The New and Old Diseases
A Study of Mortality Trends in the United States, 1900-1969
Ward Burdick Award Address
T H O M A S M. P E E R Y ,
M.D.
Department of Pathology, The George Washington University School of Medicine and Health Sciences,
2300 Eye St., N.W., Washington, D.C. 20037
O N E O F T H E MAJOR F U N C T I O N S of
the
pathologist, although seldom so stated, is
the recognition and characterization of
new diseases as they appear. We are in a
better position to do this than are most
other physicians, for several reasons: we
are seldom involved as directly as they in
the personal and emotional problems of
the patient and his family; our methods of
study, covering the whole range of the
clinical and anatomical laboratories, tend
to make us more objective in our judgments; we maintain diagnostic files,
specimens, photographs and slides, and
thus are able to review these materials
whenever necessary to compare the basic
features of old and current cases.
Perhaps I should define the terms "new
diseases" and "old diseases" as used in this
connection. I would classify as a "new
disease" one that was formerly either
unknown or rare but became common,
was formerly mild but became severe, or
one that developed important new features. Similarly, I would define an "old (or
disappearing) disease" as one that was
formerly common but became rare, or
was formerly severe but became mild.
That there are new and old diseases in
this sense is apparent to any physician
Presented on October 8, 1974 at the Fall Meeting
of the American Society of Clinical Pathologists in
Washington, D.C.
Address reprint requests to Dr. Peery, Professor
Emeritus of Pathology.
Key words: Ward Burdick Award; Mortality
trends; New diseases; Old diseases.
453
whose experience spans several decades,
or who takes the time to read old
textbooks or old mortality tables.
In the study that follows, stressing the
special importance of the new diseases, I
shall depend primarily upon mortality
data derived from official tabulations of
vital statistics', but shall check the figures
from time to time against my own autopsy
experience, which extends over a period
of forty years.
Introduction to Mortality Statistics as
a Method of Study of Disease*
From 1850 to 1900, the U.S. census
taker, on the occasion of his decennial
visit, would query the head of each
household about births and deaths that
might have occurred during the tenth
year, and would record deaths by approximate cause, age and sex. These data have
been compiled and published, and give
the only official U.S. mortality statistics
prior to 1900. Dr. Paul Steiner, 34 formerly
Professor of Pathology at the University
of Chicago, is studying these older data as
part of his broad inquiry into the history
of diseases. On his advice, data from these
early records are not included in this
study.
The annual compilation of mortality
statistics in their present form began in
* The author is deeply indebted to Ms. Joan
Klebba, of the National Center for Health Statistics,
for her guidance and direction in the field of
mortality statistics.
454
PEERY
this country with the year 1900,10 and
covered deaths in ten states, the District of
Columbia, and a number of individual
cities. Subsequently, as the various states
adopted conforming practices for registering deaths, they were admitted to the
U.S. Death Registration System. By 1933
all 48 states were included; Alaska and
Hawaii were added when they became
states.
A.J.C.P.—Vol.
63
in the population, than it was in 1900. To
eliminate this source of differences between years, the "age-adjusted death rate"
has been devised by the National Center
for Health Statistics; this rate, for a given
year, is an abstract rate that would exist if
the population had a constant age distribution from year to year. I would have
liked to have used age-adjusted death
rates for the present study, but unfortunately they have not been calculated for
all causes of death for each year since
1900. Therefore, for most purposes, I
have used deaths per 100,000 population,
without adjustment, in this report.
Official United States mortality statistics
since 1900 are the final product derived
from the analysis and compilation of all
the death certificates—currently nearly
two million each year—completed in the
U.S. Registration System and filed as
There are other variables from year to
required by law. The data are sorted and year that are difficult, sometimes impossiclassified at the National Center for ble, to correct. For example, the InternaHealth Statistics of the United States tional Classification of Diseases, hereinafPublic Health Service, under procedures ter called simply "The Classification," has
established by that agency. Causes of undergone eight revisions since it was first
death recorded on the death certificate, issued, in an attempt to keep the code in
usually by the attending physician in the step with medical knowledge. New terms
case, are translated into a uniform lan- are introduced with each revision, often
guage according to the "International simply substituted for other terms in the
Statistical Classification of Diseases, In- previous revision, sometimes splitting off
juries and Causes of Death," published by a subdivision from a major heading in the
the World Health Organization. Monthly, old listing. Thus, coronary artery disease
annual and special statistical reports show- is first listed in the fourth revision of The
ing numbers of deaths by causes, geo- Classification, issued in 1930, being degraphic regions, age, sex, race and marital rived from a broad category, "organic
status are derived from these records. By heart disease," used in the third revision.
correlating the number of deaths in each Snakebite is first listed in 1921, perhaps
category with the corresponding popula- because of an anticipated rise in fatalities
tion at risk, all sorts of rates and ratios are from snakebite following the adoption of
derived, such as "crude death rate," "age- the 18th Amendment to the Constitution.
specific death rate" and "age-adjusted
Variations in death rates for a given
death rate," to name but a few.
disease from year to year, as recorded in
In order to compare death rates by statistical tables, may thus result from an
cause from year to year, and from one actual variation in deaths from that dispart of the country to another, one would ease, or they may result from some arlike to use figures that correct for differ- tifact. An actual variation may be due to
ences in the base population. It is obvious, factors that modify the frequency of occurfor example, that the crude death rate rence of the disease (as change in climate,
from cerebral hemorrhage, i.e., the rate environment, housing, nutrition, prevenper 1,000 or per 100,000 population in a tive measures) or factors that modify the
given year, would be much higher in fatality rate of the disease (as virulence of
1960, when there were more old people infective agents, fitness of affected indi-
April J 975
WARD BURDICK AWARD ADDRESS
T H O M A S M. P E E R Y ,
455
M.D.
Recipient of Ward Burdick Award, 1974, American Society
of Clinical Pathologists
viduals, favorable or unfavorable response to therapy). Among the artifacts
that may cause false variations in the
recorded death rate from a disease are: (1)
state of medical knowledge, availability of
diagnostic tests, etc.; (2) changes in medical terminology; (3) changes in the format
of death certificates; (4) changes in coding
regulations; (5) revisions in the International Classification of Diseases; (6)
changes in the character of the population
in the death registration area, or in the
geographic outlines of the area.
The first revision of The Classification
utilized 179 causes of death (code numbers), grouped under 14 major headings.
