William Osler

Excerpts from Cushing’s Osler
Prepared by David Elpern

William Osler drawn by Brian Boyd

William Osler drawn by Brian Boyd

Many years ago, a friend gave me a copy of Harvey Cushing’s The Life of Sir William Osler. He knew I admired Osler but had read little of his work. My colleague had sought the tome out in a used bookstore, as it has been out of print for many years. Somewhat reluctantly, because of its forbidding length, I waded into the volume and was swept away by the elegance of both Cushing and Osler’s writings. You may be interested in perusing the selections which I highlighted as I read.

P. 63 [at Bovell's office] [The] drawer had been filled to overflowing with bills two or three times this afternoon and now look. One solitary bill lay in the drawer. As the patients paid their fees Osler placed them in the drawer. A needy patient came along, and Dr. B. reversed the process and handed money out so that the sick man might get his medicine and the food and other things required.

P. 81 … it was at this early period that he began his life-long habit of a half-hour’s reading in bed before putting out the light. Most medical students, alas, are too engrossed with their work for such literary pursuits, desirable though they may be.

P. 85 In that Trinity of being – of body, mind and soul – which so marvelously make up the Man, each one has its own special ills and diseases. With the first of these – the body – have we here anything to do, leaving the second to be attended to by that class of men whose duty it is ‘to minister to minds diseased”, i.e. Psychologists, while those of the third class beyond the Physician’s skill seek aid elsewhere.
To investigate the causes of death, to examine carefully the condition of organs, after such changes have gone on in them as to render existence impossible, and to apply such Knowledge to prevention and treatment of disease, is one of the highest objects of the Physician.

P. 94 I had hoped in an ophthalmic practice to have a considerable amount of time at my disposal, and a fair return in a shorter time, but in general practice which will be much slower to obtain (if it becomes of any size) what ever time you may have is always liable to be broken in upon.

P. 116 ..this is what has happened in all ages. Minerva Medica has never had her chief temples in any one country for more than a generation or two.

P. 129 “No one should approach the temple of science with the soul of a money changer” (Thomas Browne); touches on their obligations to the poor, on the question of livelihood…..

P. 143 [In 1876] his income for the year was $1178, including his professional salary…

P. 158 …very few patients ever came to [his consulting rooms]. He had little desire that they should come, for he seemed to have no inclination to take charge of any patient.
Patients were a secondary consideration.

P. 171 His belief that over-treatment with drugs was one of the medical errors of the day has been hinted at, and it was always one of his favorite axioms that no one individual had done more good to the medical profession than Hahnemann, whose therapeutic methods had demonstrated that the natural tendency of diseases was toward recovery, provided that the patient was decently cared for, properly nurses, and not over-dosed.

P. 174 He speaks also of Edison as ‘the bogie of gas companies”, and says that Edison told him in conversation that ‘he believed it would be possible to illumine the interior of the body by passing a small electric burner into the stomach’.

P. 177 Osler had the greatest contempt for the doctor who made financial gain the first object of his work; and even seemed to go so far as to think that a man could not make more than a bare living and still be an honest and competent physician.

P. 181 First appearance of Egerton Yorrick Davis 1880 with “Professional Notes among the Indian Tribes about Gt. Slave Lake, N.W.T.” “pseudo-serious and in a somewhat Rabalesian vein” This man [E.Y.D.] who was first heard of at Fort Desolation in the Great Slave Lake district and subsequently moved to Caughnawauga P.Q. had an interesting and somewhat varied life; From time to time he had a way of unexpectedly bobbing up without proper introduction, to the mystification of the uninitiated.

P. 191 “swarthy young Canadian”

P. 204 To hand on a book he had enjoyed, either as the volume itself or through a review calling attention to it, became a fixed habit with him.

P. 220 [Osler was trying to decide whether he would accept the position at Philadelphia] I finally gave it up as insoluble and decided to leave it to chance. I flipped a four-mark silver piece into he air, ‘Heads I go to Philadelphia; tails I remain in Montreal’. It fell ‘heads’. I went to the telegraph office and wrote to Dr. Mitchell etc. (May want to use this in talk, esp what follows)

P. 233 There are men and classes of men that stand above the common herd: [among them is] the physician….Generosity he has, such as is possible to those who practice an art, never a trade; discretion tested by a hundred secrets; tact, tried in a thousand embarrassments; and what are more important, Herculean cheerfulness and courage. So it is that he brings air and cheer into the sickroom, and often enough, though not so often as he wishes, brings healing. R.L.S.

P. 236-7 Osler breezes were felt everywhere in the old conservative medical centre, and yet it was not without some difficulties that he securely established himself.
Osler’s disinclination for general practice, for which a university position was coveted as a portal of entry, and his determination to limit himself largely to consultations, was mystifying to his medical colleagues, most of whom were accustomed to hold afternoon office hours and to engage actively in house-to-house practice.

P. 249 For the crass therapeutic credulity, so widespread today, and upon which our manufacturing chemists wax fat, there is no more potent antidote than the health skepticism bred in long study in the post-mortem room.

P. 253 on Osler as a pathologist doing autopsies
also “Once in a ward class there was a bid colored man whom he demonstrated as showing all the classical symptoms of croupous pneumonia. The man came to autopsy later. He had no pneumonia, but a chest full of fluid. Dr. Osler seemed delighted, sent especially for all those in his ward class, showed them what a mistake he had made, how it might have been avoided and how careful they should be not to repeat it. In 30 years of practice since then…I remember that case.

P. 258 By no means the smallest advantage of our meetings is the promotion of harmony and good fellowship. Medical men, particularly in smaller places, live too much apart and do not see enough of each other……As a result may come a professional isolation with a corroding influence of a most disastrous nature, converting a genial good fellow in a few years into a bitter old Timon, railing against the practice of medicine in general and his colleagues in particular. As a preventive of such a malady, attendance upon our annual gatherings is absolute, as a cure it is specific. ….he must indeed be a stranger in such meetings as ours who has not felt the glow of sympathy and affection as the hand of a brother worker has been grasped in kindly friendship.

