- Email: [email protected]
William Osler, Urolithiasis, and God's Own Medicine
Endourology and Stones William Osler, Urolithiasis, and God’s Own Medicine Richard L. Golden OBJECTIVES METHODS
RESULTS
CONCLUSIONS
To identify the contributions of Sir William Osler, who is regarded as the pre-eminent physician of his time, to urology, both objective and subjective. A search of Osler’s bibliography of over sixteen hundred publications, as well as his observations, some hitherto unpublished, on the episodes of renal colic that he personally experienced, was conducted. Osler was treated with morphine, which he characterized as “God’s own medicine,” and the origin of this description is explored. Osler published over 50 articles devoted to urologic topics, including 2 on vaginismus and Peyronie’s disease; the former, by his fun loving alter ego, Egerton Yorrick Davis, was a hoax. Osler discusses urolithiasis and renal colic in his magnum opus, The Principles and Practice of Medicine, citing Montaigne’s self description of his suffering as “unexcelled.” Osler later personally experienced 2 episodes of renal colic, which he graphically and eloquently describes in his Lumleian Lectures of 1910. His descriptions of renal colic before and after his own experience are compared in the light of Plato’s comment that a physician should experience the disease that he treats. William Osler was one of those giants who, in the early days of specialization, took all of medicine for their own. His contributions to urology were significant and include his descriptions of his own episodes of renal colic and the use of morphine—“God’s own medicine.” UROLOGY 74: 517–521, 2009. © 2009 Elsevier Inc.
S
ir William Osler (1849-1919) was the foremost physician of his time; his influence encompassed the English-speaking world and beyond (Fig. 1). A superb clinician, educator, historian, philosopher, and bibliophile, Osler served with distinction as Professor of Medicine at McGill University, the University of Pennsylvania, and Johns Hopkins University, and he capped his career as Regius Professor of Medicine at Oxford—an extraordinary North American and transatlantic medical odyssey unlikely to be duplicated. Specialization had begun its slow evolution, but there were still giants like Osler who took all of medicine for their own. Internists, pediatricians, neurologists, and gastroenterologists, among others, today regard Osler as a confrere. Among his more than 1600 publications, there are over 50 that deal with urologic topics, including 2 published under the influence of his fun-loving, irreverent alter ego, Egerton Yorrick Davis (E.Y.D.).1,2 The first, “Vaginismus,” was an eminently successful hoax that appeared in the Medical News of Philadelphia in 1884 with a wellcrafted tale of penis captivus.3 “The Davis case” became firmly established in the literature and has been cited as an authentic example of penis captivus as late as 1979.4 From the State University of New York at Stony Brook, Stony Brook, New York Reprint requests: Richard L. Golden, M.D., 56 Laurel Hill Road, Centerport, NY 11721. E-mail: [email protected] Submitted: November 23, 2008, accepted (with revisions): February 13, 2009
© 2009 Elsevier Inc. All Rights Reserved
Although vaginismus is a well-established disorder, penis captivus remains a debatable entity.5 Osler, continuing to display his proclivity for sexual topics, published “Peyronie’s Disease—Strabisme du Pénis”6 in 1903, signing it, no doubt in his Egerton Yorrick Davis persona, with the initials of his friend James William White Jr, a prominent Philadelphia urologist and the author (with Edward Martin) of Genito-Urinary Surgery and Venereal Diseases.7 Although written in a Rabelaisian manner, this was a legitimate case of Peyronie’s disease. White, quick to detect the style of “Davis,” took up the gauntlet and engaged Osler in a literary duel, firing back a humorously biting reply to the Boston Medical and Surgical Journal signed “E.T.D., Jr.”8 The middle initial was probably a typographic error, and the signature was an unmistakable reference to Osler’s E.Y.D. pseudonym. Among Osler’s extensive urologic writings, urolithiasis is discussed in a case report9 and in his magnum opus, The Principles and Practice of Medicine.10 The subject is also extensively covered in Osler’s Modern Medicine in a chapter written by the eminent Johns Hopkins urologist, Hugh Hampton Young.11 Osler personally experienced 2 graphically described episodes of renal colic, the first in Baltimore in December 1904, where he was attended by Dr Thomas B. Futcher (his former resident at Johns Hopkins and now Associate Professor of Medicine) who gave the following account12: 0090-4295/09/$34.00 doi:10.1016/j.urology.2009.02.041
517
No true renal calculi found in either specimen. One bottle contained 3 and the other 2 quartz stones gathered from the gravel walk. Impression of Case—Patient undoubtedly had an attack of renal colic probably induced by calculus. In January 1910, Osler experienced a recurrent and more prolonged episode of ureteral colic, this one associated with a urolithiasis, which he made light of in a postcard to his friend Henry M. Thomas (Clinical Professor of Diseases of the Nervous System at Johns Hopkins)13,14: I am in bed with another attack of renal calculus—rt. side. You remember the one 8 (sic) years ago in which I passed the unique quartz stone. This has lasted longer and I have enjoyed the luxury of two hypodermics. I am writing flat on my back which improves my handwriting! In a note to Henry Barton Jacobs, a colleague at Johns Hopkins, he playfully relates15: TB F[utcher] will have told you of my rocky experience. Got rid of it yesterday (Uric acid). It took a week of squirming. Gout, I suppose. I shall live on aq. destil. and hominy grits. I am feeling a bit shaken but very well. Figure 1. William Osler, 1909, photograph by Notman, Montreal. From the collection of the author.
