Did Sir William Osier Have Carcinoma of the Lung? My Canadian Pharmacy Gives Explanations

smokeIt is necessary to consider Osiers attitude to tobacco, which, like alcohol, he looked on as an enjoyable indulgence, harmless in moderation. There is no doubt that he regarded alcohol as far more perilous than tobacco—he had the sad example of his own brother, Frank, who, in spite of his weakness for the bottle outlived them all, dying in 1933. This fear of alcoholic over-indulgence was deeply ingrained, for when Osiers mother was approaching 90, her son prescribed a little whisky, though she demurred “But Benjamin, if I should get the habit?”

At any rate, Osier was a teetotaller until he came to Europe on his first visit, as a young postgraduate from McGill; it was about the same time that he began to smoke. In 1896, he said he was a cigarette smoker of 24 years standing, which would date his initiation as 1872 when he was 23, and working in Burdon-Sandersons laboratory at University College. A year later he was in Berlin and noted that:

“The students have a curious habit of forming small societies of 10 or 12, who have a room at some restaurant where they meet to drink beer, smoke, and discuss various topics. If tobacco and beer have such a deteriorating effect on mind and body, as some of our advanced teetotallers affirm, we ought to see signs of it here; but the sturdy Teuton, judging from the events of the past few years, has not degenerated physically, at any rate, while intellectually he is still to the fore in most scientific subjects; whether, however, in spite of—or with the aid of—the ‘fragrant weed’ and the ‘flowing bowl’ could hardly be decided.”

Osier returned to Montreal in the summer of 1874 with a consulting room in Radegonde Street and prospects of starting in the autumn as lecturer in the Institutes of Medicine at McGill. It was only during these early years that he kept an itemized account book of his expenditure. From September, 1874 to June, 1876, Osier spent about $7 on tobacco and $20 on cigarettes, that is to say about 1 percent of his income and at the tobacco prices then applying, this would be roughly equivalent to a monthly consumption of 150 cigarettes, 12 oz of tobacco and 3 cigars (personal communication from Miss M. Beacock, Librarian of the Tobacco Research Council ). It is probable that friends and students enjoyed his hospitality, though it may be significant that expenditure on cigarettes was slowly rising. Unhappily, detailed entries of expenditure cease in the middle of 1876, shortly after Osier became pathologist to the Montreal General Hospital.

In the spring of 1891, two years after his appointment as Physician-in-Chief at Johns Hopkins, Osier gave the principal public address on ‘Recent Advances in Medicine’ at the University Anniversary Commemorations and spoke, as he would do on many other occasions, on the need for moderation, when we of the profession have gradually emancipated ourselves from a routine administration of nauseous mixtures on every possible occasion and when we are able to say, without fear of dismissal, that a little more exercise, a little less food, and a little less tobacco and alcohol may possibly meet the medications of the case….”

A year later, on February 24, 1892, Osiers Textbook of Medicine appeared, but there is little about the adverse effects of tobacco—only a short section on the cardiovascular manifestations, with a reference to Huchard’s work, while in discussing pulmonary neoplasms he mentions its high incidence in the Schneeberg miners. It was of this period, when the Osiers were settled in West Franklin Street, that W. S. Thayer, one of the “latchkeyers” and later professor at Johns Hopkins, gave a graphic account, which contains one of the few observations on Osier’s smoking habits, “His life was a rare example of temperance in all things. He smoked, without inhaling, I think, two or three cigarettes after luncheon and dinner….”

tobaccoWe learn a little more from the clinical lectures on angina pectoris and allied states which he gave to the postgraduate students at Johns Hopkins in the Spring of 1896 and formed the foundation for his famous Lumleian Lectures to be delivered at the College of Physicians 14 years later. His fifth lecture at Baltimore was on pseudo-angina pectoris, of which the second part was devoted to toxic angina, dealing almost entirely with “Tobacco which as a rule produces only slight and transient disturbance of the heart’s action, but which may culminate in attacks of angina. When one considers how universal is the custom, the infrequency of serious heart symptoms in users of tobacco is remarkable…. You all know, some of you have experienced the acute toxic symptoms on beginning to use tobacco. The effects of habitual use are very varied. In the large majority of persons the habit in moderation is harmless, to many it is beneficial. Among the injurious features those relating to the heart are perhaps the most important certainly they are the most common.”

