With the cooperation of E. M. Marvin, Assistant Professor
of Medicine, Yale School of Medicine.

This is only part of the story, however. Organic heart disease is one of a closely related group of maladies in which the heart, arteries and kidneys are more or less affected by degenerative changes. The chief of such allied conditions are apoplexy and nephritis and these two headings during the last five years have consistently appeared among the six leading causes of death (along with cancer, pneumonia and diseases of early infancy). Heart disease during this period has been first (except in 1922 when it was second); apoplexy has been third or fourth, nephritis, fifth or sixth.

These three conditions taken together account for an average of 672 deaths a year in New Haven, with a rate of 382 per 100,000 or one-third of the total annual death rate from all causes (these figures based on 1922-6 average).

Fifty years ago, (average for 1876-8) the combined rate for these three diseases was only 173 per 100,000 or one fourteenth of the mortality from all causes. Twenty years ago (in 1906-8) it had risen to 415 or one-fourth of the mortality from all causes! An analysis of the death rates from organic heart disease by age periods, made by Mr. H. H. Walker and Miss M. E. Farris, brings out the facts indicated in the table below.

MORTALITY FROM ORGANIC HEART DISEASE
BY AGE PERIODS.
DEATHS PER 100,000.

It will be noted that under the age of 20 the last four years show an increased death rate which may possibly be due to fuller recognition of cardiac conditions at early ages as a result of the emphasis placed on this matter in the children's cardiac clinic. In any case the need for increased attention to the problem of cardiac disease among school children is clearly indicated.

From the age of 20 to the age of 39 on the other hand the last 14 year period shows a decrease in mortality and from the age of 40 to the age of 69 the last nine year period shows a decrease. Only at ages of 70 and over is the rate from organic heart disease still on the increase. (The drop in a]l rates during the period 1918-1922 is due to the influenza epidemic which killed off many individuals with weak hearts who would otherwise have died in 1918 and in succeeding years from this cause but whose deaths in 1918 were credited to influenza).

It will be noted from the detailed figures to be cited in Chapter XXIX that while the rate from both organic heart disease and nephritis tended to rise pretty steadily up to 1915-1917, since that date, the rate from heart disease has remained almost stationary, while the rate from nephritis has shown a marked decrease. This is due to improved methods of medical diagnosis, many deaths in which the whole arterio-renal complex was involved, and which were once put down to Bright's disease (or nephritis) being now more correctly classed as due primarily to diseases of the heart and arteries. The best picture of the whole situation can be obtained by considering the sum total of deaths from organic heart disease, cerebral hemorrhage and apoplexy and Bright's disease and nephritis taken together. In the table below and in the accompanying diagram a smoothed curve has been prepared for this whole group of diseases by adding together the deaths from each of the three causes for each year and then averaging the total for each year with the total for the preceding and succeeding year.

DEATH RATE FROM ORGANIC HEART DISEASE, APOPLEXY
AND NEPHRITIS COMBINED.
Smoothed 3-year averages. Deaths per 100,000.

It is evident that the mortality associated with damage to, and degeneration of, the heart, arteries and kidneys rose steadily and rapidly from 1877 to 1907, then rose slowly to 1916, fell sharply to 1920 and then rose again, but slowly.

In general there is distinct encouragement in these figures to hope that the increasing mortality from heart disease is really in process of abatement. The outlook is distinctly better than that revealed by our analysis of cancer statistics in a preceding chapter.

It is evident, then, that many different phases of the public health movement have an indirect but powerful effect upon the mortality from cardiac, arterial and renal diseases. These elements in the death rate cannot fail to be influenced by all that is being done for the control of scarlet fever and diphtheria, for the correction of defective teeth and tonsils, for the reduction of venereal disease and for the promotion of habits of healthy living. We are inclined to believe that the check in "the rising tide of heart disease ' manifest in New Haven since 1907 and the encouraging reductions manifest at ages under 70 are the result of such efforts.

In addition to these indirect methods of control it is of course essential that every community should provide specific machinery for dealing directly with the problem of heart disease when it actually arises. Furthermore it is vital that such machinery should be, so far as possible of a preventive, rather than of a purely ameliorative type. We cannot too strongly emphasize that the heart, like any other organ of the body, has remarkable powers of repair if the healing force of nature be given its opportunity. Even with the person past middle life, where actual repair may be improbable the observance of a proper hygienic regimen may postpone for years any serious results; and with children such a regimen will frequently lead to a complete elimination of the abnormality.

In dealing with the diseases of the heart, arteries and kidneys we need, then, just as in the ease of tuberculosis or cancer, provision for early diagnosis, for medical and hygienic treatment and for after care.

Among adults the chief agency to which we can look for bringing early cases of heart disease to the attention of the medical profession is the Visiting Nurse Association. During the year 1926 the Association discharged 45 cases of cerebral hemorrhage and apoplexy (13 visits having been made to the average case since its admission) 68 cases of heart disease (29 visits per case) and 101 chronic diseases of the genito-urinary system (8 visits per case). The work of the association, however, is chiefly confined to the care of definite and pronounced conditions of this type and but little is done either in the seeking out of early cases for examination or in the follow-up care of post-hospital cases.

During 1927 the statistics of these clinics were as follows:

It is of interest to note that the total number of patients carried increased from 246 in 1926 to 299 in 1927; the number of visits to both clinics from 846 in 1926 to 880 in 1927; and the number of new patients in the children's clinic from 37 in 1926 to 56 in 1927.

Excellent hospital care for heart cases is of course provided at all three hospitals.

In New Haven the Children's Community Center furnishes excellent facilities for the after-care of children with cardiac impairments but on a very limited scale. Twenty five cardiac cases were thus cared for in 1926. The Convalescent Cottage where such cases are received has, however, only 24 beds, a figure quite insufficient to meet the needs which would be revealed by an intensive program of school medical inspection. It seems probable however that the facilities for convalescent cases at the Community Center could be materially expanded without additional building costs.

For adult cases there are no good provisions at all in New Haven for post-hospital care; and this deficieney seems to us an urgent and a serious one.

New Haven is adequately provided for in the central feature of community machinery for dealing with heart disease, - a well-equipped cardiac clinic. Our weaknesses lie in ease-finding through adequate medical inspection of school children (a problem discussed in an earlier chapter ) and in provision for post-hospital care. The after care of adults will be considered in a later chapter. The after care of children clearly demands expansion of the admirable facilities of the Community Center.

Finally, in the case of these diseases of the heart, arteries and kidneys, as in the case of cancer, it seems most desirable that the Health Department should recognize the existence of this vital problem by providing central facilities for studying the statistics of these diseases and coordinating the general program for their control. Continuing study of mortality from the various diseases of this group by age, and of their relation to rheumatic fever, acute communicable disease and focal infections should prove of the greatest interest and value.

The problems of medical inspection of school children and of after care for convalescent adult cases being dealt with elsewhere, there remain three specific suggestions for the development of this important field of public health work in New Haven.

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