A Legacy of Scientific Racism: William Osler's "An Alabama Student".

William Osler's essay "An Alabama Student" made John Young Bassett (1804-1851) a widely admired avatar of idealism in medicine. However, Bassett fiercely attacked the idea that all humans are members of the same species (known as monogenesis) and asserted that Black inferiority was a justification for slavery. Antebellum physician-anthropologists bequeathed a legacy of scientific racism that in subtler forms still runs deep in American society, including in the field of medicine.

THE MAKING OF ENCYCLOPEDIA OSLERIANA.

An encyclopedia pertaining to Sir William Osler (1849-1919), the most iconic physician in the history of North American medicine, has been prepared to mark the centenary of his death. Here, we address three questions: Why is Osler emblematic of medicine's "heroic age"? What was he really like? What would he say to us were he alive today? Regarding the first question, Osler's life illustrates certain commonalities of high achievers as identified in Malcolm Gladwell's 2008 bestseller, Outliers. These include at least 10,000 hours of focused hard work, a favorable family of origin, and a series of lucky breaks. Regarding the second question, analysis of published reminiscences of, or tributes to, Osler by 205 of his contemporaries using the framework developed by the Values in Action (VIA) Classification Project revealed his signature strengths to be vitality and kindness. Regarding the third question, Osler's interests evolved, especially during and after the Great War (1914-1918). He became less interested in burnishing the image of medicine as a "profession" as he worried about human survivability and whether science would ultimately prove a force for good or evil. In his last public address, Osler opined that "there must be a very different civilization or there will be no civilization at all." He alluded to the "New Humanism" being developed by George Sarton (1884-1956), who championed "humanized science" as humanity's best hope.

Reducing High-Users' Visits to the Emergency Department by a Primary Care Intervention for the Uninsured: A Retrospective Study.

Reducing avoidable emergency department (ED) visits is an important health system goal. This is a retrospective cohort study of the impact of a primary care intervention including an in-hospital, free, adult clinic for poor uninsured patients on ED visit rates and emergency severity at a nonprofit hospital. We studied adult ED visits during August 16, 2009-August 15, 2011 (preintervention) and August 16, 2011-August 15, 2014 (postintervention). We compared pre- versus post-mean annual visit rates and discharge emergency severity index (ESI; triage and resource use-based, calculated Agency for Healthcare Research and Quality categories) among high-users (≥3 ED visits in 12 months) and occasional users. Annual adult ED visit volumes were 16 372 preintervention (47.5% by high-users), versus 18 496 postintervention. High-users' mean annual visit rates were 5.43 (top quartile) and 0.94 (bottom quartile) preintervention, versus 3.21 and 1.11, respectively, for returning high-users, postintervention (all P < .001). Postintervention, the visit rates of new high-users were lower (lowest and top quartile rates, 0.6 and 3.23) than preintervention high-users' rates in the preintervention period. Visit rates of the top quartile of occasional users also declined. Subgroup analysis of medically uninsured high-users showed similar results. Upon classifying preintervention high-users by emergency severity, postintervention mean ESI increased 24.5% among the lowest ESI quartile, and decreased 12.2% among the top quartile. Pre- and post-intervention sample demographics and comorbidities were similar. The observed reductions in overall ED visit rates, particularly low-severity visits; highest reductions observed among high-users and the top quartile of occasional users; and the pattern of changes in emergency severity support a positive impact of the primary care intervention.

Pellagra Pre-Goldberger: Rupert Blue, Fleming Sandwith, and The "Vitamine Hypothesis".

The conquest of pellagra is commonly associated with one name: Joseph Goldberger of the US Public Health Service, who in 1914 went south, concluded within 4 months that the cause was inadequate diet, spent the rest of his life researching the disease, and--before his death from cancer in 1929--found that brewer's yeast could prevent and treat it at nominal cost. It does Goldberger no discredit to emphasize that between 1907 and 1914 a patchwork coalition of asylum superintendents, practicing physicians, local health officials, and others established for the first time an English-language competence in pellagra, sifted through competing hypotheses, and narrowed the choices down to two: an insect-borne infection hypothesis, championed by the flamboyant European Louis Westerna Sambon, and the new "vitamine hypothesis," proffered by Casimir Funk in early 1912 and articulated later that year by two members of the American Clinical and Climatological Association, Fleming Mant Sandwith and Rupert Blue. Those who resisted Goldberger's inconvenient truth that the root cause was southern poverty drew their arguments largely from the Thompson-McFadden Pellagra Commission, which traces back to Sambon's unfortunate influence on American researchers. Thousands died as a result.

