FAVORABLE ASPECTS OF
HEART DISEASE

with Special Reference to
the Health Officer

by

Louis I. Dustin, Pa.D.

THIRD VICE-PRESIDENT AND
STATISTICIAN

and

Donatp B. Armstronc, M.D.
THIRD VICE-PRESIDENT

of the

METROPOLITAN LIFE
INSURANCE COMPANY

>

A paper presented before the Health Officers Section, +
American Public Health Association, Indianapolis, Ind.
October 9, 1933

 
FAVORABLE ASPECTS OF HEART DISEASE
with Special Reference to the Health Officer*

BY

Louis I. Dusuin, Pu.D., Third Vice-President and Statistician,
and Donatp B. Armstrone, M.D., Third Vice-President,
Metropolitan Life Insurance Company, New York

I

ie ScopE and outlook of the
public health movement have undergone great change in the last
generation. In 1900, the deathrate from typhoid fever in the
Registration Area was 31.3 per 100,000. Last year it was only
1.1 in the same ten states which originally constituted the Area.
Today, typhoid fever is a serious problem in only a few of our
cities and in certain rural areas. In 1900, the diphtheria deathrate
was 40.4 per 100,000; last year it was 2.5 per 100,000 in the same
states. So far as diphtheria is concerned, we are well on our way
to eradicating the disease altogether. Tuberculosis, at the be-
ginning of the century, was the leading cause of death in our popu-
lation. Its deathrate then was 195.2 per 100,000, but last year it
was only 58.7. The trend of mortality from this disease is still
rapidly downward and by 1940 we are confident that it will have
become a relatively minor item in our public health program.
With the decline in the acute diseases of childhood and of early
adult life, new problems have come to the fore which demand
attention on the part of public health workers. The chronic
diseases of later life have been constantly forging ahead and today
occupy a position of outstanding importance. Over 60 per cent
of all deaths now occur after age 45, and of this total nearly two-
thirds are accounted for by chronic diseases of the heart and
arteries, Bright’s disease, cerebral hemorrhage, cancer and diabetes.
Of these, heart disease is responsible for far more deaths than any
other cause. This new situation in heart disease is becoming more
and more insistent, and for a number of reasons. It hasa just claim
upon the time and thought of the health officer, because any

*A paper presented before the Health Officers Section, American Public Health Association,
Indianapolis, October 9, 1933.

1

 
 

program of control will center about him. He can play his part
well only if his attitude is based on the facts of the heart disease
problem.

What are these essential facts? First, heart disease leads as a
cause of death. In addition, it ranks very high as a cause of
disability. Only rheumatism exceeds it in this respect. On the
basis of their recent survey of chronic illness in Massachusetts,
Bigelow and Lombard! estimate that there were approximately
84,000 persons ill with heart disease in that state alone. This
incidence is probably higher than in most states because the
population of Massachusetts has a higher average age than the
country at large. In New York City, the study of chronic illness
under the auspices of the Welfare Council? disclosed that at least
one out of every eight of the chronically ill suffered from heart
disease, and this figure did not include a large number of old
persons, many of whom suffered from cardiovascular disease in
some form. On a conservative estimate, the number of persons
suffering from heart disease in the United States is probably close
to two millions.

Another excellent measure of the current heart disease situation
is the probability of dying from the disease. Under present con-
ditions of mortality, one out of every five white males born will
eventually die from the disease. The proportion is slightly larger
for white females. Indeed, the chances of dying from it are not
only greater than those from any other single cause, but exceed
those for tuberculosis and cancer combined. These chances
increase with advancing age so that one out of every four females
at age 40 will, under present conditions, die ultimately from heart
disease, and one out of every four males at age 50.

These figures present in bold outline the great importance of
heart disease from the point of view of incidence and mortality.
A great number of the cases, however, are old people who have
lived out their life span. Their heart disease is, from one point
of view, hardly more than a manifestation of senescent changes
that are going on simultaneously throughout the body. Obviously,
heart disease of this type is not a public health problem. What isa
matter of concern to the health officer, however, is the frequency
of heart disease that is preventable or postponable, and how much
of it is premature and amenable to control through his efforts. To
throw light on this problem we must consider whether or not this

2
disease is increasing, whether various types of the disease behave
differently, and at which ages of life each type predominates.

Il

Crude figures on heart disease mortality show a very definite
rise in rates. Thus, in the Registration Area, the deathrate from
organic disease of the heart in 1932 was 184.3 per 100,000, whereas
at the beginning of the century, the rate was only 111.2 per 100,000.
An increase of over 60 per cent in the crude rates has been recorded
in the space of a generation. These figures, however, do not take
into account the changes in the age distribution of our population.
In this interval, the population of the country has increased by
62 per cent, whereas the population at ages past 45 has more than
doubled. Stated in another way, persons over 45 constituted only
17.7 per cent of our population at the beginning of the century,
but in 1930 they made up 22.8 per cent. A large part of the
increase in heart disease is necessarily a result of this increasing
proportion of older persons in our midst.

We may correct for this factor by means of deathrates standard-
ized in respect to age, sex and color. We have such a series of
corrected deathrates available, covering the Expanding Regis-
tration Area from 1911 to 1920, and the Registration States of 1920
from 1920 to 1930. The course of the standardized deathrate
from organic heart disease in that twenty-year period is shown in
Chart 1. The effect of the increasing proportion of older persons
is here eliminated. In the early years of this series, heart disease
was increasing at a rather moderate pace. The rate for the popu-
lation as a whole did not show any appreciable increase during the
influenza pandemic. The first important change in the picture
was the sharp decline in heart disease mortality immediately follow-
ing the pandemic. The deathrate in 1919 represented a new
minimum and was approximately 15 per cent below the average
for the eight years preceding. The most striking feature of this
curve, however, is the rapid and almost uninterrupted increase
since 1919. By 1922 the pre-influenza level was reached, and in the
very next year exceeded. The extent of rise has been such as to
carry the heart disease rate in recent years to a level approximately
25 per cent higher than that prevailing prior to 1918. It is clear,
then, that even making allowance for changes in the age and sex

3

 
 

composition of our people, the recorded mortality from heart
disease, compiled from official data, is higher than ever before.

STANDARDIZED DEATHRATES FROM ORGANIC HEART DISEASE
IN THE UNITED STATES *
1911 Zo 1930

STANDARDIZED
DEATHRATES
R 000

 

190
180 /

170 7

160 A]

150 LZ.

140 oe VAY
130

120

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Ae eee ee hee eee SNH L~~A—~

eo lo ee
1911 1915 1920 1925 1930
* Expanding Registration Area, 1911-1919 aad Registration States of 1920, 1920-1930

CHART 1

iit

There are two reasons, however, why we are somewhat uncer-
tain regarding the validity of the comparisons of present levels of
heart disease mortality with those previous to 1920, as compiled
from official data. In the first place, changes in heart disease
classification introduced in 1921 tended to increase somewhat the
rates from this disease, especially between 45 and 60 years of age.
In the second place, the Registration Area grew very considerably
between 1911 and 1920, and the level of heart disease rates in the
states admitted to the Area from time to time was not the same as
in the states comprised in it before. Consequently, we cannot be
certain that the variations in the rates from 1911 to 1920, and the
comparative levels before and since, reflect much more than these
changes. Another item of some importance is that earlier official

4
data did not segregate the facts for white and colored persons, and
consequently differential changes in the rates for the two races
cannot be measured.

