Reprinted from the New York Medical Journal for April 10, 1920. ILE INCI DENCH OF HEART DISEASE IN ADULIS. By Louis. > DUBLIN; Phew. New York, Statistician, Metropolitan Life Insurance Company, New York. There are today two outstanding public health problems in America, namely, tuberculosis and heart disease.. Both are responsible for about the same amount of sickness and death. There are about two million persons in the United States who are seri- ously impaired from heart disease and also from pulmonary tuberculosis and approximately one hundred and fifty thousand of them die each year from each of these two causes. These two fields of public health work have been very differ- ently exploited. That of tuberculosis has for over a period of thirty years received the greatest public attention. Many millions- of dollars have been spent annually in the campaign against this condi- tion. Thousands of doctors have been trained in the special diagnostic and therapeutic work for the tuberculous. Large numbers of sanatoria and of hospitals for the care of the tuberculous have been established. ‘In fact, a well defined, nationwide program has been in operation against this disease. The results obtained have been commensurate with the effort expended, for during the same period the death rate from tuberculosis has been reduced about a third. On the other hand, in the campaign against heart disease, virtually nothing has been done. The Association for the Prevention and Relief of Heart Disease is only a few years old and is the pioneer in the field of preventing heart disease. The surface has hardly been scratched, but we have come to *Read at the New York Academy of Medicine, February 5, 1920, before the Association for Prevention and Relief of Heart Disease. Copyright, 1920, by A. R. Elliott Publishing Company. Dublin: Heart Disease in Adults. realize how large_a field of public health work is presented by the incidence of heart disease. The evidence upon which these statements are based is derived from various sources. In the first place, about two per cent. of persons examined by the insurance companies are rejected each year because of various organic heart defects. This agrees with the findings in the examination of in- dustrial workers, such as those of Dr. J. W. Schereschewsky, of the United States Public Health Service, among garment workers in New York; of Robinson and Wilson: among employees in various industries in Cincinnati; and of Harris and Dublin among food handlers in New York. About the same results were obtained by the army medical ex- aminers in connection with the draft and camp examinations, 2.6 per cent. of the men examined having been rejected on account of heart defects. Likewise children in the schools of New York show on examination an incidence between one and one half and two per cent. of important cardiac defects. We may, therefore, summarize with the statement that about two per cent. of the population or, in continental United States, over two million persons of all ages, suffer from heart impairments. Medical research has also shown that the presence © of heart disease seriously curtails the longevity of persons thus afflicted. Studies of statistics of the New York and the Metropolitan life insurance companies indicate that insured persons suffering from well compensated mitral regurgitations at the time of their insurance have a subsequent mortality varying from fifty to 100 per cent. in excess of the normal for persons at their respective ages. It should be remembered that these cases of mitral regurgitation were carefully selected as to every other physical character and that this form of heart disease is probably the least serious of the more important cardiac impairments. Similar results were shown for females in these insurance studies. 2 Dublin: Heart Disease in Adults. For other heart impairments, such as aortic regurgitation and aortic stenosis, the excess mortal- ity is much higher than for mitral regurgitation. MORTALITY FROM HEART DISEASE. It should not surprise us, therefore, in view of the heavy incidence of heart impairments and of their serious effect on longevity, to find high death rates from heart disease. In 1917, the figures for the registration area showed organic heart disease to be the first cause of death, with a rate of 153.1 in 100,000. In 1918, the year of the epidemic, the rate for heart disease was 152.3, second only to pneumonia and influenza. Among the insured lives in the industrial population, organic heart disease is second only to tuberculosis. These are very high death rates and if they have risen to first place in the list of causes of death, it is because the mortality from heart disease has re- mained high for a number of years, while that from tuberculosis has steadily declined. A remarkable condition as to the death rate from heart disease in 1919 is disclosed by the experience of the Metro- politan Life Insurance Company. The rate for the first time in years dropped about twenty-one per cent., compared