P. 267 – ref to an article by Jacob Bigelow ‘On the Self- Limitation of Disease’ – published in early to mid 1800′s – try to get it. also “Osler’s rational use of drugs was much too far advanced for staid Philadelphia.” etc

P. 276 his “inkpot career”

P. 294 We speak of death as the King of Terrors, yet how rarely does the act of dying appear to be painful, how rarely do we witness AGONY in the last hours. Strict, indeed, is the fell sergeant in his arrest, but few feel the iron grip; the hard process of nature’s law is for most of us mercifully effected, and death, like birth, is ‘but a sleep and a forgetting’. etc. etc. excellent.

P. 301 Literature has often been enriched by those who have deserted medicine for the muses. But to drink deep draughts at Peirian springs unfits and when the thirst is truly divine should unfit a man for the worrying rounds of practice. It is shocking to think had Goldsmith secured the confidence of the old women in Bankside, Southwark, we should probably never have known the Vicar, Olivia or Tony Lumpkin. Still worse, to think of what we should have lost had Keats passed on from a successful career at Guy’s to obtain even a distinguished position as a London Surgeon! Happily, such men soon kick free from the traces in which the average doctor trots to success.

P. 308 – first ref to “Aequanimitas”

P. 310 …he helped some of us to do a little thinking. At length, after the fashion of the nautilus, he builded a more stately mansion and left us [for JHH]. We would have fain kept him; but that could not be.

P. 311 (Councilman) He [Osler] was then not quite forty and looked younger, a well-knit but rather spare figure, of about average height, a rather long moustache, the position at the ends of which seemed to vary with his mood; hair even then a little spare, a clear but sallow complexion, a broad forehead, good eyes and a lively expression.

P. 324 ….whenever there were cold about he was almost certain to be victimized and it became his custom to surrender immediately, to remain in bed for a day or two and to saturate himself with literature in lieu of drugs.

P. 328 Reference has repeatedly been made to Osler’s habit of note-taking…..It was a habit that he strongly recommended to his students as one of the three essentials in their education:
“Given the sacred hunger and proper preliminary training, the student-practitioner requires at least three things with which to stimulate and maintain his education, a note-book, a library and a quinquennial brain dusting. I wish I had time to speak of the value of note-taking. You can do nothing as a student in practice without it. Carry a small note-book which will fit into your waistcoat pocket, and never ask a new patient a question without note-book and pencil in hand……Begin early to make a three-fold category – clear cases, doubtful cases and mistakes. And learn to play the game fair, no self-deception, no shrinking from the truth; mercy and consideration for the other man, but none for yourself, upon whom you have to keep an incessant watch. You remember Lincoln’s famous mot about the impossibility of fooling all of the people all of the time. It does not hold good for the individual, who can fool himself to his heart’s content all of the time. If necessary, be cruel; use the knife and the cautery to cure the intumescence and moral necrosis which you feel in the posterior parietal region…It is only by getting your cases grouped in this way that you can make any real progress in your post-collegiate education; only in this way you gain wisdom with experience. etc, etc. [all of this is very good and important]

P. 340 His only weak spot was in therapeutics, if a healthy skepticism concerning drugs may be regarded as a weakness.

P. 342 ‘the desire to take medicine is perhaps the greatest feature which distinguishes man from animals’ Of one thing I must complain – that when we have gradually emancipated ourselves from a routine administration of nauseous mixtures on every possible occasion, and when we are able to say, without fear of dismissal, that a little more exercise, a little less food, and a little less tobacco and alcohol, may possibly meet the indications of the case – I say it is a just cause for complaint that when we, the priests, have left the worship of Baal, and have deserted the groves and high places, and have sworn allegiance to the true god of science, that you, the people, should wander off after all manner of idols, and delight more than ever in the hands of advertising quacks. But for a time it must be so. This is yet the childhood of the world, and a supine credulity is still the most charming characteristic of man.

P. 344 The study of the phenomena of disease without books is to sail an uncharted sea, while to study books without patients is not to go to sea at all…For the general practitioner a well- used library is one of the few correctives of the premature senility which is so apt to overtake him. Self-centered, self- taught, he leads a solitary life, and unless his everyday experience is controlled by careful reading or by the attrition of a medical society it soon ceases to be of the slightest value and becomes a mere accretion of isolated facts, without correlation. It is astonishing with how little reading a doctor can practice medicine, but it is not astonishing how badly he may do it.

P. 349 He [Osler] asked me if I would loan him the use of my library for an hour or so in the mornings. The first morning he appeared with one book under his arm…..and so on for the next two weeks, so that the table and all the chairs and the sofa and the piano and even the floor was covered with open books. As a consequence I never was able to use the room for fully six months. etc.

P. 352 On nurses and nursing

P. 359 Osler is a therapeutic conservative, a therapeutic skeptic, though by no means a nihilist. ‘Many specifics have been vaunted in scarlet fever, but they are all useless.’ ‘Pneumonia is a self-limited disease and runs its course uninfluenced in any way by medicine. etc’ These are hard words for the neophyte but not for the experienced. Drugs, drugs is the cry of the average doctor, and the average patient, too. But drugs are not all, and in many cases it is well for us to remember their uselessness as compared to other means. Weir Mitchell, in his little book on Doctor and Patient, admirably puts the fact that, all along the history of medicine, the really great physicians were peculiarly free from the bondage of drugs…..

P. 361 The various organs, the diseases of which are subdivided for treatment, are not isolated, but complex parts of a complex whole, and every day’s experience brings home the truth of the saying, ‘when one member suffers, all the members suffer with it’. [Goes for families and communities, too]

P. 367 From one who has passed la crise de quarante ans….with most of us this physical change has its mental equivalent, not necessarily accompanied by loss of the powers of application or of judgment; on the contrary, often the mind grows clearer and the memory more retentive, but the change is seen in weakened receptivity and in an inability to adapt oneself to an altered intellectual environment…The only safeguard in the teacher against this lamentable condition is to live in and with the third decade, in company with the younger, more receptive and progressive minds.

P. 371 On Literature and Medicine

P. 395 He pointed out, also, that permanence of residence, good undoubtedly for the pocket, is not always best for wide mental vision in the physician….[Browne] Myself a peripatetic, I know what it is to bear the scars of parting from comrades and friends, scars which sometimes ache as the memories recur of the days which have flown and of the old familiar faces which have gone.

