Reprinted from the NATION’s HEALTH, August, 1922, issue, Vol. IV, No. 8

Incidence of Heart Disease in the Community’

Out of Systematic Study and Full Records in Every
Case Will Grow Adequate Preventive Methods

By LOUIS I. DUBLIN, PuH.D., STATIsTICAN, METROPOLITAN LIFE INSURANCE COMPANY, NEW York CITY.

DISCUSSION of the incidence
a of heart disease in the commu-
nity is especially pertinent at

this time in view of the high death rate
from this disease that has prevailed
during the present year. We in the
Metropolitan Life Insurance Company
have an advantageous position watch-
ing the experience among the many
millions of our policyholders. We can
see month by month and, in fact, week
by week, just what conditions of
health prevail in the country at large.
Since November, 1921, and continu-
ing each month to date, the death
rate from heart disease has been ap-
preciably higher than it was during
the corresponding months of the pre-
vious year. The same has been true
for the associated organic diseases,
such as, Bright’s disease, cerebral
hemorrhage, and apoplexy. It must be
remembered that the last three years
were favorable ones for heart disease

mortality... [he sates fer-4919,-1920,-

 

 

The fundamental importance of
collecting all pertinent facts in
regard to the incidence of heart
disease in the community is
urged. Uniformity of record,
with such details of history and
physical findings as will enable
comparison, would bring out a
mass of data which would just-
ify definite prognosis which is
now impossible. Effective pre-
ventive work on a wide scale
must await such a mode of pro-
cedure.

Nor should such data, to be ef-
fective, be drawn exclusively
from mortality records. Morbid-
ity records need to be so ex-
tended as to point out the in-
ciptent case, and the. predispos-
ing environmental or constitu-
tional condition which led to
disabling heart lesions. Our

portant as these two conditions are
in affecting the heart disease rate ad-
versely. We shall have to watch the
developments for the rest of the year
very carefully.

These facts are disturbing to all
engaged in public health work because
the figures for recent years had given
some encouragement that a definite

downward tendency had come for

heart disease. It must be remem-
bered that the great improvement in
the rate for tuberculosis has left
heart disease in the first place as the
leading cause of death. During the
first eight years of the decade, there
was hardly any decline in the figures
among insured lives. In the general
population of the Registration Area,
there was an almost continuous in-
crease in the mortality from heart
disease. But, in the years 1919, 1920,
and 1921, the great improvement in
the figures already referred to gave

 

and 1921 were the lowest recorded
during the last decade. When the in-
crease began in the winter months of
1921, the change attracted little at-
tention. The possibility that it
ushered in a definite check in the fa-
vorable downward tendency for heart
disease mortality was not seriously
considered. But, by the end of Jan-
uary, 1922, there could be no longer
any question that a definite upward
tendency was in progress. As _ will
be seen from the graph, the heart
disease death rate increased sharply
month by month until in March the
rate reached the maximum of 168.2
deaths per 100,000 living, one of the
highest figures recorded in recent
years among Metropolitan Industrial
policyholders. (Chart I)

Obviously, some of this increase for
heart disease is the direct result of
the influenza epidemic which broke
out in the early months of this year.
But this cannot be the whole cause
because heart disease death rates that
were higher than normal prevailed
for several months before the influ-
enza epidemic and have continued for
several months after its close. The
experience among insured lives would
seem to indicate that we are experi-

*Read before the Boston Association of
Cardiac Clinics, Boston, Mass., May 18, 1922.

present statistical studies are
sertously inadequate in this re-

 

 

 

 

gard.

 

 

encing in the current year a serious
increase in the incidence of heart dis-
ease deaths quite apart from the ef-
fect of influenza and pneumonia, im-

 

Chart 1
Death Retes per 100,000 from ORGANIC DISKASES OF HEART
In Specified Menthe of 1921 and 1922.

hetropolitan Life Insurance Company, Industrial Departnent,

 

 

 

 

 

Chart I.—The heart disease rate increased
sharply month by month until in March
the rate reached the maximum of 168.2
deaths per 100,000 living, one of the high-
est figures recorded in recent years among
Metropolitan industrial policy holders.

