For Christmas I received a copy of The Quotable Osler, (Silverman, Murray, Bryan, ed., American College of Physicians, 2008), a collection of short statements and observations drawn from the writings of Sir William Osler. Osler has been a voice in my head throughout my career and I found myself “listening” once again to his words of wisdom.
Most of the medical residents and students I encounter have no notion of who Osler was. This is a pity; it bespeaks an ignorance of the career of a man who shaped the way we work to this day. He wrote the first comprehensive textbook of Internal Medicine. He transformed the way we are educated. He wrote extensively on what the ideal physician should be and how he should behave. (I use the male gender pronoun here, as this was a time when physicians were overwhelmingly male.) His shadow was so long that, decades after his death he was quoted constantly. In fact, so many of his alleged “aphorisms” were falsely attributed to him that a book like The Quotable Osler is a scholarly documentation of statements that can be truly proven to have come from his pen. He was a man of humor, humility and wit; he was also deeply reflective on behaviors and the pitfalls of physicians. His chief devotion was to medical students and teaching at the bedside.
My father-in-law taught at Johns Hopkins Medical School years after Osler was among the founding giants. He spoke of Osler as the symbol of a group of people, a large cadre of physician educators who effected changes in medical education and practice in the 1890’s through the first quarter of the 20th Century. Most of their names have fallen into oblivion but Osler’s remains. If he was exemplary of a class of new clinicians, it is perhaps because he is best remembered by the massive content of written advice he left to us. I would argue that especially now, as medical practice for so many reasons appears to become more complicated by the minute, his words are worthy of reconsideration.
It can also be argued that his professional life must be placed in the context of the era. The time of his life was one of expansive change in medical and biological knowledge and medical technology. At the time of his birth (1849) there was literally no knowledge of the bacterial and viral etiologies of illness. By the time he was in his prime the exact bacterial pathogens as causative agents of many diseases had been identified and typed and bacteriology and virology laboratories flourished. Within his lifetime microscopic histology and pathology were born and flourished as sciences, physiology as a discipline shed ever more light on organ function. Surgery at his birth was brutal and primitive; by the time he was a distinguished professor, safe surgical interventions into every body cavity but that of the skull were being performed. The x-ray began to offer its internal images. During his lifetime massive changes in public heath infrastructure, spurred by expanding understanding of mechanisms of infection transmission, were taking place across Europe and North America.
Within that context, the physician himself was rapidly changing, from something not much better than a bumbling observer to a potentially accurate diagnostician and interventionist. The role and the methodology of the physician were changing and Osler offered through his lectures and papers a paradigm of what that new doctor should be. Much of what he advised his students was related to communicating with patients: “Listen to the patient, he is telling you the diagnosis.” (p. 98)
Osler began his days as an educator by rounding with his students at the bedside. He would expect a student to give a history “in the patient’s own words” and he would verify the history with the patient. He advocated calm silence in hearing the patient and then careful observation and physical examination.
He reminded his students that while they were examining patients, the patients were evaluating them: “Remember, however, that every patient upon whom you wait will examine you critically and form an estimate of you by the way in which you conduct yourself the bedside.” (p.103)
He advocated using clear, plain language in communicating with patients:
“And from the standpoint of medicine as an art for the prevention and cure of disease, the man who translates the hieroglyphics of science into the plain language of healing is certainly the more useful.” (p.58)
He also urged his students to treat persons as individuals, not disease states: “There is a tendency among young men about hospitals to study the cases, not the patients, and in the interest they take in the disease, lose sight of the individual. Strive against this.” (p. 102)
In four relatively short sentences, Osler sums up the essence of good patient communication: 1) Listen; 2) Be aware that a doctor’s behavior in the patient interview is a means by which the patients judge the doctor; 3) Use simple, plain language in explanations; and most important 4) Approach the ill patient as an individual with problems, not a disease state.
Dr. Osler was an advocate for an empathetic approach to each patient: “The motto of each of you as you undertake the examination and treatment of a case should be ‘put yourself in his place.’ Realize, so far as you can, the mental state of the patient, enter into his feelings…Scan gently his faults …the kindly word, the cheerful greeting, the sympathetic look.” (p. 46)
Of all the pieces of advice in The Quotable Osler, one paragraph has captivated my thought. In a world in which time seems compressed and we are sometimes crippled by malignant memories of the past and fears for a catastrophic future, Osler advises us to disregard anything but the present, to focus on the day’s work, to live “earnestly and intently:”
“The load of tomorrow, added to that of yesterday, carried today makes the strongest falter. Shut off the future as tightly as the past. No dreams, no visions, no delicious fantasies, no castles in the air, with which, as the old song so truly says,‘hearts are broken, heads are turned.’ To youth, we are told, belongs the future, but the wretched tomorrow that so plagues some of us has no certainty, except through today. Who can tell what a day may bring forth? The future is today—there is no tomorrow! The day of a man’s salvation is now—the life of the present, of today, lived earnestly, intently, without a forward looking thought, is the only insurance for the future. Let the limit of your horizon be a twenty-four hour circle.”