P. 404 On Physician Writers

P. 408 He does not spare the physician who ‘without physiology and chemistry flounders along in an aimless fashion, never able to gain any accurate conception of disease, practicing a sort of pop-gun pharmacy, hitting now the malady and again the patient, he himself not knowing which.

P. 425 A consultant’s life is not without unpleasant feature, chief among which is the passing of judgments on the unhappy incurables – on the cancerous, ataxics and the paralytics, who wander from one city to another. Few are able to receive the balm of truth, but now and again one meets with a cheery, brave fellow who insists upon a plain, unvarnished statement of his prospects.

P. 426 Revere’s birth

P. 431 Osler’s ward rounds and daily JHH schedule

P. 435 Humanity has but three great enemies: fever, famine and war; and of these by far the greatest, by far the most terrible is fever…etc

P. 440 [Thayer] Observe, record, tabulate, communicate. Use your five senses. The art if the practice of medicine is to be learned only by experience; ’tis not an inheritance; it can not be revealed. Learn to see, learn to hear, learn to feel, learn to smell, and know that by practice alone can you become an expert. Medicine is learned by the bedside and not in the classroom.

P. 445 He [would] give over his Saturday evenings to his fourth year group of clinical clerks – a custom he continued throughout his entire Baltimore period. etc

P. 447 “No class of men needs friction so much as physicians; no class gets less. The daily round of a busy practitioner tends to develop an egoism of a most intense kind, to which there is not antidote. The few setbacks are forgotten, the mistakes are often buried, and then years of successful work tend to make a man touchy, dogmatic, intolerant of correction, and abominably self- centered. To this mental attitude the medical society is the best corrective, and a man misses a good part of his education who does not get knocked about a bit by his colleagues in discussions and criticisms.

P. 448 [on the library] “Books are tools, doctors are craftsmen, and so truly as one can measure the development of any particular handicraft by the variety and complexity of its tools, so have we no better means of judging the intelligence of a profession than by its general collection of books. A physician who does not use books and journals, who does not need a library, who does not read one or two of the best weeklies and monthlies, soon sinks to the level of the cross-counter prescriber, and not alone in practice, but in those mercenary feelings and habits which characterize a trade.

P. 454 J.D. Rockefeller’s involvement and important letter

P. 460 No other disease kills from one-fourth to one-third of all persons attacked; and ‘so fatal is it, that to die of pneumonia in this country is said to be the natural end of elderly people.

P. 461 “At the end of twenty years, when about forty-five, our Lydgate should have a first-rate reputation in the professional, and a large circle of friends and students. He will probably have precious little capital in the bank…..He may awake some day, perhaps quite suddenly, to find that twenty years of quiet work, done for the love of it, has a very solid value.

P. 463 “In the affairs of the heart, in which I have had a long and curious experience, I do not remember an instance in which my adverse counsel was taken……………A doctor needs a woman who will look after his house and rear his children, a Martha whose care will be for the home. Make her feel that she is your partner arranging a side of the business in which she should have her sway and her own way. Keep the two separate. Consult her

and take her advice about the house and children, but keep to yourself, as far as possible, the outside affairs relating to the practice.

P. 479 the curious tendency of physicians to become victims of the malady in which they have specialized

P. 483 Hopkins Librarian Miss Theis

P. 489-90 In an extemporaneous address the Albany, NY medical student in 1899 he addressed the need of cultivating the head and the heart. “There is a strong feeling abroad among people – you see it in the newspapers – that we doctors are given over nowadays to science; that we care much more for the disease and its scientific aspects than for the individual. I don’t believe it, but at any rate, whether the tendency exists or not, I would urge upon you in your own practice, to care more particularly …for the individual patient than for the special features of the disease….Dealing as we do with poor suffering humanity, we see the man unmasked, exposed to all the frailties and weaknesses, and you have to keep your heart soft and tender lest you have too great a contempt for your fellow creatures. The best way is to keep a looking-glass in your own heart, and the more carefully you scan your own frailties the more tender you are for those of your fellow creatures.

P. 492 [Osler with a patient] She was an old woman of 75 in hospital for acute rheumatism, who also showed a wind tumor of the Steno’s duct the size of a walnut, which she could inflate and deflate at pleasure. Osler said it was the second one he had seen. Both of these conditions, however, were incidental to her general history.
‘Mother’ said Osler, ‘I would like you to tell Dr. Walsh something about your past life. When were you first in hospital?’ ‘At 27. ‘What was the matter’ ‘I had a sarcoma of the right knee’ ‘What did they do for it?’ They cut off the right leg at the hip. ‘Did you get entirely well? Yes, entirely well. ‘ When were you in again?’ ‘ At 42. I had cancer of the breast. They cut off the left breast and the left arm. After that I was entirely well. ‘What are you in the hospital for now?’ ‘For rheumatism; and Doctor,’ she said with tears in her voice and catching his hand, ‘I hope you will make me well in a hurry, because I have to go home to take care of my grandchildren.’
Osler, in short, never forgot the patient in his interest in the malady.

P. 503 Undoubtedly the student tries to learn too much, and we teachers try to teach him too much – neither, perhaps, with great success. The existing evils result from neglect [of the fact that] education is a life-long process, in which the student can only make a beginning during his college course. …To cover the vast field of medicine in four years is an impossible task…Perfect happiness for the student and teacher will come with the abolition of examinations, which are stumbling-blocks and rocks of offense in the path of the true student.

P. 526 In all of us senility begins at forty – forty sharp – sometimes earlier. To obviate the inevitable tendency – a tendency which ends in intellectual staleness as surely as in bodily weakness – a man must not live in his generation; he must keep fresh by contact with fresh young minds, and ever retain a keen receptiveness to ideas of those who follow him.

P. 537 If we add the deaths due to tuberculosis of the other organs, we are well within the mark in saying that one-tenth of the deaths in this city [Baltimore] are due to this disease….The white plague is the scourge of the race, killing 5,000,000 yearly. then De Quincy “Then comes the startling question – that pierces the breaking hearts of so many thousand afflicted relatives – Is there no remedy? Is there no palliation of the evil?”