Fortunately, in the Metropolitan Life Insurance Company, we
have kept mortality records of the many million Industrial policy-
holders in such manner that the difficulties arising from classifi-
cation changes have been avoided, and we have a separate record
for the white and colored races from the very beginning of our
series in 1911, In regard to geographical spread, the area covered

DEATHRATES FROM ORGANIC HEART DISEASE

IN THE GENERAL POPULATION

AND AMONG METROPOLITAN INDUSTRIAL POLICYHOLDERS
I9ll - 1932

TOTAL PERSONS, AGES | to 74
STANDARDIZED

DEATHRATES
PER 100,G00
160

ae
150 N

"Taber AA NL
mn

 

 

 

 

 

 

 

* United an Loe »
Lf)
110 4 A
7 me. [E Soh \ on
peas + mete, Sc e ee ae \ Ls 0 ome a
7 \ of

100 \ :

\

\ ry

\’

90

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

191] 1915 1920 1925 1930
# Expanding Registration Area, 1911-1919 and Resistration States of 1920, 1920-1930
CHART 2

by the Company has changed little and the growth in the number
of Industrial policyholders is simply in the nature of an increasing
proportion of persons living in the same communities. These
policyholders reside, for the most part, in cities and towns of the
United States and Canada, and the facts on heart disease relating

5

 
 

to them, must therefore, be construed as more typical of the urban
population of the two countries than of the total population. They
do constitute a sizeable fraction of this urban population, however,
nearly one-fourth of the total—and the greatest single sample for
which a record of heart disease mortality consistent in definition is
available. This insured group, it should be pointed out, is deficient
in its proportion of persons over age 75, and the rates for the insured
group past this age are not reliable. Consequently, the experience
is limited to ages 1 to 74. That the experience is dependable over
this range of life is seen by comparing the general course of the
heart disease rates, adjusted for age, sex and color, among these
insured persons—the upper line in Chart 2—with the trend for
ages 1 to 74 in the general population The latter is shown in the
lower line of the chart. The main features of the two curves are
similar, namely, a fairly stable level from 1911 to 1918, a sharp
decline resulting in minimal rates between 1919 and 1921, and an
unmistakable increase since that time. There is, however, one
important difference: the recent level of mortality is still slightly
below that of the pre-influenza years in the case of these Metro-
politan policyholders, whereas in the population, rates of recent
years have already far exceeded the level prevailing before 1918.

This general situation in heart disease mortality for the popu-
lation as a whole does not hold true, however, for all the constituent
parts. Analysis of the data reveals distinct differences between
the trends for men as compared with women; for white persons, as
compared with negroes; and for young persons as compared with
older ones. For the reasons previously given we must use the
insurance records for this part of our study.

Chart 3 shows for this group of policyholders the separate
trends of the heart disease rate by color and sex. The rates are
suitably adjusted to discount differences in age composition be-
tween the various groups and the changes from year to year in the
composition within each group. For white males, the trend has
the characteristic detail of the insured population as a whole,
namely, a level trend from 1911 to 1918, an upward trend since
1919 and a sharp break between the two periods. The rise since
1919 has been so great that the rates in some recent years have
reached. or exceeded the level prevailing before the pandemic.
Among white females, the course of the heart disease rate shows
somewhat similar tendencies, but there are two important differ-

6
ences. First, heart disease rates among women began to fall after
1918, a year later than in the case of men; the decline was by no
means so sharp, and the rebound has been very slight. As a result,
heart disease deathrates among white females in recent years have
remained appreciably lower than fifteen to twenty years ago.
Among colored persons, pre-influenza rates fluctuated markedly,
with no definite trend. This group likewise experienced a sharp
fall in heart disease mortality, following upon the influenza
pandemic, and a return towards pre-pandemic levels since. This
is true for both sexes, but as among whites, the rebound has been
sharper among colored males than.among colored females. There
is, then, a distinct difference between males and females in the
trends of heart disease mortality over the last twenty-two years.

TRENDS IN HEART DISEASE MORTALITY BY COLOR & SEX,AGES I-74

Metropolitan Life insurance Company , Industrial Department

 

1911-1932
STANDARDIZED STANDARDIZED
Bap 00.000. WHITE PERSONS "Figo 000 COLORED PERSONS
2

sliies YN
NHLTTITISAVAN

 

 

 

200 soo HS uy [ y / sof NL
i
NN / Ti)
2 PTT | \ TTTNUA NU 2 N
Book “Al sy
WA ZT SLL

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

i911 1915 1920" 1925 1930 191 1915 1920 i925 1930
YEARS YEARS

CHART 3

Even more significant departures from the general trend are
found at the various ages of life. Chart 4 shows the trends by
color and sex at ages 1 to 24. The four curves are in general
agreement, but distinctly different from the picture shown at all

7

 
 

ages. Among these young people, irrespective of color or sex,
heart disease rates have declined and this is true both before and
since the influenza outbreak. In young persons of both races, the
minimal rates have been recorded in recent years. Among white
persons, the rates have fallen nearly 50 per cent. The record
among the colored is not so good as among whites, but they exhibit
some improvement. In contrast to the generally unfavorable
picture at all ages combined, therefore, a very healthy situation
prevails at the younger ages.

TRENDS IN HEART DISEASE MORTALITY OF CHILDREN AND YOUNG ADULTS
Metropolitan Life Insurance Company, Industrial Department

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

I911- 1932
BY COLOR & SEX, AGES 1to24
STANDARDIZED STANDARDIZED
Be 100,060 WHITE PERSONS PER 1Gd000 COLORED PERSONS
45 45
40 40
35 35 ane ]
emales,! |
Yh
30 Fe | . 30 ta \
males

- \ J Ke N
25 NZ ic t 25 oe 4 ra

YS x J N \ i\

ANN ) LAIN A
20 \ Be 20 \/ AWA Ae
=, v
males] | SEAL UY TIM IM
NN
10 10
5 5
0 OL!
1911 1915 1920 1925 1930 1911 1915 1920 1925 1930
YEARS YEARS

CHART 4

The changes in the heart disease picture in the main working
ages of life—between 25 and 44—are brought out in Chart 5.
Among white males at these ages, there has been a rather steady
decline in heart disease mortality up to and including 1918; a
precipitate fall during the next two years to a minimum level
which was maintained through 1922; then a rebound back to the
1919 level around which the deathrate has fluctuated with very

8
moderate variations. Despite this sharp rebound, heart disease
rates in these working ages have remained approximately 25 per
cent below the pre-influenza level. Among white females, the
heart disease deathrate prior to the pandemic also showed a down-
ward tendency. The havoc which the epidemic played with
pregnant women with heart disease is shown by an abrupt increase
in heart disease rates in 1918. The next year, however, showed a
fall in the rate to a lower level than in any previous year, and since
that time the heart disease rate among women between ages 25
and 44 has shown, if anything, a downward tendency. Among the
colored, the situation is somewhat more mixed. Colored males in
this important period of life have suffered a sharp increase in
mortality so that the rates in some recent years have approached

TRENDS IN HEART DISEASE MORTALITY IN THE MAIN WORKING PERIOD OF LIFE
Metropolitan Life Insurance Company, Industrial Department

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1911-1932
BY COLOR & SEX,AGES 25 to44
STANDARDI.
PER ens WHITE PERSONS ren gate COLORED PERSONS
|
140 140 A\ / V
ANALY Males J
r g) i VY
Females IN mls,
4 os N
120 120 NCU ‘
\V \L Hi \
100 100 =
MN
80 NN 80
i Males
tok j
60 \ q SI = 60
N,
ENA er | 1] f
Females eggs ST NAN
40 chee 40
La | Rei eA tS LALIT PAC) Pt tO ASN
Ol) ot er
i911 915 1920 1925 i930 1911 915 1920 1925 1930
YEARS YEARS

CHART 5

the levels obtaining fifteen years ago. The trend has been slightly
more favorable among young colored women. On the whole, then,
the situation as regards heart disease in the important productive
years is far better today than two decades ago and as in childhood

9

 
 

and adolescence, contrasts sharply with the unfavorable condition
at all ages combined.

