The Tale Of Three Physicians

The tale of three physicians ~ Sir Thomas Browne 1605-1682 , Sir William Osler 1849-1919 and Sir Geoffrey Keynes 1887- 1982 . Three physicians, linked over the centuries by a shared love of literature and medicine . And by chance .

Sir Thomas, the goode physician of Norwich and writer of Religio Medici .- the Religion Of A Physician – first printed in 1642 . Sir William Osler – a founding father of Johns Hopkins and later Regius Professor of Medicine at Oxford University . Osler acquired his first copy of Religio Medici at age seventeen when , declaring himself ” athirst for good literature ” , he was given a volume while at Trinity College . Religio Medici became Sir William’s lifetime companion . And in 1908, Geoffrey Keynes , then a second year undergraduate at Cambridge first made acquaintance with Osler – through a shared love of the work of Browne .

” To read Sir Thomas Browne is always to be filled with astonishment , to remember the surprises, the despondencies, the unlimited curiosities of youth … We are in the presence of sublime imagination .” Virginia Woolfe

Yet Sir Thomas is not for the faint hearted reader . Woolfe describes ” the splendid pomposities, the astonishing conjectures ” of the Religio Medici . Browne reflects on the inner loneliness of humanity .There are confronting passages – the physician’s thoughts on the limits of mortality . “Oblivion is not to be hired… The night of time far surpasses the day, and who knows when was the AEquinox …. our longest sunne sets at right descencions , and makes but winter arches… ” ” But the iniquity of oblivion blindely scattereth her poppy and deals with the memory of men without distinction to merit of perpetuity .” ( Urn Burial )

What is one to make of the quaintness of the quincunx . ( Garden Of Cyrus ) Quincunx : geometric pattern consisting of five points … ) ” For all things are seen Quincunxially ; for at the eye the Pyramidal rayes , from the object, , receive a decussation… ” ( Garden Of Cyrus ) . Browne is not without his critics . And passages such as ” Pyramids, Arches and Obelisks were but the irregularities of vain-glory, and wilde enormities of ancient magnanimity ” led one critic to describe Browne’s work as ” splendidly baroque arrogance .”

Yet Sir Thomas was not an arrogant man . Educated at Oxford, Leiden and Montpelier and knighted by King Charles, he chose to live his life with his wife and children in Norwich . And to write and to care for his patients . ” He was charitable and brave and adverse to nothing. He was full of feeling for others .” ( Woolfe )

Of himself he wrote : ” For my Conversation, it is like the Sun’s, with a friendly aspect to good and bad .” ” I rejoyce not at unwholesome Springs, nor unseasonable Winters : my Prayer goes with the Husbandman’s.” ( Husbandman – one who tills the soil . ” Sir, I am a true labourer .” Shakespeare . As You Like It . )

Browne wrote of the illnesses suffered by his patients saying that he would , like Caesar, ” wish rather to go off at one blow, than to be sawed in pieces by the grating torture of disease . Men that look no further than their outsides, think health an appurtenance unto life, and quarrel with their constitutions for being sick ; but I that have examined the parts of man, and know upon what tender filaments that Fabrick hangs… do thank my God we can die but once .”

Freed from the constraints of inward ponderings on the mysteries and maladies of mortality though Sir Thomas soars like a bird . ” Life is a pure flame and we live by an invisible sun within us . ” Darknesse and light divide the course of time , and oblivion shares with memory , a great part even of our living beings … Sense endureth no extremities, and sorrows destroy us or themselves . Miseries… fall like snow upon us… ” Browne reflects however that ” The Caterpillar will shew again in the Butterfly .”

The emphasis here in not solely on Sir Thomas’ writings though – it is on that unique combination of skills – as a caring, compassionate physician and as among ” one of the greatest of English prose writers.” ( Keynes) Nowhere is this more evident than To A Friend Upon Occasion Of The Death Of His Intimate Friend . Browne combines clinical acumen with compassion , insight and writing of great beauty . ” Give me leave to wonder that News of this nature should have such heavy Wings… Upon my first visit I was bold to tell them who had not yet fall hopes of his Recovery, that in my sad Opinion he was not like to behold a Grasshopper, much less to pluck another Fig… He was fruitlessly put in hope of advantage by change of Air… but being so far spent, he quickly found the most healthful air of little effect, where Death had set her Broad Arrow . ( Broad Arrow: a mark made upon the trees in the King’s forests that were to be felled . ) … With what strife and pains we came into the World we know not ; but ’tis commonly no easie matter to get out of it … He was now past the healthful Dreams of the Sun, Moon and Stars in their Clarity and proper Courses.”