540 He touched further on his favorite theme that no hospital could fulfill its mission that was not a centre for the instruction of students or doctors; and he told how a staff should be organized…etc

P. 546 A third noteworthy feature in modern treatment has been a return to psychical methods of cure, in which faith in something is suggested to the patient. After all, faith is the great lever of life. Without it man can do nothing….Faith in us, faith in our drugs and methods, is the great stock-in-trade of the profession. In the one pan of the balance, put the great pharmacopoeias of the world…in the other put the simple faith which from the days of the Pharaohs until now the children of men have swallowed the mixtures these works describe, and the bulky tomes will kick the beam. It is the aurum potable, the touchstone of success in medicine. As Galen says confidence and hope do more than physic – ‘he cures most in whom most are confident’…We doctors often overlook or are ignorant of our own faith-cures, we are a bit too sensitive about those performed outside our ranks. We have never had, and cannot expect to have, a monopoly in this panacea, which is open to all, free as the sun, and which may make of everyone in certain cases…’a good physician out of Nature’s grace’. Faith in the gods or in the saints cures one, faith in little pills another, hypnotic suggestion a third, faith in a plain common doctor a fourth. In all ages the prayer of faith has healed the sick, and the mental attitude of the suppliant seems to be of more consequence than the powers to which the prayer is addressed. The cures of the temples of Aesculapius, the miracles of the saints, the remarkable cures of those noble men the Jesuit missionaries,… and the wonder-workings of the so-called Christian Scientists, are often genuine, and must be considered in discussing the foundations of therapeutics. We physician use the same power every day…We enjoy no monopoly in the faith-business. (can be found in Aequanimitas)

P. 553 To us who were his students in the early days of the JHMS, his memory is so vivid, so fresh….what follows is a student’s view of Osler. from Osler and the Student JHH Bull July 1919, XXX 200

P. 584 Chief Justice Taft said of W.O. “..The wonder that came over me was at the universal knowledge of the man. He was not only the most learned, but applied himself with a keen common- sense and a sense of proportion that must have been the basis of the influence he wielded not only in his profession but in the community at large.

P. 588 Osler wrote..”It is amusing to read and hear of the passing of the family physician….He still does the work; the consultants and the specialists do the talking and the writing – and take the fees. By the work, I mean the great mass of routine practice which brings the doctor into every household in the land and makes him, not alone the adviser, but the valued friend…A well-trained sensible family doctor is one of the most valuable assets of a community, worth today, as in Homer’s time, many another man…Few men live lives of more devoted self-sacrifice than the family physician but he may become so completely absorbed in work that leisure is unknown….More than most men he feels the tragedy of isolation…Even in the populous districts the practice of medicine is a lonely road which winds up-hill all the way and a man may easily go astray and never reach the Delectable Mountains unless he early finds those shepherd Guides of which Bunyan tells, Knowledge, Experience, Watchful and Sincere…etc

P. 595 Death (poor Ochsner) The oppressive stillness of the chamber in which he lay dying was made more oppressive by the soft hurried and just audible respiration. I sat by the bed holding the poor chap’s hand & and beside me were my two assistants & and at the foot of the bed an angel in white, one of the two who had shared the fight with us. For three weeks we had worked in hope but in vain. We silently waited the end with sad hearts & brimming eyes. The young life so full of promise & and only just equipped for the race, was dear to us….A strange half frightened look lightened the apathy of his countenance. Far from his home- far from the loved one who had watched with pride his career – and – [a student dying of Typhoid]

P. 596 At one time Osler wanted his epitaph to read “Here lies the man who admitted students to the wards.” For the junior student in medicine and surgery it is a safe rule to have no teaching without a patient for a text, and the best teaching is taught by the patient himself.

P. 601 ‘On the Educational Value of the Medical Society’. … hardly anyone keeps up his interest in knowledge throughout a whole life. The troubles of family, the business of making money, the demands of a profession destroy the elasticity of the mind. The waxen tablet of the memory, which was once capable of receiving ‘true thoughts and clear impressions’, becomes hard and crowded;

P. 602 the 40-visit-a-day man is most to be pitied) to remember that education is a life-long business; that experience is fallacious and judgment difficult; and that attendance on a medical society, particularly one which maintains a library, may prove the salvation of the man who from success in practice ‘needs to pray the prayer of the Litany against the evils of prosperity’ lest he tend towards slovenliness in his methods of work. ….Garth “Now sickening Physick hangs her pensive head/ and what was once a Science, now’s a trade.”
P. 616 ff “The Master Word in Medicine”…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…..The Master-Word is WORK, a little one, as I have said, but fraught with momentous consequences if you can but write it on the tables of your heart, and bind it on your forehead.
P. 618 He urged the students to ‘get a relish for the good company of the race by daily intercourse with some of the great minds of the ages. Learn to accept the minor aggravations, cultivate the gift of taciturnity 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 complaints. More than any other, the practitioner of Medicine may illustrate the second great lesson, that we are here not to get all we can out of life for ourselves, but to try to make the lives of others happier. The practice of medicine is an art, not a trade: a calling not a business; a calling in which your heart will be exercised equally with your head. Often the best part of your work will have nothing to do with powders or potions, but with the exercise of an influence of the strong upon the weak, of the righteous upon the wicked, the wise upon the foolish…..Courage and cheerfulness will not only carry you over the rough places of life, but will enable you to bring comfort and help to the weak-hearted, and will console you in the sad hours when, like Uncle Toby, you have ‘to whistle that you may not weep’.

P. 636-637 [Osler was] recognized from Hudson Bay to the Gulf, from Nova Scotia to California, as the doctor’s doctor, even though he might curtail the number of ordinary professional consultations, this could not be done when some member of a physician’s immediate family was concerned. Love of his profession meant love of his professional kind, and there was a rare afternoon when……And this to a a neurasthenic doctor “It is very satisfactory to feel that you have a good grip on your gray cortex. Go slowly and attend to your work, live a godly life, and avoid mining shares. I doubt if quinine could have very much influence.

P. 639 describes the important study Osler had made of the last sensations of the dying.

P. 649 He had often said his ideal of life would be to live within an hour of the British Museum and to have The Times on his breakfast table.