It is obvious from the foregoing that the increasing deathrate
from heart disease must be a phenomenon of middle life and of
old age. Chart 6 shows the deathrates in the broad age group, 45
to 74, by color and sex. Among insured white men at these ages,
the deathrate from 1911 to 1918 is almost a straight line, except
for a dip in the rate in 1915, and a moderate rise in 1917. Follow-
ing 1918 there was a sharp fall, and the low level attained in 1919
was maintained for the next two years, since when the rate has
risen sharply. In most recent years, the rate has exceeded the
level of 1911 to 1918. Among white females at these ages, also,

TRENDS IN HEART DISEASE MORTALITY OF MIDDLE LIFE AND OLD AGE
Metropolitan Life Insurance Company, Industrial Department

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1911-1932
BY COLOR & SEX, AGES 45 to74
STANDARDIZED STANDARDIZED
Pe ioe obo WHITE PERSONS PER 193.308 COLORED PERSONS
00
N
: /\
900 900 \ /\ / \
y soe | aes
|
\
800 + 800 An ! 4
Wn A \ K l LJ
a, i NK
Males 2 Vv 1 Vag
700 7 N / NL 700 f + fi!
PTT / \ / NV Females ~/ N\ i
MLA
/
600;—- / N 600
iS Pade 7 rs \ / -
\ ALAS
WW an / Y Ne
500 , 7G
WAY iy 500
ne |
400 aee8 +HHHH | | 400
Noe c ee eee ee OCC Cee
1911 1915 1920 1925 1930 1911 1915 1920 1925 1930
YEARS YEARS

CHART 6

the trend from 1911 to 1918 was practically level. After 1918, the
rate fell to new low levels, but since 1921 has experienced a rebound;
not so sharp, however, as among males. In this broad age group,
the white female rate has remained slightly below the level of the
early years of this experience. Among the colored, the situation

10

SF
resembles that among white males. Indeed, the increases in their
- deathrates from heart disease since 1921 have been so large that,
within the past five years, the rates have attained a level higher
than that of fifteen to twenty years ago.

If we dissect this broad age group further, we find that the
heart disease situation grows steadily worse with advancing age.
Thus, as Chart 7 shows, among white men between ages 45 and
4, the current rates are still below those prevailing prior to 1918.
At all ages past 55, however, the rates have not only been increas-
ing, but have attained a level appreciably in excess of those pre-
vailing in the earlier years. Among white women between 45
and 54, the rate has been remarkably stable, and has displayed

DETAILED TRENDS IN ORGANIC HEART DISEASE MORTALITY AFTER AGE 45

Metropolitan Life Insurance Company , Industrial Department
I9t} - 1932

WHITE MALES WHITE FEMALES

750

650

550

450

350

250

 

150
OR ee eee Oe oe ee ee
1911 915 1920 1925 1930 — 91 1915 (920 1925 1930
YEARS YEARS

CHART 7

 

little, if any, tendency to increase. Between 55 and 64, despite a
perceptible upward trend since 1919, the mortality in recent years
has not reached the pre-influenza level. Only at ages past 65 have
recent deathrates among white women exceeded those of earlier
years.

1l

 
 

This chart does not include curves for ages 75 and over because,
as was stated earlier, the insurance experience contains too few
persons at these older ages to give reliable deathrates. Official
statistics indicate, however, that the rise in the deathrate at these
advanced ages has gone on at a more rapid pace than for any other
period of life. This is most significant because nearly one-third
of all the deaths from heart disease occur after age 75.

Among older negroes, the situation is worse than among white
persons. The detailed rates for them in these ten-year age groups
fluctuate so widely from year to year, that it is difficult to make any
clear-cut generalizations. Among colored men, however, even
beginning with age 45, the deathrates in recent years have fre-
quently attained the level of two decades ago, and in negroes of
both sexes past 55, the rates in the past five years have been equal
to, or even exceeded those of the pre-influenza years.

Summarized briefly, then, the heart disease mortality situation
is amixed one. Certain aspects are decidedly favorable. In child-
hood and in early adult life, heart disease mortality, in the aggre-
gate, has been falling and the rates are now at minimal levels. In
white women, this improvement extends well into middle life.
Only in old age is the increase in heart disease mortality really
serious. Among colored persons, the improvement in the situation
has been much less substantial than among whites.

IV

The question has been raised by many as to whether the rise
in heart disease, even in later life, is really authentic. They assert
that the change in frequency of heart disease as a cause of death is
very largely the result either of changes in the statistical methods
of classifying deaths where two or more causes are stated by the
physician on the official certificate; of the decline in the number of
deaths assigned to senility and of the increased propensity of
physicians to specify heart disease as the cause of death where it
is accompanied by so-called degenerative changes in the kidneys
and arteries. An example of this attitude toward the situation is
the attempt of the Bolduans? to show that there has been no
increase whatever in heart disease in New York City. To demon-
strate this thesis, they bring together all the diseases of the heart—
including the acute bacterial types—apoplexy, arterial disease,

12
nephritis and half the deaths assigned to senility. At all ages
combined, the mortality from this aggregate of conditions has not
increased for New York City, but some rise is recorded at ages 65
and over, and, in the last decade, between ages 45 and 65. There
is, in some degree, a medical basis for the assumptions underlying
this reasoning, but the case for it is not proved by the purely
arithmetical procedure of adding up the deaths from this varied
list of causes. The extent of the changes in heart disease mortality
is too great to be explained away in this manner. Moreover, the
trend from this composite of diseases has certainly less validity
than the carefully compiled statistics on heart disease alone. It is
not convincing for the additional reason that, among men past 45,
there has been an increase in the deathrate from all causes some-
what parallel to that in heart disease. In older females, where the
increase in heart disease occurs only at advanced ages, the total
deathrate during old age has maintained a fairly constant level.
During this period there has been a decline of considerable pro-
portions in the mortality of old people from infections, notably the
pneumonias and tuberculosis. These declines would have resulted
in an appreciable fall in the total deathrate, but were counteracted
by an increase in the deathrate from some other cause or causes.
It is logical then to assume that at least part of the recorded
rise in heart disease is authentic.

Vv

What do these varying and contrasting trends mean? Why
should deathrates from heart disease in early life go down and the
rates in later life increase? The reasons for this diversity in trend
must be sought in a consideration of the causes and types of heart
disease which prevail in the main age periods of life. For heart
disease is not a single entity. It is a complex of many factors,
etiological and pathological. Not only are there many recognized
types of heart defects, but some of them have the same origins,
others are of different origins. Moreover, in the same diseased
heart there may coexist two or more types of structural change
which may or may not be of the same etiological origin.

It will clarify our discussion considerably if we review rapidly
the causes of heart disease and their relation to structural changes
in the heart. Unfortunately, careful study on a statistical basis

13

 
 

of the frequency of the various etiological types of heart disease
has been long in getting started, and only in recent years have
really reliable facts been collected. Even this limited material
must be handled with caution because often the groups studied
are selected from one point of view or another, and due regard is
not given to the differences in age composition between various
groups studied. The facts given in the literature must be taken as
tentative, and not as final. For them we are indebted to the
investigations of Cohn and his co-workers, 56 in New York,
White,’ in Boston, and others.8-6 Acute rheumatic fever is found
to be responsible for about 30 per cent of all cases of heart disease
in and around New York. Under age 20, however, four out of five
cases of heart disease have a rheumatic origin, and indeed, if we
exclude cases of unknown etiology, nine out of ten cases. In the
next decade of life, two-thirds of all cases have a rheumatic back-
ground; in the fourth decade more than half, and in the fifth, one-
fourth of male heart cases and one-third of female cases. After
age 50, rheumatic infection plays a relatively small part in the
causation of heart diseases.

Syphilis is responsible for about one out of twenty cases of heart
disease. But this cause shows very sharp differentials in the various
sex and age groups. Under age 30, it is relatively uncommon as a
factor in deaths except for a negligible proportion of children with
congenital syphilis. Among females, on the whole, it is also
relatively uncommon except between ages 40 and 50, when it
reaches a maximum of 10 per cent of all heart disease cases. The
problem of syphilitic heart disease is largely concentrated in men.
Between ages 30 and 40, about 10 per cent of the cases of heart
disease have this origin; between 40 and 60, about 20 per cent;
and after 60, about 10 per cent.

