STUDENT, TEACHER AND COLLEAGUE The reserves of life: William Osler versus Almroth Wright Marvin J Stone Summary: William Osler’s address, The Reserves of Life, was given to students at St Mary's Hospital Medical School in London in 1907. In the talk Osler likened a medical career to a race through London, pointing out that to be successful one had to have sufficient ‘reserves’ or staying powers. He also commented on several of his favourite topics and included some of his most memorable aphorisms. Almroth Wright was the colourful and controversial physician at St Mary's Hospital who described opsonins and. was a strong advocate of vaccine therapy for bacterial infections. Wright was often critical of clinicians and scoffed at their crude methods. During the address to the St Mary's students, Osler abruptly departed from his theme to criticize Wright (‘that Celtic Siren’) and defend clinicians, emphasizing that the art and science of medicine were inseparable, Despite their differences, Osler and Wright maintained a cordial relationship. Picture this: You are invited to give a guest lecture at a prominent medical school. It is the beginning Of the new term and you are asked to stimulate and inspire the students. You are well on your way to fulfilling these goals when, near the middle of the talk, you depart from your theme to roundly criticize the most distinguished faculty member of that school! That's what William Osler did in The Reseroes of Life. The target was Almroth Wright. What prompted such unusual behaviour? What were the circumstances? Osler (1849-1919) delivered many addresses that have been revered by generations of students and physicians." The Reserves of Life, given by Osler (Figure 1) to the medical students at St Mary's Hospital in London on 2 October 1907, is not so well known. It was published in the St Mary's Hospital Gazette and thus had only limited circulation® The address appears in two Osler anthologies, each edited by John P McGovern and Charles G Roland.” Osler’s address Osler gave his talk at the opening ceremony of the Winter Session for St Mary's medical students. Having just handed out the awards, he started by Marvin J Stone has boen Chief of Oncology and Director of the Charles A Sammons Cancer Center at Baylor University Medical Center in Dallas, Texas, since 1976. He heads the junior medical student clerkship and the medical oncology [ellowship programme. He has published widely in haem tology and immunology. He i 4 past president of the ‘American Osler Society. Correspondence: Baylor Sammons Cancer Center, 3500 Gaston AAvenve, Dallas, Texas 75246, USA (Gmail marvinstbaylorhealthedu) providing perspective to the students, asserting that ‘Prizes and certificates, while of good omen and meaning... are of no value unless they impart fa stimulus to higher and better effort. Osler likened medical practice and career to a race through London, saying, ‘For final success the race winner must have reserces, not merely the cap- ability and energy for the short run (such as that in ‘which you have been engaged) but endurance or, as the expression is, staying powers’. He posed the question of how to acquire these reserves and answered “The few who reached Charing Cross did so because of three factors: you were built for the racetrack; you were properly trained, and you knew the road; and for the long race ahead these same three factors are the essentials’. Osler said “You will be glad to know that the training is only in three subjects ~Science, Art, and the Knowledge of Men -of equal importance one with another’. He mentioned several of his pet topics including the Uselessiess of examinations, the equal uselessness Of most drugs, and the value of medical history in teaching medicine. He also referred to what had become and would continue to be one of his favourite themes: ‘Let me repeat to you the motto which I have been dinning into the ears of students for the past 25 years: ‘Take no thought for the morrow" = let the interest in the day’s work absorb all your energies, and the future, with the exem- nations, will look after itself”. He stated ‘a devotion to science, a saturation with its spirit, will give you that most precious of all faculties —a sane, cool reason which enables you to sift the true from the false in life and, at the same time, keeps you well in the van of progress’. About half-way through the talk Osler shifted to the importance of the art of ‘medicine, announcing ‘It is much harder to acquire Jourant of Mesice Bagraply 2007; 15 (Suppl. 1): 28°31Figure 1 it portrait of Sir Willi Osler hi academic gen by Kennet PM J Try, 1983. This portrait es donated bythe artist tthe tex of Dundas, Ontario, ere thangs he To Hal (courtesy of ‘he City of Hamilton, Outro, Canna) the art than the science’. Then he fired this fusillade: Stop your ears with the wise man’s wax against the wiles of that Celtic Siren, Sir Almroth, who would abolish Harley Street anc all that it represents. There is still virtue, believe me, in that ‘long unlovely street” and the old art cannot possibly be replaced by, but must be absorbed in, the new science. Osler honed in on some other key issues ~ ‘in the first place the fundamental law should be ingrained that the starting point of all treatment is in a knowledge of the natural history of a disease’, Later came an explicit comment about the