The current (eighth) revision, made effective in 1968, utilizes nearly a thousand
causes of death, grouped under 17 major
headings. Some of these headings corre-
due
due
due
due
due
due
to
to
to
to
to
to
infections
degenerative diseases
neoplasms
accidents, poisonings and violence
other diseases
unknown diseases and ill-defined conditions
T O T A L S , I - V I as regrouped
Deaths
Deaths
Deaths
Deaths
Deaths
Deaths
1,298.9
493.8
396.0
88.4
87.9
213.4
17.5
1,297.0
1,468.0
589.4
426.3
81.5
104.3
244.5
22.0
1,468.0
785.1
439.7
69.7
88.2
261.0
67.4
1,711.1
1920
1,719.1
1910
285.6
436.2
105.6
106.1
177.3
20.5
1,131.3
1,132.1
1930
963.8
82.0
533.3
139.8
77.0
115.4
11.2
958.7
181.5
499.5
129.5
94.4
147.5
16.0
1,068.4
1950
1,076.4
1940
63.4
550.5
149.2
67.5
110.8
9.9
951.3
954.7
1960
I.
Infections
A. Intestinal infections
B. Meningitis (nontuberculous)
C. Measles
D. Diphtheria and croup
E. Influenza, acute bronchitis, pneumonia
F. Tuberculosis (all forms)
G. Other
785.1
194.9
40.6
13.3
40.3
228.4
195.1
72.5
1900
1920
493.8
78.8
6.0
8.8
15.3
215.1
113.1
56.7
1910
589.4
154.8
13.8
12.4
21.1
169.8
153.8
63.7
285.6
48.8
6.2
3.2
4.9
103.9
71.1
47.4
1930
1950
82.0
7.8
1.8
0.3
0.3
33.0
22.5
16.3
1940
181.5
23.2
2.2
0.5
1.1
71.2
45.9
37.4
Table 2. Death Rates, United States, 1900-1969, by Major And Secondary Categories of Causes
(Death Registration States, 1900-1930; U.S. as a whole, 1940-1969.) (Rates per
100,000 Population. Causes of Death Grouped in Major and Secondary
Categories According to the Author's Schema. Table 65 in
PHS Publication No. 1677 is the Source Document.)
63.4
5.4
1.7
0.2
0.0
39.0
6.1
11.0
1960
* Rates per 100,000 population.
t Causes of death, as shown in Table 65, "Vital Statistics Rates in the U.S., 1940-1960, PHS Publication No. 1677 and in Table 1-23 "Deaths and Death Rates for Each Cause, U.S. 1969"
have been re-grouped by the author into broad categories according to a "schema" devised for this purpose, to be published separately.
I.
II.
III.
IV.
V.
VI.
All Causes (as shown in Table 65, "Vital Statistics Rates in the
U.S., 1940-1960," PHS Publication No. 1677)
1900
Table 1. Death Rates,* United States, 1900-1969, by Major Categories! of Causes
(Death Registration States, 1900-1930; U.S. as a Whole, 1940-1969)
51.5
2.6
1.3
0.0
0.0
35.4
2.8
9.4
1969
51.5
551.6
162.1
78.8
95.4
12.2
951.6
951.9
1969
o
^
n
m
"0
pn
4^
0)
VI.
V.
IV.
III.
II.
Degenerative diseases
A. Vascular disease of CNS
B. Other chronic CNS diseases; senility
C. Chronic diseases of heart and blood vessels; hypertension
D. Chronic diseases of lungs and bronchi
E. Cirrhosis of liver
F. Chronic renal disease
G. Chronic diseases of bones and joints
Neoplasms: all forms
A. Malignant, digestive tract
B. Malignant, respiratory tract
C. Malignant, breast
D. Malignant, female genital
E. Malignant, male genital
F. Malignant, lymphatic and hematopoietic systems
G. Other neoplasms, benign and malignant
Accidents, poisonings and violence (all causes)
A. Ground transport accidents
B. Water transport accidents
C. Air and space transport accidents
D Accidental falls
E. Accidents caused by fire
F. Accidental poisonings
G. Surgical and medical misadventures
H. Suicide
I. Homicide
J. Other accidental deaths
Other diseases (all causes)
A. Endocrine, nutritional and metabolic
B. Diseases of the various organ systems other than infections,
degenerative, neoplastic and external traumatic
C. Mental disorders (other than senile) (includes alcoholism
and drug addiction when noted)
D. Maternal complications of pregnancy, childbirth and
puerperium
E. Congenital anomalies
F. Certain causes of mortality in early infancy
Unknown diseases and ill-defined conditions
39.0
3.1
0.5
8.4
21.4
12.2
37.8
2.3
0.9
12.2
37.4
9.9
38.9
56.3
67.8
—
15.6
8.8
20.6
177.3
31.1
11.8
8.7
6.6
2.5
2.0
12.2
40.5
11.2
1.9
6.7
10.0
39.2
16.0
4.9
12.7
11.2
49.6
20.5
—
10.2
6.8
22.1
213.4
24.4
82.6
2.8
19.0
15.2
69.4
17.5
—
15.3
4.6
31.9
244.5
20.8
111.1
8.9
15.3
15.2
73.2
22.0
2.0
20.8
87.9
21.7
1.8
17.9
104.3
23.4
15.6
8.7
4.8
—
—
—
—
7.6
12.2
7.1
11.0
—
—
—
—
1 551.6
102.6
4.6
406.4
16.7
14.8
4.2
2.3
162.1
50.2
32.7
14.4
11.3.
8.8
16.2
28.5
78.8
28.2
0.9
0.9
8.9
3.5
2.2
1.3
11.1
7.5
14.3
95.4
23.0
550.5
108.0
6.8
405.6
10.0
11.3
7.2
1.6
149.2
54.2
22.2
13.4
13.0
8.6
14.3
26.3
67.5
22.0
0.8
0.8
10.6
4.3
1.6
0.6
10.6
4.5
11.7
110.8
20.2
533.3
104.0
9.9
386.2
5.0
9.2
17.4
1.6
139.8
57.6
14.1
12.6
14.9
8.1
11.1
25.0
77.0
24.9
1.0
1.0
13.8
4.3
2.3
0.4
11.4
5.0
12.9
115.4
19.3
499.5
90.9
12.5
302.8
3.9
8.6
79.0
1.8
129.5
59.1
7.2
11.8
16.0
7.5
4.3
23.5
94.4
29.1
0.8
0.4
17.3
5.7
2.8
0
14.4
6.2
17.7
147.5
33.4
436.2
89.1
17.0
230.0
4.4
7.2
86.7
1.8
105.6
52.8
3.2
9.2
13.8
4.3
3.4
19.3
106.1
31.6
0.6
0.5
16.9
7.2
4.3
396.0
88.4
23.8
182.0
8.1
7.1
82.4
4.2
88.4
45.8
426.3
92.1
37.0
182.8
12.9
13.3
84.6
3.6
81.5
43.7
458
A.J.C.P.—Vol.