Diagnosis: Renal colic; gouty diathesis. Family History—Not taken. Personal History—with few exceptions has always been a healthy man. No previous attacks similar to the present one. Present Illness—While reading at the Medical and Chirurgical Library an article on “Strangulation of the Bile Ducts by Round Worms” by Ebstein, patient began to have pain in the left lumbar region of back. He immediately started for home, hailing a cab on the way. Pain gradually became more severe and was intense by the time he reached home about 6:30 pm. It was so intense that he felt faint. He immediately went to bed and a hot water back was applied to the back. It seemed to relieve the pain. The attack was accompanied by garrulousness. Pain had gradually subsided by 8 o’clock, but was followed by considerable soreness in the left lumbar region. The night and morning urine was kept separate. There was no macroscopic evidence of blood in either specimen. Urine—Night specimen: High color; clear; slightly cloudy precipitates; acid; 1.026; no albumen; no sugar. Microscopic—No casts; an occasional red blood cell seen; numerous oxalates; no uric acid crystals. 518
In the same spirit he informed Marjorie Futcher (wife of T. B. Futcher): Tell T. B. that the enemy left me yesterday morning (composition C2H10 ⫹ N20S2). I had a miserable week but managed to get thro. in fairly good spirits and am thankful that it is over. I had an xray taken to see if this is a quarry or only diamonds.16 In a more serious vein, Osler recorded terse daily comments in his day book (Fig 2) covering this period of January 17-24, 191017: Monday 17th. 530 in eve. a twinge of pain in right side, thot. it was in bowels. Tuesday 18th. 8 AM. very severe attack, pain in right side, nausea, vom, sweats, ¼ [gr] morphia gave relief. Wednesday 19th. Return slight. in eve. Thursday 20th. Bad attack middle day. Morphia again. Good night. Friday 21st. Slight attack this day. Saturday 22nd. Slight attack this day. Sunday 23rd. 130-530 steady pain and down groin— comfortable all night. Monday 24th. 830 passed a uric acid calculus—and very well tho shaken & used up. In the throes of his suffering, Osler, ever the scholar, advised his doctor to read Montaigne’s description of renal colic, which he believed to be unexcelled.18 Montaigne, a frequent sufferer, had observed10,19: UROLOGY 74 (3), 2009
Figure 2. Page from Osler’s day book describing his episode of renal colic in 1910. (BO # 7668). Courtesy of the Osler Library, McGill University, Montreal.
Thou art seen to sweat with pain, to look pale and red, to tremble, to vomit well-nigh to blood, to suffer strange contortions and convulsions, by starts to let tears drop from thine eyes, to urine thick, black, and frightful water, or to have it suppressed by some sharp and craggy stone, that cruelly pricks and tears thee . . . In March 1910, Osler delivered the prestigious Lumleian Lectures at the Royal College of Physicians in London. His topic was “Angina Pectoris,” and in the course of discussing involuntary muscle pain, Osler drew upon his own recent episode of renal colic to graphically portray the nature of the pain20: Involuntary muscle pain has its peculiarities, and . . . comes in crises, storms, and outbursts. I have recently taken advantage of an unpleasant experience in my own person to observe the phenomena of these paroxysms in a ureter struggling with a calculus. Periods of complete freedom extended from two to three, to eight or ten hours, attenuated by three types of disturbance of sensation—a dull, steady, localized pain, the situation of which could be covered with a penny. It could be imitated exactly by firm pressure with the handle of a knife, or, indeed, with a finger upon a bone, particularly upon that tender spot on the sternum just a little above the ensiform cartilage. Lasting for hours and unmoved it was fairly bearable. Now and then, when free from pain, there were remarkable flashes, an explosive sort of sensation, not actually unpleasant, and accompanied by a glow-like wave along the course of the ureter and out through the flank, as it were through the muscles. And then abruptly, of working out of the steady pain, come the paroxysm, like a twisting tearing hurricane, with its well-known radiation, followed by the vaso-vagal features, the pallor, cold extremities, feeble pulse, nausea, vomiting, and in two attacks, a final, not altogether unpleasant period, when unconsciousness and the pain seemed wrestling for a victory reached only with the help of God’s own medicine—morphia. UROLOGY 74 (3), 2009
