EH^w^ Class Hl^ \ :^3J^ PRESEN'TKU BY l^nistnUh to ..-CiOj\gr.ftaalofiBl..LiJt»rsry. mitlj tl)t CEompltm^nta of liftr0|iolttan ^xtt Jusuranc^ fflompattg N^m fork (Etta ffiopHNnmbfr .1.7.48 V MORTALITY STATISTICS OF INSLRED WAGE-EARNERS AND -THEIR FAMILIES EXPERIENCE OF THE METROPOLITAN LIFE INSURANCE COMPANY INDUSTRIAL DEPARTMENT, 1911 TO 1916, IN THE rNITED STATES AND CANADA LOUIS I. DUBLIN, Ph.D. STATISTICIAN "WITH THE COLLABORATIOX OP EDWIX W. KOPF AflSISTA2tT STATISnCAK AND GEORGE H. VAX BUREX erPEETISOB, STATISTICAl. BUBEAC NEW YORK Metropolitan Life Insurance Company 1919 Gift; <^5 To HALEY FISKE, Esq. President Metropolitan Life Insurance Company whose broad vision of the aims and purposes of Industrial Insurance inspired the produc- tion of this work. PEEFACE. It has been one of the major activities of the Statistical Bureau of the Metropolitan Life Insurance Company to compile the medical statistics of mortality among policyholders of the Industrial De- partment. After seven years' work, data are available in consider- able detail for the many millions of policyholders who constitute its membership. In fact, nearly fifty million years of life and more than 635,000 deaths are represented in the period 1911 to 1916 covered in this report. The volume is an analysis of this material and is submitted as a contribution by the Company to the public health movement in the United States and Canada. Facts herein compiled have already had wide public uses. From time to time, reports have been issued in scientific and medical journals on various diseases and conditions. A large part of the whole field of mortality statistics has been considered and a mass of important scientific information has been put into circulation. The completeness and accuracy of the data have commended the studies to physicians and others who are guided in their work by medical statistics. The present volume is, however, more than a compilation of the papers and reports which have appeared in recent years. The previous discussions have been much amplified and much new in- formation has been added. The report is, in fact, a comprehensive treatment of the entire field of mortality as related to wage earners and their families. This work should serve as a supplement to general population mortality statistics as published by the Bureau of the Census and by the several State and municipal registration offices. Large areas of the country still outside the Eegistration Area of the United States are included in the insurance field and for these sections there are as yet no authentic compilations of mortality statistics. This report also contrasts the mortality experience of wage earners and of the general population. The medical profession especially will profit from the study of the individual diseases with their de- tail of death rates by color, sex and age period. In some cases, the figures will suggest new lines of medical research. IV PEEFACE. It is appropriate that the insurance companies should contribute to the advance of medical science and to the public health move- ment. The extensive health work carried on by the Metropolitan demands that a specific answer be given to the many persons who are interested to know what the effect of the life conservation pro- gramme has been on the mortality experience of policyholders. Health and social workers all over the country are awaiting a report, showing the extent of the mortality saving among insured lives and the diseases and conditions which have been most affected. In presenting this volume to the public, the author desires to acknowledge how completely this and other scientific contributions from the Statistical Bureau are the result of the continued co- operation and encouragement of the executives of the Company. To Dr. Lee K. Frankel, Third Vice President, his obligation is especially great for the many suggestions concerning the develop- ment of the Bureau's work. It is appropriate also that proper acknowledgment be made to the medical profession of the United States and Canada. About thirty-five thousand letters from thousands of physicians have materially helped to complete and clarify the medical data in obscure cases. Finally, it is a pleasure to acknowledge the loyal and effective assistance received through- out the progress of this work from Mr. Edwin W. Kopf, Assistant Statistician, and from Mr. George H. Van Buren, Supervisor, both of whom I am honored to have associated with me in this publi- cation. Louis I. Dublin. Sept. 12, 1918. CONTENTS PAGB Preface iii-iv Chapter I — Introductory 1-10 Uses of Industrial Insurance Medical Statistics^ — Scope of the Present Statistics with respect to Area, Occupation, and Color, Sex and Age — Technical Processes of Compiling the Statistics. Chapter II — Mortality from All Causes of Death Com- bined 11-29 Deaths and Death Bates according to Color, Sex and Age — Death Rates of White Persons in Insurance Experience Com- pared with Death Eates in Expanding Eegistration Area of the United States, by Sex and by Age Period — Factors Influ- encing Industrial Insurance Mortality — Downward Trend of Mortality among Insured Wage Earners. Chapter III — Mortality from Principal Causes of Death 30-42 'Sources of Data — Improving Accuracy of Certified Causes of Death of Wage Earners — Nomenclature and Classification of Diseases. Chapter IV — Tuberculosis 43-64 Mortality according to Organs or Parts Affected — Mortality from Tuberculosis of the Lungs according to Color, Sex and Age Period — Types of Pulmonary Tuberculosis Mortality among Wage Earners — Mortality among Insured Wage Earners and Population of Expanding Registration Area Compared — Trend of Tuberculosis Mortality — Tuberculous Meningitis — Abdominal Tuberculosis — Tuberculosis of Other Organs. Chapter Y — Organic Diseases of the Heart 65-71 Heart Disease Mortality according to Color, Sex and Age Period — ^Mortality among Insured Wage Earners and among Population of Expanding Registration Area — Trend of the Death Rate — iCertification of Diseases of the Heart. Chapter VI — Pneumonia 72-86 a. Pneumonia (Lobar and Undefined) : Mortality from' Pneumonia according to Color, Sex and Age — Pneumonia as a Cause of Death among Wage Earners and among General Population of Expanding VI CONTENTS. Registration Area Compared — Effect upon Pneumonia Mortality Statistics of Improvement in Certification of Causes of Death. h. Bronchopneumonia: Mortality from Bronchopneumonia according to Color, Sex and Age — Trend of Bronchopneumonia Mortality — Bronchopneumonia among Insured Wage Earners and among Population of Expanding Eegistration Area Com- pared' — Reliability of Mortality Statistics of Broncho- pneumonia. > Chaptee YII— Blight's Disease 87-92 Complications of Bright 's Disease with Cardiovascular Dis- eases — ^Bright's Disease Mortality according to Color, Sex and Age Period — Bright 's Disease among Insured Wage Earners and among General Population of Expanding Regis- tration Area Compared — Trend of the Death Rate. Chapter VIII — External Causes of Death (Accident, Suicide and Homicide) 95-146 a. Accidents, including Unspecified Violence: Accident Death Rate according to Color, Sex and Age Period — ^Fatal Accidents among Insured Wage Earners and among Population of Expanding Registration Area Compared — Fatal Accidents according to Specific Means or Nature of Injury: Traumatism by Pall — Accidental Drowning — ^Burns (Conflagration Excepted) — Steam Railroad Accidents and Injuries — Automobile Accidents and Injuries — ^Street Car Accidents and Injuries — In- juries by Other Vehicles — Traumatism by Machines — Acute Accidental Poisonings — Absorption of Deleterious Gases — Traumatism by Firearms — Industrial Fatal Acci- dents — Trend of the Accident Death Rate. h. Suicides : Suicide Mortality according to Color, Sex and Age Period — ^Suicide Death Rate among Insured Wage Earn- ers and Population of Expanding Registration Area Compared — Suicide according to Principal Means of Injury: Suicide by Poison — Suicide by Asphyxia — Sui- cide by Hanging or Strangulation — Suicide by Drown- ing — Suicide by Firearms. c. Homicides: Homicide, all Forms of Injury, by Color, Sex and Age Period — Homicide Mortality among Insured Wage Earn- ers and among General Population of Expanding Regis- tration Area — Trend of the Homicide Dearth Rate. CONTKNTS. Vll PAGE Chapter IX— Cancer 147-173 -Certification of Cancer as a Cause of Death — Cancer Mortal- ity according to Organs or Parts Affected — Cancer Mortality according to Color, Sex and Age Period — Cancer among In- sured Wage Earners and among Population of Expanding Eegistration Area of United States Compared — ^Eolation of Cancer to Economic Condition^ — Trend of the Cancer Death. Rate — Detailed Mortality Statistics of Cancer according to Organs or Parts: Cancer of the Stomach and Liver — Cancer of the Female Genital Organs — ^Cancer of the Breast — Can- cer of the Peritoneum, Intestines and Eectum — Cancer of the Buccal Cavity — Cancer of the Skin — Cancer of Other Organs or of Organs not Specified. Chapter X — Cerebral Hemorrhage and Apoplexy 173-177 Certification of Cerebral Hemorrhage and Apoplexy as a Cause of Death — Mortality according to Color, Sex and Age Period — 'Cerebral Hemorrhage among Insured Wage Earners and among Population of Expanding Eegistration Area Com- pared — Trend of the Death Eate, Chapter XI — Four Principal Communicable Diseases of Childhood 178-192 Measles, Scarlet Fever, Whooping Cough, Diphtheria and Croup. Chapter XII — Diarrhea and Enteritis 193-196 Diarrhea and Enteritis as Primary and Secondary Causesi of Death — ^Mortality according to Color, Sex and Age Period — ^Diarrhea and Enteritis Mortality among Insured Wage Earners and among General Population of Expanding Eegistration Area — Trend of the Death Eate from Diarrhea and Enteritis. Chapter XIII — Diseases and Conditions Incidental to the Maternal State 197-214 Methods of Studying Maternal Mortality — ^Color and Age Incidence of Principal Causes of Maternal Mortality: All Puerperal Diseases and Conditions Combined — Puerperal Septicemia — Puerperal Albuminuria and Convulsions — Acci- dents of Pregnancy — Puerperal Hemorrhage — ' ' Other Acci- dents of Labor" — ^Maternal Mortality among Insured Fe- males and among Population of the Expanding Eegistration Area Compared: All Puerperal Diseases and Conditions — Puerperal Septicemia and Puerperal Albuminuria by Age. Chapter XIV — Diseases of the Arteries ; Typhoid Fever ; Cirrhosis of the Liver; Influenza; Diabetes .... 215-232 Viii CONTENTS. PAGE Chapter XV — Appendicitis; Hernia, Intestinal Ob- struction; Syphilis; Chronic Bronchitis; Rheu- matism; Acute Bronchitis; Alcoholism, Acute and Chronic 333-248 Chapter XVI — Pellagra; Malaria; Angina Pectoris; Ulcer of Stomach ; Acute Poliomyelitis 249-263 Chapter XVII — Miscellaneous Diseases and Conditions 264-290 Dysentery — Erysipelas — Purulent Infection and Septicemia — Gonocoeeus Infection — Anemia, Chlorosis — ' ' Other Chronic Poisonings" — Encephalitis — Meningitis — Cerebrospinal Fever — 'Locomotor Ataxia — Softening of the Brain — Oeneral Paralysis of the Insane — Convulsions — "Other Diseases of the Nervous System" — 'Diseases of the Ears' — Pericarditis — Acute Endocarditis — Embolism and Thrombosis — ^Diseases of the Xiarynx — Pulmonary Congestion, Pulmonary Apo- plexy — Asthma — ^" Other Diseases of the Eespiratory Sys- tem" — .Diseases of the Pharynx — "Other Diseases of the Stomach (Cancer Excepted)" — 'Biliary Calculi — "Other Diseases of the Liver" — Simple Peritonitis (Nonpuerperal) — Acute Nephritis — "Other Diseases of the Kidneys" — ^Dis- eases of the Bladder — Diseases of the Prostate — Uterine Tumor (Noncancerous) — "Other Diseases of the Uterus" — Salpingitis, Other Diseases of the Female Genital Organs — Gangrene — Old Age — Ill-Defined Diseases. Supplement 293-302 Mortality Statistics of Insured Wage Earners, 1917. Appendix A 304-365 Table Showing Number of Deaths from each Specified Dis- ease or Condition. Classified by Color, Sex, and by Age Groups. Period 1911 to 1916. Appendix B 366-376 Table Showing Number of Deaths from each Specified Dis- ease or Condition, and Death Bates per 100,000 Exposed, for the Period 1911 to 1916, and for each Calendar Year. Appendix C 377-384 Effect of System of Inquiry to Physicians upon Death Kates of Principal Diseases and Conditions; with Tables. Appendix D 385-387 Standardized, or Corrected Death Kates. Metropolitan In- dustrial and United States Kegistration Area Death Kates, all Causes, Corrected on Basis of Standard Million of Popu- lation of England and "Wales, 1901. Index 389 et seq. MORTALITY STATISTICS OP INSUEED WAGE EARNERS AND THEIR FAMI- LIES IN THE UNITED STATES AND CANADA. CHAPTEE I. Inteoductoky. Public Health and Social Data of the Industrial Population. This report is presented as a contribution to the facts on the vitality of American wage earners. The great Metropolitan family of ten million policyholders is, more than any group for whom data are available, typical of our industrial population. The policy- holders are bound together by many ties which justify and add in- terest to a presentation of the facts of their mortality. This report is intended, however, to be more than a compilation of death rates. It is hoped that it will serve as a contribution to the public health and social welfare movements of recent years. The six year period covered by the report, 1911 to 1916 inclusive, is coincident with the period during which a wide programme of life conservation has been developed by the Company for its policyholders. Education in personal and civic hygiene, the care of the sick by visiting nurses and a number of other activities have been put into operation to improve the health of this large body of insured men, women and children. The facts which will be presented should, therefore, show what has been achieved through this programme and what still remains to be done in checking preventable sickness and premature death. Experience has proved that the ever broadening movement for life conservation must rest upon a firm foundation of well established facts. Area Covered hy These Data. These data are of interest and value to public health and social workers because they are comprehensive. They relate to an area 2 1 2 MORTALITY STATISTICS OF INSURED WAGE EARNERS. which includes nearly all the states of the United States and the provinces of Canada. The statistics, therefore, reflect the sanitary and social conditions prevailing throughout the industrial popula- tion of two great national units. The only states not included in this experience are Mississippi, North and South Dakota, Wyom- ing, Colorado, Texas, Nevada, Arizona and New Mexico. It should be remembered that even in these states reside a considerable num- ber of policyholders who transact their business by correspondence with the Home Office of the Company in New York City. It may be said, therefore, that the figures are truly representative of the entire wage earning population of the United States and Canada. The geographic range of the data is much broader than that of the Eegistration Area established by the United States Bureau of the Census for the collection of mortality statistics of the general popu- lation of the United States. A large proportion of the insured wage earners reside in the so-called non-registration area and the facts for them will be included in our compilation. The im- portance of this will be brought out in some detail in the discussion of some diseases and conditions whose incidence is confined very largely to certain sections of the country where state-wide registra- tion of mortality does not as yet exist. In fact, the data for insured wage earners presented herein will for some time remain the only authentic compilation of mortality for these areas. Wide Range of Occupations among Insured Wage Earners. The facts presented in this report are unique also because they present for the first time a connected and detailed analysis of the facts of mortality among the industrial workers of the country. All the important industries and occupations are represented. Laborers form the largest single group, followed by teamsters, drivers and chauffeurs, by machinists, by textile mill operatives, by clerks and office assistants in the order named. In fact, all the more skilled industrial workers are represented, and in a proportion not very different from that found among occupied persons in the general population. The diversity of occupations among white males in this mortality experience will be seen by referring to page 87, of Bulletin 207, United States Bureau of Labor Statistics, March, 1917. This document displays the occupational mortality experience of the Industrial Department of this Company, accord- ing to principal causes of death. INTEODUCTOET. 3 Women and Children in Wage Earners' Families. The members of wage earners' families are also accounted for in good measure in this collection of data. A very large proportion of the total number of persons observed are the wives and children of wage workers. In this respect, it is believed that this study pre- sents for the first time a discussion of the facts of mortality among women and children of the wage earning groups of the American population. We shall see later in our discussion of the age char- acteristics of this group of insured persons that a fairly close corre- spondence with the age distribution of the general population is maintained for a considerable span of life. Although all the statistics which follow include the women and children in wage earners' families, reference is usually made to the group as that of insured wage earners, the full title being thus abbreviated for simplicity. Mortality Data of the White and Colored Races. The facts also display the mortality characteristics of both the white a-nd colored races among the insured wage earning popula- tion. These facts of comparative mortality, considered according to sex and age, are practically unavailable in any official vital sta- tistics for the general population. Such comparisons between the mortality of the white and colored races as do exist have been based upon figures which included all classes of the white population on the one hand and all classes of the colored population on the other. For purposes of determining race characteristics of mortality, these comparisons are invalid because of the sharply different environ- mental circumstances of the groups. The colored race in the United States, especially in urban centers of population, suffers sanitary and other social disabilities which must be discounted before fair comparisons of colored with white mortality can be made. When the statistics of white and colored wage earners are compared, how- ever, much of the objection to the usual figures for white and colored mortality is removed. The insurance data have the further advantage that the number of colored persons is large, covering all urban areas in the North as well as in the South. The data are also representative of both sexes and of all ages of colored persons exclusive of infants. 4 MORTALITY STATISTICS OF INSUEED WAGE EAENEKS. Number and Composition of the Insured Group as to Color, Sex and Age. This widely distributed and representative group of wag« earners contributed very nearly 54,000,000 years of life for observation in the mortality experience of the period 1911 to 1916. Of this num- ber, more than 47,000,000 years of life, or 87.5%, pertained to white policyholders and nearly 6,700,000, or 13.5%, to colored pol- icyholders. It is evident that there was a sufficient number of lives exposed in this inquiry to warrant drawing reliable conclu- sions. This mass of data, considered in relation to its wide geo- graphic distribution, its special application to the wage earning group of the population, its substantial characteristics as to color, sex and age classes, and the completeness of the registration of the facts is, in our opinion, unparalleled in the history of American vital statistics. The following table gives the color and sex characteristics of the data: TABLE 1. Number and Percentage op Policyholj)ers 1911 to 1916, Classified BY Color and by Sex. Experience of Metropolitan Life Insurance Company. Industrial Department. Color and Sex. Number. Percentage. Total 53,796,547* 100.0 White 47,098,458 87.5 Male 21,389,717 25,708,741 6,698,089 39.8 Female 47.8 Colored 12.5 Male ' 3,051,956 3,646,133 5.7 Female 6.8 * strictly speaking these represent years of life exposed during the six year period and not so many different persons. The method employed to obtain this figure from the number of policies in force will be explained on page 8. Very nearly one-half of the total, (47.8 per cent.) were white females. The proportions of the white and the colored, respectively, in this group of policyholders, are different from those found in the general population of the Eegistration Area for deaths in the INTRODUCTORY, O United States. The proportion of negroes represented in this in- vestigation is nearly three times that found in the expanding Eeg- istration Area of the United States. For the latter area, over the period 1910 to 1915, 4.6 per cent, of the total estimated population was of negro extraction. This variation in our data is due pri- marily to the choice of localities in which the Company conducts industrial life insurance business. It has been thought desirable, therefore, to confine our comparisons in the later sections of this report to specific race, sex and age classes and not to discuss to any great extent the aggregate results of both white and colored mortality experiences. Age Constitution of the Insurance Experience. The age composition of the group of policyholders observed in this mortality investigation is also of interest, especially when it is desired to make comparison of our data with those for the general population. In the following table we present a comparison of the TABLE 2. Pbrcentagk Distribution of Estimated Number of Classified by Age Period for each Sex, Policyholders Metropolitan Life Insurance Company, Industrial Department, 1911 to 1916, and Estimated Population of Expanding Registration Area of the United States, 1910 to 1915. Males. Females. Age Period. M. L. I. Co., 1911 to 1916. Reg. Area, 1910 to 1915. M. L.I. Co., 1911 to 1916. Reg. Area. 1910 to 1915. All ages — one and over 100.00 100.00 100.00 100.00 1 to 4 5 to 9 10 to 14 15 to 19 20 to 24 25 to 34 35 to 44 45 to 54 55 to 64 65 to 74 75. and over .... 9.35 15.05 13.62 12.30 10.14 14.55 10.18 7.37 4.95 2.15 .32 8.30 9.45 9.05 9.38 10.12 18.15 14.49 10.34 6.07 3.33 1.33 7.59 12.27 11.05 10.43 10.11 16.72 12.80 9.53 6.29 2.78 .44 8.57 9.82 9.45 9.98 10.27 17.33 13.81 9.72 5.96 3.53 1.57 percentage of policyholders and of estimated population in the several age classes. The matter of color distinction is not of basic importance in this discussion of age distribution and the data are MORTALITY STATISTICS OF INSURED WAGE EAENEES. O 10 Si o .2 2 (0 a ■o Ui u c c .3 a. 3 o O < O c « o o 41* in £ n U O) (0 u U E «i- ■o o c «s c <0 o o 0> «. ^ o •»• T- o 0) o *" Ol ^ n c ^■i c E o k w Q. 1 «> Q 1 ra M 10 m 3 ^ * •jj ? !5 S ^ S § * a "^ s ^ - - - - t — c^ " " — t- « "^ * — 5 rn J - ^ ># i? - - s - il - — ■o - H « i- (rt "1 r^ "»■ N 0^ ;s^ ^ ^ •S _ _ a o ^ **? t^ 1 ^ 1 1 K) lo N r- >«; 2 -., . s ■^ t -* o> ? * - N ?: E 't- is : 2> ^ 1-^ N» ■fr -1 ^- — 5 ^ t—i—t J crp 2 ^ - >0 - ^ - vj o - I-) - « V) 'i ?> ^ VS " ^ 2 ■♦■ " ^ Si 1 1 3 INTEODUCTOEY. 7 accordingly presented, in this particular instance, by sex only, for all classes of insured persons combined and for all race groups of the general population in the Eegistration Area of the United States. Comparisons are confined to ages one year and over because no children under one year of age are included in the insurance ex- perience. In the foregoing table we find a considerably larger bulk of both males and females under twenty years of age in the insur- ance experience than in the general population experience. In the population group, we find a slightly greater representation of women at the child-bearing ages than among the insured females. The main working period of life contains a larger representation of males of the general population than of males in the insured group. The graph on page 6 shows the tendency of the population group to bulk more heavily in the later ages of life. Together with Table 2, it emphasizes the necessity for considering age and sex distinc- tions in analyzing the experience of the two groups. Comparisons between the population and insurance experience can be made with safety only when the higher average age of the population group is discounted by confining such comparisons strictly to similar age and sex classes. Composition with Respect to Other Factors. The composition of the group of policyholders with respect to nativity, parentage and other factors which materially affect a mor- tality experience, is also different for this group of insured wage earners than for the general population. There are no figures available at the present time to indicate thp precise proportions of native and foreign born persons nor of the number of persons of the several foreign white race stocks among the insured. It is not possible, therefore, to say how much our figures are affected by the single factor of nationality or by the racial mortality characteristics of the foreign white stocks in our experience. It should be borne in mind that these policyholders reside almost altogether in cities and towns and therefore have all the characteristics of an urban population. Technical Processes of Compiling the Data. The foregoing comment has described briefly the broader charac- teristics of our data — their scope and application to the study of 8 MORTALITY STATISTICS OF INSURED WAGE EARNERS. the public health problems affecting the wage earning population. In order better to understand the exposition of the detailed data in the report, it will be well to view in summary the chief tech- nical processes employed. Estimating the Number of Policyholders Exposed to Risk-. The registers of an industrial life insurance company do not show the number of separate persons exposed to risk. The ac- counts of mortality are in everyday actuarial practice related only to the policy exposure. Industrial insurance medical statistics, however, require that a reliable estimate of the number of separate persons, or the years of life exposed, be prepared. We may say briefly that this estimate of the number of years of life exposed to risk according to the several color, sex and age classes of the data was prepared on the assumption that the ratio in each of these classes of the number of claims paid to the number of decedents in- volved in these claims was the same as the number of policies out- standing to the number of lives insured. From the tabulation of the number of deaths and the number of claims according to color, sex and age classes these ratios were prepared. They were applied to the mean numbers of policies outstanding in each of the calendar years of this experience and the number of years of life exposed to risk was thus estimated for the entire six-year experience. Classifying and Tabulating the Data for Deaths. The preparation of the data from the primary records of the claims paid in the Industrial Department involved a number of technical processes. The accuracy and planning of these matters of office practice have an important l>earing upon the value of the conclusions to be drawn from the tabular material displayed in this report. A brief discussion of these processes follows: All of the necessary records in connection with each claim were examined and the items which it was desired to consider in the tabulation of the statistics were abstracted upon so-called "tran- script sheets," each line containing the necessary information for a single claim. Some of the facts, such as age, amount of insurance and other strictly numerical data, were directly copied upon the line corresponding to the particular claim document. Other items such as the disease causing death, the occupation, place of birth, etc., were first classified in terms of numerical symbols INTKODUCTORT. 