In his novel, Portnoy’s Complaint, the writer Philip Roth writes that words are “little gifts, containing meanings.” Rudyard Kipling said, “Words are, of course, the most powerful drug used by mankind,” and the poet Ezra Pound, “Good writers are those who keep the language efficient. That is to say, keep it accurate, keep it clear.” If our words themselves are the cellular-level building blocks of our communication, and our writing, it’s worth taking a moment for us to consider how they may be working in our clinical and other workspaces.
Consider that our photographic artist, Molly Humphreys, saw these two action verbs displayed visually during her work on the Healthcare Is Human project, and in an instant captured them in an image.
Inhale. Exhale.
Most creative writers know that a single, precise active verb does more on the page than almost any other linguistic move. And perhaps we all understand the way specific action verbs work. These words directly link us to action, the way to communicate the “doing” of our world. Without action, one might argue, how can we feel or be? In the case of “inhale” and “exhale,” we encounter one of the fundamental actions of sustaining life, a simple directive of receiving oxygen and releasing carbon dioxide. But, of course, it’s more than that.
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If narrative medicine taught us that close attention to language through literary and other texts can build skills that help us be more empathetic towards patients, perhaps the natural evolution, accelerated during the Covid-19 pandemic, is to find the language of self-compassion that, perhaps, can help stave off burnout. Because when you stop to consider the specific verbs, “inhale,” and “exhale” they are not the codified language of medicine. There is a rhythm being invoked, one both biological and emotional.
So, if medical practitioners, on any given busy day in clinic, see the simple directives, “inhale” and “exhale,” aren’t they, too, invited to and reset? In the current medical environment, one shaped increasingly by financial and business outcomes over patient health and recovery, such simply communicated directives can serve as powerful reminders of their own self-care.
In fact, we could argue that seeing a word box with the simple active verbs of breathing in a medical space can be quietly liberating. John Fox, in his book Poetic Medicine, reminds us that we “make a poem with words—but also, you build an interior place when you write, a place where your intuitive voice may awaken and thrive.” Perhaps our physical text box gives the busy, overstretched physician a micro version of what Fox maintains writing does. As well, Fox’s idea of the ways in which language shapes us is quite different than the deployment of language as diagnosis, like one might find in a medical chart. And as we consider the single words, “inhale” and “exhale,” we are invited to see them as the foundation of other metaphors of breathing we encounter both inside and outside clinic. Medical practitioners toggle between these two worlds, two ways of meaning making, every time they work with patients, and it is worth parsing through that language to better examine the experiences of both practitioners and those in their care.
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“Take a few deep breaths” is an instruction that countless patients have received in exam rooms and hospital beds, so routine that they may have never contemplated it. Doctors make this request and then wait for the contraction that pulls the diaphragm towards the center of the earth, the one that decreases the intrathoracic pressure and, in doing so, pulls a draft through the nostrils, down the trachea, and into the depths of the lungs. The working unit of the lung is a tiny space called an “alveolus,” a word derived from the Latin “alveus” meaning “basin” or “trough,” and “aulos,” Greek for flute. This is the final destination for the inhaled breath, into tiny clusters—“alveoli” in the plural—that resemble popcorn.
Patients describe “air” as what they breathe, but “atmosphere” is a more apt description of the complex substance entering the body, one that includes humidity, pollen, Canadian wildfire smoke, whiffs of perfume, body odor, and dust. Doctors watch the chest rise and fall, an arc sometimes called “excursion,” which, in labored breathing, involves “flaring” of the nostrils and “tugging” of the trachea, easily seen above the suprasternal notch. In much this same way, nailbeds are examined for signs of cyanosis or clubbing, and extremities are inspected for edema. This sequence is described as “listening,” but is, in fact, a seamless quartet of look-listen-think-feel, disparate skills blended in harmony, so quiet they are not noticed.
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What would happen if we applied that same quartet of look-listen-think-feel to the simple directives of our Inhale/Exhale picture? When we start to see that the language we use in clinic isn’t so different than the language we rely on outside of it, perhaps the malleable magic of our words begins to reveal itself to us. Speaking to this idea in her book The Faith of A Writer,” Joyce Carol Oates tell us that writers use their individual voices to try to speak to others who know nothing of them. We can make a case that this is true of medical practitioners working with large caseloads of patients, and when we look to health humanities practices like narrative medicine, we find common ground between the writing desk and the medical clinic. “The individual voice is the communal voice,” Oates writes, and if we accept this as both true of art and of medicine, language itself unfurls in many unexpected directions. We take pleasure in the contours and edges of words, and our ways of communicating with others, as well as those conversations we have with our deep interior selves, deepen.
Perhaps the discussion naturally comes back to words about breath. It is not only the raw material of our speech, but breath also invites rich and varied words to depict it. “Crackles,” “wheezing,” and “ronchi” are a few of the colorful terms that are used to describe abnormal breath sounds, the last derived from “rhenchein,” from the Greek “to snore,” a term that first appeared in medical English in 1827. Each of these sounds is heard through a stethoscope, developed in 1816 by Rene Laennec, who rolled paper into a tube and placed his ear at one end, creating an analog instrument still in use today. Laennec’s mother had died of TB and his hobby was carving wooden flutes by hand, factors that make him particular sensitive to the properties of sound.
To the trained ear, all manners of turbulence, stasis, and abnormalities can be heard within the solid, liquid, and gaseous elements that are “auscultated,” a term created from “auris” – the ear—and a suffix indicating action. While being examined, patients often stare across the room where they may focus on hospital ephemera, or not. Sicker patients, many of them on “supplemental” oxygen, can sometimes be seen gazing at a indistinct point. Is it a meaningful moment from the past, or is it a looming point of the horizon?
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Maybe those same patients see Inhale/Exhale. A patient’s lens on those two action verbs will be quite different than the lens of our photographer or the lens of the attending physician. All sets of eyes take in the same woodblock with painted letters, and yet the meanings shift and move. If we understand this shape-shifting quality of language, we can better parse the experiences of others, even the extraordinary ordinary act of breath itself, and how it, too, communicates.
As breathing gets more difficult, patients may involuntarily engage in “pursed-lip breathing,” an action that creates a backpressure, one that keeps weakened or damaged airways from collapsing on themselves. And if the ultimate extremis, “air hunger,” develops—as visceral in real life as it appears printed on the page—can produce a “last gasp,” a metaphor out in the world but one that is a different reality within the walls of the hospital.
Or is it so different? The poet and novelist Sylvia Plath wrote, “I took a deep breath and listened to the old brag of my heart. I am, I am, I am.” These words, from Plath’s The Bell Jar, come from her protagonist, Esther, as she both attends a funeral and reflects on her struggles with mental illness. We read them not as last gasps, which the stifling bell jar—a type of “air hunger”—represents, but as both breath and heartbeat our means of vital endurance. Throughout the novel, Plath uses breath to explore the boundaries between being trapped and being free. Her words imitate the directive in Inhale/Exhale, using their incantatory properties to exercise control. A tether, the words are a minimalist reminder of our most resilient selves.
Inhale. Exhale. Two simple directives become something remarkably complex inside a medical space: physiology, rhythm, self-compassion, illness, attention and the quiet reminder that we are still here.