Osier then considers three types of tobacco heart —the irritable heart of smokers, heart pain and tobacco angina, and as his experience is limited, he paraphrased Huchard’s view on tobacco angina. Osier remarks that disturbance of rhythm is the most constant effect of tobacco and is readily relieved by stopping the use of the weed. Weakening of the vagus control is the most frequent, “though in my own case the slightest excess in the use of tobacco causes intermission with slowing not increase of the pulse rate….”

Osier revealed a little more of his attitude to smoking, in a shortened version of this lecture, which appeared as an essay on tobacco angina in one of the “Ephemerides” that he wrote for the Montreal Medical Journal to help the editors, his old friends Roddick and Blackader. This ends “… In connection with this question of smoking, I would like to enter a protest against the indiscriminate abuse of what Ben Johnson calls ‘the most sovereign and precious weed that ever the earth has tendered to the use of man, particularly in the form of the cigarette. In the British Medical Journal for February 15, 1896, there is an extract purporting to be taken from a paper by Dr. G. F. Shrady, in which he says, To smoke a cigarette is to use tobacco in its very worst form. It will produce physical irritability and mental and moral strabismus. As a cigarette smoker of some 24 years’ standing, I would like to make the counter-statement that to smoke a cigarette (a good one of course!) is to use tobacco in its very best form, and that in moderation it soothes physical irritability and corrects mental and moral strabismus. (I am speaking of adults. Boys and young men are better without tobacco in any form). The inference is obvious, quoad the editor of the Medical Record, at least from my point of view.”

The British Medical Journal annotation which started “The cigarette in modern life is as ubiquitous as the bacillus and if we are to believe some who profess to speak with authority, it is as mischievous as the most truculent of invisible enemies…”; was a light-hearted comment on the reported remarks of Dr. Shrady, a New York laryngologist, editor of the Medical Record and a member of the Charaka Club, the bibliophilic dining society of which Osier was a member, but seldom attended.

Harvey Cushing refers to this essay and remarks that Osiers indulgence in tobacco, “as a matter of fact was always in great moderation and was for the most part restricted to a postprandial cigarette or two,” and Sir George Savage, in a reminiscent letter, wrote that, “Osier never posed, but over the fire, with his cigarette, any medical question or any specially difficult mental or moral problem associated with insanity always awoke his interest, and from him one got profound and simple advice.” Fielding Garrison recalled that a relative of his, while convalescing, asked Osier if he might smoke. “You may,” said the friendly chief, “and here (suiting the action to the word) is a good long cigar.” Eight years later Osier had need of tobacco “to soothe his physical irritability,” for in 1904, the Baltimore fire came within two blocks of their home. “That Osier, usually imperturbable, was nervous, was evident from the way he twiddled his watch chain and exceeded his allotted number of cigarettes through the anxious afternoon and evening.”

AlcoholJust over a year later, the Osiers were installed in Oxford and it is from this last period that all the photographs of Osier holding a cigarette occur; a possible explanation is that they were casual snapshots, probably taken after luncheon, in the garden, whereas the majority of the earlier photos were posed indoor portraits.

Naturally Osier was invited to join some of Oxford’s select dining clubs, and at one of these, The Tutors’ Club, he met Albert Dicey, Vinerian Professor of Law at All Souls’ College and a frequent visitor to America. Dicey had been brought up in the tradition of the Clapham evangelists and it was his interest in social problems that led to his becoming Principal of the London Working Men’s College, one of the early organizations for adult education. So it came about that on November 17, 1906, Osier found himself in Camden Town, delivering a Saturday night lecture before a large audience, on “The Care of the Body;” it was widely reported, extracts appearing in the Times, the Standard and the Abingdon Herald, as well as the Working Mens College Journal *l Osier compared the human body to a steam engine and discussed the various types of fuel or food required to stoke the human engine. He then went on to say,

“Throw all the beer and spirits into the Irish Channel, the English Channel and the North Sea for a year and people in England would he infinitely better. Do you suppose you need tobacco? On the day after you had dumped all the tobacco into the sea, you would find it was very good for you, and hard on the fishes (although he added, amid laughter), I smoke myself.”