9 and then copied upon the transcript sheets. The final product of this transcribing and classification process, for each claim, is a single line of numerical symbols, the meaning of which can be in- terpreted according to a previously arranged coding system. Ages were recorded in this investigation according to the age at the nearest birthday. The symbols for color and sex of the deceased presented no problems worthy of mention. The diseases causing death and the occupations of the deceased, however, were classified only through the exercise of extreme care in the examination of the claim papers and only after the full requirements of standard systems of nomenclature and classification in each of these chief subjects had been complied with. Classification of Diseases Causing Death The system of nomenclature and classification employed in arriv- ing at numerical designations for use in this analysis of wage earners' mortality experience was the excellent " International List of Causes of Death." The requirements of this well known and widely accepted system of preparing statistical data of diseases were followed out in every important respect. Where two or more diseases or conditions were reported by physicians on the death certificate, assignment of the death to one particular disease or condition was made according to the rules laid down in the Classi- fication Manual and to certain general rules of selective classifica- tion procedure authorized by the United States Bureau of the Cen- sus, Division of Vital Statistics. Classification of Occupations. Occupations of deceased persons were recorded generally in satis- factory detail upon the Company's forms for the reporting' of deaths. This permitted us to compile fairly precise information on the oc- cupational aspects of this mortality experience. The occupations were classified in accordance with the rulings of the " Classified Index to Occupations" issued by the United States Bureau of the Census in 1910. The full list of occupation titles given in this official index was not used. The list of titles was in fact limited to a certain number of occupations in the leading industries which were of interest either because of the number of deaths reported in them annually, or because of some special feature of hazard or hygiene. It is believed that much time and unnecessary work were 10 MOETALITY STATISTICS OF INSURED WAGE EARNERS. thus saved in the tabulation and interpretation of the material. No detailed occupation data are given in this report, but the full account of the mortality experience of the Industrial Department of this Company according to the occupations of deceased persons over the years 1911 to 1913 was rendered in Bulletin No. 207 of the United States Bureau of Labor Statistics quoted in another section of this report. Tabulating the Data from Perforated Cards. The material of this study was tabulated by machine processes which necessitated the use of perforated tabulating cards. It is necessary to say only that the information on each claim was trans- ferred from the transcript sheets mentioned above to the tabula- ting cards by means of Hollerith Punching Machines. For pur- poses of accuracy the information on each claim was perforated in duplicate, first upon a buff card, then upon a red card. The buff and red cards for each claim were perforated by different operators. The buff card for each claim was checked against the corresponding red card by holding both cards against an illuminated glass plate. When discrepancies were revealed, reference to the line on the tran- script sheet covering the case showed which card was correct. This process insured the accurate transfer of the facts from the transcript sheets to the tabulating cards. The first process in the tabulation of the data was to identify the deaths in the experience separately from the claims. Often more than one claim was reported for one death; that is, in cases where the insured carried a number of policies on his or her life. The extra or secondary claims were designated by a distinguishing symbol which made it possible to sort out those cards which corre- sponded to deaths only. It was further decided to confine this in- vestigation to the so-called " premium-paying business " of the In- dustrial Department. This excluded a small proportion of the ex- perience on the lives of persons who were insured on a " paid-up ^' or similar basis. The reason for this will be made clearer as we pro- ceed, but at this point it may be said that sufficiently detailed in- formation with regard to the age, sex and color of these " paid-up " policyholders is not at hand. On the other hand, information with regard to the living premium-paying policyholders is especially complete, making possible the most detailed comparisons of the living and of the deceased policyholders. CHAPTEE II. MOKTALITT FEOM AlL CaUSES OF DeATH COMBINED. In this section we shall consider in some detail the total mortal- ity of the insured group, that is, without distinction of the indi- vidual causes of death. We shall comment also upon the death rates for the several color, sex and age classes. Later we shall con- sider the special factors which we believe influence more or less the general mortality experience of those insured in an industrial life insurance company. Deaths according to Color, Sex and Age. A total of 635,449 deaths is represented in this experience for the calendar years 1911 to 1916 inclusive. Of this number 520,079 deaths were of white persons and 115,370 were deaths of colored persons. The following table gives a view of the color and sex composition of the deaths : TABLE 3. Number and Percentage of Deaths, Classified by 'Color and by Sex. Experience of Metropolitan Life Insurance Company. Industrial Depart- ment. 1911 to 1916. Color and Sex. Number of Deaths. Percentage. Total 635,449 100.0 White 520,079 81.8 Male 252,742 267,337 115,370 39.8 Female 42.1 Colored 18.2 Male 53,795 61,575 8.5 Female 9.7 It will be seen that a little more than four-fifths of the deaths were of white persons. Colored deaths were recorded in 18.2% of the total cases. Since only 12.5% of the number of persons ex- posed were colored, this higher representation of colored persons 11 12 MORTALITY STATISTICS OF INSURED WAGE EARNERS. in the total of deaths indicates the higher death rate of that group of policyholders. For both white and colored persons there were more female than male deaths. This is accounted for by the fact that there is a larger proportion of females than males in the ex- posure. The significance of these several relations will be clearer when we proceed to relate the deaths to the number of living, that is, when we compare the death rates per 1,000 persons exposed in each class. Age Composition of the Deaths. It will be of interest to inquire also into the age composition* of the deaths recorded in this aggregate experience for the period 1911 to 1916. No deaths of persons under one year of age were in- cluded. Among the 635,449 deaths at ages one year and over, 58,009 or 9.1%, were between the ages of one and four jesLvs. Slightly more than one-fifth of the deaths (20.1%) occurred under the age of 20. Between the ages 20 and 64 years, the main work- ing period of life, 60.1% of the deaths occurred. For the ages 65 and over there were recorded 19.7%, or just under one-fifth of the total. In other words, there was approximately the same pro- portion of deaths at the ages 65 and over as at the group of ages under 20 years. The foregoing facts are displayed in the follow- ing table: TABLE 4. Number axd Percentage of Deaths Classified by Age Period. Experience of Metropolitan Life Insurance Company. Industrial Depart- ment. 1911 to 1916. Age Period. Number. Percentage. All ages — one and over 635,449 100.0 1 to 4 58,009 26,645 16.606 26,655 35,027 73,429 80,152 87,734 105,673 97,361 28,158 9 1 5 to 9 4 2 10 to 14 2 6 15 to 19 4 2 20 to 24 5 5 25 to 34 11 6 35 to 44 12 6 45 to 54 13 8 55 to 64 16 6 65 to 74 15 3 75 and over 4.4 * Ages of deceased persons were classified according to age nearest birth- day. The age period 5 to 9 years, for instance, ranges from average ag« 44 to average age 9i years. MORTALITY FROM ALL CAUSES, 13 Death Rates per 1,000 Persons Exposed for the Entire Experience. The 635,449 deaths reported during the six year period 1911 to 1916 represented a death rate of 11.81 per 1,000 exposed. Among the entire group of white persons the death rate was 11.04 per 1,000 and among colored lives, 17.32 per 1,000 exposed. This excess of practically one-half in the colored death rate will be treated analyt- ically from various angles in the following text. The causes of death responsible for the larger part of this excessive mortality among colored persons, with especial comment upon the age and sex characteristics of the experience, will also be duly taken up. The following table gives a comparative view of the death rates per 1,000 persons exposed for each of the color and sex classes of this mortality experience for the entire period 1911 to 1916 : TABLE 5. Deaths, and Death Bates Per 1,000 Persons Exposed. All Causes of Death Combined. Classified by Color and by Sex. Experience of Metropolitan Life Insurance Company. Industrial Depart- ment. 1911 to 1916. Color and Sex. Number of Deaths. Death Rates per 1,000 Exposed. Total 635,449 11.81 White 520,079 11.04 Males 252,742 267,337 115,370 11.82 Females 10.40 Colored 17.22 Males 53,795 61,575 17.63 Females 16.89 Considering only all ages in this experience combined, white females show the most favorable mortality record, followed by white males and colored females, with colored males exhibiting the highest death rate in this present mortality study of insured wage earners. More detailed comment upon these differences in mortality will be given in the following section on the age characteristics of mortality among insured wage earners. 14 MOKTALITT STATISTICS OF INSURED WAGE EARNERS. Deaths and death rates by color, sex and age period. All causes of death combined. The preceding table, giving the death rates per 1,000 persons ex- posed for each of the color and sex classes, is indeed too broad in its scope to warrant our drawing any conclusions on the differences in mortality of the several color and sex classes. A conclusion of this kind can be drawn only after an examination of the death rates for each of the color and sex classes, properly grouped accord- ing to ages. The following table gives the facts of mortality accord- ing to age period in this experience for insured wage earners : TABLE 6. Mortality peom All Causes of Death Combined, Classified by Color, Sex and by Age Period. Death Bates Per 1,000 Persons Exposed. 1911 to 1916. Experience of Metropolitan Life Insurance Company. Industrial Department. Persons. White. Colored. Age Period. Males. Females. Males. Females. All ages — one and over 11.81 11.82 10.40 17.63 16.89 lto4 5 to 9 10 to 14 15 to 19 20 to 24 25 to 34 35 to 44 45 to 54 55 to 64 65 to 74 75 and over . . . 12.86 3.66 2.53 4.39 6.43 8.67 12.83 19.08 34.56 72.53 135.21 12.69 3.64 2.32 3.76 5.97 9.24 15.90 23.64 40.03 79.68 145.13 11.75 3.33 2.16 3.58 5.27 6.70 9.23 14.37 28.98 66.91 129.16 21.79 5.42 4.65 9.32 12.04 14.23 19.20 27.64 46.91 84.21 137.61 20.77 5.64 5.72 11.36 12.57 12.36 16.14 24.12 40.17 73.39 135.74 We shall discuss first the variation in the death rate from one age period to another for the total mortality experience. The age series of death rates shows a high mortality rate at the outset, beginning with the age period 1 to 4 years, followed by a sharp decline to a minimum for the age period 10 to 14 years. In most mortality investigations, the minimum death rates at any age period in life are usually to be found between 10 and 14 years of age. There- after, there occurs a gradually rising death rate up to the highest age period in the series. Not until we reach the age group 35 MORTALITY FEOM ALL CAUSES. 15 to 44 years do we find the mortality rate approximately as high, 12.83 per 1,000 persons exposed, as it was at the outset of this series. The rate rises in the next ten year divisional period of life to a figure of 19.08 per 1,000 and in the succeeding ten year period to a rate of 34.56 per 1,000. The highest significant age group in this study, 65 to 74 years, shows a rate of 72.53 per 1,000 persons exposed. In this report we shall not place much emphasis upon our figures for the age group 75 years and over, because of the unusual composition of the group as to the ages of the persons included in it. For white males in this mortality experience we find the same point of minimum incidence of mortality as was observed for the total experience. In adult life however the rise in the curve of mortality among white males is very much sharper than for the total experience. White females in this mortality investigation show a much more gradual upward slope of the mortality curve in adult life, in contrast to the sharpness of the upward trend of mor- tality among white males at the later adult ages. It should be noted that for colored females the minimum mortality rate is found between 5 and 9 years and not between 10 and 14 years as was the case for the other three main classes in this mortality study. We shall now consider a few comparative ratios of mortality between the white and colored races according to sex and between the two sexes within each color or race group. Ratios of Mortality of White and Colored Races hy Age Period. a. White Male and Colored Male Death Rates Compared. Considering all ages of the mortality experience of males, the colored show a mortality rate nearly fifty per cent, higher than that of the white race. The ratio of colored to white male mortality varies decidedly with the several age periods. In the ages of early adolescence, fifteen to nineteen years, colored male mortality shows its greatest ratio of excess over white male mortality. The col- ored male death rate, at this age period, is practically 250 per cent, of the rate for white males. Between five and twenty years of age, for each five year period, there is an increment of practically fifty per cent, in the excess of colored male over white male mortality. Between five and nine years, the excess of mortality was prac- tically fifty per cent., between ten and fourteen years, one hundred per cent., and between fifteen and nineteen years, one hundred 16 MOETALITY STATISTICS OF INSUKED WAGE EARNERS. and fifty per cent. Beginning with the age period twenty to twenty-four years, there is a gradual decline in this excess of col- ored male over white male mortality. The only exception is the age period fifty-five to sixty-four years, which shows a practically stationary ratio of excess mortality, with respect to the preceding age period forty-five to fifty-four years. After these two age periods, the rate of colored male mortality does not differ greatly from that for white males. The following table displays the ratios of white and colored mortality for males : TABLE 7. MOETALITY FROM AlL CAUSES OP DEATH COMBINED. WHITE MALES AND Colored Males Compared. Beath Bates Per 1,000 Persons Exposed. 1911 to 1916. Experience of Metropolitan Life Insurance Company. Industrial Department. Percentage Colored Age Period. White Males. Colored Males. of White Rate. AH ages — one and over . 1L82 17.63 149.2 1 to 4 12.69 3.64 2.32 21.79 5.42 4.65 171.7 5 to 9 148.9 10 to 14 200.4 15tol9 3.76 9.32 247.9 20 to 24 5.97 12.04 201.7 25 to 34 9.24 14.23 154.0 35 to 44 15.90 19.20 120.8 45 to 54 23.64 27.64 116.9 55 to 64 40.03 46.91 117.2 65 to 74 79.68 84.21 105.7 75 and over 145.13 137.61 94.8 The reduction of these comparative figures to graphic form brings out a number of interesting characteristics of the mortality of the two races. The curve of the death rates of white male mortality, for instance, is continuously concave throughout. The colored male curve, between central age 13.5 years and central age thirty years, shows a somewhat convex form. The high death rate from pulmonary tuberculosis is the chief influence at work to produce this significant difference in the contour of the colored mortality curve. The chief item of interest in the graphic illustration (on page 17) of these two curves is the general tendency of mortality among colored males to approach mortality among white males at the advanced ages. MORTALITY FEOM ALL CAUSES. 17 Chart li. — Pi/!ortaeity from All Causes of Death Death R&tes per 1,000 Persons Exposed. CtassEfied by Age Periods. White Males and Colored Males Compared Cxperlsnce of Metropolitan Life Insurance Company, Industrial Department, 1S11 to 1916 D'ceth Rste per t.OOO '' 1 AO 1 1 1 1 1 ( ii i ' 1 n il Cohrt i 1 I I f n 1 / 1 / 1 1 // / V > / i 1 y^ .^ / \\ ^ /^ \ / ^ O i /-<' .r-f yff-y-f /s-jg xo-n Af-J« A7'«4 «f-.r* AGE PERIOD 18 MORTALITY STATISTICS OF INSUKED WAGE EAENERS. b. White Female and Colored Female Death Rates Compared. For all ages combined, the mortality among colored females was very nearly two-thirds in excess of the mortality among white females. The ratio of excess varied with age period. The point of maximum excess in colored female over white female mortality occurred in the age period fifteen to nineteen years — the period of adolescence. The rate for colored females was then more than three times as high as for white females (317.3%). In fact, the tendency of the colored mortality rate to diverge from the white mortality rate was more marked for females than for males at every age period of life. The following table displays the figures of comparative mortality of white and colored females: TABLE 8. MOETALITY FEOM ALL CAUSES OF DEATH COMBINED. WHITE FEMALES AND Colored Females Compared. Death Bates Per 1,000 Persons Exposed. 1911 to 1916. Experience of Metropolitan Life Insurance Company. Industrial Department. Percentage, Colored of Age Period. White I'emales. Colored Females. White Rate. AU ages — one and over . 10.40 16.89 162.4 1 to4 11.75 3.33 2.16 20.77 5.64 5.72 176 8 5 to9. . . 169 4 10 to 14 264.8 15 to 19 3.58 11.36 317.3 20 to 24 5.27 12.57 238.5 25 to 34 6.70 12.36 184.5 35 to 44 9.23 16.14 174.9 45 to 54 14.37 24.12 167.8 55 to 64 28.98 40.17 138.6 65 to 74 66.91 73.39 109.7 75 and over 129.16 135.74 105.1 The contour of the mortality curve for colored females shows de- cidedly more profound disturbance between central age 13.5 years and central age 30 years than did the curve for colored males. The white female curve shows a slightly convex tendency between these two central ages. It will be recalled that the white male curve was concave throughout. Furthermore, the colored female curve is emphatically more convex between central ages 12.5 years and 30 years than the colored male curve between these limits. It will MORTALITY FROM ALL CAUSES. 19 Chart !I9.^ Mortality from Ail Causes of Death Death Rates per 1,000 Persons Exposed. Classified by Ago Periods. Whlt« Females and Colored Females Compared Experience o1 Metropolitan Life Insurance Company, industrial Department, 1911 to 1916 J-9 19-14 *S-19 20-Z4 £S-J* JS-4* AGE PERIOD 20 MOKTALITY STATISTICS OF INSURED WAGE EAENEES. be pointed out in a later section just how much of this deforma- tion in the mortality curve for colored males is due to tuberculosis, and for colored females to tuberculosis and the diseases and condi- tions incidental to the gravid and puerperal states. The graphic illustration on page 19 gives a convenient view of the course of white and colored mortality throughout the various age periods for females. The reader will be inclined to speculate upon the disproportion between the ratio of white and colored female mortality and the ratio of white and colored male mortality. It would seem, oifhand, from the standpoint of comparative mortality, that colored females were by far the worse off. It must be remembered, however, that white male mortality bears a much more unfavorable relation to the total white mortality than does colored male mortality to tlie total mortality of colored lives. This situation should be borne in mind in drawing conclusions from a comparison of white and colored mortality according to sex. It will be of interest and profit, there- fore, to view briejfly the ratio of mortality according to sex within each color class. Ratios of Mortality of Males and Females hy Age Period. For all ages combined, white male mortality Avas about fourteen per cent, in excess of white female mortality. This ratio was not constant, however, for the several age periods. Below twenty years of age, the excess of white male over white female mortality was never less than five nor more than ten per cent. Beginning with the age period twenty to twenty-four years, with its central age at 22.5 years, the excess of white male over white female mortality began to assume considerable proportions. In this age period, when white males begin to take up the arduous and toilsome labor of the great mass of the male wage earning population, white male mortality was over thirteen per cent, in excess of white female mor- tality. Between twenty-five and thirty-four years, with the central age at thirty years, white males showed a mortality rate thirty-eight per cent, in excess of the rate for white females. Between thirty- five and forty-four ye^rs, with the central age at forty years, we find the maximum point of excess in the mortality of white males over that of white females, namely, over seventy-two per cent. The relative excess of white male mortality begins to decline after that MORTALITY FROM ALL CAUSES. 21 age period, but thereafter never approaches the figure for white female mortality nearer than twelve per cent, and that at the highest significant age period in this study. We shall see later that tuberculosis and accidents account for a very large part of this excess of white male over white female mortality. As already suggested, the ratios of male and female mortality among colored lives present an emphatically different picture than do the ratios for white lives. Colored male mortality at any age period is never in excess of colored female mortality by more than twenty per cent. The range of life between central age 7.5 years and central age 22.5 years shows decidedly more favorable mor- tality among colored males than among colored females. Between ten and fourteen years, colored male mortality is nineteen per cent, more favorable than colored female mortality. The particular causes of death responsible for this favorable showing among colored males will be pointed out in succeeding parts of this report. Colored male mortality is in excess by nearly twenty per cent., the maximum ratio of excess, in the age period thirty-five to forty-four years. The following table gives a comparison of the sex ratios of mortality for the white and colored races: TABLE 9. Percentage. Male of Female Death Bates Classified by Color and bt Age Period. Experience of Metropolitan Life Insurance Company. Industrial Depart- ment. 1911 to 1916. Age Period. White. Colored. All ages — one and over 113.7 104.4 1 to 4 108.0 109.3 107.4 105.0 113.3 137.9 172.3 164.5 138.1 119.1 112.4 104.9 5 to 9 96.1 10 to 14 81.3 15 to 19 82.0 20 to 24 95.8 25 to 34 115.1 35 to 44 119.0 45 to 54 114.6 55 to 64 116.8 65 to 74 114.7 75 and over 101.4 We may conclude, then, with the following general comment: among white persons the mortality rate of males is always in 22 MOKTALITY STATISTICS OF INSURED WAGE EAENEES. excess of that of females. This excess is least marked below age 25 and above 75, but not inconsiderable even at these ages. At the point of greatest difference, namely, at the age period 35 to 44 years, the male rate is nearly three-fourths in excess. Among colored persons, the picture is different in a number of essential respects. The male rate is lower than the female rate under age 25, with the single exception of children of one to four years. After 75 years the two rates are much the same. The actual death rate between 25 and 75 years is higher for colored males than females, but the excess is altogether moderate as compared with what we have noted among white lives. Comparison of Death Rates per 1,000 exposed. White Persons in Insurance Experience, 1911 to 1916, and General Population of Expanding Registration Area, 1910 to 1915. The mortality experience of insured wage earners, 1911 to 1916, may now be compared profitably with that for the general popula- tion of the expanding Eegistration Area of the United States, 1910 to 1915. A number of limitations to the completeness of this com- parison must first be pointed out. We must make the comparison in the first place between the experience of white insured lives on the one hand and the total population, white and colored, of the expanding Registration Area, on the other. This is because the white insurance experience is most like that of the Eegistration Area from which the small proportion of colored cannot accurately be eliminated. The proportion of colored persons in the insurance experience for 1911 to 1916 (12.5%) is large and affects the total Metropolitan death rate too much to permit a comparison with the rate of the total Eegistration Area, with its very much smaller pro- portion of colored lives. It must be remembered also that at the time this comparison is being made there are available for the Eeg- istration Area only the data for the years 1910 to 1915 according to sex and age period. This constitutes a six-year period not very different from the period 1911 to 1916 for which the insurance data are at hand. There are. other differences- of area, occupational com- position, etc., to which, reference has already been made. But all considered, the differences in the figures which we shall point out fairly represent a true difference in the vitality of the two groups. The annual reports of the United States Bureau of the Census on MOKTALITY FEOM ALL CAUSES. 23 mortality statistics for the years 1910 to 1915 give tables showing the number of deaths classified by sex and age period and for each of the diseases or causes of death in the International List. There is, however, no corresponding record giving an official estimate of the populations exposed to risk in the Registration Area at the sev- eral age periods and by sex. In order to compute death rates it is necessary first, to estimate such population exposure. This was obtained by combining the estimated populations for each sex and age class in the expanding Registration Area for each year from 1910 to 1915 inclusive. Our thanks are due to Dr. F. L. Hoffman, Third Vice-President and Statistician of the Prudential Insurance Company of America, who placed at our disposal these estimates of population. The following tables show the death rates per 1,000 living, for each of the sexes, in the Registration Area, 1910 to 1915, and a comparison with similar data for insured white males and females : TABLE 10. MOETALITY FEOM ALL CAUSES OF DEATH. Death Bates Per 1,000 Persons Exposed. Classified by Sex and hy Age Period. White Lives in Experience of Metropolitan Life Insurance Company, Industrial Dept., 1911 to 1916, and Estimated Gen- eral Population of Expamding Eegistration Area, United States, 1910 to 1915. Males. Females. Age Period. M. L. I. Co. (White). U. S. Reg. Area. Percentage M. L.I. Co. of Reg. Area. M. L. I. Co. (White). U. S. Reg. Area. Percentage M. L. I. Co. of Reg. Area. AH ages — one and over 11.82 12.41 95.2 10.40 11.08 93.9 lto4 12.69 12.28 103.3 11.75 11.28 104.2 5 to 9 3.64 3.32 109.6 3.33 3.03 109.9 10to.l4 2.32 2.29 101.3 2.16 2.12 101.9 15 to 19 3.76 3.72 101.1 3.58 3.45 103.8 20 to 24 5.97 5.42 110.1 5.27 4.96 106.3 25 to 34 9.24 6.81 135.7 6.70 6.10 109.8 35 to 44 15.90 10.05 158.2 9.23 8.03 114.9 45 to 54 23.64 16.03 147.5 14.37 12.58 114.2 55 to 64 40.03 29.88 134.0 28.98 24.48 118.4 65 to 74 79.68 59.13 134.8 66.91 51.72 129.4 75 and over. . 145.13 138.72 104.6 129.16 132.99 97.1 The facts for all ages combined in the two mortality experiences, on their face, indicate a more favorable mortality among insured 24 MORTALITY STATISTICS OF INSURED WAGE EARNERS. white persons than among the general population. These figures are of significance, however, only with respect to the specific sex and age classes of the data. We shall see below that this favorable condition for all ages results from the peculiar age distribution of the group of policyholders. A larger proportion of policyholders appears at the ages of low mortality and a smaller proportion at the ages of high death rates than occurs in the general population. Let us make a comparison first of the figures for males, remember- ing throughout this discussion that the data for the insured group relate entirely to white lives. The first fact of importance in this comparative view of the mor- tality of wage earners and of the general population is that for all ages under 25 years there is no marked divergence between the rates for the two groups under review. There are differences, of course, but these are not great. Beginning with the age group 25 to 34 years and thereafter there is, however, a marked excess in the rate of mor- tality among insured male wage earners over that among males in the general population. At these age periods, the special stresses of adult life and of employment in arduous labor make themselves felt in the mortality experience of males in an industrial life in- surance company. Male insured wage earners in the age period 25 to 34 years, show a mortality rate nearly 36% in excess of the rates prevailing among males in the general population. The divergence between the two series of mortality figures increases somewhat in the next age period, 35 to 44 years, to 58%, and then declines to 48% between 45 and 54 years. Thereafter the excess of mortality among male insured wage earners is practically stationary at about 35%. After age 75, the figures are of no great value. It will be the function of the succeeding sections of this report on the several causes of death to point out in greater detail the reasons for this percentage of excess mortality among insured male wage earners. The comparative table for the death rate of insured females in the families of wage earners and of females in the general popula- tion shows no such striking excesses of mortality as were observed in the table for males. Under the age of 35 years there are no marked divergences of the mortality curve. After 35 years the ex- cess of the mortality rate among insured females becomes significant. For the age group 35 to 44 years we observed an excess of 15%, which ratio is about the same as that for the succeeding age group, 45 to 54 years. For the divisional period 55 to 64 years MORTALITY FKOM ALL CAUSES. 25 we notice an excess of 18% and for the age group 65 to 74 years an excess of 39% in the mortality rates of insured females. The reader will observe a marked peculiarity in the course of the ratio of excess mortality of insured females as compared with that re- corded for insured males. In the latter group there was a sharp rise in the ratio of excess mortality from age 20 up to and includ- ing the age period 35 to 44 years and a decline for the age groups thereafter. Among insured females, however, there was no im- portant excess in the mortality rates under 35 years of age over the rates for females in the general population, but a gradually ris- ing rate for each age period thereafter up to and including the last significant divisional group, 65 to 74 years. The explanation for the difference between one series of ratios and the other will be found only upon careful analysis of the facts for the particular causes of death in the mortality experience. Factors Influencing Industrial Insurance Mortality. Before proceeding with any further comparison between the mor- tality experience of this group of insured wage earners and the mortality experience of the general population, it will be instructive to outline briefly some of the important factors which condition the mortality experience of an industrial life insurance company, and which are not prevalent in the general population. The first important source of difference is that these data relate entirely to a group of wage earners and their families — independent, self-reliant wage earners, to be sure, who have endeav- ored to protect themselves as much as possible from the losses inci- dent to the last illness and the cost of burial. The great mass of the wage earning population in America, however, are not in ordi- nary times as well situated to safeguard themselves against the effects of accident and disease as are the better situated strata of the population. The occupations they engage in are more hazard- ous, their families are larger and their incomes smaller than those of the general average of the population. These factors determine such important health situations as the adequacy of diet, housing, clothing, and equally, the standards of medical service at their dis- posal. These policyholders, too, live in the larger cities and towns, and are subjected to the unfavorable influences of city life. It may be expected, therefore, that the mortality experience of this 26 MORTALITY STATISTICS OF INSURED WAGE EARNERS. large group of insured wage earners will show characteristics quite different from those of the general population or of special groups in the general population which have distinctly better living and working conditions. It is perhaps one of the chief functions of this report to point out definite lines of further inquiry into the general welfare of the wage earning group of the population. The more detailed and specialized questions as to the adequacy of wages, the level of the standard of living of American workingmen's fami- lies, of housing conditions, of hours of labor, of the intensity of labor, and of hygienic conditions in workshops and factories should be submitted to careful and conclusive inquiry. The supply of data on these important vital facts is at present severely limited. These mortality statistics provide, we believe, a sound point of departure for such qualified inquiry into the facts of the life and work of the American wage earner. Downwa/rd Trend of Mortality of Insured Wage Earners from 1911 to 1916. The important feature of this mortality experience is the capac- ity for decrease shown by the death rate in the brief period covered by this study. In the six years 1911 to 1916 inclusive, the death rate fell from 13.53 to 11.68 per 1,000 exposed, or a decline of 6.8%. Between the five years 1911 to 1915 the tendency was steadily down- ward year after year. It was only in 1916 that this tendency was cheeked, apparently as the result of a widespread prevalence of acute respiratory diseases, chiefly of the influenzal type. But even this serious condition had only a minor effect, raising the death rate by .4 per 1,000 persons exposed over the figure for 1915. The amount of decline is much more marked if we consider white lives only. Between 1911 and 1916, the per cent, decline among white lives was 7.2. There is also a slight difference in the amount of improvement in the two sexes, the per cents, of decline among white males and white females being 6.0 and 8.2 re- spectively. For colored persons, the decrease was only 1.4%. There were fluctuations in the colored rates in an upward and down- ward direction during the several years. The colored males show an actual increase of 1.4% in mortality while the colored females show an improvement of 3.7%. The following table gives the death rates for the several groups of insured wage earners for each of the years 1911 to 1916 and for the entire six-year period : MOKTALITY PROM ALL CAUSES. 27 TABLE 11. Mortality from All Causes of Death Combined. AND BY Sex. Classified by Color Death Bates Per 1,000 Persons Exposed. Single Years 1911 to 1916. Experience of Metropolitan Life Insurance Company, Industrial Department. Persons. WWte. Colored. Year. Males. Females. Males. Females. 