It is germane to compare this highly subjective account to the accurate but essentially dispassionate description that Osler wrote in the 1st edition of The Principles and Practice of Medicine (1892), long before his first attack: Renal colic ensues when a stone enters the ureter. An attack may set in abruptly without apparent cause, or may follow a strain in lifting. It is characterized by agonizing pain, which starts in the flank of the affected side, passes down the ureter and is felt in the testicle and along the inner side of the thigh. The pain may also radiate through the abdomen and chest, and be very intense in the back. In severe attacks there are nausea and vomiting and the patient is collapsed. The perspiration breaks out on the face and the pulse is feeble and quick. A chill may precede the outbreak and the temperature may rise as high as 103°.10 It is of interest to note that it was in this section on nephrolithiasis that Osler made mention of the rare and elusive indigo calculus that has been the subject of recent speculation.10,21 Osler also began another paper on the subject of this recent experience, “An auto-clinique,” that he never completed.22 In it, he waxed philosophic, citing “Plato’s remark that no physician is fit to treat a disease that he has not had”23 and “that only women who have borne children should be midwives,”24 quickly adding how few patients many of those that adhered to this rule would have. Nevertheless, Osler felt that “there is more than a grain of truth in the statement and we look with very different feelings upon a disease to which our own machinery is liable”—analogous to the paradigm of the wounded healer of Aesculapian myth. He added that “I am always glad when I hear that some surgical colleague has had his appendix removed,” no doubt focusing on improved empathy with patients rather than what might otherwise be construed as schadenfreude. There is significant family history, in that Osler’s older brother, Edward, had a history of gout and tophi.14,25 519
Osler later grumbled: “I cannot take a glass of champagne without feeling it in my great toe.”26When he died in 1919 of bronchopneumonia with multiple abscess formation and empyema, the autopsy revealed mild arteriosclerotic atrophy of the kidneys and scattered urate deposits in the left cortex.27 Osler combined his clinical skills with his masterful power of expression to leave for posterity a poignant description of renal colic, perhaps rivaling that of Montaigne. He had little faith in the remedies and polypharmacy of his day and was considered by some to be a therapeutic nihilist.28 He used but a handful of drugs that he considered efficacious, usually not in combination, including iron, quinine, digitalis, ergot, amyl nitrate, nitroglycerin, thyroid, and morphine, the drug that he anointed as “God’s own medicine,”20 and sometimes, using an acronym, as “G.O.M.,” when he wanted to conceal it from a patient.29,30 Morphine had been isolated from opium by a young German pharmacist, Friedrich Sertürner (1783-1841), whose investigations began in 1803.31 In 1860, Thomas Sydenham (16241689), called the English Hippocrates, wrote that “among the remedies that it has pleased Almight God to give to man to relieve his sufferings, none is so universal and so efficacious as opium.”31It is possible that William Osler, an assiduous medical historian, took his cue for “G.O.M.” from this observation. In the late 19th century, when opium addiction was rampant in China, the missionaries, in their zeal for converts and with a mistaken belief in its curative powers, dispensed morphine tablets, which the grateful recipients referred to as “Jesus opium.”32,33 Francis W. Peabody (1881-1927), a Harvard University professor of medicine, paraphrased Osler’s description and added a caveat in describing his experience with parenteral morphine during the terminal phase of his malignancy: “My own professional and personal experience has shown me that morphine is the gift of God, but depending upon how it is used it may be either ‘God’s Own Medicine’ or ‘The Devil’s Own Poison.’”30Among the legacies of Francis Peabody was his inspiring dictum of medical humanism: “One of the essential qualities of the clinician is interest in humanity, for the secret of the care of the patient is in caring for the patient.”34 Osler’s relationship to urology was that of an internist in an era where specialization was not yet firmly established, and his alter ego and occasional hoax were tolerated with good-natured affection. It would appear that despite Osler’s vast clinical experience and well-known humanism, the episodes of renal colic that he endured served as an epiphany that spurred him, remembering Plato’s “rule,” to leave a vivid account of his signs and symptoms, the unimaginable agony of the stone’s progression, and the wonder of the relief rendered by morphine—“God’s own medicine.” Acknowledgments. The author thanks Pamela J. Miller, Christopher Lyons, Diane G. Philip, and Lily Szczygiel of the 520
Osler Library of the History of Medicine, McGill University, Montreal, for their kind and enthusiastic research assistance.
