“Ninety-nine, ninety-nine, niiinetee-niiine.” For centuries, English-speaking doctors the world over have been taught this magical number. Doctors learn and teach how to ask patients to repeat the number over and over and over again while feeling/listening for tactile vocal fremitus and whispered pectoriloquy. Few, however, question the reasons for 99, assuming the singsong-like nature of the phrase has some relevant sonic qualities.
Back in 1973, in an article published in the Bulletin of the New York Academy of Medicine, the physician William Dock1 protested in horror that 99 was inappropriate for physical examination. With passionate argumentation, he asserted that 99 was a too-literal translation of the German 99—neun und neunzig—that touring English doctors had observed during their travels being used on German and Austrian hospital wards. Dock showed, through elaborate testing with microphones and graph paper, how the English 99 did not create the necessary vibrations required for an appropriate physical examination.
Four decades after Dock's outcry, and despite the frenzied pace of evidence-based medicine, the “queer linguistic baggage” of 99 persists.1 In 2013, I spent 6 months observing medical students being taught the respiratory examination in medical schools in the Netherlands and Australia. I was doing anthropological fieldwork, examining the role of sound and listening in contemporary medicine as part of a larger project on sonic skills across professions, based in Maastricht, the Netherlands. The use of 99 was still prolific in Australian hospitals and medical schools, as it was during my days as a medical student. As a patient declared during a ward round I observed, “Always 99, never 100!” I have no doubt it is still used elsewhere, too, judging from the physical examination videos I have found online that recommend the technique.
In the Netherlands, where the instruction was predominantly Dutch, undergraduate students were taught a different number: 88, or achtentachtig. Some teachers I spoke with in Maastricht, however, said that the southern, softer Dutch accent didn't produce the right kind of resonance when this number was spoken, and they suggested that the students use an alternative word—Amsterdam—which produced nice, deep tones in the chest cavity.
The Dutch played with sounds to find the right word. One teacher taught his learners that it didn't actually matter which word they asked their patients to say, as long as it produced a lot of tremor. Dock also offered some alternative suggestions, such as “boogy woogy.”1
As these wonderful words demonstrate, not only do phrases need to make the right sounds, but their meaning matters as well. Which resident or student these days knows what the boogie-woogie is (let alone how to play it)? I believe we need to take more care with words in medicine,2 and here we can take inspiration from those who deal carefully with words every day: writers, especially those traveling across language differences.
The novelist, poet, and translator Lydia Davis3 describes how she would, in her translation of Marcel Proust's famously long sentences in À la recherche du temps perdu (In Search of Lost Time), attend to fidelity through reproducing, when she could, the sounds of the original. She explains why: “In translating Proust, I attended closely to just such details of sound, mainly because he himself did.” Proust was careful with language, as is Davis in her translations, and as should medical educators and doctors be, too.
Why are English-speaking medical educators still teaching the word 99, despite the microphone and graph tests, despite the evidence that shows that words such as boy and toy are better for the job? Because 99 is a habit, ingrained in the ritual of physical examination, and rituals are, as Verghese and Horwitz4 point out, very important.
But rituals can also change and adapt, as anthropologists have long shown. Educators should be encouraged to think of contemporary alternatives to the words they use when teaching the physical examination, as the Maastricht teacher did, and play with their sonic qualities. This would not only offer trainees refined skills of careful observation, of more closely attending to why techniques are used and what is happening during a physical examination, but also encourage more active engagement in their learning.
Residents and students alike could be encouraged to share their terms with each other, to debate and discuss their suggestions. For while the boogie-woogie may have been wonderful to dance to, perhaps there are other words that vibrate the alveoli and the ribs in ways that also resonate meaningfully with contemporary doctors and patients.
The ethnographic research discussed in this article was conducted as part of the “Sonic Skills: Sound and Listening in the Development of Science, Technology, Medicine (1920–now)” project funded by NWO (Dutch Research Council), from a Vici Grant (Number: 277-45-003) awarded to Karin Bijsterveld.