with the preceding year. But this drop is probably only a temporary one and may only reflect the result of the influenza epidemic of the preceding fall and winter. It should be remembered that during the last three months of 1918 and the first few months of 1919 the influenza pneumonia epidemic carried off a large number of persons who had impaired hearts who would have lived for some time longer had not the influenza prevailed. The heart disease death rate went up sixteen per cent. in the last three months of 1918 coincident with the epidemic. Many deaths from heart disease, which would normally have occurred in 1919, took place in 1918 and the 1919 rate accordingly dropped. It is interesting also to find that during 1919 the im- provement in the death rate from heart disease was felt at every age period. . Dublin: Heart Disease in Adults. The death rate from heart disease varies con- siderably with the age period of life, being lowest at the early ages and highest at the advanced ages. But it must not be supposed that deaths from heart disease are of rare occurrence even in early life, for the death rate under twenty-five years is as high as that from typhoid fever. For ages between twenty-five and thirty-four years, the death rate from heart disease is as high as for lobar pneu- monia; between thirty-five and forty-four years, it is higher than for Bright’s disease, and after forty- five years the death rate is higher than for any other cause of death. The accompanying table presents the rates in 100,000 for persons insured in the In- dustrial Department of the Metropolitan Life for the period of 1911 to 1916 inclusive. MortaLity FRoM OrGANIC DISEASES OF THE HEART CLASSIFIED BY Cotor, SEx anp By AGE PERIOD. Death Rates in Joo,000 Persons Exposed, 1911 to 1916. ——— _ W hite—, ———Colored-—— Age Period. Persons. Males. Females. Males. Females. All ages—one and over 140.1 125.9 137.0 191.0 202.0 BECO so aysra io oye, olen oes 7.2 7.0 6.4 14,1 14.6 GrtO 00 cco = 6.2 14.9 18.2 11.4 I4.1 TOs COA asa as do ss 26.7 2237, 3154 19.9 28.3 Teh tQ; SO} ae ce oss 0b 30.2 28.7 31.2 20.4 34.9 2010! 24 ee 30:02 20.5 30.4 22,2 42.8 2h S10 84. oes de 53.5 51.6 45.6 89.6 72.8 95% 10 AAs ae is es T2185 120.1 92.6 201.2 2IT.7 4540 54 SES Ae 253.6 259.0 201.1 416.0 433-1 Shs €0.04 neu as cue 604.8 641.2 526.8 SOSA 2787.8 65 10-74-35... 1523.1 1624.2 1443.0 1702.2 1530.3 75 and Sovers i447 2808.1 3033.1 2703.1 2647.8 2613.2 ‘The death rates, it will be observed, are very dif- ferent for the two races and the two sexes. Colored persons suffer much more seriously than do white persons. This is especially marked during the first years of life and during the period of thirty-five to fifty-four, when the rates for the colored are almost double those for the whites. Almost without - exception the rates for females are higher than for males up to and including the age period of twenty to twenty-four years. After this age period, how- ever, the situation is reversed, the death rates for 4 Dublin: Heart Disease in Adults. males being much higher than for females. This is uniformly true for white persons but there are a few exceptions among the colored. It would appear, therefore, that these organic heart diseases in their higher incidence among adult males strike heavily at the chief or only income producers of families, often after long periods of sickness in which the wage earner has been unable to work actively all or part of the time. These diseases thus bring about hardship and distress which cannot be shown in figures. In fact, if it were possible to calculate the money loss to the country through deaths from the heart affections and the long periods of sickness which precede them, the importance of cardiac disease economically would be much more impres- sively demonstrated than is possible by the publica- tion of mere numbers of deaths and the corresponding death rates. I believe I have presented sufficient evidence to justify the statement with which I began this paper, namely, that heart disease is as important as tuber- culosis as a public health problem. A _ splendid opportunity awaits the medical profession in its attack on this disease. A carefully planned program must be developed by Federal, State, municipal and private agencies against this disease. The older organization of public health activities, which was directed toward sanitation of the environment, must be augmented by activities aimed at improvement of the physical state of the individual. The con- quest of heart disease and the related disorders of the vascular and renal. systems will depend in a measure upon the continuation of time tried en- deavors in public hygiene, but more so upon the knowledge of personal hygiene disseminated by the educational arm of health services. Especially promising is the development of the routine annual physical examinations of children and young adults. In many instances these will disclose incipient heart lesions which instruction and treatment may either abort or control. |