1911 to 1916 11.81 11.82 10.40 17.63 16.89 1916 11.68 11.31 11.53 11.99 12.01 12.53 11.83 11.05 11.48 12.20 11.97 12.58 10.21 10.04 10.18 10.49 10.55 11.11 17.68 17.42 17.38 17.90 17.98 17.42 16.85 1915 17.12 1914 1913 16.51 16.29 1912 17.12 1911 17.50 Reduction of Mortality in the General Population of the Expanding Registration Area and among Insured Wage Earners Compared. For purposes of comparison, we must again turn to the facts for the general population as reflected in the figures of the expanding Registration Area. These figures will indicate whether the marked improvement which we have observed among insured lives is par- alleled by the conditions in the general population or whether the insured have enjoyed conditions which were especially favorable to them. In view of the fact that the detailed figures for 1916 for the Eegistration Area are not as yet available and also because the in- surance experience begins with 1911, we shall limit our comparison of the two experiences to the five-year period 1911 to 1915 inclusive. For the total Eegistration Area of the United States there was observed between 1911 and 1915 a decline of only 4.7 per cent. This compares with a 9.7 per cent, decline among the white in- sured group in the same five year period. It must be remembered also that the insurance figures do not include facts for infants under one year of age as do the foregoing data for the Eegistration Area of the United States. The improvement in infant mortality dur- ing the period under examination has been very marked and this undoubtedly has had a very favorable influence on the total death rate of the Eegistration Area. If the expanding Eegistration 28 MORTALITY STATISTICS OF INSURED WAGE EARNERS. Area data at all ages were to be arranged for only those lives above one year of age, as is the case for the Metropolitan experience, a less favorable reduction than 4.7% would undoubtedly be found and the advantage in favor of the insured would be even more striking. In order to compare the facts for each of the two sexes, we may safely use the figures for all males in the Eegistration Area and contrast them with those for white males in the insurance expe- rience, because the composition of the Eegistration Area is sub- stantially white. Between 1911 and 1915, males in the Eegistra- tion Area showed a reduction of exactly 5% in mortality as com- pared with a percentage reduction of 13.3 among the insured white males. Females in the general population at all ages show a decline of only 4.3%, as compared with a decline of 9.6% among insured white females at ages one and over. Taking all white lives together, the insured group showed a decline in mortality of eleven per cent, and all the white lives in the Eegistration Area a decline of only 5.4%. The percentage of decline of mortality among colored lives was more pronounced for the general population than for insured col- ored wage earners, but was small in each instance. The group of colored persons in the population of the Eegistration Area showed a reduction of 2.7 per cent., whereas, the entire group of colored lives in the insurance experience showed a reduction of only 1.3% between 1911 and 1915. This improvement was entirely confined to the colored females. The percentage of decline of colored mor- tality in the general population and among insured wage earners does not affect a very large number of lives exposed in either experi- ence and may be disregarded for comparative purposes in the present discussion. This can readily be done in view of the fact that insured colored persons are located almost entirely in urban areas, whereas a fair proportion of the negroes in the Eegistration Area are rural dwellers. It will be seen, therefore, that the mor- tality experience of insured white wage earners shows by far the more favorable general tendency when compared with the mortality experience of the general population. The following table presents a comparison of the death rates of the aggregate white and colored groups among the insured and the general population for the period 1911 to 1915 as well as the per cent, reduction between the two periods. MORTALITY FROM ALL CAUSES. 29 TABLE 12. Mortality from Au:, Causes of Death Combined. Death Bates Per 1,000 Persons Exposed, 1911 to 1915. White and Colored Lives, Males and Females, of Expanding Registration Area of the United States and in Experience of Metropolitan Life Insurance Company, Industrial Department, Compared.* Wlite Lives. Colored Lives. Males. Females. Year. M. L. I. M. L. I. Reg. M. L.I. Reg. M. L.I. Reg. Co. Wh. Keg. Co. Wh. Area. Co. Area. Co. Area. Males. Area. Females. 1915 13.00 10.49 23.04 17.26 14.26 11.05 12.69 10.04 1914 13.16 10.77 21.96 16.90 14.46 11.48 12.71 10.18 1913 13.65 11.26 21.92 17.02 15.00 12.20 13.09 10.49 1912 13.47 11.20 22.92 17.51 14.75 11.97 12.94 10.55 1911 13.74 11.79 23.69 17.46 15.01 12.58 13.26 11.11 Per cent de- ^ cline 1911 [5.39 11.03 2.74 1.15 5.00 12.16 4.30 9.63 to 1915.. . J * Registration Area rates are for all ages; insurance experience applies only to ages one and over. A more intimate view of these two experiences will be afforded when the data for each of the important diseases and conditions are taken up. In these later sections we shall direct attention to the conditions which are largely responsible for the progressively favor- able mortality of white insured lives as compared with the general population of the expanding Registration Area of the United States. CHAPTER III. Mortality feom Peincipal Causes of Death. The main outlines of the mortality experience of insured wage earners for all causes of death combined appear in the foregoing text. Data of this type, however valuable, are rather bare in their public health value unless supplemented by further analysis accord- ing to the principal diseases and conditions responsible for the mor- tality. It is one of the favorable features of this report that we were able to secure exceptionally complete statistics of the causes of death in the course of our tabulations. The documents avail- able for our study, namely, the so-called " claim papers " contain, usually, a number of statements of the disease or condition causing death. The most important of these is, of course, the certificate as submitted by the attending physician, who, in the great majority of the cases, also completes the official death certificate for the use of the general registration service of the community in which the in- sured person dies. There are also at hand the statements of the cause of death as made by the beneficiary, who represents the fam- ily of the deceased, as well as that completed by the local represen- tatives of the company. Often newspaper clippings and other il- luminating additions are attached to the papers, and especially in cases of accidental death or where a coroner's inquest is called for. Effort to Improve Accuracy of Certified Causes of Death. Every effort has been made in the conduct of this mortality study to secure from certifying physicians as complete and accurate state- ments of the diseases or conditions causing death as practicable. This end was achieved by means of an extensive system of corre- spondence with the certifying physicians, pointing out where cer- tain forms of statements of diseases causing death were unsatis- factory for statistical use, and what manner of additional clarify- ing information we desired to have. A few examples may be cited to illustrate the procedure. 1. The physician reports on the death certificate that a child has died from "bronchopneumonia." In view of the fact that this disease or condi- 30 MOKTALITY FROM PRINCIPAL CAUSES OF DEATH. 31 tion is so often a terminal state of infectious disease, our letter asked the physician to say whether any infection, such as measles or whooping cough, or whether trauma was the primary causative condition. In numerous in- stances, physicians replied to our inquiries and said that they had omitted to certify to the primary infection or condition, i. e,, measles, whooping cough, scarlet fever, etc. 2. "Peritonitis" is also a statement of cause of death which does not convey to the compiling statistician the information he must have in order to report upon the prevalence of the socially important primary diseases and conditions which result in fatal "peritonitis." In this instance, the letter of inquiry asks the physician whether the "peritonitis" followed a surgical operation for any one of many conditions such as appendicitis, ulcer of the stomach, cancer of the stomach or of the intestines, etc., or whether, in the case of a woman of child-bearing age, the "peritonitis" was the sequel of any condition associated with the maternal state. The facts of mode and nature of accidental, homicidal or suicidal injury, were also inquired for. 3. "Injury" is a report which may be properly chargeable to either of the primary subdivisions of violence: suicide, homicide or accident. These, in turn, are classified accurately only if the means of "injury" is given. A death reported in this way, if it was suicidal, may have been primarily due to suicide by gunshot wound, or by a cutting instrument, or by jumping from a high place; if accidental, the means of "injury" may have been a firearm, a cutting instrument, an accidental fall, a fall or an explosion in a mine or quarry — death may have been due, indeed, to a machinery accident, a railroad accident, a street-car accident, or to any one of many accidental causes. Inasmuch as the International List of Causes of Death provides for the separate grouping of each of the means of "injury" cited above, we can not classify a report like "injury," "frac- ture," "wound," "traumatism," or any of many similar reports with accuracy unless information is provided as to the means or manner in which the "injury," etc., occurred. The letter of inquiry sent to the certifying physician in such cases usually results in the receipt of data covering the additional circumstances that are required for the final assignment of the cause of death. These three examples, of many, indicate in general the principle underlying this method of clearing up indefinite and otherwise un- satisfactory reports of diseases or conditions causing death.* In another publication,! there will be found a rather complete discus- sion of the methods and results of this inquiry system and the prob- * Other indefinite terms subject to inquiry are : ' * Accident, " " operation, ' ' *' acute nephritis," "meningitis," "tumor," "septicemia," and many others. t ' ' Improvement of Statistics of Cause of Death through Supplementary Inquiries to Physicians." Quarterly Publications of the American Statis- tical Association, June, 1&16. 32 MOETALITY STATISTICS OF INSURED WAGE EAENEKS. able effect of the method in improving the precision of the state- ment of the various primary causative factors in mortality. There were received from certifying physicians in connection with the deaths reported in this six year mortality investigation about 25,000 letters. In the great majority of cases, the information conveyed by these letters made it possible for us to reach a much closer ap- proximation to the real facts respecting the several important dis- eases and conditions among insured wage earners. An analysis of the returns from the inquiry procedure shows that in a period of six years the death rate for such an undesirable title as "frac- tures" was reduced 65%, for "simple peritonitis" the reduction was 41% and for " acute nephritis " 21%. The registration of cer- tain more definite causes of death was improved; for example, measles and scarlet fever showed an increase of 3% each, cancer of the breast 5%, tuberculous meningitis nearly 13%, syphilis 97%, and gonococcus infection 138%,— all through the direct in- fluence of this inquiry method. Appendix C shows the number of deaths charged to certain causes before and after inquiry, and the percentage of changes in classification. Nomenclature and Classification of Diseases. If no pains were spared to secure complete original data on the diseases and conditions responsible for mortality among insured wage earners, every effort was also made to handle the material received by the Statistical Bureau in a manner so approved that the tabulations would be comparable with those of the best statis- tical offices of the country and especially the Federal Bureau of the Census. The diseases and conditions causing death reported upon the certificates were compiled according to the "Interna- national List of Causes of Death." The great variety of terms used by physicians in various parts of the country were thus brought together and made to agree with the standard nomenclature as followed by the Census Bureau. In addition, the rules and regu- lations of the "Manual of the International List of Causes of Death" were followed in handling "jointly reported causes of death." While published statistics of causes of death are neces- sarily stated in terms of single diseases or conditions, physicians on their certificates often give a number of such causes. The rules of the Manual indicate clearly the procedure to follow in such MOETALITY FEOM PEINCIPAL CAUSES OF DEATH. 33 cases and these were strictly adhered to. The list of precedents of the Bureau of the Census as published in the "Index of Joint Causes — 1914 " served also as our guide in the treatment of " Jointly reported causes of death." The results of this mortality experience for insured wage earners are, therefore, substantially comparable with the facts published for the Eegistration Area. To carry on this work, as well as to tabulate the various non-med- ical items of our study, it was necessary to organize a specially selected and trained staff. Virtually every item appearing in this volume was codified by one clerk and checked by another. The sorting and tabulation processes were in like manner always certi- fied as to their accuracy. The watchword throughout the whole study conducted over a period of six years has been " care." These precautions have been taken because it was felt from the very be- ginning that we should do all in our power to offset the inherent deficiencies in the material as returned by physicians ; for, even in large cities, where the best conditions of medical practice prevail, there is a certain irreducible amount of uncertainty and inaccuracy in statements of cause of death. We have felt that these should not be augmented through any element of indifference or careless- ness in the statistical procedure followed. It is our firm belief that we have in this mortality investigation of insured wage earners as accurate and authentic a record of the principal diseases and condi- tions causing death as it has ever been possible to obtain in any similar enterprise anywhere. 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V m S Is 3 — < 111 ^ c >> .oi --'II 03 in Xi "o n 4^ St b 'c 1 S g^t> HfeO 3 1 a T E ,03 a > ffl 'S, M fl 32 3 fl a >.^ CQ a; fl § a u a > g" : a . JS ■ t^ : m . -C . lU „ ® cfl !-§ i-r* St»o • w 0>-< (NcocO'* in in lO 'CiOOt^XCaO'-'tOCD (M CO ■* 02 t~ 00 05 wil I? i>t-. t~ ^ < ^ r- i> cc XQOQO CO 00 00 t~ I- 00 oc 00 S fl 42 MOETALITY STATISTICS OF INSUIIED WAGE EARNERS. The remainder of this report will be concerned with a detailed consideration of the more important diseases and conditions which appear in this experience. These will be taken up in the order of their numerical importance. At this point we need point out only that, as in most other experiences, a few conditions account for the larger part of the mortality. Tuberculosis (all forms), for ex- ample was responsible for 17.4% of all the deaths. This title was followed by "organic diseases of the heart" with 11.9% ; by pneu- monia (all forms), with 9.1%; and by Bright's disease with 8.2% of all the deaths. The entire group of " external causes," of which accidents form the largest part, was responsible for 8.0%. To- gether these five principal disease groups accounted for 54.6% of the total mortality. In addition, we may mention cancer (all forms) with 5.9% of the deaths, cerebral hemorrhage and apoplexy with 5.8% and the four communicable diseases of childhood, namely, measles, scarlet fever, whooping cough and diphtheria, which, together, accounted for 4.0%. These, added to the figure already noted, bring the total up to 70.3% of all the deaths. We shall now consider each of the conditions in the order named, and shall add a number of others which seem to be of suJBScient value to merit discussion because of their great interest to medical science or because they throw light on the vital phenomena of wage earners and their families. CHAPTEE IV. Tuberculosis. Notwithstanding the great development in America of the cam- paign against tuberculosis, detailed statistics of mortality from this condition are not as yet available for the general population in a manner suitable for the purposes either of intensive study or of practical health work. The present collection of data of mor- tality from tuberculosis among wage earners presenting the facts in full for color, sex and age, constitutes therefore an important contribution to the literature on the subject. The value of these figures is commensurate with the gravity of the condition. For not only is tuberculosis the first cause of death as to incidence among wage earners and their families, but mortality from this cause is most pronounced at a time in life when there is still con- siderable expectation remaining to each individual and when death seriously disrupts family life. The economic losses thus entailed are still further augmented by the long periods of physical disabil- ity which usually precede the fatal termination. Tuberculous dis- ease is clearly the chief burden upon the vital resources of wage earners and their families. The figures we present, it is hoped, will become a point of departure for further inquiry into the pos- sible effect of environmental and other factors which condition the physical welfare of the great mass of the wage earning population. Tuberculosis in all its forms accounted for 110,363 deaths or 17.4% of the 635,449 deaths in the entire Industrial mortality ex- perience for the six year period, 1911 to 1916. The deaths cover a number of conditions which are clearly distinguishable according to the main organs or parts of the body affected by the tuberculous infection. The following table shows the number of deaths re- sulting from each of the several forms of tuberculosis as distin- guished in the nomenclature of the International List : 43 44 MORTALITY STATISTICS OF INSURED WAGE EARNERS. TABLE 14. MOETALITT FROM TUBERCULOSIS, SPECIFIED ACCORDING TO ORGANS OR PaBTS Affected. Deaths, and Death Eates Per 100,000 Persons Exposed. All Color and Sex Groups Combined. Experience of Metropolitan Life Insurance Company. Industrial Depart- ment. 1911 to 1916. All Color and Sex Groups In Mortality Experience. Organ or Part Affected. No. of Deaths. Percentage of Total, All Causes. Percentage of Total Tubercu- losis. Rate per 100,000 Exposed. Tuberculosis — all forms 110,363 17.4 100.0 205.1 Tuberculosis of the lungs . . . Acute miliary tuberculosis . . Tuberculous meningitis Abdominal tuberculosis Pott's disease 93,526 6,380 4,647 3,155 866 573 959 257 14.7 1.0 .7 .5 .1 .1 .2 t 84.7 5.8 4.2 2.9 .8 .5 .9 .2 173.9 11.9 8.6 5.9 1.6 White swellings Tuberculosis of other organs Disseminated tuberculosis . . 1.1 1.8 .5 t Less than .05 per cent. Considered according to organs or parts affected, tuberculosis of the lungs was the chief form of the disease, accounting for 84.7% of all the deaths from tuberculosis. The rate of mortality was 173.9 per one hundred thousand exposed. In the discussion of tubercu- losis of the lungs to follow, we shall accept the practice of the Abridged International List of Causes of Death and shall include with this form of tuberculosis, the deaths from acute miliary tuber- culosis, of which there were 6,380 recorded during the six year period of this investigation. Considering these two forms together as tuberculosis of the lungs, this disease was responsible for 15.7 per cent, of the deaths from all causes and 90.5 per cent, of the deaths from all forms of tuberculosis. A rate of 185.7 per one hundred thousand exposed is registered. The only other forms of tuberculosis of numerical importance in this mortality experience were tuberculous meningitis and abdominal tuberculosis, which assume considerable importance at certain periods of life. The above picture is a composite covering both races and sexes and all age periods of life. Our very first analysis, however, indi- cates that this composite reduces itself into a number of varying elements. Thus, we find that the colored have a much higher in- cidence than the white policyholders, that the rates for the males TUBERCULOSIS. 46 exceed those for females, and finally, that the figures for each main color and sex class vary markedly with age. The first five year period of life presents a comparatively high rate. This drops to the minimum between 5 and 9 years. With the next period, 10 to 14 years, the figures mount again and increase continuously to their maximum which is attained between 35 and 44 years, among males and somewhat earlier among females. The rates then de- cline rapidly with advancing age. These facts are presented in the following table: TABLE 15. Mortality from Tuberculosis, All Forms, Classified by Color, Sex AND BY Age Period. BeatTi Bates per 100,000 Persons Exposed. 1911 to 1916. Experience of Metropolitan Life Insurance Company. Industrial Department. Persons. WWte. Colored. Age Period. Males. Females. Males. 1 Females. All ages — one and over 205.1 211.9 147.3 430.0 385.1 1 to 4 5 to 9 10 to 14 15 to 19 .. 20 to 24 25 to 34 35 to 44 45 to 54 55 to 64 65 to 74 75 and over . . . 90.7 37.6 46.4 165.0 287.8 344.4 360.4 279.6 237.2 196.0 177.7 78.4 26.3 19.0 98.5 243.8 385.8 540.4 463.5 365.5 268.2 197.2 76.5 29.3 38.5 144.5 238.0 252.2 215.2 147.8 139.1 140.3 151.5 269.2 135.2 145.8 420.7 584.4 568.9 570.1 465.1 438.8 342.4 315.5 268.4 152.5 277.5 621.3 643.9 488.6 349.9 243.9 198,9 175.0 245.0 This marked variation with age and especially the presence of two modal points of incidence, namely in infancy and in adult life, suggest that we are concerned with heterogeneous material. In fact we know that the variations result in large part from the inclu- sion in our figures of the several forms of tuberculosis which affect the age periods very differently. It will be more instructive, therefore, in our further analysis to consider each of the chief forms of tuberculosis separately. We shall discuss first the data for tuberculosis of the lungs, follow with tuberculous meningitis and abdominal tuberculosis and close with a brief reference to the few remaining titles included in our main group. 46 MORTALITY STATISTICS OF INSURED WAGE EARNERS. Tuberculosis of the Lungs. It will be understood that this title includes the deaths under the title as such and also the group of deaths assigned to acute miliary tuberculosis, i. e., titles Nos. 38 and 29 of the Interna- tional List together. A total of 99,906 deaths is reported under this head correspond- ing to a death rate of 185.7 per 100,000 in the six years, 1911 to 1916. In view of the fact that 90.5% of the total tuberculosis deaths are thus covered, we may expect that many of the color, sex and age characteristics observed for all forms of tuberculosis will again be in evidence — ^but we shall note also some variations. The following table presents the death rates per 100,000 exposed for tuberculosis of the lungs, grouped according to the color, sex and age classes represented in our data : TABLE 16. Mortality feom Tuberculosis op the Lungs,* Classified by C!olob, Sex AND BY Age Period. Death Bates per 100,000 Persons Exposed. 1911 to 1916. Experience of Metropolitan Life Insurance Company. Industrial Depari;ment. Persona. White. Colored. Age Period. Males. Females. Males. Females. All ages — one and over 185.7 193.7 131.5 391.2 348.5 1 to 4 5 to 9 10 to 14 15 to 19 20 to 24 25 to 34 35 to 44 45 to 54 55 to 64 65 to 74 75 and over . . . 26.3 16.2 33.9 150.5 273.4 330.1 345.4 267.3 221.1 178.7 156.1 17.0 7.7 9.8 87.7 232.9 373.3 527.1 450.6 345.0 250.0 180.2 18.2 11.1 28.5 133.7 226.2 241.2 203.5 137.8 128.5 126.2 127.2 135.2 79.3 110.4 377.8 547.6 541.2 542.7 444.0 408.2 309.0 301.8 152.3 99.1 232.4 572.7 608.0 461.8 322.3 226.1 175.2 146.8 217.8 * Includes "tuberculosis of the lungs," title 28, and "acute miliary tuberculosis, ' ' title 29 of the International List. It will be seen that the group of colored persons in this ex- perience shows a pulmonary tuberculosis death rate at all ages, one and over, between two and two and one-half times that of white TUBERCULOSIS. 47 persons. Colored males, for instance have a tuberculosis death rate at all ages which is 203.0 per cent, that of white males; col- ored females show a tuberculosis death rate 265.0 per cent, that of the white female rate. These figures vary markedly when consid- ered by age; in fact, the most instructive relations between the two races are thus brought to light. One interesting feature is the comparatively early age at which the maximum death rate is found among the negroes, namely, between 20 and 24 years. Among white males, ^he maximum is reached between 35 and 44 years, and among white females, between 25 and 34 years. As will be ob- served in the table above, the mortality from tuberculosis of the lungs among colored males at the age period 5 to 9 years is over ten times as great as among white males at that age. Between the ages 10 and 14 years, the colored male rate for tuberculosis of the lungs is over eleven times that for white males. Among colored females under 15 years of age, the excess of mortality for tubercu- losis of the lungs over the figures for white females is also very great, being over eight times as high in each five-year period. It is of more than ordinary interest to indicate that between the ages 45 TABLE 17. MORTAIilTY FBOM TUBEECULOSIS OP THE LUNGS.* Percentage, Colored of White Death Bates for Each Sex, Classified by Age - Period. 1911 to 1916. Experience of Metropolitan Life Insurance Company. Industrial Department. Percentage, Colored of White Mortality. Age Period. Male. Female. All ages — one and over 202.0 265.0 1 to 4 795.3 1029.9 1126.5 430.8 235.1 145.0 103.0 98.5 118.3 123.6 167.5 836 8 5 to 9 892 8 10 to 14 815 4 15 to 19 428 3 20 to 24 268 8 25 to 34 191 5 35 to 44 158 4 45 to 54 164 1 55 to 64 136.3 65 to 74 116 3 75 and over 171 2 * Includes "tuberculosis of the lungs," title 28, and tuberculosis, ' ' title 29 of the International List. ' acute miliary 48 MOETALITY STATISTICS OF INSURED WAGE EAENERS. and 54 the death rate from tuberculosis of the lungs among colored males was slightly less than that recorded for white males. The maximum percentage of excess of colored mortality from tubercu- losis of the lungs over the figures for white persons occurred in the age period 10 to 14 years for males and 5 to 9 years for females. There is at present no explanation at hand as to why this ex- cess of colored over white mortality from tuberculosis of the lungs should be so great at the periods of early life and so much smaller in later years. The preceding table presents a picture of the relative incidence of pulmonary tuberculosis among white and colored persons. Tlie Death Rate of Pulmonary Tuberculosis according to Sex. The second main classification of these data will be made ac- cording to sex. As is to be noted in Table 16, the differences in the rates of the two sexes were very marked indeed, the degree of differ- ence varying somewhat for each of the two races. The following table exhibits the ratio of the male to the female death rate at each age period for the two color classes of this experience : TABLE 18. MOETALITY FROM TUBERCULOSIS OF THE LUNGS.* Percentage, Male of Female Death Bates for Each Color or Bace Group, Classified hy Age Period. Experience of Metropolitan Life Insurance Company. Industrial Depart- ment. 1911 to 1916. Percentage, Male of Female Mortality. Age Period. White. Colored. All ages — one and over 147.3 112.3 1 to 4 93.4 69.4 34.4 65.6 103.0 154.8 259.0 327.0 268.5 198.1 141.7 88.8 5 to 9 80.0 10 to 14 47.5 15 to 19 66.0 20 to 24 90.1 25 to 34 117.2 35 to 44 168.4 45 to 54 196.4 55 to 64 233.0 65 to 74 210.5 75 and over 138.6 * Includes "tuberculosis of the lungs," title 28, and "acute miliary tuberculosis," title 29 of the International List. TUBERCULOSIS. 49 Considering all ages one and over together, the ratio of white male to white female mortality is 147.3, which means an excess of nearly one half. The excess in the rate of colored males over col- ored females is only 12.3%. In both races, however, the picture is a shifting one when we introduce the factor of age period. Thus under age 20 for the whites and under age 25 for the colored, the male rate for pulmonary tuberculosis is considerably lower than that for females. In fact between the ages 10 and 14 years the rate for white males is over 65% more favorable than that for white females. Beginning with the age period 20 to 24 years, however, mortality from tuberculosis of the lungs among white males is, at every age period, in excess of the figures for white females. The maximum percentage of difference is found in the age period 45 to 54 years where the white male rate is over 3| times that for the white females. For the group of colored persons, beginning with the age period 25 to 34 years, the death rates from tuberculosis of the lungs for males exceed those for females in marked degree. The percentage of male excess under the age of 65 is not as great for colored lives as for white lives. The figures themselves suggest no clue toward an explanation of the remarkable differences prevailing in the rates for pulmonary tuberculosis among boys and girls of both races. At these younger ages, conditions of life are very much the same, and it is difficult to understand what factors can be at work unless they be the differ- ing inherent physical characteristics of the two sexes. The following graph shows clearly the incidence of pulmonary tuberculosis in each of the age periods of our main groups, namely, white males, white females, colored males and colored females. It will be observed that the curves in each instance show a local maxi- mum or modal point at the earliest age period, namely, one to four. The lowest point is attained in the next age period. Thereafter, a distinctly different contour is observed in each of the four curves. That for white males is the most symmetrical of all, showing one modal point between 35 and 44 years of age. Colored males, on the other hand, present an asymmetrical distribution with two modal points, one at 20 to 24 years and the other at 35 to 44 years. A further irregularity is observed at the period 55 to 64 years. The curves for the females are both skew, and are also characterized by the early age at which the maximum incidence is attained. Of 5 50 MORTALITY STATISTICS OF INSURED WAGE EARNERS. w o o •o z J o LJ U I a 0> 1- s S b. (9 O (0 •a s o o 1 • O 0) o O c Ij 3 • •z o 3 i U ? m • & D o o 1- £ U S s • « o < i a >« u. •o J > « c a t- • ut • H < O T 1- « % cc « • o o a g S U s 1 c £ > O a o ■e a. o a o £ o o "■" ■^-^ 1 .5 / r / / J J 1 ^ / y / / ^ 3 / ^'"'^ ^•'-•' ,.^-'' V, \ ^"^ ^-^ '■-•—- — — ■■ ■•^- A / ^ ,-^ /- y / y \ 1 / / .'-^ / J •v^,^^^ 1 1 "~-- "^ ■---- -- — . -^^ ■— —- . — . ^^ v^ "" \ .-" f^ / TUBERCULOSIS. 51 the two, the colored females show a much more symmetrical distri- bution of the rates by age. These graphs recall those which Dr. Brownlee has presented for certain geographical areas and occupation groups in his analysis of the incidence of pulmonary tuberculosis in Great Britain.