Words matter. At its best, etymology gives us insight not only into the origins of words, but why they remain so important today, especially in medicine, where we’ve been accruing jargon for millennia. In this episode, we’re delving into four specific words — doctor, cerebrovascular accident, rounds, and zebras.  And along the way, we’re going to discuss pre-historical pastoralists on the Eurasian steppes, medieval universities, Octagonal air-ventilated chambers in 19th century Baltimore, and of course, early 21st century sitcoms.

Works cited:

• OSLER W. THE NATURAL METHOD OF TEACHING THE SUBJECT OF MEDICINE. JAMA. 1901;XXXVI(24):1673–1679. doi:10.1001/jama.1901.52470240001001
• Fair, A 2014, ‘A Laboratory of Heating and Ventilation: The Johns Hopkins Hospital as experimental architecture, 1870–90’, The Journal of Architecture, vol. 19, no. 3, pp. 357-81.
• https://doi.org/10.1080/13602365.2014.930063
• Engelhardt E. Apoplexy, cerebrovascular disease, and stroke: Historical evolution of terms and definitions. Dement Neuropsychol. 2017 Oct-Dec;11(4):449-453. doi: 10.1590/1980-57642016dn11-040016. PMID: 29354227; PMCID: PMC5770005.
• Coupland AP, Thapar A, Qureshi MI, Jenkins H, Davies AH. The definition of stroke. J R Soc Med. 2017 Jan;110(1):9-12. doi: 10.1177/0141076816680121. Epub 2017 Jan 13. PMID: 28084167; PMCID: PMC5298424.
• An Updated Definition of Stroke for the 21st Century
• Ralph L. Sacco, MD, MS, FAHA, FAAN, Co-Chair, Scott E. Kasner, MD, MSCE, FAHA, FAAN, Co-Chair, Joseph P. Broderick, MD, FAHA, Louis R. Caplan, MD, J.J. (Buddy) Connors, MD, Antonio Culebras, MD, FAHA, FAAN, Mitchell S.V. Elkind, MD, MS, FAHA, FAAN, Mary G. George, MD, MSPH, FAHA, Allen D. Hamdan, MD, Randall T. Higashida, MD, Brian L. Hoh, MD, FAHA, L. Scott Janis, PhD, Carlos S. Kase, MD, Dawn O. Kleindorfer, MD, FAHA, Jin-Moo Lee, MD, PhD, Michael E. Moseley, PhD, Eric D. Peterson, MD, MPH, FAHA, Tanya N. Turan, MD, MS, FAHA, Amy L. Valderrama, PhD, RN, and Harry V. Vinters, MD on behalf of the American Heart Association Stroke Council, Council on Cardiovascular Surgery and Anesthesia, Council on Cardiovascular Radiology and Intervention, Council on Cardiovascular and Stroke Nursing, Council on Epidemiology and Prevention, Council on Peripheral Vascular Disease, and Council on Nutrition, Physical Activity and Metabolism
• Harrison F, Roberts AE, Gabrilska R, Rumbaugh KP, Lee C, Diggle SP. A 1,000-Year-Old Antimicrobial Remedy with Antistaphylococcal Activity. mBio. 2015;6(4):e01129. Published 2015 Aug 11. doi:10.1128/mBio.01129-15
• Furner-Pardoe J, Anonye BO, Cain R, Moat J, Ortori CA, Lee C, Barrett DA, Corre C, Harrison F. Anti-biofilm efficacy of a medieval treatment for bacterial infection requires the combination of multiple ingredients. Sci Rep. 2020 Jul 28;10(1):12687. doi: 10.1038/s41598-020-69273-8. PMID: 32724094; PMCID: PMC7387442.
• American Heritage Dictionary of Indo-European Roots, third edition, 2011
• Oxford English Dictionary Online
• Johnson S, Dictionary. Retrieved online: https://johnsonsdictionaryonline.com/doctor-noun/
• Riva MA. No renaissance for doctors in Shakespeare’s plays. BMJ. 2017 May 22;357:j2223. doi: 10.1136/bmj.j2223. PMID: 28533302.

