Sir William Osler's Philosophy on Death

Clinician Osler and Dying Patients

William Osler was born in 1849, the eighth son of a minister in a small Canadian village. His initial desire to enter the clergy led him to enter Toronto University. During his studies there, however, he was influenced by Dr. James Bovell, Professor of Toronto Medical School, and decided to pursue medicine instead. He transferred to McGill University to complete his medical degree. After graduation he went to Europe to study British and German medicine for a year. He then taught for 10 years at McGill Medical School, for 5 years at the University of Pennsylvania, and then for 15 years at the Johns Hopkins University Medical School. In 1905 he became the Regius Professor at Oxford University, where he died in 1919 at home at the age of 70 (Figure 1).

The way that Osler cared for dying patients is vividly reflected in his letter to the father of a dead patient and the remembrances of the mother of a dead child-patient for whom he used to make house calls.

Patient 1

In the autumn of 1875, Osler, then 26 years old, was working at Montreal General Hospital as an internist. While dining one day, he met a young Englishman who had come to Montreal on business. Osler noticed that the young man appeared ill and admitted him to the hospital; however, the young man died of smallpox 3 days later. As the physician present at the time of death, Osler wrote to the young man's father in England to relate the sad news.

To Mr. N from W.O. My dear Sir,No doubt before this, the sorrowful intelligence of your son's death has reached you, and now when the first shock has perhaps to a slight extent passed away, some further particulars of his last illness may be satisfactory. He was well aware of his dangerous state. He spoke to me of his home, and his mother, and asked me to read the 43rd chapter of Isaiah, which she had marked in his Bible. I spent the greater part of the morning talking and reading with him.About 12 o'clock I heard him muttering some prayers, but could not catch distinctly what they wereGod the Father, Son and Spirit. Shortly after this he turned round and held out his hand, which I took, & he said quite plainly, Oh thanks. These were the last words the poor fellow spoke. From 12.30 he was unconscious, and at 1.25 a.m. passed away, without a groan or struggle. As the son of a clergyman and knowing well what it is to be a stranger in a strange land I performed the last office of Christian friendship I could, and read the Commendatory Prayer at his departure. Such, my dear sir, as briefly as I can give them, are the facts relating to your son's death.

Young Osler gave not only medical attention but pastoral care to this dying patient. The parents of the young man were deeply grateful for his kind care of their dying son. Some 30 years later, when Osler was appointed Regius Professor of Medicine at Oxford, he happened to meet the young man's sister and visited the mother who had long wanted to thank him personally [4].

Patient 2

In 1918, a year after Osler lost his son in the war, an epidemic of influenza struck Europe, killing many people. Osler, who was 69, made frequent house calls to see patients. Among them was a girl named Janet, whom he visited twice daily. Knowing the end was drawing near for little Janet, Osler made a final visit to her home [5], which Janet's mother described as follows:

The most exquisite moment came one cold, raw, November morning when the end was near, and he mysteriously brought out from his inside pocket a beautiful red rose carefully wrapped in paper, and told how he had watched this last rose of summer growing in his garden and how the rose had called out to him as he passed by, that she wished to go along with him to see his little lassie. That evening we all had a fairy tea-party, at a tiny table by the bed, Sir William talking to the rose, his little lassie, and her mother in a most exquisite way; and presently he slipped out of the room just as mysteriously as he had entered it, all crouched down on his heels; and the little girl understood that neither fairies nor people could always have the colour of a red rose in their cheeks, or stay as long as they wanted to in one place, but that they nevertheless would be very happy in another home and must not let the people they left behind, particularly their parents, feel badly about it: and the little girl understood and was not unhappy.

In this way Osler conveyed to the dying young girl that death is unavoidable for any living thing. The rose he picked from his garden illustrated this. The delicacy and careful attention in his choice of words and actions are both impressive and touching.

This letter, written by Janet's mother, has important implications for future studies on how to approach terminally ill children and their parents and to help them achieve an understanding and acceptance of the inevitability of death.