The physician notes in their friend the appearance of the Hippocratic facies . ( A diagnostic term derivative from the Hippocratic Corpus , meaning the facial appearance of a person close to the end . ) Death had indeed set its Broad Arrow Keynes writes of The Letter as ” one of Browne’s most remarkable compositions being a clinical report on one of his patients converted into a literary masterpiece.

” A man very well studyed .” Thomas Browne – Naturalist .

Sir Thomas : Sketch of a seabird . A Natural History Of Norfolk . (Graphic collage. )

The physician, writer – polymath was also a noted naturalist . References to the art of nature appear throughout his writings . And he observes that ” Right lines and circles make out the bulk of plants . In the parts therefore we find heliacal or spiral roundness, volutes, conicall Sections, circular Pyramids… And cannot overlook the orderly hand of nature .” ( Garden of Cyrus . Fibonacci Sequence . 12th Century . )

Sir Thomas Browne died in 1682 at the age of seventy seven . Writing as often of the iniquity of oblivion – ” We cannot hope to live so long in our names , as some have in their persons .” – what might he thought of the young Canadian student who nearly two hundred years later was first read Religio Medici ?

William Osler was born in Canada in 1849 . At age seventeen while a student at Trinity College he was undecided between the ministry and medicine . He had already attended lectures on medicine , but was uncertain . Sir Thomas Browne’s effect on the young student was profound . ” It moreover is an important thread which from this time weaves its way through Osler’s story to the end.” ( Harvey Cushing . The Life of Sir William Osler .)

It is not difficult to ascertain the appeal Browne’s work would have had for the young Osler . Already an ardent reader – and later a noted bibliophile – Osler would have delighted in being introduced to such a unique literary work . And Browne’s work is quite unique . It is not only a work of great literacy , but a strongly individualistic statement of a caring and compassionate physician . And a keenly curious and observant mind .

And for the as yet undecided medical student , it is not difficult to find in Browne’s writings – particularly Religio Medici and Letter To A Friend – the passages that would so strongly influence Osler’s practice of medicine . The physician’s struggles with illness and mortality : ” There be diseases incurable in Physick… I , that have examined the parts of man , do know upon what tender filaments that Fabrick hangs .” Religio Medici )

And Browne is unafraid to speak out against those physicians he views as making ” scarce honest gain.” “I feel not in me those sordid and unchristian desires of my profession ; I do not secretly implore and wish for Plagues… I am…. heartily sorry… there are diseases incurable; yet not for my own sake, or that they be beyond my Art, but for the general cause of humanity . ” ( Religio Medici) The strongly ethical element in Browne’s writing influenced and shaped the young Osler’s early years of practice and were a constant throughout the physician’s lifetime .

Osler began his medical studies in 1868 – the beginning of a long and distinguished career . ” Give me… the old Hippocratic service of the art and of the science of ministering unto man, and I will come .” ( Harvey Cushing ) Osler shaped the teaching of medicine in a way that continues to this day – the residency system, teaching at the bedside . And his maxims pertaining to good patient care and diagnosis seem more than ever relevant as technology increasingly influences and intrudes on the principles Osler defined : ” Listen to your patient , he is telling you the diagnosis .” ” Medicine is learned by the bedside and not in the classroom.” In an address to graduating medical students in 1889 Osler said : ” I desire no other epitaph … than … that I taught medical students in the wards.. ” Aequanimitas .