cause tor—hepefulness—that-—a new—-sit--——

uation had been inaugurated. Condi-
tions at the present time are not very
encouraging in this respect and would
seem to indicate that the favorable
heart disease mortality experience of
the last few years was possibly only
a temporary one, reflecting in part
the result of the influenza epidemic
of 1918 and 1919, when a large num-
ber of advanced cardiac patients were
very likely eliminated, and also the
effect of improved economic conditions
for the wage working population dur-
ing the war. It is a good deal of a
question in view of all the facts, as
shown in the _ following graph,
whether there has been any lasting
improvement in heart disease mor-
tality during the last decade. This
disease is today the chief cause of
death. It is likewise a condition of
the greatest importance from a public
health standpoint. In spite of its
leading position in mortality and mor-
bidity, there has been virtually no
gain in its control; the campaign
against heart disease is very much
in the same position as that against
tuberculosis fifteen or twenty years
ago (Chart II).

The incidence of any disease may
be studied from two angles: (1) as
a cause of sickness and, (2) as a
cause of death. In respect to sick-

 
 

 

Chart If

 

Death Rates per 100,200 from ORGANIC DISSASES OF HRAPT.
Experience of the Metropolitan Life Insurance Co., Industrial Tep't.,
and of the U. 8. Registration Aren (ages 1 tc /4) Compared.

Death Rates 1911 to 1921.

per 100,000

 

 

 

 

 

 

 

(ees er

‘ peabe ssl
1911 1912 1913 1914 1915 1916 1917 1918 1919 1920 1921

,
Trend line, 1911 to 1920.

 

 

 

Chart II.—Conditions at present would seem
to indicate that the favorable heart disease
mortality experience was possibly only a
temporary one. All facts considered, it
is a question whether there has been any
lasting improvement in heart disease mor-
tality during the last decade.

ness or morbidity, we have very few
facts indeed. There is very little au-
thentic information on the preval-
ence of various types of heart affec-
tions. More recently, some informa-
tion has been accumulated on the prev-
alence of heart lesions among school
children as a result of the work of
school medical inspectors. The exam-
inations are, however, often made and
recorded in a perfunctory manner.
The greatest variations appear in the
tabulations. It is not always possible
to determine whether the figures in-
clude functional as well as organic
disturbances. The result is the great-
est variability, some cities showing
an incidence of two per cent of the
children affected and others less than
one-half of one per cent. On the other
hand, careful examinations have been
made among certain industrial groups
which show a considerable prevalence
of heart affections. The findings of Dr.
Schereschewsky of the United States
Public Health Service among gar-
ment workers in New York; of Rob-
inson and Wilson among employees
in various industries in Cincinnati;
and of Harris and Dublin among food
handlers in New York, indicate that
about two per cent of working adults
have organic heart disease of one kind
or another. The army medical ex-
aminers in connection with the draft
and camp examinations rejected about
four and a half per cent of those ex-
amined because of heart defects. The
figures will, of course, vary consid-
erably with the group of persons ex-
amined, the severity of their occu-
pations and the age of the men ex-

amined. But, altogether, the evidence
would seem to indicate that at least
two per cent of the population show
cardiac defects on examination. This
means that in the population of the
United States, more than two million
persons of all ages suffer from serious
heart impairments. This fact alone
indicates the magnitude of this par-

ticular health problem, and what pro-.

vision we must expect to make in the
next decade to provide for the discov-
ery and the care of these persons.
The statistics of heart disease mor-
tality are more satisfactory, both in
point of areas covered, of detail as

' to color, sex and age, and of diagnos-

tic accuracy. Deaths are reported,
even if the cause is not always stated
absolutely clearly, especially in con-
ditions where heart disease is asso-
ciated with disturbances of the vas-
cular and renal systems. Valuable
use may be made of the figures, how-
ever, both in the reports of the Reg-
istration Area, and more especially
for persons insured in the larger com-
panies. ° 1. am- in ~a - ‘position. to
present the figures for the ten-year
period 1911 to 1920 among the many
millions of persons insured in the In-
dustrial Department of the Metro-
politan and to show the incidence of
heart disease as a cause of death at
the various age periods of life, in
each one of the main classes of this
group, that is, among the white males,
the white females, the colored males,
and colored females.

Before we proceed, it is well to

explain just how we measure the mor-
tality from the several diseases. The
index, or death rate, is the number of
deaths from any disease during a
calendar year for each 100,000 per-
sons exposed during the year. The
figures in the following table are ob-
tained in this way. The only point
to be remembered is that the rates
are specific and refer to the particular
class of persons designated. Thus,
the rate 7.1 in the column “white
males” at the ages one to four years
means that seven deaths from heart
disease occurred among white male
children ages one to four for every
100,000 such white male children who
were insured in that year. The other
figures are obtained in a similar man-
ner—(Table I and Chart IIT).

