Bedside Rounds

How can we medically tell whether or not someone is alive or dead? The answer is much more complicated than you'd think. In this episode, which is a live podcast I gave with Tony Breu at the Massachusetts Chapter of the American College of Physicians annual meeting on October 16, 2021, we track the evolution and controversies of the death exam, from a trans-Atlantic scandal surrounding a possible vivisection, a 19th century "X-prize" to determine a technology that could diagnose death, the important distinction between "permanent" and irreversible, and the mysterious Lazarus phenomenon.

References:

• Rodman A, Breu A. The last breath: historical controversies surrounding determination of cardiopulmonary death. Chest. 2021; [online ahead of print August 13, 2021]. https://doi.org/10.1016/j.chest.2021.08.006

During World War II, the US Army launched a seemingly routine experiment to find the ideal way to screen soldiers for tuberculosis. Jacob Yerushalmy, the statistician in charge of this project, would succeed at this task -- and end up fundamentally changing our conception of medical diagnosis in the process. This episode features Dr. Shani Herzig, as well as a new segment featuring Dr. Umme H. Faisal on Yellapragada Subbarow and his discovery of ATP.

Bedside Rounds store: https://www.teepublic.com/stores/bedsiderounds

Umme H. Faisal on Twitter: @stethospeaks

What does it mean when different physicians disagree about a diagnosis? I am joined by Dr. Shani Herzig as we explore this issue in the second part of my series on the development of diagnosis. We're going to discuss the advent of signal detection theory in the middle of the 20th century as new diagnostics such as laboratory testing and x-rays started to challenge the classical view of diagnosis. Along the way, we're going to talk about focal infection theory and why it seems that everyone in older generations had their tonsils removed as children, early and very inefficient chest x-rays, British radar operators trying to figure out if they were looking at a flock of geese or a German bomber, and finally probably one of the most important people in medical diagnostics that you've never heard of -- Jacob Yerushalmy.

If you want to purchase any Bedside Rounds swag, the store is at https://www.teepublic.com/stores/bedsiderounds.

Elizabeth Blackwell -- the first woman to earn a medical degree in the United States -- and her sister Emily Blackwell are some of the most important physicians of the 19th century, firmly establishing the role of women as physicians, starting an infirmary and hospital for poor women and children, and founding a women's medical college that was decades ahead of its time. In this episode, Dr. Nora Taranto joins me to explore the legacy of the Blackwells along with Janice Nimura, who recently published a biography of the sisters.

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.

For a special holiday treat, we're going to explore two tales of salmonella disease detectives -- the first about Mary Mallon ("Typhoid Mary") and the birth of the genre; and the second about a mysterious salmonella outbreak at Massachusetts General Hospital solved with the assistance of a very jolly patient. Along the way, we'll talk about clinical epidemiology, the long-lasting influence of Berton Roueché, and the joys of being an internist!

You can sign up for the Digital Education conference at cmeregistration.hms.harvard.edu/digitaleducation.

Sources:

• Buckle GC, Fischer Walker CL, and Black RE, Typhoid fever and paratyphoid fever: Systematic review to estimate global morbidity and mortality for 2010.J Glob Health. 2012 Jun; 2(1): 010401.
• Marineli F et al, Mary Mallon (1869-1938) and the history of typhoid fever.Ann Gastroenterol. 2013; 26(2): 132–134.
• Soper GA, The Curious Career of Typhoid Mary, read on May 10, 1939 before the Section of Historical and Cultural Medicine. Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1911442/pdf/bullnyacadmed00595-0063.pdf
• Norrington B, Cochineal: A Little Insect Goes a Long Way, UCSB Geography.
• Roueche B, The Santa Claus Culture, The New Yorker, Aug 27, 1971.
• Lang DJ et al, Carmine as a Source of Nosocomial Salmonellosis, NEJM. Apr 13, 1967.

