Book Review

Osler: Inspirations from a great physician

N Engl J Med 1997; 337:1324-1326October 30, 1997

Article

Osler: Inspirations from a great physician
By Charles S. Bryan. 253 pp. New York, Oxford University Press, 1997. $37.95. ISBN: 0-19-511251-2

Max Brödel's 1896 cartoon, “The Saint,” depicts William Osler atop a tornado, garbed as a heavenly angel (Figure 1Figure 1William Osler, by Max Brödel.). Haloed, small-winged and robed, with baby feet, large head, and familiar drooping moustache and dour countenance, he is part of the firmament above Johns Hopkins Hospital, ready to face down a horde of microbes assembled in ranks on the earth below. In later years, former colleagues and students, their students, and other assorted “Oslerians” would add to this early humorous depiction of sainthood a body of serious hagiography larger than that for any other physician except, possibly, St. Luke.

The most recent addition to the genre is Charles Bryan's parsing of “the Osler message” in a new format that he hopes will make “his ideals and examples easily accessible to the present generation.” Dr. Bryan forewarns that his book is not a new biography of Osler — “his life has been celebrated and dissected by at least four full-length biographies and more than 1500 journal articles.” Instead, he has selected what he considers the main guideposts to be found in his subject's life and writings, and has organized them in 48 compartments — eight chapters of six sections, each addressing a different Osler ideal. For example, the chapter “Be Positive” includes “Be an Optimist,” “Be Generous,” “Work,” “Be Decisive,” “Be Tolerant of Others,” and “Use the Mature Defenses.” The entire book abounds with excerpts from Osler's own writings, writings about him, and authors he was fond of quoting. Reading through the 24 pages of notes will instruct those who, like me, were vaguely aware that Osler himself was a prolific writer and that much has been written about him, but never realized just how much. One comes away admiring the author for having pored through it all.

Of course, Osler's life exemplifies some of his virtues more readily than others, and so Bryan's treatment of them is necessarily uneven. Clearly, Osler worked hard as a young faculty member at McGill, training himself, Morgagni-style, by performing countless autopsies and correlating his findings with the clinical record. This experience would later ground his extraordinary skill as a diagnostician and enable him to write — not edit — his textbook of medicine, first published in 1892. He became, as well, a revered teacher, a well-read medical historian, and a fine writer (despite the Victorian-baroque prose style and excessive references to ancient and mythological figures that make him all but inaccessible to some modern readers). Beyond these obvious attributes, Osler's life was an exemplar of the self-discipline and public persona most admired by proper Victorians. But Bryan is unconvincing in drawing from the Osler example the precept “Be Political.” He tells us that Osler attended one political rally in his life (in England) and advised the average doctor to “shun politics as he would drinking and speculation.” His political activism seems to have been limited to speaking his mind in an occasional letter to the editor. On the other hand, he was a natural leader and joiner of professional organizations at a time when “the search for order” was beginning to dominate American life, including medical life. Yet, beyond his support of the campaign for public health, one finds in Osler's life little of what we might now call social concern — although as the Progressive Era reforms in the United States were barely getting under way, he was already in England ensconced as an Oxford don.

The author's method of modernizing the Osler message is to show that the old adages are still relevant. He does this throughout the book by citing experts in “time management,” “leadership,” “adult development,” “motivation,” “self-esteem,” “personnel management,” “male friendship,” and “mentoring” and then showing how closely their teachings parallel one or another of the Osler “inspirations.” On the other hand, this exegesis slights the historical context. Bryan mentions only indirectly, for example, that his hero's manners and core beliefs were Victorian, his attitudes and social practices typically Edwardian. Osler's dogged persistence and optimistic outlook in fact more clearly resemble the virtues vindicated in more than a hundred Horatio Alger novels (which during Osler's lifetime sold over 30 million copies, or 3 titles for every American home) than they anticipate the Reverend Norman Vincent Peale's 1952 self-help sermon, The Power of Positive Thinking. Similarly, Osler's tight schedule, practiced punctuality, and methodical “day-tight compartments” (for which he credited Thomas Carlyle) seem more naturally aligned with the early 20th-century efficiency movement of Frederick Winslow Taylor than with today's time-management gurus.