P. 657-8 [Aequanimitas] had been written for medical students, nurses and practitioners of medicine and proved to contain ‘a deep mine of golden counsel’ equally suited to others. A series of lay sermons they are, wrote one reviewer…..They showed not only lofty feelings but a sense of humor and a love of good literature; appended to the volume was a list of 10 items constituting a ‘bedside library for medical students’; who were advised not to rest satisfied with their professional training but to get the education, if not of a scholar, at least of a gentleman.

P. 667 As it can be maintained that all the great advances have come from men under 40, so the history of the world shows that a very large proportion of the evils may be traced to sexagenarians…it is only those who live with the young who maintain a fresh outlook on the new problems of the world. The teachers live should have three periods, study until 25, investigation until 40, profession until 60, at which age I would have him retired on a double allowance. [this is the source of the chloroform episode]

P. 676 – Second Valedictory Address – ‘The Student Life’…is an address to be read and re-read, not only by every doctor young and old but by those in any way interested in doctors. Goes on to talk of “books, balances and bairns”, “reading as an avocation” and a “quinquennial brain dusting”

P. 679 It may be that in the hurry of and bustle of a busy life I have given offense to some – who can avoid it? I have striven with none, not as Walter Savage Landor says, because none was worth the strife, but because I have had a deep conviction of the hatefulness of strife, of its uselessness, of its disastrous effects, and a still deeper conviction of the blessings that come with unity, peace and concord.

P. 682 I have three personal ideals. One, to do the day’s work well and not to bother about tomorrow. The second has been to act the Golden Rule, as far as in me lay, towards my professional brethren and towards patients committed to my care. And the third has been to cultivate such a measure of equanimity as would enable me to bear success with humility, the affection of my friends with pride, and to be ready when the day of sorrow and grief came to meet me with the courage befitting a man. I have made mistakes, but they have been mistakes of the head not the heart. [To these parting words, when published later on, he prefixed the line from Tennyson's Ulysses] I am part of all that I have met.

P. 690 fr F.C. Shattuck (1919) on Osler’s 70th Birthday: To no member of its body does the profession of medicine owe so great a debt…He has made no profound or fundamental discovery; but no one of our day has, in his life, teaching and example so radiated, far and near, an inspiration to his fellow physicians….Who that meets him, who that reads his essays and addresses, in particular, does not come forth or rise with renewed strength and hope to the service of hiss fellow man, a better soldier in the medical corps of the Divine army?

P. 695 ..it was not merely the skillful doctor, the great scholar, the research student, or often the wise and tactful reformer, but far more the sympathetic friend which made him what he was to others.

P. 702 Reminiscences of Dr.. Gunn, “a distinguished ophthalmologist” on meeting Osler when the latter was on vacation to Scotland and the former had “not then begun the study of clinical medicine”.

P. 709 For the student of medicine the writings of Sir Thomas Browne have a very positive value. The charm of high thoughts clad in beautiful language may win some readers to a love of good literature; but beyond this there is a still greater advantage. Like…..the ‘Religio’ is full of counsels of perfection which appeals to the mind of youth, still plastic and unhardened by contact with the world. Carefully studied, from such books come subtle influences which give stability to character and help to give a man a sane outlook on the problems of life. Sealed early of this tribe of authors, a student takes with him a compagnons de voyage, lifelong friends whose thoughts become his thoughts and whose ways become his ways. Mastery of self, conscientious devotion to duty, deep human interest in human beings – these best of all lessons you must learn now or never – and these are some of the lessons which may be gleaned from the writings of Sir Thomas Browne.

P. 727 “Is the Miss Green I met at the Fischels still without cardiovascular attachments?”

P. 761 – it had become a saying in Oxford that the Oslers spent their weekends in America.

P. 769 One of the most satisfactory things in Oxford is the way they have settled the athletic problem. All the men are at exercise in some form, every day, rain or shine, as part of their regular routine.

P. 781 “A.S. McNalty – “In 1907 when up for my final examination at Oxford – the examination last a fortnight and is always a time of anxiety for the victims – Sir William’s (then Dr. Osler) innate kindness cheered us through the wastes of written papers, practicals and orals. Every one of the candidates felt that he was as anxious for each of one of us to do well as if he had been a personal relative. The smile, the jest and the inquiry as to how we had got on helped us greatly. Bending over a heart case on which a full clinical report was asked for, unexpectedly the candidate would find the Regius Professor at his elbow and a hand laid on the patient’s precordia – “a good thrill that – that’s a nice case to have” would be the comment, and he passed on. British examinations too often are rigid and formal. Sir William lightened them to the candidates by the human touch.

P. 791 People say sometimes that on this side of the Atlantic we have only weather and no climate. But peripatetic as I have been, living in many places, I have always regarded climate and weather as two of the non-essentials, and I think the people who take that view of both climate and weather are the only happy ones…..Sunshine is not an essential for the cure of the disease [tbc]. The things that are essential are fresh air, good food, good houses and hope.

P. 800 I am very glad to hear that you have started a library. There is no better index of the intellectual status of the profession in any town than the condition of its medical library. It will do you all so much good to work at it, particularly in connection with the medical society. Let me indicate briefly the lines along which you should develop:
1) The current journals, general and special, taking particularly those not likely to be subscribed for by the individual members
2) as soon as possible fill up one or two sets of first-class journals: the Lancet, the BMJ, the American Journal of the Medical Sciences, the Annals of Surgery and the journals of that type
3) of the books get the good systems and special works in each department rather than the ordinary school texts….Tell some of the members from me, please, that money invested in a library gives much better returns than mining stock.

P. 809 Unexpected acts of kindness of this sort, the possibility of which so many people recognize but rarely pursue, represented his normal reaction – done quickly and on impulse.

P. 813 He spoke on the Functions of the Out-patient Department, saying that he had haunted these for years…..and dwelt on their relation to the general practitioner who might regard an outpatient department as a rival, but for whom it should really play the part of consultant when dealing with his poorer patients, should they be in need of a second opinion.