PEERY
63
1600
1400-
1200
1000
FiG. 1. Diagrammatic representation of death rates from all causes,
U.S.,
1900-1969,
by
major
categories as indicated. Compiled
from Table 1.
800
600
400
200-
1900
1910
1920
1930
1940
1960
spond to etiology (as I. Infective and Parasitic Diseases 000-136), others correspond
to topography (as VII. Diseases of the
Circulatory System 390-458), and still
others overlap etiology and topography
(as XI. Complications of Pregnancy,
Childbirth and Puerperium 630-678).
Some causes of death are grouped under
one heading in an early revision of The
Classification and under another in a later
one. Other inconsistencies in The Classification are readily apparent, making it
difficult to follow through its various
revisions.
In order to compare the death rates for
the entire period since 1900, corresponding to eight revisions of The Classification, I have, with some trepidation, simplified T h e Classification by reducing the
number of major categories to six and
subdividing each of these into secondary
categories. Using this "schema," which will
1969
be published in detail elsewhere, I have
regrouped all of the entries used in the
various revisions of The Classification.
Table 1 shows the six major categories
of my schema, with death rates per 100,000
population assigned to each, for every
tenth year, 1900 to 1969. (Final data for
1970 were not available in the spring of
1974 when this study was undertaken.)
Table 2 provides a further breakdown of
the six major categories of Table 1 into
secondary categories. All figures are derived from data published by the National
Center for Health Statistics.11
Death Rates from AH Causes
Figure 1 provides a graphic presentation of the data in Table 1, giving deaths
from all causes grouped under my six
major categories, for each tenth year,
1900 to 1969.
April 1975
459
WARD BURDICK AWARD ADDRESS
FIG. 2. Death rates for infections,
U.S., 1900-1969, by major types,
compiled from Table 2.
1900
1910
1920
1930
1940
1960
1960
1969
In Figure 1 and in Table 1 you can see death rates for each of the six major
that the death rate for all causes com- categories of causes of death.
bined was slightly more than 1,700 per
100,000 population in 1900, and that the
/. Infections
death rate decreased to about 950/100,000
in 1969, in spite of some aging of the
In Figure 2 the major category, "infecpopulation. Note that the curve denoting tions" is subdivided graphically into its
death rates for all causes, i.e., the top line secondary headings; this figure and the
of the graph, is steep at the beginning of corresponding figures that follow are
the period covered, but that it flattens out based upon Table 2. T h e remarkable
beginning about 1950: the increase in the overall decline in deaths from infections is
death rates for degenerative diseases and very evident. Note that the decline was
neoplasms cancels out the decrease in the particularly sharp prior to 1930, and
death rates for infections and for other recall that sulfanilamide was introduced
diseases. We will have more to say later into the United States in the late 1930's,
about the flattening of this curve since penicillin in the early 1940's. Hence an1950.
tibiotic agents should not be given credit
Note that the overall death rate for for the decrease in the death rate for
accidents, when compared with the infections from 800 per 100,000 popula"natural" causes of death, is relatively tion to 300, as shown for 1900-1930. One
small and decreasing, in spite of the must conclude that other factors, probaadvent of the motor car and the airplane bly improved nutrition, better housing,
better water supplies and sanitation, and
during this period.
Let us now examine in more detail the p e r h a p s b e t t e r climatic conditions,
460
A.J.C.P.—Vol.
PEERY
63
200
FIG. 3. Death rates for tuberculosis, all forms, U.S., 1900-1969.
I960
brought about the reduction in the incidence of these diseases. Reduction in
incidence of a disease seems to cause a
greater decrease in the death rate than
reduction in the case fatality rate as a result
of new and more effective therapeutic
agents.
Death rates for intestinal infections, a
great killer of infants in the earlier decades of this century, show a great reduction, and the death rates for diphtheria,
measles, and meningitis have become insignificant; these can be grouped under
the "old or d i s a p p e a r i n g diseases."
Another disappearing infection, gas gangrene, is not shown in this graph, since
most of the deaths from that disease were
war casualties that occurred outside the
U.S., and they are not included in these
figures.
1969
No "new diseases" are shown among
the infections, a l t h o u g h i n f l u e n z a pneumonia might deserve such a rating if
the peak year of its incidence were shown.
The slight rise in the death rate for
influenza shown in the graph for the year
1920 represents the tail end of the great
epidemic of 1918 (not shown in the
graph), during which year the death rate
for this one cause was 588 per 100,000
population.
The decline in the death rate for tuberculosis, shown in more detail in Figure 3,
is also very significant. Again, however,
we cannot give the antibiotics credit for
conquering tuberculosis; note the slope of
the curve and recall that streptomycin was
introduced here in 1945, isoniazid in
1952, long after the major reduction in
the death rate had occurred. Thus again
April 1975
461
WARD BURDICK AWARD ADDRESS
800760700"
CHRONIC DISEASES OF BONES AND
660-
JOINTS
CIRRHOSIS
EMPHYSEMA. ETC.
600-
OTHER CHRONIC CNS DISEASES
660
600460-
FIG. 4. Death rates for degenerative diseases, U.S., 1900-1969, by
major types, compiled from Table 2.
400
'/////y///7/{////A(.
1900
1910
it would appear that prevention of a
disease is apt to have a greater impact on
the death rate than is improvement in
treatment. Tuberculosis of bones and
joints, and of all organ systems except the
lungs, can be grouped with the disappearing diseases.
//. Degenerative Diseases
The death rates for the degenerative
diseases are shown in some detail in
Figure 4. All the members of this group
are essentially chronic diseases, conspicuously associated with aging, although age
is not the only determining factor. Higginson 16 has raised the question whether
diseases associated with aging may, at least
to some extent, be a result of environmental poisoning, since there is such wide
variation in the incidences of these diseases in different parts of the world.