* Our curve for white males corresponds very closely with that for males of London, where the middle age type of pulmonary tuberculosis prevails. The colored males, on the other hand, present a picture not very different from that described by Brownlee for Ireland, where the young adult type of pulmonary tuberculosis prevails. This is even more marked among the colored females, where the young adult type prevails with very little admixture of the middle age type. The curve for the white females recalls nothing m the presentation by Dr. Brownlee but seems to be an admixture of all three types. We are not inclined, however, to consider these graphs a verification of the hypothesis of Brownlee, which was that there are three types of tuberculosis; one causes death among the young, the second affects middle ages chiefly, the third type affects persons in old age. Our purpose is only to show that the same conditions which that writer found in Great Britain are repeated here, whatever may be the ultimate explanation for the irregular distributions which are found to characterize the death rates from pulmonary tuberculosis in the several color and sex classes. Comparison of Rates with Those of the Expanding Registration Area. We wish now to present some comparative data for the incidence of tuberculosis of the lungs among the group of insured white wage earners and the entire population of the expanding Eegistration Area of the United States. In the first instance our data relate to observations in the period 1911 to 1916 and in the second or popu- lation group, the period of observation is 1910 to 1915. This minor difference in the years covered by the two studies does not materially affect the comparison. The following table gives the death rates per 100,000 : * * ' Certain Considerations Eegarding the Epidemiology of Phthisis Pul- monalis," Public Health, March, 1916, London. 52 MOKTALITY STATISTICS OF INSURED WAGE EAENEES. TABLE 19. MOETALITT FEOM TUBERCULOSIS OF THE LUNGS.* Death Bates Per 100,000 Persons Exposed. Classified by Sex and hy Age Period. Insured White Lives in Experience of Metropolitan Life In- surance Company, Industrial Department (1911 to 1916) and Gen- eral Population of Expanding Registration Area of the United States (1910 to 1915). Males. Females. Age Period. M. L. I. Co. (White). U. S. Keg. Area. Per Cent. M. L.I. Co. of Reg. Area. M. L. I. Co. (White) . U. S. Reg. Area. Per Cent. M. L. I. Co. of Reg. Area. All ages — one and over . . 193.7 147.9 131.0 131.5 116.7 112.7 1 to 4 17.0 24.3 70.0 18.2 23.6 77.1 5 to 9 7.7 9.8 78.6 11.1 12.7 87.4 10 to 14 9.8 13.3 73.7 28.5 31.6 90.2 15 to 19 87.7 81.6 107.5 133.7 116.5 114.8 20 to 24 232.9 167.6 139.0 226.2 181.2 124.8 25 to 34 373.3 207.4 180.0 241.2 189.7 127.1 35 to 44 527.1 237.9 221.6 203.5 153.8 132.3 45 to 54 450.6 232.2 194.1 137.8 117.2 117.6 55 to 64 345.0 231.5 149.0 128.5 122.3 105.1 65 to 74 250.0 205.5 121.7 126.2 147.1 85.8 75 and over. . 180.2 160.0 112.6 127.2 140.7 90.4 * Includes ' ' tuberculosis of the lungs, ' ' title 28, and ' ' acute miliary tuberculosis," title 29 of the International List. The foregoing (iata indicate that among insured white males, all ages one and over, the mortality from tuberculosis of the lungs was 31% higher than among all males of the general popula- tion (excluding under one year of age). Females in the families of wage earners showed an excess of only 13%. It is of the greatest interest, however, to discover that in the ages of child- hood, that is, under 15, for each sex, the death rate for this con- dition was lower among those in the insured white group than among those in the general population. The advantage in favor of the male children of wage earners was even greater than that discovered for female children. Thus between the ages 10 and 14 years, the mortality rate from tuberculosis of the lungs among males in the insured white group was 26.3% less than in the general population. The advantage in favor of insured female children for the same age period was only 9.8% when compared with the rate for female children in the general population. It is difficult to say to what this favorable showing for pulmonary TUBEECULOSIS. 53 tuberculosis among the insured may be due, but two factors un- doubtedly play an important part. The first is the fact that we are comparing white insured children with a mixture of white and colored children in the Registration Area. Although the propor- tion of colored in this population group is small, the effect of their inclusion on the tuberculosis rate may be considerable because of the extraordinarily high rates for this condition which prevail among colored children. Unfortunately, it is impossible to elim- inate the small proportion of the colored from the data of the Reg- istration Area. The second factor is one of medical selection which results in eliminating a certain number of children of obviously poor physique from the insurance experience. Such children would later appear in the mortality experience of the Registration Area but would not affect the records of the insurance company. It is not possible to estimate at the present time the exact weight of these two factors. But in any case it is a matter of great interest that the children of wage earners, who reside in cities and are undoubtedly more exposed to infection and to the hard- ships incident to their economic stratum, should show no higher rates from pulmonary tuberculosis than children in the general population, of whom about one-half reside in rural areas where the rate from pulmonary tuberculosis is usually lower than in cities. Beginning with the age period 15 to 19 years and continuing up to age 64 years for females and up to and beyond age 75 for males,- the mortality rates for tuberculosis of the lungs among insured white persons were greater than the death rates for this disease in the general population of the Registration Area. Thus from 15 to 19 years the rate for tuberculosis of the lungs among male wage earners was 7.5% and the rate among females in wage earning fam- ilies was 14.8% in excess of the corresponding rates recorded at the same period in the general population. Between 20 and 24 years of age, male wage earners show an excess of 39%; between 25 and 34 years an excess of 80% ; between 35 and 44 years an excess of 121.6%. Among females the excess of mortality from tuberculosis of the lungs among wage earners increases gradually up to the period 35 to 44 years. Thereafter the percentage of excess mortality decreases until age 65. In the two highest age periods, the insured white females show lower death rates than females of the general population. The following table presents an interesting set of ratios showing 54 MORTALITY STATISTICS OP INSURED WAGE EARNERS. the relative sex distribution of mortality from pulmonary tuber- culosis, by age, among Industrial policyholders and the population of the Eegistration Area. TABLE 20. Mortality prom Tubee,cuix)sis op the Lungs.* Percentage, Male of Female Death Bates Per 100,000 Persons Exposed. Classified hy Age Period. White Lives, Experience of Metropolitan Life Insurance Company, Industrial Department, 1911 to 1916 and General Population of Expanding Registration Area of the United States, 1910 to 1915. Percentage, Male of Female Rate. Age Period. M. L. I. Co. "WMte Lives, 1911 to 1916. Ksp. Reg. Area, U. S. 1910 to 1915. All ages — one and over 147.3 126.7 1 to 4 93.4 69.4 34.4 65.6 103.0 154.8 259.0 327.0 268.5 198.1 141.7 103 5 to 9 77 2 10 to 14 42.1 15 to 19 70.0 20 to 24 92.5 25 to 34 109.3 35 to 44 154.7 45 to 54 198.1 55 to 64 189,3 65 to 74 139.7 75 and over 113.7 * Includes "tuberculosis of the lungs," title 28, and tuberculosis," title 2& of the International List. ' acute miliary This table shows that for the ages between 5 and 20 years males show a more favorable mortality from tuberculosis of the lungs than do females at the same age periods. The difference in favor of insured males was even greater than for males in the general population. Thus between 5 and 9 years, male mortality from tuberculosis of the lungs in wage earning families was 69.4% of the mortality among females; the corresponding ratio for the gen- eral population was only 77.2%. For the next higher age period, 10 to 14 years, the advantage in favor of males is even greater than before. For the insured experience, males had a rate only 34.4% of the female rate, while for the general population the male rate was 42.1% of the female rate. Between 15 and 19 years the ratio for wage earning families was 65.6% and for the general popula- tion 70.0%. It would be interesting if we knew first, why males under 20 years of aige show nearly uniformly a lower mortality from TUBEECULOSIS. 65 tuberculosis of the lungs than do females, and second, why this ad- vantage should be more pronounced among male wage earners than among males in the families of the general population of the United States. Beginning with the age period 30 to 24 years, however, the excess of male over female mortality for tuberculosis of the lungs was greater in wage earning families than in the gen- eral popula-tion of the expanding Registration Area of the United States. The foregoing ratios suggest a number of interesting in- quiries for future investigation. The Downward Trend of Mortality from Tuberculosis of the Lungs. In the introductory section of this report, it was pointed out that the mortality experience of the insured wage earners had declined very appreciably during the six year period covered by this study. This decline has been effected primarily through the reduction in the incidence of a number of the more important causes of death. Pulmonary tuberculosis is one of these. In fact, the decline in the death rate from this condition has been more marked in this in- surance experience than that from any other single condition of nu- merical importance. The following table is presented to show the trend of mortality for each of the years since 1911. It will be ob- served that the decline has continued generally throughout the en- tire period. TABLE 21. MOETALITT FROM TUBERCULOSIS OF THE LUNGS,* CLASSIFIED BY COLOR AND BY Sex. Death Bates Per 100,000 Persons Exposed. Single Years in Period 1911 to 1916. Experience of Metropolitan Life Insurance Company. Industrial Department. Persons. White. Colored. Year. Males. Females. Males. Females. 1911 to 1916 185.7 193.7 131.5 391.2 348.5 1916 172.8 180.0 185.3 186.6 191.6 203.0 178.1 184.0 197.4 200.0 198.2 210.4 122.8 127.3 127.5 130.7 137.3 148.4 386.8 399.9 396.8 387.0 397.3 378.7 336.8 1915 357.0 1914 347.8 1913 328.9 1912 348.0 1911 375.1 * Includes ' ' tuberculosis of the lungs, ' ' title 28, and ' ' acute miliary tuberculosis," title 29 of the International List. 66 MORTALITY STATISTICS OF INSURED WAGE EARNERS. Chart V. — Mortality from Tuberculosis of the Lungs Death Kates perlOO.OOOPersons Exposed By Single Years 1911 to 1916 Experience of Metropolitan Life Insurance Company, Industrial Department Death Rate per 100,000 400 300 ZOO JtOO J^j'/s Fe/nsIeJ •_•- CoJoreef Females —.. J91I ipie JfiiJf J914 igis 1916 TUBERCULOSIS. 67 The decline in the death rate from pulmonary tuberculosis shown in the above table, especially for white lives, is more pronounced than that to be noted for the general population in the Registration Area. In fact, the acceleration in the decline of the tuberculosis rate among wage earners is tending rapidly to close the gap which still exists between the death rates for pulmonary tuberculosis among wage earners and in the general population. This is indi- cated by the fact that in 1911 the excess of the Metropolitan rate for white lives over that for the white mortality experience in the Registration Area was 40.1%, whereas in 1916 this excess was re- duced to 33.8%. Chart V, on page 56, gives a graphic view of these facts. More instructive figures indicating the nature of the decline in the death rate for pulmonary tuberculosis are those which show the conditions for each race and sex at each age period of life. For by this means, we can localize the groups of the insured where the greatest improvement has occurred, where the improvement is not so great, and where no improvement has occurred at all. For the purpose of this comparison we shall take as our starting point the experience of the two years 1911 and 1912 combined and con- trast them with the corresponding facts for the two years 1915 and 191^. The variations which sometimes characterize the experience of a single year are in this way reduced. The table on page 58 pre- sents the ratios between the experience of 1915 and 1916 combined and that for 1911 and 1912 combined, for each one of the groups which compose this experience. The total experience shows a reduction of 10.6% which is a re- markable decrease for a short period of years. The most pro- nounced reduction appears for the group of white females although the improvement among white males is only slightly less, the per- centages of decline being 12.4 and 11.3 respectively. In the Reg- istration Area between 1911 and 1915 the per cent, decline for males was 5.4 and for females 10.2. Among the colored in the in- sured experience the picture is not so encouraging; for among the males a slight increase in the rate is found and among the females a decrease of but 4%. It is difficult to observe any definite law in the amount of re- duction in the pulmonary tuberculosis rate in relation to age groups, the figures varying so with age period. Among white lives there is considerable improvement in the period of childhood after age five 58 MORTALITY STATISTICS OF INSURED WAGE EARNERS. TABLE 22. Mortality from Tuberculosis of the Lungs.* Percentage, Death Bate Per 100,000 Exposed in 1915-1916 of Death Bate in 1911-1912 Classified by Color, Sex and by Age Period. Experience of Metropolitan Life Insurance Company. Industrial Department. 1 Percentage. 1915-1916 Rate of 1911-1912 Rate In Specified Age Period. Age Period. Persons. Wiite. Colored. Males. Females. Males. Females. All ages — one and over 89.4 88.7 87.6 101.3 96.0 lto4 5 to 9 10 to 14 15 to 19 20 to 24 25 to 34 35 to 44 45 to 54 55 to 64 65 to 74 75 and over . . . 88.0 85.5 93.4 91.2 84.3 85.1 88.5 95.6 97.6 92.5 94.5 101.8 88.6 90.5 78.3 79.8 82.5 89.7 101.1 99.0 98.1 115.4 98.9 94.6 92.7 96.6 87.5 82.0 83.2 89.5 94.7 84.2 73.6 86.0 92.7 103.8 101.2 91.6 101.8 103.7 88.9 106.6 93.9 216.5 88.2 92.4 104.4 102.9 92.7 96.5 87.9 109.0 103.5 112.9 91.2 * Includes "tuberculosis of the lungs," title 28, and "acute miliary tuberculosis," title 29 of the International List. and in early adult life. That is true for both sexes. Beginning with age 15 the improvement becomes more marked among white males. In fact, the greatest reduction of any is to be noted between the ages 15 and 24 years. Between 25 and 44 years favorable conditions are also noted for both white males and females. There- after, the picture is very confusing with a general indication of a stationary death rate for the years covered by the study. Among the colored, we find a substantial saving in mortality under age 10. Between 10 and 19 years the rates show slight in- creases. Between 20 and 25 years there is again a noticeable de- crease but thereafter the prevailing condition is one of increase more or less variable according to age. On the whole, the figuies among colored females are more encouraging than those recorded for colored males. But even for this sex certain age periods, such as 10 to 14 years and 45 to 54 years, show substantial increases. The present condition of the evidence does not allow safe prejudg- ment of the tendency of the death rate among the colored. Per- TUBEECULOSIS. 59 haps with the accumulation of data in future years a more definite tendency may be established. There is distinct cause for encouragement in the main findings of our inquiry into these facts of tuberculosis mortality according to age period. If the rate of 1911 had continued into 1916, the number of deaths from pulmonary tuberculosis among policy- holders of this Company would have been 20,659 instead of the 17,590 which actually occurred, a saving of 3,069 lives. We have seen, moreover, that the greatest relative decline in the tuberculosis death rate has occurred at those age periods where the rates are highest and when life is most valuable to the community. The favorable aspect of this tuberculosis experience in adult life may be the cumulative effect of all phases of public health and spe- cialized anti-tuberculosis work of the past twenty years. It is per- haps true that the greatest results have been obtained through pre- ventive work in behalf of children. Certainly these various efforts have tended to increase the vital resistance of children and have also changed favorably the circumstances which control the infec- tion of young people. Tuberculous Meningitis. This form of the disease is second only in importance to pul- monary tuberculosis. Indeed, in the ages of childhood under age 10, tuberculous meningitis is the chief form of tuberculosis. In- cluded in this tabulation of deaths are fatal cases of tuberculosis of the brain and of the cerebrospinal meninges. In all, 4,647 such deaths were reported in the six year period between 1911 and 1916c Of these deaths, 2,324 or fifty per cent, occurred in the age period one to four years. A little more than one-fifth of the cases were between five and nine years of age. Beginning with age ten, the number of deaths is small, although not unworthy of consideration. The table on page 60 shows the experience for tuber- culous meningitis according to color, sex and age class. It should be recalled again that the first age period, one to four, does not include infants under one, in which age the highest death rates from tuberculous meningitis occur. Thus, in the population generally, between one-fourth and one-fifth of all the deaths from this disease occur in the first year of life. On the other hand, the death rate in the second year of life when the insurance experience 60 MORTALITY STATISTICS OF INSURED WAGE EARNERS. begins is not much lower than in the first. Such comparisons as we shall make with the population figures will, of course, be lim- ited to the comparable age period over one and under five years. TABLE 23. Mortality from Tuberculous Meningitis, Classified by Color, Sex and BY Age Period. Death Bates Per 100,000 Persons Exposed. 1911 to 1916. Experience of Metropolitan Life Insurance Company. Industrial Department. Persona. White. Colored. Males. Females. Males. Females. All ages — one and over 8.6 • 9.1 7.7 11.7 9.7 lto4 5 to 9 10 to 14 15 to 19 20 to 24 25 to 34 35 to 44 45 to 54 55 to 64 65 to 74 75 and over . . . 51.5 13.8 5.4 4.3 3.4 2.6 2.5 1.5 1.6 1.3 1.4 48.8 12.5 4.5 3.6 2.7 3.0 3.0 1.9 2.1 .9 1.4 49.1 13.0 4.9 4.4 3.4 2.0 1.7 1.1 1.0 1.5 1.7 87.8 26.3 10.1 9.9 7.2 3.9 4.2 1.6 1.8 1.7 83.8 25.3 14.6 4.7 4.0 3.1 3.4 2.9 3.1 1.2 During the six year period, deaths from tuberculous meningitis were recorded at a rate of 8.6 per one hundred thousand persons ex- posed. This crude rate is very low when compared with the rate for pulmonary tuberculosis, because the deaths are concentrated at the early ages and the exposure includes all ages. Our analysis will be significant, therefore, only as we limit ourselves to very definite age periods, in fact, to those under fifteen; thereafter, tuberculous meningitis is of no very great account as a cause of death. The death rate is highest for colored males and least for white females. There is no very marked difference between the two sexes of each color, although males have a somewhat higher rate than females, especially between twenty-five and sixty-five years among the whites, and fifteen and forty-five years among the colored. The death rates, beginning with the maximum point under five years of age, decrease regularly with age up to and in- cluding ages forty-five to fifty-four years. There is a somewhat fluctuating experience thereafter. Practically the same form of TUBEECULOSIS. 61 curve is observed for each of the color and sex classes in this ex- perience. A comparison of the death rates for this condition with those prevailing in the Eegistration Area should be limited to the ages under fifteen, where the death rates for tuberculous meningitis are really significant. Under age ten, the children of white wage earners show a somewhat higher mortality rate than do children at the same ages in the population of the expanding Eegistration Area of the United States. This is true for each sex. Some part of the excess may be due to better registration of the disease among insured children than in the general population. Our sys- tem of inquiry into causes of death results in adding materially to the total number of deaths from tuberculous meningitis, for such reports as " meningitis " are always returned to physicians for additional information. It should be recalled that a net increase of fourteen per cent, in the number of deaths recorded for " tuber- culous meningitis" was produced by this system of inquiry over the number which would have been recorded had the method of querying physicians not been adopted. The age period ten to four- teen years shows almost identical rates in the population and among the insured. The following table presents a comparison of the death rates for a few significant age periods for insured lives as well as those of the general population of the expanding Eegis- tration Area: TABLE 24. MORTALITT FEOM TUBERCULOUS MENINGITIS. Death Hates Per 100,000 Persons Exposed. Classified ty Sex and by Age Period. Insured White Lives in Experience of Metropolitan Life Insurance Com- pany, Industrial Department (1911 to 1916) and General Population of Expanding Eegistration Area of the United States (191 (> to 1915). Males. Females. Age Period. M. L. I. Co. (White). U. S. Reg. Area. M. L.I. Co. (White). U. S. Reg. Area. 1 to 4 48.8 12.5 4.5 41.9 10.8 4.5 49.1 13.0 4.9 40 5 to 9 10.7 10 to 14 5.0 Like pulmonary tuberculosis, tuberculous meningitis shows a very favorable trend in its incidence during recent years. In the age period one to four years the rate for white males for the two 62 MORTALITY STATISTICS OF INSURED WAGE EARNERS. years 1911 and 1912 was 51.5 and, for 1915 and 1916 combined, it was only 46.0 per one hundred thousand. The per cent, decline was, therefore, 10.7. The greatest decline among the insured ap- pears to have occured among white females, where the rate for 1915 and 1916 was 18.0 per cent, lower than that for 1911 and 1912 combined. Abdominal Tuberculosis. Abdominal tuberculosis is the third form of tuberculous disease of interest in this discussion. "We have included in our figures deaths from tuberculosis of the gastroenteric tract, including the peritoneum, the omentum and the mesenteric glands. In all, there were 3,155 such deaths. Deaths from this disease seem to be fairly well distributed over the entire range of life. The variation in the death rate from one age period to another is not so marked as was observed for pulmonary tuberculosis or for tuberculous meningitis. There appear to be in this present series of data three points of modal incidence, the first at the age period one to four years, the second in the age period 35 to 44 years and the third after age 75. Between each of these points the curve tends to assume a concave form. The least rate was registered in the age period ten to four- teen years. Our facts according to color, sex and age period are displayed in the following table: TABLE 25. Mortality from Abdominal Tuberculosis, Classified by Color, Sex and Age Period. Death 'Rates Fer 100,000 Persons Exposed. 1911 to 1916. Experience of Metropolitan Life Insurance Company. Industrial Department. Persons. White. Colored. Age Period. Males. Females. Males. Females. All ages — one and over 5.9 3.7 4.6 15.4 19 6 lto4 5 to 9 10 to 14 15 to 19 20 to 24 25 to 34 35 to 44 45 to 54 55 to 64 65 to 74 75 and over . . . 6.8 3.4 3.2 5.3 6.4 6.7 7.9 6.3 7.6 8.4 10.6 6.2 2.2 1.1 2.2 3.2 3.9 5.2 5.4 7.7 8.4 8.5 5.2 2.1 2.3 3.4 5.3 5.1 6.5 5.5 5.9 7.7 11.7 28.2 16.9 14.2 19.8 17.1 13.4 13.8 10.7 16.2 6.7 14.6 18.2 21.1 32.8 23.8 19.8 18.6 11.3 13.6 16.4 18.1 TUBERCULOSIS. 63 The colored show higher death rates in this series than do the whites, and the rate for females of each color group exceeds that for the males. Among white lives, there is no great difference between the rates of the two sexes under ten years of age. Beginning with the age period ten to fourteen years, however, the death rates for abdominal tuberculosis among white females begin to exceed the rates for white males to a significant extent, up to and including the period thirty- five to forty-four years. This suggests the influence of puerperal traumata as causes contributing to the development of abdominal tuberculosis. For the period forty-five to fifty-four years, the rates for both sexes for white lives are approximately the same. After fifty-Sve years of age, the figures for white males exceed those for white females up to and including age seventy-four. White males and white females show in general a decreasing death rate from abdominal tuberculosis in this experience. Col- ored males, however, show a variable rate with no definite tendency in either an upward or downward direction. There seems to be only a slight downward tendency in the death rate from abdominal tuberculosis among colored females. These facts are displayed in the following table: TABLE 26. Mortality from Abdominal Tuberculosis, Classified by Color and BY Sex. Death Bates Per 100,000 Persons Exposed. Single Years in Period 1911 to 1916. Experience of Metropolitan Life Insurance Company. Industrial Department. Persons. White. Colored. Year. Males. Females. Males. Females. 1911 to 1916 5.9 3.7 4.6 15.4 19.6 1916 5.1 5.2 5.5 6.2 6.6 6.9 3.2 3.3 2.9 3.7 4.8 4.6 3.7 4.0 4.6 5.1 4.8 5.8 15.3 14.5 14.3 17.1 17.0 14.3 18.4 1915 18.6 1914 20.0 1913 19.2 1912 20.6 1911 21.1 Comparison of the death rates for abdominal tuberculosis among white insured persons and among persons in the Eegistration Area shows some items of interest. These are displayed in the following table : 64 MOETALITY STATISTICS OF INSURED WAGE EARNEKS. TABLE 27. Mortality from Abdominal Tuberculosis. Death Bates Per 100,000 Persons Exposed. Classified hy Sex and by Age. Insured White Lives in Experience of Metropolitan Life Insurance Company, Industrial Department (1911 to 1916) and General Population of Expanding Registration Area of the United States (1910 to 1915). Males. Females. Age Period. M. L. I. Co. (VFWte). U. S. Reg. Area. Per Cent. M. L. I. Co. of Reg. Area. M. L. I. Co. (WWte). U. S. Reg. Area. Per Cent. M. L. I. Co. of Reg. Area. AH ages — one and over . . 3.7 4.8 77.1 4.6 6.0 76.7 1 to 4 6.2 6.9 89.9 5.2 5.3 98.1 5 to 9 2.2 2.7 81.5 2.1 2.2 95.5 10 to 14 1.1 1.9 57.9 2.3 2.6 88.5 15 to 19 2.2 3.3 66.7 3.4 5.1 66.7 20 to 24 3.2 4.4 72.7 5.3 6.9 76.8 25 to 34 3.9 4.6 84.8 5.1 7.2 70.8 35 to 44 5.2 4.9 106.1 6.5 7.0 92.9 45 to 54 5.4 5.6 96.4 5.5 6.9 79.7 55 to 64 7.7 8.4 91.7 5.9 9.1 64.8 65 to 74 8.4 10.4 80.8 7.7 10.4 74.0 75 and over. . 8.5 7.6 111.8 11.7 10.6 110.4 It is a matter of great interest that the male mortality for the general population of the Eegistration Area exceeds that for white males in the insurance experience. The only exception is in the age group 35 to 44 years and beyond age 75. Among females, the population rates are in excess of those for the insurance ex- perience for all age periods except 75 years and over. The least ratio of excess is to be observed in the age period 1 to 4 years. Tuberculosis of Other Forms, and Disseminated Tuber- culosis. We did not deem it desirable to bring out in any great detail the facts for the remaining forms of tuberculosis registered in our mortality records. In addition to mortality from the forms of tuberculosis which have been discussed in the preceding sections, we recorded 2,655 deaths from tuberculous infection of other or- gans. These deaths occurred at a rate of 4.9 per 100,000 exposed. According to our records, there was a gradual decrease in deaths from these miscellaneous forms of tuberculosis, from a rate of 5.8 per 100,000 in 1911 to a rate of 4.1 in 1916. CHAPTEE V. Organic Diseases of the Heaet. The deaths classified as due to "organic diseases of the heart" form a group which is second in numerical importance only to tuberculosis in this mortality experience of insured wage earners. In the experience of the general population of the expanding Reg- istration Area in recent years, organic heart disease has ranked first as a cause of death. During the six-year period, 1911 to 1916, 75,345 deaths from organic cardiac diseases were recorded among the Company's Industrial policyholders. This number is 11.9 per cent, of the 635,449 deaths from all causes. The deaths corre- spond to a rate of 140.1 per 100,000 exposed. This is for the en- tire experience period ; but in four of the six years the rate was higher than that for the period as a whole. The chief interest in connection with the study of the mortality from cardiac disease lies, of course, in its variable age, color and sex incidence. The disease is primarily one of advanced life, although, as we shall see, it takes a significant toll at the younger adult ages. The rate is considerably higher among colored persons than among the white group, which condition also obtained in the Registration Area for the period as a whole and for each included year. This was true for each sex for every significant age group with the exception of that relating to decedents 75 years of age and over. The death rates are very different for the two sexes. Almost without exception the rates for females are higher than for males up to and including the age period 20 to 24 years. After this age period, however, the situation is reversed, the death rates for males being very much higher than for females. This is uniformly true for white lives 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 sick- ness in which the wage earner has been unable to work actively all or part of the time. These diseases thus bring about hardship and 6 65 66 MORTALITY STATISTICS OP INSURED WAGE EARNERS. distress which can not be shown in figures. In fact, if it were pos- sible 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 impressively demonstrated than is possible by the publi- cation of mere numbers of deaths and the corresponding death rates. Considered irrespective of color or sex, we find that the death rates for the organic diseases of the heart increase regularly with age, but show their greatest increases in the higher age periods. This is brought out clearly in the following table and in the ac- companying graph : TABLE 29. Mortality from Organic Diseases of the Heart, Classified by Color, Sex and by Age Period. Death Bates per 100,000 Persons Exposed. 1911 to 1916. Experience of Metropolitan Life Insurance Company. Industrial Department. Persons. White. Colored. Age Period. Males. Females. Males. Females. All ages — one and over 140.1 125.9 137.0 191.0 202 lto4 5 to 9 10 to 14 15 to 19 20 to 24 25 to 34 35 to 44 45 to 54 55 to 64 65 to 74 75 and over.. 7.3 16.2 26.7 30.2 30.6 53.5 121.8 253.6 604.8 1523.1 2808.1 7.0 14.9 22.7 28.7 28.5 51.6 120.1 259.0 641.2 1624.2 3033.1 6.4 18.2 31.4 31.2 30.4 45.6 92.6 201.1 526.8 1443.0 2703.1 14.1 11.4 19.9 29.4 32.2 89.6 201.2 416.0 885.4 1702.2 2647.8 14.6 14.1 28.3 34.9 42.8 72.8 211.7 433.1 787.8 1530.3 2613.2 Significant relations may be brought out by comparing the fore- going figures for white persons with those for the total expanding Eegistration Area of the United States. We shall use for this pur- pose the population figures for the six year period 1910 to 1915 inclusive. Taking all ages one and over together in the two expe- riences, we find that the mortality rate for insured white males (135.9 per 100,000) was lower than that for males of the Registra- tion Area (147.0 per 100,000) and that the rate for insured white ORGANIC DISEASES OF THE HEART. 67 < bJ X u X i- o m < m Q O z S 1 __ ""^ ::^ ^,^ \ '\ N 1 1 \ \ > \\ •Is ^ i 1 ^ Xj 1 O o I > u * u 68 MORTALITY STATISTICS OF INSUEED WAGE EARNERS. females (137.0) was lower than the rate for females in the general population (140.7). No mistake should be made, however, as to the meaning of these figures. The apparent advantage in favor of the insured group results simply from their more favorable age distribution. A larger proportion of them are in the younger age groups where the death rate from the heart diseases is low, and only a small proportion of the policyholders are found in the ad- vanced ages when the death rate from these conditions is very high. A comparison between the two series must, therefore, be strictly limited to each age period and to each of the sex groups, separately. The following table shows, side by side, the figures for males in the expanding Eegistration Area compared with those for insured white males and for females in the Eegistration Area compared with insured white females: TABLE 30. Mortality from Organic Diseases of the Heart. Death Bates per 100,000 Persons Exposed. Classified hy Sex and by Age Period. Insured White Lives in Experience of Metropolitan Life In- surance Company, Industrial Department {1911 to 1916) and General Population Experience of Expanding Registra- tion Area of the United States (1910 to 1915). Males. Females. Age Period. Percentage Percentage M. L. I. Co. U. S. Reg. M. L. I. Co. M. L. I. Co. U. S. Reg. M. L.I. Co. (White). Area. of Keg. Area. (White). Area. of Reg. Area. AH ages — one and over . . . . 