Transcript

This is Adam Rodman, and you’re listening to Bedside Rounds, a monthly podcast on the weird, wonderful, and intensely human stories that have shaped modern medicine, brought to you in partnership with the American College of Physicians. This episode is called “Etymologies.” One of my more popular features has been the #AdamAnswers segment, where I answer listener questions. And of course, I’ve gotten pretty terrible at actually doing them. So in this episode, I’m going to again dip into my backlog of #AdamAnswers, and this time we’re talking etymology — where words come from. Medical jargon has been evolving for thousands of years, spanning cultures and intellectual epistemes; there’s no wonder that we’ve accrued some strange language. So in this episode, we’re going to discuss four different words — “doctor,” cerebrovascular accident,” “rounds,” and “zebras.” But the point of this isn’t to only talk about where words come from — but why we still care so much about it today. And along the way, we’re going to discuss pre-historical pastoralists on the Eurasian steppes, medieval universities, Octagonal air-ventilated chambers in 19th century Baltimore, and sitcoms. So basically, your typical Bedside Rounds episode. Let’s do this!

Let’s jump right in! Paul Kunnath, who for disclosure purposes I must add is newly on the Bedside Rounds peer review board: 

Hey @AdamRodmanMD, how’s this for a #adamanswers? How/why did physicians get the title of ‘doctor’?

Well “doctor” Kunnnath — this is an absolutely fascinating question, and I love the way you ask it, because it belies a lot of the assumptions and controversies about what seems a pretty basic question. The first is that the word “doctor” in English is probably older than the word “physician”. And the second problem is that doctor is not only an academic title but also the commonly used word in English to describe what we both do. This word — the noun, not the title — came long before the title, so that’s what I’m going to focus on. And this question of course belies a long-controversial meta-question: who gets to use the title doctor. People very strongly about this, so I am going to illustrate the whole situation by using clips from lighthearted sitcoms. 

The first is from Friends, and the context is that Ross is a paleontologist — that is, he has a PhD and is a college professor — and he is with Rachel to see her father in the hospital:

That actually means something here

https://www.youtube.com/watch?v=FIaXFw3xhTA&ab_channel=Micka%C3%ABlRoy

)

And the second, opposite clip is from Brooklyn 99, where Captain Holt is interrogating a dentist who is accused of murdering his partner, but gets carried away with his love of etymology.

https://www.youtube.com/watch?v=1BCXJ3yC65o&ab_channel=Chaotic

I share a similar love of etymology to Captain Holt, so I want to uber-nerd this discussion all the way back to the beginning. And I literally mean that, since we’re going to start with proto-Indo-European! So a brief word about proto-Indo European — throughout history, it’s always been clear that disparate languages share many words, from proximity, trading, conquest. That has never been controversial. But in the late 18th century, proto-linguists started to realize that ancient languages separated by immense distances — in this case, Sanskrit, Latin, and Greek — also shared considerable vocabulary. This strongly suggested that they had a common ancestor. Throughout the 19th century, scholars identified the branches of this extinct language — which extends from extinct languages like Hittite, to the predecessors of European languages like Latin, Greek, and the Germanic languages, to Persian, and the languages of the Indian subcontinent — Sanskrit, Hindi, Urdu, and more. The whole process of reconstructing this ancient language and the people who spoke it is absolutely fascinating — and I’m definitely not qualified to go over the whole process, but the TL;DR, which I’m drawing from Anthony’s The Horse, The Wheel, and Language, is PIE arose from pastoralists on the Eurasian steppe, and then combined with the twin innovations of domestication of the horse, and then the wheel, gave these people a competitive advantage to spread widely. 

So a good portion of proto-Indo-European has been reconstructed over the past 200 years from analysis of cognates — words in different languages that have the same “parent.” And it’s from this that we get our first sense of the original words for a medical practitioner. 

In English, the oldest word for doctor is “leech” — the exact same as the blood-sucking worm from the class hirudinea, of which hirudo medicinalis, the medicinal leech, was used for bloodletting for millennia, and is still used today in a more limited capacity in medicine. So you might think that a doctor was named after the worm, or vice versa. This is certainly what has traditionally been though, but it’s not the case. Both originally come from completely separate roots in PIE. We will start with the worm, which comes from the PIE root leig, meaning to bind, presumably because a leech looks like a rope. Modern English words that share this same root are “ligate,” ally, religion, ligament, liaison, rely, and many others, all coming from latin, which had ligare, to bind.

