Sir William Osler's emphasis on physical diagnosis and listening to symptoms.

DOES Sir William Osler's emphasis on physical examination and communication with patients and other physicians have application in teaching medical students and residents in the 21st century? How did he convey such strong values at the bedside? Why are so many of his aphorisms timeless? You decide.

My first recollections of time spent with Wilburt C. Davison, Dean of the Duke University School of Medicine, founder of the Duke University Medical Center, Professor and Chairman of the Department of Pediatrics, were his daily mentioning, "Osler said this," or "Osler would do this." Sir Williams Osler's picture was on the wall behind his desk, in a position of honor among other notables, but with the absence of diplomas and awards. I had the distinct honor and pleasure to work for him, translating and abstracting pediatric literature from German and English literature and correcting grammar; misspellings, etc, in his textbook, The Compleat Pediatrician. (1) He rarely stated specifically, "Osler said this" in his book or otherwise, but I grew in the opinion that Osler was a great part of this book too. Many times, Dean Davison would tell me (2):

Osler has had more influence on the practice of modern medicine than any other individual in this and the last century. He most successfully blended his universal education and knowledge and excellent scientific background in medicine to simply state better about every disease he encountered than anyone else could. His name was placed upon many syndromes and diseases discovered by others. Yet he did describe many clinical, pathological, and laboratory findings of great importance. His contributions to pediatrics were also extensive in cardiology, infectious disease, endocrinology, genetics, etc. He loved children best of all humanity. His mind was always active. He first thought of finding the tubercule bacillus in the stomachs of children because they swallowed their sputum. He appreciated congenital heart disease, asphyxia, cyanosis, even the effect that absence of abdominal muscles caused in prune-bellied babies. He first pointed out the features of congenital cretinism to the American Pediatric Society (o f which he was a founder and fourth president). He was the penultimate diagnostician, par excellence.

He used to rattle off some of Osler's aphorisms without acknowledging from where they came, possibly because he thought I needed them. I later read many of them (or similar to them) in Sir William Osler's Aphorisms From His Bedside Teachings and Writings Collected by Robert Bennett Bean, M.D., (3) edited by the first president of the American Osler Society, William Bennett Bean:

The practice of medicine is an art, based on science.

There is no more difficult art to acquire than the art of observation, and for some men it is quite as difficult to record an observation in brief and plain language.

The good observer is not limited to the large hospital.

He would almost always end with: "Observe, record, tabulate, communicate. Use your 5 senses." He pushed me to write papers in medical school, though Osler had said, "The young physician should be careful what and how he writes." (3) Davison also said (2):

Use the ophthalmoscope, the retina reflects the brain.

The skin is a mirror of the body. Look to the skin for specific manifestations of diseases.

I have not found these attributed to Osler, but they certainly sound like him.

Dean Davison let me know that I was an academic grandchild of Sir William Osler, and must continue Osler's high ideals and practice. Many of the members of this society are also academic grandchildren, great grandchildren, and possibly even great, great grandchildren of Sir William Osler. Last year Richard 5. Miles, (4) a former student of mine at the University of Louisville School of Medicine, acknowledged this lineage in the Journal of the Kentucky Medical Association. William Smith, a member present today, and Charles Thomas Lucas, a visitor, also share this distinction as do many of you. There are active Osler Societies in North America, Europe, and Asia, whose members continue to meet, write papers, and publish books. In the recent past, we have had books about Osler from members. Charles Bryan's, Osler: Inspiration From a Great Physician (5); Philip Leon's, Walt Whitman and Sir William Osler: A Poet and His Physician (6) Michael Bliss', William Osler: A Life in Medicine (7) and Medicine in Quotations: Views of Health and Disease Through the Ages, by Edward Huth and T. Jock Murray, (8) which greatly favors Osler's quotations. We have soon-to-be published by Dr. Shigeaki Hinohara, an honorary member, and Hisae Niki, Osler's "A Way of Lift" and Other Addresses With Commentary and Annotations, (9) which should help many of us less classically educated to appreciate Osler even more. Numerous articles will continue to be published by members of this Society and many others. These efforts acknowledge that Osler is still alive in medical and literary reviews.