By far the largest proportion of heart disease is of the senescent
or arteriosclerotic type. Such cases constitute about one-half of
the total at all ages combined. They include primarily those
suffering arterial changes in the heart, and the rarer cases in which
the degenerative change in the heart muscle is not associated with
the arteries. Arteriosclerotic heart disease is found very infre-
quently before age 40, but after that age constitutes a large and
increasing proportion. Between 40 and 50, about one-sixth of
the cases are of this type; between 50 and 60, about one-half; but
after age 60 about three-fourths.

14
Other causes, in the aggregate, account for a sizeable proportion
of heart disease, but no single one of them stands out, except
hyperthyroidism, which, in women between 30 and 50, is a rather
frequent cause of heart symptoms.

The proportions just cited relate to conditions in the north-
eastern section of the country. It will be realized without going
into detail that they vary from place to place. For example, in the
south, the frequency of the rheumatic type of heart disease is much
less than in the north. On the other hand, there, and in many
communities with large negro populations, the syphilitic types are
more common. It should be noted also that the proportion of
cases of undetermined etiology differs so widely from place to place
and from study to study that they tend to make exact comparison
difficult.

Next let us review briefly the diseases of the heart structures
arising from these various causes. Endocarditis or inflammation
of the internal serous membrane of the heart is caused chiefly by
diseases of the infectious type; rheumatic, streptococcicor syphilitic.
Disease of the heart valves is frequently caused by these infections
but often it is the result of atheromatous or sclerotic changes.
Mitral valve disease is chiefly but not exclusively of rheumatic
origin. This type of heart disease is most common in youth and
middle age, and particularly affects females, among whom the
incidence is probably 50 per cent greater than in males. Aortic
valve disease is also of infectious origin, but the offending organism
is more frequently the spirochete of syphilis. Aortic disease is
most common in middle life and affects males more frequently than
females, the ratio being roughly three to one.

Myocardial disease is by far the most important type of heart
trouble. Its principal manifestation is an increase in the size of
the heart. The cause of this cardiac enlargement, whether by
hypertrophy or dilatation or both, is heart strain, the chief factors
of which are ascribed, on the one hand, to hypertension and,
on the other, to valvular disease. The latter is, as we have
seen, chiefly of rheumatic origin. But hypertensive cases greatly
out-number those with a valvular background. Degeneration
and fibrosis, the other important type of myocardial change,
result’ chiefly from coronary disease. Cases of this kind are
practically limited to middle life and old age, more especially to
the latter.

15

 
 

Now, since 1921, the mortality records of chronic heart disease
among Metropolitan policyholders distinguish two broad struc-
tural groups: valvular heart disease, on the one hand, and chronic
myocardial disease, on the other. The trend of the rates from each
of them, shown in Chart 8, has distinct bearing on the preventive
situation in heart disease. During the period for which the data
are available, the mortality from valvular disease has fallen
steadily. The chart does not show the details, but the decline in
deathrates from these conditions has affected every age, both males
and females, and negroes, as well as white persons. The rate of
fall has been greatest among young persons. Current deathrates
at ages under 25 are barely half what they were in 1921-1922.
TRENDS IN MORTALITY FROM CHRONIC VALVULAR HEART DISEASE#

AND CHRONIC MYOCARDITIS

Metropolitan Life Insurance Company, Industrial Department
I92i - 1932
TOTAL PERSONS, AGES | toT4

Myocarditis *\

Valvular Heart a

 

1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932
#* Includes chronic endocarditis YEARS

CHART 8
Between ages 25 and 44 there has also been substantial improve-
ment, although less than at the younger ages. Even past 45 years
of age, the improvement in the recorded mortality from valvular
disease has been substantial, and in white persons, curiously
enough, it is even somewhat greater than at ages 25 to 44.

16
In marked contrast with these trends are the changes in mor-
tality from disease of the heart muscle. Even among young
persons, where chronic heart disease of this type is relatively infre-
quent, there has been a slight increase in the mortality. Between
ages 25 and 44, the increases have been enormous. The rate for
white men at these ages has doubled, and for white women risen by
nearly two-thirds. Among negroes at these ages the increases are
even more striking. In middle life and old age, also, there have
been large increases in the rates for myocardial disease, and this is
most significant because the bulk of the deaths from these con-
ditions are concentrated in the ages past 45. Among white men
past 45, deathrates for myocardial disease have doubled, and
among white women have gone up by 75 per cent. Among colored
persons, current levels of myocardial deathrates at these older ages
are two and one-half times their level of a dozen years ago.

Striking parallels with this increasing myocardial mortality are
found in the similar trends from coronary disease and from angina
pectoris. Full recognition of the importance of coronary disease
has been slow in developing. Consequently, only in 1930 did it
appear as a separate entity in the classification of causes of death.
In the short interval of two years, however, the recorded mortality
from it has doubled. For angina pectoris which is usually sympto-
matic of coronary trouble, the mortality record is more complete.
The deathrate from this condition has more than doubled in the
last twenty years. Due to the close association in a great many
cases of coronary disease with myocardial degeneration, these facts
are of especial significance, though coronary disease is often re-
ported under age 50, especially in males, without associated signs of
ageing.

‘These diverse trends of valvular and myocardial disease and
also of coronary disease are so sharply defined that we must be
cautious in interpreting them. Both White!” and Halsey'8 point
out that changes in medical opinion constitute a major factor in
the situation. A generation ago, attention was focused on valve
changes in heart disease. But, largely as a result of the teachings
of the late Sir James Mackenzie, the efficiency of the heart muscle
of cardiac patients was more and more stressed. Despite a ten-
dency to return to the earlier attitude, the influence of Mackenzie’s
views still predominates. Unfortunately, we cannot measure
the effect of these shifts in medical opinion upon the heart disease

17

 
 

picture; but, on the whole, we are convinced that the trends of the
deathrates indicate the direction of change, even if they are not a
good measure of its degree.

These contrasting trends are of great import in the light of the
facts given on the etiology of heart disease in relation to structural
changes in the organ. Cardiac disease of young persons is, as we
have seen, chiefly due to morbid changes in the heart valves,
usually of infectious origin. The decline in heart disease mortality
in early life, therefore, is not surprising, for these germ enemies of
mankind have been the objects of successful attack. The incidence
of rheumatic fever and of other rheumatic type conditions, the
communicable diseases of childhood and certain other infections,
has long been decreasing. This development is too familar to
warrant recounting in detail. The result of it has been a reduction
in the frequency of heart disease at the ages where this background
is the usual one. This change in the heart disease picture is greatest
in early life, but continues well up to age 50. Among men in the
broad working ages when syphilis is so often the cause of aortic
damage, better control of this disease has also played a part in
reducing heart mortality of the valvular type. The decline in
syphilis mortality among white men has been real and substantial.
Moreover, late manifestations of syphilis have probably been re-
duced by better and more intensive treatment, resulting in a
greater proportion of cured cases. This aspect of the situation
does not show as much improvement among colored men, but this
phenomenon may be a statistical artifact because syphilis is
probably more frequently diagnosed in colored men than formerly.

It is logical to connect the decline of heart disease mortality
among young persons, and presumably its incidence, too, with the
decline in incidence or mortality from syphilis, acute rheumatic
fever, the communicable diseases of childhood, and other diseases
of bacterial origin which are the frequent precursors of heart
disease at those ages at which it is declining. But actual proof is
lacking. At the Metropolitan, we have tried to prove these re-
lationships statistically by computing coefficients of correlation
between the deathrates of several of these diseases with the death-
rates from chronic heart disease, using suitable intervals between
each pair of rates and choosing our age groups in such manner that
the rates would refer to the same cohort of individuals. In this
investigation, we used the mortality statistics of the State of

18
Massachusetts for the years 1870 to 1930, so that our period of
observation would be sufficiently long. Our results, however, were
substantially negative. In view of the etiological background of
heart disease in children and young adults, one would perhaps
expect the relation between heart disease and the infectious dis-
eases of childhood to show itself when statistics of mortality rates
from the pertinent causes are compared for specific age groups over
a series of years. But, as a matter of fact, the after effects of these
childhood diseases are so varied and spread out over so long a period,
that the method of correlation, howsoever applied to the mortality
data, appears to be incapable of showing the relationship between
the decline in these bacterial diseases in early life and in heart
disease at succeeding ages. We frankly admit the failure of our
investigation of this aspect of the problem, but we hope that it
will be taken up by other research workers. It is worthy of serious
study.

