Tea with Sir William Osler
==========================

* D. J. Weatherall

*Having unexpectedly recovered after 70 years of cryopreservation precipitated by the heating arrangements in the bedrooms of 13, Norham Gardens, Oxford, where he was Regius Professor of Medicine, Sir William Osler recently visited the current Regius Professor to take tea with him in the Master's Garden at the Almshouses of Ewelme. Excerpts from the tea-time conversation between the "Regii" follow.* 

**DJW:** Sir William, it is wonderful to see you back in the Oxford scene again, but I suspect you must have mixed feelings. In your valedictory address to Johns Hopkins University, just before you moved to Oxford, you suggested that men over 60 are useless in commercial, political and professional life. Indeed, I believe that you concluded your speech by concurring with Anthony Trollope's suggestion that an institute be established to which men aged 60 years could retire for a year's quiet contemplation before a peaceful departure by chloroform.

**WO:** Yes, although I suspect my colleagues thought that I was jesting, in truth I was never very happy about the prospects of growing old. It was a happy coincidence that I was invited to the Regius Chair in Oxford because, after visiting the university, I couldn't imagine anywhere less stressful in which to pass my final years of contemplation, although, after experiencing a night or two in an English bedroom, I soon realized that chloroform would not be necessary.

**DJW:** I thought that you might like to meet out here at Ewelme rather than in Oxford. Curiously, it is not well known that the Regius Chair of Medicine in Oxford also carries the title of Master of the Almshouses of Ewelme. The current Vice-Chancellor of Oxford University was completely unaware of this fact when I mentioned it to him recently, though I believe it dates from the time of James I. Like you, I chair the meetings of the Trustees, and we still look after the needs of the old people who live in these beautiful buildings, established by a relative of Geoffrey Chaucer. To refresh your memory of your times here, I have brought along this rather battered but still beautiful book, *Historical Notices of the Parishes of Swyncombe and Ewelme,* published in 1858, which bears the inscription "Sarah Angelina Acland gives this book to Dr. W. Osler, Oxford, August 12th, 1906." I see that you have written on the same page "This book is to go to Ewelme and to be handed on from Master to Master in memory of Sir Henry Acland." So far, your wishes have been followed; I shall be passing it on to my successor next year. (Figure)

![Figure1](http://www.cmaj.ca/https://www.cmaj.ca/content/cmaj/161/7/837/F1.medium.gif)

[Figure1](http://www.cmaj.ca/content/161/7/837/F1)

Figure. Almshouses at Ewelme, where the conversation between the "Regii" took place. Reprinted from *Historical Notices of the Parishes of Swyncombe and Ewelme in the County of Oxford,* by the Honorable and Reverend Henry Alfred Napier, 1858.

**WO:** Yes, indeed, Acland did so much to improve conditions for the old people here. I knew many of them well. They were not all old; I looked after patients here with Friedreich's ataxia and alkaptonuria for many years, and occasionally I brought students out to see my "country practice." As you probably know, the Trustees were kind enough to erect a plaque in the beautiful church in Ewelme in memory of my son Revere. Though tinged with sadness, I remember spending many happy hours in this place. But enough of the past, what I really want to know is what has happened to medical practice over the last 80 years.

**DJW:** Where to begin? It has been a most extraordinary period for the development of the medical sciences. You will certainly find that the Oxford scene has changed beyond all recognition. Two events occurred that had a major impact on medicine in Oxford after your time. First, a rich businessman, Lord Nuffield, was persuaded by one of your successors to donate a large sum to the university to establish a clinical school. At about the same time, World War II broke out, and because London was being bombed incessantly, medical students were evacuated to Oxford to complete their training. Although Nuffield and his advisors had originally conceived that his benefaction would be used to found a postgraduate research school, in the event, and mainly due to the efforts of Adolf Hitler, an undergraduate medical school evolved at Oxford. You will be delighted to hear that it is based very much on the traditions that you and your colleagues established at Johns Hopkins all those years ago.

**WO:** You mean a system of student apprentices and tiers of residents in training?

**DJW:** Yes, although now rigidly controlled by the Royal Colleges and other bureaucracies in ways that you wouldn't have imagined possible.

**WO:** And what of the Radcliffe Infirmary, where I used to attend on Sunday mornings to do my teaching rounds?

**DJW:** It's still there and probably hasn't changed much since your time. It will be closed shortly and its departments amalgamated with a teaching hospital built in Headington in the late 1970s named, much to the confusion of the local taxi drivers, the John Radcliffe Hospital. This is now the home of the Clinical School and, together with the Churchill Hospital, another relic of World War II, forms a large complex in Headington, just outside the city.

