Osler Under 40

In his valedictory address at Johns Hopkins University in 1905, a few weeks before his departure for England, Osler stated: “The teacher's life should have three periods, study until twenty-five, investigation until forty, profession until sixty, at which age I would have him retired on a double allowance” (1). To illustrate his idea, Osler referred to Anthony Trollope's novel, The Fixed Point, in which “the plot hinges upon the admirable scheme of a college into which at sixty men retired for a year of contemplation before a peaceful departure by chloroform” (1). Unfortunately, he was misinterpreted by some as having implied a uselessness of men older than 60 years of age and subsequently was castigated by the press (2). Included in a response which Osler promptly issued to the newspapers was this statement: “Nothing in the criticism has shaken my conviction that the telling work of the world has been done, and is done, by men under 40 years of age” (3). In the first 39 years of his own life, Osler accomplished his own “telling work,” work that would afford him enough knowledge at age 40 to begin writing his textbook, The Principles and Practice of Medicine (4). It took him a year to complete and was published in 1892. What is not always appreciated is that his work until his arrival at Baltimore was chiefly that of a pathologist in the laboratory, not a clinician on the ward (Figure). Figure William Osler at work in the Blockley Mortuary, Philadelphia General Hospital, 1886 or 1889. Reprinted with permission from the William Osler Photograph Collection, McGill University Library. Born in Canada in 1849, Osler attended Weston School, where he was introduced to the microscope by Rev. W. A. Johnson (5), one of three consecutive teachers to whom he would later dedicate his textbook. At age 16 Osler studied insects that he found in pond water. During his 4 years at Trinity College in Toronto, Dr. James Bovell further instructed him in histologic technique, and in 1868, Osler entered Toronto Medical School, where he studied basic sciences for 2 years. He lived in Bovell's home during this period, and his interest in microscopy continued. At age 20 he had published an account of his observations of organisms in pond water (6). During his 2 clinical years at McGill University, Osler demonstrated an interest in morbid anatomy, coming under the influence of Dr. Palmer Howard, the third teacher to whom he dedicated his textbook. Osler evidently took part in autopsies while still a student (7), and his graduation thesis consisted of a report of 50 postmortem examinations, with 33 specimens. Osler was awarded a set of books by the faculty as a prize for his thesis, “which was greatly distinguished for originality and research” (8). After graduation from McGill in 1872, Osler went abroad for 2 years of study. He continued in pathology, largely at University College in London, where he made original observations on blood platelets (9). In addition, he spent 3 months in Berlin attending Virchow's autopsies, from which he profited enormously, and 5 months in Vienna with Rokitansky, for whose methods he had little enthusiasm (10). Soon after his return to Montreal in 1874 at age 25, Osler joined the medical faculty of McGill University, first as instructor in the Institutes of Medicine and within a year as professor. His course consisted of five lectures a week, four on physiology and one on pathology, as well as a voluntary course in microscopy (11). On Saturday mornings, he held postmortem demonstrations in the same fashion as Virchow. In 1876 at age 27, Osler was appointed pathologist to the Montreal General Hospital, taking responsibility for conducting all autopsies during the next 8 years. Though his technique of postmortem examination was not recorded, he claimed, “The postmortems are performed under my supervision by the students attending the hospital, and the system of inspection followed is that of Virchow, at the Charite, Berlin, fully given in his Sections-technik. The notes are taken on the spot from dictation” (12). According to Rodin who examined the existing records, “Osler did a thorough, fairly detailed and competent autopsy. The language is terse; non-verbose and clear. There is little of the flowery rhetoric of his later years. The descriptions are readily understandable to a modern pathologist. Weights and measurements are abundant and include heart weights, valve circumferences, and thickness of ventricular walls. The protocols are modern in their methodology” (13). The number of autopsies that Osler performed in his 10 years at McGill is estimated by Abbott (14) to be over 1000 and by Bunting (15) to be almost 800. He performed a total of 786 as pathologist of the Montreal General Hospital, which constitutes about 100 autopsies a year for 8 years; as Rodin points out (10), a significant number for any one pathologist. Osler's publications during his McGill period are mostly short descriptions of individual specimens. His contribution to the literature on cardiovascular disease was particularly significant, including articles on endocarditis, valvular stenosis, myocardial fibrosis, cardiac hypertrophy, pericarditis, and congenital heart disease. In 1884 at age 35, Osler accepted the chair of clinical medicine at The University of Pennsylvania, and during the next 5 years in Philadelphia continued his interest in pathology. Within 1 month of his arrival, he improvised a small clinical laboratory; in order to teach students, he used his own microscope, the only one in use at the University Hospital (16). Despite the presence of an appointed pathologist, Osler also performed 162 autopsies, 94 from his own wards and 68 from those of his colleagues (17). His enthusiasm for autopsies in Philadelphia was best described by “a physician in a Maryland town who commented on the fact that often he was unable to get Dr. Osler to come for a consultation with a large fee, but he would always come to attend an autopsy in which he was interested” (18). Osler's move to Baltimore in 1889 at age 39 marks the end of his active participation in postmortem examinations (10). Within a year at Johns Hopkins University, Osler began work on his textbook. For this purpose, he evidently borrowed all five volumes of Pathological Reports of the Montreal General Hospital, which he compiled while at McGill (19). The remarkable feature of The Principles and Practice of Medicine is that he is its sole author and that it is based largely on his own clinical and morphologic observations. The two works cited more than any other in the book are the Pathological Reports of the Montreal General Hospital, from which he extracted detailed descriptions of morbid anatomy, and the Bible, to which there are many allusions (20). Perhaps because of Welch's presence, Osler performed no complete autopsies at the Johns Hopkins Hospital; but he would, on occasion, present himself at the morgue, usually to focus on a specific question: “The Chief with silk hat jauntily perched and frock coattails flying would arrive at the table followed by a panting crowd. Itching fingers would request a scalpel and with a flip of his cuffs he was soon deep in what was obviously to him a fascinating job, that of solving a medical problem directly in the cadaver” (15). Dr. Charles H. Mayo, a founder of the Mayo Clinic and friend of Osler, said that “reading his Practice after those that precede it is like opening a window in a closed room” (21). Nevertheless, it has been suggested that the 22 essays in Equanimitas constitute in time to come the most lasting of all his writings and outdo the Religio Medici of his beloved Sir Thomas Browne (22). It is intriguing that Osler delivered the first of these addresses at age 39, after his “telling work,” and the last at age 56, before he would rest.

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