Osler's world view, like that of many men of his time and station, embraced Darwin and Spencer, war and empire, and medicine as a patrician — not just scientific — calling. And largely from the success of his textbook, but also because he spent the afternoons in a lucrative private consultative practice, he was able to accumulate enough wealth to employ five servants in his Baltimore household and later move into an Oxford mansion — this during the last period in history when (in cultural historian James Laver's words) “the fortunate thought they could give pleasure to others by displaying their good fortune before them.” Osler's ambitions were to be a successful and much-admired generalist physician-teacher, a university don, and an intimate of the classics. His good fortune was to have attained all of these and more.

Explaining why Osler “seldom if ever pontificated about caring and compassion,” Bryan suggests it was because “the subject was not one for serious debate when doctors could often offer little else. Things are different today.” True, the clinical armamentarium is infinitely greater; but practitioners of Osler's time, some of whom were as lacking in compassion as they were in therapeutic options, could surely have benefited from hearing a serious discussion (though not pontification) on this topic. Bryan explains simply that Osler was competent and benevolent and that, “In a sense, acts of benevolent competence are compassion, while compassion without competence is fraud.” Yet he quotes a remarkable example of Osler's thought on caring, albeit in the context of advising students how to avoid boredom in their “humdrum” routine: “Nothing will sustain you more potently than the power to recognize . . . the true poetry of life — the poetry of the commonplace, of the ordinary man, of the plain, toil-worn woman, with their loves and their joys, their sorrows and their griefs.” And this Osler aphorism speaks volumes about compassion: “Care more particularly for the individual patient than for the special features of the disease.”

But Bryan's Osler isn't all saintly perfection, and some of his examples and precepts would be valued less highly in today's culture. His life seems to have lacked intimacy. He kept his career, work, and hobbies foremost, postponed marriage until he was 42, and counseled his younger colleagues to do likewise by putting their affections “in cold storage for a few years,” lest they succumb to a fate like that of George Eliot's character Tertius Lydgate, the young surgeon in Middlemarch whose career is ruined by early marriage to the wrong woman. When his most-favored students left on their obligatory medical tours of Germany, Osler gave them wedding bands as protection from any (in the words of his protégé Harvey Cushing) “matrimonially minded Gretel they might encounter. . . .” Yet, for the trained nurse, marriage was the natural course. “So truly as a young man marred is a young man married, is a woman unmarried . . . a woman undone,” Osler once told a class of nursing students. Perhaps the best known of the Osler guideposts is his advocacy of the calm life (in contrast to “the strenuous life” promoted by his contemporary Theodore Roosevelt). The title address in Aequanimitas (Philadelphia: Blakiston, 1904) — a collection owned by a generation of American medical graduates, courtesy of one of the drug houses — celebrates Osler's devotion to the Stoic philosophers and recommends that young physicians cultivate the Stoics' attitudinal ideal of an emotionless “cheerful equanimity.” He went so far as to urge his students to educate their “nerve centres so that not the slightest dilator or contractor influence shall pass to the vessels of your face under any professional trial.” As Gerald Weissmann once wrote, “Dylan Thomas's rage, not Osler's aequanimitas, ought to be the proper human response to disease and death.”

Since his entire career was spent at academic institutions, it is not surprising that much of the Osler wisdom was directed at various facets of academic life. One bit seems especially apropos now. It might be directed at the phenomenon of multiple authorship, or more particularly to those members of the medical faculty who in their rush to lengthen their vitae insist on appending their own names to their subordinates' papers. Osler's admonition (as paraphrased by his colleague William Sydney Thayer): “Let every student have full recognition for his work. Never hide the work of others under your own name. Should your assistant make an important observation, let him publish it. Through your students and your disciples will come your greatest honor.” As it did to him.

Donald L. Madison, M.D.
University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC 27514

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