The New England Journal of Medicine started in 1812 in part to bring information west from the great medical cities of the day — Berlin, London, Paris — translated and reprinted in brief, to doctors in the Boston region. Two hundred years later, Boston has taken its place among the greats. And so has the Journal, read by more than 600,000 people weekly, online or in print, with subscribers in 177 countries. It contains some of the most sought-after space for publishing new medical research. “There’s absolutely no other place that has the same impact in terms of validating the importance of what your study is and also reaching everybody on the globe,” says Dr. Daniel Haber, former genetics editor and director of the Massachusetts General Hospital Cancer Center.
The Journal has not always gotten things right, sometimes ignoring developments that would prove significant and celebrating others more than they deserved. But it has established itself as essential reading for medical professionals. The publication’s rise to dominance came after World War II. The nation invested heavily in medical education and research. Boston institutions benefited. A string of editors in the second half of the 20th century “who made good choices” about what to publish secured the Journal’s place at the top, says Dr. Jeffrey Drazen, editor since 2000. The Journal, owned by the Massachusetts Medical Society, has devoted itself both to research considered cutting edge and practical information that doctors need, Haber says. “It’s the hybrid of the ivory tower with being very, very aware of all the concerns of practicing physicians,” he adds.
The Journal is celebrating its 200th year with commemorative articles, an interactive website, and a symposium Friday exploring the evolution of medicine over two centuries. Here’s a look at how the Journal editors have shaped our understanding of disease and treatment, balancing the new with the necessary, and of what it means to be a doctor.
July 1, 1812
“BILL OF MORTALITY FOR THE TOWN OF BOSTON” (population 33,250)
Included in the Journal’s debut year — the full name was the New England Journal of Medicine and Surgery, and the Collateral Branches of Science — were a French physician’s advice for treating gunshot wounds, a weather almanac, instructions for breeding leeches, and, in this issue, an accounting of Boston’s dead. In 14 months ending December 1811, 942 people died. Consumption, or tuberculosis, caused 221 deaths. The second leading cause was “flux infantile,” what today Dr. Scott Podolsky, a Mass. General physician and director of the Countway Library Center for the History of Medicine, says may have been infection due to poor sanitation. Some causes seem nonsensical 200 years later. “Drinking cold water,” for example, was less common but still fatal, according to this record.
November 18, 1846
ETHER: “INSENSIBILITY DURING SURGICAL OPERATIONS”
Dr. William T.G. Morton, a Boston dentist, had devised a system for dulling his patients’ pain using ether vapor. With his help, Dr. John Collins Warren, a Mass. General surgeon and founder of the Journal, conducted the first successful demonstration of ether’s use in surgery on October 16, 1846, removing a tumor from the neck of a young man. The technique, wrote Warren’s colleague Dr. Henry Jacob Bigelow in this issue, “promises to be one of the important discoveries of the age.” Others had tried ether as anesthesia, but Bigelow’s article was a catalyst for its widespread acceptance. It also marked one of the first times that new medical knowledge migrated from Boston to the health care centers of Europe, Podolsky says. Today, ether is a celebrated part of Boston medical lore.
May 3, 1855
“SUCCESSFUL CASE OF EXTIRPATION OF THE UTERUS”
Large clinical trials would not become common for decades, so doctors at this time relied on reports about how individual patients fared with new treatment. Dr. Gilman Kimball of Lowell explained in the Journal — then called the Boston Medical and Surgical Journal, a name it would have for 100 years — how he removed the diseased uterus of a 34-year-old woman in one of the first successful hysterectomies. Kimball conceded that he had tried the procedure on three women. The other two had died.
December 12, 1867
SKEPTICISM FOR LISTER: “CARBOLIC ACID AND ITS COMPOUNDS IN SURGERY”
In 1867, doctors were beginning to understand infection. Dr. Joseph Lister published a series of articles in the British journal the Lancet about preventing infection by using carbolic acid to sterilize bandages and clean wounds. But some early mentions of the British surgeon’s work in the Journal were critical. Dr. J.Y. Simpson wrote in this issue that Lister’s practices “were not in any way original” and in some places had fallen out of vogue. Lister’s plight was similar to that faced by many with new ideas, the Journal’s Drazen now says: “People think you’re nuts.”