Now the word “leech” meaning doctor is far more interesting. This comes from a separate root leg- which means to speak, and in particular from proto-Germanic lekjaz — literally one who speaks magic words, or enchanter. This is why I love etymology — it gives the sense of how this job would have originally been seen, as a mystic, or at least partially supernatural healer. I should mention that while leech died out 900 years ago, the descendents of leg live on, through Latin legere — to read, where we get lecture, legend, intelligent; the Latin lex, through which we get the word “law”, legal, and loyal, and through the greek “Legein and logos”, through which we get lexicon, the suffix -ology”, dialogue, and eclectic.

What did the work of the old English leech look like? On that, we know even less. There are only a handful of medical texts that persist from the end of this era, the most famous one known as Bald’s Leechbook, which draws heavily from Galenic thought. The third part of Bald’s Leechbook, however, appears to be drawn from an older text, and lists a number of herbal treatments from the British Isles, and is written in such a way that suggests the author is himself familiar with these therapies. There’s an interesting piece in Drug Discovery Today, which I’m linking in the show notes, which suggests that a number of these herbal medications have active metabolites that are still used today. And famously, a few years ago, an experiment was performed on an eye salve — meant for treating a stye — from the leechbook: The recipe reads: “take cropleek and garlic, of both equal quantities, pound them well together… take wine and bullocks gall, mix with the leek… let it stand nine days in the brass vessel”. The researchers tested its efficacy against MRSA biofilms taken from mice and grown in a culture, with dramatic efficacy. They also tested it as a “salvage” treatment from those MRSA left over after exposure to vancomycin, and it similarly showed “significant bactericidal activity.” The exact mechanism is unknown — they mention bile salts, Ace-AMP1 in onion, saponins in leek — though it’s important to mention that a similar study, in which the exact steps were not followed as closely, failed to show efficacy. They ultimately conclude “the untapped potential of premodern remedies for yielding novel therapeutics at a time when new antibiotics are desperately needed.”

The word leech would start to die out in English from the 12th century to about the 14th, starting with the Norman invasion and the introduction of many French (and by extension, Latin) words; this is also the period in the British Isles that medicine started to subdivide itself. Leech had originally referred to all medical providers — lumping physicians, surgeons, barbers, apothecaries, and midwives together. And as the medieval period gave way to the renaissance, these professions started to become more distinct, eventually having their own societies, hierarchies, and training structure.

So first let’s talk about the Latin word for physician — medicus. This, of course, also comes from PIE, the root med- meaning to take appropriate measures, and then the Latin root mederi, meaning to heal or cure. This is still the root of most of the words for physician in Romance languages — medico or medica in Spanish, Italian, and Portugeuse and medicin in French, and the own root of our word “medicine.” 

In this period, two other French and Latin words took hold in the British Isles. The first is “doctor”. I should note that much of the early history of the word doctor is obscured in history; among the other sources I’m using here in Samuel Johnson’s Dictionary, the first dictionary of the English language, from 1755, and using sources from a century earlier.

Our “doctor” comes from two apparent sources, both of which are alive in the modern use of the word doctor. The first is the medieval university; by the 11th century, ecclesiastic universities would bestow the title “doctor” — literally just nominative of docere, to teach, so doctor, a man who teaches — on those who had completed their studies in the clergy, law, or medicine, and had a license to teach.Those were the three traditional “professions” of the university, though Johnson also adds music to the list. So for example, in the Merchant of Venice, Bassanio exclaims:

No woman had it, but a civil doctor,

Who did refuse three thousand ducats of me,

And begged the ring

Civil doctor basically means lawyer. 

The second definition is often overlooked and is rather old fashioned these days, but might even be an older definition — doctor as a learned or wise person. This actually survives as a somewhat antiquated turn of phrase in English as the honorific “doc”. The most famous example in pop culture would be Bugs Bunny and “What’s up doc,” which Tex Avery took from what was a common expression in his childhood (the 1920s in Dallas). 