Osler's Interpretation of Death through Plato and Dr. William Munk

From the latter half of the nineteenth century to the early twentieth century, Osler emphasized the scientific aspects of medicine, especially the importance of clinical laboratory examination and postmortem pathologic studies. On the other hand, Osler did not sanction the unnecessary use of drugs, and he rejected pseudo-psychotherapeutic treatment. He was more attracted to the natural therapy of the Hippocratic era, which relied on the self-healing ability, or the self-restorability, innate to humans.

In 1893 he gave a speech titled Physic and Physicians as Depicted in Plato at the Historical Club of the Johns Hopkins Hospital. In it, he referred to the following passage in Plato's Timaeus [6]:

For that which takes place according to nature is pleasant, but that which is contrary to nature is painful. And thus death, if caused by disease or produced by wounds, is painful and violent; but that sort of death which comes with old age and fulfills the debt of nature is the easiest of deaths, and is accompanied with pleasure rather than with pain.

Osler later presented a number of clinical examples in which dying was not necessarily accompanied by physical and mental agony. He supported Plato's view, especially in the case of death from old age, that excessive medical treatment simply to prolong the patient's life might even lessen the patient's quality of life. In this respect, his philosophy is consistent with the basic idea of the hospice.

Osler believed that under certain circumstances euthanasia should be allowed for dying patients, especially when the patients were in the terminal stage of their illnesses and experienced physicians concluded that there was no possibility of a cure. While at the University of Pennsylvania, Osler read Euthanasia: or Medical Treatment in Aid of an Easy Death, by Dr. William Munk [7], the accomplished historian of the Royal College of Physicians of London. He concurred with Munk's suggestion of free but judicious administration of opium in the particular cases of dying patients and published an article in the Canada Medical & Surgical Journal [8] introducing Munk's work on euthanasia. This essay provides an important clue to Osler's thoughts on death and dying. He wrote that although death is described as the King of Terror in the Old Testament (Job 18:14) because of the belief that it is accompanied by agony, in reality dying patients rarely suffer; his experience was that death often comes in a state that can be called sleep and forgetting, just like birth. Osler further referred to Shelley's verses that say death comes slowly without groan or fear and that life closes in peace. He also agreed with Munk's opinion that the use of opiates not only alleviated pain but also relieved the feeling of exhaustion and sinking associated with dying. He also quoted Dr. C. W. Hufeland [9], a German physician, as saying, Opium is not only capable of taking away the pangs of death, but it imparts even courage and energy for dying. Osler also quoted On some of the phenomena of dying, William Hunter's (Professor of Anatomy at the Royal Academy of Arts) last words [10]: If I had strength enough to hold a pen I would write how easy and pleasant a thing it is to die.

Osler's Study of Dying

In large institutions such as university hospitals, doctors and nurses face death daily. John Milton aptly called this the business of deaths [11]. Osler studied such deaths and concluded that when a person is dying, he or she usually does not know what to expect. Even well-educated people are not prepared to face it, and although feeling apprehensive, they often fall unconscious, collapse, and pass away.

Between 1900 and 1904, Osler conducted a survey of 486 dying patients at the Johns Hopkins Hospital. He observed their mental and physical conditions as they went through the process of dying in order to learn how patients felt when facing death [3].

A sample questionnaire used by Osler in this survey is kept in the Osler Library at McGill University in Montreal (Figure 2). The nurse interviewed the patient at his or her last moment of life. Each item was filled in by a chief nurse and countersigned by the patient's doctor. Osler's summary of this survey on dying [11] follows:

I have careful records of about five hundred death-beds, studied particularly with reference to the modes of death and the sensations of the dying. The latter alone concerns us here. Ninety suffered bodily pain or distress of one form or another, eleven showed mental apprehension, two positive terror, one expressed spiritual exaltation, one bitter remorse. The majority gave no sign one way or the other; like their birth, their death was a sleep and a forgetting. The preacher was right: in this matter man hath no preeminence over the beast,as the one dieth so dieth the other (Ecclesiastes, 3:19).