"An aristocracy of talent": the South Carolina physician-naturalists and their times.

During the natural history movement of the 18th and early 19th centuries, Charleston as a center was rivaled in the United States only by Philadelphia, New York, and Boston. Prominent physician-naturalists included Alexander Garden (for whom the gardenia is named), John Edwards Holbrook ("father of American herpetology"), and Francis Peyre Porcher (whose Resources of Southern Fields and Forests helped Confederates compensate for drug shortages). The Charleston physician-naturalists belonged to an "aristocracy of talent" as distinguished from the "aristocracy of wealth" of lowcountry planters, who probably did more than any other group to perpetuate slavery and propel the South toward a disastrous civil war. None of the physician-naturalists actively opposed slavery or secession, a reminder that we are all prisoners of the prevailing paradigms and prejudices of our times.

Sir William Osler's fatal trip to Scotland: "Mrs M" and the University Grants Committee.

On 23 September 1919, Sir William Osler, after a telephone call from his friend Dyson Perrins, went to Glasgow where he saw a 40-year-old woman, Bethia Fulton Martin, in consultation with three local physicians. Osler called it "one of those remarkable Erythema cases (all sorts of skin lesions and three months on and off consolidation of both lower lobes)." Mrs Martin died 114 days later; her death certificate listed "angioneurotic oedema with chronic nephritis" and "tuberculous enlargement of the mediastinal lymph nodes." Osler died 18 days before Mrs Martin of complications from a respiratory infection acquired on his way home from Scotland. We discuss factors that possibly prompted Osler to go to Scotland, including his role with the newly formed University Grants Committee, and the differential diagnosis of the case, which is mainly between systemic lupus erythematosus and Henoch-Schönlein purpura.

Ira Remsen, Osler, the Flexner Report, and the full-time plan.

A famous letter from Sir William Osler to Ira Remsen, dated September 1, 1911, concerns Osler's objections to the full-time plan, whereby clinical professors should focus on research and abstain from private practice. Previous accounts of this well-known episode make little or no mention of the recipient other than his being president of the Johns Hopkins University. Remsen, in retrospect, was uniquely positioned to champion ideas advanced by Abraham Flexner, the General Education Board of the Rockefeller Foundation, and some of Osler's former colleagues at Johns Hopkins, notably William H. Welch. Remsen had previously expressed the need for Hopkins to advance science-based medicine; he had introduced Abraham Flexner to the Carnegie Foundation (which led to the Flexner Report); and he appears to have been the first US-born person to possess both a medical degree and a doctorate in basic science. Caught in the middle of a faculty controversy, Remsen chose not to pursue the matter further for reasons that included a passive administrative style, concerns about his health, and friendship with Osler.

Sir William Osler, eugenics, racism, and the Komagata Maru incident.

A recent critic levels two new charges against Sir William Osler: (1) that in 1912 he was a vice president of the First International Eugenics Congress; and (2) that in 1914 he asserted Canada should remain a "a white man's country." Osler was indeed among the 31 vice presidents of the First International Eugenics Congress, but he did nothing further in this area. Osler indeed asserted that Canada should remain a "white man's country," but his context was the Komagata Maru incident during which most Canadians felt the same way about 376 passengers from the Punjab Province of British India who sought to defy Canadian immigration law. There is little or no indication of racism elsewhere in Osler's deeds and writings, and the idea that race is largely a social construct emerged only after his death. Advocates for racial equality should view Osler not as an adversary but rather as an ally in today's battles for global justice and also for human survival.

New observations support William Osler's rationale for systemic bloodletting.

Bloodletting has been called William Osler's "blind spot," especially with respect to pneumonia. Also puzzling has been his endorsement of bleeding in selected cases of heatstroke. Recent clinical observations on pneumonia and, to a lesser extent, heatstroke lend support to Osler's rationale for bloodletting in these conditions. A 21st-century rationale now exists for all eight indications for systemic bloodletting listed by Osler in the first edition of his textbook, The Principles and Practice of Medicine (1892): treatment of acute heart failure (seven of the eight indications) or rapid lowering of blood pressure (in subarachnoid hemorrhage accompanied by severe hypertension). These observations support the narrative that during Osler's lifetime, bloodletting became more "rational" largely on the basis of cumulative clinical experience.

The centenary of 'The Old Humanities and the New Science,' the last public address of Sir William Osler (1849-1919).

