Did Hippocrates call consults for chest pain? Were there specialists in black bile? Where does our poetic terminology for heart and lung sounds come from? Is there a historical parallel for #MedTwitter? I’ve fallen off the bus with #AdamAnswers, so in this month’s episode I’m playing catch up with the first Winter Short (#spoileralert — not actually short) — the Backlog!
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. If you’ve been listening to the show for a while, you’ve probably noticed the distinct lack of a very theoretically popular feature for the past several months — #AdamAnswers, where I do my best to answer listener questions about medicine and medical history, no matter what they are. There are many good reasons for this — I’ve become insanely busy, all for exciting reasons, and some that I’ll be talking more about in the months to come. But I also feel pretty guilty that my “backlog” of submitted questions just keeps growing,and you guys have asked some great questions, both over Twitter, email, and in person! So in this episode, I’m going to start addressing the backlog. So buckle up — it’s nothing but #AdamAnswers from here on out!
We’re going to start with a great question that I got about six months ago, when the backlog started to grow. Jesse Kane asks via Twitter: Does the concept of medical specialization and consultation predate modern medicine? Was Hippocrates sending out consultations for chest pains? Could you specialize in one of the four humors?
I love this question because specialization has become such a fundamental part of life in the modern medical world. I think back to my graduating day at Tulane University, sitting with all my fellow medical students who were off to become internists, pediatricians, gynecologists, radiation oncologists, pathologists. That was probably the last time that we all spoke the same language as it were, since our jobs are so different, despite all being doctors. It’s tempting to think that this was the state of medicine for our forbears as well. However, Dr. Kane, the answer to your question is a very unsatisfying “it depends,” and is largely going to hinge on what you define as “specialization.” I’ve talked about this on the show before, but the earliest documented naturalistic medicine — that is, the idea that disease is natural, though clearly supernatural ideas comingled as well — comes from Egypt, arguably dating back as far as 1600 BCE to the Edwin Smith papyrus. So it’s probably appropriate that the first textual reference of medical specialization comes from Egypt; Herotodus, writing in the 5th century BCE, writes in what is essentially a travelogue, “Medicine is practised among them on a plan of separation; each physician treats a single disorder and no more: thus the country swarms with medical practitioners some undertaking to cure diseases of the eye, others of the head, others again of the teeth, others of the intestines, and some those of uncertain origin.”
This has been held up as evidence of specialization; in a 1969 article by P Ghalioungui argues that Herotodus’ comments, as well as our fairly extensive knowledge of Greek medicine, shows that the Egyptian model was quite in contrast to the Greek model. He and other contemporary scholars argue this was because of the differing models of disease — to the Egyptians, disease was local, so it made sense to specialize. To the Greeks, however, disease was systemic — both eye disease and heart disease could both be caused by imbalances in the fundamental body humors. So the argument that was made for decades was that there was pre-Classical medical specialization, which humoral medicine largely caused to die out, only to be reborn as medicine abandoned the four humors thousands of years later.
Now here is where things get interesting, and keep in mind this is coming from someone who is in no way an expert on classical medicine. First, Herotodus actually did visit Egypt, but he got a LOT wrong in his travelogue, and is largely relaying stories that he had been told from locals. Think of absurd things local tour guides have told you while traveling, and you have Herotodus. Given all the other exaggerations, there’s no reason to believe he’s performed anything close to a systematic review of the Egyptian medical system. Second, more modern scholarship has suggested that in the time of Herotodus, the Egyptians had their own proto-humoral system (roughly contemporaneous to Hippocrates — the idea of balances in body fluids seems to have been accepted by physicians across the Mediterannean). And third — we know that medical specialization similar to what Herotodus describes actually existed in Galenic Rome — because Galen tells us!
So what did specialization or a consult look like? Here is where it gets more interesting, and more to the idea of what a “specialist” actually is. So we know that in Greece, Rome, the Arab empires, and medieval Europe, there were lay or semi-professional providers who would pull teeth, remove cataracts, deliver babies, and cut for kidney stones. And on top of this, there were any number of herbalists, mystics, pisse prophets, alchemists, and “quacks” available widely. Up until the modern era, these alternative providers probably served more of the populace than physicians did. Depending on time or place, these groups could have had different status; oculists in the Fatimid Empire had high status and their own hospitals; man-midwives largely took over what had been a lay female occupation in early modern Europe; lithotomists were looked down upon in Greece (“thou shall not cut for stone”) and highly sought after in early modern London. Barber-surgeons literally separated into two groups — barbers, and surgeons, and it doesn’t take much to see the status difference today.
Some of these divisions have persisted to this day — dentistry, optometry, and midwifery all still exist. Do you consider these medical specialization? I think this is an open question, and probably not what you were alluding to.