Leaf,24 in his study of exceptionally longlived populations, has suggested that ex-
1930
1940
1960
1960
1969
cessive dietary intake and too little exercise may be important factors in aging.
Two things are noteworthy about the
overall curve for degenerative diseases
(top line of the graph): the slight dip in
the curve in 1920, and the gradual rise
since 1920, the rise being sharpest between 1920 and 1950. T h e dip of the
curve in 1920 is almost certainly due to
the great loss of life, chiefly in the older
age groups, that occurred from influenza-pneumonia during
1917-18.
People suffering from chronic degenerative diseases simply died a few years
earlier than would have been the case
otherwise, as a result of influenzapneumonia rather than their degenerative diseases.
The increase in the death rate for
chronic diseases of the heart and blood
vessels accounts for the rise in the overall
curve for deaths from degenerative diseases that occurred between 1920 and
1950. This increase in the death rate for
462
PEERY
A.J.C.P.—Vol.
63
heart disease more than equalizes the mention of coronary artery disease; since
decrease for chronic renal diseases and that date, as a result of a change in
chronic nonvascular diseases of the cen- regulations, such a case would be coded as
ischemic heart disease with no mention of
tral nervous system.
T h e decline in deaths assigned to diabetes. It is also possible that some cases
chronic renal disease appears to be due of myocardial infarction have been mislargely to a change in the physician's takenly diagnosed as "acute indigestion"
concept of the disease. As the sphyg- a n d coded u n d e r "diseases of the
momanometer came into common use, stomach"; prior to 1920 there was an
the term "hypertensive disease" was ex- unaccountably high incidence of "other
tensively substituted for "chronic nephri- diseases of the stomach" (not cancer, not
tis" on death certificates (see top of Fig- ulcer).
ure 5). By whatever name it may have
It is my belief, however, that ischemic
been called, this disease, which is more heart disease should be looked upon as a
frequent in blacks than in whites, and in new disease, and that we should seek its
males than females, appears to have de- cause among conditions that developed
creased sharply as a cause of death since during the 1920's and 1930's. Certainly it
1950. This is in keeping with my own is a disease that was rarely diagnosed
autopsy experience. This decrease is prior to 1930, and since then has come to
parallelled by a decrease in the death rate be the leading cause of death in the
from toxemia of pregnancy, which may United States. Herrick 15 reported the first
have a related etiology. The suggestion of cases of coronary thrombosis in the United
Schroeder 32 that cadmium intake may be States in 1912. Textbooks of pathola factor in hypertension is certainly ogy and medicine published in the late
worthy of further study.
1920's devoted little space to the disease.
Peery
and Langsam, 30 in a review of 518
The single disease showing the most
striking increase in death rate in this autopsied cases of cardiovascular disease
whole set of statistics is ischemic heart in Charleston, South Carolina, covering
disease, which is shown in detail in the the period 1928-1938, found only 22
bottom part of Figure 5. In United States cases (4%) of coronary thrombosis. My
mortality statistics, "angina pectoris" has recent experience shows a very high incibeen listed since the beginning of the dence of the disease, corresponding to the
modern period (1900), but "ischemic national mortality statistics.
heart disease" (or equivalent term),
What could account for this remarkable
"chronic myocarditis," and "chronic rise? Increase in cigarette smoking may
rheumatic heart disease" were first listed account for a small part. 33 I am inclined,
in 1930. Prior to 1930 all of these diseases however, to go along with what apparwere listed under "organic heart disease." ently is the majority opinion, that the
Careful analysis of the data reveals two increase is largely due to the greater
artifacts which together account for consumption of meat and dairy products,
perhaps a fifth of the apparent increase in and the more sedentary life style, that
the death rates for ischemic heart disease. have been adopted in the United States as
A change in the system of coding is a result of our greater affluence. Both of
responsible for an estimated 14% in- these factors would presumably promote
crease. Prior to 1940, if a death certificate higher blood levels of cholesterol, trishowed "diabetes mellitus" and also a glycerides, and related compounds, and
second entry for "coronary artery disease," thereby promote the occurrence of both
that case was coded as diabetes with no the coronary thrombus and the coronary
April 1975
463
WARD BURDICK AWARD ADDRESS
HYPERTENSIVE
100-
DISEASE
60
1900
FIG. 5. Changing terminology of
heart disease and rise of ischemic
heart disease in U.S., vital statistics,
death rates 1900-1969.
1910
1920
1930
1940
1960
19(0
19(9
400"OTHER300ANGINA
PECTORIS
200
100
1900
19(9
plaque. I think that cholesterol is central
It is of considerable interest to note
to the problem and to its solution. Bur- also the changes that have occurred in the
kitt3 and his colleagues have recently death rates for emphysema. As is shown
emphasized the role that diminished con- in Figure 11, the death rate for this cause
sumption of vegetable fiber in the modern was quite high in 1900, declined from
diet may have on blood cholesterol and 1900 to 1940, and since 1940 has risen
ischemic heart disease.
sharply again. The high rate during the
Although Figure 5 does not show it, first part of this century, and its subsince my data do not take into account the sequent fall, are probably a result of an
aging of the population, there has been a association with pulmonary tuberculosis.
slight but significant decline since about The recent rise is almost certainly due to
1963 in the age-adjusted death rates for the great increase in cigarette smoking,
ischemic heart disease for most age and to other forms of air pollution.
groups, as pointed out by Walker. 36 Figures since 1968, including tentative
Perhaps this is a result of public education data for 1972, seem to show a modest
about cholesterol and its precursors in the decline in the death rate from emdiet, and of general increase in physical physema. Perhaps the Surgeon General's
4
exercise, as is evidenced by the great warning, issued in 1959 and aimed at
recent popularity of jogging, hiking, cy- lung cancer, has had more effect than we
cling, and tennis, especially along those realized.
most susceptible to coronary artery disDeath rates for cirrhosis of the liver also
ease. Unfortunately we have no good way show a double trend between 1900 and
to document changes in diet or physical 1969, but probably for another reason.
activity and to note differences from year High in 1900 and 1910, deaths from
to year.
cirrhosis were significantly reduced in the
464
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A.J.C.P.—Vol.
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63
MALE GENITAL
FIG. 6. Death rates for neoplasms,
U.S., compiled from Table 2.
1900
1940
1960
1920's and 1930's, corresponding to the
Prohibition Era, and rebounded sharply
following repeal of the 18th Amendment.