References 1. Golden RL, Roland CG. Sir William Osler: An Annotated Bibliography with Illustrations. San Francisco, CA: Norman Publishing; 1988. 2. Golden RL. The Works of Egerton Yorrick Davis, MD: Sir William Osler’s Alter Ego.Montreal, QC: Osler Library, McGill University; 1999. 3. Davis EY. Vaginismus. Medical News. 1884;45:673. 4. Taylor FK. Penis captivus— did it occur? Br Med J. 1979;2:977-978. 5. Nation EF. William Osler on penis captivus and other urological topics. Urology. 1973;II:468-470. 6. Osler JWW Jr. Peyronie’s disease—strabisme du pénis. Boston Med Surg J. 1903;148:245-251. 7. White JW, Martin E. Genitourinary Surgery and Venereal Diseases. Philadelphia, PA: JB Lippincott; 1897: p 30. 8. ETD Jr. Peyronie’s disease—strabisme du pénis. Boston Med Surg J. 1903;148:485. 9. Osler W. Pyelitis consequent on stone in bladder and pyelonephritis. Montreal General Hospital Report No I, for the year ending May 1, 1877. Montreal, QC: Dawson Brothers Publishers;1878:76-77. 10. Osler W. The Principles and Practice of Medicine. New York, NY: D Appleton & Co.;1892: pp 765-770. 11. Young HH. Urinary Lithiasis: Renal and Ureteral Calculi In Osler W, ed. assisted by McCrae T. Modern Medicine: Its Theory and Practice. Philadelphia, PA; New York, NY: Lea & Febriger; 1909 VI:315-335. 12. Futcher TB. Dr. Osler’s renal stones. Ann Int Med. 1949;84:40. 13. Cushing H. The Life of Sir William Osler. Oxford, UK: Clarendon Press; 1925; vol. II: p 207. 14. Bensley EH, Bates DG. Sir William Osler’s autobiographical notes. Bull Hist Med. 1976;50:596-618. 15. Cushing H. Life of Sir William Osler. Oxford, UK: Clarendon Press; 1925; vol. II, p 208. 16. Howard RP. The Chief: Dr. William Osler. Canton, MA: Science History Publications; 1983: p 47. 17. Osler W. Day Books. # 7668. Montreal, QC: Osler Library, McGill University; January 1910: pp 40, 42. With the permission of the Board of Curators of the Osler Library. 18. Barondess JA. A hitherto unpublished appreciation of Sir William Osler by Dr. A. G. Gibson. Johns Hopkins Med J. 1977;140:47-55. 19. Hazlitt W. (Wight OW, ed). Works of Michael de Montaigne. New York, NY: Hurd and Houghton; 1875; Book III, Ch XIII, p 434. 20. Osler W. The Lumleian lectures on angina pectoris. London, UK: Lancet I: 697-702, 839-844,973-977, 1910. 21. Moran ME, Das, S, Rosenberg SA. Sir William Osler’s perceptions of urolithiasis and the case of the indigo calculus. J Endourol. 2005;19:1157-1160. 22. Osler W. An auto-clinique. # 7664, Vol V, Osler Library, McGill University, Montreal, QC, Canada. With the permission of the Board of Curators of the Osler Library. 23. Jowett B (trans). The Republic of Plato. 3rd ed., III, analyses 408-409. Oxford, UK: Clarendon Press; 1888 (impression of 1925): p xlvi. 24. Paley FA (trans). The Theætetus of Plato. London, UK: George Bell & Sons; 1875: p 14. 25. Wilkinson A. Lions in the Way: A Discursive History of the Oslers. Toronto, ON: The Macmillan Company of Canada Limited; 1956: p 214. 26. Bliss M. William Osler: A Life in Medicine. New York, NY: Oxford University Press; 1999: p 366. 27. Barondess JA. A case of empyema: notes on the last illness of Sir William Osler. Tr Am Clin Climatol Assoc. 1975;86:59-72. 28. Cushing H. The Life of Sir William Osler. Oxford, UK: Clarendon Press; 1925, vol. I, p 166. 29. Knopf SA. Personal reminiscences of Sir William Osler In Abbott ME, ed. Appreciations and Reminiscences: Sir William Osler Memorial
UROLOGY 74 (3), 2009
Number, Bulletin No. IX of the International Association of Medical Museums, Montreal; 1925: pp 321-327. 30. Peabody FW. Notes of the effects of morphine In Paul O, ed. The Caring Physician: The Life of Dr. Francis W. Peabody, Boston, The Francis A. Countway Library of Medicine & The Harvard Medical Alumni Association, Harvard University Press; 1999: pp 137, 175-182. 31. Jaffe JH. Narcotic analgesics In Goodman LS, Gilman A, eds. The Pharmacological Basis of Therapeutics. New York, NY: The Macmillan Company; 1970: p 237.
UROLOGY 74 (3), 2009
32. Lodwick KL. Crusaders Against Opium: Protestant Missionaries in China, 1847-1917. Lexington, Lexington-Fayette, KY: University Press of Kentucky; 1995: p 35. 33. Booth M. Opium: A History. New York, NY: St. Martin’s Griffin; 1999: p 145. 34. Peabody FW. The care of the patient In: Paul O, ed. The Caring Physician: The Life of Dr. Francis W. Peabody, Boston, The Francis A. Countway Library of Medicine & The Harvard Medical Alumni Association, Harvard University Press; 1999: pp 155-174.