P. 865 To accept a great group of maladies against which we have never had and can scarcely ever hope to have curative measures, makes some men as sensitive as though we were ourselves responsible for their existence. These very cases are ‘rocks of offense’ to many good fellows whose moral decline dates from the rash promise to cure. We work by wit and not by witchcraft, and while these patients have our tenderest care, and we must do what is best for the relief of their sufferings, we should not bring the art of medicine into disrepute by quack-like promises to heal or by wire-drawn attempts at cure in what old Burton calls ‘continuate and inexorable maladies. From The Treatment of Disease BMJ, 1909, ii, 185-9……the great struggle with that many headed monster, Polypharmacy – the practice of discharging a heavily- loaded prescription at every malady, or at every symptom of it ….I have often been branded as a therapeutic nihilist…I bore this reproach cheerfully, coming as I knew it did, from men who did not appreciate the difference between the giving of medicine and the treatment of disease.

P. 866 cont. he went on to discuss the ‘specious and seductive pamphlets issued by pharmaceutical houses’ which ‘indicate a thralldom not less dangerous than the polypharmacy from which we are escaping’; the other ‘the outbreak of faith-healing which seems to have the public of the American continent in its grip’. ‘The less the clergy have to do with the bodily complaints of neurasthenic and hysterical persons the better for tier peace of mind and the reputation of the cloth.

P. 867 Credulity in matters relating to disease remains a permanent fact in our history, uninfluenced by education. But let us not be to hard on poor human nature. Even Pericles, most sensible of men, allowed the women to put an amulet around his neck. [and this goes on in tis vein]…..he looked over the large literature on the subject of ‘faith healing’: In all ages, and in all lands, the prayer of faith, to use the words of St. James, has healed the sick; and we must remember that amid the Aesculapian cult, the most elaborate and beautiful system of faith- healing the world has seen, scientific medicine took its rise. As a profession, consciously or unconsciously, more often the latter, faith has been one of our most valuable assets, and Galen expressed a great truth when he said, ‘He cures most successfully in who the people have the most confidence. It is in these cases of neurasthenia and psychasthenia [in these days chronic fatigue syndrome, fibromyalgia, etc] the weak brothers and the weak sisters, that the personal character of the physician comes into play, and once let him gain the confidence of the patient,. he can work the same sort of miracles as Our Lady of Lourdes. Three elements are necessary: first a strong personality in whom the individual has faith – Christ, Budda….or, what has served the turn of common humanity very well, a physician. Secondly, certain accessories, s shrine, a sanctuary….or, for us, a hospital or its equivalent with a skillful nurse. Thirdly, suggestion, either of the ‘only believe’, ‘feel it’, ‘will it’, attitude of mind which is the essence of every cult and creed, or the active belief in the assurance of the physician that the precious boon of health is within reach.

P. 869 an epitaph of sorts

P. 870 [on reading] He emphasized the importance of reading as a part of post-graduate study….The average non-reading doctor might play a good game of golf or of bridge, but professionally he was a lost soul. The driven or tired practitioner might plead that he could not find the time to read. He could not unless he had formed the practice in less busy days; then, the habit of reading, like any other habit, became his master…One or two journals and a few books were enough if read properly….It was easier to buy books than to read them, and easier to read than absorb them…………….’Were there time I should like to say a few words on the subject of how to read, but the essence of the whole matter I found the other day…..in the opening address, 1714, De recto usu Biblothecae, the Abbe Carsughi discusses the subject and gives some rules. He urges two important points – top read in a certain order and with definite object, and lente festinans – unhasting but unresting. [Later] he urges the necessity of careful note-taking.” He [Carsughi] then dwells upon the importance of study in the morning, which was all very well in those days, but is not one hour after six in the evening worth now two before eight in the morning [not for DJE!!]. With half an hours reading in bed every night as a steady practice, the busiest man can get a fair education before the plasma sets in the periganglionic spaces of his gray cortex.

P. 875 Osler at play at tea (his lighter side)

P. 881 the Balkan volcano (Bosnia/Croatia/Serbia) was in its perennial state of threatened activity.
P. 886 ….Robert Burton lived as he says, ‘a silent, sedentary, solitary, private life’ in the university, dying in 1639. …. ‘fatally driven (to use his own expression) upon the rock of melancholy, to ease his mind, and out of fellow feeling for others, he composed his immortal work, ‘The Anatomy of Melancholy’.
The Anatomy of Melancholy has not always been understood, it is much more than
A mire, ankle deep of deliberate confusion
Made up of old jumbles of classic allusion.
It is a great medical treatise (the greatest ever written by a layman), orderly in arrangement, intensely serious in purpose, and weighty beyond belief with authorities. The sources are to be found in sacred and profane literature, to the time of Burton. There is probably no English author who quotes from so many writers on so many subjects.

P. 893 How well his friends remember the alert carriage and elastic tread etc [description of W.O.]

P. 899 “Angina in Doctors” “A point that stands out prominently in my experience is the frequency of the disease in our profession. For the same reason, doubtless, that Sydenham gives for the incidence of gout, “more wise men than fools are afflicted” angina may almost be called ‘morbus medicorum’….the frequency with which doctors die from the disease has become the subject of common remark. From John Hunter onwards, a long list of most distinguished men have been its victims. In a group of 20 men, every one of whom I knew personally, the outstanding feature was the incessant treadmill of practice; and yet if hard work – that ‘badge of our tribe’ – was alone responsible would there not be a great many more cases? Every one of these men had an added factor – worry; in not a single case under 50 years of age was this feature absent,…Listen to some of the comments I jotted down of the circumstances associated with the attacks: ‘A man of great mental and bodily energy…involved in speculations in land’, domestic infidelities;….troubles with the trustees; lawsuits, domestic worries, and the case goes on. At least six or seven men of the sixth decade were carrying loads light enough for the fifth, but too much for a machine with an ever lessening reserve….

P. 907 The BMJ for June 18, 1910 was given over to a series of articles on so-called faith healing….included was Osler’s paper on ‘The Faith that Heals’. [He wrote, "Nothing in life is more wonderful that faith - the one great moving force which we can neither weigh in the balance nor test in the crucible....

P. 908 Apart from the more specific methods to be dealt with, faith has always been an essential factor in the practice of medicine.....Literature is full of examples of remarkable cures through the influence of the imagination, which is only an active phase of faith. Phenomenal, even what could be called miraculous cures are not very uncommon. Like others I have had cases any one of which, under suitable conditions, could have been worthy of a shrine....Faith in St. Johns Hopkins, as we used to call him, an atmosphere of optimism, and cheerful nurses, worked just the same sort of cures as did Aesculapius at Epidaurus. Once again, a great gulf has opened between pastor and flock, and the shepardless sheep at large upon the mountains have been at the mercy of anyone who could pipe new tunes.

