The past few weeks have been very demanding on me and I have not had the best of times, either on the personal or on the professional front. So, today, I took a break from the usual drudgery of life and decided to take a step back and remind myself of the bigger picture of things. While reading through Osler’s Aequanimitas (check it out here) I was reminded of how Osler had been a guiding spirit in the life of another great medical hero that we have idolized over the years: Tinsler Randolph Harrison.
Tinsley Harrison (TH) was the son of a sixth generation physician, William Groce Harrison, who worked in close proximity with Osler for a short period and was the conduit through which the Oslerian wisdom flowed down into TH. If I have my dates correct, the lives of TH and Sir William Osler did not overlap too much because Osler passed away when TH entered Johns Hopkins in 1919.
TH was a bit of a prodigy and was done with high school at the age of 15 years and entered the sophomore class of 1916 at the University of Michigan. He excelled there and was permitted to pursue graduate school while in the fourth year of college. TH was intensely interested in studying Law and probably would have done that has his father not intervened. Osler had advised Groce Harrison to make his son a “teacher of medicine” when TH was barely three years old. At this juncture it is worthwhile to mention that Groce Harrison virtually worshipped Osler. In fact, anecdotes go that young Tinsley could distinguish between God, Jesus Christ and Sir William Osler by the time he was four years old! So, at the behest of his father, Tinsley decided to take up Medicine. So, his final year at Michigan in college was also his first year in medical school. It was 1918 and he had started medical school at the unusually precocious age of 18 years only!
Now Groce Harrison, being the protégé of Osler that he was, insisted that Tinsley complete the rest of his medical training at Johns Hopkins, which was virtually synonymous with the work of Osler. As I said before, unfortunately, Osler passed away the same year as TH went to Johns, but that did not stop him from building Osler up as the model of the perfect physician. Osler was not just an inspiration for TH during his medical school, but throughout his career and life. Osler and his musings were a part of the very fabric of life and philosophy that TH believed in. In fact, it is famously said by his students that TH would ask all his students to keep a copy of Osler’s Aequanimitas by their bedside and read it as often as possible!
Image Credits: Wikimedia
It must be mentioned that TH was in great company while he was in medical school itself. His room mate and tennis partner at Johns was none other than Alfred Blalock, pioneer surgeon, who developed a greater understanding of the pathophysiology of hemorrhagic shock, the Blalock-Taussing Shunt and surgical treatment of Tetralogy of Fallot, the so-called series of Blue Baby surgeries (on account of the fact that the babies became blue during cyanotic spells). Blalock himself was no mean a mind and though he was dogged with ill health, suffering several bouts of tuberculosis that impeded his work to a large degree in the early years, he left an indelible mark in the world of Surgery. He shared a lifelong friendship with his med school friend Harrison and their careers would cross paths several times in the years to come. Interestingly, one should note that like TH, Blalock was also an early prodigy and entered med school at the unusual age of 19 years! It is said that the first paper that he published in 1927 regarding the pathophysiology of surgical shock was originally written by none other than TH himself, based on the data collected by Blalock because he was down with a severe bout of tuberculosis at that point of time.
Image Credits: Medical Archives of the Johns Hopkins Medical Institutions
Harrison’s protégés remember him as a fantastic teacher, a passionate clinician and in the true Oslerian philosophy, a believer in the ways of the clinical diagnoses rather than an over-reliance on instruments/investigations. It is said that he possessed a disdain for gadgetry and over reliance on testing in order to reach a diagnosis and believed in a thorough history taking and clinical examinations. One of the most famous stories about TH is about the time when he was the Distinguished Professor of Medicine of the Veterans’ Administration. There was a case at one of the VA hospitals that had left the Housestaff stumped for a diagnosis despite multiple tests. TH started on the patient with the history and followed it up with a three minute long palpation of the precordium which led him to a diagnosis of ventricular aneurysm. So remarkable was his method that it is said that the audience gave him a standing ovation for this. Of course, later cardiac catheterization was done and the diagnosis was confirmed. More recent studies have concluded that the precordial palpation has special importance in the diagnosis of cardiac diseases (1);
An apical impulse lateral to the mid-clavicular line or greater than 10 cm from the mid-sternal line was sensitive but not specific as an indicator of left ventricular enlargement. In patients without left ventricular hypertrophy, an apical diameter greater than 3 cm in the left lateral decubitus was sensitive (92%) and specific (91%) for an enlarged left ventricle. The positive and negative predictive values were 86% and 95% respectively.