521
RESULTS
CONCLUSIONS
To identify the contributions of Sir William Osler, who is regarded as the pre-eminent physician of his time, to urology, both objective and subjective. A search of Osler’s bibliography of over sixteen hundred publications, as well as his observations, some hitherto unpublished, on the episodes of renal colic that he personally experienced, was conducted. Osler was treated with morphine, which he characterized as “God’s own medicine,” and the origin of this description is explored. Osler published over 50 articles devoted to urologic topics, including 2 on vaginismus and Peyronie’s disease; the former, by his fun loving alter ego, Egerton Yorrick Davis, was a hoax. Osler discusses urolithiasis and renal colic in his magnum opus, The Principles and Practice of Medicine, citing Montaigne’s self description of his suffering as “unexcelled.” Osler later personally experienced 2 episodes of renal colic, which he graphically and eloquently describes in his Lumleian Lectures of 1910. His descriptions of renal colic before and after his own experience are compared in the light of Plato’s comment that a physician should experience the disease that he treats. William Osler was one of those giants who, in the early days of specialization, took all of medicine for their own. His contributions to urology were significant and include his descriptions of his own episodes of renal colic and the use of morphine—“God’s own medicine.” UROLOGY 74: 517–521, 2009. © 2009 Elsevier Inc.
S
ir William Osler (1849-1919) was the foremost physician of his time; his influence encompassed the English-speaking world and beyond (Fig. 1). A superb clinician, educator, historian, philosopher, and bibliophile, Osler served with distinction as Professor of Medicine at McGill University, the University of Pennsylvania, and Johns Hopkins University, and he capped his career as Regius Professor of Medicine at Oxford—an extraordinary North American and transatlantic medical odyssey unlikely to be duplicated. Specialization had begun its slow evolution, but there were still giants like Osler who took all of medicine for their own. Internists, pediatricians, neurologists, and gastroenterologists, among others, today regard Osler as a confrere. Among his more than 1600 publications, there are over 50 that deal with urologic topics, including 2 published under the influence of his fun-loving, irreverent alter ego, Egerton Yorrick Davis (E.Y.D.).1,2 The first, “Vaginismus,” was an eminently successful hoax that appeared in the Medical News of Philadelphia in 1884 with a wellcrafted tale of penis captivus.3 “The Davis case” became firmly established in the literature and has been cited as an authentic example of penis captivus as late as 1979.4 From the State University of New York at Stony Brook, Stony Brook, New York Reprint requests: Richard L. Golden, M.D., 56 Laurel Hill Road, Centerport, NY 11721. E-mail: [email protected] Submitted: November 23, 2008, accepted (with revisions): February 13, 2009
© 2009 Elsevier Inc. All Rights Reserved
Although vaginismus is a well-established disorder, penis captivus remains a debatable entity.5 Osler, continuing to display his proclivity for sexual topics, published “Peyronie’s Disease—Strabisme du Pénis”6 in 1903, signing it, no doubt in his Egerton Yorrick Davis persona, with the initials of his friend James William White Jr, a prominent Philadelphia urologist and the author (with Edward Martin) of Genito-Urinary Surgery and Venereal Diseases.7 Although written in a Rabelaisian manner, this was a legitimate case of Peyronie’s disease. White, quick to detect the style of “Davis,” took up the gauntlet and engaged Osler in a literary duel, firing back a humorously biting reply to the Boston Medical and Surgical Journal signed “E.T.D., Jr.”8 The middle initial was probably a typographic error, and the signature was an unmistakable reference to Osler’s E.Y.D. pseudonym. Among Osler’s extensive urologic writings, urolithiasis is discussed in a case report9 and in his magnum opus, The Principles and Practice of Medicine.10 The subject is also extensively covered in Osler’s Modern Medicine in a chapter written by the eminent Johns Hopkins urologist, Hugh Hampton Young.11 Osler personally experienced 2 graphically described episodes of renal colic, the first in Baltimore in December 1904, where he was attended by Dr Thomas B. Futcher (his former resident at Johns Hopkins and now Associate Professor of Medicine) who gave the following account12: 0090-4295/09/$34.00 doi:10.1016/j.urology.2009.02.041
517
No true renal calculi found in either specimen. One bottle contained 3 and the other 2 quartz stones gathered from the gravel walk. Impression of Case—Patient undoubtedly had an attack of renal colic probably induced by calculus. In January 1910, Osler experienced a recurrent and more prolonged episode of ureteral colic, this one associated with a urolithiasis, which he made light of in a postcard to his friend Henry M. Thomas (Clinical Professor of Diseases of the Nervous System at Johns Hopkins)13,14: I am in bed with another attack of renal calculus—rt. side. You remember the one 8 (sic) years ago in which I passed the unique quartz stone. This has lasted longer and I have enjoyed the luxury of two hypodermics. I am writing flat on my back which improves my handwriting! In a note to Henry Barton Jacobs, a colleague at Johns Hopkins, he playfully relates15: TB F[utcher] will have told you of my rocky experience. Got rid of it yesterday (Uric acid). It took a week of squirming. Gout, I suppose. I shall live on aq. destil. and hominy grits. I am feeling a bit shaken but very well. Figure 1. William Osler, 1909, photograph by Notman, Montreal. From the collection of the author.
