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Pathology – Research and Practice 209 (2013) 264– 265

Contents lists available at SciVerse ScienceDirect

Pathology – Research and Practice

jo u r n al hom epa ge: www.elsev ier .com/ locate /prp

orrespondences

sler’s “Quote”: “As is Our Pathology So is Our Practice”

Sir William Osler, one of the most revered physicians of all time,oned his expertise in internal medicine by performing vast num-ers of autopsies in Montreal and Philadelphia; this experiencellowed him to correlate the signs and symptoms he observed athe bedside with his pathologic findings at the autopsy table [4,12].n fact, Osler had such a passion for pathology that he sometimes

ent to great lengths to obtain coveted pathological specimens,ven when it was not always possible to obtain autopsy consentrom the next of kin [15,16].

One of the more popular quotes related to pathology attributedo Sir William Osler is “As is our pathology so is our practice”,hich has been widely quoted by Canadian pathologists, pathology

ssociations, and the press [8,14].As a pathologist preparing a lecture, I had already added a

lide containing this quote when, as a member of the Americansler Society (http://www.americanosler.org/) and a past recip-

ent of the American Association for the History of Medicine’silliam Osler Medal (http://www.histmed.org/osler past.htm), I

aused and decided that I really needed to know the context inhich Sir William uttered these famous words.

I assumed this could be accomplished in minutes; however, annitial Google search provided pages of quote citations (all simplyttributed to Osler) and even a paper with the quote as its title [3],ut proved fruitless in providing additional context. I then turnedo my fairly extensive personal Osler library, including the standardeference for Oslerian quotes, The Quotable Osler [13]. The famousuote was not there. Even Rodin’s Oslerian Pathology [12] made noention. I immediately e-mailed three individuals I consider to be

he preeminent current day Osler scholars, who responded almostmmediately. Their e-mail discussion can essentially be summa-ized by quoting one: “I don’t think he said it, or at least it isn’tocumented!!!.”

Where did I first hear these words? My source was Williamoyd [7,10], the famous Scottish/Canadian pathologist who servedequentially as Professor/Chair of Pathology at Universities of Man-toba, Toronto, and British Columbia from 1915 to 1954. Boyd was

prolific author who became legendary (and very rich) for hisbility to write pathology textbooks directed at specific audiences,ncluding allied health professionals, medical students, surgeons,nternists, and pathologists [1,10]. Boyd’s textbooks were popularecause of his engaging writing style. From the age of 17, Boyd vora-iously collected quotes from literature, poetry, historical figures,reat doctors, etc. and put them in his “commonplace book”, a hand-ritten memory device used historically by Renaissance scholars

o record compelling bits of poetry, prose, or oratory [6]. Boyd latersed some of these quotes to make his textbooks so readable and

opular. I first found this quote, which Boyd attributed to Osler, onhe title page of one of his textbooks [5] as I was preparing to give

344-0338/$ – see front matter © 2013 Elsevier GmbH. All rights reserved.ttp://dx.doi.org/10.1016/j.prp.2013.02.003

the Canadian Association of Pathologists’ William Boyd Lecture in2003.

With perseverance (and a more comprehensive search), I even-tually identified the source of the quote, a lecture entitled “Anaddress on the treatment of disease” that Osler gave to the OntarioMedical Association in Toronto on June 3, 1909, while he was RegiusProfessor of Medicine at Oxford, and which was fortuitously pub-lished in the BMJ, allowing it to be found on-line [11]. How did thisphrase from an obscure lecture that had eluded the most scholarlyexperts on the life of Osler become part of Canadian pathology lore?I think the linkage of this quote to William Boyd’s textbook Surgi-cal Pathology, which was published through eight editions and 17“reprintings” from 1925 to 1967 and which targeted both surgeonsand pathologists, is responsible [n.b., most or all editions includethis quote on both the title page and as the first sentence of ChapterOne [5]]. Considering that Boyd was widely read and that he soldover a million books during his >50 year long publishing career[n.b., two of Boyd’s text books were actually credited with keepingLea & Febiger Publishing Co. (Philadelphia) solvent during the greatdepression [10]], I think we can safely credit Boyd with preservingOsler’s quote.

How Boyd found and remembered the quote is somewhat morespeculative, as he had only graduated from Edinburgh Universitywith his MBChB in 1908 and was practicing psychiatry at mentalhospitals in the English midlands when it was published in 1909.However, Boyd was also responsible for performing asylum autop-sies, and he published his first pathology case report in the BMJ in1909. Likely, Boyd read Osler’s article and, recognizing the closerelationship between pathology and sound clinical practice, thissentence resonated with him as he was functioning as a clinician-pathologist just as Osler had earlier in his career; therefore, helikely either copied the quote into his commonplace book [6] orsimply committed it to memory for future use. Interestingly, 1925until 1937, the time period in which Boyd wrote the first edi-tion of each of his four most popular pathology textbooks, was atime when competitive pathology textbooks were almost devoidof clinical information, focusing only on pathological findings. Instark contrast, Boyd was rather fanatical about inclusion of clinicaldetails in all of his textbooks, which were often designed to teachpathology to clinicians rather than pathologists. One Boyd biog-rapher astutely noted that “in Osler’s book (i.e., The Principles andPractice of Medicine) the pathology played an essential part, basedupon the author’s autopsy dissections. Boyd’s book seemed a mirrorimage of Osler’s in that Boyd emphasized the relations of symp-toms to lesions, making the pathology clinically important . . .” [10].Although clearly kindred spirits, there is no known evidence thatBoyd knew Osler (personal communication, Boyd biographer, IanCarr, June 14, 2012, and Osler biographer, Michael Bliss, June 17,

2012), and this would seem logical as they were barely contempo-raries.