125.9 147.0 85.6 137.0 140.7 97.4 1 to4 7.0 7.6 92.1 6.4 7.6 84.2 5 to 9 14.9 12.6 118.3 18.2 15.3 119.0 10 to 14.... 22.7 16.6 136.7 31.4 21.2 148.1 15 to 19.... 28.7 19.7 145.7 31.2 20.4 152.9 20 to 24.... 28.5 20.0 142.5 30.4 23.0 132.2 25 to 34.... 51.6 33.4 154.5 45.6 36.9 123.6 35 to 44.... 120.1 76.0 158.0 92.6 76.8 120.6 45 to 54.... 259.0 175.5 147.6 201.1 160.9 125.0 55 to 64.... 641.2 474.4 135.2 526.8 409.2 128.7 65 to 74.... 1624.2 1213.8 133.8 1443.0 1044.1 138.2 75 and over 3033.1 2665.6 113.8 2703.1 2438.6 110.8 Thus compared, a very different picture is presented, for, with the single exception of the period of early childhood, namely, 1 to 4 years, the death rates are much higher for the insured group than ORGANIC DISEASES OF THE HEART. 69 for the general population. It is especially at the working agos of life that the disadvantage of the policyholders is evident. The facts of mortality from organic diseases of the heart, as for tuberculosis, show with advancing age the cumulative effect upon the vitality of wage earners of more severe conditions of life and work, and per- haps of less favorable hygienic circumstances, than are found in the general population of the United States. This conclusion is apparently substantiated when we compare the relation between the death rates of the two sexes in the popula- tion and in the insured group. We find, for example, in the twenty year age period, from 25 to 45 years, very much higher rates for males than for females in the wage earning element. On the other hand, in the general population, females at these ages do not enjoy any such advantage ; in fact, the rates are slightly higher for them than for the males. This would seem to be the result of the severer strain of life and work to which male wage earners are exposed. The trend of the death rate from organic heart diseases in the Industrial Department of the Metropolitan Life Insurance Com- pany during the six years is interesting and is in marked contrast with the tendency shown by the figures of the general population. In the insurance figures the rate for 1916 is lower than for 1911 (140.2 as compared with 141.8). This represents a decline of 1.1 per cent, in the period. On the other hand, in the expanding Reg- istration Area the figures show a very considerable increase in the six year period from 140.9 in 1911 to 150.1 per 100,000 in 1916 (6.5 per cent.). It is quite true that in both experiences there is a certain irregularity in the trend; but the rates for the insured group, very generally speaking, show downward tendency, whereas those for the population, especially since 1913, show a continuous rise. The changes that have occurred in the population figures are even more strikingly brought out when we go back a number of additional years. In 1900 the Eegistration Area rate was only 111.2 per 100,000; by 1904 it had, through continuous increases, reached 133.4. From that year until 1911 there was considerable fluctuation; the 1911 rate (140.9) marked a 26,7 per cent, increase over the figure for 1900. The following table presents the trend of mortality among in- sured wage earners in the years 1911 to 1916: 70 MOETALITY STATISTICS OF INSURED WAGE EAENEES. TABLE 31. Mortality from Obganic Diseases of the Heabt, Classified bt Color AND BY Sex. Death Bates per 100,000 Persons Exposed. Single Years in Period 1911 to 1916. Experience of Metropolitan Life Insurance Company. Industrial Bepartment. Persons. White. Colored. Year. Males. Females. Males. Females. 1911 to 1916 140.1 125.9 137.0 191.0 202.0 1916.... 1915.... 1914.... 1913.... 1912.... 1911.... 140.2 136.7 138.1 140.6 143.8 141.8 126.0 119.4 125.5 127.3 129.4 128.8 135.8 136.1 134.6 137.2 139.5 139.9 197.2 183.9 191.5 194.6 202.6 175.5 212.9 207.1 193.1 193.9 205.7 198.7 The increase in mortality from organic heart diseases which we have just discussed for the Eegistration Area has, in recent years, given rise to the prevalent opinion that there has heen a marked increase in the so-called "degenerative diseases." Certainly this conclusion is not substantiated by the facts presented by the mor- tality data for insured wage-earners. If, however, we limit our- selves to a consideration of the expanding Eegistration Area alone, we should keep in mind that even these data with their marked in- creases in the interval since 1900 must not be taken on their face as final. The Census Bureau itself has continually cautioned the readers of its reports on Mortality Statistics against comparing the more recent figures for organic diseases of the heart with those run- ning prior to 1910. Very important changes in the statistical treatment of this return of cause of death have been instituted by the Census Bureau. Certain statements of cause, such as, " endo- carditis" and "myocarditis" for decedents over 60 years of age which were formerly excluded from this title are now classified under it. Methods of treating jointly reported causes of death as well as the accelerated tendency of physicians to report more defi- nitely the conditions causing death, have undoubtedly resulted in the increased reporting of organic diseases of the heart. The evi- dence, therefore, is clear that a large part, at least, of the increase in the death rate of the heart diseases is fictitious, resulting merely OKGANIC DISEASES OF THE HEAET. 71 from changed reporting and compiling procedure; and so far as this concerns insured wage earners where the greatest amount of increase might be expected, it does not show at all. Organic diseases of the heart, International List title No. 79, as compiled in this report, include all chronic valvular diseases, fatty degeneration, chronic myocarditis and chronic dilatation. It in- cludes a number of deaths which are ascribed by physicians to " heart disease " without further definition. It also comprehends chronic heart diseases of rheumatic origin. On the other hand, the title does not include acute endocarditis, acute myocarditis, " endo- carditis " or " myocarditis " with no further qualification, for dece- dents under 60 years of age. Deaths reported as due to pericar- ditis and those reported as due to many indeterminate cardiac symptoms such as "palpitation of the heart," "functional disease of the heart" and others are not included. CHAPTEE VI. Pneumonia (All Forms). Pneumonia, as the term is popularly used, is a most important cause of death in this experience, the incidence of which has been increasing significantly during recent years. Unfortunately, the term has no great scientific value since it is used, in the main, to cover two very different conditions, namely, lobar pneumonia and bronchopneumonia. Lobar pneumonia is a disease affecting, for the most part, the adult ages of life. Bronchopneumonia, on the other hand, is a disease affecting chiefly the periods of childhood and old age. In fact, two-thirds of all the deaths in the general population experience from bronchopneumonia are those of chil- dren under five years of age. For these reasons and because of the different clinical pictures presented by these two conditions, it will be much more instructive to treat in detail each of the types of pneumonia separately. At this point it is necessary only to remark that in the period between 1911 and 1916 the total number of deaths from "pneumonia (all forms) " was 57,931 ; this is the total for lobar pneumonia, so defined, bronchopneumonia and "pneu- monia" without further qualification. Together the death rate TABLE 32. MOBTALITT FROM PNEUMONIA (ALL FORMS), PNEUMONIA (LOBAR AND UN- DEFINED) AND Bronchopneumonia. Death Bates per 100,000 Persons Ex-posed. Single Years in Period 1911 to 1916. Experience of Metropolitan Life Insurance Company. Industrial Department. Year. " Pneumonia (AH Forms)." Pneumonia (Lobar and Undefined) . Bronchopneumonia. 1911 to 1916 107.7 77.5 30.2 1916 1915 1914 1913 1912 1911 114.3 106.5 100.3 106.1 103.9 115.3 80.8 74.4 68.9 77.7 75.8 89.2 33.5 32.1 31.4 28.4 28.1 26.1 72 PNEUMONIA. 73 for the six year period was 107.7 per 100,000 exposed. The preced- ing figures show the trend in the rate for this large group of causes of death since 1911. (a) Pneumonia (lobar and undefined). Statistics of mortality from pneumonia (lobar and undefined) are interesting from many standpoints. Lobar pneumonia is the most important numerically of the infectious diseases. It kills every year more people than die of such infectious diseases as measles, scarlet fever, diphtheria, whooping cough and acute polio- myelitis combined. Any one stricken with lobar pneumonia, more- over, has a smaller chance of recovery than have those afflicted with any one of the other conditions just mentioned — even polio- myelitis or "infantile paralysis." Several health departments have, therefore, placed lobar pneumonia on the list of reportable diseases, thus officially recognizing the fact of its infectiousness and calling attention to its extremely fatal nature. During the six-year period 1911 to 1916, in this experience, 41,707 insured wage earners and members of their families died of pneumonia (lobar and undefined). The death rate correspond- ing to this number of deaths was 77.5 per 100,000. This group of diseases shows a higher death rate among colored policyholders than among the white. The table on page 74 shows also that these facts are true both for males and females. The ages of high- est mortality are the extremes of life. This applies to both white and colored persons and to males and females. The excess of col- ored over white mortality is shown in every age period for both males and females. Further consideration of this table shows that the rate for males is almost uniformly higher than that for females. There are, to be sure, two exceptions among white lives, one at ages 10 to 14 years, the other at the very advanced age period 75 years and over, but in both cases the difference between the two sexes is slight and does not materially affect the conclusion drawn. Beginning with the period 25 to 34 years and continuing up to 65 to 74 years, the rate for males is much in excess over the rate for females ; in fact, for a number of these age periods the rate for males is more than twice that of females. Much the same conclusion may be drawn from the comparison of the rates for the two sexes of the insured 74 MOETALITY STATISTICS OF INSURED WAGE EARNERS. TABLE 33. Mortality feom Pneumonia (Lobar and Undefined), Classified by Color, Sex and by Age Period. Death Bates per 100,000 Persons Exposed. 1911 to 1916. Experience of Metropolitan Life Insurance Company. Industrial Department. Persons. White. 1 Colored. Males. Females. Males. Females. All ages — one and over 77.5 82.6 63.0 141.5 97.2 1 to 4 5 to 9 10 to 14 15 to 19 20 to 24 25 to 34 35 to 44 45 to 54 55 to 64 65 to 74 75 and over. . 108.0 19.7 11.5 20.8 29.5 50.1 89.7 139.6 247.9 468.7 791.3 103.5 17.9 9.5 19.4 29.0 62.6 130.9 197.4 300.7 500.0 774.6 93.2 17.5 10.8 14.6 17.9 29.4 50.8 92.7 203.3 441.1 794.4 240.4 32.8 22.8 52.4 94.0 119.8 175.2 242.7 346.4 542.9 836.9 232.2 47.6 24.9 51.8 60.5 55.8 86.2 126.9 251.8 482.7 834.8 colored group, although the differences are not, on the whole, as great as those observed among the whites. The charts on page 75 graphically illustrate these facts for pneumonia mortality ac- cording to age. The rate already noted for the entire experience, namely, 77.5 per 100,000, is somewhat more favorable than that found in the expanding Registration Area of the United States for the six-year period 1910 to 1915. This condition is still in evidence when the estimated population of the Area under one year of age is elimi- nated, and the rates are computed for persons of the same age groups as those covered by the insurance experience. Thus, we find that in the six-year period 1910 to 1915 the population rate for males was 84.3 per 100,000, while the rate for females was 66.6. These compare with the policyholders' figures of 82.6 and 63.0 for insured white males and white females respectively. The gen- eral population figures would be somewhat lower if it were possible to eliminate the effect of the colored element which is included. This cannot be done but it is evident that the exposures in the two experiences are, by and large, in very close agreement. An analysis by age groups shows, however, a number of impor- tant points of difference when we compare the experience in the PNEUMONIA. 75 u bJ z k o u. u p a a r. E 3 O G n i: o o < O < •o o o 5 03 o o 1 -1 c n j < S z i c o J> ^ m a 3 o InI o U z a. £ Q. a « < ^ >t O u q: a e k. £ 2 >■ ■ n 1 1- O -1 •o T; < s h o bl 1 iff 1 c o II 5 Q. > o o "C o o 16 £ 1) ****= p=«=«* -:__. . -^ ■■V ^^^::>>s \ s 1 i i \ \ \\ 1 I.* w « IS \ ^ UJ a S O iL 5° -— « — — — , p== - >^^ %, \ 1 N \ \ § 5; \ ^ 1 ] J .----- ::==== 82 MOKTALITT STATISTICS OF INSUEED WAGE EAENEES. lower than that for 1913, and the 1916 rate was lower than that for 1915, The death rate for bronchopneumonia in the expanding Eegistration Area is higher than that for the group of insured wage earners because bronchopneumonia is a disease which takes its largest toll among infants under 1 year of age. The expanding Eegistration Area experience shows that about 40 per cent, of the mortality from this disease is that of infants under 1 year of age. It is also the cause of death of many thousands of people of 70 years and over. Since there is no exposure among policyholders for the period of early infancy and a smaller proportionate exposure among elderly people than in the Eegistration Area, it is easy to account for the higher bronchopneumonia death rate of the latter group. In other words, the experiences are not comparable, so far as the crude death rates are concerned, on account of the differing age distributions of the two populations. The following table gives the death rates for bronchopneumonia for all policyholders, and for white and colored policyholders by sex, for the six-year period as a whole and for each year compre- hended. The upward trend of the mortality charged to this dis- ease is obvious. Chart IX graphically illustrates the data on the trend of bronchopneumonia mortality in this experience. TABLE 36. Mortality from Bronchopneumonia, Classified by Colob and by Sex. Death Bates per 100,000 Persons Exposed. Single Years in Period 1911 to 1916. Experience of Metropolitan Life Insurance Company. Industrial Department. Persons. White. Colored. Year. Males. Females. Males. Females. 1911 to 1916. 30.2 29.6 29.2 37.7 33.7 1916.... 33.5 32.7 32.6 43.3 37.5 1915.... 32.1 30.8 31.2 38.3 41.8 1914.... 31.4 31.1 29.7 39.9 37.8 1913.... 28.4 28.7 26.8 38.8 29.3 1912.... 28.1 27.7 27.7 34.4 27.5 1911.... 26.1 25.6 25.8 30.6 26.9 Since bronchopneumonia is a disease with a very pronounced age incidence, interest in comparing the mortality among wage earners PNEUMONIA. 83 Chart IX. — Mortality rrom Bronchopneumonia Death Rates per100,000Persons Exposed By Single Years 1911 to 1916 Experience of Metropolitan Life Insurance Company, Industrial Department D««tli Rate par 100,000 84 MOETALITT STATISTICS OF INSURED WAGE EARNEES. and their families with that among the general population attaches chiefly to the comparative mortality for the several age groups. In order to compare the death rate of young children it is, of course, necessary to eliminate the exposure under 1 year of age in the general population, since there is no corresponding exposure for the policyholders. For the age group 1 to 4 years the estimated death rate for bronchopneumonia among males in the Kegistration Area for the sexennium 1910 to 1915 was 143.3 per 100,000 popu- lation. This is lower than the corresponding rate for white males among the Industrial policyholders (145.4). It is believed, how- ever, that this slight difference is more than accounted for by the higher proportion of reports of cause of death in the insurance experience changed from "pneumonia" to bronchopneumonia as the result of information additional to that contained in the origi- nal certification and obtained through correspondence with the physicians who made the reports. Comparison by age groups shows, in every important instance, a higher mortality for the white male policyholders than for males in the general population, and this excess becomes more pronounced in the higher age periods. It is probable that a part of this excess in the rate for insured wage earners is real and represents the effect of their economic and sani- tary disadvantages. The age period of maximum mortality among males in the Reg- istration Area is shown to be the same as among the insured, namely, the highest age group, 75 years and over. In the general population experience, however, the lowest group, one to four years, shows a higher death rate than the group 65 to 74 years. This is contrary to the experience for the Industrial policyholders in that the death rate for white males for the age period 65 to 74 years (173.1) is considerably higher than that covering early childhood (145.4). The following table presents a comparison of the death rates for bronchopneumonia among insured lives and in the general popula- tion of the expanding Registration Area. While the chief interest in the mortality caused by bronchopneu- monia does not attach to the main wage earning periods, there are to be noted a few rather important differences in the ratios of the rates for males and of females which are in evidence in comparing the general population with the insurance experience on white lives. Beginning at the period 15 to 19 years, the death rate among the PNEUMONIA. 85 TABLE 37. Mortality from Bronchopneumonia. Death Bates per 100,000 Persons Exposed. Classified hy Sex and hy Age Period. Insured White Lives in Experience of Metropolitan Life In- surance Company, Industrial Department {1911 to 1916) and General Population Experience of Expanding Begistra- tion Area of the United States (1910 to 1915). Males. Females. Age Period. M. L. I. Co. (White). U. S. Reg. Area. Percentage M. L. I. Co. of Reg. Area. M. L. I. Co. (White). U. S. Reg. Area. Percentage M.L.I. Co. ol Reg. Area. All ages — one and over .... 29.6 26.9 110.0 29.2 30.0 97.3 lto4 145.4 143.2 101.5 139.9 134.5 104.0 5 to 9 11.5 10.9 105.5 13.0 11.2 116.1 10 to 14.... 2.7 2.7 100.0 3.1 3.7 83.8 15 to 19.... 2.6 2.9 89.7 2.9 2.9 100.0 20 to 24.... 2.8 3.3 84.8 3.3 3.6 91.7 25 to 34.... 6.7 4.7 142.6 4.6 4.2 109.5 35 to 44.... 14.0 8.7 160.9 8.2 6.5 126.2 45 to 54.... 29.0 16.0 181.3 18.2 13.3 136.8 55 to 64.... 65.0 35.9 181.1 60.6 39.5 153.4 65 to 74.... 173.1 94.1 184.0 202.7 124.2 163.2 75 and over. 350.4 304.3 115.1 484.7 430.0 112.7 general population is identical for males and females, namely, 2.9 per 100,000 population. In the insurance experience that for females (also 2.9) exceeds slightly that for males (2.6). In the next age period (20 to 24 years), there is a slight excess in each experience in the rate for females, hut in the period 25 to 34 years, the white male insurance experience with a rate of 6.7 per 100,000 exposed shows a much greater excess over the rate for insured white females (4.6) than is in evidence for the general population, for which the corresponding death rates were for males (4.7) and for females (4.2). The next age group shows higher rates for the males in each experience, hut the difference hetween the rates by sex is much greater among the insured (14.0 for white males as compared with 8.2 for white females) than among^ the general population (8.7 for males and 6.5 for females). For the period 45 to 54 years with higher death rates (insured white males 29.0, white females 18.2; general population: males 16.0, females 13.3) there is, again, a greater divergence between mortality of males and females among the wage earning group than prevails for the popu- lation as a whole. When the age group 55 to 64 years is reached,^ 86 MORTALITY STATISTICS OP INSUEED WAGE EAENERS. we find that the death rate for females in the general population exceeds that for the males (males 35.9, females 39.5), which is con- trary to the facts shown for the insured group (white males 65.0, white females 60.6; colored males, 69.0, colored females, 56.8). Reliability of the Figures for Bronchopneumonia Mortality. Death rates for bronchopneumonia should be used with caution. It will be noted that the figures indicating the mortality among insured wage earners from this disease show a continuous increase during the six years covered by this report. The rates for the expanding Registration Area also show an increase which was con- tinuous during the same period with the exception of two years, for each of which the deviation was too small to be significant. Prior to 1911 the published rates for the Registration Area were still lower than those for the period 1911 to 1916, and a superficial analysis of Registration Area experience would lead one to believe that in the seventeen years covered thereby there had been an increase in the mortality caused by this disease of 124 per cent. Briefly, it may be said that the increased published death rates for bronchopneumonia in both the insurance and general population experience have been brought about, first, by improved statements of cause of death on certificates and insurance forms, and second, by the ever-increasing strictness with which reports of "pneumonia,^' unqualified, are sent back to certifying physicians with requests for information as to the type of the disease. Still another matter should be considered in analyzing the published mortality from bronchopneumonia in this or any other volume. To a certain ex- tent the statement of "bronchopneumonia" itself is an unsatis- factory report of cause of death. While it is probably true that the disease is idiopathic in the majority of cases where it is the only cause reported, it is also true, and has been demonstrated, that in many cases the condition is a sequela of other diseases not men- tioned on the physician's original report. CHAPTER VII. Beight's Disease. Certification of Bright' s Disease. The statistical treatment of Brighf s disease mortality presents a number of difficulties. The condition, as will be described more fully later, often occurs in conjunction with the so-called cardio- vascular diseases, such as organic diseases of the heart, arterio- sclerosis, cerebral hemorrhage, etc. In such instances, much depends, in the statistical registration of the death, upon the definiteness with which the cause of death has been certified by the physician. Where, for example, the statement is " Bright's disease " combined with valvular disease of the heart, the death is assigned to the latter condition. A more specific statement of Bright's disease as chronic interstitial nephritis and valvular disease of the heart is, on the other hand, registered as a death from Bright's disease. The sev- eral terms used by physicians may refer to precisely the same dis- eases and conditions in each of the cases, but, in the one instance, the assignment of the death is to a heart condition, and in the other to the condition of the kidney. Standard practice requires such assignment; nevertheless, it is generally believed that, as a result of the present status of reporting, many cases of true Bright's dis- ease which would receive precedence if fully described, are lost from the record in view of the fact that few tables contain any ref- erence to the secondary causes of death. Mortality from Bright's Disease among Insured Wage Earners. Even under the above considerations, Bright's disease appears as the fourth cause in numerical importance in the Industrial expe- rience of the Metropolitan Life Insurance Company. In all, 52,067 deaths were registered in the six-year period, corresponding to a rate of 96.8 per 100,000 living.* In general, the contour of the * These deaths include those certified as due to "Bright's disease," or "nephritis," without further qualification; also those reported as due to chronic Bright's disease, chronic nephritis, and to the several types of 87 88 MORTALITY STATISTICS OF INSURED WAGE EARNERS. curve of mortality according to age is very similar to that for or- ganic heart disease, although the figures are in every case lower than those for the other condition. The mortality is comparatively low until the age period 20 to 24 years is reached. From this point onward, the increases are very marked, the rates (with one excep- tion) more than doubling from age period to age period until the maximum is reached in the most advanced age group, 75 years and over. The following table and graph present the detailed relations of the death rate from Bright's disease by color, sex and age classes: TABLE 38. Mortality from Bright's Disease, Classified by Color, Sex and by Age Period. Death Bates per 100,000 Persons Exposed. 1911 to 1916. Experience of Metropolitan Life Insurance Company. Industrial Department. Persons. WMte. Colored. Age Period. Males. Females. Males. Females. AU ages — one and over 96.8 97.1 88.1 138.7 121.3 lto4 5 to 9 10 to 14 15 to 19 20 to 24 25 to 34 35 to 44 45 to 54 55 to 64 65 to 74 75 and over. . 5.7 4.3 4.9 8.6 15.3 36.3 101.3 216.7 453.3 970.6 1715.2 5.8 4.2 3.8 7.8 14.8 38.5 119.3 259.8 539.3 1146.3 2106.7 4.4 4.2 5.6 8.8 14.2 31.8 80.0 171.5 364.7 826.0 1466.6 18.6 4.9 7.6 9.9 20.7 41.5 130.6 301.9 709.5 1501.8 2140.2 9.5 6.1 5.9 12.9 22.2 46.9 127.8 264.8 501.3 873.8 1624.2 Bright's disease is more commonly represented in the mortality experience of colored persons than among white persons. This is true for each of the sexes and for every age period. At some of the age periods, the excess among colored persons is very marked in- deed, although there is some irregularity as to the amount. There is also a sex distinction in Bright's disease mortality which merits some attention. Males show higher rates in all of the more Bright's Disease, for example, chronic interstitial nephritis, chronic paren- chymatous nephritis, chronic diffuse nephritis, etc. Deaths from acute nephritis are not included. BRIGHT S DISEASE. 89 u < u (0 S S — o s (A I S I- ^ s I 5 o 2 " 1 ffl S I O 5 i OC ^ " > I- < h cc o (0 c o i ==^=«= ''a^^ 'v.^ ^ X \ \ 1 ^•> . \ \ ^ \\ \ ^ C5 — 1 sS Hi 1 1 1 1 > 1 1 1 i ^ 5 1 "* OS "■^a^ •^ -» ^^ "* «^ ■"••^ "«» ^ ^ ^^ . 4 J ■^^ -^ "NS. \ 1^ n n * ^ 90 MORTALITY STATISTICS OF INSURED WAGE EARNERS. significant age periods. In those few age periods where females show higher rates, the incidence of the disease is not high and the facts are somewhat clouded by the possibility of incorrect certifica- tion. Thus, in the age period 15 to 19 years, where the death rate for females for both white and colored lives is significantly higher,, it is quite possible that this results from the inclusion of deaths from puerperal nephritis, which, if more complete statements had been made would not have been assigned to Bright's disease, but to the puerperal cause. Beginning with ages ten and over, the rate increases regularly with advancing age. The peculiar situation under ten, and espe- cially between one and four years, is probably explained by the inclusion of deaths from acute nephritis improperly certified as "Brighfs disease" or "nephritis." Many of these deaths should, properly, have been classified under one of the communicable dis- eases of childhood, which, in so many instances, are the primary factors in such deaths. Mortality from Brighfs Disease among White Insured Wage Earn- ers and among the General Population of the Expanding Registration Area Compared. As was the case in the discussion of organic heart disease, we find here a higher incidence of Bright's disease among insured white lives than in the general population. This is true for each period beyond age 20 years for both males and females. The com- parison is limited to the ages beyond 20 years because it is desired to eliminate the questionable data of the ages under 20 when, also, the rates are comparatively low. The excess is pronounced among males but by no means so marked among females. The maximum ratio of excess among white males occurs in the period 35 to 44 years when the rate is 88.2 per cent, higher among the insured than in the general population. This ratio of excess decreases there- after, with a single exception. If it were possible to eliminate the small percentage of colored persons from the population of the Registration Area, the excess of the insurance experience would be even larger. Among females, the maximum difference in favor of the population occurs in the period 65 to 74 years (44.9 per cent.). These facts in the statistics for insured wage earners suggest that the more arduous pursuits of the industrial population may well be BRIGHT S DISEASE. 91 contributing factors in causing, or at least exciting, abnormal con- ditions of the kidney. Other factors, also, undoubtedly play their part; possibly the more general use of alcohol is important here, especially at the ages of middle adult life. The following table presents the death rates for the insured and the population of the expanding Eegistration Area, side by side, by sex and from ages 20 upward : TABLE 39. Mortality from Bright 's Disease. Death Bates per 100,000 Persons Exposed. Classified by Sex and hy Age Periods, 20 Yeairs and Over. Insured White Lives in Experience of Metropolitan Life Insurance Company, Indiistrial Department (1911 to 1916) and General Population Experience of Expanding Eegistration Area of the United States (1910 to 1915). Males. Females. Age Period. Percentage Percentage M. L. I. Co. U. S. Reg. M. L. I. Co. M. L. I. Co. U. S. Reg. M. L. I. Co. (White). Area. of Reg. Area. (White). Area. of Reg. Area. All ages— 20 and over 198.1 156.8 126.3 149.7 131.4 113.9 20 to 24.... 14.8 11.0 134.5 14.2 13.4 106.0 25 to 34.... 38.5 24.1 159.8 31.8 27.0 117.8 35 to 44.... 119.3 63.4 188.2 80.0 62.3 128.4 45 to 54.... 259.8 157.3 165.2 171.5 131.7 130.2 55 to 64.... 539.3 368.4 146.4 364.7 275.2 132.5 65 to 74.... 1146.3 773.1 148.3 826.0 569.9 144.9 75 and over. 2106.7 1587.9 132.7 1466.6 1129.5 129.8 Trend of the Death Rate from Bright's Disease. On the face of the figures there is a slight upward trend in the death rate from Bright's disease in this experience. The tendency is not alarming, in any sense, in view of the possibility that in more recent years physicians have been more definite in their state- ments of cause of death than at the beginning of the six-year period. The office practice of the Sta,tistical Bureau has also affected the figures, since a larger number of inquiries to physicians has been made in more recent years than at the beginning of the study, more particularly with reference to undesirable statements of "acute nephritis." There should, therefore, be no unrestrained interpre- tation of the figures shown below, especially in view of the diffi- culties pointed out at the beginning of this section on the still 92 MORTALITY STATISTICS OF INSURED WAGE EARNERS; unsettled condition of the cause of death classification procedure in cases where Bright's disease is associated with cardiovascular diseases. The figures are presented by color and sex for the indi- vidual years between 1911 and 1916 : TABLE 40. Mortality from Bright's Disease, Classified by Color and by Sex. Death Rates per 100,000 Persons Exposed. Single Years in Period 1911 to 1916. Experience of Metropolitan Life Insurance Company. Industrial Department. Persons. White. Colored. Year. Males. Females. Males. Females. 1911 to 1916 96.8 97.1 88.1 138.7 121.3 1916.... 1915... 1914... 1913.... 1912.... 1911... 