John P. McGovern, founder of the American Osler Society, is the prime example of one who has spent most of his life promoting the high ideals of Sir William Osler in medicine, ethics, and the humanities in his own speeches and writings, and in establishing over 2 dozen lectureships, the last for the History of Medicine at Green College, where he has been acknowledged as the major benefactor who enabled Green College to preserve 13 Norham Gardens, "The Open Arms," home of the Regius Professor of Medicine, Sir William Osler. Many members of this Society have also supported and contributed to this important place. It was most appropriate that the governing body of Green College selected Dr. McGovern as the first Osler Honorary Fellow in the History of Medicine. Green College is one of the major colleges for medicine at Oxford University, so medical students, registrars, fellows, and faculty will continue to have the influence and benefit of Sir William Osler and John P. McGovern in the Osler-McGovern Centre. The Centre will provide facilities for academic visitors and encourage a community of scholars through programs involving lectures, seminars, and small conferences concerning themes that Osler exemplified and related to medical history, health care, ethics, and society. The American Osler Society should be most appreciative for the faithful, kind, and gentle care our member from the United Kingdom, Lord John Walton, has taken of the Osler memorabilia at 13 Norham Gardens for so many years. Yes, the memory and works of Sir William Osler are alive, but our profession and patients all over the world need more knowledge of him.

Sir William Osler first put his hooks into me as a medical student at Duke University, when my wife, Faye, gave me A Way of Life (10) for my first birthday after our marriage. I continue to read and reread it. My children, although not physicians, greatly appreciate it. This book has become a road map for medicine and life for me and so many others. For Christmas that same year, Faye gave me the 2-volume Pulitizer Prize winner, The Life of Sir William Osler by Harvey Cushing, (11) which I read during the holidays. Then I started the second edition of Principles and Practice of Medicine (12) in my spare time, which really impressed Dean Davison, who had recommended that I read this edition first. By spring, a dear friend and Duke divinity student, Harold Metcalf, gave me Sir William Osler's Aphorisms From His Bedside Teachings and Writings Collected by Robert Bennett Bean, M.D. (3) Robert Bennett Bean, MD, was the father of the editor, William Bennett Bean, MD, first president of the American Osler Society. An inscription in Greek, which I could not read, was translated for me as "pray without ceasing." I have saved this copy, but have given away and worn out several other copies. Dean Davison was correct, "Sir William Osler could state anything more simply, beautifully and with more wit and humor than anyone else." (2) His aphorism about history taking from patients, symptoms, signs, note taking, then on to the library, I appreciate, as do many of you, while I am with patients, students, residents, fellows, and faculty. I am pleased and honored to teach medical students in the wards, clinics, and in my travels, as I am sure you are.

Earl F. Nation and John P. McGovern (13) gave us Student and Chief: The Osler-Camac Correspondence, which showed the great bond, friendship, and many cooperative efforts between Osler and Camac; in this book are many of their shared observations and experiences with patients and research. Osler gave Camac permission to publish Counsels and Ideals From the Writings of William Osler. (14) Their correspondence revealed that Osler used every instrument, laboratory test, and even photography to teach and show the clinical changes of scleroderma, gallstones, liver signs, abdominal aortic aneurysm, trypanasomiasis, and even the observation of recovery from paralytic poliomyelitis during an epidemic. Diagnosis was paramount. Outcome and prognosis were given in numbers and percentages for survival and morbidity.

C.N.B. Camac was possibly Osler's first student who tried hardest to pass on the wisdom of his great chief to everyone in medicine. Osler was pleased with Camac's efforts and work too. In Counsels and Ideals, (14) Camac got to the essence and message of Osler's speeches, conferences, and at the bedside:

'Take as little as possible on trust,' Osler taught him from Hunter and to use 'Do not think, but try. Attitude of mind is the important one to cultivate.' The question came up one day, when discussing the grooves left on the nails after fever, how long it took for the nail to grow out, from the root to the edge. A majority of the class had no further interest; a few looked it up in books, 2 men marked their nails at the root with nitrate of silver, and a few months later had a positive knowledge on the subject. They showed the proper spirit.

Routines and systems when once made a habit facilitate work and the busier you are the more time you will have to make observations after examining a patient. Jot a comment at the end of the notes clear case, illustrating obscurity of symptoms; error in diagnosis, etc.

