Show Notes
The southern United States was hit by a dramatic epidemic of a mysterious disease called pellagra in the early twentieth century. This episode discusses the cultural and scientific sources of the outbreak -- from the cotton fields of the south, to the cow pastures of rural Germany, to the river basins of Uganda -- and the incredible lengths a young doctor named Joseph Goldberger went through to try and put an end to this plague. Plus, a new #AdamAnswers about the source of the name "internal medicine." All this and more on episode 36 of Bedside Rounds, a tiny podcast about fascinating stories in clinical medicine!
Bean WB, "Origin of the Term Internal Medicine," N Engl J Med 1982; 306:182-183 Blevins SM and Bronze MS, Robert Koch and the 'golden age' of bacteriology, Int J of Inf Dis, Vol 14, #9, Sep 2010. Bloomfield AL, "The origin of the term 'internal medicine," JAMA, April 4, 1959. Bressani R et al, Corn Nutrient Losses, Chemical Changes in Corn during Preparation of Tortillas, J Agr and Food Chem, 6, 10, 770-774. Brim CJ. Job's Illness: Pellagra. Archives of Dermatology and Syphilology. 1942;45:371-6. Carpenter KJ, The relationship of pellagra to corn and the low availability of niacin in cereals, Experientia Suppl. 1983;44:197-222. Clay K et al, Rise and Fall of Pellagra in the American South. Elmore JG and Feinstein AR, Joseph Goldberger: An Unsung Hero of American Clinical Epidemiology, Ann Intern Med. 1994;121:372-375. Goldberger J. The transmissibility of pellagra: Experimental attempts at transmission to human subjects. Public Health Rep. 1916;31:3159–73 Goldberger J. Public Health Reports, June 26, 1914. The etiology of pellagra. The significance of certain epidemiological observations with respect thereto. Public Health Rep. 1914;29(26):1683–1686. Goldberger J, Wheeler GA, Sydenstricker E. A study of the relation of diet to pellagra incidence in seven textile-mill communities of South Carolina in 1916. Public Health Rep. 1920;35(12):648–713. Goldberger J, Waring CH, Willets DG, et al. The Treatment and Prevention of Pellagra. Washington, DC: Government Printing Office; 1914. Goldberger J, Wheeler GA. Experimental pellagra in the human subject brought about by a restricted diet. Public Health Rep. 1915;30(46):3336–3339. Harris HF: Ankylostomiasis in an individual presenting all of the typical symptoms of pellagra. Am Med 1902; 4:99-100, retrieved from: https://babel.hathitrust.org/cgi/pt?id=uc1.c3312358;view=1up;seq=107;size=125 Lavinder CH, Pellagra, The American Journal of Nursing, Vol. 13, No. 10 (Jul., 1913), pp. 746-754. MacNeal WJ, The Alleged Production of Pellagra by an Unbalanced Diet, JAMA. 1916;LXVI(13):975-977. Middleton J, Pellagra and the blues song 'Cornbread, meat and black molasses'. J R Soc Med. 2008 Nov 1; 101(11): 569–570. Mooney et al, The Thompson-McFadden Commission and Joseph Goldberger: Contrasting 2 Historical Investigations of Pellagra in Cotton Mill Villages in South Carolina. Am J Epidemiol. 2014 Aug 1; 180(3): 235–244. Morabia A (2006). Joseph Goldberger's research on the prevention of pellagra. JLL Bulletin: Commentaries on the history of treatment evaluation. Niles GM. Pellagraphobia: A word of caution. JAMA. 1912;58:1341. Roberts CS, Goldberger and the Mal de la Rosa, Clinical Methods: The History, Physical, and Laboratory Examinations. 3rd edition. Roberts SR, SAMBON'S NEW THEORY OF PELLAGRA AND ITS APPLICATION TO CONDITIONS IN GEORGIA, JAMA. 1911;LVI(23):1713-1715. Searcy GH: An epidemic of acute pellagra. Transactions of the Medical Association of Alabama, 1907, pp 387-393 Wacher, C. (2003). Nixtamalization, a Mesoamerican technology to process maize at small-scale with great potential for improving the nutritional quality of maize based foods.
More from Bedside Rounds
What does it mean when a computer can make better medical decisions than a human? The progress in large language models, and in particular the popularity of ChatGPT, has brought these questions to the forefront in 2023, but we've been discussing this for over 50 years. In this episode, Dr. Shani Herzig and I are going all the way back to the early 1970s with the invention of AAPHELP, the first real clinical decision support system, and the first time doctors had to contemplate working with – or competing against – computer systems.
What happens when a patient far from surgical care – say, at the bottom of the Pacific ocean on a submarine, or at a research base in Antarctica in the middle of the winter – develops a surgical abdomen? This dilemma was the impetus to build the first truly effective clinical decision support system – and to grapple with what it means when a computer can make better medical decisions than a doctor. In this episode, part one of three, we discuss the dramatic stories of appendectomies at Novolazarevskaya and aboard the submarine Seadragon. Also, there's a brand new #AdamAnswers about the origin of the word "scut."
American doctors spend the majority of their time during the day on the computer, either writing or reading notes about their patients; only a small fraction is spent with the human beings in their care. Technology itself – especially the electronic medical record – has often been blamed for this. But in this episode – a recorded grand rounds that I gave at the San Francisco VA in 2022 – I argue that this alienation has its roots in the way we've decided to organize clinical data, and the assumptions that we've made about the nature of medical care. In particular, I'm going to discuss one of the most influential medical thinkers of the second half of the 20th century, Larry Weed, his invention of the problem-oriented medical record and the SOAP note, and how his insight – that medical documentation fundamentally influences how we think about our patients – changed the way we think about our patients.
In the past episode, cultural and medical historians Lakshmi Krishnan and Mike Neuss discussed the history of the actual work of the doctor – Holmesian detective, data entry clerk, or something else altogether. In this episode, we conclude our discussion by talking about what type of metaphors are best suited for clinical work. Plus a brand new #AdamAnswers about the reason that American doctors are so obsessed with using, well, the # symbol in our notes.
What do doctors actually do? Are they Sherlockian detectives, hunting down obscure clues to solve intractable cases? Are they virtuosic experts, training for half a lifetime to bring the latest science to bear to cure disease? Or are they clerks, whose main job is to collect and enter data into the electronic health record? In this episode, Adam is joined by medical and cultural historians Lakshmi Krishnan and Mike Neuss to discuss the stories we tell about our own work – and how this often conflicts with the realities of clinical practice.