99.0 95.7 95.4 96.0 99.4 95.0 99.0 91.6 94.7 99.0 101.5 97.3 90.3 88.4 86.7 85.2 90.4 87.4 138.9 154.1 142.7 138.6 132.9 122.9 130.8 126.2 121.7 117.5 120.7 108.5 The problem of increase in Bright's disease mortality, if there is one, is much more acute among colored lives than among white lives and if any significance attaches to the increasing mortality in more recent years, it applies entirely to the colored race. It is not possible at this time to explain satisfactorily what forces are at work behind the rapidly changing figures for the colored group. CHAPTEE VIII. ExTEENAL Causes of Death (Accident, Suicide and Homicide). The group of the external causes of death is the fifth in order of numerical importance in this investigation. In any discussion of mortality, we may, in general, distinguish two main classes; first, those diseases and conditions which arise from pathologic processes within the body, and second, conditions which follow injury by some means or agency external to the hu- man economy. Under each of these two fundamental divisions, we attempt to identify the specific agencies at work. Oftentimes, we must have recourse simply to a statement of the disease or condition present, without reference to the particular causative agency pro- ducing the disease. This observation applies especially to diseases of internal origin. The "external" conditions are by comparison less difficult to determine causally. Our first approach to them is to establish three classes, the division being made with respect to the element of human volition involved in the fact of injury. The first group consists of the accidental deaths, those accomplished by pure chance or through personal negligence without deliberate in- tent to kill, maim or incapacitate. The second group of external causes of death consists of the suicides, or cases where there was deliberate intent to accomplish self-destruction Under the third class, we consider all deaths (except war deaths) which arise from the impulse of one person to kill or injure another. These latter are "homicides." For each of these main classes of violence, we shall endeavor further to distinguish the means or agency of in- jury. War deaths have been taken from the class of accidental and unspecified violence and shown separately for purposes of this report. During the six-year period covered by this investigation of wage earners' mortality, there were 50,712 deaths from external violence of all kinds. The following table gives the incidence of the three chief groups of external causes represented in our records : 93 94 MOKTALITY STATISTICS OF INSURED WAGE EARNERS. TABLE 41. Mortality from External Causes of Death. Classified According to •Main Groups. Deaths and Death Bates per 100,000 Persons Exposed and Per Cent, of Total Mortality from External Causes Represented in Each Main Group. 1911 to 1916. Experience of Metropolitan Life Insurance Company. Industrial Department. Class of External Violence. Number of Deaths. Per Cent, of Total External Causes. Death Rate per 100,000 Exposed. Total external causes 50,712 100.0 94.3 Accidents, ind. unspec. violence* Suicides 39,268 6,542 3,753 1,149 77.4 12.9 7.4 2.3 73.0 12.2 Homicides 7.0 War deaths 2.1 * Excludes ' ' war deaths. ' ' The total death rate corresponding to the 50,712 deaths was 94.3 per 100,000, which, as we shall see later, is very considerably in excess of the rate for the external causes prevailing in the general population of the expanding Registration Area. More than three quarters of these deaths were due to accidents. If " war deaths " were included, as perhaps they should be to follow classification practice, the proportion would reach nearly 80 per cent. Suicides comprise 12.9 per cent, and homicides 7.4 per cent, additional. We shall consider in detail first the group of accidents. Accidents, Including Unspecified Violence. The general accident problem in the United States, and espe- cially as it affects the wage earner, should interest us because of the very considerable mortality which results from this group of causes. It would appear that the special conditions of American life and industry still give rise to hazards which result in an extra- ordinarily large fatal accident rate. When compared with acci- dent mortality in England and Wales, the American figures show up especially badly. In the year before the war, 1913, the fatal accident rate of England and Wales was, for males 35 to 44 years, 62.4 per 100,000. In the Eegistration Area of the United States, the rate for males at these ages was 139.6 per 100,000, and, among EXTEENAL CAUSES OF DEATH. 95 the insured white males, the rate was 154.3. In other words, the rate for England and Wales was 44.7 per cent, of that for the ex- panding Eegistration Area of the United States and only 40.4 per cent, of the rate for insured white males. Even when we consider the chief types of fatal accidents, such as falls, burns, drowning, and steam railroad accidents in these three series of figures, the rates of mortality as recorded for the United States are much above the figures for England and Wales, and those for the Industrial policyholders are, for the significant age periods, highest of all. The data on fatal accidents and especially the specific forms of ac- cidental injury which we have included for American wage earners should, therefore, constitute a very valuable contribution for the further study of the accident problem and should prove especially useful in the movement for increased industrial and public safety which has been developed during the last ten years. The 39,368 fatal accidents of all kinds, as we have seen, corre- sponded to a rate of 73.0 per 100,000 persons exposed. The fatal accident rate for males of both white and colored groups was more than three times the rate for females. The recorded fatal accident rate for colored males was somewhat higher than the rate for white males ; all ages one and over being combined for purposes of these comparisons. The accident death rate varies considerably with age; in fact, we may distinguish three divisional periods of age incidence. These are the period of early childhood, the period of occupational stress and finally the period of old age. Considering the group as a whole, we find that the highest accident death rate under age 45 was recorded between the ages 1 and under 5 years. There is a decline in the rate from the figure under 5 years of age (93.7 per 100,000) to the rate at the age group 10 to 14 years (41.4 per 100,000). This latter rate is the minimum for any age period. Beginning with the age group 15 to 19 years there is a gradually rising rate up to the highest significant age period. For the white male and white female groups the minimum accident death rate is recorded, as for the total experience, between 10 and 14 years; but for colored males the minimum rate is reached between 5 and 9 years and for colored females between 15 and 19 years. Only the white males exhibit a progressively increasing accident death rate with advancing age, beginning with the period 15 to 19 years. White females show a rather stationary tendency in the mortality 96 MOKTALITY STATISTICS OF INSUEED WAGE EAENEES. o s hi i O ? > S o i Si. o. us o Ol Z O E Q ■ _ z » ? h- ■ ^ 2 5 S 5° S Dig o s i o < i s ? ^ O E I cc s & S*. ■ S «- ■§ : log cc s a o s X g t: : ID " o s ■■ " — - — — , L. '_ • "-~ ~^ ^ ^. 1 i i i \ ■§ ! 1 \ 11 \ ^ g"^ ^ 1// o >^ ~"~~~ ■ — - _. ^ ^ s^ \ \ \ \ \ > » \ \ \ 1^ N . \ \ \ ^ ^ A \ '\ A V „-'- V " u EXTERNAL CAUSES OF DEATH. 97 rate between 15 and 35 years of age. Between 15 and 34 years colored males show a tendency toward decline; thereafter they ex- hibit a rising death rate. Colored females show a fluctuating fatal accident rate between 10 and 44 years and a rising rate thereafter. These facts are shown in the following table, and in Chart XI on page 96 : TABLE 42. Mortality from Accidental and Unspecified Violence,* Classified by Color, Sex and by Age Period. Death Rates per 100,000 Persons Exposed. 1911 to 1916. Experience of Metropolitan Life Insurance Company. Industrial Department. Persons. White. Colored. Age Period. Male. Female. Male. Female. All ages — one and over 73.0 115.9 36.4 121.4 38.8 1 to 4 5 to 9 10 to 14 15 to 19 20 to 24 25 to 34 35 to 44 45 to 54 55 to 64 65 to 74 75 and over . 93.7 51.4 41.4 53.4 55.6 57.9 71.6 95.2 137.2 251.4 100.9 68.9 65.1 85.7 99.8 114.5 154.3 195.1 246.5 346.0 79.4 31.9 14.4 16.9 16.5 15.7 19.4 35.5 73.2 201.1 496.4 151.3 67.9 83.5 131.7 109.4 115.3 124.8 145.6 180.7 247.2 315.5 126.3 51.2 22.7 18.2 25.6 22.5 27.1 41.1 59.0 167.9 477.8 482.4 353.9 * War deaths excluded. Color Ratio of Accident Mortality. The fatal accident rates of the white and colored races are, as we have seen, very different. We find, for example, that under 5 years of age, colored children, both males and females, show a fatal accident rate about 1^ times that of white children. In the period 5 to 9 years colored males show a fatal accident rate just a little less than the white male rate. Between 15 and 19 years, how- ever, we observe the maximum percentage of excess of colored male over white male accident mortality. Colored females, on the other hand, show their maximum percentage of excess in accident mor- tality between 5 and 9 years of age. After the age period 25 to 34 years, colored males show a lower mortality than white males, which condition is probably the result of their safer occupational condi- 98 MOETALITT STATISTICS OF INSURED WAGE EAENEES. tions. A similar condition of lower mortality prevails among the colored females after 45 to 54 years, but the cause for this is difi&- cult to ascertain. The following table affords a comparison of white and colored accident mortality according to sex : TABLE 43. Mortality from Accidental and Unspecified Violence.* Percentage, Colored of White Mortality at Specified Age Periods for Each Sex. 1911 to 1916. Metropolitan Life Insurance Company, Mortality Experience. Industrial Department. Percentage, Colored of Wbite Mortality. Age Period. Males. Females. All ages — one and over . . 104.7 106.6 1 to 4 5 to 9 ' 10 to 14 15 to 19 20 to 24 25 to 34 35 to 44 45 to 54 55 to 64 65 to 74 75 and over 150.0 98.5 128.3 153.7 109.6 100.7 80.9 74.6 73.3 71.4 65.4 159.1 160.5 157.6 107.7 155.2 143.3 139.7 115.8 80.6 83.5 71.3 * War deaths excluded. Sex Ratio of Accident Mortality. The differences in the stresses of occupation between the sexes are clearly reflected in the accident death rates. Considering white lives first, there was an excess of the male accident rate over the female rate in every age period of our data, with the exception of the last age group, 75 years and over. The maximum percentage of excess of male accident mortality is found between 35 and 44 years of age, when the male rate is nearly eight times greater. Among white lives between 1 and 45 years of age there is increasing per- centage of excess of male over female accident mortality ; after 45, the excess becomes regularly less. Colored persons did not show any such increase with age in the excess percentage of male over female mortality. The maximum percentage of excess of males over females among colored persons is found between the ages 15 and 19 years, where colored males show a fatal accident rate nearly EXTERNAL CAUSES OF DEATPI. 99 71 times that of colored females. These facts are exhibited in the following table : TABLE 44. Mortality feom Accidentai, and UNSPECiFna) Violence.* Percentage, Male of Female Mortality at Specified Age Periods for Each Color Class. 1911 to 1916. Experience of Metropolitan Life Insurance Company. Industrial Department. Percentage, Male of Female Mortality. Age Period Wliite. Colored. All ages — one and over . . 318.4 312.9 1 to 4 127.1 216.0 452.1 507.1 604.8 729.3 795.4 549.6 336.7 172.1 97.2 119 8 5 to 9 132 6 10 to 14 15 to 19 20 to 24 25 to 34 35 to 44 45 to 64 55 to 64 65 to 74 75 and over 367.8 723.6 427.3 512.4 460.5 354.3 306.3 147.2 89.1 * War deaths excluded. Fatal Accident Rate among Insured Wage Earners and Population of the Expanding Registration Area Compa/red. Before proceeding to a detailed consideration of the various forms of accidents represented in our experience, it might Be well, in passing, to exhibit a table of the accident death rates per 100,000 among white insured wage earners and in the general population of the expanding Registration Area of the United States. The table on page 100 affords a view of these data. Under 20 years and after 35 years of age white males of the in- sured wage earners' group show a higher accident mortality than do males in the Registration Area in general. For the ages under 5 years, insured white males show an accident death rate 5 per cent, in excess, between 5 and 9 years, 17 per cent., and between 10 and 14, 14 per cent, in excess of the rates among males in the corre- sponding age groups of the general population. Between 20 and 34 years of age insured white male wage earners show a lower mor- tality from accidents than was recorded among males in the Regis- tration Area record. Beginning with the age period 35 to 44' 100 MORTALITY STATISTICS OF INSURED WAGE EARNERS. TABLE 45. Mortality from Acicidental and Unspecified Violence.* Death Mates per 100,000 FersonS Exposed. Classified hy Sex and by Age Period. Insured White Lives in Experience of Metropolitan Life In- surance Company, Industrial Department (1911 to 1916) and General Population Experience of Expanding Begistra- tion Area of the United States (1910 to 1915). Males. Females. Age Period. Percentage Percentage M. L. I. Co. U. S. Reg. M. L. I. Co. M. L. I. Co. U. S. Reg. M. L. I. Co. (White). Area. of Reg. Area. (White). Area. of Reg. Area. All ages — one and over . . . . 115.9 120.8 95.9 36.4 37.4 97.3 lto4..... 100.9 96.4 104.7 79.4 76.5 103.8 5 to 9 68.9 58.8 117.2 31.9 29.6 107.8 10 to 14.... 65.1 56.9 114.4 14.4 13.0 110.8 15 to 19.... 85.7 85.0 100.8 16.9 15.4 109.7 20 to 24.... 99.8 116.6 85.6 16.5 17.0 97.1 25 to 34.... 114.5 123.4 92.8 15.7 15.5 101.3 35 to 44... 154.3 139.6 110.5 19.4 18.9 102.6 45 to 54... 195.1 156.8 124.4 35.5 27.7 128.2 55 to 64... 246.5 178.5 138.1 73.2 49.0 149.4 65 to 74... 346.0 214.3 161.5 201.1 118.1 170.3 75 and over 482.4 418.0 115.4 496.4 534.8 92.8 * War deaths excluded. years, however, accident mortality among white male insured wage earners begins progressively to exceed the rates among males in the general population up to and including the period 65 to 74 years. The figures for ages beyond 75 years are not significant in view of the small exposure. The comparisons between insured white females and females in the general population also show higher death rates for the insured group, with the exception of the age period 20 to 24 years, than for the group of females in the general population. The differences are not so marked, however, as they were for the males. Below 20 years of age the percentages of excess of accident mortality among insured white females are variable. Beginning with the age period 25 to 34 years there is a progressive increase in the excess of acci- dent fatality rates among white female wage earners over the rates for females in the general population. Fatal Accidents According to Specific Means or Nature of Injury. The foregoing observations on accident mortality were made without reference to the specific nature or means of injury. We EXTERNAL CAUSES OF DEATH. 101 shall now consider briefly the several inclusions under the general title as shown in the followinar table : TABLE 46. Mortality from Accidental and Unspecified Violence.* Deaths and Death Bates per 100,000 Persons Exposed hy Specified Ca/uses and hy Color and Sex. 1911 to 1916. Experience of Metropolitan Life Insurance Company. Industrial Department. Cause of Death. Persona. Rate per 100,000. White. Colored. Rate per Deaths. 100.000. Males. males. Males. Fe- males. 39268 73.0 115.9 36.4 121.4 38.8 622 1.2 1.2 1.0 1.5 1.8 1144 2.1 2.4 1.8 2.7 2.0 576 1.1 1.2 .7 2.0 2.0 4714 8.8 7.2 9.3 8.4 14.3 1431 2.7 3.9 1.9 2.3 .9 5757 10.7 20.1 2.6 23.2 2.1 1029 1.9 3.0 .3 8.1 1.5 93 .2 .2 .1 .7 .2 6917 12.9 18.8 8.9 13.3 5.3 660 1.2 2.5 t 3.6 612 1.1 2.4 t 3.4 — 48 .1 .2 t .2 — 905 1.7 3.4 .1 4.8 .1 4485 8.3 16.8 1.2 17.3 1.6 1600 3.0 5.3 1.2 4.1 .9 2507 4.7 8.1 2.3 4.6 1.3 1658 3.1 5.7 .9 5.6 .5 381 .7 1.4 .1 1.9 .1 233 .4 .9 t 1.1 — 16 t t t .1 t 217 .4 .6 .1 1.5 .5 1247 2.3 3.4 1.3 4.3 1.6 96 .2 .3 t .5 — 452 .8 2.0 t .7 .1 806 1.5 1.9 1.2 1.9 .5 1722 3.2 5.4 1.2 7.5 1.4 Accidents and Unspecified Violence — Total* Poisoning by food Other acute poisonings Conflagration Burns — conflagration excepted . . . Absorption of deleterious gases — conflagration excepted .... Accidental drowning Traumatism by firearms Traumatism by cutting or piercing instruments Traumatism by fall Traumatism in mines and quarries (total) — in mines — in quarries Traumatism by machines Steam railroad accidents and injuries Street car accidents and injuries. . Automobile accidents and injuries Injuries by other vehicles Landslide, other cnishing Injuries by animals Starvation Excessive cold Effects of heat Lightning Electricity — lightning excepted . . . Fractures — cause not specified . . . Other external violence* * War deaths excluded. t Less than .05 per 100,000. Thus, among all accidents included in the above table, falls were the most frequent of the specified forms of violence. There 102 MOETALITT STATISTICS OF INSUEED WAGE EAENEES. were 6,917 deaths from falling recorded among insured wage earn- ers over the six-year period 1911 to 1916, at a rate of 12.9 per 100,000 exposed. Accidental drowning was next in importance with 5,757 deaths at a rate of 10.7 per 100,000 in the six-year period under observation. Burns, excluding burns in conflagra- tions, followed with 4,714 deaths, or at a rate of 8.8 per 100,000 exposed. Steam railroad accidents and injuries showed 4,485 deaths, producing a rate of 8.3 per 100,000. Automobile accidents and injuries were recorded in 2,507 cases, with a death rate of 4.7 per 100,000 exposed. A detailed discussion of the facts for some of the more important of these modes of injury in external causes of death follows. Teaumatism by Pall.* We have previously indicated that traumatism by fall was the chief form of the fatal accidents. The 6,917 deaths from this con- dition corresponded to a rate of 12.9 per 100,000 exposed. The TABLE 47. MORTAT.TTY FROM TRAITMATISM BY FALL,* CLASSIFIED BY COLOR, SeX AiiT) BY Age Period. Death Bates per 100,000 Persons Exposed. 1911 to 1916. Experience of Metropolitan Life Insurance Company. Industrial Department. Persons. White. Colored. Age Period. Males. Females. Males. Females. All ages — one and over 12.9 18.8 8.9 13.3 5.3 1 to 4 5 to 9 10 to 14 15 to 19 20 to 24 25 to 34 35 to 44 45 to 54 55 to 64 65 to 74 75 and over. . 10.1 4.3 3.1 3.4 4.4 7.2 13.3 20.9 39.3 103.8 243.9 11.7 6.1 4.8 5.9 8.8 15.5 31.3 42.6 64.0 116.5 208.5 7.7 2.4 1.1 1.0 .9 1.9 3.5 9.7 27.2 105.4 288.0 19.9 7.5 5.1 5.4 5.6 8.8 16.2 22.1 37.2 51.8 68.6 9.5 1.9 2.5 1.8 2.4 2.3 2.6 5.8 14.1 57.5 108.9 * Falls from steam railroad trains, street cars, automobiles and other vehicles, as well as falls in mines or quarries, from machinery (travelling cranes, for example), and falls in burning buildings are classified under other headings. In short, not aU falls are classified under ' ' Traumatism by fall." EXTERNAL CAUSES OF DEATH. 103 rate was highest for white males and least for colored females. Males of both the white and colored groups showed a higher rate for this cause of death than did females. The facts by age are given on page 103. The death rate from traumatism by fall showed a high point for the ages 1 to 4 years in our experience. The rate for all persons was 10.1 per 100,000 exposed in this age group. This rate is not exceeded in any age period thereafter until the period 35 to 44 years is reached, when it begins to rise sharply. For this age period a rate of 13.3 per 100,000 exposed is recorded. After a series of increments the maximum rate for any age period is reached at the group of ages 75 years and over (243.9 per 100,000 exposed). The fatal accident rate for this specific cause exhibits the same age characteristics for white males as we have pointed out for the entire experience with this exception : the rate for the age group 1 to 4 years is exceeded by that for 25 to 34 years instead of by that for 35 to 44 years. For white females, however, there seems to be a practically stationary death rate from this cause between 10 and 24 years. For the ages thereafter, a rapid increase in the rate is observed. For the highest age group in our series (75 years and over) the white female fatal accident rate for this specific cause exceeds the white male rate considerably. Colored males, with advancing age, show a gradually increasing death rate from this cause, beginning with the period 10 to 14 years. Colored females between 20 and 44 years show a fairly stationary rate from trau- matism by fall. The figures for the individual years from 1911 to 1916 do not show very marked differences. The highest rate was observed in 1913, 13.7 per 100,000, and the minimum in 1915, 11.9. Unlike the acute infections and the organic diseases, we may hardly expect a definite trend over a short period of years. The average rate of the six-year period, 12.9 per 100,000, may be taken as a fair indi- cation of the present incidence of this cause of death. Nor is there any very marked difference in incidence of this condition among the insured and the general population, all ages considered. When we analyze the facts by age period, we find that up to age 25 the rates are very much the same. Beyond that period the figures are higher for the insured group. This is especially so among the males where the occupational factor is important as a fruitful 104 MORTALITY STATISTICS OP INSURED WAGE EARNERS. source of mortality among wage earners. Thus, at some age peri- ods of advanced life, such as 55 to 64 years, the rate is very much higher among insured white males than among males in the Eegis- tration Area, the rates being 64.0 and 38.1 per 100,000, respectively. Accidental Drowning.* The 5,757 deaths from drowning during the period 1911 to 1916 correspond to a rate of 10.7 per 100,000 exposed. As might be expected, the rate shows a very marked difference for the two sexes. The rate for white males is a little less than eight times the rate for white females. Colored males show a rate from this cause more than ten times the rate for colored females. Deaths from Accidental Drowning hy Color, Sex and by Age Period. The death rates per 100,000 for accidental drowning, according to color, age and sex classes are presented in the following table : TABLE 48. Mortality from AcciDENTAii Drowning,* Classified by Color, Sex and BY Age Period. Death Bates per 100,000 Persons Exposed. 1911 to 1916. Experience of Metropolitan Life Insurance Company. Industrial Department. Persons. White. Colored. Age Period. Males. Females. Males. Females. AH ages — one and over 10.7 20.1 2.6 23.2 2.1 1 to 4 5 to 9 10 to 14 15 to 19 20 to 24 25 to 34 35 to 44 45 to 54 55 to 64... . 65 to 74 ... . 75 and over. . 6.2 10.2 13.9 17.0 12.7 9.0 8.0 9.3 8.7 9.1 9.1 9.1 18.6 23.8 27.4 22.0 17.8 18.7 21.5 21.3 21.9 22.7 3.6 2.3 2.7 4.7 4.4 1.7 1.2 1.9 1.3 1.6 2.5 5.8 10.7 34.8 50.2 30.2 25.2 15.6 16.3 10.2 11.7 1.9 1.6 2.8 2.6 2.6 1.5 2.1 2.9 2.2 1.2 * Under this heading are classified, first, the deaths from drowning that are known to be accidental and, second, those which are not definitely re- ported as accidental but which can not be identified as suicidal or homicidal. EXTERNAL CAUSES OF DEATH. 105 The death rates for accidental drowning are highest for per- sons under age 25 years. Considering all persons in this experience combined, the maximum rate is reached in the age period 15 to 19 years, 17.0 per 100,000 exposed. After this period, there is a decline in the rate from this cause up to and including the period 35 to 44 years. After that period we show a slightly variable death rate, tending to vary somewhat around an average of 9.0 per 100,000 exposed at these ages. White males show a maximum rate in the period 15 to 19 yeara and a declining rate thereafter up to and including 35 to 34 years. Between 45 and 74 years, the rate is almost stationary at a little more than 21 per 100,000 exposed. The colored male statistics also show a maximum rate between 15 and 19 years of age, 50.2 per 100,000 exposed. The reader will observe that this rate is practically twice the rate recorded for white males between these ages. The colored male rate is higher than the white male rate from 10 years up to and including the age period 25 to 34 years, but is lower thereafter. Considering the series of years 1911 to 1916, we are again unable to detect any distinct downward tendency in the death rate from this cause. The rates seem to vary but slightly from a figure of a little more than 10 per 100,000 exposed for all classes in the expe- rience. The highest death rate was recorded in 1913, 12.1 per 100,000, and the lowest in 1916, 9.7 per 100,000. During this period the death rate from this cause showed two points of maxi- mum incidence, in 1913 and in 1915. The high rate for 1913 is perhaps explained by the floods in the Ohio Eiver Yalley in the spring of that year. The figures for 1915 result from the inclusion of the deaths reported in connection with the Eastland disaster in Chicago. There were, in fact, 171 deaths of policyholders reported as arising out of this catastrophe. The death rate from drowning among white male policyholders was higher at every age period with the exception of the years under five than among males in the general population. The reader will ob- serve that a comparison of the death rates for this accidental cause in the two experiences is first conditioned by the differences in the areas covered by the two experiences. It is evident that for a population situated near water courses, where there is opportunity for employ- ment in the pursuits connected with navigation, one may expect a 106 MOETALITY STATISTICS OF INSURED WAGE EARNERS. higher death rate for accidental drowning. We are not able to say whether the differences in the hazards of accidental drowning are greater in the localities covered by this Company than in those areas comprising the total Eegistration Area of the United States. Burns (Conflagration Excepted).* The 4,714 deaths from burns in this mortality experience of in- sured wage earners during the six-year period 1911 to 1916 repre- sented a rate of 8.8 per 100,000 exposed. The rate for this cause among white males was lower than among the other three color and sex classes of this experience. The col- ored death rates for males and females were higher than the white death rates in the corresponding sex classes. Colored females showed a rate for burns practically one and one-half times that of white females. The death rates according to color, sex and age distinctions are set forth in the following table : TABLE 49. moktality from bubns (conflagration excepted),* classified by color, Sex and by Age Period. Death Bates per 100,000 Persons Exposed. 1911 to 1916. Experience of Metropolitan Life Insurance Company. Industrial Department. Persons. WTilte. Colored. Age Period. Males. Females. Males. Females. AH ages — one and over 8.8 7.2 9.3 8.4 14.3 1 to 4 5 to 9 10 to 14 15 to 19 20 to 24 25 to 34 35 to 44 45 to 54 ... . 55 to 64 65 to 74 75 and over. . 43.8 10.4 2.6 2.1 3.0 3.2 4.3 6.7 10.0 20.3 41.8 42.8 6.7 1.2 1.1 1.7 1.9 3.2 4.6 5.8 8.8 17.0 40.0 12.5 3.7 2.7 3.3 3.7 4.6 7.5 11.4 23.4 49.4 74.3 9.4 2.5 2.6 3.0 3.3 4.6 3.9 7.8 23.4 41.2 76.8 30.1 7.1 5.9 7.7 5.0 6.0 12.8 20.7 55.2 118.0 * Burns and scalds due to railroad, machinery, and mining accidents, as well as those caused by electricity and lightning are not classified under this heading. This explains, to some extent, the comparatively low rate for males. EXTEENAL CAUSES OF DEATH. 107 The age characteristics of this cause of death present a maximum rate in the entire experience at the ages under 5 years, a decline to a minimum between the ages 15 to 19 years and a gradual rise in the rate for succeeding age periods to a figure approaching the maximum at ages 75 years and over. The conformation of the mortality curve for hums is in general the same for each of the color and sex classes of this experience, although, as we have pointed out, the actual figures show considerable differences. From the figures at hand no upward or downward tendency of the death rate for burns is evident. The incidence of fatal burns is higher among the insured than in the general population at a number of age periods. Thus, among insured white males, there is an excess in the ages under 10. and after 45. The figures for all ages combined are in favor of the general population, 6.2 per 100,000 as compared with 7.2 for insured white males. Comparison of the mortality facts for burns among insured white females and among females in the general population shows no important differences in the experi- ence of the two groups. Steam Raileoad Accidents and Injueies. Fatalities arising out of railroad accidents are an important ele- ment in mortality experiences generally. Among the wage earners represented in this study we recorded during the period 1911 to 1916, 4,485 deaths arising from railroad accidents and injuries. These deaths corresponded to a rate of 8.3 per 100,000 exposed. For colored males we recorded a higher rate, 17.3 per 100,000, than for white males, 16.8 per 100,000. The colored female rate is higher than the corresponding white rate, but that for each group of females is low. The death rate from this cause shows a minimum at the ages under 5 years and a maximum at the highest age group in this discussion. There is a fairly progressive rise in the rate by age period throughout life. Between 20 and 54 years of age, however, there is no upward tendency. After the latter age period the rate rises quite sharply. The same general age charateristics in the mortality rate from this cause are shown for white males as for the general experience. White females show no important 108 MORTALITY STATISTICS OF INSURED WAGE EARNERS. mortality from this cause at the ages under 45 years. Beyond that age, however, a rising rate is in evidence for this group. The table below exhibits the data for steam railroad accidents and injuries according to the several color, sex and age classes : TABLE 50. Mortality from Steam Eailroad Accidents and Injuries, Classified BY Color, Sex and by Age Period. Death Bates per 100,000 Persons Exposed. 1911 to 1916. Experience of Metropolitan Life Insurance Company. Industrial Department. Persons. White. Colored. Age Period. Males. Females. Males. Females. All ages — one and over 8.3 16.8 1.2 17.3 1.6 1 to 4 5 to 9 10 to 14 15 to 19 20 to 24 25 to 34 35 to 44 45 to 54 55 to 64 65 to 74 75 and over. . 1.1 2.3 3.5 8.4 11.8 11.3 10.7 11.3 15.6 17.3 17.8 1.5 3.9 6.1 15.2 25.1 26.6 26.7 27.1 35.3 39.4 34.0 .7 .8 .7 1.2 .7 .7 .7 1.7 3.6 4.1 5.9 .6 3.6 7.0 19.8 25.0 20.7 19.8 21.5 27.6 23.4 41.2 .3 .6 1.5 1.1 1.6 2.4 1.8 2.2 4.7 27.2 Colored males show a rather variable rate with age. There is a rising incidence for the ages under 35 years. Between 25 and 74 years the rate tends to vary somewhat between SO and 28 per 100,000 exposed. Beyond the latter age period our figures are not of much significance. The rates by age for colored females are too small and too variable to warrant extended discussion. Considering the period as a whole, there appears to be a decrease in the rate, especially among white males. The three years, 1914 to 1916, however, show a slight upward tendency. In the following table we present our data for railroad accidents and injuries for single years from 1911 to 1916 : EXTERNAL CAUSES OF DEATH. 109 TABLE 51. Mortality from Steam Eailroad Accidents and Injuries, Classified by Color and by Ses:. Death Bates per 100,000 Persons Exposed. Single Years in Period 1911 to 1916. Experience of Metropolitan Life Insurance Company. Industrial Department. Personis. White. Colored. Year, Males. Females. Males. Females. 1911 to 1916 8.3 16.8 1.2 17.3 1.6 1916.... 7.9 15.3 1.3 18.5 1.8 1915.... 7.4 15.0 1.0 16.0 1.1 1914.... 7.5 15.1 1.0 16.0 1.3 1913.... 9.0 18.8 1.1 16.9 1.2 1912.... 9.2 18.5 1.4 17.6 2.2 1911.... 9.5 19.2 1.3 18.6 2.2 Automobile Accidents and Injuries. Automobile accidents and injuries are beginning to constitute an important cause of accident fatality. In the six years under dis- cussion we registered 2,507 deaths from this cause. The death rate TABLE 52. Mortality from Automobile Accidents and Injuries, Classified by Color, Sex and by Age Period. Death Bates per 100,000 Persons Exposed. 