Diagnosis: Renal colic; gouty diathesis. Family History—Not taken. Personal History—with few exceptions has always been a healthy man. No previous attacks similar to the present one. Present Illness—While reading at the Medical and Chirurgical Library an article on “Strangulation of the Bile Ducts by Round Worms” by Ebstein, patient began to have pain in the left lumbar region of back. He immediately started for home, hailing a cab on the way. Pain gradually became more severe and was intense by the time he reached home about 6:30 pm. It was so intense that he felt faint. He immediately went to bed and a hot water back was applied to the back. It seemed to relieve the pain. The attack was accompanied by garrulousness. Pain had gradually subsided by 8 o’clock, but was followed by considerable soreness in the left lumbar region. The night and morning urine was kept separate. There was no macroscopic evidence of blood in either specimen. Urine—Night specimen: High color; clear; slightly cloudy precipitates; acid; 1.026; no albumen; no sugar. Microscopic—No casts; an occasional red blood cell seen; numerous oxalates; no uric acid crystals. 518
In the same spirit he informed Marjorie Futcher (wife of T. B. Futcher): Tell T. B. that the enemy left me yesterday morning (composition C2H10 ⫹ N20S2). I had a miserable week but managed to get thro. in fairly good spirits and am thankful that it is over. I had an xray taken to see if this is a quarry or only diamonds.16 In a more serious vein, Osler recorded terse daily comments in his day book (Fig 2) covering this period of January 17-24, 191017: Monday 17th. 530 in eve. a twinge of pain in right side, thot. it was in bowels. Tuesday 18th. 8 AM. very severe attack, pain in right side, nausea, vom, sweats, ¼ [gr] morphia gave relief. Wednesday 19th. Return slight. in eve. Thursday 20th. Bad attack middle day. Morphia again. Good night. Friday 21st. Slight attack this day. Saturday 22nd. Slight attack this day. Sunday 23rd. 130-530 steady pain and down groin— comfortable all night. Monday 24th. 830 passed a uric acid calculus—and very well tho shaken & used up. In the throes of his suffering, Osler, ever the scholar, advised his doctor to read Montaigne’s description of renal colic, which he believed to be unexcelled.18 Montaigne, a frequent sufferer, had observed10,19: UROLOGY 74 (3), 2009
Figure 2. Page from Osler’s day book describing his episode of renal colic in 1910. (BO # 7668). Courtesy of the Osler Library, McGill University, Montreal.
Thou art seen to sweat with pain, to look pale and red, to tremble, to vomit well-nigh to blood, to suffer strange contortions and convulsions, by starts to let tears drop from thine eyes, to urine thick, black, and frightful water, or to have it suppressed by some sharp and craggy stone, that cruelly pricks and tears thee . . . In March 1910, Osler delivered the prestigious Lumleian Lectures at the Royal College of Physicians in London. His topic was “Angina Pectoris,” and in the course of discussing involuntary muscle pain, Osler drew upon his own recent episode of renal colic to graphically portray the nature of the pain20: Involuntary muscle pain has its peculiarities, and . . . comes in crises, storms, and outbursts. I have recently taken advantage of an unpleasant experience in my own person to observe the phenomena of these paroxysms in a ureter struggling with a calculus. Periods of complete freedom extended from two to three, to eight or ten hours, attenuated by three types of disturbance of sensation—a dull, steady, localized pain, the situation of which could be covered with a penny. It could be imitated exactly by firm pressure with the handle of a knife, or, indeed, with a finger upon a bone, particularly upon that tender spot on the sternum just a little above the ensiform cartilage. Lasting for hours and unmoved it was fairly bearable. Now and then, when free from pain, there were remarkable flashes, an explosive sort of sensation, not actually unpleasant, and accompanied by a glow-like wave along the course of the ureter and out through the flank, as it were through the muscles. And then abruptly, of working out of the steady pain, come the paroxysm, like a twisting tearing hurricane, with its well-known radiation, followed by the vaso-vagal features, the pallor, cold extremities, feeble pulse, nausea, vomiting, and in two attacks, a final, not altogether unpleasant period, when unconsciousness and the pain seemed wrestling for a victory reached only with the help of God’s own medicine—morphia. UROLOGY 74 (3), 2009