The first point that comes to view
from an examination of the tables and
of the graphic illustration is that the
incidence of heart disease as a cause
of death increases consistently with
age. At the age period 35 to 44 when
persons should be at the height of
their productivity, one white person
dies from heart disease in every
thousand living and two colored per-
sons out of each thousand. At the
age period 65 to 74, the number of
deaths from heart disease has in-
creased to about 15 in each one thou-
sand living, or to put the facts in
another way, deaths from heart- dis-
ease constitute 9.8 per cent of all
deaths at ages 35 to 44, but, at the
older period, 65 to 74, they are re-
sponsible for 21.9 per cent of the

 

Death Rates
per 100,000

2614.

2000
1600

1600 | White Males

1400 colored: Males *-357—"* |

1200

1000

254034

Age Periods

 

Chart Ill
Death Rates per 100,000 from ORGANIC DISHASES OF HHART.
white and Colored Groups Compsred by Sex and by Age Periods.

Metropolitan Life Insurance Company, Industrial Department, 1911 to 1920. Death Rates

 
   
 
 
 
 
 
  
  
 
   

100,000
2ebat

2000

1800
whee}
Fenales): —.:- .

Colored
Females

1600
De 1400
1200
1000

800 |

600

Age Periods

 

 

Chart III.—Statistics of heart disease distributed according to color, «ge and sex, and diagnosis
jndieate increased incidence with age, greater incidence among colored persons than white.
Tho rates are higher for females in the age groups below thirty, but higher for males from
that age onward, the difference being regularly greater for males with advancing years.

2

eT)
 

TABLE I.—Death Rates per 100,000 from Organic Diseases of the Heart.

Metropolitan Life

Insurance Company, Industrial Department, 1911 to 1920.

 

 

 

 

 

 

 

 

 

 

 

White Colored
Age Periods |
Male Female Male Female
Miiaes ison ee ee isa 199.8 189.1 200.4
DA ls ee aa tee te | it 5.9 13.4 | 17.5
Gch a eee cee | 14.0 16.7 i | 16.5
OSI eo ee | 21.8 29.1 20.2 28.9
USO a, ies 28.9 30.0 PAS ee 36.7
ONG et ee | O76 30.8 BOA 40.2
Deen eke ca, | 47.5 45.3 83.2 15.7
BE res ewe ee ieee cal 108.6 89.3 199.0 199.8
Ab EOE i ne eae eet | 245.1 195.2 403.1 414.5
DDIOA oe cout ae 622.2 516.0 BE3.0-72) 785.6
ObTAe eee ate oe 6000 1,445.9 1,717.0 1,570.0
Gore ee ee | 3,158.5 2,910.4 2,674.1 2,662.1
}
deaths. There is no exception to this Some relations have been discovered
rule. The rates are also very much to exist between the prevalence of

higher for colored persons than for
whites. The sex ratios of heart dis-
ease mortality are also rather inter-
esting. The rates are usually higher
for females than for males up to age
30. From that age onward, the
rates for males are higher, the dif-
ference becoming regularly greater
with advancing years.

But, if heart disease is particularly
important in middle life and at
the older ages, it is already an impor-
tant condition in childhood and early
adult life. Thus, the number of
deaths between the ages of 5 to 9
are as many as from two such impor-

 

tant infectious diseases of childhood ~

as measles and whooping cough. Be-
tween 15 and 24 years, the deaths
from heart disease are more numer-
ous than from typhoid fever. Be-
tween the ages 25 and 34, heart dis-
ease caused each year almost as many
deaths as lobar pneumonia. So heart
disease is not to be overlooked as a
factor in the mortality of young peo-
ple. It takes a heavy toll through-
out life.