Johnson gives this example from Kenelm Digby writes:

The simplest person, that can but apprehend and speak sense, is as much judge of it as the greatest doctor in the school.

Doctor here does not refer to any specific profession, but any wise man. 

The second word that replaced leech is, of course, “physician” which I’ve talked about on the show before. It comes from the Latin “physica” natural science, though is a direct loan word from Old French “fisicieen” meaning a practitioner of the healing arts, though physicien in French now means physicist. 

So when did doctor and physician become synonyms? Certainly by the dawn of modern English. Shakespeare is full of references to doctors, such as when Macbeth calls to his wife’s doctor:

How does your patient, doctor?

— Not so sick, my lord,

As she is troubl’d with thick coming fancies. Shakesp. Macb.

Or when Jonathan Swift anticipated the claims of the medical nihilist 200 years in the future when he wrote, “I have heard a physician pronounce with great gravity that he had cured so many patients of malignant fevers, and as many more of the small pox, whereas in truth nine parts in ten of those who recovered owed their lives to the strength of nature and a good constitution, while such a one happened to be their doctor.”

Unfortunately Dr. Kunnath, it’s a little less clear when the title became commonly used. In Macbeth, Macbeth doesn’t call his doctor “Doctor So-and-so”; the same with the Doctor in King Lear. Doctor is a profession. And this is one of the points that Ross Gellar and Captain Holt get wrong, which, I mean, that’s why the joke is funny. The word “doctor” when used as a noun in English means a medical practitioner, and has meant that for over half a millennium. The word almost certainly pre-dates the title, and at least prior to the 18th century didn’t even necessarily connote formal schooling. Take the example of Edward Jenner,the inventor of vaccination, who was called in his time and ours “Doctor Jenner.” He apprenticed under John Hunter at St. George’s, and while he attended lectures, he was never awarded a degree. 

Controversy over titles started to brew in the 19th century.  As any listener to this podcast will know, this is the period in which alternative practices started to flourish — starting with mesmerism and homeopathy, and soon spawning chiropractic, osteopaths, Thomsonians, hydropaths, and eclectics. Many of these new providers also used the title doctor — and as Captain Holt can tell you, so did newly professionalizing dentists and occulists, as well as apothecaries.  As the field of medicine started to professionalize in both the UK and the new United States, organizing bodies started to regulate just who could use the title doctor. This led to regulatory bodies in the 19th century restricting the medical use of the word doctor. I should also note that these laws had absolutely nothing to do with PhDs, or the ability of non-medical professions to use the title doctor — they were focused on professionalizing and legitimizing medicine by making sure physicians had proper credentials (plus in the mid 19th century, there just weren’t that many PhDs; no one could foresee the spectacular growth in PhDs that a highly-technical post-industrial society would require).

So like I mentioned at the beginning of this now very-long #AdamAnswers, one of the reasons I love etymology is that it gives a sense of the intention surrounding a word in its original use. So I want to speculate for a second about why the words “doctor” and physician largely replaced the old English “leech.”  The first is purely practical — many French terms replaced Anglo-Saxon ones after the Norman invasion, and it’s likely that leech was no different. But there’s a second reason that was quite clear — power and status. The word “leech” afforded no individual medical group status above the other. But as the field specialized, physicians found the word and title “doctor” to be useful to assert their status above other health professions, especially the barber-surgeons.

This desire for power and respectability is what propelled early 19th century hydropaths and chiropractors towards the title doctor for the same reason. And don’t think this is a thing of the past.  The number of health professions granting doctorates has exploded in the past several decades in the United States. As of 2015, all physical therapists in the United States earn a DPT — a Doctorate of Physical Therapy. OTs and speech and language pathologists will be soon to follow. Many nurse practitioners earn DNPs, a doctorate of nursing practice. There is a continued active debate in medicine about who, and in what settings, gets to use the title “doctor,” and I think you can imagine where the American Medical Association comes down on this. But these acrimonious 21st century debates over the title doctor are just part of a millennium long argument dating at least back to the medieval leeches — which group of people gets to use language to wield professional power. 

