Episode 4: Happy Birthday

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In Episode 4, I wish a hearty 202nd birthday to the New England Journal of Medicine, and look at how much things have changed over the centuries by looking at the 1912 and 1812 editions. #spoileralert: the answer is a LOT.

1812 was a big year. Napoleon propelled the metric system across Europe. He also invaded Russia. It didn’t go well. Louisiana became a state, while the US declared war on the United Kingdom. That also didn’t go well. And in Boston, two physicians published the first issue of New England’s first medical journal, The New England Journal of Medicine and Surgery and the Collateral Branches of Medical Science. Two hundred years later, this eminent medical journal, now with a much shorter name, is one of the world’ preeminent sources for breakthroughs in medical science. For me, it’s mostly a source of guilt as little towers of journals build up on my coffee table, frustrating my wife and reminding me how much I procrastinate.

The New England Journal had its bicentennial a couple years ago, and included a fascinating review article called the Burden of Disease and the Changing Task of Medicine, which looked at journals throughout 1812 and 1912, compared with 2012. As I was not podcasting then (nor did I have a subscription), this this podcast will serve as something as a belated birthday to the New England Medical Journal.

Flipping – or rather scrolling, since the NEJM has all its early issues in PDF form for free – through these early articles in a fascinating experience. Some could describe any patient walking into my clinic. Starting on page 1 of volume 1, number 1 is a review on angina pectoris, the chest pain caused by blocked coronary arteries, and describes the disease essentially as I would: “a diminished action of the heart, the effect of bodily motion, chiefly walking, preceded by a stricture and remarkable pain in the breast,” and that “the disease itself is excited more especially upon walking up hill – and that on, stopping the distress immediately abates.” The cause is attributed to “ossification” of the coronary arteries. The treatment described is not even that foreign to modern medicine – opium tincture. Other articles in these early issues examined gunshot wounds, diabetes, epilepsy, cancer, osteomyelitis or bone infections rabies, and even the tetralogy of Fallot, a congenital heart defect.

And then there’s disease syndromes that are unrecognizable. An article entitled “Wind of Cannon Balls” in the first issue describes a syndrome in which a cannon ball passes near a person (mind you, not hitting them, which is very well-documented, even today) which produces the “tearing of epaulets and buttons from the clothes, producing extensive lividity of that part of the body near which the ball has passed, causing a sudden or gradual blindness, fracturing the bones to a thousand pieces without tearing the skin.” A few pages later, there’s also a report of spontaneous combustion especially of “brandy-drinking men and women,” as part of a review of burn injuries, with graphic descriptions of gruesome experiments on rabbits.

Maybe most interestingly, the first edition has a list of the causes of death for the “town” of Boston in 1811 (with a population of ~30,00 was very much still a town). By far and away, consumption, or tuberculosis, is the number 1 killer, followed by the infantile flux, and pulmonic fever. This list also includes “white swelling”, apparently a chronic swelling of the knee, quinsy, a great name for tonsillar abscesses, worms (ew), “cramp in the stomach”, and of course, intemperance, which claimed two lives that year.

In 1912, the New England Journal (then called the Boston Medical Journal, and a daily broadsheet instead of the magazine it is is today) threw itself a centennial birthday full of unbridled optimism, with paeans to American success at the 1912 Stockholm Olympics, marveling over the dramatic drop in death rates in major cities with the advent of modern sanitation, and increasing prevalence of centenarians. It even gently made fun of the same article I did above, of Boston’s death rates in 1811.

They conclude, and I quote:

“Verily, the medicine of even three generations ago, though quite as full of serious purpose as that of to-day was not yet out of its swaddling clothes. Perhaps in 1993, when all the preventable disease 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, our successors will look back at these pages with an even greater measure of superiority. It is thus that the history of human progress has still been written.”

As a physician practicing a century later, this confidence seems, at the very least, misplaced. Mind you, the last 100 years have introduced antibiotics, open heart surgery, CT scanners and MRI machines, chemotherapy, monoclonal antibodies, solid organ transplants, and the elimination of smallpox. I can’t imagine how it felt for one of Dr. Debakey’s residents in the 50s to perform the first angioplasties, mechanically bypassing the heart. Or how Farber must have felt when he watched leukemia melt away before his eyes. But infectious diseases are far from cured – the Spanish flu epidemic just 6 years after those laudatory words were published killed 3-5% of the world’s population, not mention the HIV/AIDS epidemic which still burns today. Even now, we are just beginning to unravel the molecular nature of cancer – see imatinib, which targets a fusion tyrosine kinase only present in cancer cells in CML. And despite new therapies for cancer (including a number of cures), the death rates for cancer continued to climb throughout the 20th century and have just recently started to decline for men.

And the burden of disease has continued to shift. A 1912 article entitled “the automobile knee” describes a syndrome which has become commonplace today: “Anyone who has watched the physical characteristics of the urban population of our large cities cannot fail to have noticed a decrease in the number of thin people … this is particularly noticeable in women of easy circumstances.” The article goes on the describe the knee pain seen with obesity today,. “The treatment of this condition needs little comment,” the author says, and prescribes gradual strengthening. Well, that’s author’s fears have come to pass, and much of the world now suffers from an obesity epidemic. Heart disease and cancer make up almost 2/3s of our deaths. In 1912, it was pneumonia or influenza, tuberculosis, and GI infections. And I’m not going to even start with where our nation’s experiments with eugenics left us, except to say we certainly haven’t superseded evolution.

In contrast to the Journal’s sanguine centennial, the 2012 is far more guarded. It points out that many of the health achievements we physicians like to brag about, such as the development of antibiotics, are more likely due to increases in standards of living, especially diet. Staggering health disparities remain in the world and in our country – does the ability to use extra-corporeal membranous oxygenation (ECMO) to breath for someone with respiratory failure really matter in the grand scheme of things when some populations in America live twice as long as others? Not to mention how quaint it was that the 1812 edition was worried about cannonball injuries – now the medical system has to cope with climate change, environmental pollution, and thermonuclear war. 21st century NEJMs – and I vouch for this as a proud owner of many partially-read stacks of the NEJM – frequently focus of health systems, quality improvement, and population health.

The 2012 article concludes, “In many respect, our medical systems are best suited to disease of the past, not those of the present or future…. Diseases can never be reduced to molecular pathways, mere technical problems requiring treatments or cures. Disease is a complex domain of human experience, involving explanation, expectation and meaning. Doctors must acknowledge this complexity and formulate theories, practices, and systems that fully address the breadth and subtly of disease.”

I’d love if the New England Journal’s 200th birthday was more of what it’s 100th birthday predicted – cancer defeated, infectious disease a thing of that past, “preventable” diseases like heart disease and stroke tamed, leading to a race of transhuman ubermensch who have superseded evolution itself. But that is, and always has been a fantasy. Quite frankly, I’m glad we live in a world where we as physicians recognize our limits, and what work has to be done. So with that, happy 200th birthday – or, I guess 202nd birthday, since I’m fashionably late – New England Journal of Medicine. Hopefully by your 300th anniversary edition we’ll have more to be proud about.

As always, thanks for listening. This will be the last episode before our official launch, so start getting excited!

If you want to read more about the topics in today’s episode, I recommend “The Burden of Disease and the Changing Task of Medicine,” by Dr.s Jones, Podolsky, and Greene published in the New England Journal of Medicine in 2012. This free article lists at its end many of the articles I’ve read from in this podcast. I highly recommend scrolling through them for a bit.


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