VI

The attitude which the health officer may take toward the
improvement in heart disease mortality in early life, which is in a
degree synonymous with the reduction of endocardial and valvular
disease, is justifiably one of satisfaction. Many forces have, of
course, played a part in the result. Much of it represents the
advance of medical science and the efforts of physicians everywhere.
A good part of it is probably the result of public education in health
matters and of betterment in living conditions of the masses. But
no factor has been of greater importance than the work of public
health officers and their co-workers. To them is due a large part
of the credit in reducing heart disease in the young and in adults
in their most productive years, and they may be proud of their
share in it.

It would seem that the attitude toward the increasing heart
disease in later life should be a very different one. Many have
been concerned about this development. Why cardiac mortality
at these later ages of life has increased has been a matter of wide
conjecture. Much has been said regarding the pace of modern
life in explaining it. But the picture is not very clear. It is true,
of course, that the crowding of immense populations into cities,
their intense activity, and the excitement in which increased earn-
ings have enabled people to indulge are not conducive to orderly

29

 
 

and reposeful living. The many strains of modern life on the
nervous system and indirectly upon the heart are by no means
negligible, but in how far they add to the incidence of heart disease
and its mortality is not easy to determine. In contrast with these
harmful effects of modern life, no one can deny that very con-
siderable benefits to the health and well-being of the masses accrue
from the advances in modern science and technology. On the
whole, men today, whether on the farm or in industry, work less
hard than before. Machinery carries most of the burden of the
work and, consequently, the heart strain from hard manual labor
in which a very large proportion of our population had to engage
in times past, is much less common today than formerly. Under
conditions of present day life the masses are, in general, better fed,
better clothed, better housed, and receive more frequent and
better medical attention. In the face of all these advantages of
modern life, one must proceed slowly in regarding the increase in
its pace as the correct explanation of the rise in heart disease.

Part of the increase may very reasonably be ascribed to better
knowledge and treatment of heart disease. The many improve-
ments in medical technique and facilities, and the greater familiarity
of the physicians with these improvements would have this effect.
Take, for example, the electrocardiograph, the X-ray, and other
laboratory procedures which have been developed for testing heart
function and determining heart size. The result has been more
frequent identification of cases, but the proportion of the increase
in heart disease due to this factor is a matter of congratulation
rather than of concern. The same may be said of better treatment
of patients with heart disease that prolongs life and often enables
useful members of the community to carry on many of their
activities.

Whatever the cause, it seems certain that the increase in heart
disease mortality at the older ages must be accepted as a real one.
It is our conviction, however, that the various conjectures and
explanations which would cause us to look upon this situation with
alarm are largely uncalled for. In our view, and we think it the
proper one for the public health officer to take, this phenomenon
is not a discouraging development, but is a natural result of lower-
ing the mortality at the younger ages. To the extent that this is
true, the increase in heart disease may surely be looked upon as a
reward of accomplishment. By bringing under control the im-

20
portant communicable diseases, tuberculosis, typhoid and many
other conditions, we have enabled larger numbers of individuals
to survive to the later ages of life than ever before. There is reason
to believe that a large proportion of the individuals so saved are
of weaker constitution than those who formerly attained middle
age and, consequently, the middle-aged today are, on the average,
less able to round out a full expectation of life. This is, however,
a moot question.

So far as this country is concerned, we have, further, the
evidence of the differential mortality of native and foreign race
stocks. Earlier studies by one of us,!”° of mortality from all
causes, and from heart disease in particular, show that the lowest
rates are found among the native white population. The foreign born
and their children have suffered consistently higher rates from all
causes of death and from heart disease. Since, in the course of time,
they have become a progressively larger fraction of our white popu-
lation, they have tended to increase these deathrates in later life.

Another reason for our concern about the increased mortality
from heart disease among the old has arisen, as Cohn2! has aptly
pointed out, from a choice of terms. We have become accustomed
to call changes in the heart, which are an accompaniment of ad-
vancing age, ““degenerative’’ and this term has conditioned our
attitude towards them. But we know that such changes are
perfectly natural and are going on not only in the heart but
throughout the whole body. Essentially, functioning tissue is
gradually replaced by non-functioning or connective tissue, and,
according to the site or degree of this change, the function of the
various structures suffers more or less interference. Many of these
changes through the body have no serious effect on longevity and
are hardly more than symptomatic as, for example, the loss of
keenness of sight and hearing, the increased brittleness of the
bones and the graying of the hair. In the heart and other vital
organs, the case is different. In the heart, senescent or degener-
ative changes limit the efficiency of the heart and, despite the in-
crease in size of the heart, result in its eventual failure. Or these
changes directly or indirectly may result in injury to the muscle
wall as, for example, following thrombosis or infarction—types of
vascular accidents which are fraught with danger to the heart.
Frequently the damage is so serious that death results in a few
hours or days. Since the bulk of heart disease in later life is of

21

 
 

this senescent type, often hastened, it is true, by infections of
various types, it follows that a large part of the heart disease at
these ages is a matter of little if any practical concern.

The heart picture, therefore, in its aggregate, is an encouraging
one, in spite of the increasing deathrate from cardiac disease. At
the older ages where it is most frequent and where it is increasing,
the health officer is really least concerned and, indeed, may look
upon it as a measure of the effectiveness of his earlier work. This
does not mean that he should look upon the problem of heart
disease with indifference. From the point of view of its control,
there is every reason to look forward to a continued improvement
in mortality from heart disease in children and young adults, par-
ticularly from the valvular conditions. But further accomplish-
ment along these lines will be a result largely of his continued
efforts in combatting infections such as rheumatic fever, diphtheria,
scarlet fever and syphilis, and in providing public facilities for their
prevention. For the unfortunates who may still acquire heart disease
in early life, he must see that adequate care is available, particu-
larly for convalescents. The public health officer must be active
in pushing projects for better housing of the poor because we know
definitely that this will be fruitful in reducing still further the
incidence of rheumatic infections.

Little may be expected in the way of reduction of heart disease
in later life, particularly from myocardial disease. The health
officer need. not be concerned about deaths of this type which are
the result of the inevitable breakdown of the organism with advanc-
ing age. But even though he may not check the upward course of
myocardial disease, he should not neglect that part which is
premature and responsible for much unnecessary suffering and
disability among persons still in the prime of life. Very material
benefit may be expected to accrue from education in better health
habits, especially in the value of a moderate amount of exercise
and of sufficient rest. Of especial importance is the promotion of
the periodic health examination of persons in middle life. Many
cases of heart lesions in their early stages may thus be detected,
enabling the affected individuals to derive the benefits of prompt
treatment and suitable alteration in their mode of life. The health
officer should be prominent in advancing such measures. He will
find in them further scope for his work and the further rewards of
real accomplishment. |

22
REFERENCES

1 GrorcEe H. BiczeLow and Hersert L. Lomparp, Cancer and Other Chronic
Diseases in Massachusetts, Houghton, Mifflin Co., Boston and New York,
1933, p. 18.

2 Mary C. Jarrett, Chronic Illness in New York City, Columbia University
Press, Vol. 1, p. 148.

3 CHaRLES F. Botpuan and Nits W. Botpuan, Is the Appalling Increase in
Heart Disease Real? Journal of Preventive Medicine, Vol. 6, No. 4, July, 1932,
pp. 321-333.

