A sleep and a forgetting

In the depth of winter I finally learned that there was in me an invincible summer.

Albert Camus¹

Canada has produced some great physicians: Frederick Banting, one of the pioneers in the discovery of insulin; Fred Tisdale, Theo Drake, and Alan Brown, collaborators on the development of Pablum; Drs Till and McCulloch, researchers who proved the existence and defined the key properties of stem cells; and Stanley Zlotkin, inventor of Sprinkles, a product used to treat micronutrient malnutrition in children, to name a few. But William Osler was arguably one of Canada’s greatest physicians, although he spent much of his professional life at Johns Hopkins in Baltimore, Md, years before the brain drain to the United States had even been recognized as a phenomenon. Osler had a lively curiosity about aging and dying, and made it his secret study over the years, amassing a formidable library on the subject. The interest might have developed during the many hours² he spent doing autopsies as a pathologist, handling the brains of the aged, noticing the scars of previous mini strokes or traumas, and meditating on the gradual decline of one’s faculties as the years wear on. As Michael Bliss describes it in his excellent biography William Osler: A Life in Medicine,² Osler believed that most of his acquaintances experienced aging as a “slow descent into ‘dull oblivion.’” His interest developed to such an extent that he got his staff to do a small qualitative study, asking them to list on index cards the answers to the following questions for his ward patients: The act of dying If sudden Did respiration stop before pulse—how long? Coma or unconsciousness before death—how long? If any fear or apprehension, of what nature— Bodily, ie Pain Mental Spiritual—ie remorse, etc. NB The object of this investigation is to ascertain the relative proportion of cases in which

1. the death is sudden;

2. accompanied by coma or unconsciousness;

3. by pain, dread or apprehension.

By this investigation, Dr Osler marked himself as a physician with an interest in palliative care, years before that term was coined by yet another great Canadian physician, Dr Balfour Mount. Osler revealed with this study his true colours as an investigator, one with a range of thinking not only on medicine as we know it today but also on spiritual, philosophical, and metaphysical topics. The results of this study were brief: I have careful records of about five hundred death beds … Ninety suffered bodily pain or distress of one sort or another, eleven showed mental apprehension, two positive terror, one expressed spiritual exaltation, one bitter remorse. The great majority gave no sign one way or the other; like their birth, their death was a sleep and a forgetting.²

Whether the results were an accurate depiction of deaths at the turn of the 20th century³ or would be achieved by a similar study today is arguable. Whether aging has been modified positively or negatively in the 21st century with the development of antihypertensives, cholesterol-lowering agents, and contemporary theories is also a matter of ongoing debate. Certainly it is the view of some that, with the help of today’s medical armamentarium, we have extended not active and enjoyable life but the slow descent into dull oblivion described by Osler.

Dr Osler used his study of death and dying to comment publicly on euthanasia. He had read William Munk’s book Euthanasia: or, Medical Treatment in Aid of an Easy Death,⁴ which was actually a text on palliative care. But in his speech on the occasion of leaving Johns Hopkins at the age of 56, Osler presented fixed ideas about the relative value of men—he did not comment on women at all—at certain ages. He believed that the most valuable contributions to the science of medicine came from men between the ages of 25 and 40, and that men should be put out to pasture after the age of 60. During his public address, the press misinterpreted an idle reference to Anthony Trollope’s The Fixed Period,⁵ a novel about the death-by-venesection of all 68-year-old men. He commented on the disposal of men at that age, referencing the novel with a lighthearted turn of phrase: “Whether Anthony Trollope’s suggestion of a college and chloroform should be carried out or not I have become a little dubious, as my own time is getting so short.”²

Although Osler was accused on the basis of this chance remark of being an advocate for euthanasia, as the term is used today, he lived differently. First, his observations of his family and how they experienced death might have modified his views on aging. His brother and sister died relatively young, of heart disease at age 61 and of cancer at age 62, respectively.² His father and mother, however, lived to the ages of 90 and 100, respectively, retaining vigour and a curiosity about life in their latter years. On the rare occasion that he let loose his personal views in public, Osler seemed to favour life after death and advocated Platonic, if not actively religious, ideas.

And in his own aging and dying, an irony transpired. He continued to contribute valuable lectures and insights about medicine into his seventh decade. Then Sir William Osler, who had prefaced his textbook on medicine by changing pneumonia from the old man’s enemy to the old man’s friend, himself came down with pneumonia in the days surrounding his 70th birthday. The man who had once been accused of advocating for active deaths of the aged then underwent vigorous and painful treatments for months to try to ameliorate the disease and prolong his life. The treatments were unsuccessful and he passed away peacefully on December 29, 1919. Morphine contributed to his comfort during the illness. One of his last requests, on Christmas Eve, was for the reading of Milton’s “Hymn on the Morning of Christ’s Nativity,”⁶ a decidedly spiritual poem, which he had traditionally shared at Christmas with his beloved son Revere. Revere had predeceased him, on the battlefield in Belgium near Ypres.

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