P. 911 Of all the blows of circumstance that may help to temper a man;s metal, chronic illness is the most uncertain in its effects....Now and then men are fortunate enough to overcome the worst foes encountered in the battle of life - chronic ill health and an enforced residence in a paralyzing environment.

P. 918 'Specialists and Specialism' [found among his unpublished papers "To two great groups of minds the world has been indebted for its progress - the hypermetropic, the wide-visioned men of the type of Aristotle, Darwin and Spencer; and the myopic - men with concentrated penetrating vision of the type of Pythagoras, Vesalius, Harvey and Pasteur. Who shall say which was the more important? Those who think that at the present day specialism has run riot, are purblind critics and cannot see that we are safe so long as each generation in each department produces a few men with hypermetropia enough to synthesize the work of their colleagues, and so far these have never been wanting.....In the cultivation of a specialty as an art there is a tendency to develop a narrow pedantic spirit..... [ also see p. 361]

P. 922 [with regards to tbc] He knew the question in all its aspects – social and medical – its difficulties, the prolonged nature of the illness, the patient living the ordinary life of the people, half disabled himself and a danger to others for many months of the year – to end at last, hidden away, to die slowly, often forgotten by the outside world. (sort of like AIDS)

P. 984 The truth is, an immense majority of all die as they are born – oblivious. A few, very few, suffer severely;y in the body, fewer still in the mind. Almost all Shelley’s description fits:
Mild is the slow necessity of death;
The tranquil spirit fails beneath its grasp,
Without a groan, almost without a fear,
Resigned in peace to the necessity;
Calm as a voyager to some distant land,
And full of wonder, full of hope as he.

P. 1065 …the pupil and the teacher working together on the same lines, only one a little ahead of the other. This is the ideal towards which we should move. The pity of it all is that we should have made an intolerable burden of the study of one of the most attractive of the professions, but the reform is in our own hands and should not be far off.

P. 1072 [with regards to the medical clinic and medical school]… it is attractive to think of a group of super-clinicians, not bothered with the cares of a consulting practice, and whose interests are in scientific work. Against [this] may be urged the danger of handing over students who are to be general practitioners [or dermatologists in practice - DJE] to a group of teachers completely out of touch with the conditions under which these young men will have to live. The clinician should always be on the fighting line, and in close touch with the rank and file, with the men behind the guns, who are doing the real work of the profession…..Would there not be the danger of the evolution…of a set of clinical prigs, the boundary of whose horizon would be the laboratory, and whose only human interest would be research?…..I know how hard it is ‘to serve God and mammon’ to try to do one’s duty as a teacher and to live up to the responsibility of a large department etc…I had 31 years of uninterrupted hard work. William Pepper, my r\predecessor in Philadelphia, died of angina at 55; John Muser, my successor, of the same disease at 53! After listening to my story you may wonder how it was possible to leave a place so gratifying to the ambitions of any clinical teacher: I had a good innings and was glad to get away without a serious breakdown.

P. 1104 ‘The history of chemistry, as indeed of all science, is but a succession of epitaphs upon forgotten men and forgotten discovery. What then, do these men not owe to him who gathers up their works, and in so doing recalls their achievements…..

P. 1113 In war the microbe kills more than the bullet. Malaria, cholera, typhus, typhoid, dysentery have been the scourges of armies…What I wish to urge is a true knowledge of your foes, not simply of bullets, but of the much more important enemy, the bacilli. In the wars of the world they have been as Saul and David – the one slaying thousands, the other tens of thousands. I can never see a group of recruits..without mentally asking what percentage of these fin fellows will die legitimate and honorable deaths from wounds, and what percentage will perish miserably from neglect of ordinary sanitary precautions.

P. 1119 “A university regiment of students will be organized at once and they will be under military discipline. Revere will of course join.”

P. 1128 [on WWI] It’s the deuce of a mess, this old humanity has got into. We will never be any different. I don’t suppose we are a bit better than the Greeks – in some ways not so good. My chief comfort is to think that after all we are living in the childhood of civilization. What are the few thousand years since Hammurabi in comparison with the million since the Stone Age.

P. 1164 Completed today ten years in Oxford. Extraordinarily happy years…..Altogether it has been a most successful experiment. I have kept very well. I have not had many substernal threatenings such as I used to have in Baltimore…The one thing I miss is the active teaching and close association with students and a large group of young doctors, but I console myself with the 31 years of strenuous work I had in Canada and the United States.
P. 1236 To my son on his 21st Birthday.
..You are all a father could wish, a dear good laddie.
And it is not often I am sure that a father and son have been so happy together….

P. 1263 [Revere's death - August 1917] We saw him buried in the early morning. A soggy Flanders field beside a little oak grove to the rear of the Dosinghem group – an overcast, windy autumnal day – the long rows of simple wooden crosses – the new ditches half full of water being dug by Chinese coolies wearing tin helmets – the boy wrapped in an army blanket and covered by a weather-worn Union Jack, carried on their shoulders by four slipping stretcher bearers. A strange scent – the great-great grandson of Paul Revere under a British flag, and awaiting him a group of some six or eight American Army medical officers – saddened with thoughts of his father…The Padre recited the usual service – a bugler gave the ‘Little Post’ and we went about our duties. Plot 4 Row F

P. 1263-64 I was sitting in my library working on the new edition of my text-book when a telegram was brought in, ‘Revere dangerously wounded, comfortable and conscious, condition not hopeless.’ I knew it was the end. We expected it. The fates do not allow the good fortune that has followed me to go with me to the grave – call no man happy till he dies. The War Office telephoned at 9 in the evening that he was dead. A sweeter laddie never lived, with a gentle and loving nature. He had developed a rare taste in literature and was devoted to all my friends in the spirit – Plutarch, Montaigne, Browne, Fuller, and above all Izaak Walton whose Compleat Angler, he knew by heart and whose ‘Lives” he loved. We are heart broken, but thankful to have the precious memory of his loving life.