In conclusion, Prof. Osiers advice for the care of the body was—‘no alcohol, less tobacco, less tea and coffee, good plain food, cleanliness, plenty of fresh air and plenty of hard work.” Provide care with remedies of My Canadian Pharmacy mycanadian-pharmacynet.

It was advice which he had given before and would give again, and in Camac’s Counsels and Ideals from the Writings of William Osier, there is an extract on the perils of intemperance which has caused trouble to Oslerian bibliographers. The reference is given as “Alcohol. St. Elizabeth Parish Magazine (London) 1905,” but so far as can be determined there was only one parish church dedicated to St. Elizabeth in existence in the London area in the early part of this century and they did not have a parish magazine at that time, nor is there a parish of St. Elizabeth in London, Ontario. The Osiers arrived in Oxford at the end of May 1905, but they had barely settled down when Camac joined them, and June and July were spent choosing the extracts for the book. By the end of September, Osier had seen the proofs and filled in the dates of the references, while Mrs. Osier received an advance copy on November 17, 1905. There is no note of a talk to a church community in Osiers diary for this period and so the question must arise as to whether E. Y. Davis, rather than Osier, entered the reference for Camac’s extract when the bibliography was being checked on September 29th, 1905; this hypothesis still leaves unsolved the mystery as to where the paper was originally published or delivered. It is true that in the Osier Library there is a manuscript (B.O. 7662) in Osiers hand headed “Alcohol and the…” which is incomplete but it is more in the style of “The Care of the Body” with its mechanistic analogies than the factual didactic approach of the Camac ‘St. Elizabeth’ address; furthermore, it mentions the Lusitania which made her maiden voyage in September, 1907.

In 1910, Osier delivered the Lumleian lectures of the College of Physicians on angina pectoris, but he had less to say on the effects of tobacco on the heart than in his 1896 Baltimore postgraduate lectures. However, he commented: “We may look forward to an increasing number of cases of heart pain and of the mild type of angina in women with the rapid increase of cigarette smoking. I saw last winter in Italy an American woman whose daily allowance of cigarettes was never under 25” and he discussed sudden death due to vagus inhibition in heavy smokers of strong cigars.. There had also been changes in the Textbook. In the sixth edition (1905) the section on toxic angina was shortened and this persisted in subsequent revisions, but in the eighth edition (1912), although the cardiac manifestations of smoking were discussed very briefly, there was mention of tobacco amblyopia, smokers tongue and chronic laryngitis, pharyngitis and gastritis induced by smoking, while in the first edition of the System (1908), Osier had written the chapter on “Diseases of Arteries” and discussed, with little conviction, the influence of smoking on vascular disease. Get rid of smoking habit fast with preparations of My Canadian Pharmacy.

carcinomaThere was no mention in either book of the influence of smoking on respiratory disease or lung cancer, though Adler had suggested such an association in 191234 and Brinkmann had pointed out the high incidence of pulmonary neoplasms in Leipzig tobacco workers two years later. In fact, it was not until the eleventh edition (1930) of the Textbook that attention was drawn to the increasing incidence of pulmonary neoplasms, reflecting the observations from Prof. Hueck’s Department of Pathology at Leipzig. Although the finger of suspicion had been pointed at smoking as a causative factor from about this time, a suspicion which approached a certainty with the findings of Wynder and Graham, and the Statistical Research Unit of the Medical Research Council, it was Sir Austin Bradford Hills brilliant idea of a prospective enquiry on mortality in doctors, in relation to their smoking habits, that brought unwilling acceptance of the evidence, an enquiry in which he enlisted the help of Dr. Richard Doll, recently demobilized from the army and showing an enthusiasm for statistical investigation.