That TH was a prodigy is also stated by some of his peers who talk about how an IQ test was administered to him when he was once hospitalized during the later years of his life. It is said that he came out with a score of 185! (2)
Harrison embodied the concept of the researching physician. His prolific clinical skills are legendary but his foray into the world of medical research, the numerous breakthroughs in the disciplines of cardiology and shock are somewhat dwarfed by the image of Harrison the clinician and Harrison the educator. He joined the newly reopened vanderbilt University school of medicine at Nashville as the Chief Resident in 1925 (incidentally, Blalock joined as the Chief Resident in Surgery at the same time). He stayed on the staff of Vanderbilt for 16 years, during which he published a mind boggling 107 original papers! He also brought out the first two editions of the authoritative tome, The Failure of Circulation while he was there in 1935 and 1938. There is an interesting tale about the 3rd edition of the book, which, incidentally never got published. In 1944, the Harrison family was moving from North Carolina to Texas in two vans when one of them caught fire. The fire was so devastating that nothing could be salvaged, including the completed manuscript of the 3rd edition of The Failure of Circulation, which, ultimately, never came out.
After a brief stint at Dallas, where he served as the Dean for a short period of time, he went back to his roots at Birmingham to Chair the Department of Medicine at the University of Alabama School of Medicine. He initiated here, like he did previously at Vanderbilt, a unique system of coordination between the different clinical and pre-clinical/diagnostic departments of both the medical and surgical specialties. He would use his personality and his stature to recruit physicians of national prominence from Harvard and Mayo. Under his leadership, the University of Alabama School of Medicine rose to be one of the most respected institutes nationally.
It was in 1950 itself, when he was moving back to Birmingham, that the thought of editing the first edition of what is today THE textbook for all medicine aspirants was conceived. (3) He led a team of the best professors – Adams, Beeson, Resnick, Thorn and Wintrobe – to bring out 5 editions of the tome in his lifetime. Now in its 18th edition, this book represents a unique movement in the world of medical texts seeing as how it is closest to being one of the most complete texts possible. Now while that makes the size of this book a little intimidating, yet, it remains a joy to read. I searched extensively online to see if I could dredge out an image of the very first edition, but it was in vain, so here, let me show off mine!
Tinsley Harrison was not just a clinician. He was a remarkably well rounded personality. Aside from his academic life, he is said to be the prototype of the forgetful professor that one would guess he was. His peers say that it was a largely his wife’s credit to have kept the absent minded professor free from dealing with the drudgeries of daily living by making his life as organized as possible. Following the completion of his medical school at Johns Hopkins, Harrison moved to Peter Bent Brigham hospital where he worked for two years. It was during his sojourn at the Brigham, that he married Betty Woodward, who remained a strong and calming influence in his life. Notably, while he was working at the Brigham, he was associated with the likes of Samuel Levine, William Dock, Chester Keefer and henry Christian. His lifelong love for the circulation system was also implanted during this phase when Samuel Grant introduced him to the clinical investigations of the cardiovascular system using the Fick principle.
CO = Cardiac Output, Ca = Oxygen concentration of arterial blood and Cv = Oxygen concentration of mixed venous blood. Image Credits: Wikipedia
Harrison was also a bit of a sportsman. He was the Southern Doubled Tennis Champion (his partner was none other than Blalock!), an avid golfer and even at the age of 70, he was adept at water skiing!