It is difficult to understand just
why the rates for young girls after
age 5 should be much higher than for
boys at the corresponding ages.
Perhaps the same causes are at
work which make the death rates
from tuberculosis higher among grow-
ing girls than among boys. The
greater prevalence of heart disease
among colored people is notorious.
Colored males show rates from
heart disease during the main period
of lite trom 65. to. 80 per cent
higher than for white males at the
same ages; those for colored women
are twice as high as for white women
at a number of age periods of life.
Possibly, the higher prevalence of
such diseases as syphilis, malaria, and
typhoid fever in the colored race
plays an important part in creating
the excess of heart disease mortality.

heart disease and occupation. While
the figures are not entirely trust-
worthy, it would appear that of all
occupations, those which are carried
on upon the water have the highest
heart disease rates. Thus, sailors,
fishermen, and to a less degree, barge-
men, show a very high prevalence of
heart affection. It is possible that
this relationship is in some way re-
lated to exposure to greater dampness
and cold. Next to these occupations
are those exposed to alcoholism, in-
cluding brewers, and those exposed to
lead poisoning. There are high rates
for metal workers, blacksmiths, and

 

All sedentary occupations have favor-
able death rates from heart disease.

Summary

To summarize the facts then, we
may say that, according to our best
knowledge, there are about two and
one-half million persons in the United
States who, on examination, would
show some type of organic heart le-
sion. These persons are not all sick.
Many of them are engaged in their
ordinary pursuits and have no idea
of their impairment. Yet, they are
seriously impaired lives who, unless
they take note of their condition and
adapt themselves to their lesser ca-
pacity to labor, will break down at
a premature age. Insurance studies
have shown that persons impaired
with such minor defects as mitral re-
gurgitation have, as a group, double
mortality for their age. It is the
business of American physicians, and
especially of those in the cardiac
clinics, to discover for each commun-
ity those who are in any way suffer-
ing from one type or another of heart
defect. No one knows the amount
of loss sustained annually through
the disability for work which results
from the varying incapacity among
these two and one-half million people.

3

In addition, there are each year in
the United States about one hundred
and fifty thousand deaths from heart
disease and the number is not de-
clining. Even under age 45, there
are each year over 22,000 deaths.
Each one of these deaths represents
a distinct loss to the community since
these persons are presumably at an
age where production may be ex-
pected to be at its highest. They
leave good sized families of minor
children who suffer from the loss of
a parent and, more usually, the
father. This is the extent of the com-
munity problem which is brought
about each year by heart disease.

It is very obvious, however, that
our information with reference to
heart disease both as a cause of
sickness and of death is very frag-
mentary. At the present time, there
is really no agency or machinery for
collecting the facts by means of
which the campaign against heart dis-
ease can be properly guided. It is
just this sort of machinery that is
called for at the present stage of the
movement. This information will
provide checks against misdirected
enterprise, and will suggest which of
many possible lines of activity are
really worthwhile.

What promises to fill this need is _

the plan of the Association for the
Prevention and Relief of Heart Dis-
ease in the City of New York. This
Association, which conducts a consid-
erable number of cardiac clinics, pro-
poses to keep systematic records in
connection with its work. The great-
est emphasis has been placed upon
a full history in each case, and on
a complete record of the findings on
each examination. A series of fol-
low-up visits by social workers is
planned, and the findings from this
source are likewise provided for in
the record. A system of tabulation
and of analysis is being considered, so
as to answer the outstanding ques-
tions which the directors of this As-
sociation have in mind. It is hoped
that out of these records it will be
possible to throw light on the prog-
nosis in various types of cases, on the
duration of the various heart lesions
from inception to death and on the
value of certain types of treatment in
relation to the restoration of work-
ing capacity. A goodly number of
other factual items will naturally sug-
gest themselves at the outset of a
campaign against a disease of such
magnitude as heart disease. We ap-
pend to this article a reproduction of
the first page of the record form
(Fig: 1).
_ What is being planned for the city
of New York should, of course, be
seriously considered by associations of
heart disease clinics in other cities
of the country. It is certainly to be
hoped that the clinics of such cities
as Boston, Chicago, and Philadelphia,
whether carried out under municipal
or private auspices, will develop a
similar system of records and plan
similar tabulations and analyses. The
greatest value of this effort will
come from the multiplication of
sources of information and out of the
exchange of experience from place to
place. :

What will probably remain a most
fertile field for the development of
knowledge is the practice of individ-
ual physicians who must, for a long
time, continue to be the chief instru-
ments in the campaign against heart
disease. The individual doctor should
appreciate, more and more, the neces-
sity of keeping a full history and cur-
rent record of his cardiac patients.
The record form recommended for use
in New York City should be indorsed
by the leaders of the profession, and
its use encouraged by the great body
of physicians. It will then be pos-
sible at regular intervals to send the
material to some central agency
where the records might be tabulated
and the conclusions made available
to the whole profession. On a foun-
dation of established fact, the cam-
paign against heart disease will make
rapid and substantial progress.