ideals of the medical profession: Get your relationship clearly defined ~ you are in this profession asa calling, not as a business, as acaling which exacts from you at every tum self-sacrifice, devotion, love find tenderness to your fellow-men, Ina lighter vein he added: But whatever you do, take neither yourselves nor your fellow-creatures too seriously. There is tragedy MJ Stone Osler and Almroth Wright 29 ‘enough in our daily routine, but there is room too for a keen sense ofthe absurdities and incongruities of life, and inthe shifting panorama no one sees better than the doctor the perennial sameness of men’s ways. (Osler returned to the race metaphor and said, “In ordinary training you run the course over, but life's race is run but once; and, though the course may seem long to you, it is really very short, but very hard to learn. Fortunately, you are not alone on the track, as your brothers are ahead, and if you are willing there is always help at hand’. He concluded the address by paying tribute to some of the previous renowned physicians at St Mary’s includ- ing Sir William Broadbent (1835-1901). Almroth Wright Almroth E Wright, MD (1861-1947) (Figure 2) was the most lustrous faculty member at St Mary's in 1907.12 Like Osler, he was the son of a minister and became a classical scholar. He was educated at Dublin University. After postgraduate studies, he held_positions in Pathology at Cambridge and Physiology at Sydney University. Wright devel- ‘oped longstanding interests in language, logic and philosophy. He disliked mathematics and avoicled exercise. In 1892, he was appointed Professor of Pathology at the Army Medical College at Netley. There he performed important work in blood coagulation demonstrating the importance of cal- cium in the clotting mechanism. He became a ‘master of laboratory technique by inventing meth- ‘ods to analyse smail volume blood samples in fine- bore glass capillary tubes." His principal investi- gative activities were focused on testing for Bacterial diseases and the vaccine approach for their prevention. In 1902 Wright was appointed Pathologist, Bacteriologist and Director of the Inoculation Department at St Mary's Hospital, ppositions he held for nearly half a century." His department became largely independent by sup- porting its research activities through income derived from vaccine production, private practice and donations. The year before Osler’s address, Wright had been knighted and elected a Fellow of the Royal Society. He had achieved wide recog tion in immunology, having described opsonins and developed typhoid vaccine.'8 He passi nately believed that vaccines would become the preferred treatment of bacterial infections and predicted that “The physician of the future will be an immunisator’.”” Wright was also the mentor of ‘Alexander Fleming, a St Mary's graduate who had joined the staff of the Inoculation Department the year before Osler’s talk. Fleming's 1928 discovery Of penicillin in Wright's own department eclipsed his teacher’s view that vaccines would be the favoured treatment for bacterial diseases. Another of Wright's pupils, Leonard Colebrook, pioneered the use of sulphonamides in puerperal fever. Antibiotics were to far surpass vaccines and30 Journal of Medical Biography Volume 15 Supplement 1 2007 Figure 2 Porto of Sir Alnroth Wright by Gerald Kelly, 1934 (repro eth permission of Mr Kevin Broa, St Mary's Hospital Mata! School, London investigators trained at St Mary’s by Almroth ‘Wright were in the vanguard of the revolution! Wright made one of the first public appeals for funding of medical research in an article published in the. Liverpool Daily Post of 30 August. 1905 entitled “The World’s Greatest Problem"? He wrote ‘It will, perhaps, now come home that after food and shelter and external defence and admin- istration of justice have been provided, the most urgent need in every civilized community is the need for medical research’. Wright was brilliant, industrious, tenacious, steadfast, provocative, inspiring and influential. However, he was also eccentric, dogmatic, arrogant, tactless, argumenta- tive, intolerant’ and controversial. He believed women were inferior to men and strongly opposed female suffrage." He attracted many nicknames, especially from the St Mary's students. These included ‘the old man’, ‘the Praed Street Plato’, ‘Sir Almost Wright’ and ’Sir Almost Wrong’.1/"224 He had a keen understanding of scientific investi- gation and declared ‘every novel idea or new invention must, before it wins general acceptance, pass through three stages. It is, to begin with, Feputed as absurd. After that it is allowed to be reasonable. And, finally, it is belittled as obvious’. Bernard Shaw knew Wright well and used him as the model for Sir Colenso Ridgeon in Shaw's play The Doctor's Dilemma? first produced in 1906. In the play one of Ridgeon’s physician colleagues proclaims ‘There is at bottom only one genuinely scientific treatment for all diseases, and that is to stimulate the phagocytes. Stimulate the phago- cytes. Drugs are a delusion’, Shaw noted Wright's work on opsonins in his Preface on Doctors. In Shaw's words ‘the white corpuscles or phagocytes which attack and devour disease germs for us do their work only when we butter the disease germs appetizingly for them with a natural sauce which Sir Almroth named opsonin...” Wright's