///. Neoplastic Diseases
T h e graph for neoplasms, Figure 6,
shows that the death rate for this group of
diseases has had the steepest overall rise
of all the major categories in this study.
Tentative figures since 1969, however,
suggest that the increase in death rates
from this cause may be tapering off
somewhat.
Death rates for neoplasms of the digestive tract have been falling slightly since
1940 (Fig. 7). This decrease is due almost
entirely to a decrease in deaths from
cancer of the stomach. Cancer of the
colon has actually shown a considerable
increase. Burkitt 3 suggests that the lower
fiber content of the modern diet has
caused an increase in cancer of the colon
by slowing transit time of the stool-mass
through the intestine, thus giving a longer
1969
time for carcinogenic agents in the stool
to act on the bowel mucosa. The wide
variation in the death rates for the disease
in different countries and in different
parts of a single country may lead to
discovery of the causes of these neoplasms.
Death rates for cancer of the breast
(Fig. 6) have increased slightly for the 70
years covered by this study, in spite of the
development of many forms of therapy.
Improvement in the death rates for
cancer of the female genital system is a
result of improvement in the death rate
for cancer of the cervix; death rates for
cancer of other parts of the genital tract
have actually risen in recent years. Most
of us would assign the fall in deaths from
cervical cancer to the widespread use of
exfoliative cytology.
Cancer of the lung and bronchus is, of
course, the chief "new disease" among the
neoplasms. Prior to 1930 it was so infrequently diagnosed on death certificates
that it was not coded separately but was
April 1975
465
WARD BURDICK AWARD ADDRESS
FIG. 7. Changing statistics of
stomach and intestinal cancer, death
rates, U.S., 1900-1969.
1900
1910
lumped with "other neoplasms." In the
1926 edition of Karsner's textbook of
pathology, 19 which I studied in medical
school, it was said that carcinoma of the
lung comprised 1-2% of all malignant
neoplasms; at the present time it accounts
for about 20% of all deaths from cancer.
There seems to be little doubt that the
major cause of the increase in the incidence of lung cancer is the increase in
cigarette smoking.
Cancer of the male genital system seems
to have increased significantly in recent
years also. It, too, was not identified
separately in United States mortality
statistics prior to 1930. Carcinoma of the
prostate makes up the great bulk of this
group. Jackson' 8 has pointed out that
prostatic cancer in the United States is
somewhat more common among blacks
than whites, and is five times as common
among U.S. blacks as among blacks in
Nigeria.
The death rate from leukemia has
increased significantly in the period covered by this study. Miale27 has suggested
that leukemia was apparently extremely
rare prior to about 1850, but offers no
explanation. I have often wondered
whether the extensive use of fluoroscopy
of the chest during the years 1925-1950,
especially in relation to the treatment of
pulmonary tuberculosis by p n e u m o thorax, might have resulted in leukemia
or related disorders.
Higginson 16 has estimated that 8 0 - 9 0 %
of all neoplasms in the United States are
1920
1930
1940
1950
1960
1969
"partly or predominantly conditioned by
exogenous factors." Various agents have
been cited as causing small groups of
cancers, but no overall exogenous agent
has been identified to date. The difficulty
in identifying causes of cancer stems in
part from the fact that present deaths
from cancer are probably a result of
factors that acted many years ago, and
perhaps also acted indirectly, as through
some imbalance of the ecosystem. Thus
man-made pollutants may be concentrated as a result of population growth or
migration, specialization in agriculture, or
other factors. 17
IV. Accidents, Violence
and Poisoning
The graph for accidents, violence and
poisoning (Fig. 8) shows a dip in the curve
at 1920 like that in the death rate for
degenerative diseases, presumably because some older individuals died from
influenza-pneumonia during 1917-18
rather than from falls or other accidents
in 1920. From 1930 to 1960, total deaths
in this category declined steadily, but they
have surged upward again since 1960.
Death rates for ground transport accidents reached a peak in 1930, then declined slightly thereafter until 1960. Since
1960 a sharp upturn has occurred, presumably because of the greater speed of
motor vehicles in recent years. Deaths
from water and air transport accidents,
first recorded in 1930, remain relatively
insignificant.
466
A.J.C.P.—Vol.
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63
160
160
140
MEDICAL 6
SURGICAL MISADVENTURE
AIR TRANSPORT
130"
120
110
WATER TRANSPORT
ACCIDENTS CAUSED BY FIRES>
ACCIDENTAL
POISONING
100
90
FIG. 8. Death rates for accidents,
poisoning and violence by major
types, U.S., 1900-1969. Compiled
from Table 2.
80
70
60
60
40
3020
10
1900
1910
1930
It is my belief that there is a group of
"new diseases" associated with high-speed
transport accidents of modern times. Violent deceleration, which was not a feature
of horse and buggy accidents, or of motor
car accidents on dirt roads, is an extremely common feature in modern auto
and airplane accidents. This results in an
increase in what Nahum 2 9 and associates
have referred to as the "third collision," in
which movable portions of the internal
anatomy are violently displaced within the
body, resulting in tears of the aorta at the
site of the ligamentum arteriosum, or
intracranial h e m o r r h a g e s from torn
meningeal vessels. In some instances the
patients survive the acute injuries and die
years later, perhaps from rupture of an
aortic aneurysm at the site of an earlier
tear, the late effects of head or spine
injury, or renal vascular hypertension.
"Medical and surgical misadventures" is
the somewhat euphemistic term used in
The Classification to designate the occasional ill effects that result from chemical,
1960
1969
biologic or physical agents used by the
physician for diagnosis or treatment of his
patient. T h e Classification introduced
such a heading with the Fifth revision in
1939, but apparently few diagnoses suitable for this heading have been recorded
in death certificates. I believe that it
deserves much more attention than the
graph would indicate, and that there are
several new diseases in this group.
Much has been written about adverse
drug reactions, especially by Guff 5 and
his colleagues, but only a start has been
made to date, in my opinion. It is essential
to develop a data base for drug reactions
so that we can know how frequently a
given adverse effect occurs among the
population receiving a certain drug.