I have left one of the most interesting aspects of Harrison’s bedside teaching for the last because this is something I really enjoyed learning about. His bedside teaching skills are legendary but he would organize the bedside teaching in a unique way which would cater to all the echelons of medical professionals that flocked to his lectures. In every bedside excursion, he would take the history only and make his diagnosis or set of differentials based on the findings that he would elicit in the history. He would then ask the resident to do the physical examination in addition to the history of the case and based on those findings, the resident had to reach a set of differentials, if not a final diagnosis. The intern was allowed a little more leeway in that he would have access to the routine laboratory findings in addition to the history and physical examination in order to aid his diagnosis. And finally, the “lowly” medical student would be allowed to ask for additional investigations, imaging, etc. in order to get to the diagnosis. This is a unique format that would provide an intellectual stimulus to all the people present there and not just let the residents run away with the game. As an avid mediquizzer myself, I can only imagine the kind of excitement that this format of bedside teaching would generate!
Tinsley Randolph Harrison and Sir William Osler have been two of the biggest names in Medicine in the past century. They are legends in their own rights, but somehow, the more I read about Tinsley Harrison, the more I seem to think that he was somehow the carrier of the baton that Sir Osler left behind. It feels wonderful to be part of a profession that boasts of intellectual giants as these. It reminds me that I am part of a much larger game, extending much further beyond the limits of a few examinations and a few disappointments. I am part of a culture of medicine that has triumphed over mechanization of thoughts, actions and execution.
From time to time a personality scintillates across the medical firmament, who dazzles all beholders. Tinsley Harrison was such a person, a delightful, passionate, vivacious physician. He stimulated everyone with whom he came in contact and he placed an indelible stamp on the medical events of his day. (4)
Dedication page of the 9th edition of Harrison’s Internal Medicine which was published after the death of Tinsley R. Harrison in 1978.
The dedication above was wrong. Tinsley Harrison continues to stimulate and inspire people. People like me, who sometime lose sight of the real reasons they fell in love with Medicine in the first place while navigating through the bumpy terrain of life. People whose closest association with him is through a book… Thank you for reminding me of the real reason that inspired the passion in me to do medicine. Thank you for making me fee rejuvenated once again so that I can take the bull by the horns and live to fight another day. And above all, thank you, for reminding me of the “master word” that your idol asked us students of medicine to engrave in the tablets of our hearts:
“Though a little one, the master-word looms large in meaning. It is the ‘Open Sesame’ to every portal, the great equalizer in the world, the true philosopher’s stone which transmutes all the base metals of humanity into gold. The stupid man among you it will make bright, the bright man brilliant, and the brilliant student steady. With the magic word in your heart, all things are possible, and without it all study is vanity and vexation. The miracles of life are with it; the blind see by touch, the deaf hear with eyes, the dumb speak with fingers. To the youth it brings hope, to the middle-aged confidence, to the aged repose. True balm of hurt minds, in its presence the heart of the sorrowful is lightened and consoled. It is directly responsible for all advances in medicine during the past twenty-five centuries.
And the master-word is Work, a little one, as I have said, but fraught with momentous sequences if you can but write it on the tablets of your hearts, and bind it upon your foreheads.” (5)
References:
1. Eilen SD, Crawford MH, O’Rourke RA. Accuracy of precordial palpation for detecting increased left ventricular volume. Ann Intern Med. 1983 Nov;99(5):628-30. PubMed PMID: 6227265.
2. Merrill AJ. Memorial. Tinsley Randolph Harrison. Trans Am Clin Climatol Assoc. 1979;90:xxxviii-xi. PubMed PMID: 390820; PubMed Central PMCID: PMC2279388.
3. Dalton ML (2001). William Osler’s influence on the career of Tinsley Randolph Harrison. Southern medical journal, 94 (7), 724-7 PMID: 11531181
4. Isselbacher KJ, Adams RD, Braunwald E, et al. Harrison’s Principles of Internal Medicine. New York. McGraw Hill Inc. 9th Ed. 1980, Dedication page.
5. Osler W. An Address ON THE MASTER-WORD IN MEDICINE: Delivered to Medical Students on the Occasion of the Opening of the New Laboratories of the Medical Faculty of the University of Toronto, October 1st, 1903. Br Med J. 1903 Nov 7;2(2236):1196-200. PubMed PMID: 20761153; PubMed Central PMCID: PMC2514735.