1911 to 1916. Experience of Metropolitan Life Insurance Company. Industrial Department. Persons. White. Colored. Age Period. Males. Females. Males. 1 Fema!es. All ages — one and over 4.7 8.1 2.3 4.6 1.3 1 to 4 5 to 9 10 to 14 15 to 19 20 to 24 25 to 34 35 to 44 45 to 54 55 to 64 65 to 74 75 and over. . 3.7 8.6 5.1 2.9 3.2 3.0 3.2 4.4 7.3 9.5 10.1 4.5 12.5 8.5 4.9 5.9 6.4 6.6 9.1 14.1 18.6 17.0 2.9 4.9 1.8 1.2 1.5 1.0 1.6 2.0 3.6 4.5 6.7 3.8 10.4 6.3 3.5 2.0 2.9 3.6 3.3 7.8 6.7 13.7 1.3 3.2 1.6 .3 .8 .9 .3 1.8 2.2 4.7 110 MORTALITY STATISTICS OF INSURED WAGE EARNERS. was 4.7 per 100,000 exposed. The highest death rate was shown for white males and the least for colored females. The color, sex and age statistics for automobile accidents and injuries are shown on previous page (Table 52). There is a high point of mortality from automobile accidents and injuries at each end of the age curve. There is one very high rate in childhood between 5 and 9 years and another in old age at the period 75 years and over, although the ages beginning with 55 years are all heavily weighted with automobile deaths. Males of both color groups in this experience show a higher death rate than do females. According to our records there is a progressively increasing death rate year by year from this cause. In 1911 we recorded a rate of 3.3 per 100,000 exposed. In 1916 the rate had increased to 7.4 per 100,000. This corresponds to an increase of 221.7 per cent, in the rate. The following table and Chart XII on page 111 show the general trend of the death rate for automobile fatalities : TABLE 53. Mortality from Automobile Accidents and iNJURrES, Classified by Color and by Sex. Death Bates per 100,000 Persons Exposed. Single Years in Period 1911 to 1916. Experience of Metropolitan Life Insurance Company. Industrial Department. Persona. White. Colored. Year. Males. Females. Males. Females. 1911 to 1916 4.7 8.1 2.3 4.6 1.3 1916.... 7.4 12.9 3.4 8.2 2.5 1915. . 5.4 9.4 2.6 5.7 1.3 1914 ... 4.8 8.5 2.4 4.2 .8 1913... 4.1 7.5 1.9 3.8 1.2 1912.... 3.0 4.8 1.8 2.9 .7 1911.... 2.3 4.0 1.1 1.9 1.1 Available population mortality data show a similarly increasing rate for automobile fatalities. This fact calls for further inquiry into the causes contributing to this category of traffic accidents, especially in cities where the growth of population and the volume of street traffic conduce to an increase in liability to automobile accidents. EXTERNAL CAUSES OF DEATH. Ill Chart Xil. — Mortality from Automobile Accidents and Injuries .Death Rata* perlOO.OOOParaona Expoaed By Singia Yaara 1911 to 1916 Cxparlanoa of Metropolitan Life Insurance Company, Industrial Department Death Rate par 100,000 I* ign tgtz /g/J /p/4 /p/S JQl6 112 MORTALITY STATISTICS OF INSUEED WAGE EAENERS. Steeet Cae Accidents and Injueies. Fatalities registered as street car accidents and injuries in this experience included deaths, not only of persons riding on or oper- ating street cars, but also those deaths on elevated and subway trains and on tracks and rights of way of street railways, inter- urban roads operated electrically, subways and elevated railroads. There were registered 1,600 deaths from this cause, the correspond- ing rate being 3.0 per 100,000 exposed in the six years under obser- vation. The rate is highest among white males and least among colored females. There is a fairly high rate for the ages under 5 years and a declin- ing one thereafter through the age period 20 to 24 years. After that age group, however, the rate increases up to the maximum at the highest age group in our series. The same general observations apply to the experience of white males and white females. For the former, however, the age groups 5 to 9 years and 20 to 24 years show increases over those immediately preceding, while for the latter the decline continues through the period 25 to 34 years. The data for colored lives according to age group are based upon a small TABLE 54. Mortality from Street Car Accidents and Injuries, CLASsmED by Color, Sex and by Age Period. Death Bates per 100,000 Persons Exposed. 1911 to 1916. Experience of Metropolitan Life Insurance Company. Industrial Department. Persons. White. Colored. Age Period. Males. Females. Males. Females. All ages — one and over 3.0 5.3 1.2 4.1 9 1 to 4 5 to 9 10 to 14 15 to 19 20 to 24 25 to 34 35 to 44 45 to 54 55 to 64 65 to 74 75 and over. . 2.7 2.6 1.6 1.6 1.4 2.1 3.1 4.9 7.8 10.3 22.1 3.0 3.6 2.6 2.4 2.7 4.9 7.5 11.1 15.3 20.6 41.1 2.5 1.6 .6 .5 .4 .2 .5 1.4 3.8 4.4 12.6 1.9 3.2 1.9 4.5 2.0 3.4 4.6 5.2 9.0 13.3 27.4 1.9 1.3 .9 .6 .3 .2 .8 2.4 1.3 2.3 EXTERNAL CAUSES OF DEATH. 113 number of deaths under 20 years of age and there is, therefore, some irregularity in the rates for the divisional periods of life. From twenty years of age upward among colored males an increas- ing death rate from this cause is found. The table on page 112 gives the rates for street car accidents, and injuries by color, sex and by age period. For the six years under discussion a generally declining death rate from this cause is observed. This is in contradistinction to the observed facts for automobile accidents and injuries. The fol- lowing table gives a view of the trend of this phase of the mortality experience for the period 1911 to 1916: TABLE 55. MOKTALITT FROM STREET Car ACCIDENTS AND INJUEIES, OlASSIPIED BY Color and by Sex. Death Bates per 100,000 Persons Exposed. Single Years in Period 1911 to 1916. Experience of Metropolitan Life Insurance Company. Industrial Department. ^^^llte. Colored. Year. Persons. Males. Females. Males. Females. 1911 to 1916 3.0 5.3 1.2 4.1 .9 1916.... 2.6 4.4 1.2 3.5 .9 1915.... 2.2 3.9 .9 2.1 .9 1914.... 2.7 4.5 1.1 4.2 1.4 1913.... 3.6 6.4 1.4 4.6 1.2 1912.... 3.5 6.4 1.4 4.6 .5 1911.... 3.6 6.7 1.3 5.8 .5 Injuries by Other Vehicles. The record of deaths from injuries by "other vehicles" is also available. Under this group, 1,658 deaths were included arising from accidents and injuries to passengers, pedestrians, drivers or riders on wagons, carriages, bicycles and other miscellaneous forms of vehicles not motor driven. The rate, 3.1 per 100,000 exposed, is similar to that for street car accidents and injuries. The following table gives the rates per 100,000 by color, sex and age period: lU MOKTALITT STATISTICS OF INSURED WAGE EAENBRS. TABLE 56. Mortality from Injuries by Other Vehicles, Classified by Color, Sex AND BY Age PiaiiOD. Beaili Bates per 100,000 Persons Exposed. 1911 to 1916. Experience of Metropolitan Life Insurance Company. Industrial Department. Persons. White. Age Period. Colored Males. Males. Females. All ages — one and over. 3.1 5.7 .9 5.6 lto4 3.8 4.6 3.2 2.6 5 to 9 3.8 6.0 1.5 5.5 10 to 14 1.6 2.8 .5 2.8 15 to 19 1.8 3.0 .5 4.5 20 to 24 2.0 4.0 .5 2.6 25 to 34 2.4 5.6 .3 3.9 35 to 44 3.2 7.7 .3 6.0 45 to 54 4.6 10.1 1.0 10.7 55 to 64 5.0 11.4 .9 12.0 65 to 74 8.2 16.1 3.1 16.7 75 and over .... 5.3 12.8 .8 13.7 There seems to be a slight downward tendency in this group of specific causes of accidental injury. The following table gives a survey of the death rates over the period 1911 to 1916 : TABLE 57. Mortality from Injuries by Other Vehicles, Classified by Color and BY Sex. Death Bates per 100,000 Persons 'Exposed. Single Years in Period 1911 to 1916. Experience of Metropolitan Life Insurance Company. Industrial Department. Persons. White. Colored. Year. Males. Females. Males. 1911 to 1916 3.1 5.7 .9 5 6 1916 2.8 5.4 .7 6.0 1915 3.0 5.6 .8 6.2 1914 2.9 5.4 .9 4.4 1913 3.4 6.4 1.4 3.6 1912 3.4 6.2 .9 7.3 1911 3.1 5.5 1.0 6.0 EXTERNAL CAUSES OF DEATH. 115 The death rate for this group of miscellaneous vehicular injuries is stationary for the age periods under 10 years, and declines to a minimum rate between 10 and 14 years. It then gradually rises to a maximum in the age period 65 to 74 years. There was a slightly higher rate for white males than for colored males. White females had a low rate of .9 per 100,000 exposed. The deaths among colored females were too few to give any significance to the rates. No figures for this class are therefore presented. Traumatism by Machines.* A total of 905 deaths from traumatism by machines is recorded. It will be understood that this title includes deaths by means of machines in most industries and through mechanisms such as ele- vators, which are not always concerned in industrial processes. This latter fact does not materially affect our figures, however, for the main working period in life. The experience available, ac- cording to age period, for all persons exposed to risk in this investi- gation, and for white males and colored males is shown in the fol- lowing table. The experience for females is not significant. TABLE 58. moetalitt from traumatism by machines,* (classified by color for Males, and by Age Period. Death Bates per 100,000 Persons Exposed. 1911 to 1916. Experience of Metropolitan Life Insurance Company. Industrial Department. Age Period. Persons In Total Experience. White Males. Colored Males. AH ages — one and over. . . . 1.7 3.4 4.8 1 tol4 15 to 19 20 to 24 25 to 34 35 to 44 45 to 54 55 to 64 65 to 74 75 and over .3 2.3 2.1 1.9 2.7 3.2 3.0 2.3 1.9 .4 4.2 4.5 4.0 6.7 7.7 7.7 6.0 1.4 .5 5.1 4.6 6.5 6.2 9.8 6.6 1.7 13.7 * Deaths caused by machinery accidents in mines and quarries are classi- fied under title No. 173 (Traumatism in mines and quarries) ; those due to locomotives are charged to one of the subtitles of title No. 175 (Steam railroad accidents and injuries). 116 MOKTALITY STATISTICS OF INSUEED WAGE EAENEES. The rate for white males does not vary much from the fignre of four per one hundred thousand between fifteen and thirty-five years of age. The rate rises after that age to a figure of 7.7 per one hun- dred thousand between forty-five and sixty-five years of age and declines thereafter. The rates for this cause of death are, in gen- eral, higher among colored males than among white males. The maximum rate for colored males was observed in the age period forty-five to fifty-four years, when it was 9.8 per 100,000 exposed. There was a fairly stationary tendency in the' death rate from this cause in the present experience covering the period 1911 to 1916. The following table gives the facts for each calendar year in the investigation: TABLE 59. moetality from traumatism by machines,* classified by color for Males. Death Bates per 100,000 Persons Exposed. Single Years in Period 1911 to 1916. Experience of Metropolitan Life Insurance Company. Industrial Department. Year. Persons In Total Experience White Males. Colored Males. 1911 to 1916 1.7 3.4 4.8 1916 1.7 1.4 1.5 2.0 1.7 1.8 3.4 2.9 3.3 4.1 3.2 3.4 5.3 1915 3.4 1914 2.9 1913 5.4 1912 5.6 1911 6.9 * See footnote for Table 58 on preceding page. A brief comparison of our data with those for the Registration Area shows that for the latter part of the main working periods of life the death rate from traumatism by machines is higher among insured white males than among males in the corresponding age groups in the Registration Area of the United States. No precise interpretation can be placed upon this fact, however, because we do not have any clue as to the approximate number of persons in both experiences exposed to risk from machinery. But it is rea- sonable to assume that there is a considerably larger proportion of persons exposed to machine hazards in a group such as that com- prised- in the insurance experience than there is in the general population of the Registration Area. EXTERNAL CAUSES OF DEATH. 117 "^Othee Acute Poisonings"* (Food Poisonings Excepted). All accidental poisonings in this experience have been reported under two heads: "poisoning by food" and "other acute poi- sonings." The second of these titles, which includes the larger number of these deaths, relates to those caused by solid or liquid poisons, excepting alkaloid products of putrefaction and other poi- sons in food products. In this experience for insured wage earners 1,144 deaths from this specific cause of accidental violence occurred. The rates are slightly higher for the colored than for the white of each sex. The age and sex characteristics for the white group only are given in the following table : TABLE 60. Mortality from ' ' Other Acute Poisonings, ' '* White Persons Classified BY Sex and by Age Period. Death Bates per 100,000 Persons Ex-posed. 1911 to 1916. Experience of Metropolitan Life Insurance Company. Industrial Department. Persona In Total Experience. WMte. Age Period. Males. Females. 2 1 2.4 1 8 1 to 4 5 to 9 7.9 .8 .2 .8 1.7 2.2 2.1 2.3 2.7 3.5 4.3 7.6 1.0 .3 .5 1.4 2.4 2.5 4.3 4.8 5.6 7.1 7.1 .5 10 to 14 15 to 19 20 to 24 25 to 34 35 to 44 45 to 54 55 to 64 65 to 74 75 and over .2 1.2 1.7 2.2 1.9 1.3 1.8 2.5 3.3 " other acute poisonings " show the maximum death rate under 5 years of age, the minimum death rate between 10 and 14 years and a fairly regularly rising rate thereafter. Between 25 and 54 * Deaths reported from ' ' poisoning, " " carbolic acid poisoning, " "bi- chloride of mercury poisoning," etc., although not reported as accidental, are classified here unless identified as due to suicide or homicide. Deaths caused by accidental inhalation of poisonous gases are classified under another heading; see page 119. 118 MORTALITY STATISTICS OF INSUEED WAGE EAENEES. years there is a slackening in the rise in the death rate. After 55 years of age the rate rises again rapidly. The rates for males ex- ceed those for females very generally throughout life. A slight downward tendency in the death rate for this cause is in evidence recently. In 1914 the maximum rate (2.6 per 100,000) was registered; the minimum rate was 1.6 per 100,000 in 1916. Considering the series of years from 1911 to 1916, we may perhaps be justified in concluding that recent efforts toward restriction of the sale of poisonous substances have had some favorable influence upon the death rate from acute accidental poisonings. We must remember, however, that the recently increased tendency to specify suicidal and homicidal findings in cases which would have been formerly returned as undefined violence, may have had some influ- ence in reducing the recorded death rate for acute accidental poi- sonings. The following table gives the death rates for " Other acute poisonings" (food poisonings excepted) by single calendar years during the period 1911 to 1916 classified according to color and sex: TABLE 61. Mortality from "Other Acute Poisonings,"* Classified by Color and BY Se:x;. Death Bates per 100,000 Persons Exposed. Single Tears in Period 1911 to 1916. Experience of Metropolitan Life Insurance Company. Industrial Department. Persons. White. Colored. Year. Males. Females. Males. Females. 1911 to 1916 2.1 2.4 1.8 2.7 2.0 1916 1915 1914 1913 1912 1911 1.6 2:0 2.6 2.2 2.3 2.2 1.8 2.2 3.3 2.4 2.4 2.3 1.5 1.5 2.1 1.9 2.1 2.2 1.8 3.4 3.5 3.2 2.5 1.7 1.4 2.4 2.1 1.5 2.4 2.2 See footnote on page 117. The available population experience also shows a slightly down- ward trend. EXTEKNAL CAUSES OF DEATH. 119 Absoeption of Deleterious Gases.* By far the largest proportion of deaths included under this title were caused by accidental inhalation of illuminating gas. There was, of course, a significant number of deaths from the absorption of other poisonous gases and vapors, such as sewer gas, anesthetic vapors, and gases evolved in the domestic and industrial operation of stoves and furnaces. The following table gives the data for this cause of death with respect to color, sex and age classes of the experience: TABLE 62, Mortality from Absorption of Deleterious Gases,* Classified by Color, Sex and by Age Period. Death Bates per 100,000 Persons Exposed. 1911 to 1916. Experience of Metropolitan Life Insurance Company. Industrial Department. Persons. White. Colored. Age Period. Males. Females. Males. Females. All ages — one and over 2.7 3.9 1.9 2.3 .9 1 to 4 5 to 9 10 to 14 15 to 19 20 to 24 25 to 34 35 to 44 45 to 54 55 to 64 65 to 74 75 and over 1.0 .7 .8 1.0 .7 1.2 1.0 .7 .4 1.2 1.1 1.5 1.7 3.2 5.7 8.6 18.4 1.3 .6 1.0 1.6 2.8 3.6 5.5 1.8 3.3 1.3 .3 .3 .6 1.3 1.5 .7 1.0 .4 1.2 1.1 1.8 2.3 3.4 5.4 8.5 12.2 20.2 1.2 2.7 3.5 6.8 10.1 15.6 21.0 28.4 There were 1,431 deaths reported for this cause. This number of deaths represented a rate of 2.7 per 100,000 persons exposed. The highest death rate was recorded for white males, 3.9 per 100, 000, the next highest for colored males, 2.3 per 100,000, followed by the rate for white females, 1.9 per 100,000. The death rate from this cause among colored females was .9 per 100,000 of such persons exposed. Under twenty years of age the rate for both sexes varies from .7 to 1.1 per 100,000 persons exposed. After twenty * Deaths reported as due to "asphyxia by gas," ''gas poisoning," "il- luminating gas poisoning," etc., although not reported as accidental, are classified here unless identified as due to suicide or homicide. 120 MOKTALITY STATISTICS OF INSURED WAGE EAENEES. years of age it rises gradually from a figure of 1.8 per 100,000 in the age group 20 to 24 years to 20.2 in the highest age group in this series. Under twenty years of age, only one period shows a difference between the death rate for this cause of white males and white females. Beginning with the age period 20 to 24 years, how- ever, the rate for accidental poisoning by deleterious gases among white males was significantly higher than that among white fe- males. Thus, for the age period 25 to 34 years, white males showed a rate of 3,5 per 100,000 and white females one of only 1.5 per 100,000. In the two next higher groups the excess of mortality among males was even more pronounced. In the age period 55 to 64 years the death rate for this cause among white males was 15.6 per 100,000 and among white females 5.7 per 100,000. The death rate among colored males wgis much higher after 25 years of age than among colored females. TABLE 63. Mortality from Absorption of Deleterious Gases, Classified by Colob AND BY Sex. Death Eates per 100,000 Persons Exposed. Single Years in Period 1911 to 1916. Experience of Metropolitan Life Insurance Company. Industrial Department. Persons. White. Colored. Year. Males. Females. Males. Females 1911 to 1916 2.7 3.9 1.9 2.3 .9 1916 1915 1914 1913 1912 1911 2.9 2.3 2.9 2.5 3.0 2.3 4.5 3.6 4.2 3.4 4.3 3.4 1.8 1.6 2.1 1.9 2.2 1.8 3.3 1.3 1.5 2.2 3.7 1.5 1.4 .5 1.3 1.0 .7 .7 The death rate throughout the period 1911 to 1916 seems to be fairly stationary for insured wage earners. It should be recalled that in former years a fairly significant number of deaths from illuminating gas poisoning was registered under this cause of death title which, if more modern methods of certifying causes of death had then been in vogue, would have been recorded under " suicide by asphyxia." This factor of improvement in the desig- nation of illuminating gas deaths as suicides does not affect the EXTERNAL CAUSES OF DEATH. 121 present figures from 1911 onward as much as it does other figures which refer back perhaps fifteen years or more. It should be borne in mind, however, in viewing the table on page 130, that this matter of increased precision in the certification of causes of death may have affected our figures somewhat and that there may have been, therefore, an actual, though slight, decline in the death rate for this cause of death. Teaumatism by Fireaems.* Accidental deaths due to injury by firearms were recorded in 1,029 cases in this mortality experience at a rate of 1.9 per 100,000 persons exposed. This cause of death has a distinct color and sex incidence. The mortality rate among colored lives is decidedly in excess of that among white lives. Colored males, for instance, show a rate of 8.1 per 100,000 as compared with a rate of 3.0 for TABLE 64. Mortality from Traumatism by Firearms,* Classified by Color, Sex AND BY Age Period. Death Bates per 100,000 Persons Exposed. 1911 to 1916. Experience of Metropolitan Life Insurance Company. Industrial Department. Persona. ^mte. Coiorea. Age Period. Males. Females. Males. Females. All ages — one and over 1.9 3.0 .3 8.1 1 5 1 to 4 5 to 9 10 to 14 15 to 19 20 to 24 25 to 34 35 to 44 45 to 54 55 to 64 65 to 74 75 and over. . .9 1.4 3.2 4.0 2.5 1.8 1.5 .6 .7 .8 .9 1.9 5.4 6.0 3.5 2.5 2.2 1.2 1.2 1.5 .5 .4 .3 .8 .2 .1 .3 .2 .2 .4 2.6 5.8 10.4 18.5 13.5 10.1 5.2 .7 1.8 1.7 3.2 1.6 1.6 .6 3.7 1.2 2.0 .5 * Under this title are classified, also, deaths reported from ' ' gunshot wound," "shot,'' etc., without qualification as to accidental, suicidal or homicidal character. Every effort is made to obtain definite information, however, in such cases, and they constitute only a small proportion of the 1,029 deaths classified here. 122 MORTALITY STATISTICS OP INSUEED WAGE EARNERS. white males. A death rate of 1.5 per 100,000 is registered for col- ored females and a rate of only .3 per 100,000 for white females. The table on page 121 presents a statement of the death rates accord- ing to the several color, sex and age classes in this investigation. Among white males the highest death rate for this means of injury occurs between 15 and 19 years of age with a declining death rate thereafter up to the advanced ages in this series. Among colored males, also, the highest death rate occurs between 15 and 19 years of age. It will be noted also that the death rate for this cause between 5 and 9 years among colored males (5.8 per 100,000) is almost as high as the maximum rate for white males (6.0). A very large proportion of these deaths in late childhood and in ado- lescence are caused by children playing with firearms and by reck- less youths in the pursuit of sport. A considerable number, no doubt, are of the " didn't know it was loaded " type. At this time of life death rates from all causes are at a reasonably low level. A further reduction of mortality in late childhood and adolescence could be accomplished, no doubt, by concentration upon the single fact of accidental death from firearms. TABLE 65. Mortality from Traumatism by Firearms, Classified by Oolor and BY Sex. Death Bates per 100,000 Persons Exposed. Single Years in Period 1911 to 1916. Experience of Metropolitan Life Insurance Company. Industrial Department. Persons. White. Colored. Year. Males. Females. Males. Females. 1911 to 1916 1.9 3.0 .3 8.1 1.5 1916 .... 1915 .... 19H .... 1913 .... 1912 .... 1911 .... 1.9 1.7 2.0 2.2 2.0 1.7 3.1 2.7 2.7 3.5 3.1 2.8 .3 .4 .4 .5 .3 .3 8.4 5.7 10.2 9.3 7.9 7.3 .8 1.7 1.9 1.5 2.1 1.1 The figures for the period 1911 to 1916, unfortunately, do not indicate any marked declining tendency in the death rate from this cause. The rate for each year approaches closely that for the sex- ennium, 1.9 per 100,000 exposed. In recent years in the Eegistra- EXTEENAL CAUSES OF DEATH. 123 tion Area of the United States a practically stationary death rate has also been observed. How far the figures in each experience are reliable for purposes of determining the general trend of mortality from accidental shooting we cannot say at present. A consider- able number of deaths have been reported in the more recent years of our experience as accidentally due to the use of firearms which would have been reported in former years in such manner as to justify tabulation under some indefinite title such as "Other ex- ternal violence.^' The table on page 122 gives a brief view of the course of accidental mortality from firearms during the period 1911 to 1916. Accident Fatalities Arising Out op or in the Course of Employment. The records of accident mortality of insured wage earners pre- sent a very favorable opportunity for the collection of informing statistics on fatalities arising out of or in the course of employ- ment. We have already observed in the preceding sections a clear indication that these industrial policyholders suffer from higher accident death rates, almost uniformly, at ages where the occupa- tional factor plays a part. Provision was therefore made early in ' the course of this study to distinguish and keep a record of those deaths where the occupation was clearly the primary cause of the accident. The period covered is only five years, from 1912 to 1916, inclusive. Although it was not possible to discover every case of occupational origin, there is nevertheless sufficient evidence to show that the cases overlooked or disguised were relatively few. In order to confine the data to the ages at which policyholders are gainfully employed the tabulations of deaths due to occupational violence have been limited to white males at the ages 15 years and over. Thus, between 1912 and 1916, there were recorded 14,151 deaths from a group of selected and specific accidental causes of death, in which we might reasonably expect that occupation would play an important part. This number of 14,151 deaths does not, therefore, cover all of the deaths from occupational violence among white males 15 years of age and over. The following table gives the total number of accidental deaths reported for the specified accidents and injuries and the number and percentage of deaths of occupational origin : 124 MORTALITY STATISTICS OF INSURED WAGE EARNERS. TABLE 66. Number of Deaths from Specified Accidental Causes of Death and Number and Percentage of Such Deaths Due to Occupational Stress. White Males, Fifteen Years of Age and Over, 1912 to 1916. Experience of Metropolitan Life Insurance Company. Industrial Department. Cause of Death. Total Deaths No. Deaths of Percent. Deaths From Specified Occupational of Occupational Form of Violence. Origin. Origin. 14,151 3,963 28.0 149 23 15.4 333 61 18.3 665 41 6.2 2,381 151 6.3 2,889 685 23.7 443 405 91.4 585 473 80.9 2,710 954 35.2 710 137 19.3 890 97 10.9 733 321 43.8 205 133 64.9 112 43 38.4 323 200 61.9 311 4 1.3 712 235 33.0 Total Specified Causes .... Conflagration Burns Absorption of deleterious gases . . . Accidental drowning Traumatism by fall Traumatism in mines and quarries Traumatism by machines Railroad accidents and injuries . . . Street car accidents and injuries . . Automobile accidents and injuries Other vehicular ace. and injuries Other crushing ace. and injuries . . Injuries by animals Electricity — lightning excepted . . . Fractures — cause not specified . . . Other external violence Out of the group of accidents selected from this experience of white males, 15 years of age and over, we found 28 per cent, to have been certified as arising out of or in the course of emplojonent. For the various types of accidents, or means of injury, the per- centage of occupational deaths varies. Thus for traumatism in mines and quarries the highest percentage of occupational acci- dents was registered, namely, 91.4. Under "absorption of dele- terious gases " there was recorded the lowest percentage for any of the definite types of accidental violence, 6.2. It was found that 24 per cent, of the falls were certified to have occurred in the course of the employment of the deceased. We do not deem it desirable at the present time to apply these ratios to any other body of data than to the one we have given. Our table and the accompanying text will, it is hoped, stimulate further statistical inquiry, perhaps in our published official vital statistics, into the number and per- centage of deaths from violence arising out of industry. An interesting corollary to the foregoing text on the probable number of deaths due to occupational causes, is the comparison of EXTEKNAL CAUSES OF DEATH. 125 the variation from year to year in the ratio of deaths due to such occupational stress. The following table gives a survey of this situation by single years from 1913 to 1916: TABLE 67. mortalitt from a group of specified accidental causes of death. Number and Percentage of Deaths Due to Occupational Stress. Single Years in Period 1912 to 1916. Experience of Metropolitan Life Insurance Company. Industrial Department. Year. Total Deaths from Group of Specified Accidental Causes. Number of Deaths of Occupational Origin. Per Cent. Deaths of Occupational Origin. 1912 to 1916 .... 14,151 3,963 28.0 1916 1915 1914 1913 1912 3,237 2,742 2,683 2,931 2,558 816 638 777 948 784 25.2 23.3 29.0 32.3 30.6 It would appear, therefore, from these figures that the proportion of deaths resulting from occupational accidents was on the decline during the five years under observation. The increase in the gen- eral accident rate for males at the ages 15 years and over must be due to other than occupational dangers, to which conclusion much other evidence points*- Trend of the Death Rate for Accidents. The table on page 126 gives the total accident death rate from 1911 to 1916, qualified according to the color and sex classes of our data. We observe from the following data a rather variable accident death rate. The maximum figure in the total experience was re- corded in 1913 at 77.6 deaths per 100,000 persons exposed and the minimum in 1915 with a rate of 67.3. Perhaps if we had a longer series of annual rates to consider, we should be able to detect a slight tendency toward decline in the death rate from accidents of all kinds. From the figures at hand we are unable to say definitely whether there has been any considerable reduction in the total acci- dent rate among insured wage earners. The conditions of grave hazard in American life and industry may not have improved, therefore, to any great extent. 126 MORTALITY STATISTICS OF IN8UKED WAGE EARNERS. TABLE 68. Mortality from Accidental and Unspecified Forms of Violence,* Classified by Color and by Sex. Death Bates per 100,000 Persons Exposed. Single Years in Period 1911 to 1916. Experience of Metropolitan Life Insurance Company. Industrial Department. Persons. White. Colored. Year. Males. Females. Males. Females. 1911 to 1916 73.0 115.9 36.4 121.4 38.8 1916 1915 1914 1913 1912 1911 73.2 67.3 69.9 77.6 73.8 77.4 118.7 105.8 109.3 124.9 115.2 123.6 34.8 34.7 36.5 37.2 37.2 38.8 122.7 108.5 118.2 134.8 128.4 116.5 37.5 37.7 35.5 39.6 41.2 41.6 * War deaths excluded. For white females and for colored females we are able to detect a fairly consistent but slight downward trend of total accidents. This is perhaps an indication that the graver hazards which sur- round women in home life have been mitigated in part by the various educational and other efforts toward security of the person from accidental violence. The white male total accident rate fluctuates somewhat from year to year and from a view of the figures in our present series we do not feel able to say that there has been any marked change for better or worse in the accident situation as it affects this group. The colored male total accident rate likewise offers no particularly encouraging evidence that the graver general accident hazards surrounding wage earners have been mitigated to any great extent. SuiCIDES.f The suicide problem has in recent years attained considerable prominence in discussions of the aims and purposes of preventive t Under "Suicides" are classified only those cases in which the fact of suicide or of attempt at suicide is clearly shown. By careful "editing" of our data relating to cause of death, hundreds of eases originally re- ported under such terms as "poisoning," "inhalation of gas," ^'drown- ings" "gunshot wound," "cut" and others have been added to this title instead of being placed under the class "accidental or unqualified," EXTERNAL CAUSES OF DEATH. 127 medicine. Suicide is often a preventable source of mortality, espe- cially when it is recaUed that in many cases the suicidal impulse is the end product of a psychosis, which, if treated in good time, might have been relieved. That suicide is a serious source of mortality is indicated by the fact that in the six-year period of this experience 6,542 deaths from this cause were recorded. Interest attaches also to this mass of deaths because they have occurred among a group of wage earners. If, as has been supposed, the suicide death rate is a measure of the mental health of a people, the figures at our disposal should help us determine an important characteristic of the American industrial population in relation to that of other groups of the population. In the following table we present a statement of the suicide death rates for each of the color and sex classes of our data. Chart XIII graphically illustrates these age data. TABLE 69. Mortality from Suicide (All Forms), Classified by Color, Sex and BY Age Period. Death Bates 'per 100,000 Persons Exposed. 