The writings of Sir Thomas Browne, his compassion for the patient and their illness find perpetuity in the writing and teachings of the Canadian physician throughout his lifetime .” Nothing will sustain you more potently than the power to recognise… the true poetry of life – the poetry of the commonplace , of the plain, toil-worn woman, with their loves and their joys, their sorrows and their griefs .” Sir Thomas : ” My prayer is with the Husbandman’s….” ” Of the three factors in practice, heart, head, and pocket, and to our credit, be it said, the first is most potent .” Osler . There was no clinical detachment in Osler’s approach to patient care – the emphasis was on ” the kindly word, the cheerful greeting, the sympathetic look.” ” The complex varied influences which mold the minds of developing physicians… Only come with that sustaining love that burns bright or dim as each are mirrors of the fires for which all thirst.”Osler on the ” work of clinicians – physicians dedicated to the care of their patients .” Osler 1894 The Leaven Of Science ( Ref.www.ericcassell.com)

Osler insisted that wide reading accompany his student’s learning . It is unlikely though that today’s busy medical student could find time for such indigestibles as the weighty tomes of Galen – physician to the Emperor Marcus Aurelius . Harvey Cushing writes of Osler : ” How he found time to acquire his familiarity with general literature has always been a source of mystery… Most medical students, alas, are too engrossed with their work for such literary pursuits, desirable though they may be .”

Given Osler’s extraordinary breadth of reading, it is not difficult to find in his writings acknowledgement of other physicians : the great Jewish physician Maimonides 12th. century CE : ” May I never see in the patient anything but a fellow creature in pain.” The Daily Prayer Of the Physician , attributed to Maimonides (?) is sometimes used in place of the Hippocratic Oath . ” Inspire me with love for my Art… Do not allow thirst for profit, renown or admiration, to interfere with my profession…”

And it is hard to resist here a comparison of one of Osler’s famous quotations with the writings of the ancient Indian physician and surgeon , Sushruta . Osler : ” He who studies medicine without books sails an unchartered sea, but he who studies medicine without patients does not go to sea at all .” Sushruta : ” The student who hath only learning and not practice is like an ass laden with logs of sandalwood .” The sacred Sanskrit texts first became available in the early 20th Century and it is easy to imagine how the sayings interspersed throughout the text would have appealed to Osler’s notorious sense of humour . ” One should flee the incompetent physician as one would a conflagration .” Sushruta .

Among the items in Osler’s library was a text derivative from ancient Sanskrit and worth quoting – it epitomises Osler’s approach to life :

Salutation To The Dawn

“… Look to this Day ! For it is Life, the very Life of Life. In its brief course lie all theVerities and Realities of your Existence… Look well therefore to this Day .” Kalidasa 2500 BCE

Throughout Osler’s writings and teachings it is Browne that dominates . Not all are so loyal to Sir Thomas . Browne divides his followers for a variety of reasons . And his writings are in places difficult to navigate . Herman Melville termed him a ” cracked archangel .” But Coleridge described Browne as ” rich in various knowledge ; exuberant in conceptions and conceits ; contemplative, imaginative .” And, as stated , it is also the strong ethical principles in the Religio Medici – the Religion Of the Physician – that would have had such meaning for Osler . He was never without his copy of the Religio Medici .

Osler’s work as a bibliographer began in 1867 while still a student . He must have had prodigious energy to read and write as he did . His text The Principles and Practice Of Medicine became a standard teaching text for many years . At the time of his death , Osler’s library comprised thousands of volumes he had collected, most of which went to his alma mater , McGill University .

It was through a shared love of the writings of Browne that Geoffrey Keynes first made Osler’s acquaintance . Like Osler, Keynes was an avid reader and collector .The young medical graduate later went on to become a surgeon – and was responsible for a number of particularly innovative advances in surgery and medicine . He also became a noted bibliographer – of William Blake, John Donne, Jane Austen – and Sir Thomas Browne . Keynes had an early interest in the work of Browne .

And it was through this interest Keynes in 1909, still a young medical undergraduate at Cambridge, was granted the friendship of Osler , Regius Professor Of Medicine at Oxford . Keynes and a friend , having already having already begun work on a bibliography of Browne , decided to write to Osler on the pretext of being able to view Osler’s library . Despite Osler and his wife Dorothy being noted for their hospitality, Keynes was not optimistic of a response . Instead says Keynes , in his Oslerian Oration to the Royal College Of Physicians in 1968 , he was ” granted the friendship of a man thirty eight years my senior .” A friendship which lasted until Osler’s death in 1919 .