You can buy Medical Detectives here: https://www.amazon.com/Medical-Detectives-Collection-Award-Winning-Investigative/dp/0452265886

Diagnosis is arguably the most important job of a physician. But what does it actually mean to make a diagnosis? In this episode, we'll explore this question by tracking the development of the "classical" model of diagnosis and pathological anatomy and discussing three cases over three hundred years. Along the way, we'll ponder the concept of the lesion, iatromechanistic theories of the human machine, the birth of the International Classification of Diseases, and the rise and decline of the autopsy.

You can sign up for the iMED Digital Education conference at cmeregistration.hms.harvard.edu/digitaleducation.

Sources:

1. Hooper R, The Physician's Vade-Mecum: Containing the Symptoms, Causes, Diagnosis, Prognosis and Treatment of Diseases. 1812.
2. Holdman L et al, The Value of the Autopsy in Three Medical Eras. N Engl J Med 1983; 308:1000-1005.
3. Cabot RC et al. CASE RECORDS OF THE MASSACHUSETTS GENERAL HOSPITALANTE-MORTEM AND POST-MORTEM RECORDS AS USED IN WEEKLY CLINICO-PATHOLOGICAL EXERCISES. Case 9431. Boston Med Surg J 1923; 189:595-599.
4. Shojania KG and Burton EC, The Vanishing Nonforensic Autopsy. N Engl J Med 2008; 358:873-875
5. Morgagni GB. The seats and causes of diseases investigated by anatomy in five books, containing a great variety of dissections, with remarks. To which are added ... copious indexes. 1769. Retrieved online: https://openlibrary.org/works/OL15821973W/The_seats_and_causes_of_diseases_investigated_by_anatomy
6. Castiglioni A, GB Morgagni and the Anatomico-pathological Conception of the Clinical. Proceedings of the Royal Society of Medicine, November 7, 1934.
7. Thiene G, Padua University: The role it has played in the History of Medicine and Cardiology and its position today. European Heart Journal, Volume 30, Issue 6, March 2009, Pages 629–635.
8. Zampieri F et al, Origin and development of modern medicine at the University of Padua and the role of the "Serenissima" Republic of Venice. Glob Cardiol Sci Pract. 2013; 2013(2): 149–162.
9. Conner, Annastasia (2017) "Galen's Analogy: Animal Experimentation and Anatomy in the Second Century C.E.," Anthós: Vol. 8: Iss. 1, Article 9.
10. Zampieri F et al. The clinico-pathological conference, based upon Giovanni Battista Morgagni's legacy, remains of fundamental importance even in the era of the vanishing autopsy. Virchows Arch. 2015 Sep;467(3):249-54.
11. Ghosh SK, Giovanni Battista Morgagni (1682-1771): father of pathologic anatomy and pioneer of modern medicine. Anat Sci Int. 2017 Jun;92(3):305-312.
12. O'Neal JC, Auenbrugger, Corvisart, and the Perception of Disease. Eighteenth-Century Studies Vol. 31, No. 4, The Mind/Body Problem (Summer, 1998), pp. 473-489
13. Brown TM, THE COLLEGE OF PHYSICIANS AND THE ACCEPTANCE OF IATROMECHANISM IN ENGLAND, 1665-1695. Bulletin of the History of Medicine Vol. 44, No. 1 (JANUARY-FEBRUARY 1970), pp. 12-30
14. Roos AM, Luminaries in Medicine: Richard Mead, James Gibbs, and Solar and Lunar Effects on the Human Body in Early Modern England. Bulletin of the History of Medicine Vol. 74, No. 3 (Fall 2000), pp. 433-457 (25 pages)
15. Frith J, History of Tuberculosis. Part 1 – Phthisis, consumption and the White Plague. JMVH. 2014; 22(2).
16. World Health Organization, History of the development of the ICD. https://www.who.int/classifications/icd/en/HistoryOfICD.pdf
17. Laennec RTH, A treatise on diseases of the chest and on mediate auscultation. 1834. Retrieved from: https://archive.org/details/b21987002.
18. Marinker M, Why make people patients? J Med Ethics. 1975 Jul; 1(2): 81–84.
19. King LS, Medical Thinking: A Historical Preface. Princeton University Press, 2016.