Medical specialization as we know it took off in the early 19th century in Paris, and then Germany, with the birth of pathological anatomy. Very soon after the idea that disease lay inside organs came to be, doctors started to specialize, and then offer courses to help others specialize. Carl Wunderlich, arguably the inventor of clinical thermometry and the myth of 98.6 being the average body temperature, wrote dismissively in 1841: “Now a specialty is a necessary condition for everybody who wants to become rich and famous rapidly. Each organ has its priest, and for some, special clinics exist.” And by 1845, we have a register of Parisian physicians (that is, not surgeons) that shows that 12 percent were specialists. Weisz in an awesome paper in 2003 basically argues that I argue on the show all the time — that the explosion of specialization was NOT due to accumulated medical knowledge, but due to a new conception of disease and localizing in the organs, of pathological anatomy.
So to get back to your question Dr. Kane — does specialization predate modern medicine? Probably not, and most sources that claim this (and yes, people do claim this) are probably anachronistic. Hippocrates was not sending out consults for chest pain, though he’d turn his head (or maybe give a suggestion) if you were desperate enough for a lithotomist. And there were no black bile specialists; the idea of balance DEMANDED the skills of a physician.
The next from my friend and frequent partner in crime Tony Breu, who asks very simply: Is it crackles, or rales? By the way, he ran a Twitter poll on the subject. I’ll give you the answer to THAT at the end of this answer.
So crackles and rales both refer to lung sounds heard with a stethoscope. They’re terms unique to American English in particular, and they have surprisingly nonspecific definitions (theoretically they’re synonyms for a Velcro-y vesicular sound associated with liquids in the lungs). To get to the heart of the confusion, and what Tony is alluding to, we have to start with the birth of lung auscultation back with Rene Laennec, inventor of the stethoscope. Rene Laennec used the French word “rale” to describe all adventitious breath sounds that he heard — terms that are still MOSTLY used in French today. And despite three semesters of French in college, I am going to butcher all of this:
Rale humide ou crepitation — a wet rale, or crackle
Rale muquex or gargouillment — mucous or gurgling rale
Rale sec sonore ou ronflement Dry or snorting rale
Rale sibilant sec ou siffement — Dry whistling or wheezing rale
Rale crepitatn sec a grosse bulles ou craquement — Dry crackling rale with large bulles
On Mediate Auscultation is written in French, so used the French word “rale”, but when he wrote his case notes, which if you’ve ever read the book you know are copied verbatim in a series of 20 or so patient cases, he copied them in Latin and used the direct Latin translation of rale, rhoncus. The English translators, who were aware that French rale translated to the English “rattle” and had a negative connotation with the sound made during death, adopted this Latin term for some of his lung sounds, which has led to incredibly confusing terminology in lung sounds ever since where we talk about crackles, rales, and rhonci — all of which should probably mean the same thing.
When I was a wee medical student, I remember listening to lung sounds and feeling frustration that I never quite heard what my preceptor heard. Turns out there’s good reason for this. If you’ve ever had the suspicion that no one really has any idea of what’s going on with lung sounds, you’re right. We went on blithely pretending to discuss simila r things with lung sounds until recording equipment improved to the point that we could make phonograms of the sounds in the 1980s, similar to what cardiologists had done since the 60s with heart sounds. And since then, there have been several studies with recorded lung sounds showed that while doctors might generally agree that there’s an adventitious sound, no one can really agree with that that sound is, or what it might signify. This, combined with archaic and confusing terminology, led to some new attempts to standardize lung sounds. In 1987, the International Symposium on Lung Sounds was held, which defined four lung sounds based on waveforms, with their recommended terminology: in the US, fine crackles, coarse crackles, wheezes, or rhonchi. The American Thoracic Society has their own terminology, which I won’t go into, but largely agrees with this but has far more sub-categories. In all event, all the classification systems recommend getting rid of the term rale, which they feel causes confusion and refers to multiple different lung souinds. I should also note, there’s a study in 1987 that suggests at least among pulmonologists, rales and crackles are synonyms, and they argue this terminology should be kept.
To add to the debate, the European Respiratory Society had another study using modern recording equipment to try and determine which lung sounds were the most useful (that is, that doctors could actually agree about). With even better recording equipment, it turns out that doctors agree EVEN less. Based on their findings, they recommended using only two terms — crackles and wheezes. Lung auscultation is one of my pet peeves, because it’s one of those things that we pretend to be useful, but at the end of the day, it really isn’t. I’ve never found the finding of crackles helpful one way or another (and the data would tend to back this up), and often when a nurse for example tells me she’s hearing crackles, I hear what I would describe as upper airway sounds. Wheezes are more useful to help diagnose, say, COPD or asthma — but at the end of the day, when I’m treating these patients, they’ll tell me when they feel better, no matter what their lungs sound like. For large pneumonias, lung percussion, egophony, tactile fremitus are all helpful, and for a pleural effusion absent lung sounds can certainly help — but in a world where chest x-rays are widely available, and ultrasound is becoming more common at the bedside, I can hardly say it’s particularly useful. Honestly, outside of, say, intubation of the stomach or a single bronchus, and pneumothorax, I’m hard pressed to say that lung auscultation really drives any clinical decisions, and I’m saying this as someone who “stans” Rene Laennec, as the kids would say.