On 16 May 1919, Sir William Osler (1849-1919) gave what would be his last public address, 'The Old Humanities and the New Science,' to the Classical Association of which he was president. British educators were locked in a struggle between classics teachers, who wished to preserve their dominance in public schools and universities, and science teachers, who wanted more time in the curriculum. Osler had supported the science teachers' position three years earlier in his presidential address to the Association of Public School Science Masters. What could he now say to the classicists without making enemies? He gently chided both groups, but he was less concerned that day with the curricular dispute than with the question whether 'Science … can rule without invoking ruin.' He averred that 'there must be a very different civilization or there will be no civilization at all.' He invoked the Hippocratic ideal of 'philanthropia and philotechnia' (love of humanity and love of science of technology) not just for medicine, but for all of humankind.

Sir William Osler (1849-1919) and the paternity of William Willoughby Francis (1878-1959): Review of the evidence.

It has been suggested that beneath the sunny personality and enormous productivity of Sir William Osler (1849-1919) lurked a deep sorrow. A longstanding rumor suggests this sorrow was a prolonged affair with an older first cousin, Marian Osler (Bath) Francis (1841-1915), which resulted in Osler's paternity of William Willoughby Francis (1878-1959). Osler treated W.W. Francis like a son. Francis after Osler's death devoted the rest of his life to preserving Osler's memory. Osler's great-great niece Anne Wilkinson (1910-1961) strongly endorses this rumor; Osler scholar George T. Harrell (1908-1999) strongly suggests its truth, while Osler biographer Michael Bliss (1941-2017) dismisses it. Evidence supporting the rumor includes ample opportunities for mating, biographical details, and phenotypic resemblances that are hard to explain otherwise. Barring a DNA-based family study, the truth will probably never be known.

Osler goes viral: "The Fixed Period" revisited.

William Osler's parting address to faculty at the Johns Hopkins University, given on February 22, 1905, and published as "The Fixed Period," clouded his departure from North America after reporters sensationalized a playful suggestion that aging professors be chloroformed. A newly available collection of newspaper clippings affords a semiquantitative analysis of the press reaction. Only 40% of the writers openly criticized Osler. Some (about 15%) defended him; many (33%) merely attempted humor; and a few (about 6%) wrote poetry. Often overlooked are the main points of Osler's address: awareness of one's place in the adult life cycle and the need for self-renewal with advancing age.

The ethics of infection control: philosophical frameworks.

Recent developments that are relevant to the ethics of infection control include the patient safety movement, the appearance of new diseases (notably, severe acute respiratory syndrome) that pose threats to healthcare workers, data confirming the suspicion that infection control measures such as isolation may compromise patient care, and, in philosophy, renewed interest in virtue ethics and communitarianism. We review general ethical frameworks and relevant vocabulary for infection control practitioners and hospital epidemiologists. Frameworks for the ethics of infection control resemble those of public health more than those of clinical medicine but embrace elements of both. The optimum framework, we suggest, takes into account a virtue-based communitarianism. The virtue ethics movement stresses the need to consider not only rules and outcomes but also the character of the individual(s) involved. Communitarianism emphasizes the well-being and values of local communities, best determined by shared, democratic decision making among stakeholders. Brief discussions of 15 consecutive cases illustrate the extent to which the daily practice of infection control poses problems heavily freighted with ethical overtones.

Fever of unknown origin: is there a role for empiric therapy?

Empiric therapy has little or no role to play in cases of classic fever of unknown origin with three important exceptions: cases that meet criteria for culture-negative endocarditis; cases in which findings or the clinical setting suggests cryptic disseminated tuberculosis (or, occasionally, other granulomatous infections); and cases in which temporal arteritis with vision loss is suspected. Several studies indicate that patients with prolonged, undiagnosed fever of unknown origin generally have a favorable prognosis. A small and largely anecdotal literature suggests a small role for symptomatic use of corticosteroids or nonsteroidal anti-inflammatory agents in highly selected cases.

The Osler industry: insightful history or insipid hagiography?

The life and legacy of Sir William Osler (1849-1919) have been celebrated by nearly 1900 articles, 10 special issues of medical journals, several biographies, numerous lectures and orations, and regular meetings of 'Osler Societies' throughout the world. To what extent does this 'industry' reflect serious history as opposed to hagiography? The overarching purpose of this special issue of the Journal of Medical Biography is to present Osler as a real person from whom useful examples--both admirable and not so admirable--can be drawn for a 21st century readership.