In 1897, Osler said that when a patient is dying, he or she may prefer to be left alone. But it was often the professional nurses who did not understand this feeling rather than the patient's close friends and relatives at the bedside. He wrote [12]:

For generations has not this been his immemorial privilege, a privilege with vested rights as a deep-seated animal instinctto turn his face toward the wall, to sicken in peace, and, if he so wishes, to die undisturbed? All this the trained nurse has, alas! made impossible. And more, too. The tender mother, the loving wife, the devoted sister, the faithful friend, and the old servant who ministered to his wants and carried out the doctor's instructions so far as were consistent with the sick man's wishesall, all are gone, these old familiar faces; and now you reign supreme, and have added to every illness a domestic complication of which our fathers knew nothing. You have upturned an inalienable right in displacing those whom I have just mentioned. You are intruders, innovators, and usurpers, dislocating, as you do, from their tenderest and most loving duties these mothers, wives and sisters.

I assume that this critical remark about nurses was made because of the quality of nurses and their attitudes toward patients in Osler's day. The level of nursing has since advanced greatly, and Osler's criticisms no longer apply. Indeed, this might be a more appropriate warning to today's physicians, who, through well-meaning interventions and ministrations, may be seen as intruders and usurpers, dislocating the patient from those closest to him.

Osler's Library on Death

In the library of his house in Oxford, Osler kept one corner devoted to Death, Heaven and Hell, where he kept old and new books on such subjects as dreams and ghosts, witchcraft, immortality, longevity, resurrection, suicide, euthanasia, cremation, and embalming. Among them was Words in Pain [13], a collection of letters written by an anonymous lady to her doctor telling about her illness and its pain and distress. The November 1911 issue of the journal Spectator [14] included a letter to the editor by Osler. Introducing himself as a student for many years of the art and of the act of dying, he commented that he was very dissatisfied by an essay on the act of dying by Maeterlinck that had appeared in Spectator.

Maeterlinck's essay described death as the tortures of the last illness, the useless prolonged torments, the unbearable memories of the chamber of pain, the pangs of death, the awful struggle, the sharpest peak of human pain, and horror [15]. Osler countered that most people die in oblivion and that physical pain had little to do with actual dying.

Maeterlinck wrote in his essay about the type of doctor who has not, at a bedside, twenty times wished and not once dared to throw himself at their (the dying person's) feet and implore them to show mercy [16]. Osler, criticizing this kind of doctor, referred to Thomas Fuller, whom he respected, and his good physicians [17]. He said that patients will die in peace if they are looked after by good physicians who will act so that when he can keep life no longer in, he makes a fair and easy passage for it to go out. In his letter to the editor [15], Osler referred to Socrates who, having taken hemlock and dying in peace, wanted to thank the god of medicine, Asclepius, saying, I owe a cock to Asclepius with his last breath. Osler implied that everyone faced with a peaceful death will share Socrates' feelings [18].

When Osler was 56 he moved to Oxford. His chronic bronchitis worsened, and although he continued to carry on his usual full working schedule, it was obvious that his health was gradually deteriorating. Osler himself realized this, but through this personal experience he tried to study the effect of illness on the human body. As early as 1904, Osler appeared to have a foreboding that his chronic bronchitis would eventually demand his life, according to his letter of June 21, 1904, sent to Sir J. B. Sanderson, who recommended Osler as his successor to the Regis Professorship at Oxford.

In 1902 Osler was invited by Charles Eliot, the President of Harvard University, to deliver the Ingersoll Lecture, but because of the serious nature of this assignment and his deteriorating health, he was reluctant to do so. After repeated requests by Eliot, he finally accepted and in 1904 delivered a lecture titled Science and Immortality [11].

Speaking on the concept of spiritual eternity or immortality, Osler classified the conventional interpretations and their actual practices of people into the following three categories:

1. Although accepting a belief in immortality and accepting the forms of religious rituals, the person lives practically uninfluenced by them.

2. The person considers a belief in immortality to be unscientific and unacceptable.

3. The person has a religious belief in the eternal life.

Osler affirmed the opinion that scientists could live with a belief in immortality. He closed the lecture with the following words:

Some of you will wander through all phases, to come at last, I trust, to the opinion of Cicero, who had rather be mistaken with Plato than be in the right with those who deny altogether the life after death; and this is my own confessio fidei.

Immortality is a complex problem, difficult to talk about, still more difficult to write upon with any measure of intelligence or consistency. A majority of sensible men will feel oppressed by the greatness of the subject and the feebleness of man; and it is with these feelings I close.