4 AtrreD E. Coun, Statistical Studies Bearing on Problems in the Classification
of Heart Diseases, 1. Introduction, American Heart Journal, Vol. 1, No. 4,
April 1926, pp. 442-445.

5 Joun Wyckorr and Cxuarre Line, Statistical Studies Bearing on Problems
in the Classification of Heart Diseases, 11. Etiology in Organic Heart Disease,
American Heart Journal, Vol. 1, No. 4, April 1926, pp. 446-470.

6 May G. Witson, Cuarre Linee and GENEvA CroxForp, Statistical Studies
Bearing on Problems in the Classification of Heart Diseases, III. Heart Disease
in Children, American Heart Journal, Vol. 4, No. 2, December 1928, pp.
164-196.

7Paut D. Warts and T. Ducxert Jonss, Heart Disease and Disorders in New
England, American Heart Journal, Vol.3, No.3, February 1928, pp. 302-318,
8 J. Epwin Woop, T. Duckett Jongs and Ray D. Kimprouen, The Etiology
of Heart Disease, American Journal of the Medical Sciences, Vol. 172, No. 8,
August 1926, pp. 185-194.

9 CHarLeEs T. Srone and Frances R. Vanzant, Heart Disease as Seen in a
Southern Clinic, Journal of the American Medical Association, Vol. 89, No. 18,
October 29, 1927, pp. 1473-1477.

10 Merritt M. Myers and Joun H. Peck, Occasional Heart and Lung Clinics
in a Rural State, American Heart Journal, Vol. 3, No. 3, February 1928,
pp. 287-301.

11 Hat M. Davison and J. C. THoroucHMman, A Study of Heart Disease in the
Negro Race, Southern Medical Journal, Vol. 21, No. 6, June 1928, pp. 464-469.
2 Pair B. Marz, Statistical Studies Bearing on Problems in the Classification
of Heart Diseases, V. Heart Disease Among Ex-Service Men, American Heart
Journal, Vol. 4, No. 3, February 1929, pp. 313-335.

13T. Homer Corren, The Incidence of Heart Disease in the Pacific Northwest,
American Heart Journal, Vol. 5, No. 1, October 1929, pp. 99-103.

147,. E. Vixo, Heart Disease in the Rocky Mountain Region, American Heart
Journal, Vol. 6, No. 2, December 1930, pp. 264-273.

15 Epwarp H. Scuwas and Vicror E. Scuuuze, Incidence of Heart Disease
and of the Etiological Types in a Southern Dispensary, American Heart Journal,
Vol. 7, No. 2, December 1931, pp. 223-234.

16 CLARENCE L. Laws, The Etiology of Heart Disease in Whites and Negroes in
Tennessee, American Heart Journal, Vol. 8, No. 5, June 1933, pp. 608-615.

17 Paut D. Warts, Heart Disease, Macmillan Co., New York, 1931, p. 300.
18 Ropert H. Hausey, Etiology of Heart Disease, Journal of the American
Medical Association, Vol. 98, No. 8, February 20, 1932, pp. 593-598.

19 Louis I. Dusiin, Factors in American Mortality, A Study of Deathrates in
the Race Stocks of New York State, 1910, American Economic Review, Vol.
VI, No. 3, September 1916, pp. 523-548.

2 Louts I. DusBiin and GLappEN W. Baker, The Mortality of Race Stocks in
Pennsylvania and New York, Quarterly Publication of the American Statistical
Association, March 1920, pp. 13-44.

21 AurRED E. Conn, The Degenerative Forms of Heart Disease, Hospital Social
Service, Supplement No. 2, July 1933, pp. 56-68.

23
 

 

 

 

 

 
APPENDIX

The following tables contain the funda-
mental statistical material on heart dis-
ease mortality discussed in this article.
They will make available to students the
detailed experience of the Metropolitan
Life Insurance Company on the subject,
as well as certain official data of the
United States. It is hoped that these
tables will be useful to public health
workers and others who are engaged in
research problems of heart disease.

 
 

TABLE 1

Deathrates from Organic Heart Disease in the General Population* and
Among Metropolitan Industrial Policyholders—Total Persons, 1911-1932.

 

STANDARDIZED DEATHRATES PER 100,000

 

 

 

 

Att AGES Aces 1-74
YEAR METROPOLITAN
nited State nited Sta 1909 1920
United Sis | Une ree Classification of|Classification of
Heart Disease | Heart Disease

1939 144.0 150.1
19ST ee ee 142.7 149.1
19350--2 =. 180.3 115.9 143.7 153
19279". 186.7 120.4 151-2 158.9
1928 184.9 119.8 149.6 156.6
1927. 171.0 112.9 141.0 147.8
1926 2. 173.8 114.6 146.0 152.6
1925: . 162-1 108.8 138.7 144.8
1924 155.9 106.3 134.4 140.0
1923 2... 154.4 105.5 138.7 144.1
1922 2. 145.5 100.2 131.1 135.6
1924. 136.3 95.2 121.0 123.9
19207. 138.2 96.6 15S
119s 127.9 90.6 POG Qe,
4913. =. 149.7 110.5 1565-0 =o os
TOUT... 148.4 108.9 15G4 Sl
1916.3... 147.0 106.5 154052 es
1915 3... 145.3 108.8 VAR .2
IIA 140.2 105.7 15205 2
1913. 2: 136-7 103.0 W551
1912... 140.6 106.1 155i.
LOE. 2: 139.4 105.9 Vg le ee

 

 

 

 

 

 

*Expanding Registration Area, 1911-1919 and Registration States of 1920, 1920-1930
Heart disease classification of 1909 in 1911-1919 and classification of 1920 in 1920-1930.

26
Deathrates per 100,000 from Or

TABLE 2

ganic Heart Disease (1909 Classification)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Among White Persons, By Sex and Age Periods. Ages 1 to 74 Years.
Metropolitan Life Insurance Company, Industrial Department, 1911-1932.
y MA EE S
ea AGES AGES AGES AGES AGES AGES AGES
1-74* 1-24* 25-44* | 45-74* 45-54 55-64 65-74
193284— 157-9 12.0 58.5 706.3 242.2 1371 1901.4
193TS3| 153.8 12.0 56.8 691.2 2525 696.6 1864.7
1930..] 153.7 23 57.9 686.6 240.2 72 1795.6
1929..| 164.6 15 LE 61.9 14 252.1 746.4 1995.4,
1928..| 163.0 14.5 60.8 727.8 263.5 748.8 1935.2
1927 | 152-9 15.8 60.6 666.2 239.8 686.3 1782.3
1926..) 156.2 164 59.8 687.8 244.4 706.8 1852.5
1925..| 447.2 16.1 56.6 645.2 22.3 707.5 1659.7
1924..) 142.0 174 60.2 609.4 228;8 625.4 1611.6
1923..} 145.8 17.6 59.7 628.9 215.8 647.0 1714.6
1922. = 133:8 18.5 51.6 575.8 206.6 57525 1574.1
1921..} 119.7 19.7 49.5 501.6 171:6 502.2 1393.6
1920..} 121.6 18.4 49.0 DISS 190.6 SLE 1398.9
1919..| 124.6 16.3 60.3 519.8 186.6 534.8 1386.5
1918..] 159.9 DO 78.6 659.8 263.1 660.2 1725.4
1917..] 169.6 20.7 18.2 TITS 288.2 715.4 1875.9
1916..| 161.0 20.5 80.5 668.8 278.0 698.0 1670.0
T1915). | 215212 20.6 79.1 624.3 242.0 630.0 1645.0
1914..} 160.6 20.7 82a 663.9 275.0 660.0 1720.0
1913..} 163.0 19.7 88.5 668.7 270.0 660.0 1760.0
1912..| 163.0 19.8 90.7 665.5 270.0 700.0 1670.0
1911..} 165.0 99.1: 86.8 675.9 285.0 665.0 1750.0
EekMwWA EE Ss
YEAR AGES AGES AGES AGES AGES AGES AGES
1-74* 1-24* 25-44* | 45-74% 45-54, 55-64 65-74,
1932.4. 1907 12.5 44,4, 539.1 164.6 52322) year
1931..| 120.3 14.1 A4T.7 522.3 167.7 500.0 1519.0
1930..} 120.5 13.6 42.7 532 7 166.5 510.4 1562.6
1929, .| 126.4 154 48.3 551.0 167.2 52733 1626.3
1928 \2 12537 173 4755 542.9 168.9 51529) 1604.3
1927..| 120.0 L2 46.7 513.9 162.4 510.1 1473.1
1926..| 125.6 16.2 51.5 538.6 164.6 531.4 1558.7
1925.-| 119.6 LET 51.0 503.6 166.4 494.6 1433.7
1924..| 116.9 185 48.4 491.5 158.7 473.7 1420.9
1923. |. P2381 17.9 48.7 D20-5 160.2 509.1 1542.7
1922../; 120.8 19.4 46.8 512.4 161.0 467.5 1541.8
1931..|° 1154 20.7 48.2 476.5 151.2 457.3 1389.7
1920:.|- 1202 18.7 53.8 499.8 173.4 495.4 1390.6
1919..} 115.9 18.4 54.8 476.6 107% 450.8 1351.9
1918..| 142.3 26.9 80.8 552.1 207.6 530.3 152351
LOL. 13720 22:8 63.5 562.7 208.3 545.5 1549.2
1916..| 138.1 22.0 64.4, 568.7 215.0 512-0 1625.0
1915...) 135.7 23.2 64.4 552.9 200.0 550.0 1510.0
1914..| 136.8 25.4 66.5 549.8 210.0 520.0 1520.0
1913...) 138.1 22:6 72.0 955.2 218.0 580.0 1420.0
1912..| 140.8 24.4 71.0 566.5 210.0 582.0 1500.0
TOL 14321 25.9 72.0 572.8 215.0 585.0 1516.0
*Standardized.