Having been so admonished, keeps these words within reach, and when you awaken with a remorse for the past and fear for the future, read them again and again.
-Peter S. Kibbe
in·flu·en·za noun inflew’enze A highly contagious viral infection of the respiratory passages causing fever, severe aching and catarrh, and often occurring in epidemics.
We are in the middle of the influenza season. We medical practitioners dread this illness because there is nothing we can do about it. It can vary from an illness of relatively mild symptoms to a deadly syndrome, and can have terrible complications in those already infirm with other conditions. As it varies in its morbidity and mortality it varies in its clinical course.
For many hundreds of years physicians described febrile diseases by their “stadia” or stages. This works very well for certain illnesses such as yellow fever or hepatitis, which tend to unfold predictably. With influenza the course is variable according to the strain, which of course differs from year to year. Even then, there is a great discrepancy in symptom expression. In the last part of the nineteenth century and the first half of the twentieth, clinicians carefully examined and studied huge numbers of patients who presented during outbreaks of the disease, demonstrating repeatedly that depending on the strain or at certain stadia, the disease seemed to have a favorite organ system through which it would express itself. It might be neurologic, laryngeal, pulmonary, gastrointestinal, dermatologic, or myocardial. There was nearly always some form of pulmonary involvement, however.
Expert reviews of the disease written around 1900, while surely tainted with some mistaken diagnoses, are long on physical findings leading to separate classifications. Even through the great pandemic of 1918 the exact pathogen causing the illness had not been identified. Many experts felt it was bacterial, and thus the suppurative complications of the viral disease tended to be “lumped” into the case mix. Nevertheless, it is interesting to read the accounts of these physicians because, unlike today, they describe the illness through their meticulous history taking and through very thorough physical examination of patients on a day by day basis. So transient rashes, pericardial friction rubs or murmurs of papillary muscle dysfunction that come and go are noted, suggestive of far greater attention to physical findings than any of us today would claim to afford our patients. We have our radiology, lab tests and echocardiography; they had their eyes ears and hands. “Use makes master.” 1
By the latter half of the twentieth century, descriptions of the “stadia” of influenza are replaced with the more modern term, the “clinical course.” The modern description is more generalized: a sudden onset of systemic malaise and myalgia, cough and other upper respiratory symptoms, fever and chills and possibly a big bag of other symptoms. The patient is ill for about a week and almost always looks and feels much sicker than can be explained by the clinical, X-ray or laboratory findings. Most will recover with no intervention.
Hiding, lurking, in the sub consciousness of all practitioners who confront the victims of an outbreak with a modicum of knowledge, there has always been the possibility that, at times, during rare outbreaks, particularly 1918, many of those patients would be dead within a day or two. Thus, if you walk into the clinic waiting room on the first day of an epidemic and the face of every person there appears ghastly, you have no way of knowing whether this is one of those times.
There is no choice for physicians other than to carefully examine everyone. This is the way I recall the epidemic of 1977-78 when I was in training as an intern in pediatrics. The outpatient clinic rapidly filled its waiting rooms with coughing, febrile, wheezing kids who all looked limp and listless, who all had to be examined to determine the severity of the primary disease and for complications—worsening asthma, pyogenic otitis, localized pneumonia, dehydration. I was lucky that year. My mentor was a courageous and tireless young man who was fully trained in pediatrics and even though he was a very gentle soul he was heroic and marshaled all of us into the breach, as it were.
I also did not contract the illness that year. In terms of suffering myself, I do have a vague memory of probably having the illness at the age of five— I recall days of cough and febrile hallucinations, I can still see the face of the local general practitioner at my bedside, and feel his antibiotic injections, I recall his huge black bag, and days of sleep morphing into nights of paroxysmal cough. For me personally the disease then ends except as a practitioner, until last week.
If patient experience is enhanced by practitioners with empathy, my recent personal case of influenza will be a fount of empathy on my part forever. If this is a disease that can kill you, but usually does not, let me suggest that it pretends to be killing you very convincingly, to the point that at times you wish it would just get on with the job and do so.
My Personal Stadia Begins
The first stage is marked by a sort of prodromal day of the mental blues. Life seems listless, happiness a distant memory, an anhedonia sets in; there is no pleasure, no joy. I cook my favorite soup from scratch; though the taste offers no pleasure. A sore throat develops and then rhinorrhea. My mental outlook becomes blacker as night approaches. Lines from a Yeats’ poem seem apt:”I gathered all, brought all to mind/ All life ahead seemed waste of breath/A waste of breath the years behind.” 2
Rhinorrhea worsens as the time for bed approaches. In spite of the gloom of spirits the bed seems a welcome place at first. Soon it becomes a horror chamber as the second stadium is entered. Fever begins, with violent chills that cannot be soothed by pounds of blankets. Myalgia begins, with muscle stiffness after repose, and muscle pain with motion made to relieve the joints. The mind races, and when chills abate, troubled sleep does descend and furtive, rapidly changing visual dreaming follows, colorful TV screens. Then chills return with wakefulness and pain. Then as morning approaches, the minds scaffolding seems to collapse, darkness arrives, welcome unconsciousness ensues.