It is germane to compare this highly subjective account to the accurate but essentially dispassionate description that Osler wrote in the 1st edition of The Principles and Practice of Medicine (1892), long before his first attack: Renal colic ensues when a stone enters the ureter. An attack may set in abruptly without apparent cause, or may follow a strain in lifting. It is characterized by agonizing pain, which starts in the flank of the affected side, passes down the ureter and is felt in the testicle and along the inner side of the thigh. The pain may also radiate through the abdomen and chest, and be very intense in the back. In severe attacks there are nausea and vomiting and the patient is collapsed. The perspiration breaks out on the face and the pulse is feeble and quick. A chill may precede the outbreak and the temperature may rise as high as 103°.10 It is of interest to note that it was in this section on nephrolithiasis that Osler made mention of the rare and elusive indigo calculus that has been the subject of recent speculation.10,21 Osler also began another paper on the subject of this recent experience, “An auto-clinique,” that he never completed.22 In it, he waxed philosophic, citing “Plato’s remark that no physician is fit to treat a disease that he has not had”23 and “that only women who have borne children should be midwives,”24 quickly adding how few patients many of those that adhered to this rule would have. Nevertheless, Osler felt that “there is more than a grain of truth in the statement and we look with very different feelings upon a disease to which our own machinery is liable”—analogous to the paradigm of the wounded healer of Aesculapian myth. He added that “I am always glad when I hear that some surgical colleague has had his appendix removed,” no doubt focusing on improved empathy with patients rather than what might otherwise be construed as schadenfreude. There is significant family history, in that Osler’s older brother, Edward, had a history of gout and tophi.14,25 519
Osler later grumbled: “I cannot take a glass of champagne without feeling it in my great toe.”26When he died in 1919 of bronchopneumonia with multiple abscess formation and empyema, the autopsy revealed mild arteriosclerotic atrophy of the kidneys and scattered urate deposits in the left cortex.27 Osler combined his clinical skills with his masterful power of expression to leave for posterity a poignant description of renal colic, perhaps rivaling that of Montaigne. He had little faith in the remedies and polypharmacy of his day and was considered by some to be a therapeutic nihilist.28 He used but a handful of drugs that he considered efficacious, usually not in combination, including iron, quinine, digitalis, ergot, amyl nitrate, nitroglycerin, thyroid, and morphine, the drug that he anointed as “God’s own medicine,”20 and sometimes, using an acronym, as “G.O.M.,” when he wanted to conceal it from a patient.29,30 Morphine had been isolated from opium by a young German pharmacist, Friedrich Sertürner (1783-1841), whose investigations began in 1803.31 In 1860, Thomas Sydenham (16241689), called the English Hippocrates, wrote that “among the remedies that it has pleased Almight God to give to man to relieve his sufferings, none is so universal and so efficacious as opium.”31It is possible that William Osler, an assiduous medical historian, took his cue for “G.O.M.” from this observation. In the late 19th century, when opium addiction was rampant in China, the missionaries, in their zeal for converts and with a mistaken belief in its curative powers, dispensed morphine tablets, which the grateful recipients referred to as “Jesus opium.”32,33 Francis W. Peabody (1881-1927), a Harvard University professor of medicine, paraphrased Osler’s description and added a caveat in describing his experience with parenteral morphine during the terminal phase of his malignancy: “My own professional and personal experience has shown me that morphine is the gift of God, but depending upon how it is used it may be either ‘God’s Own Medicine’ or ‘The Devil’s Own Poison.’”30Among the legacies of Francis Peabody was his inspiring dictum of medical humanism: “One of the essential qualities of the clinician is interest in humanity, for the secret of the care of the patient is in caring for the patient.”34 Osler’s relationship to urology was that of an internist in an era where specialization was not yet firmly established, and his alter ego and occasional hoax were tolerated with good-natured affection. It would appear that despite Osler’s vast clinical experience and well-known humanism, the episodes of renal colic that he endured served as an epiphany that spurred him, remembering Plato’s “rule,” to leave a vivid account of his signs and symptoms, the unimaginable agony of the stone’s progression, and the wonder of the relief rendered by morphine—“God’s own medicine.” Acknowledgments. The author thanks Pamela J. Miller, Christopher Lyons, Diane G. Philip, and Lily Szczygiel of the 520
Osler Library of the History of Medicine, McGill University, Montreal, for their kind and enthusiastic research assistance.
