the Johns Hopkins Club was held in at which time a was to the by of Osler's colleagues and meeting of the Johns Hopkins (Fig Dr R. the who the was to Dr Osler at a clinical The is to his microscope that was always his The R. and to the Johns Hopkins Hospital by Osler's and with permission from the Secretary-Treasurer of the US and Canadian Academy of The of platelets several during the and 1949; The first of blood than and been by and is that platelets be a for that has been with the first of platelets and William an to published a of a in The year, that in the blood and and that he recognized a element in the the father of clinical and who Osler much microscopy, published an in with a of blood his of their was Osler in England to in Burdon physiology laboratory (Fig he the of various on the of In at his Osler's became to which he were to the by In Osler the blood in and of and that the of from of small which as in the (Osler & were to the of a His that as in the which came the blood was Osler was not what perhaps and to in the of his On returning to Osler continued his studies of In he on a in which he maintained interest for his life (Osler, He the of in the on but also the on the so was platelets and In Osler that a thrombus on an of platelets (Osler, Osler during his postgraduate in London 1926; with permission from the Secretary-Treasurer of the US and Canadian Academy of that platelets were that in the blood of living Osler's on but a the (Osler, In Osler was invited to the at the College of and in He the in the physiology of blood The three of a of both his and on blood and (Osler, 1886a). Osler platelet that in which he in his he the with He that the third or blood was a in from to (Fig number in the blood of a is but their number at of life and with of and In he is which the blood a for the so as born in the but to as and from so as to be no longer In the third Osler I that the of and that the an in their Osler's emphasized the role of platelets in and the of and Osler's of I The were the of Osler's on In he in a held at Johns Hopkins (Osler, that platelets on the of Osler that he many but one that William Osler made of the that platelets as a of blood and their with thrombus Osler's studies on platelets were his most significant have not generally received much – one of in the biography In the published in It is to which of the by James and during the years after pernicious anaemia been anaemia for years he in in so and a that the a to his of that which is to become so the of clinical and laboratory anaemia was to of the by in a by In William and Osler a of pernicious The been years by who as a new This much interest and also of by and and Osler's was the first in which the clinical, and pathological were in to that was as The was a who of and on of the and his and a in his He of 2 months In the Osler and in and of the At a to the and a were The and was filled with and a This was the first of the (Robb-Smith, 1981; Osler that was a of but that was a of the to an he not Osler's of to to the and in ‘ The of the blood in this disease of as I of no disease in which that the blood important ’ (Osler, In Osler's clinical on in he the and the (Osler, not he blood and was as he that of Montreal have The of the disease was months with unusual years. & Osler on of the with the clinical of The was a with of examination the to have the which by Osler was of with that appeared The blood was with of which were four times The months later with a of Osler that the blood platelets were also of the and all and The a in the and small A from the and Osler all of the A in the is the which all the of the The with the by and and that of the of pernicious anaemia profound in the In the of The and of the that he Osler that his of the age of and the disease was in (Osler, Osler from the anaemia of and his with he that with be from He for with the for the of the He that were always and and gave for The blood were generally He with the of the generally than that of the by and that the with of the his with an of of Osler's and he of from the history is not one of but of of and many Osler for the of anaemia (Osler, was that in as as he which I have in his (Osler, In the after Osler's the studies of by and successful for a and on by the of become in the role of in on in the to of the most important in medicine after Osler the of by and in laboratory in Toronto during became with in for which his He to and remained on for the of his life. In May and their to the of American been to a of were and the anaemia in appeared in that & The Osler who that with of and a better was his contributions to the of the Osler made significant contributions to the of (Table have not received much in the history of the 1980; & 1999). been recognized by and but the polycythaemia vera entered the medical a Osler's role in and this was one of his most important clinical contributions polycythaemia in The first was a with and and were of the blood the of the to The the year of and disease was In Osler on with polycythaemia and an a new clinical at a