P. 1270 One may control one’s emotion before others, but not when alone. His wife, whose own loss was wellnigh forgotten in sympathy for him, could hear him sobbing night after night, till overcome by a restless sleep. Though ‘a shadow of his former self’ he found solace in three things – in his avocational studies; in keeping young people about him; and in his devotion to other peoples’ little children.

P. 1272 With a hobby a man is reasonably secure against the whips and arrows of the most outrageous fortune -

P. 1291 “We are making this house freehold, and I am arranging to leave it to Christ Church as a permanent home for my successors.” [Cushing] Such things must always be when a man is confronted with the extinction of his line.

P. 1306 The epidemic of influenzal pneumonia will be well remembered [1918], for it was world-wide…and the Regius Professor…became engaged for one of the few occasions in his life in the actual house-to-house practice of medicine. He had his own ways of doing this and with children was a veritable Peter Pan. [A little child's mother writes:] “He visited our little Janet twice every day from the middle of October until her death a month later, and these visits she looked forward to with a pathetic eagerness and joy. There would be a little tap, low down on the door which would be pushed open and a crouching figure playing goblin would come in…..Instantly, the sick room was turned into a fairy land, and in fairy language he would talk about the flowers, the birds and the dolls….In the course of this he would manage to find out all he wanted to know about the little patient.
The most exquisite moment came one cold, raw, November morning when the end was near, and he mysteriously brought out from inside his pocket a beautiful red rose wrapped in paper, and told how he had watched this last rose of summer growing in his garden and how the rose called out to him as he passed by, and she wished to go along with him to see his little lassie. That evening we had a fairy tea party…Sir William talking to the rose, his ‘little lassie’, and her mother in a most exquisite way; and presently he slipped out of the room just as mysteriously as he entered it, all crouched down on his heels; and the little girl understood that neither fairies nor people could always have the colour of a red rose in their cheeks, or stay as long as they wanted to in one place, but that they nevertheless would be very happy in another home and must not let the people they left behind, particularly their parents, feel badly about it; and the little girl understood and was not unhappy.

P. 1325 Thrilled this week by my election to the Johnson Club… There have been only six doctors in the club since its foundation – Paget the last – Goldsmith, Nugent & Fordyce the early ones….

P. 1346 [Osler's comments at the celebration of his 70th birthday] “…recalls my vagrant career- Toronto, Montreal, London, Berlin and Vienna as a student; Montreal, Philadelphia, Baltimore and Oxford as a teacher. Many cities, many men. Truly with Ulysses I may say, ‘I am part of all I have met.’…Loving our profession, and believing ardently in its future, I have been content to live in and for it. A moving ambition to become a good teacher and a sound clinician was fostered by opportunities of an exceptional character, and any success I may have attained must be attributed in large part to the unceasing kindness of colleagues and to a long series of devoted pupils whose success in life is my special pride.
To a larger circle of men with whom my contact has been through the written word – to the general practitioners of the English-speaking world – I should say how deeply their loyal support has been appreciated. Nothing in my career has moved me more, pleased me more, than to have received letters from men at a distance – men I have never seen in the flesh – who have written to me as a friend.

P. 1348 A bibliography of my writings extending to 730 articles!

P. 1357 I had a good night, and smell the rose above the mould this morning. And on being asked to explain this he replied that Thomas Hood’s ‘Stanzas’ was a good poem for doctors, and all should know it. And so things dragged on, with increasing fever and cough, till one day between his paroxysms he announced that ‘pneumonia at 70 is fatal; here is a list of people to give my love and good-bye to.’ But in spite of his premonition, the irrepressible spirit and sense of humor was usually uppermost, and it was rare for the mould to get the upper hand….
I have had a ____ of a time, yet with it all no pain, no headache, distress only when the heavy paroxysm of coughing grips me in a convulsion. There is nothing I do not know of the varieties and vagaries of coughs and coughing – the outcome is far away. Shunt the whole pharmacopoeia, except opium. It alone in some form does the job. What a comfort it has been.

P. 1359 Sister Edwards his nurse wrote “When every night between the hours of 2 and 4 a.m. those dreadful attacks of coughing were at their worst, he never complained, and though utterly exhausted with the effort his face would suddenly light up and his eyes flash as he made some humorous remark. He disliked mixtures very much and would as he put it only take something ‘plain’…’Why spoil a wonderful drug like opium by mixing it with inferior things?’ he would say….I am quite sure that he knew from the first that his illness would prove fatal…once after the consultants had left him, with a cheery word about his recovery to which he had as cheerily responded, he looked up at me and said, ‘Ah, Sister, we know, don’t we?’….

P. 1361 …All bronchial therapy is futile – there is nothing my good doctors have not made me try, but the only things of any service whatever in checking the cough have been opiates – a good drink of the paregoric bottle or a hypodermic of morphine. I have a splendid nurse.

P. 1361 [an old servant at the laboratory said to Sir Charles Sherrington] “No sir, I don’t think Sir William will get well. …the last months I’ve noticed him greeting you quite merry-like; but betweentimes his face has been grave as though he had something heavy on his mind and he has walked in and out without once having noticed me. It’s Revere, sir, and Sir William won’t get better” So the old servant had long seen what others had missed……[that] Osler….carried a grief he could not throw off.

P. 1365 …No fever & pulse good; but the confounded thing drags on in an unpleasant way i and in one’s 71 year the harbour is not far off. And such a happy voyage! and such dear companions all the way! And the future does not worry. It would be nice to find Isaac there [Revere], and his friend Izaak Walton & others, but who knows.

P. 1369 He forgot no details – the disposition of his Text-book; of his manuscript writings; the completion of the Catalogue; the promise of his brain to the Wistar Institute; the post-mortem examination and by whom it should be conducted, even the mentioning that Edwin, his ‘boy’ at the Museum should be present…..with scarcely legible notes, one of the last of which read: ‘Nothing to worry about but leaving Grace & no Isaac to comfort her & my inability to write letters to my dear friends & the dear little children in Canada….

P. 1370 But I feel with Franklin that “I have been too far across the rivet to go back and have it all over again.”

P. 1371 He advanced the science of medicine, he enriched literature and the humanities; yet individually he had a greater power. He became the friend of all he met – he knew the workings of the human heart metaphorically as well as physically.