Topics in public health




It is just minutes before noon on October 7, 1896 - 110 years ago now.

Something momentous is about to happen in the new amphitheater

of the Johns Hopkins Medical School........ in Baltimore Maryland

.... a new school which has only opened its doors three years earlier.


The place is charged with excitement.

The medical students hurry to take their seats


The topic to be discussed is a vital one:........The topic is......Fever!

Fever.... Is a vital sign ... an elevation of temperature.

It is a vital sign ....that has puzzled and fascinated physicians

since the beginning of recorded medical history.


And the a leading figure in the medical establishment of the day

He is... none other than Professor William Osler-

a Canadian physician who was born in Ontario

 trained at McGill

 now in 1896 a consultant at Johns Hopkins

and an expert in fever.

There is a lot to discuss.

Baltimore in 1896... leads the nation in typhoid fever deaths

as well as ....suffering the effects of numerous other contagious diseases.


So consequently, a standard feature in Professor Osler's classroom

is an elaborate series of interlocking...... blackboards ...a high tech innovation

which summarize every case of typhoid fever,

and its many complications,

in patients who have been admitted

to the Johns Hopkins Hospital during that year.


In 1896 Professor Osler is internationally regarded

as a leading advocate  for public health reforms

which are  essential ...if infectious disease is  to be controlled.

We need to recall that in Professor Osler's time

It was an era before the microbiological causes  

of infectious disease had been identified,

It was not until the later development of  more advanced technologies

Microscopes.....And other  laboratory techniques...

that bacteria.....and viruses.

 were identified as the cause of much infectious disease


So physicians had to rely on other methods....clinical, not laboratory,  methods..

In order to diagnose which infectious disease was which.

And this was not an easy thing to do


For example the exact pattern of a patient's fever curve

often served as a key to accurate diagnosis.


So there was carefully charting at the bedside.....

over the days of the patient's illness

Of the fever's ascent..... highest point... and its subsequent decline...


Various terms were developed

To describe the graphical pattern of a fever...terms that we rarely hear now.

For example.....Was it  a tertiary (every 3rd day) or quotidian (daily) fever?

Was it  relapsing..... or intermittent?


So it is no surprise that Osler has chosen fever

As the subject of the first lecture of  the academic year to the medical students

Osler himself was rather feverish in his activity .

He had a precise daily routine.


At 9:00 am ....3 hours before the medical students assemble for his lecture,

a horse-drawn cab brings him to the hospital's main entrance.


He steps out of the cab.


He is impeccably dressed in a charcoal gray morning coat,

 With a silk cravat, and a fresh flower in his lapel,

and a gold chain hanging from his  waistcoat,


He Bounds up the steps into the building

He hands his gloves, top hat, and umbrella to a waiting nurse


There he is greeted by the resident physician who has been on duty

And who is eager to report about the patients  admitted during the night.


 From there, Osler walks through the hospital lobby.

The lobby is a domed octagonal atrium

which is said to be one the grandest hospital lobbies in the world.


There is an enormous marble statue of the Divine Healer

in the middle of the lobby.

Professor Osler walks around this,   and then up an impressive oak staircase

to the second floor, where he then enters the library.

Here he greets some of his colleagues who are gathered there.


And only then does he make his way to the wards

to begin his rounds, visiting  his patients

and to do some teaching of the training physicians and student clerks

who are assigned to the care of those patients.


Most days, when he was not giving a special lecture,

Osler finished his clinical rounds at approximately 1 PM


Then he has a cold lunch, and 20 minutes of rest.

This is followed by  several more hours of

rather well paying consultations with private patients

or..... of time spent writing one of many medical articles

and best-selling textbooks ....that he authored during his career.

But on this Wednesday, as the clock strikes noon,

Osler makes his way into the amphitheater

to meet with his medical students


On this occasion Osler presents the cases of 4 patients

Each suffering from a different infectious disease

and each therefore having a markedly different fever pattern from the others.


The professor repeatedly emphasizes to his students

Details of the 3 great killers of the day:

Which were...typhoid fever, tuberculosis, and pneumonia.


Indeed Osler himself died of pneumonia ....23 years 1919

The control of fever

and the prevention of contagious diseases

was a principle goal of that generation of physicians.


In the decades that followed,

That goal seemed to be attainable.


Antibiotics, and antipyretic, and Vaccines were invented.

And modern sewage and water treatment systems were developed

All to stem the tide of fever and infectious disease.


But today, 110 year later....the goal in fact still remains elusive...

 the problem remains unsolved.


Many impoverished nations around the world

cannot provide their citizens with clean water and food

so is said 1500 people die every hour of an infectious disease,


And to complicate things..

newly emerging and reemerging infectious diseases

stalk the planet.

So Professor William Osler's teaching and advice..........

Which was..... to pay close all aspects of fever

-whether at the bedside.....or on a global scale

And... to pay close attention to  its causes its effects

-is as vital today............. as it was a century ago.



From JAMA     OSLER'S RELAPSING FEVER      July22,06