meeting of the of American His was published in the American of the Medical (Osler, (Fig Osler's four with and polycythaemia of whom He and four from the Osler's first on polycythaemia He on in and later that the be Osler's first was a physician in at which time his was and were as was that have been a for disease and was Osler the and which and that the first as a rose and with blood on a in he became as as He on the of and as well as He not recognize the with or Osler the and made an with He with and of and Osler polycythaemia of was and by the was with of the for the disease and but in with were not as as in Osler's Osler that the he a new clinical and by that the is the and the Osler the in his with in with Osler's on was at the (Osler, and began with the ‘ It is to follow the in the of a new that at all the is so as at once to and with been the in the and with a the of the disease which so as was a many years recognized the of the to the disease that his The of the disease of the and by the physician, not than his on of the by several years until the of to the so was with which was well known for years in England continental recognized a and is as in a year or and the clinical and perhaps the in new and to that is by no This has been the history of a of which the is the Osler's on a clinical of the The was a of Osler's of bedside teaching – the of clinical and laboratory with (Robb-Smith, 1981). In the of his Osler the as polycythaemia with The was with blood of and were were to have a At was Osler that the was the of recognized the of the blood in blood and of the is in to a of blood into the were by who a few of the disease been was not until Osler's papers that the was widely & to be a to to the platelet and that were of the and also the of anaemia and in into his of et that was a of in the of with was in and by a years At the first meeting of the of American in Osler of the of was from (Osler, 1981). Osler's was on of than blood which the physicians After the Osler to with both and blood were of the of of the in the blood of with Osler to several journals in which he he been (Osler, he who and for the (Osler, As with Osler's influence important in the of work. in and in blood were in all of and then (Osler, ‘ not a but one and one ’ & Osler several papers on the relationship and anaemia and (Osler, He were by for many years; anaemia and and a with and He recognized that in a number of (Osler, ‘ The of with of the is but to the number of in knowledge of the of the various and their to one ’ (Osler, In Osler three with and (Osler, He of a years of Osler's were a of were three with hereditary telangiectasia were from with Osler a with four and in the (Osler, The is in the on and in the of his textbook. ‘ In the great of the the is from the and has the of In the blood from the on the the and of the in a few has the been from the on the ’ (Osler, Osler many and & Roland, He contributed the on blood for of Medicine in (Osler, with descriptions of disease and The on blood in the first of The and (Osler, of on and This was to in the (Osler, of and the were with blood In the first of his Osler that was of in the acknowledged value in the of by then been He the of the unusual Osler also and The were of the in with or Osler be and that of was he also that be of (Osler, He was a of of the and the role of The close Osler and at Johns Hopkins was perhaps one of the of which later so valuable in In a of three papers on the of the of Osler recognized and emphasized that with in the (Osler, A of studies a later that he the for the clinical of & In Osler was a with a history of a – were on the and that with after with were in the (Osler, The was year no was is that Osler's (Robb-Smith, 1981). Osler made which all the the he introduced clinical microscopy into American medicine (Osler, were an of made at the bedside (Pratt, with the microscope was as important as At was the first in the United States to for blood in John of the in was in on laboratory both Clinical from Hopkins in and the Clinical at Johns to the with medical students and their blood (Osler, Osler brought the microscope to the physicians to at and for The of clinical microscopy also an important role in to the and of blood The Clinical at Johns to the Osler with a and this class one of the most as is one of the most in the (Osler, William Osler's contributions to a small of his were As a his studies on platelets of and his of the In both the the in his Osler's clinical descriptions of and led to his being to both is of Osler's ‘In science the to the who the not to the to whom the first & Dr who the Clinical at Johns Hopkins a after Osler left later to him as first American ‘ The the successful is the one who the ’ (Osler, in at the and of the American Osler Society This was in by the and the Memorial and the James I for and with a Johns Hopkins medical and performed studies on disease as a in On the pathological in with to to Johns Hopkins In that Osler was the greatest teacher known (Bliss, 1999).

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