February 1, 1912
“PAST AND PRESENT METHODS IN THE PRACTICE OF MEDICINE”
Medicine advanced at a terrific speed in the 20th century. At its start, Dr. Alfred Worcester, an influential family physician from Waltham, wondered what was lost as the “healing art” became a field of diagnoses. Worcester told a story of two fictional doctors: The more experienced knows his patients well and finds time each day to visit a girl dying of consumption, comforting her family with his presence. Another, fresh from medical school, visits weekly and responds to the mother’s complaints with “another prescription.” The essay was a reminder that medicine is more than science, that it has a social context, says Dr. Jeremy Greene, a Brigham and Women’s physician who teaches the history of science at Harvard.
February 24, 1944
“PENICILLIN IN WOUNDS”
During World War II, Journal editor Dr. Robert Nayson Nye sent copies to medical officers serving in the field. “When you’re a soldier doctor, you spend hours doing nothing, and then you have moments of terror,” Drazen says now. “During those moments of terror, they had the knowledge, some of which they gleaned from the hours of boredom when they had a chance to read the Journal.” Here, next to a call for blood donors and nurses, was an article summarizing research published in the Lancet on the use of penicillin in treating wounds.
June 3, 1948
“TEMPORARY REMISSIONS IN ACUTE LEUKEMIA IN CHILDREN”
Not all of the 16 children to whom Dr. Sidney Farber gave the antifolate drug responded well. But Farber and his colleagues at the Children’s Medical Center of Boston reported on five children with acute leukemia, a mostly fatal cancer of the blood, who had gone into temporary remission after treatment. “No evidence has been mentioned in this report that would justify the suggestion of the term ‘cure’ of acute leukemia in children,” the authors cautioned. But they had laid the groundwork for developments that would change the lives of many. Today, about 90 percent of children diagnosed with acute lymphoblastic leukemia, the most common form, survive five years or more.
November 13, 1952
“RESUSCITATION OF THE HEART”
One way doctors could restart a heart that had stopped beating was to cut a person’s chest open and pump it with their hand. Dr. Paul Zoll, a cardiologist at Beth Israel Hospital, presented another option. Zoll delivered repeated electric shocks to the stopped hearts of two men using needle electrodes. One patient died. The heart of the other, after five days of shocks, resumed beating on its own. An editorial in this issue called Zoll’s results “exceedingly promising.” Three years later, according to a Globe report, more than 20 people in the Boston area had been kept alive by Zoll’s “artificial heart stimulator.” Today, pacemakers are used by millions around the world.
June 16, 1966
“ETHICS AND CLINICAL RESEARCH”
At a time when funding for medical research was growing exponentially, Mass. General anesthesiologist Dr. Henry Beecher sounded an alarm. People were being experimented on without being told of the risks and often with no benefit to themselves. Beecher outlined 22 cases, many involving children and people with disabilities. In one case, 23 “charity patients” died after treatment for typhoid fever was deliberately withheld. “There is no ethical distinction between ends and means,” Beecher wrote. Beecher’s views were denounced by researchers as obstructive to medical study. But his work helped shape federal policy requiring oversight of the use of human subjects in research.
September 19, 1969
“DEFINITION OF ‘SOLE CONTRIBUTION’ ”(The Ingelfinger Rule)
Facing competition from a new crop of medical publications circulated for free, Journal editor Dr. Franz Ingelfinger issued a warning. If work had been published elsewhere, including in the news media, it would not be published in the Journal. Commonly called the Ingelfinger rule, the policy made many researchers reluctant to talk to reporters, says Dr. Lawrence Altman, longtime medical writer at the New York Times and one of the first journalists to regularly cover the Journal. It made the Journal, which was acting in its own economic interest, arbiter of how and when to release research that often was publicly funded, he says.