The editors of the British Medical Journal, whose predecessors, 60 years before, had laughed at Dr. Shradys contention that “to smoke a cigarette is to use tobacco in its very worst form,” were now writing, “it is imperative for all concerned that the public is repeatedly informed of the possible dangers to health and life from smoking cigarettes.”

But to return to Sir William Osiers views on smoking. In April, 1913, he arrived in America, on what was to be his last visit, primarily to give the Silliman lectures at Yale on “The Evolution of Modem Medicine,” which still provides the finest introductory conspectus of medical history that has ever been written, though Osier never found time to complete the proof-reading and alterations. The Sunday before the lectures were to start, Osier delivered an address, “A Way of Life,” to the Yale undergraduates, a lay sermon which, it was rightly said, an archbishop might not be ashamed to have written. The text was “Do today’s work today.” Tracing how each day should be spent, he said that it was the morning’s sensation which controlled the day. “The young man who feels on awakening that life is a burden or a bore has been neglecting his machine, driving it too hard, stoking the engines too much, or not cleaning out the ashes and clinkers. Or he has been too much with Lady Nicotine, or fooling with Bacchus, or, worst of all, with the younger Aphrodite —all “messengers of strong prevailment in unhardened youth.” Having advocated abstinence in drink, he continued, “A hitter enemy to the bright eye and the clear brain of early morning is tobacco, when smoked to excess, as it is now by a large majority of students. Watch it, test it, and if need be, control it. That befogged, woolly sensation reaching from the forehead to the occiput, that haziness of memory, that cold fish-eye, that furred tongue, and last week’s taste in the mouth—too many of you know them—I know them—they often come from too much tobacco.” My Canadian Pharmacy gives explanation why smoking is so deteriorating.

Despite these warnings, Osier had no objection to, indeed fostered, the postprandial cigarette or cigar. A pre-war Rhodes scholar recalled Osier’s lectures on medical history.

“Wu would receive a notice giving the subject of the lecture, and the time appointed and each notice would be accompanied by an invitation to dinner. The lecture would be preceded by a nine course dinner, the dishes cleared away, cigars and cigarettes passed around and while we all remained seated around the table, Dr. Osier would proceed to give the lecture in an informal manner and conversational tone. Rare old books and pictures would be passed around during the lecture to add interest to the subject under discussion.”

When the Oxford Architectural and Historical Society visited Ewelme on the afternoon of St. Lukes Day 1909, Osier offered cigars to the gentlemen after tea and it would seem that it was Osier who persuaded the students (fellows) of Christ Church to change an immemorial custom and start smoking when coffee was served in common room, rather than waiting till they moved to the smoking room proper.4(i Now the old smoking room houses a television set. Certainly one of the cherished possessions of the Osier Society of McGill is the large silver cigar box which Capt. W. W. Francis brought to the No.

Canadian General Hospital in August 1916 as a memento of Osier’s visit to the unit in France a year before, and which now plays a part in the ritual of the Osier Banquet. It is said, on the authority of Prof. Sir Walter Raleigh, who as a Celt knew the seductions of M’Connachie, that in the autumn of 1914, when the Russian troops, identified by the snow on their boots, were reported to have been seen in almost every town and village in England, Osier strengthened the probability of their visit to Oxford by judiciously scattering the ash of some partly consumed Russian cigarettes on the railway tracks at the stations.

respiratoryIt was after Osier’s visit to France, when he was in no joking mood, that he went up to Leeds, to give the address on “Science and War” at the opening of the medical school. This was preceded by a more informal talk to the Leeds Luncheon Club on “Nerve and Nerves” in which he said,

“We should avoid everything that artificially stimulates and so irritates the nervous system. It indicated a certain lack of nerve, an oyster-like flabbiness of the nation, not to have followed the King’s example in the matter of alcohol. Nothing so weakens the will of the workers, of mind or of muscles, as leaning upon that Egyptian reed. Too much tobacco also increases the irritability of the nervous system and many of our young soldiers smoke far more than is good for their hearts or brains….”