opsonins appeared to reconcile Metchnikoff's cellular theory ‘of immunity with Ehrlich’s humoral thesis of antibody formation.1”25 Wright had excellent scientific training but had acquired only limited clinical experience. Although hhe got along well with many of his clinical colleagues, he scoffed at clinical methods and often spoke disparagingly of clinicians.!? Clearly, this attitude did not endear him to medical practi- tioners. In the autumn of 1907, when Sir William spoke to the St Mary's students, Sir Almroth had already addressed the annual dinner with Osler present as the honoured guest. On that occasion Wright opined that it appeared to be his lot to be the critic of his own profession and, speaking of bacteriology, he indicated a belief ‘that in that science lay all hope of great progress. In particular, he ridiculed the crudeness of methods that faced disease with knives and drugs and yet expected to be called modern. Apparently it was this tirade that prompted Osler’s sharp response in his lecture.”227 ‘The Aftermath Osler held no grudge. He and Wright remained friends and Osler supported Wright's scientific work, When World War I began, Osler endorsed Wright's typhoid vaccine in print on three separate occasions** In an article entitled, The Waar and Typhoid Fever he referred to ‘the brilliant investiga- tions of Sir Almroth Wright’. Nevertheless, Osier did not hesitate to denounce Sir Almroth in 1907 for lack of respect for professional colleagues and even did so on Wright's home turf in front of his ‘own medical students. The question has been raised whether Osler’s censure of Almroth Wright in The Reserves of Life might have been meant a5 a joke." I believe this is unlikely because of the context of Osler’s remarks and also because this was an address directed to medical students, not faculty, Although Oslers criticism of Wright is cited in ‘the Cushing and Bliss Osler biogra- phies,*=¥ neither the lecture nor Osler’s rebuttal is mentioned in the recent biography of Sir Almroth Wright Harvey Cushing admired Wright. They had been together during the war when Wright became embroiled in another controversy regarding the treatment of war wounds. In From a Surgeon's Journal, Cushing wrote ‘Sir Almroth simplyMJ Stone Osler and Alnvath Wright 31 paralyzing. Does not believe in exercise ~ has not ‘walked a mile since he can remember—told the War Office if he was to come out he must have a car, even though his billet and laboratory are only a half mile apart. Asked them if they wanted him over here to use his legs or his head”. Before returning to the USA after the war, Cushing visited 13 Norham Gardens in the winter of 1919 for one of the gatherings at the ‘Open Arms’. There he was surprised to see none other than Almroth Wright. Cushing wrote in his diary ‘Wright and Osler — could there be a greater contrast? ~The professional cynic and the professional optimist’ * ‘Wright lived to see his star pupil, Alexander Fleming, share the Nobel Prize with ‘Howard W Florey and Ernst B Chain in 1945 ‘for the discovery of penicillin and its curative effect in various infectious diseases’. After Wright's death, Flemin; twas appointed director ofthe department which was renamed The Wrightfleming Institute at St Mary’s Hospital The Reserves of Life was one of Osler’s exceptional presentations. In addition to containing some of his most pithy aphorisms, he cleverly developed the theme of the race metaphor in life. We also see that Osler did not let the defamation of his fellow clinicians pass without defending them while, at the same time, wisely emphasizing the necessity of blending the art of medicine with its science. Acknowledgements: Presented in part at the 34th ‘Annual Meeting of the American Osler Society, Houston and Galveston, Texas, April 2004. This paper is dedicated to John P McGovern, MD and Robert Howard Stone. I thank [ill Stone for editorial assistance and support, References and notes 1 Osler W. Asuna wilt Other Address fo Mati Students, Nurs nd Practitioners of Matin: Phildelphi: Blakiston, 1901 2 Osler W. An Alatunan Stufert and Other Biographical Essays London: Oxford University Pres, 1908 3 Stone MY. The wisdom of Sir Wiliam Osler. Ameren Journal of Carcology 1995,75269-76 4 Bryan CS. Over, Inspirations foo a Grent Physicim. New York: Oxford University Press, 1997 5 Stone Mj. Historical review. Wiliam Osler's legacy and his contribution to hematology: Brits Journal of Haematology 20085125318 6 Osler W, The reserves of life. S! Mary's Hospital Gazette 190713958 7 Golden RL, Roland CG. Sir Willi Osler. An Arnott Biblograpy th lustatins. San Francisco: Norman Pub lishing, 198 a 2 3 8 36 Osler W. The Reserves of Life. n: McGovern JP, Roland CG, feds. William Osler ~ The Contining Eaucaion. Speingild Charles C: Thomas, 1969: pp. 193-202 (Osler W. The Reserves of Life. In: McGovern JP, Roland CG, eds. The Clleced Essays of Si Willan: Osler. The Educational Essays, Birmingham: Classics of Medicine Library, 1985: vol 2 pp 323-32 Osler W. A Why of Life, London: Constable & Co, 1913, aolebrook 1. Alroth Weight. Proocaise Doctor and Thinker London: Heinemann, 1954 Cope Z. Alnrath Wright. Founder of Modern Vacine-Therapye London: Nelson, 1966, Wright AE, Colebrook L. Technique ofthe Tet and Captary Glass Thbe, Landon: Constable & Co, 1912 Cope Z. 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