That took over a millennium to answer, so I’m going to to pick an equally expansive etymological question next. So David Serota — and I lost track a long time ago, but I think he’s winning for the most #AdamAnswers that I’ve answered — he asks: How did doctors end up referring to strokes as “cerebrovascular accidents”? Is this the dumbest name in medicine?

We clearly need to have some modern definitions first. Just to be clear, there’s even some debate today about the exact definition — but broadly speaking, a stroke is a disruption of blood flow to the brain, resulting in damage to the brain and neurological deficits. A cerebrovascular accident, or CVA, is basically that — a more “medically” term for a stroke. But the term accident in particular has always seemed a bit wrong, and I think it’s fair to say that many stroke neurologists dislike the phrase. So how did we all agree on such strange language? So to answer this one, we’re going to have to understand how the understanding of stroke has changed over different epistemes. Essentially we have to talk about nosology — my favorite!

While “stroke” has been the common name for the condition in English for hundreds of years, until basically the early 20th century, the traditional name was still used in medical settings — apoplexy, from the Greek apoplexia, meaning “struck down with violence”. The name is also wonderful evocative — you can see how an embolic stroke would have seemed instantaneous and terrifying to pre-modern people.

Hippocratics spoke about apoplexy in a way that suggested it was an old diagnosis — that they were just passing down traditional information. For example, we get a definition from the Hippocratic aphorisms: #42. It is impossible to remove a strong attack of apoplexy, and not easy to remove a weak attack.(http://classics.mit.edu/Hippocrates/aphorisms.2.ii.html

And by the time of Galen, apoplexy had received described and received its definition that would persist until the dawn of pathological anatomy:

“Apoplexy is an unconsciousness of the mind, with a privation of the senses and a palsy of the body. Apoplexy is a privation of sense and motion in all the nerves. In apoplexy

the whole body suddenly is deprived of sensation and motion, with only respiration remaining, and if it is prevented, the apoplexy is maximum and very severe.”

There are some major nosological challenges with this definition from a 21st century perspective; while it most certainly includes our modern definition of hemorrhagic and ischemic strokes, it also includes a great deal of other diagnoses — seizures present like this, cataplexy certainly, even complex migraines.

Apoplexy stuck around until the early 20th century in English, and you can still occasionally find it in Romance languages. When did the word word “stroke” become used?  The OED traces the first usage to the 1590s, with an official cause of death listed as a “stroke of God’s hand.” Given the similarities of definition between “stroke” and apoplexy, you can imagine that this was likely used earlier than this in common language. In any event, Cole was the first to use it in medical literature in 1689, but again didn’t become standard in medical literature until the 20th century.

The ancient concept of apoplexy started to shift with the slow introduction of pathological anatomy. Starting with Wepfer in the 17th century, anatomists became increasingly clear that apoplexy could be divided into two broad categories — hemorrhagic and non-hemorrhagic. By the 19th century, patterns of strokes that we would recognize all had been well described. Virchow himself came up with the modern classification into hemorrhagic and ischemic, as well as positing that the major risk factor for apoplexy was arteriosclerosis of the vessels of the brain — cerebrovascular disease. By the 1890s, apoplexy was not a mysterious case of being “struck down by violence,” but a ticking time bomb of diseased brain vessels waiting to catch an embolism or burst and bleed, a time bomb that doctors and patients alike were helpless to stop.

So when Bertillon started his project that would become the International Classification of Diseases, the term apoplexy was included, subdivided into categories. The term actually lasted until the ICD-4, published in 1929 by the League of Nations, but was removed in the 5th revision published in 1938. In the ICD-3, published in 1930, a new term would be introduced based on the new dominant scientific understanding of stroke — arteriosclerosis with cerebral vascular lesion. I actually haven’t found an exact reference to when cerebrovascular accident — CVA — started to be used as a medical term, but it seems to date to this period in the 1920s when the literature starts to shift from “apoplexy” to cerebrovascular disease; the earliest references I’ve found are from the 1930s, and by the 1950s the term is dominant. Similarly, it’s used in other languages — accidente cerebrovascular is commonly used in many Spanish-speaking countries. So to get to the weird terminology that so irks Dr. Serota and so many of my neurologist colleagues:  Why accident? This is some speculation here, but in reading articles in this period you can hear the frustration of the physicians with stroke — while the risk factors became increasingly apparent, there did not seem to be anything that could be done to prevent a stroke, there were definitely no effective treatments, and their timing appeared to be completely random. Unstoppable and random — the word accident is apropos.