Richard E. Verney, in The Student Life: The Philosophy of Sir William Osler, (15) stressed Osler's desire to teach diagnosis, pathology, prognosis, and treatment at every chance:

Of still greater educational value is the clinical side of the [medical] Society. No meeting should be arranged without the presentation of patients, particularly those illustrating rare and unusual forms of disease. Many diseases of the skin and the joints, a host of nervous affections and many of the more remarkable general maladies, as myxedema, cretinism, achondroplasia, etc, are seen so rarely and yet are as distinctive, requiring only to be seen to be recognized, that it is incumbent upon members to use the [medical] society to show such cases.

Today we still recognize better attendance and interest in such meetings when we use Osler's suggestions.

Osler's words on progeria, rarely seen after adolescence, ring so true today (15):

A rare, but still more extraordinary, bodily state as that of progeria, in which, as though touched with the wound of some malign fairy, the child does not remain infantile but skips adolescence, maturity, and manhood, and passes at once to senility, looking at eleven or twelve years like a miniature Tithomus marred and wasted, wrinkled and stunted, a little old man among his toys.

You have seen and remember this most exact and eloquent statement. Osler calls across the ages from The Army Surgeon: (15)

Observations are made with accuracy and care, no pains are spared, nothing is thought a trouble in the investigation of a problem. The facts are looked at in connection with similar ones, their relation to others is studied, and the experience of the recorder is compared with that of others who have worked upon the question.

This process is still necessary, but computer science has made our work easier. This gives us, and would have given Osler, more time for other activities, problems, and entertainment; time to read more books.

Richard E. Verney (15) uses Osler's statement from The Student Life, "The whole art of medicine is observation, as the old motto goes, but to educate, the eye to eye, the ear to ear, and the finger to feel takes time, and to make a beginning, to start a man on the right path, is all that we can do." Osler was most appreciative of and lauded America's first physiologist, William Beaumont, in The Army Surgeon (15):

Who amid circumstances the most unfavorable saw his opportunity and was quick to grasp the skirts of happy chance....On June 22, 1822, the accidental discharge of a musket made St. Martin a voyageur, as one of the most famous subjects in the history of physiology, for the wound laid open his stomach, and he recovered with a permanent gastric fistula of an exceptionally favorable kind.

Thus, Beaumont established the signs, symptoms and physiologic principles that he learned from studies of gastric function under different dietary and other influences.

The aphorisms of Sir William Osler are the largest collection included in Medical Quotations: Views of Health and Diseases Through the Ages by Edward Huth and T. Jock Murray (8) of the American Osler Society. I only have time for a few that are cogent to the subject, but hope you will read them all:

Failure to examine the throat is a glaring sin of omission, especially in children. One finger in the throat and one in the rectum makes a good diagnostician.

The four points of a medical student's compass are inspection, palpation, percussion and auscultation.

One swallow does not a summer make, but one tophus makes gout and one crescent, malaria.

A patient with a written list of symptoms--neurasthenia.

Never forget to look at the back of a patient. Always look at the feet. Looking at a woman's legs has often saved her life.

Don't touch the patient--state first what you see, cultivate your powers of observation.

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

In taking histories, follow each line of thought; ask no leading questions; never suggest. Give the patient's own words in the complaint.

Never ask a new patient a question without a notebook and pencil in hand.

Learn to see, learn to hear, learn to feel, learn to smell and know that by practice alone can you become experts.

Medicine is learned by the bedside and not in the class room. Let not your conception of manifestations of disease come from work heard in the lecture room or read from the book: see and then research, compare and control. But see first.

Time does not permit me to say more, but I am sure you will continue to enjoy Osler's wit and knowledge. We cannot escape the need for learning to communicate with patients and to learn physical diagnosis. Osler would have us use our brains, but encourage use of new technology to bring better and quicker diagnosis and treatment to our patients, and to speak out to the profession and society about their patients' needs. Yes! Osler's spirit is still among us to point out the highest values in medicine and life. We should all work hard to see that his ideals remain with our profession.