In this episode, I talk about my podcasting journey -- how I started Bedside Rounds for inspiration during a low period in residency, how it changed me as a physician, and how it has changed my views about digital education and the future of medical education in general. This is a live recording of a talk I gave at the Michigan ACP annual meeting last month.

Also, we are hosting the first annual iMED conference in January (virtual this year, of course) -- the link is cmeregistration.hms.harvard.edu/digitaleducation to sign up!

The COVID-19 pandemic laid bare the racial health disparities in the United States, with markedly increased mortality especially among Blacks and Native Americans. In this episode, Tony Breu and I discuss the conception of race, racism, and the social determinants of health through three historic plagues in the United States -- from yellow fever in New Orleans, to poliomyelitis, and finally the early days of HIV/AIDS -- and what lessons we can draw for COVID-19. Along the way, we'll discuss the unique social capital afforded by acclimation, immunity passports, the concept of the "original antigenic sin," and constitutionalism and eugenics. This presentation was performed live at the annual meeting of the Massachusetts American College of Physicians, and is only lightly edited.

SOURCES:

• Monath TP, Yellow fever: an update. Lancet Infect Dis. 2001 Aug;1(1):11-20. doi: 10.1016/S1473-3099(01)00016-0.
• Kallas EG, D'Elia Zanella LGFAB, Moreira CHV, Buccheri R, Diniz GBF, Castiñeiras ACP, Costa PR, Dias JZC, Marmorato MP, Song ATW, Maestri A, Borges IC, Joelsons D, Cerqueira NB, Santiago E Souza NC, Morales Claro I, Sabino EC, Levi JE, Avelino-Silva VI, Ho YL. Predictors of mortality in patients with yellow fever: an observational cohort study. Lancet Infect Dis. 2019 Jul;19(7):750-758. doi: 10.1016/S1473-3099(19)30125-2. Epub 2019 May 16. Erratum in: Lancet Infect Dis. 2019 Nov;19(11):e370. PMID: 31104909.
• Blake LE, Garcia-Blanco MA. Human genetic variation and yellow fever mortality during 19th century U.S. epidemics. mBio. 2014 Jun 3;5(3):e01253-14. doi: 10.1128/mBio.01253-14. PMID: 24895309; PMCID: PMC4049105.
• Jelili Ojodu, MPH1, Mary M. Hulihan, MPH2, Shammara N. Pope, MPH2, Althea M. Grant, PhD2,, MMWR, Incidence of Sickle Cell Trait — United States, 2010.
• IthaMaps, Haemoglobin Epidemiology. https://www.ithanet.eu/db/ithamaps?country=GR
• Serjeant GR, The natural history of sickle cell disease. Cold Spring Harb Perspect Med. 2013 Oct; 3(10): a011783.
• Hamosh A, FitzSimmons SC, Macek M Jr, Knowles MR, Rosenstein BJ, Cutting GR. Comparison of the clinical manifestations of cystic fibrosis in black and white patients. J Pediatr. 1998 Feb;132(2):255-9. doi: 10.1016/s0022-3476(98)70441-x. PMID: 9506637.
• Gershman KD et al, Yellow Fever Vaccine & Malaria Prophylaxis Information, by Country. CDC.
• Kofler N and Baylis F, Ten reasons why immunity passports are a bad idea. Nature 21 May 2020.
• NASEM, National Academies Release Framework for Equitable Allocation of a COVID-19 Vaccine for Adoption by HHS, State, Tribal, Local, and Territorial Authorities.
• Schmidt H et al, Covid-19: how to prioritize worse-off populations in allocating safe and effective vaccines.BMJ 2020; 371 doi: https://doi.org/10.1136/bmj.m3795 (Published 05 October 2020).
• Siegal FP, Lopez C, Hammer GS, Brown AE, Kornfeld SJ, Gold J, Hassett J, Hirschman SZ, Cunningham-Rundles C, Adelsberg BR, et al. Severe acquired immunodeficiency in male homosexuals, manifested by chronic perianal ulcerative herpes simplex lesions. N Engl J Med. 1981 Dec 10;305(24):1439-44. doi: 10.1056/NEJM198112103052403. PMID: 6272110.
• Lushniak BD, Surgeon General's Perspectives. Public Health Rep. 2014 Mar-Apr; 129(2): 112–114.
• Booske BC et al, "Different Perspectives For Assigning Weights to Determinants of Health," University of Wisconsin Population Health Institute.
• Marc LG et al,HIV among Haitian-born persons in the United States, 1985–2007, AIDS. Author manuscript; available in PMC 2011 Aug 24.
• Rogers N, Race and the Politics of Polio: Warm Springs, Tuskegee, and the March of Dimes. Am J Public Health. 2007 May; 97(5): 784–795.
• Curran JW and Jaffe HW, AIDS: the Early Years and CDC's Response. MMWR.
• Olivarius Kathryn, Immunity, Capital, and Power in Antebellum New Orleans. The American Historical Review, Volume 124, Issue 2, April 2019, Pages 425–455,