November 18, 1971
“TUMOR ANGIOGENESIS: THERAPEUTIC IMPLICATIONS”
Dr. Judah Folkman, a surgeon at Children’s Hospital Medical Center of Boston, had noticed something about tumors: They were bloody. He and colleagues posited that tumors could recruit blood vessels to supply them with nutrients they needed to grow. The tumors released a protein that signaled new pathways to form from a mother vessel, they wrote in the Journal. It was a courageous paper, says Dr. Marsha Moses, now director of the vascular biology program at Boston Children’s Hospital founded by Folkman, who died in 2008. The idea “was so elegantly simple that people thought it couldn’t possibly be true,” she says. Folkman’s work launched a new field of cancer drug development and led to effective treatment of age-related macular degeneration.
October 23, 1980
“THE NEW MEDICAL-INDUSTRIAL COMPLEX”
Journal editor Dr. Arnold S. Relman had seen a dramatic shift in medical care since he became a doctor in 1946. Once supported primarily by charity, hospitals and other health care organizations increasingly were for-profit. This “new medical-industrial complex,” he wrote, was driving up health costs and overuse of services. “The private health-care industry is primarily interested in selling services that are profitable, but patients are interested only in services that they need,” he noted in a provocative essay. Asked in an interview about the state of the industry today, Relman says, “It’s worse than I thought it could be.”
December 10, 1981
“SEVERE ACQUIRED IMMUNODEFICIENCY IN MALE HOMOSEXUALS”
Six months after federal health officials published a notice about gay men diagnosed with a rare pneumonia, papers in the Journal described 19 similar cases. Though not the first to write about AIDS, the Journal provided an analysis when physicians were desperate for information. An editorial explained the stakes: “Two thirds of the patients described in this issue of the Journal have died.” The Journal later marked milestones in treatment: The drug azidothymidine prolonged the lives of people diagnosed with AIDS (1987), treatment lowered risk of transmission from mother to baby (1994), and a combination of drugs significantly slowed HIV’s progression (1997).
November 23, 2000
DIMINISHED EFFECTS OF VIOXX: “ROFECOXIB AND NAPROXEN”
Vioxx was about as effective as naproxen for alleviating pain related to rheumatoid arthritis and it caused fewer gastrointestinal problems, a study published in this issue said. The researchers, who had financial ties to drug maker Merck, did report that more people on Vioxx had a heart attack, but they explained the difference as a benefit of naproxen, not as a problem with Vioxx. Less than four years later, Merck pulled the widely used drug from the market, facing concerns about heart risks and, later, legal action. The Journal’s leaders in a December 2005 editorial blasted the researchers for withholding pertinent data. They, too, would be criticized for not more carefully scrutinizing the pharma-funded research.
February 7, 2002
“REDUCTION OF THE INCIDENCE OF TYPE 2 DIABETES”
Studies in other countries had shown that diet and weight loss counseling could prevent diabetes in people who were at risk. But a large group of researchers wanted to see how effective such lifestyle changes could be in the United States. They randomly assigned 3,234 patients to receive an anti-diabetes drug, a placebo, or ongoing one-on-one counseling. After about three years, those who received counseling were 58 percent less likely to have developed diabetes than those on the placebo. And the lifestyle changes proved more effective than the drug.
March 31, 2003
“A CLUSTER OF CASES OF SEVERE ACUTE RESPIRATORY SYNDROME”
Drazen was on the treadmill when he saw the news on TV. Health investigator Carlo Urbani had been responding to an epidemic in Vietnam when he contracted the disease himself. It was unclear how fast severe acute respiratory syndrome, or SARS, could spread. Drazen called colleagues in Canada and Hong Kong, where there were outbreaks. “Describe this for us,” he recalls telling them. The Journal published two papers online March 31, 2003, and more days later, including a tribute to Urbani, who died of the disease, and other affected health workers. In the month that followed, the SARS articles were viewed more than 700,000 times.
December 13, 2007
“THE FIRST HUMAN PARTIAL FACE TRANSPLANTATION”
French surgeons in 2005 performed the first partial face transplant on a 38-year-old woman who had lost the lower part of her face from a dog bite. Eighteen months later, the woman was “very satisfied” with the results, they reported in 2007. Last year, 25-year-old Dallas Wiens became the first person to receive a full face transplant in the United States. Lead transplant surgeon Dr. Bohdan Pomahac and his colleagues at Brigham and Women’s Hospital wrote in February in the Journal about the process they used for Wiens and two others.