For all the listeners who may not know Tony, I guarantee that he asked this question just to get me riled up, or, shall we say, “raled” up, which he has thoroughly succeeded in doing. So many answer Tony — Rene Laennec would be aghast that the term “rale”, which he intended to mean ANY adventitious breath sound, was being used as a synonym for rale humide ou crepitation. And both the International Symposium of Lung Sounds, the ATS, and the European Respiratory Society would back him up — it’s crackles, rather than rales. And fortunately that was what the vast majority of voters in his poll went with too.
I’m going to keep the theme of auscultation alive! Next Avraham Cooper asks: I had asked you this earlier but why are they called cardiac “murmurs”? Where did that term come from? There’s something poetic and sort of melancholic about a sick hurt murmuring at us.
Avi, to answer this question, I actually had to do some original research, which included reading French, which, as I alluded to, is not my strong suit. So all of that is to say, you owe me Avi. This dovetails very well with Tony’s question, because the terminology again starts with Rene Laennec and the invention of the stethoscope. It makes sense, if you think about it — direct or immediate auscultation probably didn’t allow anything but the harshest aortic stenosis murmur to be heard. And just like with rales, the term you find so endearing is really due to the translators into English, not Laennec himself. In French, he uses the word “murmure” to refer to what he calls a “bronchial murmur,” which is the normal diminished sounds of a person talking when you listen to healthy lungs through a stethoscope. The word “murmure” and “murmur” mean basically the same thing in English — quiet talking, so his use of the word is very descriptive and makes perfect sense.
The problem? Laennec also talks about “bruits” heard over different heart valves, which he identified (in some cases wrongly) as pathological flow. That’s a talk for another episode though. This word, foreign then in English, was ALSO translated as “murmur.” It’s telling that we now use bruit as Laennec would have intended, such as the bruit of a narrowed carotid artery. And so a word that was so descriptive in the lungs (whose use has completely died out), has come to have the melancholic subtext you ask about. This particuar use of the word murmur mostly only exists in English, as you would expect.
In Spanish it’s “soplo cardiaco” referencing a blowing sound; and soffio al cuore in Italian with the same reference. In German in herzgerausch, a noise of the heart. In Mandarin, it’s Xīnzàng záyīn, or heart noise. In French, it’s souffle au cœur, a respiration of the heart. All of these are more or less straight-forward and not poetic. So again, Laennec’s English translators appear to have overcomplicated medical terms!
Let’s leave the 18th century and jump into the 21st, with a question from Keenan Boulnemour. Regarding #adamanswers — I like to think that history really does repeat itself, and that for every major event there was a historical equivalent (i.e. vaccine resistance, alternative medicine popularity, administrative/political encroachment in healthcare, etc.), but try as I may, I can’t make an analogy to the effects social media has on health & healthcare. Is there a social media equivalent in history where connections like this could be made, or communications with patients were easy? All I can think of is the birth of the printing press…
So Keenan, I love your question because you’re positing a fascinating premise here — does history “repeat” itself? Or to ask a more relevant question, is the past somehow predictive of the future? Or at the very least does it serve as an analogy or a mirror to view our own time?
Clearly, I think that history is very important, especially to the thoughtful physician. I mean, why else would I make this show? And why else are you listening? Which is why I’m disappointed to report that the short answer to that assumption is “no” — history — even medical and scientific history — doesn’t always show clear patterns or cycles. Take some of your examples; the vaccine resistance movement actually predates the history of vaccines (it formed around variolation), and was active against smallpox vaccination pretty much nonstop into the early 20th century, all the way up to smallpox’s elimination. “Alternative medicine” likewise has been a fixture of Western medicine since, well, probably as long as people have been around, but doctors have been complaining about “quacks” since the 15th century at least. In both these examples, vaccine resistance and alternative medicine seem to be cycling back for a couple reasons, the first likely being the Internet, making them more visible, and the second being that from post-WW2 to, let’s say, the 1980s, scientific medicine developed an authority that served to drown out some of these movements. Really, I’d argue that vaccine resistance and the popularity of alternative medicine are far more the status quo throughout the last three hundred years.