That, of course, has not been the case for a very long time. For 70 years or so we have known about modifiable risk factors for stroke, and we now have a panoply of medications that can lower the risk, like aspirin, statins, and blood thinners, and effective treatments for acute stroke — the infusion of tissue plasminogen activator, and even using a vascular catheter to physically remove the clot. As you can imagine, the term accident and CVA have generally been frowned upon by neurologists. One piece in STAT actually advocates the name “brain attack,” similar to heart attack, since pathophysiology is so similar to that of an MI, or myocardial infarction. 

But you asked two questions. So to answer the second part of your question — is this the dumbest name in medicine? We have some especially ridiculous historical names in our field — for Dr. Serota, an infectious disease doctor, he has to contend with a “mycotic aneurysm,” which has absolutely nothing to do with a collection of mushrooms in the vasculature; we have “sarcoid” and all the diseases ending in “oid”, described because the first cutaneous sarcoid seen by Hutchinson appeared similar to a sarcoma; and of course we have names that are just constructed of lists of eponyms of physicians who couldn’t share credit, like Charcot-Marie-Tooth disease. Is “accident” dumber that those? I’m not certain — but if you have opinions dear listeners, please Tweet them to me @AdamRodmanMD.

Onto the next question!

From Malvika Varma, we have:

Late night thoughts. 

Why is it called Rounding? Team rounds. Grand rounds.  What I do during the day rarely, if ever, resembles a circle. 

Then I had an idea

Hey, @AdamRodmanMD… why is it called rounding?

Dr. Varma, I am here to help! So this is one of those etymologies where the answer is sort of boring — you can literally just use the Oxford English Dictionary —  but the story BEHIND the question is actually really interesting because there’s a very strongly held, if obviously wrong, folk belief behind it.

So let’s start with the folk belief, which no matter how many times you read it on the internet is 100% wrong. The story goes that during Osler’s time at Hopkins, there was a circular medical ward, and when the venerated father of medicine walked these wards with his teams, it was called “rounding” because they would literally walk in a circle. And when when Osler himself came with a gaggle of learners on this circular ward, it was called “Grand Rounds.”

This story is obviously untrue. First, while there was an Octagon Ward at Hopkins — more on that in a minute — the majority of patients were housed in four traditional linear wards. Why would a single circular ward give the practice the name? But the second and more important reason is that the word “rounds” was used in the same sense for generations before Osler.  Our verb “to round” is from the 20th century, but it comes from “making rounds” or “going round,” which dates back to the 1590s in English and originally referred to what a watchman or a sentinel might do — walk a predetermined course on a schedule. The OED definition agrees:  “A route, course or circuit habitually used or followed by a person in the course of his or her job.” We still use this language today in the United States — if I go to a holiday party, say, and I want to say hi to all my bosses before I can relax with my friends, I might say something like, “I need to make the rounds first.” It’s not particularly hard to imagine how this regularity would be transferred to a hospital ward — instead of walking through a town, a doctor would visit each patient on a ward on a daily basis, generally walking bed to bed. When did this language start getting used in medicine? Definitely by the middle of the 19th century, rounds as a noun, and “make rounds” as a verb was being used in the name sense that it is today; for example, I just finished Janice Nimura’s amazing The Doctors Blackwell, and Elizabeth Blackwell talks about attending rounds with Clement Lee in the 1840s, by which she meant going bed to bed in a ward as part of an educational experience with an attending physician; she draws this in contrast to the educational experience of seeing patients in his home. Similarly, she talks about rounds at La Maternite in Paris, a midwifery hospital. 