A few years ago I wished for such a
reference base when I had a patient at
autopsy who had died from diffuse
scleroderma after having been given
methysergide maleate ("Sansert") for the
prevention of migraine headaches. It is
known that certain patients receiving this
April 1975
467
WARD BURDICK AWARD ADDRESS
Table 3. Partial List of Diseases and Symptoms Which May Come About as
Adverse Reactions to Therapeutic and Diagnostic Agents*
Abortion
Acidosis
Adenopathy
Agranulocytosis
Akathisia
Akinesia
Alkalosis
Amnesia
Anaphylactoid reaction
Anemia
Angina pectoris
Arrhythmia
Asthma
Blindness
Calcinosis
Candidiasis
Cataract
Charcot joint
Circulatory failure
Cirrhosis
Coma
Convulsions
Corneal opacity
Cystitis
Deafness
Depression
Dermatitis
Diabetes
Dysphagia
Dyspnea
Dystonia
Dysuria
Edema
Encephalomyelitis
Endarteritis
Enteritis
Erythema multiforme
Erythema nodosum
Erythrocythemia
Fanconi syndrome
Fever
Fibrosis
Bone marrow
Liver
Lung
Ovary
Retroperitoneal
Fracture, spontaneous
Gangrene
Glaucoma
Glomeru litis
Goiter
Gout
Heart
Arrest
Block
Failure
Ischemia
Hypertrophy
Hemorrhage
Gastrointestinal
Intracranial
Pulmonary
Hepatitis
Hodgkin's disease
Hypercalcemia
Hyperglycemia
Hyperkalemia
Hypersensitivity reaction
Hypertension
Hypocalcemia
Hypoglycemia
Hypokalemia
Hyponatremia
Hypoprothrombinemia
Hypotension
Hypovitaminosis
Ileus, adynamic
Impotence
Intestinal perforation
Iritis
Jaundice
Keratitis
Kidney
Calculus
Damage
Failure
Labyrinthitis
Leukemia
Liver
Cirrhosis
Damage
Necrosis
Lupus erythematosus
Lymphadenopathy
Malabsorption syndrome
Methemoglobinemia
Muscle
Atrophy
Damage
Fasciculation
Myelitis
Myocardial infarction
Myocarditis
Necrosis
Nephritis
Nephrosis
Nerve tissue damage
Neuritis
Optic
Peripheral
Osteomalacia
Osteoporosis
Osteosclerosis
Ovary, cyst
Pancreatitis
Pancytopenia
Paralysis
Paranoid states
Parkinsonism
Pleural effusion
Pneumonia
Polyarteritis
Polyneuritis
Porphyria
Proctitis
Prostate, hypertrophy
Pseudotumor cerebri
Psychosis
Purpura
Respiratory depression
Respiratory failure
Retinal detachment
Retinitis
Retrolental fibroplasia
Serum sickness
Shock
Spleen, hypertrophy
Stevens-Johnson syndrome
Syncope
Synechia
Tetany
Thrombocytopenia
Thrombophlebitis
Thrombosis
Thyroiditis
Torticollis
Ulcer, peptic
Ureter, calculus
Urticaria
Uveitis
Vaginitis
' Drugs causing these adverse reactions are lisled in AMA Drug Evaluations IU71.
drug over a period of time have developed retroperitoneal fibrosis, and also
pleural and pulmonary fibrosis, but I
could find no reference to scleroderma
following this drug.
Perhaps the most important group of
diseases resulting from drugs are those
that simulate naturally occurring organic
diseases. No organ of the body is exempt
from this problem, and no medical specialty can afford to neglect it. Pathologists
are in a unique position to detect these
untoward effects of treatment, since we
see and examine the therapeutic failures
of a large number of physicians. The
i m p o r t a n t publication "AMA D r u g
Evaluations—1971," prepared by the
AMA Council on Drugs and distributed a
few years ago to all AMA members, gives
more than 400 adverse reactions that may
be encountered. I have listed 150 of these
(Table 3) that seem most important. T h e
list spans the alphabet, and includes
cataract, deafness, glaucoma, hypertension, lupus erythematosus, pancreatitis,
parkinsonism, tetany, and many others.
In addition to these diseases a n d
symptoms that are drug-related, many
468
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A.J.C.P.—Vol.
63
FIG. 9. Death rates for other
diseases and conditions, by major
types, U.S., 1900-1969. Compiled
from Table 2.
1920
1940
1960
1960
abnormalities of laboratory test results must have been one of the quickest
may result from medication. 37
autopsy-to-publication t u r n a r o u n d s in
Sometimes it is relatively easy to spot a medical history—in less than three weeks
"new disease" that is drug-related. In he had the news out! T h e AMA Chemical
October 1937, while serving my residency Laboratory, also working at unbelievable
under Dr. Kenneth M. Lynch at the speed, completed preliminary chemical
Medical College of South Carolina, I was analyses, identified the substance in which
called upon to do autopsies on several the sulfanilamide was dissolved as diethchildren who had died following an un- ylene glycol, reproduced the disease in
usual illness. Each child had become sick rats, rabbits and dogs, and published a
about a week before his death with what preliminary report within a month of the
seemed to be an ordinary sore throat and alert! The final report, published 11
fever, but subsequently each had de- months later, gave a map showing disveloped vomiting, abdominal pain, scanty tribution of cases and full details. 9 Things
urinary output and coma. The autopsies really moved in those days!
disclosed swollen, mottled kidneys with
(The similarity of this "disease" to the
scattered infarct-like areas of cortical ne- strange disorder known as "Reye's syncrosis, and the livers were very pale and drome" 31 is immediately evident. Careful
slightly enlarged. The cause of death, search for a chemical cause for this new
unknown at the time, became obvious a syndrome has so far revealed nothing,
few weeks later, when Dr. O m e r and no explanation for the syndrome has
Hagebusch 12 reported in the Journal of the been found.)
American Medical Association four autopsied
By contrast with the diethylene glycol
cases of deaths following administration episode, which was acute, it may be very
of Elixir of Sulfanilamide-Massengill. It difficult to recognize iatrogenic disease if
April 1975
469
WARD BURDICK AWARD ADDRESS
FIG. 10. Death rates for unknown
or ill-defined causes, U.S., 19001969.
40'
1900
1910
1920
1930
1940
1950
1960
1969
the patient's original disease is chronic should not be compared with that from
and the medication used is slowly toxic; 1950 onward. Between 1940 and 1950
under such circumstances the untoward there was a change in the method of
effects of the medication are often inter- handling death certificates on which diapreted as a new manifestation of the betes mellitus was listed as one of several
original disease. Thus the "broad spec- causes of death, and this change resulted
trum" of symptoms in certain cases of in a reduction of about 45% in the
lupus erythematosus may be in part a number of deaths thereafter assigned to
result of untoward reactions to therapeu- diabetes mellitus. If this artificial change
had not taken place, deaths from diabetes
tic agents.