Osler seemed to want to convey the importance of the persistent pursuit of the possibility of immortality even though one retained some degree of doubt.

Osler and his Sons' Deaths

Osler married at the age of 43, and shortly thereafter, his first son, Paul Revere, was born but died only a week after birth. Osler, wishing to soothe his wife's sorrow, invented a letter from their son in heaven. In it, he tells his parents how happily he is living there.

Nothing shocked Osler more than the news of his second son's death at the war front in Europe. Edward Revere was born when Osler was 46 and became an Oxford student. When World War I broke out, Edward volunteered for military service and on 30 August 1917, died at the Flanders Front in France. He was only 21. The telegram reached Osler on 31 August 1917, when he was 67 years old. Osler never lost the deep grief of his son's death. In a letter to Dr. Campbell Palmer Howard [19], a son of Osler's teacher, whom he loved as if his own son, he wrote, We have been steeling our hearts for the blow, but now that it has come the bitterness is much more than we thought.

Osler's elder sister, Mrs. Chapin, who had lived with the Oslers, wrote [20], his heart is broken and he cannot cease weeping, poor darling, it is so cruel for his later life. Lady Osler wrote in a letter to Dr. George Dock [21], Osler's Philadelphia assistant: I could better bear this grief were it not to see him suffer such a tragedy for the end of his wonderful life.

Despite the pain of loss, they deliberately tried to recall some wonderful memories of their son. In a letter to Dr. H. M. Hurd, a colleague at the Johns Hopkins Medical School, Osler wrote, We are heartbroken, but thankful to have the precious memory of his loving life. This was no doubt the attitude that enabled the Oslers to sustain themselves through their anguish.

In an effort to seek strength to live, Osler probably repeatedly recalled his favorite verse from Lord Tennyson's In Memoriam, especially its 27th verse [22]:

Tis better to have loved and lost

Than never to have loved at all.

Osler and his wife volunteered for and occupied themselves with various wartime relief work for refugees from the European continent, which lessened their great sorrow.

Osler's Last Hours: Overcoming the Anguish of Death

One of the main reasons that Osler left the United States and went to England was his deteriorating health due to chronic bronchitis. This worsened after his second son's death. Repeated paroxysms of persistent coughing began to plague him in October 1919, and he confessed that he thought he would be shocked to death. It is appropriate to add his own act of dying to his study as the last example of a death without agony, but only because of the opiates. Although he had always held that most people, especially the elderly, died without much pain, his repeated attacks of coughing led him to request opiates.

Shunt the whole pharmacopoeia, except opium. It alone in some form does the job. What a comfort it has been! Poor sister (Mrs. Chapin) worried to death of course. For two days I felt ill and exhausted by the paroxysms [23].

This is not unlike the recent tendency of terminal care in hospices, where opiates are often administered alone to relieve pain.

On his last day, when Osler suffered the agony of lung abscess and bronchitis, opiates proved to be effective. He was unable to read very much during the last 2 weeks, but enjoyed listening to others read to him. On Christmas Eve he asked his nephew, Dr. W. W. Francis, chief editor of Bibliotheca Osleriana, to read Milton's Nativity, Osler's favorite poem [24], and on the day before his death, the verses of Coleridge's The Rime of the Ancient Mariner. Osler died at 4:30 in the afternoon of 29 December 1919. Although some hemorrhage was observed from the thoracentesis incision performed at his home on 22 December 1919, as Cushing described it, Osler quietly closed his life of 70 years and 6 months in his own bed.

Conclusion

From his youth Osler read a great deal of classic literature. Having grown up in a deep-rooted Christian tradition, he combined a superb intellect with a profound sensitivity based on Christian humanism. Through his study of pathology and human suffering in the practice of clinical medicine, Osler became a compassionate clinician who, in his practice of the art of medicine, was able to share the feelings of patients and their families. He tried to free dying patients from the physical and mental pain and to ensure their peace of mind. What Osler demonstrated in his art of medicine is consistent with the spirit of holistic hospice care.

Osler's philosophy of thanatology was formulated through the numerous encounters he had with death of his patients, close family members, and teachers. This prepared him to deal with his own terminal illness, and he died a peaceful death. We physicians at the end of the twentieth century can learn from Osler the art of today's care of the terminally ill.