In August of 1918, a horrific second wave of the Spanish Flu crashed across the world. In this episode, the third of a four-part series exploring hydroxychloroquine and COVID-19, I'll explore this single moment in time, through the mysterious origins of the Spanish Flu and historiographical controversies, scientific missions to mass burial sites in remote Alaskan villages, the ill-fated journey of the HMS Mantua, debates about how to count victims of a pandemic, and the mystery behind Pfeiffer's bacillus. Plus a new #AdamAnswers about that annoying yellow on blue powerpoint template so common in the medical field!

Sources:

1. Viboud, C. et al. Age- and Sex-Specific Mortality Associated With the 1918–1919 Influenza Pandemic in Kentucky. J Infect Dis 207, 721–729 (2013).
2. Oxford, J. S. & Gill, D. A possible European origin of the Spanish influenza and the first attempts to reduce mortality to combat superinfecting bacteria: an opinion from a virologist and a military historian. Hum Vacc Immunother 15, 2009–2012 (2019).
3. Epps, H. L. V. Influenza: exposing the true killer. J Exp Medicine 203, 803–803 (2006).
4. Patterson, S. W. & Williams, F. E. PFEIFFER'S BACILLUS AND INFLUENZA. Lancet 200, 806–807 (1922).
5. Taubenberger, J. K. & Morens, D. M. The 1918 Influenza Pandemic and Its Legacy. Csh Perspect Med a038695 (2019) doi:10.1101/cshperspect.a038695.
6. Trilla, A., Trilla, G. & Daer, C. The 1918 "Spanish Flu" in Spain. Clin Infect Dis 47, 668–673 (2008).
7. Taubenberger, J. K. The origin and virulence of the 1918 "Spanish" influenza virus. P Am Philos Soc 150, 86–112 (2006).
8. Heinz, E. The return of Pfeiffer's bacillus: Rising incidence of ampicillin resistance in Haemophilus influenzae. Microb Genom 4, (2018).
9. Barry, J. M. The site of origin of the 1918 influenza pandemic and its public health implications. J Transl Med 2, 3 (2004).
10. Johnson, N. P. A. S. & Mueller, J. Updating the Accounts: Global Mortality of the 1918-1920 "Spanish" Influenza Pandemic. B Hist Med 76, 105–115 (2002).

1. Tomkins SM, Colonial Administration in British Africa during the Influenza Epidemic of 1918-19. Canadian Journal of African Studies / Revue Canadienne des Études Africaines. Vol. 28, No. 1 (1994), pp. 60-83 (24 pages)
2. Qiang Liu et al, The cytokine storm of severe influenza and development of immunomodulatory therapy. Cell Mol Immunol. 2016 Jan; 13(1): 3–10.
3. Spreeuwenberg et al. Reassessing the Global Mortality Burden of the 1918 Influenza Pandemic.Am J Epidemiol . 2018 Dec 1;187(12):2561-2567. doi: 10.1093/aje/kwy191.
4. R. F. J. Pfeiffer: Vorläufige Mittheilungen über den Erreger der Influenza. Deutsche medicinische Wochenschrift, Berlin, 1892, 18: 28. Die Aetiologie der Influenza. Zeitschrift für Hygiene und Infektionskrankheiten, 1893, 13: 357-386.