Some "new diseases" resulting from mellitus, which had been steadily rising
adverse drug reactions may not cause prior to 1940, would have continued to do
death, and hence cannot be detected at so; the lines in the graph for endocrine
autopsy or in death statistics. These, too, diseases, and for the whole group of
may go unexplained for months or years. "other diseases of organ systems" is
The thalidomide-induced deformity of spondingly. Note that the discovery of
the newborn infant, and infantile blind- insulin in 1922 had no demonstrable
ness due to retrolental fibroplasia follow- effect upon the recorded death rate from
ing 100% oxygen therapy for prematur- diabetes mellitus.
T h e decline in the death rates for
ity, are two important examples.
"other diseases of organ systems" is
chiefly a result of the decline in deaths
V. Other Diseases
assigned to anemias, diseases of the
This is a sort of grab-bag category (Fig. stomach, intestinal obstruction, and renal
9) in which I have placed certain disease.
metabolic diseases such as diabetes melOf special interest in this graph is the
litus, certain diseases of the organ systems decline in the infant death rate. This is
that could not be otherwise classified in shown here as deaths during the first year
my schema, maternal and infant deaths, of life per 100,000 population instead of
congenital anomalies, and fatal mental the more usual way, as deaths per 1,000
disorders.
live births. Actually the height of the
T h e interruption of the line for infant death rate for 1900, and the slope
metabolic disorders is meant to indicate of the decline since then, would have been
that the death rate from 1900 to 1940 even more striking than is shown here if
470
PEERY
this category had included enteric infections in infants. T h e fall in the death rate
assigned to prematurity (43.6 in 1920, 4.4
in 1969) accounts for much of the total
decline in infant deaths.
The death rate from maternal causes is
shown as deaths per 100,000 population
of all ages, male and female, so as to be
compatible with other elements in the
graph. When expressed in the usual form,
i.e., as deaths per 100,000 live births, the
death rate actually has decreased tenfold
than 1940 to 1960 (376.0 to 37.1). This is
a result of improvement in the management of each of the major causes of
maternal mortality, as shown in Figure 12.
VI. Unknown Diseases
Assigned to this category (Fig. 10) are
such death certificate entries as "died
without sign of disease," "unknown cause,"
and "unspecified." Whether the decline
from 67.4 in 1900 to 12.2 in 1969 means
some major shift in some unknown cause
of death, or whether it means that physicians in 1900 were simply resisting the
new law requiring them to complete death
certificates, will probably never be known.
Recent Trends in Mortality
in the U.S.
In 1964, Moriyama, 28 of the National
Center for Health Statistics, raised the
important question whether the leveling
off of the United States death rate during
1950-60, following the long downward
trend in 1900-50, as shown in Figure 1,
might mark the beginning of an actual
upturn in mortality rates. Studies carried
out by Klebba20,21,22 and colleagues have
shown that the crude death rate in the
United States reached a low in 1954 and
then remained relatively stable in 195469 except for years d u r i n g which
influenza was epidemic. However, by dissecting this stable death rate into male
and female, and into age groups, she
A.J.C.P.—Vol.
63
showed that, while death rates for degenerative diseases have continued to decline slightly, this overall decline is countered by a modest increase in death rates
for males in several other categories. In
fact for males in the age group 15-44
years there has indeed been a definite
upswing in mortality rates during the
1960's. This upswing is due chiefly to
increases in the death rates in the following categories: (1) Motor vehicle accidents
(especially in the age group 15-24 years,
although declining by 23% overall since
the energy crisis.6 (2) Malignant neoplasms (a continued increase, especially for
carcinomas of the lung). (3) Emphysema
(nearly doubling in 1960-68, but declining slightly since). (4) Cirrhosis of the liver
(continuing an upward trend). (5) Nonsyphilitic aortic aneurysms (continuing an
upward trend). (6) Suicides (especially in
younger age groups and in women). (7)
Homicides (affecting all age groups).
Discussion
Note that most of the diseases enumerated in the upswing of mortality are
conditions in which social and environmental factors are thought to play a major
role. It is time, I think, that we consider
another problem which may be common
to all these social and environmental
factors: I refer to overpopulation.
As Garrett Hardin, the author of "The
Tragedy of the Commons," has more
recently pointed out, 13 "Nobody ever dies
of overpopulation." He illustrates his
point with the catastrophe in East Bengal
in 1970, in which half a million people
died. Their deaths were assigned to a
cyclone, but Hardin says they might just
as well have been assigned to overpopulation.
David Lyle25 has painted a very gloomy
picture of the effects of overpopulation.
He showed that, in animal species, it leads
to disease, fighting and cannibalism, end-
April 1975
471
WARD BURDICK AWARD ADDRESS
28
A
25-
. TOTAL POPULATION
. WHITE MALES ONLY
20-
FlG. 11. Death rates for 16 •
c h r o n i c bronchitis-emp h y s e m a - a s t h m a , U.S.,
1900-1972.
10-
6-
s
ing up in a massive die-off. In human
society, according to Lyle, overcrowding
brings a tendency to "drop out, turn on,
drink up," leading to widespread social
unrest, dissatisfaction, rioting and war.
He predicts that, unless there is a prompt
and drastic reduction in the birth rate, or
else a major catastrophe, the population
of the United States as a whole will
increase by 50% by the year 2000, urban
population by 100%. This could result in
"disaster of an unprecedented magnitude," according to Dr. B. R. Sen, 26
Director General of the United Nations
Food and Agriculture Organization.
The many problems of the environment
— pollution, accumulation of solid wastes,
inadequate food and water supplies,
energy shortage—are all related to overpopulation, as noted in a thoughtful essay
by Hardin. 14
Holdren and Ehrlich 17 point out other
ways in which the e n v i r o n m e n t is
threatened by overpopulation. In man's
~r
s
I
lllll
I lis!
attempt to increase food production, he
tends to disrupt earth's stable ecosystem,
which is based on diversity: cultivation of
new, marginal lands leads to soil erosion
and an increase of atmospheric dust;
burning of fossil fuels increases air pollution and atmospheric C 0 2 ; fertilizers and
pesticides destroy certain animal species,
including food fish in the coastal areas of
the oceans. Increased air pollution and
atmospheric C 0 2 tend to reduce the
radiant energy reaching earth from the
sun. This may bring about a cooling of
the earth, with shortening of the growing
season, agricultural failures on a large
scale, further losses of fish production,
and increases in human disease.