References 1. Golden RL, Roland CG. Sir William Osler: An Annotated Bibliography with Illustrations. San Francisco, CA: Norman Publishing; 1988. 2. Golden RL. The Works of Egerton Yorrick Davis, MD: Sir William Osler’s Alter Ego.Montreal, QC: Osler Library, McGill University; 1999. 3. Davis EY. Vaginismus. Medical News. 1884;45:673. 4. Taylor FK. Penis captivus— did it occur? Br Med J. 1979;2:977-978. 5. Nation EF. William Osler on penis captivus and other urological topics. Urology. 1973;II:468-470. 6. Osler JWW Jr. Peyronie’s disease—strabisme du pénis. Boston Med Surg J. 1903;148:245-251. 7. White JW, Martin E. Genitourinary Surgery and Venereal Diseases. Philadelphia, PA: JB Lippincott; 1897: p 30. 8. ETD Jr. Peyronie’s disease—strabisme du pénis. Boston Med Surg J. 1903;148:485. 9. Osler W. Pyelitis consequent on stone in bladder and pyelonephritis. Montreal General Hospital Report No I, for the year ending May 1, 1877. Montreal, QC: Dawson Brothers Publishers;1878:76-77. 10. Osler W. The Principles and Practice of Medicine. New York, NY: D Appleton & Co.;1892: pp 765-770. 11. Young HH. Urinary Lithiasis: Renal and Ureteral Calculi In Osler W, ed. assisted by McCrae T. Modern Medicine: Its Theory and Practice. Philadelphia, PA; New York, NY: Lea & Febriger; 1909 VI:315-335. 12. Futcher TB. Dr. Osler’s renal stones. Ann Int Med. 1949;84:40. 13. Cushing H. The Life of Sir William Osler. Oxford, UK: Clarendon Press; 1925; vol. II: p 207. 14. Bensley EH, Bates DG. Sir William Osler’s autobiographical notes. Bull Hist Med. 1976;50:596-618. 15. Cushing H. Life of Sir William Osler. Oxford, UK: Clarendon Press; 1925; vol. II, p 208. 16. Howard RP. The Chief: Dr. William Osler. Canton, MA: Science History Publications; 1983: p 47. 17. Osler W. Day Books. # 7668. Montreal, QC: Osler Library, McGill University; January 1910: pp 40, 42. With the permission of the Board of Curators of the Osler Library. 18. Barondess JA. A hitherto unpublished appreciation of Sir William Osler by Dr. A. G. Gibson. Johns Hopkins Med J. 1977;140:47-55. 19. Hazlitt W. (Wight OW, ed). Works of Michael de Montaigne. New York, NY: Hurd and Houghton; 1875; Book III, Ch XIII, p 434. 20. Osler W. The Lumleian lectures on angina pectoris. London, UK: Lancet I: 697-702, 839-844,973-977, 1910. 21. Moran ME, Das, S, Rosenberg SA. Sir William Osler’s perceptions of urolithiasis and the case of the indigo calculus. J Endourol. 2005;19:1157-1160. 22. Osler W. An auto-clinique. # 7664, Vol V, Osler Library, McGill University, Montreal, QC, Canada. With the permission of the Board of Curators of the Osler Library. 23. Jowett B (trans). The Republic of Plato. 3rd ed., III, analyses 408-409. Oxford, UK: Clarendon Press; 1888 (impression of 1925): p xlvi. 24. Paley FA (trans). The Theætetus of Plato. London, UK: George Bell & Sons; 1875: p 14. 25. Wilkinson A. Lions in the Way: A Discursive History of the Oslers. Toronto, ON: The Macmillan Company of Canada Limited; 1956: p 214. 26. Bliss M. William Osler: A Life in Medicine. New York, NY: Oxford University Press; 1999: p 366. 27. Barondess JA. A case of empyema: notes on the last illness of Sir William Osler. Tr Am Clin Climatol Assoc. 1975;86:59-72. 28. Cushing H. The Life of Sir William Osler. Oxford, UK: Clarendon Press; 1925, vol. I, p 166. 29. Knopf SA. Personal reminiscences of Sir William Osler In Abbott ME, ed. Appreciations and Reminiscences: Sir William Osler Memorial
UROLOGY 74 (3), 2009
Number, Bulletin No. IX of the International Association of Medical Museums, Montreal; 1925: pp 321-327. 30. Peabody FW. Notes of the effects of morphine In Paul O, ed. The Caring Physician: The Life of Dr. Francis W. Peabody, Boston, The Francis A. Countway Library of Medicine & The Harvard Medical Alumni Association, Harvard University Press; 1999: pp 137, 175-182. 31. Jaffe JH. Narcotic analgesics In Goodman LS, Gilman A, eds. The Pharmacological Basis of Therapeutics. New York, NY: The Macmillan Company; 1970: p 237.
UROLOGY 74 (3), 2009
32. Lodwick KL. Crusaders Against Opium: Protestant Missionaries in China, 1847-1917. Lexington, Lexington-Fayette, KY: University Press of Kentucky; 1995: p 35. 33. Booth M. Opium: A History. New York, NY: St. Martin’s Griffin; 1999: p 145. 34. Peabody FW. The care of the patient In: Paul O, ed. The Caring Physician: The Life of Dr. Francis W. Peabody, Boston, The Francis A. Countway Library of Medicine & The Harvard Medical Alumni Association, Harvard University Press; 1999: pp 155-174.
521