I close with my material expressed in rhyme to honor not only Sir William Osler, but also Dean Wilburt C. Davison, John P. McGovern, and my wife, who brought me to him:

Osler, Signs and Symptoms and Change


Osler would have us respect change as a law of Nature,
To observe each new form and characteristic,
To control if harmful or bad, if for good to nurture,
And to study change with evaluation, research and statistics.

Osler would have us think of change
As we commit ourselves to each task,
That we envision a wider range
Of options and better questions to ask.

From the vast store of knowledge of medicine, we share,
There are treasures to challenge the imagination.
For Nature's portentous power we appreciate and fear,
Yet this power we must courageously harness, use,
and ration.

We must learn all about life we can, and be bold,
To seek the experience of mighty Nature's flow,
And accept and be a positive part of change,
To take and use every opportunity to grow.

Osler's shining example and use of descriptions of diseases
With signs and symptoms with which patients present,
Will continue to be of value to physicians through the ages
As they see change in each patient with whom time is spent.

Pay attention to the patient's symptoms and chief complaint.
Across the centuries Osler will continue to call;
Change in physical and mental signs to pursue without
restraint,
Our profession to honor and patient to serve above all.

I thank each of you for your attention, patience and for the 30 wonderful years of association with the American Osler Society, which has so greatly enriched my life and the lives of many. Again, thank you.

References

(1.) Davison WC, Levinthal JD: The Compleat Paediatrician. Durham, NC, Duke University Press, 7th Ed, 1957

(2.) Andrews BF: Memories, Moments and Meditations of a Medical Student. (In prepation)

(3.) Bean WB (ed): Sir William Osler: Aphorisms From His Bedside Teachings and Writings Collected by Robert Bennett Bean, M.D. New York, Henry Schuman Inc, 1950

(4.) Miles RS: Medicine: the art of metamorphosis. J Ky Med Assoc 2000: 98:74-77

(5.) Bryan C: Osler: Inspiration From a Great Physician. New York, Oxford University Press, 1997

(6.) Leon PW: Walt Whitman and Sir William Osler: A Poet and His Physician. Toronto, Canada, ECW Press, 1995

(7.) Bliss M: William Osler: A Life in Medicine. New York, Oxford University Press, 1999

(8.) Huth EJ, Murray TJ (eds): Medicine in Quotations: Views of Health and Disease Through the Ages. Philadelphia, American College of Physicians, 2000

(9.) Hinohara S, Niki H: Osler's "A Way of Life" and Other Addresses With Commentary and Annotations. Durham, NC, Duke University Press, 2001

(10.) Osler W: A Way of Life. New York, Harper & Brothers, 1937

(11.) Gushing WH: The Life of Sir William Osler. New York, Oxford University Press, 1940

(12.) Young J: Principles and Practice of Medicine. London, Pentland, 2nd Ed, 1897

(13.) Nation EF, McGovern JP: Student and Chief The Osler-Camac Correspondence. Pasadena, Calif, Castle Press, 1980

(14.) Camac CNB: Counsels and Ideals From the Writings of William Osler. New York, Houghton Mifflin & Co, 1906

(15.) Verney RE: The Student Life: The Philosophy of Sir William Osler. London, E & S Livingstone, 1957

RELATED ARTICLE: KEY POINTS

* Sir William Osler has had more influence on the practice of modern medicine than any other individual since the 19th century.

* Numerous aphorisms of Osler related not only to signs and symptoms are most pertinent to the practice of medicine today.

* Active Osler Societies in North America, Europe, and Asia have members, along with others, who continue to meet, discuss, write papers, publish books, and continue Osler's work and message.

* The establishment of facilities such as the Osler-McGovern Centre, Green College, Oxford, 13 Norham Gardens, "The Open Arms," home of Sir William Osler, will continue to encourage scholars and students through programs related to medical history, health care, ethics, and society.

From the Department of Pediatrics, University of Louisville, Louisville, Ky. (Dr. Andrews is a visiting fellow at Green College, Oxford, England.)

Originally presented as a speech at the American Osler Society Annual Meeting, April 18, 2001, Charleston, SC.

Reprint requests to Billy F. Andrews, MD, Kosair Charities Pediatric Center, 571 S Floyd St, Suite 449, Louisville, KY 40202.