It was the counsel of moderation which he had advocated for the last 40 years and just five months before his death, he repeated his views in the Times. Prohibition was about to come into force in the United States and “Pussyfoot” Johnson was arriving in England in an endeavor to stir up enthusiasm for temperance legislation. Sir Edmund Gosse and Herbert Henson, Bishop of Hereford, had written powerful letters of disapproval to the Times. On July 18, 1919, Sir William Osier explained that, “a large majority of people in the United States and Canada have learnt that the work of life is as well or better done without the use of alcohol in any form. Taken in moderation, alcohol is among the indifferent things—with tea, coffee and tobacco.” Sir William was prepared to accept the American viewpoint, but felt it would be undesirable to press such an extreme attitude in the British Isles where it was preferable to allow moderation to take its course. Had prohibition come to Britain, it is unlikely that Sir William would have followed the example of his brother, who bricked up the spirit cellars at Craig-leigh so securely that they had to be broached with dynamite!

By now, for Osier, smoking was, as he put it, one of the indifferent things and this attitude is apparent from his library, where there were only about 30 books on tobacco. It is true that these included an early Spanish edition of Monardes’ Joyful Newes Out of The Newe Founde World, a second edition of Evaraert’s De Herba Panacea, Tobias Venner’s Treatise, Neader’s Tobaccologia, Raphael Thorius’ Hymnus Tabaci, and Magnenus’ De Tabaco Exer-citationes, but James I’s Counterblaste to Tobaco is only in a modem reprint and the great mass of ballads and pamphlets that it called forth are solely represented by ‘silver tong’d’ Sylvesters “Tobacco battered; and the Pipes shattered about their Ears that idly idotize so base and barbarous a weed, or at leastwise overlove so loathsome a vanitie; only a volley of Holy Shot thundered from Mount Helicon,” and this was probably acquired by chance as it is bound with Sylvesters translation of Fracastor’s Joseph. Furthermore, of the antismoking pamphlets of his own day there was only Lucius Sargent’s Dealings with the Dead by a Sexton of the Old School, written by the Bostonian temperance advocate who, when he passed a tobacco field, would throw tracts among the plants. A sheaf of papers by Hippolyte Depierris claiming that tobacco was the cause of the physical and moral degeneration of modem society, crime, suicide, sudden death, insanity, sterility and infant mortality, had been included in a volume of French and German reprints that Osier had bought as it contained Charles Darem-berg’s papers on early Greek medicine.

In this essay I have attempted to show that there was no substance to this Oslerian myth, that there is no evidence to support the idea that Sir William died from carcinoma of the lung, and that though he smoked, it was in moderation; he was aware of some of the adverse effects of excessive smoking, though he did not consider that it was harmful to the respiratory system.

All that remains is to consider the impact of the rumor on Oslerians; those who had known Osier at Oxford were surprised, for none of them ever remembered having seen Sir William smoke, though he was a fanatical believer in snuff. (Personal communication from Sir John Masterman). They had been brought up in the firm tradition that his death was due to empyema, and yet were hesitant to question an ex-cathedra statement from one of Sir William’s successors, who had been awarded the Bissett Hawkins medal of the Royal College of Physicians and a United States award for cancer research. However, Sir Richard Doll, when he gave the Oslerian oration in 1972, on “Osiers English School” said, “I incautiously repeated Dr. Geraint James’ remark that it would not be surprising if bronchial carcinoma had been the cause of Osiers death to a visiting American and it wasn’t long before I had an enquiry from the Professor of Surgery at Oxford about the nature of the evidence on which the diagnosis had been made.” Younger members of the Osier Club, who had heard something of the rumor, were under the impression that it was a complex joke. Nevertheless as Baron Snow wrote in The Search, “If we do not penalise false statements made in error, we open up the way for false statements by intention. And a false statement of fact, made deliberately, is the most serious crime a scientist can commit.”

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