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The ways we die (then and now)

The New England Journal of Medicine

The New England Journal of Medicine (NEJM), which celebrates its 200th anniversary this year, has just published a fascinating look at the history of disease as seen through its pages over the past two centuries.

The article’s details let us express some smug 21st-century superiority (death caused by drinking cold water — really?), but they also offer a reminder that medicine is an ever-changing science. What will 22nd-century NEJM readers think we got ridiculously (and dangerously) wrong?

The familiar and unfamiliar

Back in the early 1800s, NEJM’s papers were concerned with many illnesses and conditions that remain familiar to us today, such as angina, diarrhea, burns, diabetes, epilepsy, cancer, asthma, syphilis, gunshot wounds, spina bifida, and even a type of congenital heart defect known as tetralogy of Fallot. But other illnesses discussed in the journal back then are “unrecognizable,” as the Harvard University medical historians who wrote the current paper note:

Apoplexy, a syndrome of fainting spells that might mean stroke, seizure, or syncope today, was understood to arise from a “nervous sympathy” by which the stomach influenced the head. Doctors agree that even a near miss by a cannonball — without contact — could shatter bones, blind people, or even kill them. Reports of spontaneous combustion, especially of “brandy-drinking men and women,” received serious, if skeptical, consideration.

In the official 1811 “bill of mortality” from the “town” of Boston, teething, worms and drinking cold water were listed among the causes of death. The far and away top killer in Boston that year, however, was consumption, or tuberculosis, which is cited as causing 221 of the 942 deaths on the list.

Infectious diseases dominated

By 1912, infectious diseases — and their microbial causes — were dominating the NEJM pages. Frequent topics were tuberculosis, gonorrhea, syphilis, diphtheria, measles, pneumonia, scarlet fever and typhoid. Tropical infections brought into the country by immigrants, such as yellow fever and malaria, were also of great interest to early 20th century doctors.

Concerns were also expressed about a new health problem, “automobile knee,” and about how that new transportation device was leading to indolent — and unhealthful — habits.

Public-health improvements (things like safer sewage disposal and drinking water), as well as vaccination programs and the discovery of antibiotics, gradually led to huge reductions in the U.S. death rate from infectious diseases — and in our overall death rate as well. Today, as can be seen in the chart above, we’re much, much more likely to die from cancer and heart disease than from TB. And discussions in the NEJM of automobile knee have been replaced with papers on the causes and tragic consequences of automobile accidents.

A disturbing enthusiasm for eugenics

Unfortunately, the early 20th-century pages of the NEJM also show a disturbing enthusiasm for eugenics. Coverage in the journal of “the ‘overwhelming success’ of U.S. athletes at the [1912] Stockholm Olympics celebrated American racial vigor,” write the Harvard historians. “… [And] long-standing concern about epilepsy, alcoholism, and feeblemindedness took on new relevance in a society increasingly preoccupied by fears of race suicide and the promise of eugenics.”

Looking ahead a few decades, one 1912 NEJM editorial declared that “perhaps in 1993, when all the preventable diseases have been eradicated, when the nature and cure of cancer have been discovered, and when eugenics has superseded evolution in the elimination of the unfit [emphasis added], our successors will look back at these pages with an even greater measure of superiority.”

The persistence of health inequalities

As the Harvard historians point out, “even as prevailing diseases have changed, health disparities have endured.”

Health inequalities remain ubiquitous, not just among races and ethnic groups but also according to geography, sex, educational level, occupation, income, and other gradients of wealth and power.

The persistence of health inequalities challenges our scientific knowledge and political will. Can we explain them and alleviate them? Genetic variations don’t explain why mortality rates double as you cross Boston Harbor from Back Bay to Charlestown or walk up Fifth Avenue from midtown Manhattan into Harlem. Nor do they explain why Asian-American women in Bergen County, New Jersey, live 50% longer than Native American men in South Dakota.

Although we know something about the relationships among poverty, stress, allostatic load, and the hypothalamic-pituitary-adrenal axis, doctors and epidemiologists need more precise models that sketch in the steps between social exposure, disease, and death.

You can read the article in full on the NEJM website.

Comments (2)

  1. Submitted by Ray Schoch on 06/28/2012 - 09:38 am.

    VERY interesting

    Coming from a medically-involved family (several relatives are or were RNs and MDs), I find this really interesting stuff.

    ’Twould appear that a disproportionate number of deaths nowadays are due to living a long time, and to some degree, from living a long time in an affluent society. Long life spans – for the society as a whole, moreso than for individuals – would seem to be far more the result of public health measures, including clean water, food that meets minimum standards, and vaccination programs, than individual medical procedures. We also know far more about how injuries and diseases affect the body, and how our health is affected by both personal choices and environmental conditions around us than was the case 110 years ago.

    In short, it’s more likely that we’ll simply “wear out” in current society than be cut down by infectious disease or food poisoning or a lack of sanitation.

    • Submitted by Phil Dech on 06/28/2012 - 01:42 pm.

      Sanitation and vaccines

      indeed account for the largest share of the improvement in our lifespans over the 20th century, a point I try to bring home to the vaccine refusers in my practice.

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