And as for administrative and political encroachment into healthcare, this too dates back over two hundred years, and involves complex postmodern trends towards bureaucratization and centralization, but also towards building a health force better able to care for chronic diseases. This is the theme of a lecture, by the way, that I’m giving at the Kaiser Pacific Northwest national meeting in April, and will later release as a podcast.
The long answer, though, isn’t just a simple no, but my favorite answer: “it depends.” And that’s because medicine, seemingly more than other institutions, is incredibly reliant on its past, while ironically envisioning itself as a purely contemporary endeavor. Our drugs and technology may be new, but the ideas, structures, and constraints we use to approach disease and our patients are in some cases ancient, and at the very least locked into about 150 years of medical legacy.
So to bring this back to your question, Keenan, is social media something new and free from history? Or is it similarly contingent like so many other parts of medicine?
I’m tempted to draw a number of parallels. The first in the rise of medical journals and local medical societies. If you pick up a copy of NEJM or the Lancet today, you’ll find a series of quite dull and often industry-driven scientific articles, and usually a couple of well-written opinion pieces and perspectives. There might be a few letters to the editor tucked back in there as well. But if you pick up an early medical journal, you would find a crackling energy that rivals MedTwitter, with lively and acerbic debates (as long as you write “Dear Sirs of Messrs” it turns out you can say pretty much whatever you want) playing out in tabloids and broadsheets published weekly. Local medical societies were very well attended as well, and many published their minutes, which we still have.
What about communicating with patients? Even here there are historical parallels. Doctors (and “doctors”) would travel from town to town giving lectures on new developments in medicine — or on frank pseudoscience. Mesmerism, hypnotism, nitrous oxide, ether — demonstrations of all of these were carried out along more educational lectures, and I’ve talked about all of them on the show before. Even Phinneas Gage basically traveled as part of a somewhat dubious medical demonstration, showing off the tamping iron that had destroyed part of his frontal lobe.
And Keenan, I think this is where your question gets very interesting. Is social media new? Some of it is has certainly just replaced sections of traditional media — in my opinion, letters to the editor sections basically serve no purpose now that MedTwitter and high quality blogs exist. Outreach to patients — both with high quality information and quackery like from Goop — certainly isn’t new either. Even the power of virtual communities in a way parallels the old school medical societies that have largely gone moribund in a far more lonely society.
What is new, however, is the speed and breadth of connections, and the “flattening” of hierarchies (and removal of gatekeepers). Medicine, as you’ve noticed, is an incredibly hierarchical place, so I think social media, or new media, the term I prefer, threatens an even greater disruption to the way we do things, and we’re only seeing the beginning. Will this have as big an impact as the printing press? I doubt it — but we’re at the beginning of a great period of change, and one that I’m excited to be a part of. And now is as good a time to mention that in this vein I’ve launched the New Media in Medical Education Initiative and Beth Israel Deaconess Medical Center, and we’re going to be having our first (hopefully annual) conference in Boston on November 6th of this year. But more of that to come. So thanks for the question Keenan!
And that’s it for the show! Thank you so much for listening! Producing the #AdamAnswers segments are one of the favorite parts of the show, believe it or not, probably because I’m the sort of nerd who actually likes the deep dive into a very specific question. And I absolutely love some of the questions you guys have thrown at me over the years. Which all goes to say — my backlog is still VERY deep, so I will do my best to keep digging myself out of the hole (or at the very least do another backlog episode).
Let’s talk about some exciting chances to see me live in the next few months! So Tony and I are speaking again at the national ACP conference in April; we’re going to be talking about the medical definition of death, and how it has challenged physicians throughout the years. I’m incredibly thankful for the ACP to allow us to do another live podcast — which, believe it or not, is now a category at the ACP! I’m also speaking at the national Kaiser Clinical Educators Conference in Portland, OR. I’m going to be speaking about the development of a health care “system,” but taking a long, philosophical view that links beureaucratic reforms in with changing medical science and society. I’m really thankful to Kaiser for getting this opportunity. Both of these of course will become podcasts after the fact, so all of you will get a chance to listen to. And I’ll be giving even more “live podcasts” in the fall — so wait for details for those.
Finally, there is no CME available for this episode. However, there are HOURS of CME and MOC points available for my backlog. You can find then at www.acponline.org/bedsiderounds. My own website is www.bedsiderounds.org. I’m also on facebook at /BedsideRounds. You can find all the episodes on Apple Podcasts, Stitcher, Spotify, or wherever fine podcasts are found. I’m on Twitter @AdamRodmanMD, where I post about medical history, high value care, and generally rant about epistemology. The show’s Twitter account is @BedsideRounds, where an incredibly talented group of medical students helps come up with awesome histmed Tweetorials.
Sources are in the shownotes. 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.