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Correspondences / Pathology – Res

Osler’s love of pathology and the knowledge that Osler gainedy performing autopsies made him a better internist. So, it seemed

ntuitively obvious to me why this statement resonated with Sirilliam on a personal basis, as his practice was intimately tied

o pathology. However, in actuality, this is not what Osler meants Boyd took the quote out of context. The quote was clearlyeant for a broader audience, as most of the members of thentario Medical Association and the readership of the BMJ were not

nternist-pathologists like Osler. In fact, the entire quote was: “Ass our pathology so is our practice; what the pathologist thinks to-ay, the physician does to-morrow”. Removing the second sentencend the context allows multiple interpretations. Osler’s lecture wasn treatment of disease, and he made his statement in the con-ext of a quote by Celsus, the Roman encyclopedist who wroten De Medicina that “the dominant view of the nature of diseaseontrols its treatment.” Osler simply meant that there had histor-cally been three sequential broad concepts of disease causationi.e., direct outcome of sin, imbalance of the four humors, and the

odern concept of chemico-physical processes caused by exter-al agents, abnormal metabolism, etc.) and that determination ofational forms of treatment was entirely dependent upon one’sonceptual framework as to the cause of the disease [11].

Osler’s quote, minus the second sentence, was the perfect wayor Boyd to start his book, as it highlighted the important relation-hip between a basic understanding of pathology and sound clinicalractice. Did Boyd intentionally “misinterpret” Osler’s quote? This

s improbable as Boyd was known to collect large numbers of quotesor later use, and it seems unlikely that he would remember thisarticular quote’s precise context when writing a book almost twoecades after reading Osler’s paper in the BMJ.

In present day context, the quote has taken on a differentuance. In the time of Osler and Boyd, clinical diagnosis, and hencereatment, was mostly dependent upon the history and physicalxamination as well as the clinician’s ability to astutely interprethese based upon the clinician’s fundamental understanding ofathology and pathophysiology. In contrast, clinical treatment isow more and more dependent upon laboratory test results. Now,he quote is probably best interpreted, the way I, and likely mostf the readership, have always interpreted it. Today, high qualityedical and surgical care is dependent upon high quality labora-

ory results, a sort of motherhood statement that would be hard for

nyone to disagree with, but that shows deep insight into modernedical and surgical care.“As is our pathology so is our practice”, like any good and endur-

ng quote, is readily generalized and stands the test of time. Osler’s

and Practice 209 (2013) 264– 265 265

quote is ever true today as >70% of all critical clinical decision-making such as admittance, discharge, and medication is basedupon laboratory results [9] and laboratory data comprises >70% ofthe content of a typical electronic medical record [2].

References

[1] Anonymous, William Boyd and his books, CMAJ 86 (1962) 29–31.[2] M.J. Becich, J.R. Gilbertson, D. Gupta, A. Patel, D.M. Grzybicki, S.S. Raab,

Pathology and patient safety: the critical role of pathology informat-ics in error reduction and quality initiatives, Clin. Lab. Med. 24 (2004)913–943.

[3] J. Biswas, As is our pathology, so is our practice, Middle East Afr. J. Ophthalmol.18 (2011) 259–260.

[4] M. Bliss, William Osler: A Life in Medicine, University of Toronto Press, Toronto,1999.

[5] W. Boyd, Surgical Pathology, fourth ed., W.B. Saunders Co., Philadelphia, 1938,p. 17.

[6] I. Carr, William Boyd – the commonplace and the books, CBMH/BCHM 10 (1993)77–86.

[7] I. Carr, William Boyd: Silver Tongue and Golden Pen, Associated Medical Ser-vices Inc./Fitzhenry & Whiteside, Markham, Ont, 1993.

[8] K. Chorneyko, J. Butany, P.C. Hebert, R. Kale, M.B. Stanbrook, B. Sibbald, K. Flegel,N. MacDonald, Canada’s pathology, CMAJ 178 (2008) 1523–1526.

[9] R.W. Forsman, Why is the laboratory an afterthought for managed care orga-nizations? Clin. Chem. 42 (1996) 813–816.

10] J.F.A. McManus, William Boyd: a biographical sketch, Am. J. Surg. Pathol. 3(1979) 377–381, quote p. 379.

11] W. Osler, An address on the treatment of disease, Br. Med. J. 2 (2534) (1909)185–189.

12] A.E. Rodin, Oslerian Pathology: An Assessment and Annotated Atlas of MuseumSpecimens, Coronado Press, Lawrence, KS, 1981.

13] M.E. Silverman, T.J. Murray, C.S. Bryan, The Quotable Osler: Revised PaperbackEdition, American College of Physicians, Philadelphia, 2008.

14] S. Solomon, Canadian pathology mired in crisis, National Review ofMedicine 5 (April (4)) (2008) http://www.nationalreviewofmedicine.com/issue/2008/04/5 patients practice01 4.html (accessed 09.06.12).

15] J.R. Wright Jr., Sins of our fathers: two of “The Four Doctors” and their roles inthe development of techniques to permit covert autopsies, Arch. Pathol. Lab.Med. 133 (2009) 1969–1974.

16] J.R. Wright Jr., Why did Osler not perform autopsies at Johns Hopkins? Arch.Pathol. Lab. Med. 132 (2008) 1710 (letter).

James R. Wright Jr. ∗

University of Calgary, Pathology and Lab Medicine,Diagnostic and Scientific Centre, 9-3535 Research

Road NW, Calgary, Alta., Canada T2L 2K8

E-mail address: jim.wright@cls.ab.ca

4 October 2012