27

 
 

TABLE 3

Deathrates per 100,000 from Organic Heart Disease (1909 Classification)
Among Colored Persons. By Sex and Age Periods. Ages 1 to 74 Years.
Metropolitan Life Insurance Company, Industrial Department, 1911-1932.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

28

Mea kh ES

YEAR AGES AGES AGES AGES AGES AGES AGES

1-74* 1-24* 25-44* 45—-74* 45-54 55-64 65-T4
1932-.|— 205.1 13.9 106.6 878.8 405.0 948.2 2031.6
193Eos 227 18.3 122.6 958.1 421.4 1060.7 2220.6
19803.) 23522 17.6 138.2 978.5 475.1 1011.3 2282.5
19D Ors |e 22587 19.3 131.4 934.2 426.5 1015.7 2146.6
1928..| 216.8 22.5 L2G. 884.6 448.0 958.0 1925.5
1GQ7 |e 20828 18.8 120.4 863.6 401.5 945.6 1958.3
1926..| 218.9 16.8 121.0 921.6 406.6 1013.3 2148.9
1925.-|5 213.0 18.4 12341 882.8 445.5 911.3 2009.4
1924..} 196.1 Ze 1277. 778.8 SO-e 874.3 1709.1
1923..| 184.8 23.9 114.2 Aoe.6 310.1 784.6 1595.6
1909).-\6 W553 18.7 99.0 720.4 SOG 719.5 1652.3
1921..} 159.0 21.2 98.2 628.8 291.4 650.8 1496.9
1920..| 168.1 18.3 109.9 666.6 326.6 695.6 | 1528.5
TONOs se 75.5 22.3 117.6 682.6 328-0 747.3 1518.9
1918..| 229.0 20:1 147.2 925.2 460.7 1044.8 1971.8
1917. .)° 232.5 24.7 141.2 940.4 468.7 1083.2 1960.8
1916.2. 2077-3 22.0 147.2 805.0 429.0 918.0 1615.0
1915..| 197.6 18.1 135.5 783.0 412.0 903.0 1567.0
EOT4R le 222 24.8 138.0 837.5 460.0 835.0 1860.0
1913..| 218:0 20.9 146.8 865.5 475.0 970.0 1730.0
1912. .| 22927 14.9 155.5) 929.7 430.0 1050.0 2060.0
EOLT.. 12-199'5 QA 137.4 765.7 380.0 830.0 1690.0

Ke Me AE ES

YEAR AGES AGES AGES AGES AGES AGES AGES

1-74* 1-24* 25-44" | 45-74" 45-54 55-64 65-74
1932..| 196.0 15.7 115.6 812.2 382.8 897.0 1817.0
1931..|. 196.1 23.0 111.0 799.8 380.0 807.4 1918.5
1930..]| 208.9 18.6 122-0 860.9 382.3 900.9 2077.3
1929.) |: 215ct Past 126.3 870.6 422.5 864.0 2090.9
1928..| 209.7 19.1 125.4 859.6 423.8 923.4 1924.0
1927. -\s 19322 22.0 121.9 770.3 392.4 825.6 1693.2
1926..| 196.2 25.6 12253 775.9 342.8 849.9 1808.5
1925..} 190.9 23.9 121.5 153.5 380.7 819.1 1637.7
1924...) 190.3 26.4 119.0 747.6 384.3 801.8 1626.7
1923..| 192.9 18.8 Aled 793.3 412.3 894.3 1636.7
1922-4\6 Wv4el 23:1 110.5 684.0 362:2 702.0 1515.4
1921; |) 364.5 24.7 122.3 610.8 337.0 615.6 1339.0
1920..| 179.0 25.7 110.3 703.3 345.9 684.9 1701.0
1919..| 179.6 28.3 118.0 687.3 388.1 690.3 1487.4
1918..| 209.6 34.2 143.9 789.1 397.2 898.2 1651.1
IGM 207-7. 28.8 134.1 809.1 452.9 881.4 1638.1
1916..\- 207.7 24.4 13527. 818.7 448.0 818.0 1820.0
1915..| 196.6 25.0 133.3 1O2-a 439.0 820.0 1530.0
1914..) 188.8 23.5 L33sE A292, 457.0 730.0 1440.0
1913..| 201.6 Qed 138.3 Tei? 402.0 806.0 ish
TOAD S25 = 20757. 30.0 146.7 786.2 470.0 840.0 1542.0
1911..| 204.1 SEL 148.7 761.4 469.0 850.0 1390.0

*Standardized.
Table 4

Trends in Heart Disease Mortality at Ages 75 and Over. By Color and Sex.
United States Death Registration States of 1920 from 1920-1930
and Expanding Area* from 1911-1919.

 

 

 

DEATHRATES PER 100,000
YEAR WHITE WHITE CoLORED COLORED
Maes FEMALES MALES FEMALES
1930 3890.7 3720.4 3518.3 2731.2
#920 |g... 4009.0 3914.5 3516.3 2927.1
1928... 4034.5 3888.7 3422.7 2836.8
TOOT 3642.8 3505.8 3335.2 2528.8
1926... 3. 3743.2 3682.1 3336.9 27411,.0
1995 2S 3455.6 Sacl8 3109.5 2618.6
1974... 3280.7 3143.9 3079.2 2427.2
1923 5... 3270.3 3193.6 2721.4 2415.5
1ORe 3111.6 3027.4 2431.7 2139.0
BOOT 2884.6 2826.6 2351.8 2081.2
1920..5.22 . 3012.0 2928.6 2538.9 2181.7
1919 2 2601.3 Bog oe ae
TOTS. 2... 2112.6 BOO 3 oe ae,
1Ol7 3 S. 2786.7 CORO ke Se i pe el ae
TOTO. 2842.3 BU oe ee ee
TOPS. 2846.2 Ob ce eo el
AOA 2708.9 Poe ee ae ee
HOS 2 2562.6 Doone oh ee el ee
OTe 2637.2 POU Se
LOTT 2598.4 Bo ee a ae ee

 

 

 

 

 

*Without distinction as to color.