I wanted to find just how far back it went, so I pulled some older examples. One Dr. Walker died in 1821, and the Royal Society published at epitaph on him; he was an ardent vaccination advocate at Guy’s, and “for upwards of a quarter of a century, never omitted one lawful day doing his rounds to the numerous stations of the institution,” meaning he essentially went patient to patient in the hospital, inoculating cowpox in people’s arms; they estimate he vaccinated 100,000 patients. Even earlier, I found a letter from a British student in Paris complaining about how crowded medical education was in Montpellier; “There is always such a crowd of student about the physician and surgeon that there is nothing to be seen or heard…” and the students wrote a letter to “complain of the speed with which the hospital doctor conducted his rounds, and the lack of consideration he showed towards medical students.” Similarly, another British student complained about Paris hospitals in the early 19th century: “There are about 200 students going round every morning with each of the best physicians …so that you are tolerably lucky if you get a third row round the bed of a patient.”

And this timing, I think, makes perfect sense for the entry of the phrase “rounds” into English medical jargon. The model of a single physician staffing a medical ward with learners in tow dates to the middle of the 18th century, most famously in the French medical schools in Montpellier and Paris, but most English speakers would have encountered it during the late 18th and early 19th centuries as part of the famed Paris Clinical School; a similar model was also popular in Edinborough at this time. That seems as good a time as any for rounds to jump definitions to medicine.

But like I said, I expect some pushback from the Oslerphiles out there, so you don’t have to take my word for it; the Oxford English Dictionary 100% agrees with me. They define rounds as, “a regular visit by a doctor or nurse in a hospital to each of the patients under his or her care” — and the earliest example they cite is from the Hand-bk for Hospitals viii, p 172: clearly describing how a modern medical ward should be run: “Doctor’s rounds — By this time in an orderly ward it is nearly nine o’clock”. This reference, offered with no explanation since it is understood that “rounds” is a commonly used term — dates from 1883 — 6 years before Hopkins’ hospital even opened. 

But like I mentioned, the Octagon Ward at Hopkins does have a fascinating story behind it, even if it isn’t the source of the word “rounds.” When Johns Hopkins willed his estate to build a hospital and medical school in 1873, he wrote that the hospital should “in its construction and arrangement compare favorably with any other institution in this country and Europe.” The Trustees basically filed a request for proposal, and in 1876, the physician John Shaw Billings was tasked with bringing these ideas to fruition. Remember that the 1870s was the very infancy of germ theory, and foul air was still largely accepted as the cause of “zymotic” or infectious diseases; this new hospital gave him a chance to have a “great laboratory for teaching the practical application of the laws of hygiene to heating, ventilation, house drainage, and other sanitary matters.” I’ve posted to Twitter the original plan for Hopkins — only the administrative building still stands, but you can see five wards — the Octagon ward, three long rectangular “common wards” done in the Nightingale style  (24 beds in a 100 foot room) and a final an isolation ward — isolation here is not for the safety of the staff, but the convenience of the patients, especially for those with malodorous conditions. All of these buildings had the latest in ventilation technology, with complicated air intakes to heat, distribute, and vent the air. The Octagon Ward in particular was a technological marvel; it was based on a design at Massachusetts General up in Boston, and had a central airshaft that ran through the center of the Octagon; fresh air was vented in through the sides. Nurses in the ward spent the first month of their training course learning about the complicated ventilation system — and as Alistair Fair, who wrote about this in the Journal of Architecture pointed out — they had multiple lectures on this before getting to more germane topics such as “diseases of the digestive system.”

Unfortunately, hospital design rapidly changed as germ theory became widespread and the sanatorium model took over from the Nightingale model, and while Osler most certainly did round by walking around an Octagon ward, the buildings were torn down shortly after his time for many of the more modern structures that stand today; only the administrative building still stands of Billings’ original vision, and that has been long ago stripped of its remarkable ventilation system. 

What about Grand Rounds? Nowadays we think of Grand Rounds as a lecture, usually given by a distinguished guest. But up until the 1960s, and lasting a bit longer in some places, grand rounds would be similar to ward rounds in the sense that residents would present an actual patient — physically there in the room — but to a group of faculty and the other residents, rather than just to their individual attending, with a large educational discussion following. Again, there’s no evidence that this comes from Osler. I pulled the 1901 piece he wrote for JAMA where he describes the entire curriculum he developed at Hopkins, and he actually calls this the “Amphitheater Clinic”. I don’t know where the phrase Grand Rounds came from, but certainly by the 1920s it had become standard. I should also say that the idea certainly didn’t originate with Osler; “amphitheater rounds” were practiced in Germany and France for generations before Osler. 