**WO:** And how has clinical practice changed over this period?

**DJW:** Quite dramatically. When I looked through the first edition of your book, *The Principles and Practice of Medicine,* published in 1892, there was virtually no form of definitive treatment for any of the diseases you discussed. I don't think this changed much in the other editions that you wrote, or in the single-author editions that followed. Current texts, such as the *Oxford Textbook of Medicine,* written by almost 500 authors, do not describe many diseases for which something cannot be done, although to be honest those that can be prevented or cured are still in the minority. Perhaps the greatest advance of this period has been the partial conquest of infectious disease. You lived through a period that, against a background of considerable scepticism I believe, saw the dawning of an understanding of the causes of at least some infectious diseases. Later, vaccines became available that could prevent some serious infections, and drugs called antibiotics appeared on the scene. For example, penicillin, which was first developed for clinical use in the Dunn School of Pathology in Oxford at the beginning of the war, was found to cure a wide variety of infections, from pneumonia to syphillis. Many other antibiotics soon followed, including several that were able to cure tuberculosis. It was a remarkable period of medical advance.

**WO:** So infectious disease has been largely eradicated?

**DJW:** Well, not exactly. A few diseases, smallpox for example, appear to have disappeared, but many organisms are becoming resistant to antibiotics and other agents. We are seeing a frightening increase in drug-resistant tuberculosis, a major resurgence of malaria, a disease in which I believe you were particularly interested, and the decimation of large populations by new and frightening viral infections. The cunning of the world of microorganisms is proving to be much greater than that of the pharmaceutical industry.

**WO:** And what of the other major killers?

**DJW:** You saw the dawn of physiological chemistry and the application of developments in physiology and a greater understanding of pathology to the practice of medicine. This trend gathered extraordinary momentum. Over the last 50 years more and more has been learned about organ systems and their pathology. They can be visualized, their function assessed and their chemistry dissected in ways you could never have dreamt possible. But the increasing knowledge of disease mechanisms has not often been accompanied by a genuine understanding of their causes. Hence, we are living in a time of high-technology "patch-up" medicine. The control of infectious diseases and our ability to treat but not often cure the diseases of middle life have resulted in a remarkable increase in life expectancy, but modern medical practice is highly technological, extremely expensive and rather fragmented.

**WO:** This sounds like a frightening scene. How have patients fared in all this?

**DJW:** In the rather heady days after World War II, and with the apparent conquest of infectious diseases, people came to believe that medical science was capable of almost anything. Unfortunately, the chronic diseases of Western society that took their place - heart disease, stroke, psychiatric illness and many forms of cancer - were much harder to control. The public became somewhat disillusioned, and because modern medicine was perceived to have failed and to have become rather soulless and technological, many people sought help from what became known as alternative, or complementary, medical practitioners. Although you probably would be startled by some of the forms of therapy that are now being offered to patients, much of the success of these forms of practice is, I suspect, due in no small part to the time that the practitioners spend with their patients. I fear that some of the pastoral skills that you held to be of such great importance have been lost from conventional medicine in recent years. This is due in part to the enormous pressures on doctors. Because so much more can be done, their workload has increased dramatically. And nobody has figured out how to pay for it; whether it is the government-based funding of Great Britain or the marketplace-orientated health care system of North America, it has been impossible to contain costs. Unlike what I suspect happened in your time, doctors spend much of their time these days on committees, trying to improve their efficiency and attempting to cope with the enormous bureaucracies that control health care. This rather frenetic scene is tending to drive the doctors in our teaching hospitals away from their patients, students and research laboratories and is turning them into a mixture of businessman and politician.

**WO:** Is medical research making any inroads into these problems?

**DJW:** Over the last 20 years, there has been a remarkable revolution in the biological and medical sciences. The focus of attention has changed from patients and their organs to disease at the molecular and cellular level. Although inherited factors in disease did not make any impact during your time, your successor as Regius Professor in Oxford, Archibald Garrod, predicted in a remarkable book, written just before he died, that our inherited biochemical individuality is a major factor in making us more or less susceptible to the many environmental agents that provoke disease. In recent years it has been possible to dissect our genetic machinery, and we can now begin to define disease at the level of molecules and cells. This is starting to yield remarkable insights into what were once mysterious conditions - cancer, psychiatric disease and dementia, for example. If you were to visit the teaching hospitals today, you would find that even within their clinical departments many scientists carry out research at a level that you would have considered to be very basic. I suspect that you might not approve of this, because I know you felt that this kind of activity should be restricted to science departments. But, in truth, modern medical research is a seamless continuum between molecules and cells, patients, and the community. However, these exciting new avenues of research so far have not led to many major advances in prevention or treatment.