2$
 

TABLE 5

Standardized Deathrates per 100,000 from Chronic Endocarditis and Valvular Heart
Disease and from Chronic Myocarditis. By Color, Sex and Broad Age Periods.
Metropolitan Life Insurance Company, Industrial Department, 1921-1932.

 

Cotor; Sex; AGE 1932} 1931) 1930) 1929) 1928} 1927| 1926) 1925) 1924 1923) 1922) 1921

Curonic ENDOCARDITIS,
VALVULAR DISEASE:
Total Industrial Dept.

All ages, 1 to 74 years.| 40.6} 44.8] 49.4] 53.2) 55.3] 56.0] 60.6] 60.9] 65.5) 70.5| 68.2 67.8
Wuite Mates:

 

 

All ages, 1 to 74 years.) 41.0) 43.3] 48.1] 52.5] 55.1] 55.6| 60.3] 60.4] 65.4] 69.2] 65.61 63.4
Ages 11024... 8.1) 8.4) 9.6) 11.0) 10.3) 12.3} 12.6] 13.0) 13.7] 14.2] 15.4) 16.8
Ages 25 to 44.....: | 27.4) 26.1) 28.0) 31.2} 31.4) 31.9] 32.5) 31.4] 35.7] 37.4] 34.0) 32.3
Ages 45 to 74...... 151.7/165.2)184.1/198.8/213.8|210.5/233.4/234.6|252.21268.5/251.21238.9

Waite FEMALES: '

All ages, 1 to 74 years.) 34.8} 39.7) 42.0] 45.6] 47.6] 49.0] 53.31 54.0] 56.8) 64.1] 63.5! 65.8
Ages 14024... 8.5} 10.5} 10.1) 11.4] 13.3} 13.1) 13.1] 14.4] 15.7] 15.3] 16.1] 17.3
Agés 25044 ....2 23.3) 26.1} 23.6) 27.1] 26.7| 27.9) 31.3] 30.9] 31.2] 32.5] 32.3] 35.0
Ages 45 to 74...... |124.4)140.5)157.7/167.7|173.5|179.5)197.2/197.8|208.5|246.0/241.01245.9

CoLorep Mauss:

All ages, 1 to 74 years.) 74.2} 85.4/106.3} 99.3] 98.6! 96.7/104.8/106.0|113.0/114.9|108.0| 98.3
Ages 1to24...... CS TO9 10.8) 12.3) 14.3 12-5 19.4 12.5. 14.2) 17:5) 14 5 17
Ages 25 to 44...... 49.5} 52.6] 69.3} 64.9] 62.3! 58.1] 65.8] 70.8] 85.5] 76.6] 63.6] 68.3
Ages 45 to: 74:..... 293.4/339.2|423.9/389.7|/384.7/386.01417.0/415.5/424.7/439.6|431.6|365.7

CoLoRED FEMALES:

All ages, 1 to 74 years.| 69.7} 78.0} 88.8|101.9|101.4| 98.0/101.9| 99.0/117.3/112.7/110.611

ees
co
bh
ree
cen
nN
i
jal
bo

0
Ages 1to24...... 14.0] 13.4} 16.1] 19.5] 19.1] 20.6 11.8] 19.7] 2
Ages 25 to 44...... : 67.9] 58.3] 64.6] 65.6 38.9] 77.5] 66.5| 71.5] 8
Ages 45 to 74...... 263.1)297.5|340.21393.8/407.8/373.01382.61410. 1/442.61459.2/418.7/375

Curonic Myocarpitis:
Total Industrial Dept.
All ages, 1 to 74 years.| 82.3) 78.9) 78.9) 85.6) 80.8] 72.8] 72.2) 64.5) 56.4) 54.4) 47.5) 34.9

Waite Mates:

ASS
eo
nN
>
SS
NN
nN
N
\o

 

 

 

 

 

 

 

 

 

 

 

 

 

 

All ages, 1 to 74 years. 93.5} 90.3| 88.3] 98.5] 91.9] 83.0] 81.6] 72.8 63.7] 60.9| 51.8] 36.7
Ages Eto 24... .. PS) 2) LA 23) le a 15 eS 6s 123 LO
Ages. 25 to4d4 17.6) 18.7; 19.4) 23.1) 20.5) 19.0) 18.0) 14.3) 15.1) 14.0) 10.1) 6.6
Ages 45to 74...... 4.62.1/444,5)432.4/478 .0/447.4/403.91398.2/358.1/308.2/295.1/254.3/181.0

Waite FEMALES:

All ages, 1 to 74 years.| 70.6} 66.2) 68.0) 72.3) 69.0} 62.5] 62.8) 56.6] 50.3} 49.5] 45.1) 34.1
Ages 1.to 24... = E36 16 2 a 8 LS eG eae esi EL
Ages 25 to 44...... 1274) 13:4) 12°4|_ 15:4) 15:0) 13.3) 1325| 1327] 11 3)-10 2) 9:1] - 6.5
Ages 4510 74... > 349 .9/324.3/335.5/352.1/335.21303.2/305.61273.2/24.4.3/242.01218.8/167.2

CoLornep MALEs:

All ages, 1 to 74 years.| 90.7} 99.2) 93.3] 95.9] 93.3] 82.2) 81.1] 72.8] 55.7] 44.3] 38.9] 29.6
Ages Lio24. |. Le 23 3-5), M8) 38 sells ee, 1-6) 2-Al EO. = 6
Ages 25 to 44...... 29.8} 38.8} 41.3) 40.2} 43.9) 35.8} 27.5} 30.9] 21.9] 17.5] 13.8] 8.7
Ages 45 to 74... . 4.29.7/457.4/418.8)/438.814.13.5|369.8)382.51330.0/255.4/200.3/179.01141.3

CoLorED FEMALES:

All ages, 1 to 74 years.) 87.2) 82.6} 89.9} 87.9) 84.3] 71.9] 69.8] 58.1| 48.9] 52.1] 37.8] 29.4
Ages 1 to 24... D5 33) 320! 6.0). 229] 26 29), 23) 29) 2.6 29. 7
Ages 25 to 44... 2. 32.6| 32.8) 35.7) 36.7] 40.7} 36.5} 35.5} 26.6] 20.8] 21.9] 18.2} 16.0
Ages 45 to 74...... 4.05 .7/376.4/409 .7|390.4/373.61315.4/305.1/258.9|217.7/233.6|165.6128.5

 
TABLE 6

Deathrates from Angina Pectoris, 1911-1932, and Diseases of the Coronary
Arteries, 1930-1932. Total Persons—Ages 1-74, 45-74. Metropolitan

Life Insurance Company, Industrial Department

 

STANDARDIZED DEATHRATES PER 100,000

 

 

 

YEAR ANGINA PEcToRIS Coronary DISEASE
AGES AGES AGES AGES
1-74 45-74 1-74 45-74.
1932-2. .. 11.4 53.4 10.3 47.8
W934 ce: 11.5 53.8 8.0 36.5
1930...... 11.1 52.2 5.6 25.8
1929... 2.0: 11.3 51.4 a oan
1928... 6. 11.4 53.1
1007 eee. 10.7 50.2
1926...... 10.3 47.5
1925...... 8.2 37.0
1924...... 7.3 32.9
1923...... 7.2 33.2
1922...... 6.4 28.2
1921...... 6.3 29.1
1920...... 5:5 25.5
1919...... 5.2 23.0
1918...... 5.3 24.0
1917...... 5.1 23.4
1916... : 4.4 20.5
1915.0... 5.0 22.9
1914...... 5.0 21.5
1913, ..:.. 5.2 23.2
1912)... 5.4 22.9
191)... 4.4 19.3

 

 

 

 

 

31
 

 

 
 
METROPOLITAN LIFE INSURANCE COMPANY PRESS
NEW YORE, U.S.A.

78265