Osler acquired his first copy of Religio Medici in 1862 . Osler’s work on a bibliography of Browne’s work first began in 1899 says Keynes, when he acquired an authorised edition and two unauthorised editions of Religio Medici .” As likely as not, it was this purchase that led him into the bibliophilic pursuit of gathering a complete set of all the editions ..” Although Osler’s book collecting forays began much earlier and included Shakespeare, Harvey , Coleridge, Locke, Emerson – and particularly copies of Vesalius’ De humani corporis fabrica . The move from Johns Hopkins to Oxford in 1905 meant a reduction in his workload – and more time to devote to his beloved books .

In a 1902 address to the Association Of Medical Librarians Osler said that ” … the true bibliophile cares not so much for the book as for the man whose life and mind are illustrated in it .” But disappointment awaited Osler with regard to the completion of the bibliography of Browne . Keynes’ work was disrupted by the First War . As a surgeon in the Royal Army Medical Corps Keynes witnessed the unforgettable horror of war in the trenches . Keynes wrote ” The pattern of war is shaped in the individual mind by small individual experiences, and I can see these things as clearly today as if they just happened – the body of a terrier… lying near his master . ”

Osler too knew full well the sorrow of the First World War, when his loved son Revere was killed . An event from which Osler never recovered .

Returning to civilian life Keynes was quickly caught up in the demands of surgical practice . He continued though to search for Browne’s writings and work on the bibliography . Keynes writes with delight of his discovery of a manuscript Commonplace Book of Browne’s Letter To a Friend… in a London bookshop for the sum of three guineas .The manuscript contained an as yet unknown passage which Keynes had published in 1919 by Cambridge University Press .

Whether Osler ever sighted this is uncertain . In July, 1919 , at the time of his seventieth birthday Osler became ill with an episode of bronchial pneumonia . It was an illness from which he had suffered previously . However it became evident this time there would be no resolution – the illness was protracted . There were paroxysms of coughing, which he wrote ” Almost blew out my candle .” On a December evening , too weak to manage for himself, he asked to be read his favorite passage by Sir Thomas : ” But the iniquity of oblivion blindly scattereth her poppy , and deals with the memory of men without distinction to merit of perpetuity …. ”

The end came on December 29th . Among the many tributes paid to Osler was the following : ” He advanced the science of medicine, he enriched literature and the humanities … ” Osler left a legacy that will never know ” the iniquity of oblivion .”

Keynes finished his bibliography of Sir Thomas Browne in 1924 . While the work met with critical acclaim , it was to Keynes’ lasting regret that Osler never sighted the work . The very most Keynes could do was dedicate it to Osler – his friend and mentor . ” An outstanding clinician and a book collector… who used his books fruitfully and with generous consideration of the needs of others .” (The Gates Of Memory G.Keynes.)

The Tale Of Three Physicians is the tale of a bygone era in medicine ~ of the physician who in addition to the demands of practice , had time for reading and wide scholarship . The teaching maxims of Osler though remain of even greater importance as time and technology increasingly intrude on practice . ” Listen to your patient , he is telling you the diagnosis .”

And the aspiring medical student can find no greater insight into their chosen profession than to read Osler’s valedictory address to graduating medical students at the University of Pennsylvania in 1889 :

AEQUANIMITAS

“.. you poor, careworn survivors of a hard struggle.. my tender mercy constrains me to consider but two of the score of elements which may make or mar your lives – which may contribute to your success, or help you in days of failure .

In the first place, in the physician or surgeon, no quality takes rank with imperturbability, and I propose for a few minutes to direct your attention to this essential bodily virtue… Impertability means coolness and presence of mind under all circumstances, calmness amid storm , clearness of judgement in moments of grave peril… Aequanimitas – a calm equanimity is the desirable attitude . How difficult to attain, yet how necessary, in success as in failure ! … Remember too that sometimes ” from our desolation does the better life begin.” … you may , in the growing winters, glean a little of that wisdom, which is pure, peaceable, gentle, full of mercy… without partiality and hypocrisy …”

” … Farewell, and take with you into the struggle the watchword of the good old Roman – Aequanimitas . ” ( Aequanimitas – spelling as given by the Roman Emperor and philosopher Marcus Aurelius . )

FINIS

Osler Library Of the History Of Medicine at McGill University