Daylight again. In the third stadium it is painful to breathe or swallow. There is a cough, a general pain of all the muscles from head to foot. The mental depression has been replaced by mental lethargy, complete cognitive incompetence. My cell phone is ringing but I do not answer it. What would I say? A clinical light starts to dimly shine into self-reflection. My inner, physician’s eye notes that there appears to be no respiratory distress, no high fever, but the day is half-gone. Where? An hour of coffee drinking, acetaminophen, Motrin and hot chicken broth ingestion is all I can accomplish against a profound lethargy. As I fall back to sleep, the little clinical thought mechanism of the brain contemplates influenza, check -listing symptoms, marking the painful cough, the lack of appetite; indeed the lack of any gastrointestinal symptoms. The pulse is weak and thready, in the nineties at rest, suggesting a myocardial depression. There is no shortness of breath at rest.
On awakening, it is near dusk. The third stadium persists. There is thirst to be sated, exacerbating pharyngeal pain. Rhinorrhea persists; cough is unchanged, not paroxysmal. Myalgia persists. Mental lethargy is severe and muscle weakness is general and worse than anything I can remember except for severe post-surgical blood loss. Another night follows like the first, dreadful with chills, near hallucinatory dreams, muscle pain. An old shoulder fracture seems fresh, an old right sciatica screams off and on in the right leg. The next day repeats the previous, and is spent somnolently, but each day is now a little less symptomatic. I tell myself that since it is not worse it does not matter that it is not much better, that is one of the rules for influenza. It should be at its worst quickly and then, if worsening from a baseline, or worsening after improvement, it is time for concern. This case just lingers. The mental depression lingers, the fatigue remains severe, but there is less fever, fewer chills, finally the chills are gone. The illness throws a couple of curves—some watery diarrhea, a couple of transient episodes of severe vertigo, but in general it gradually abates. After a week it seems gone except for persistent fatigue, transient cough, breathlessness with exertion and, perhaps the worst, mental exhaustion.
As a curious clinician, contemplating the disease as it is seen in others and then through intense personal experience, one is left with a huge question: What was that all about?? An epidemic virus comes along, has done so since time out of mind, initiates a disease through the nasal/respiratory portal, then becomes protean in its acute manifestations. First you are struck by depression; next the illness racks your muscles and bones. There is the expected cough and pulmonary compromise but then, well, neurologically you are a mess as well and can’t remember what to say when you answer the phone or remember what day it is. Like to have thermoregulation? Well, let’s do without that for a few days, you can be a poikilotherm and when your body temperature drops below 90 F the chills will knock you out of it. After you have eaten nothing for a few days, let’s follow that up with some watery diarrhea, maybe some vomiting.
From symptoms alone it is clear that the immune response to this illness calls up the image of multiple battlegrounds in multiple organ systems and with multiple manifestations. Some writers and researchers call the immune response to influenza a “cytokine storm” and suggest that the problem of the disease is not the virus but our immune response to it. Some suggest that immunization is not to prevent you from getting the disease, but to prevent you from killing yourself with your own immune response the next time you do.
While the above may sound like hyperbole, the protean quality of acute symptoms is also matched by the late sequelae. Late, probably autoimmune, phenomena are well documented. For a good analysis of the acute and late manifestations as they are represented by the most severe world pandemic of influenza, see The Great Influenza by John M. Barry. He is basically a historian but, regarding the deadliness of the 1918 pandemic favors the argument that it was fatal mostly to the very healthy patients in the prime of life because they were able to mount a virtually suicidal immune response which that particular strain called forth.
When encountering a patient with influenza the example of our forebears is worth following. First, this is a serious illness and, although as examiner you may be hard-pressed to find physical changes to explain the degree of physical discomfort, the patients’ complaints are not to be minimized. In fact, I suspect it is of some comfort to the patient if he or she is reassured that their physical and mental distresses are very real and very attributable to the disease and not to some weakness on their part. Especially early in the illness this recognition of the ability of the viral syndrome to inflict such discomfort helps explain the lack of efficacy of antibiotics and can help the patient to be persuaded to avoid them. This is one of the illnesses demanding frequent and thorough physical examination as the days progress. Feel the pulse, turn on the lights, peer down the pharynx, auscultate carefully. Be that GP at the bedside with the big black bag.
- Finkler, “Influenza,” Twentieth Century Practice, Infectious Disease, ed. Thomas Lathrop Stedman, 1904
- Yeats, “An Irish Airman Foresees His Death” Public Domain