This may all sound somewhat remote,
but note that climatologists 1,8,23 have already observed the beginning of a deterioration of our climate: earth's temperatures have been dropping sharply since
about 1945, for the longest unbroken
downward trend of temperatures in hun-
472
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A.J.C.P.—Vol.
63
dreds of years.! The effect of this cooling
is to alter the planet's system of winds,
blocking vital monsoon rains, and causing
extreme and variable weather, both
droughts and floods, in many parts of the
globe.
Reid Bryson, 2 of the University of Wisconsin, says that, if the temperature
change continues, it will "affect the whole
human occupation of the earth—like a
billion people starving," and he adds that,
if there were to be three years in a row of
weather like that of 1972, the world's
population could not be sustained.
publication of their data comes far too
late for it to serve as any sort of warning
alert. If the meteorologists in government
can collect and correlate the data required
for the next day's weather forecast for
each section of the country, and if federal
economists can report each month on the
current status of the Gross National
Product, the Rate of Unemployment,
Wholesale and Retail Prices, Exports and
Imports, Cost of Living, etc., it would
appear that the nation's health statisticians
should be able to provide the medical
community with information that is both
timely and useful.
Recommendations
As to usefulness, there is a great deal of
valuable information on death certificates
that never gets into the information system. For example, only one cause of
death is coded, this being the "underlying
cause," defined as "the disease or injury
which initiated the trend of morbid events
leading directly to death" 35 . Information
on associated diseases goes totally unrecorded, although it is available on the
source document, the death certificate.
Obviously, much valuable information is
lost by this omission.
It is especially important that more
attention be paid to autopsies in mortality
statistics. In 1955, the last year for which I
have found figures, autopsies were performed in about 18% of U.S. deaths,
totaling in the one year 271,797
autopsies. 35 Just think of the professional
time, effort and cost that went into that
many autopsies, and the valuable facts
recorded in those reports. Those facts are
submerged and lost in the statistics derived from deaths in which no autopsies
were done!
Certainly most new diseases causing
death are first recognized at autopsy, as
pointed out by Gall.7 Some years later
such diseases will be recognized clinically,
and it will be years after that before the
new disease appears regularly in mortality
statistics.
All peoples must alert themselves to the
possibility that these two interrelated factors, overpopulation and climatic change,
may trigger massive fuel shortages, widespread crop failures with resulting starvation and social unrest, and a great increase in deaths from new and old diseases.
These changes, if they are to come, will
not happen overnight. Hence it is important that all nations improve their early
warning systems so that appropriate steps
can be taken to forestall or minimize such
disasters.
For our specific role as guardians of the
nation's health, physicians should join
together to improve the system for
monitoring the health picture. For example, we as pathologists should give our
support to measures that will improve the
national system for gathering and reporting mortality statistics. The basic organization of the National Center for Health
Statistics is well established, and the data
generated appear to be dependable, but
they operate more or less in a vacuum,
their analyses are limited in scope, and
t Special thanks are due Mrs. Olive Osten, of the
National Oceanic and Atmospheric Administration,
for her help in searching the literature of meteorology.
April 1975
10090
80
70
FIG. 12. Maternal mortality rates per 100,000
live births, U.S., 1939-41,
1949-51, 1959-61. From
Table 46 "Vital Statistics
Rates in the U.S.," an
HEW Publication.
473
WARD BURDICK AWARD ADDRESS
60
50
40
30
20
10
SEPSIS
TOXEMIAS
I
ABORTION
I
km m
I
y
/
III
Data from death certificates on autopsied cases should be tabulated separately,
and results from this sample should be
made available on a month-by-month
basis, using modern methods of data
processing, retrieval, correlation and publication. Coded information on this
selected sample should include the multiple causes of death as recorded at autopsy, as well as age, sex, and geographic
region. This monthly report of national
autopsy statistics would serve as an invaluable and dependable warning alert
for new health hazards. The data from
these autopsied cases could be used to
study the new diseases, and to provide a
reference base, with full reports and
tissue slides available, permanently retained, for evaluating new disease concepts.
Annual reports based on all death certificates, both those with autopsy and
those without, should continue to record
all the customary demographic data, but
should certainly be available within a year
after the end of the period covered by the
report.
With pathologists providing data from
OTHER
COMPLICATIONS
HEMORRHAGE
ECTOPIC
PREGNANCY
m
I
it
autopsies to identify the new diseases, and
with full statistical monitoring of all
deaths to see how old diseases are changing, we would have important information to guide us in our search for the
causes of some of the diseases that are still
unexplained.
To round out the data needed in the
search for causes, these changes in disease
patterns must be correlated with changes
in the environment and in the habits and
customs of the people. Environmental
monitoring is well advanced; data are
available on weather patterns, and on the
chemical composition of our food and
drink and the air which we breathe. Less
is known about the habits and customs of
the people. T h e one thoroughgoing study
of this type, which correlated smoking
and health, 33 showed that smoking is a
major cause of lung cancer and emphysema, and is also important in heart
disease, a point which had previously
barely been suspected. Similar studies of
other aspects of personal health, including diet, exercise, and alcoholic consumption, might be even more revealing.
Perhaps indices comparable to the Gross
474
PEERY
National Product could be derived from
these and other data, so that changes
from year to year could be quantitated.
With information of this sort to compare with health and mortality data, we
should be able to identify the causes of
many of the new and old diseases. With
knowledge of cause there would be hope
of prevention and prospect for cure.
References
1. Alexander T: Ominous changes in the world's
weather. Fortune 89:90-95 and 146-152,
1974
2. Quoted by Alexander"
3. Burkitt DP, Walker ARP, Painter NS: Dietary
fiber and disease. JAMA 229:1068-1074,
1974
4. Burney LE: Smoking and lung cancer: A statement of the Public Health Service. JAMA
171:1829-1837, 1959
5. Cluff LE, Thornton, GF, Seidl LG: Studies on the
epidemiology of adverse drug reactions: I.
Methods of surveillance. JAMA 188:976-983,
1964
6. Etzioni A: T h e humility factor. Science 185:817,
1974
7. Gall EA: T h e necropsy as a tool in medical
progress, Medical Progress and the Postmortem: A Symposium. Bull NY Acad Med,
second series, 44:792-861, July 1968
8. Gedeonov AD: "Eighty year cycle of mean
monthly air temperature in the northern
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