In honor of its 200th Anniversary, The New England Journal of Medicine has published a fascinating review of how our ideas about death, and the causes of death, have changed over the past 200 years. We no longer worry so much about dying from spontaneous combustion, or near-misses from cannonballs.
Instead, our attention has shifted to new threats, many of which have been come from changes to our lifestyle and environment.
How we die, and how we categorize the various ways we come to shuffle off this mortal coil, are very much akin to how language changes over time. As medical insight advances, so too does our ability to better describe and quantify those diseases that afflict us, and how they result in our deaths.
Back in 1812 when the NEJM published its inaugural issue, doctors had to deal with a number of health problems that we remain all too familiar with, conditions like cancer, diabetes, angina, burns, asthma, and epilepsy. At the same time, however, they also had to contend with deaths caused by such things as apoplexy (a syndrome of fainting spells), spontaneous combustion (especially of "brandy-drinking men and women"), drinking cold water (your guess is as good as mine), and near-misses from cannonballs (yes, seriously – they believed that the close contact could shatter bones and even cause blindness).
Exactly one hundred years later, NEJM celebrated the observation of the previous year which they described as "the healthiest of which there is any record." Physicians started noticing that more people were living past age 100, while lauding the success of U.S. athletes at the Stockholm Olympics – an achievement that was accounted for by "American racial vigor." Indeed, this was a time of great optimism, the dawn of modern health practices – and the rise of eugenics. Anticipating the future, one editorial speculated about what might come:
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diseases have been eradicated, when the nature and cure of cancer have been discovered, and when eugenics has superseded evolution in the elimination of the unfit, our successors will look back at these pages with an even greater measure of superiority.
At the same time, however, the medical establishment started to become increasingly concerned about changing lifestyle factors and how that was impacting on health. Take for example the rise of "automobile knee", a shorthand way of expressing their concern that cars were starting to create a largely sedentary society -– a change in routine that we are still dealing with today, in part owing to the rise of television and computer culture.
The authors of the commemorative NEJM article correctly point out that our conceptions of disease are constantly changing on account of many factors, and that it's an ever-moving, ever-evolving snapshot of a particular era's fears, vulnerabilities, and cultural values. They write,
By examining the many new diseases that have appeared over the past two centuries, historians have categorized the ways in which diseases emerge. New causes (e.g., severe acute respiratory syndrome, motor vehicle accidents, radiation poisoning), new behaviors (cigarette smoking, intravenous drug use), and even the consequences of new therapies (insulin transforming the course and manifestations of diabetes) can produce new diseases. Changing environmental and social conditions can increase the prevalence of once-obscure ailments (myocardial infarction, lung cancer, kuru, and "mad cow" disease). New diagnostic technologies and therapeutic capacity can unmask previously unrecognized conditions (hypertension). New diagnostic criteria can expand a disease's boundaries (hypercholesterolemia, depression). Changing social mores can redefine what is or is not a disease (homosexuality, alcoholism, masturbation). New diseases can emerge as the result of conscious advocacy by interested parties (chronic fatigue syndrome, sick building syndrome). HIV–AIDS alone demonstrates many of these modes of emergence. The emergence, recognition, and impact of disease are never just a bioscientific process; the advent of a new disease always involves social, economic, and political processes that shape its epidemiology and influence our understanding and response.
And they also point out that, while the nomenclature may be changing, we are in fact dying of different things and less frequently — life expectancy has dramatically increased in the past century. In 1900, people could primarily expect to die from pneumonia, influenza, tuberculosis, gastrointestinal infections, heart disease and cerebrovascular disease (strokes). Today, the leading causes of death are heart disease and cancer (by a country mile), followed by more infrequent, but persistent, diseases like noninfectious airways disease (respiratory diseases like bronchitis and emphysema), cerebrovascular disease, accidents, Alzheimer's, and diabetes. Even the ways we die by accident are changing.
Our ability to contend with infectious diseases like TB and influenza has had a profound impact on our health. But as time passes, we find ourselves exposed to new problems. Some 35.7% of Americans are obese — and the numbers keep climbing year after year. There are new chemicals in our environment, such as bisphenol A, that are causing very serious health problems. And by virtue of extending life we are uncovering age-related ailments like Alzheimer'ss. As the NEJM article suggests, moving forward, we can safely assume that these trends will continue – that diseases will come and go, only to be replaced by a litany of new ones, created by our ongoing technological achievements and ever-changing social norms.
At the same time however, the NEJM analysis shows cause for optimism. Steady advancements in the health sciences are helping physicians to better quantify and target specific ailments — a trend that will have the potential to result in ever-expanding lifespans.
You can read the entire commemorative article at The New England Journal of Medicine, and be sure to check out their amazing interactive graphs.