**WO:** How does an ancient university like Oxford cope with this revolution in science? In my last year at Oxford I was elected President of the Classical Association, and in my presidential address, which I seem to remember owed much to my long-standing love of the works of Sir Thomas Browne, I pointed out to the university that, although it carried a heavy burden of classical learning, I found the character of the place, particularly its Greats, completely lacking in an understanding of the claims of the role of science in modern learning. Indeed, I remember accusing them of virtually ignoring Aristotle as the founder of modern biology and attacking them on their treatment of Lucretius, whom I considered to be the greatest nature-poet. I don't think they were too pleased, or even understood my message.

**DJW:** The rather sterile debate and tension between the "two cultures" has continued unabated since your brilliant address. It reached its peak in a major confrontation between C.P. Snow and F.R. Leavis, an author and a critic, and still continues. In Oxford, science has never been fully accepted as the kind of pastime that is fit for gentlemen. But perhaps urged on more by a shortage of money than by the claim of modern physics that a "theory for everything" will soon be found, after 800 years the university is finally reorganizing itself so that the two cultures will be on something approaching an equal footing.

**WO:** It all sounds very bewildering. Perhaps the traditions of Sydenham and the importance of clinical method and an ability to talk to sick people, which my generation tried to encourage, are lost forever.

**DJW:** I don't think so. Undoubtedly, medical research and clinical practice have gone through a remarkable period of reductionism and high technology. The new millennium will require a more holistic approach to biomedical research and clinical practice. In a few years we will have a dictionary of all our genes, and then we will have the immense problem of trying to find out how they are orchestrated to make us what we are. This field has disclosed a level of biological complexity that would have been undreamt of in the past. It has tended to reunite the specialties of medicine, particularly in research, so that they use the same tools of laboratory investigation to address their particular problems. But above all, it has emphasized that each of us is unique. Over the last few years, there has been a major change in thinking about medical education, with a wish to return to the approaches that you taught all those years ago. In clinical medicine this emphasizes the skills of communication and clinical method that formed the tradition you left behind. It recognizes that, however far we reach in our understanding of disease mechanisms, because of their complexity and our remarkable variability in response to illness as individuals, medicine will always remain the kind of art that you so elegantly described in all your writings, and that the need for rounded personalities among its practitioners, which you stated so clearly, will be greater than ever in an increasingly complex world.

**WO:** You sound optimistic for the future.

**DJW:** Yes, I am. The benefits of the recent revolution in biology for patients may be a long time coming. You must well remember how, when Koch described the discovery of the tubercle bacillus in the early 1880s, the newspapers proclaimed that it was the end of the great killer. In fact, it was another 70 years before an American, Selman Waxman, announced the discovery of streptomycin, the first antibiotic that was effective against the disease. But I am sure that major advances will come, if not in my lifetime. We have lived through bewildering times in which the remarkable discoveries in whole-patient physiology were followed almost immediately by the molecular biology era. For the last 20 years medical knowledge has evolved so fast that nobody has had time to sit back and put it into perspective. The cancer field is a good example. We now know that malignant transformation can come about in many different ways, that it involves inherited or, more often, acquired changes in the many genes that look after the housekeeping of our cells, that the decision of whether a sick cell of this kind continues to thrive to produce a cancer or is sent into a program leading to its demise is based on innumerable complex genetic and environmental interactions, and so on. When and how this information will be used to the benefit of patients is unclear. Until recently it seemed likely that it would be very soon; now our thinking is becoming more realistic, a realism based on our increasing appreciation of the complexities of sickness and sick people. Medical practice is not going to change overnight. However much we learn about disease mechanisms, and whatever this information tells us about better ways of preventing and treating disease, our patients will remain frightened, sick people who will always require the traditions of kindness, sympathy, common sense and personal attention that you taught all those years ago and that left such an indelible impression on the students and physicians of Oxford who accompanied you on your Sunday morning rounds.

**WO:** So nothing really changes. Thank you for the tea. I will now retire to a warm bedroom and contemplate what you have told me. I presume that chloroform is still available.

## Appendix

*Editor's note: To learn more about Sir William Osler's tenure as the Master of Ewelme, see* CMAJ *1973;109:1128-32.*

(Figure) 

![Figure2](http://www.cmaj.ca/https://www.cmaj.ca/content/cmaj/161/7/837/F2.medium.gif)

[Figure2](http://www.cmaj.ca/content/161/7/837/F2)

Figure. Sir William Osler in the drawing room of the American Women's War Hospital, London, 1915. From *International Association of Medical Museums Bulletin* no IX, Montreal, 1927. p. 410.

## Footnotes

*   This article has been peer reviewed.
    
    Correspondence to: Sir David Weatherall, Regius Professor of Medicine, University of Oxford, Institute of Molecular Medicine, John Radcliffe Hospital, Oxford OX3 9DS, UK