ASSOCIATION FOR THE PREVENTION AND RELIEF OF HEART DISEASE--First Record

 

 

 

 

Hospital Out-patient dept. or clinic | Date Serial No. (A. P-R.H.) Issuing Clinic No.
Name of patient Address Sex Color or race Age Single Reisgion
Married
Widowed
PLACE OF BIRTH: Patient attending
Country SCHOOL?

Town or city | Country of birth of patient's mother

 

 

Number and addressof SC oo Days lost from SCHOQL during past five years:
4 5

 

OCCUPATION OF PATIENT:

 

[Time lost acct.
sickness each

History Type of Work No. of
war hours per week

Teed ough Wage Date entered

General nature of industry or business
per week

Trade or particular kind of work

 

Present occu pation

 

Past occupation (1)

 

Past occupation (2)

 

Past occupation (3)

 

 

 

 

 

 

Past occupation (4)

 

 

 

FAMILY HISTORY:

 
  
 
   
  
    
     

Ttem

age;

   

from

If of death.
disease

 

PRESENT HABITS AND HYGIENE:
Sleep—hours Sleep—{Good—fair—poor—very bad)

Sleep—How many pillows

Habits. (State “Heavy “—" moderate” —“‘none™
Alcohol | Tea Coffee Sweets | Drugs | Tobacco

Appetite (Good—fair—poor—very bad)

 

 

 

 

‘How many per day? Bowels regular?
pes ‘igars

 

 

 

 

 

Pi | Cigarettes | Ghew (Yes or no)
PATIENT'S PAST HISTORY:
HEART HISTORY:
(Congenital Giotal(derscnnyothllnere Noi times confined toibed” | Days cut of | How many days and in what year was paticnt disabled for work beeen
or acquired? Years ‘Months A 2nd attack | 3rd at -[¥ eteackalusthte taskn|icikis tase javier aca
:

tack
Yr | Ye

Yr

t Home In Hospital
Days

 

work past year] Ist attack
| Yr. | Days

 

tac!
| Days} Yr. Ee

 

ac
Yr ie

 

 

Yr eee

HISTORY OF OTHER DISEASE: (If patient has had the disease, indicate by “ Y” and give year of occurrence. If not, write"-N" Indicate severity: S"—Severe, “M""-Moderate, “L"’-Lighz}

 

       
    

      

         

     

     

Yes or No

       

  

Yes or No

    

Year Yes or No

    

Disease Year Dieease Disease Year Disease Yes or No Yenr

       
    

   

Ist attack onsillitis
2nd

Side

Rheumatic fever Ist
pr and: 2:
ordi

   
        
   

      

fever

     

Purpura ooth and gum

      
  

 

Rheumatic nodules

 

orticollis cough

    
  

Erythema nodosum or growing pains

  

PREVIOUS MEDICAL TREATMENT
Treated

   

        

» Treatment

Time in Bed

  
  
 
  
  
  
 

! Private Physician

{ Clinic

| Hospital
Sanatorium
Osteopath

Chirepractor

   

SYMPTOMS—PAST AND PRESENT: (Answer yes (Y) or no (N), and give dates if possible). _If any symptoms are brought about by exertion or excitement, apecify aymptom by writing (E).

 

 

 

 

 

 

 

 

First symptom Fatigue | Dyspnoesa Orthopnoea Palpitation Cough Swelling—lege or abdomen | Headache
Pallor Nausea | Vomiting “Pain under right costa! margin Loss of weight’ | Giddiness Faintness Flushing Sweating
t Tremor Nose-Bleed Pain—site Pain—rediation | Pain—character

 

 

 

Fig. 1.—The greatest emphasis is placed upon systematic records in each case of heart disease.
This record form, adopted by the New York Association for the Prevention and Relief of
Heart Disease provides for full history and complete record of physical findings on each
examination. Such records will develop possibilities of prognosis in given conditions.

THE MODERN HOSPITAL PUBLISHING CO., CHICAGO
cublishers, The Modern Hospital ;

The Modern Hospital Year Book

The Nation’s Health