So Dr. Varma, I hope that answers your question! I think the interesting question that I have is why we’re determined to attribute a centuries-old tradition — rounding — on the feet of one man. I produced an entire episode about Osler called “Hero Worship” trying to answer this, so give it a listen if you want my complete answer. Sufficed to say, Osler himself would be a little flummoxed that this has become part of his legacy — and in his own writing, discussed what he did with patients and students in tow as “making a visit” and not “making rounds.” 

A final short one, from Sam Schotland who simply requests “hoofbeats and zebras”. This, I assume, is a question about the etymology of the pithy Bayesian saying, “When you hear hoofbeats, think horses not zebras” — that is, the fairly uncontroversial  statement that a patient’s presentation is more likely to be a common disease rather than a rare disease. I mean, unless you are in, say, Botswana, and probability would compel you to flip the statement around. Fortunately, someone else has done all the work for me on this one — Garson O’Toole on the quote investigator blog found the earlier printed reference in the Arkansas Gazette of Little Rock, Arkansas:

“The father of a young man who was there reports that at the University of Arkansas School of Medicine this week a doctor surrounded himself with about a dozen students and sought to go to the heart of proper diagnostic procedure.

In the end he summed up good diagnosis this way: “When you hear hoofbeats in the night, look for horses — not zebras.”

And there are a number of other appearances in the popular press in the 1960s. Take this lovely profile of a 65 year-old family physician in the May 1964 Reader’s Digest:

“Doc Read fixed me with probing blue eyes, then grinned and said tolerantly, “Jack, if you hear hoofbeats around here, you can usually bet they’re made by horses, not zebras. Fortunately, when somebody gets sick, the trouble is usually something common, not one of those exotic diseases they dramatize in medical schools.”

This version apparently is what most popularized the expression; after this O’Toole has uncovered a number of other versions and variants from this time period in both lay and professional press, involving also giraffes and unicorns, all of which suggest the phrase had already been circulating for some time. 

The closest thing we have to an origin — though no direct evidence — comes from Theodore Woodward, who was a beloved professor and Chair of Medicine at the University of Maryland from 1948 until the late 90s, when he was still rounding on patients in his 80s. In teaching diagnosis, Woodward would apparently admonish his students, “Don’t look for zebras on Greene Street,” referring to a major street by the university. As far as I know, there’s no contemporaneous evidence, but many people have attested to this (though starting in the 1980s). 

The timing is at least plausible — Woodward starting to use the phrase around 1950, his students adapting it into the 1960s, where it hits Reader’s Digest and then goes big. I also buy this story for the timeline of the epistemological framing. Woodward served in World War II as part of the US Army Medical Corps, traveling around the world to study and fight rickettsial diseases , dengue, and typhus. He was a forerunner in infectious disease epidemiology, and by the time he arrived back at the University of Maryland would have been well-steeped in probability theory and the newly-rehabilitated Bayes theorem. So if anyone were going to exhort zebras, it would be him; I would be far more surprised if the phrase dated from before WW2; probability theory was far more niche before the war.

That’s not the most satisfying answer Dr. Schotland — but I hope it will do!

And that is it for the show! Sorry for the two month interregnum of the show — it ultimately ended up being a delayed “paternity leave” because the pipeline I have for episodes takes a couple months between writing, peer review, revisions, and recording. But the pipeline is currently full and I have a lot coming down the pike! 

CME is available for this episode if you’re a member of the American College of Physicians at www.acponline.org/BedsideRounds. All of the episodes are online at www.bedsiderounds.org, or on Apple Podcasts, Spotify, Google Podcasts, or the podcast retrieval method of your choice. The facebook page is at /BedsideRounds. The show’s Twitter account is @BedsideRounds. I personally am @AdamRodmanMD on Twitter, which is a great place to submit a #AdamAnswers question that will be answered in two years.

All of the sources are in the shownotes, and a transcript is available on the website.

And finally, while I am actually a doctor and I don’t just play one on the internet, this podcast is intended to be purely for entertainment and informational purposes, and should not be construed as medical advice. If you have any medical concerns, please see your primary care practitioner.