1911 to 1916. Experience of Metropolitan Life Insurance Company. Industrial Department. Persons. White. Colored. Age Period. Male. Female. Male. Female. All ages — one and over 12.2 20.1 6.8 10.1 4.9 ltol4 15 to 19.. .. 20 to 24 25 to 34 35 to 44 45 to 54 55 to 64 65 to 74 75 and over . .1 6.0 13.0 17.0 20.9 26.5 31.3 34.0 34.1 .2 5.0 18.0 27.9 42.9 60.1 72.8 79.7 86.5 .1 7.2 8.7 11.1 10.9 11.1 10.4 10.5 8.4 .3 5.1 14.8 16.3 14.8 12.7 15.6 10.0 .3 5.3 11.9 7.4 5.7 3.4 1.3 1.2 At all ages combined, the rate was 12.2 per 100,000 persons ex- posed. The group of white males shows the highest rate of any of the color or sex classes, followed by colored males, by white females and finally by colored females. Males of each color group show decidedly higher suicide rates than do females. 128 MOETALITY STATISTICS OF INSURED WAGE EAENERS. m t o i LI r a 2 1 2 o . 1 5x5 O s o la. 0- I L» >« J - « <'o J ■ o c CC • o O S E S " I .. — 1 f 1 [ j 1 i 1 1 i 1 / / ^"^ / , / / \ \ ID o O „• \ \ / \ \, / . \ \ \ 1 / 1 ! . ^^ \,, 1 1 1 1^' ii- ^ \ i 1 ^^ '«»^, \ u a. * o ■i a oj EXTEKNAL CAUSES OF DEATH. 129 Suicide Mortality According to Color, Sex and Age. The age characteristics of these suicide data are also of signifi- cance. Beginning with a rate of 6.0 per 100,000 between 15 and 19 years, we recorded a rising rate up to and including the highest significant age period, 65 to 74 years. The age group 75 years and over has been disregarded because of its heterogeneous age com- position and the small number of lives exposed and of deaths re- ported. This gradual upward slope of the curve for suicide mor- tality probably reflects very largely the experience of the white male group included in the figures for all persons. For white males there is quite a sharp rise in the curve of suicide mortality, from a figure of 5.0 per 100,000 between the ages 15 and 19 years to a rate of 79.7 per 100,000 at the age period 65 to 74 years. White females do not show as clearly this phenomenon of increas- ing suicide mortality with age. Beginning with a figure of 7.2 per 100,000 at the age period 15 to 19 years, there is a gradual in- crease to a rate of 11.1 for the age period 25 to 34 years. From this group up to and including the period 65 to 74 years there is a practically stationary suicide rate for white females, with little variation from a figure of 10.5 per 100,000. The suicide rate for colored males does not show any tendency throughout the entire range of life toward either a decrease or an increase with advancing age. After the age period 20 to 24 years for colored females, we observe a distinct drop in the suicide rate with advancing years, from a figure of 11.9 per 100,000 in the first named age period to a rate of 3.4 per 100,000 in the period 45 to 54 years, the last age group for which we have significant figures. In view of the importance of racial characters of suicide mor- tality, it will be of some interest to consider the comparative ratios of some of these mortality rates for the several color classes by sex and age. Ratio of Suicide Mortality hy Color. In a preceding section we indicated the lower suicide mortality rate among colored persons. The colored male suicide rate was only 50 per cent, of that shown for white males at all ages combined. But this relation varies markedly at the several age periods. Be- tween 15 and 19 years our figures indicate a slight excess in the colored male suicide rate over the rate for white males, but this may be purely accidental and of no real significance. Beginning with 10 130 MOKTALITY STATISTICS OP INSURED WAGE EARNERS. the age period 30 to 24 years, the colored male suicide rate becomes increasingly more favorable in respect to the white male rate. Thus, while colored males showed a suicide mortality rate 82.2 per cent, of that recorded for white males at the age period 20 to 24 years, the ratio was only 12.5 per cent, at the age period 65 to 74 years. Among colored females also, with the exception of the age period 20 to 24 years, we observe with advancing age an increas- ingly more favorable suicide rate. The foregoing facts are shown in the table given below: TABLE 70. Mortality from Suicide (All Forms). Percentage, Colored of White Mortality at Specified Age Periods for Each Sex. 1911 to 1916. Experience of Metropolitan Life Insurance Company. Industrial Department. Percentage, Colored of White Mortality. Age Period. Males. Females. All ages — one and over 50.2 72.1 15 to 19 102.0 82.2 58.4 34.5 21.1 21.4 12.5 73.6 136.8 66.7 52.3 30.6 12.5 11.4 20 to 24 25 to 34 35 to 44 45 to 54 55 to 64 65 to 74 75 and over Sex Ratio of Suicide Mortality. We have shown that for white persons, the female suicide rate was less than the male suicide rate, the ratio being about one to three. White males show a higher rate of self-destruction at all age periods with the exception of the period of 15 to 19 years. There is a distinctly higher suicide rate among white females in this age of early adolescence than among white males. This phe- nomenon is also in evidence in such population figures as we have been able to find. It is possible that the stress and strain of early adolescence is more disastrous to females than to males. We might expect, also, to find a higher index of mental disorders among female adolescents than among males of the same ages on the basis of these suicide data. It may be noted in this connec- tion that there is a much higher incidence rate of serious cases of EXTERNAL CAUSES OF DEATH. 131 dementia precox, a form of dementia characteristic of adolescence and early adult life, among females than among males in popula- tions generally. Thus, in New York State during 1916 there were in the care of the hospitals for mental diseases under the super- vision of the New York State Hospital Commission, 8,903 male and 10,046 female dementia precox cases. At the ages in the popula- tion from which these patients were drawn, there is a considerable excess of males. This would make the disparity between the male and female dementia precox rates much greater than would be indicated by the foregoing comparison of the sex ratios of such patients under hospital care. Beginning with the age period 20 to 24 years, the white male suicide rate shows a very marked excess over the white female rate. This excess increases with advancing age. Between 20 and 24 years the white male suicide rate is 207 per cent, of the white female rate, between 25 and 34 years, 251 per cent.; between 35 and 44 years, 394 per cent., increasing to a percentage of 759 at the age period 65 to 74 years. TABLE 71. Mortality from Suicide (All Forms). Percentage, Male of Female Mortality at Specified Age Periods for Each Color Class. 1911 to 1916. Experience of Metropolitan Life Insurance Company. Industrial Department. Percentage, Male of Female Mortality. Age Period. White. Colored. All agea — one and over 295.6 206.1 15 to 19 69.4 206.9 251.4 393.6 541.4 70O.0 759.0 1029.8 96.2 20 to 24 124.4 25 to 34 220.3 35 to 44 259.6 45 to 54 373.5 55 to 64 1200.0 65 to 74 833.3 75 and over Colored males also show a suicide death rate lower than that for colored females at the age period 15 to 19 years, although the advantage of the males in relation to the females among the colored is not as great as that observed among the white lives. Beginning with the age period 20 to 24 years colored males showed a suicide 132 MOETALITY STATISTICS OF INSUEED WAGE EAENEKS. rate 124 per cent, of that recorded for colored females. There is much the same precipitate rise in the percentage of excess of male suicide mortality among colored persons as we found among white persons. The greatest difference is found in age period 55 to 64 when the rate for colored males is twelve times as high as for col- ored females. The foregoing observations are shown in tabular form on page 131. Suicide Experience of Insured Wage Earners and Population of Expanding Registration Area of the United States Compared. The suicide rates for white male insured wage earners are more favorable than the rates for males in the general population of the United States only for the ages under 25 years. Beginning with the age period 25 to 34 years we observe excesses in the suicide rate of white male wage earners — an excess of 5 per cent, for the period 25 to 34 years, of 20 per cent, for the period 35 to 44 years, of 17 per cent, for the period 45 to 54 and of 11 per cent, for the period 55 to 64 years. In other words, at the ages of early adolescence and early adult life white male wage earners show a more favorable suicide rate, but continuing through the main working period of life and up to the last age group registered in this table, the suicide rate of insured white males exceeds, and rises faster, than the rate for all males in the general population of the expanding Eegistra- tion Area of the United States. The suicide experience for insured white females is, however, more encouraging. Only between the ages 15 and 19 years and 25 and 34 years do we find an excess (very negligible) in the suicide rate of the insured group over females in the general population. For all other age periods, insured white females show a more favor- able suicide rate than do females in the population of the expand- ing Kegistration Area of the United States. Moreover, between the ages 35 to 64 years, insured white females show a tendency to improve upon the already favorable ratio of their suicide rate to the rate for females in the general population. Between 35 and 44 years insured white females showed a rate 96.5 per cent, of that recorded for females in the general population ; between 45 and 54 years, a rate of 88.8 per cent., and between 55 and 64 years, a rate 78.2 per cent, of that recorded for females in the general population. These observations are shown in the following table : EXTERNAL CAUSES OF DEATH. 133 TABLE 72. Mortality from Suicide (All Forms). Death Bates pet 100,000 Persons Exposed. Clctssified by Sex and hy Age Period. Insured White Lives in Experience of Metropolitan Life In- surance Company, Industrial Department {1911 to 1916) and General Population Experience of Expanding Begistra- tion Area of the United States (1910 to 1915). Males. Females. Age Period. Percentage Percentage M. L. I. Co. U. S. Reg. M. L. I. Co M. L. I. Co. M. L. I. Co. (White). Area. of Reg. Area. (White). Area. of Reg. Are*. All agea — one and over .... 20.1 24.6 81.7 6.8 7.9 86.1 1 to 14 .2 .6 33.3 .1 .5 20.0 15 to 19 5.0 5.6 89.3 7.2 7.1 101.4 20 to 24 18.0 18.2 98.9 8.7 10.7 81.3 25 to 34 27.9 26.7 104.5 11.1 11.0 100.9 35 to 44 42.9 35.8 119.8 10.9 11.3 96.5 45 to 54 60.1 51.4 116.9 11.1 12.5 88.8 55 to 64 72.8 65.8 110.6 10.4 13.3 78.2 65 to 74 79.7 61.6 129.4 10.5 11.6 90.5 75 and over. 86.5 61.5 140.7 8.4 9.8 85.7 Suicide According to Principal Means of Injury. The above discussion reviewed the principal facts of the suicide experience in the aggregate. A more intimate view, however, is afforded by a brief consideration of this phenomenon of self- TABLE 73. Mortality prom Suicide (All Forms). Number of Deaths, and Percentage of Deaths According to Specified Means of Injury. 1911 to 1916. Experience of Metropolitan Life Insurance Company. Industrial Department. Means of Injury. Number of Deaths. Percentage of Total. StnciDES — Total 6,542 100.0 Suicide by Poison 2,352 1,040 761 316 1,519 346 107 33 68 36.0 Asphyxia 15.9 Hanging or strangulation . Drowning 11.6 4.8 Firearms 23.2 Cutting or piercing instrunaents Jumping from high places. Crushing 5.3 1.6 .5 Other suicides 1.0 134 MOETALITT STATISTICS OF INSUEED WAGE EAKNERS. destruction according to the means of injury employed. In the preceding table we display the number of deaths reported accord- ing to the chief means of injury employed, and the percentage that each "means of injury" class constitutes of the total. Poison was the chief means of suicide in the present experience. Of the total deaths from suicide, 36.0 per cent, were accomplished by this means. This ratio is, of course, not constant in all mor- tality experiences. For instance, in New York City, asphyxia is the principal mode of committing suicide for both males and fe- males and in the Registration Area of the United States it would seem that firearms were the chief means of suicidal injury as re- gards males. Poisoning seems to be the mode most frequently chosen by females in the Registration Area, corresponding prac- tically to the prevalence shown in the experience of the Industrial Department of this Company. Variation in the choice of means of suicidal injury depends, of course, upon numerous factors, such as legislative restriction upon the sale of poisons, firearms and other means of injury, the extent to which publicity is given to suicides in the newspapers of various localities, and other strictly local fac- tors difficult to enumerate. "We shall take up briefly the principal means of suicidal injury in this present experience. Suicide hy Poison* There were 2,352 deaths from this cause concerned in the present investigation, in which either solid or liquid poisonous substances were employed. These deaths corresponded to a rate of 4.4 per 100,000 persons exposed. The age and sex characteristics of this cause of death are shown in Table 74 on page 135. It will be seen that the maximum rate in the entire group for suicide by poison is that among white males in the age period 55 to 64 years. Among white females and colored males, the maxi- mum figure is found in the age period 25 to 34 and among colored females even earlier, between 20 and 24 years. The general trend of mortality from suicide by poison seems to be downward. This is indicated by the figures given in Table 75 on page 135. * Solid and liquid poisons only. Where poisonous gas is the means em- ployed the death is classified under "Suicide by Asphyxia." EXTEKNAL CAUSES OF DEATH. 135 TABLE 74. Mortality from Suicide by Poison, Classified by 'Color, Sex and by Age Period. Death Bates per 100,000 Persons Exposed. 1911 to 1916. Experience of Metropolitan Life Insurance Company. Industrial Department. Persons. White. Colored. Age Period. Males. Females. Males. Females. All ages — one and over 4.4 6.0 3.4 2.9 3.0 1 to 14 15 to 19 20 to 24 25 to 34 35 to 44 45 to 54 55 to 64 65 to 74 75 and over . t 3.3 6.2 7.7 7.5 7.3 8.1 7.3 3.8 t 1.7 6.7 10.7 14.1 15.0 17.6 16.7 8.5 .1 5.0 5.9 6.3 4.5 4.0 3.7 2.7 1.7 .1 1.3 3.0 6.2 4.8 3.3 1.8 3.8 8.5 4.9 3.1 1.0 .4 t Less than .05 per 100,000. From a rate of 5.4 per 100,000 in 1911 the decline was fairly regular to a rate of 2.8 per 100,000 in 1916. We must remember, however, that suicide mortality is subject to considerable fluctua- tion with community conditions and that an opinion on the real trend of this phenomenon must be founded upon facts over a long TABLE 75. Mortality from Suicide by Poison, Classified by Color and by Seix. Death Bates per 100,000 Persons Exposed. Single Years in Period 1911 to 1916. Experience of Metropolitan Life Insurance Company. Industrial Department. Persons. White. Colored. Year. Males. Females. Males. Females. 1911 to 1916 4.4 6.0 3.4 2.9 3.0 1916. . . . 2.8 3.5 2.4 2.4 1.8 1915.... 3.8 4.9 3.4 .9 2.8 1914.... 4.8 6.8 3.4 3.7 3.7 1913.... 5.1 7.1 3.7 4.6 3.1 1912.... 4.8 6.6 3.7 4.1 2.4 1911... 5.4 7.7 4.1 1.9 4.1 136 MORTALITY STATISTICS OF INSURED WAGE EARNERS. period of time and only after the fluctuations characteristic of sui- cide are in full view. Suicide hy Asphyxia. The experience for this cause of death among white males and females according to age periods is shown in the following table. No substantial facts for colored persons are available. TABLE 76. MOETALITT FROM SUICIDE BY ASPHYXIA, CLASSIFIED BY SeX FOR WHITE Lives and by Age Period. Death Bates per 100,000 Persons Exposed. 1911 to 1916. Experience of Metropolitan Life Insurance Company. Industrial Department. Persons in Total Experience. White. Age Period. Males. Females. All ages — one and over 1.9 3.0 1.5 lto24 25 to 34 35 to 44 45 to 54 65 to 64 65 to 74 75 and over .3 2.2 3.9 5.3 6.2 6.7 3.4 .3 3.4 6.3 10.4 13.3 14.4 5.7 .2 2.1 3.6 3.6 2.8 3.0 2.5 The rates represented in the foregoing table were based upon 1,040 deaths from suicide by asphyxia. The rate for males from this cause is, at all ages combined, twice as high as that for white females. There is a constant increase in the rate with age for white males throughout the significant age groups but no very material variation for white females. The general trend of the rate for suicide by asphyxia during the six years under observa- tion is shown in the table on page 137. There is a practically constant death rate for this cause. Such variations as do occur are of no particular moment. If anything, there seems to be a slight increase in the rate for white females. In the expanding Eegistration Area of the United States, also, there has been observed in recent years a slight increase in the re- corded death rate from suicide by asphyxia, but this may be almost entirely due to an increase in the precision of reporting on the part of coroners, physicians and others entrusted with the completing of death certificates. EXTERNAL CAUSES OF DEATH. 137 TABLE 77. Mortality fkom Suicide by Asphyxia, Classified by Sex roa White Lives. Death Bates per 100,000 Persons Exposed. Single Years in Period 1911 to 1916. Experience of Metropolitan Life Insurance Company. Industrial Department. Persons In Total Experience. WWte. Year. Males. Females. 1911 to 1916 1.9 3.0 1.5 1916 1.9 2.3 1.9 2.1 1.7 1.7 2.5 3.4 3.1 3.5 2.4 2.8 1.8 1915 1.9 1914 1.2 1913 1.5 1912 1.5 1911 1.1 Suicide by Hanging or Strangulation. Only 761 deaths from this cause were recorded. This number does not justify any detailed analysis according to age classes. It will be suflBcient to remark that the death rate for this cause was practically the same among white males as the death rate from sui- cide by asphyxia. For white females and for colored persons the data are of no significance. The total number of deaths registered was 761; of these 626 were those of white males. Suicide by Drowning. There were only 316 deaths from this form of suicide. White males showed the highest rate ; white females had a death rate about half that of white males. Suicide by Firearms. The use of firearms was next in importance to poison among the cases of suicide represented in this mortality experience. We re- corded in all 1,519 deaths at a rate of 2.8 per 100,000 exposed. The mortality rate varied quite sharply according to sex, there being an almost negligible rate among females of both color or race classes. Our facts for color, sex and age are given in the following table : 138 MOETALITY STATISTICS OF INSUEED WAGE EAENEES. TABLE 78. Mortality from Suicide by Firearms, Classified by Color, Sex and BY Age Period. Death Bates per 100,000 Persons Exposed. 1911 to 1916. Experience of Metropolitan Life Insurance Company. Industrial Department. Persons. White. Colored. Age Period. Males. Females. Males. Females. All ages — one and over 2.8 5.7 .6 4.2 .8 1 to 14 15 to 19 20 to 24 25 to 34 35 to 44 45 to 54 55 to 64 65 to 74 75 and over . . t 1.3 4.1 3.9 4.7 6.1 6.6 6.0 7.2 .1 1.9 7.3 8.1 11.7 16.5 17.8 16.5 21.3 .8 1.5 1.0 .9 .7 .4 .3 .1 1.9 7.9 7.2 5.6 5.2 4.8 3.3 .1 .6 1.1 1.3 1.0 .8 .4 t Less than .05 per 100,000. The chief fact of importance in this table is the practically sta- tionary rate between 45 and 75 years of age. The trend of the mortality from this cause is displayed in the following table : TABLE 79. Mortality from Suicide by Firearms, Classified by Color and by Sex. Death Bates per 100,000 Persons Exposed. Single Years in Period 1911 to 1916. Experience of Metropolitan Life Insurance Company. Industrial Department. Persons. WMte. Colored. Year. Males. Females. Males. Females. 1911 to 1916 2.8 5.7 .6 4.2 .8 1916 1915 1914 1913 1912 1911 2.5 2.8 2.7 3.1 2.9 3.0 4.8 5.5 5.4 6.5 6.1 5.9 .6 .6 .7 .6 .4 .5 4.2 4.3 3.7 4.2 5.0 4.1 .6 .9 .8 .5 .5 1.3 The figures at hand relate to so few calendar years that no final conclusion can be drawn on the general trend of suicide by firearms. EXTERNAL CAUSES OF DEATH. 139 We can say at a venture that a slight decrease was observed. The underlying causes of mortality from suicide by firearms are en- tirely too complex to make it possible for us to speculate in any great detail upon the data shown in the foregoing table. Homicide.* The facts on homicide among this group of insured wage earners form an important contribution to the statistics on the crime of homicide in the United States. In fact, there are not available in discussions of the homicide problem any such detailed, modern data according to age classes of the two main race groups in the popu- lation as are to be found in this present display. In this investi- gation there were recorded 3,753 homicides and these deaths rep- resent a rate of 7.0 per 100,000 persons exposed. The following table gives a statement of the number and percentage of homicide deaths according to the several means of injury employed: TABLE 80. Mortality from Homicide (All Forms).* Number of Deaths, and Percentage of Deaths, According to Specif Means of Injury. 1911 to 1916. Experience of Metropolitan Life Insurance Company. Industrial Department. Means ot Injury. Number of Deaths. Percentage of Total. Homicides — Total 3753 100.0 Firearms 2435 616 702 64.9 Cutting or piercing instruments Other homicides 16.4 18.7 Of these homicides, 64.9 per cent, were accomplished through the use of firearms. This proportion is slightly in excess of that for the general population of the expanding Eegistration Area (61.8). Homicide by means of cutting or piercing instruments * Under ' ' Homicide ' ' are classified only those cases in which the fact of homicide or of attempt at homicide is clearly shown. By careful "editing" of our data relating to causes of death many eases originally reported under such terms as "gunshot wound," "cut," "poisoning," and others have been classed as homicides instead of being placed under the "acci- dental or unqualified" group. 140 MORTALITY STATISTICS OP INSURED WAGE EARNERS. was recorded in the present investigation in 16.4 per cent, of all homicides. In the general population of the Eegistration Area only 14.2 per cent, were accomplished through this means. The homicide death rate in this insurance experience was nearly 7^ times as great for colored males as for the entire group of insured wage earners. This rate (52.2 per 100,000) was almost ten times that of white males (5.4 per 100,000). Among colored females there was registered a death rate for homicide of 14.1 per 100,000 exposed. This rate is nearly three times that recorded for white males and over seven times the rate for white females. In the following table and in Chart XIV, page 141, we give a com- parison of the homicide death rates in this insurance experience according to color, sex and age classes : TABLE 81. MOBTAUTT FROM HOMICIDE (AlL FOBMS), CLASSIFIED BY COLOR, SeX AND BY Age Period. Death Bates per 100,000 Persons Exposed. 1911 to 1916. Experience of Metropolitan Life Insurance Company. Industrial Department. Persons. White. Colored. Age Period. Males. 1 Females. Males. Females. All ages — one and over 7.0 5.4 1.9 52.2 14.1 1 tol4 15 to 19 20 to 24 25 to 34 35 to 44 45 to 54 55 to 64 65 to 74 75 and over . .7 5.8 12.5 16.0 11.4 7.3 4.6 2.8 3.4 .6 4.4 8.5 11.8 10.5 9.4 7.3 4.1 .6 2.1 3.6 3.3 2.8 1.9 1.3 1.1 1.7 3.1 40.6 95.6 106.0 66.6 40.1 19.2 13.4 41.2 1.1 14.1 30.1 26.6 13.4 6.8 5.7 2.3 18.1 The age period of maximum incidence for males in both color classes was the same — 25 to 34 years. For white and colored fe- males the maximum rate occurred at an earlier period, 20 to 24 years of age. Among colored males this maximum rate was 106 per 100,000 exposed. Homicide among colored males was one of the chief causes of death, ranking next to pneumonia in order of numerical importance at this age period in Life. It will be noted, EXTERNAL CAUSES OF DEATH. 141 o 9 o o z o DC Li. > < QC O I > X i; (0 o E ■•^.. "^. / / / / ! J i /■ •^ 1 / II § ^ / (^ •>! /* ^ 1 / / 1 ( <^ \ ^•> ^ ""^ ~~-— «. — . / / / / / 1 1 / ,^'' ^ / * ^ 1 ^^ ^'''^ ,^' _,*-"'*' .^-' i^" \ \ V —- .— — — . •*— ~« \ *■*■■ - — — .-. -\ ?' 5S -" "^ 5 f 5 f S 1 1 O " ° Z 5 i O o E £§§ cc s « > I ! r- s 3 QC « o o : s 2 o I ra s o s. --.^ '"""'" -^^ \ \ ^"*v •^ ^, ^ i s K J ^ \ ^ ,^ ^ io § ^^^^ '-^^^^ ■"--. > \ ^^ ^ 1 "^ \ 1 1 \ ■§ ^ 1 152 MORTALITY STATISTICS OF INSURED WAGE EARNERS, age course of cancer mortality are observed for white males as for white females, with the exception that the upward slope of the curve for white females is very much sharper for the ages beyond 25 years. The cancer death rates for colored persons under 25 years of age are, for the most part, very low, and fluctuate somewhat irregularly. Beginning with the age period 25 to 34 years, how- ever, there is a constantly increasing rate, up to the highest age period recorded in this series. Color Ratio of Cancer Mortality. White males show emphatically higher cancer death rates at every age period than were recorded for colored males. Compari- sons between the cancer death rates of white and colored females are practicable beginning with the age period 25 to 34 years. Be- tween 25 and 44 years, the cancer death rate of white females was decidedly lower than the rate for colored females. Between 45 and 54 years, the rates were practically the same. Beginning with the age period 55 to 64 years and continuing to the highest age period in the table, we observe that the cancer death rates of white females were much higher than the rates for colored females. These differences in the total cancer death rates of white and colored females are to be accounted for, as will be shown later, by the higher mortality from cancer of the generative organs among colored females. Sex Ratio of Cancer Mortality. We have seen that among white lives the cancer death rate of females was practically one and two-thirds that of males. Cancer mortality of white males exceeds that of white females only for cancer of the buccal cavity, where the rates are 4.6 and .9 per 100,000 persons exposed, respectively; for cancer of the skin, where the rates are 2.2 and 1.6 respectively, and for the group of '^ cancers of other organs or of organs not specified." For cancer of the stomach and liver and of the peritoneum, intestines and rectum, the death rates of white females were decidedly in excess of those for white males. In addition, white females showed a high death rate for cancer of the female genital organs (25.3 per one hundred thousand) and for cancer of the breast (11.7 per one hundred thousand). Practically the same general remarks apply CANCER. 153 to the comparative cancer death rates of colored males and colored females when compared with respect to the several organs affected by malignant growths. There are no important differences in the cancer mortality of the two saxes among white lives under 25 years of age. Beginning with the age period 25 to 34 years, however, the cancer death rates of white females exceed those of white males substantially, up to and including the age period 55 to 64 years. Thus at the age period 35 to 44 years the rate for white males was only 38.6 per cent, of that for white females. After age 65, the disproportion between the rates for the two sexes among white lives is not so great. The excess of the cancer death rate of colored females over the rate for colored males is much greater than was observed, age period by age period, for white lives. Thus between 25 and 45, the rate for colored males was only about one-fourth as great as for colored females. In the following table, we give, first, a statement of the ratio of cancer mortality between the two races and, second, the sex ratio according to age period : TABLE 89 MORTALITT FROM CaNCEH (AlL FOEMS). Percentages: Colored of White Mortality hy Sex; Male of Female Mortality iy Color; Classified hy Age Period. 1911 to 1916. Experience of Metropolitan Life Insurance Company. Industrial Department. Per Cent. Colored of White Mortality. Per Cent. Male of Female Mortality. Males. Females. WWte. Colored. All Ages — One and Over 61.5 99.3 57.0 35.3 1 to 4 5 to 9 10 to 14 15 to 19 20 to 24 Ages 25 and Over 70.3 66.7 20.0 78.6 28.3 43.0 62.5 62.5 42.9 103.6 170.3 80.1 92.5 93.8 107.1 100.0 124.3 70.5 * * * * * 37.9 25 to 34 35 to 44 45 to 54 55 to 64 65 to 74 75 and over. . . . 85.2 78.3 57.6 51.4 36.9 46.7 179.5 118.9 100.0 84.9 65.2 67.2 47.6 38.6 61.6 84.2 94.2 95.2 22.6 25.4 35.5 51.0 53.2 66.1 * Insufadent data. 164 MORTALITY STATISTICS OF INSURED WAGE EARNERS. Compari'Son of Cancer Death Rates among Insured Wage Earners with Rates for Population of Expanding Registration Area of the United States. For both males and females, at all ages one and over combined, tlie cancer death rates of white lives in the insurance experience are substantially lower than the rates recorded in the Registration Area of the United States. This favorable ratio for the cancer mortality experience of insured wage earners does not hold for all of the age periods. Thus, the cancer death rate among white male wage earners is, in general, lower than the rate for males in the general population only at ages under 35 years. Among white insured females, the cancer death rate is lower than the rate among females in the general population only between 20 and 35 years of age. The cancer death rate among both white males and white females of the insurance experience is higher than the rate for males and females in the Registration Area at every age period beyond 35 years of age, where cancer is of the most importance as a cause of death. It should be remarked also that male wage earners show much greater percentages of excess in cancer mortality than do females in wage earners' families. The following table sets forth these comparative facts of cancer mortality: TABLE 90. Mortality from Cancer (All Forms). Death Bates per 100,000 Persons Exposed. Classified hy Sex and by Age Period. Insured White Lives in "Experience of Metropolitan Life In- surance Company, Industrial Department (1911 to 1916) and General Population Experience of Expanding Registra- tion Area of the United States {1910 to 1915). Males. Females. Age Period. M. L. 1. Co. (White). V. S. Reg. Area. Per Cent. M.L.I. Co. ol Reg .Area. M. L. I. Co. (White). U. S. Reg. Area. Percent. M. L. I. Co. ot Reg. Area. AH ages — one and over 50.4 62.2 81.0 88.4 97.9 90.3 1 to4.... 3.7 3.6 102.8 4.0 3.1 129.0 5 to 9.... 1.5 2.0 75.0 1.6 1.4 114.3 10 to 14... 1.5 1.7 88.2 1.4 1.4 100.0 15 to 19... 2.8 2.9 96.6 2.8 2.6 107.7 20 to 24... 4.6 4.4 104.5 3.7 4.6 80.4 25 to 34... 8.8 9.3 94.6 18.5 20.8 88.9 35 to 44... 38.3 31.9 120.1 99.3 89.0 111.6 45 to 54... 147.0 109.8 133.9 238.6 227.0 105.1 55 to 64... 356.2 280.3 127.1 423.2 406.9 104.0 65 to 74... 625.3 503.4 124.2 665.1 607.0 109.6 75 and ovei • 822.8 710.2 115.9 863.9 828.2 104.3 CANCEE. 165 Relation of Cancer to Economic Condition or Social Statits. At this point in the discussion, brief reference may be made to the possible relation between the incidence of cancer mortality and economic status, as indicated in a paper recently published on this subject.* The following table shows the main facts of an in- vestigation based upon the comparative mortality experience of the Ordinary, Intermediate and Industrial Departments of the Metro- politan Life Insurance Company during the three years 1914, 1915, and 1916, White lives only were included in this investigation. The Ordinary Department policyholders are drawn from higher economic strata of the population than are the "Intermediate" group. The Industrial policyholders form the third class or group in order of material circumstance. In order to eliminate the slight effect of medical selection in the Ordinary and Intermedi- ate groups with respect to cancer, we considered only the mortal- ity in these classes on business in force at least five years. TABLE 91. Cancer Claim Bates per Hundred Thousand Mean in Force, Ordinary and Intermediate Departments, First Five Years of Issue Excluded Compared with Industrial Department, All Years of Issue Combined. Composite Mortality Experience 1914, 1915, and 1916. White Lives. By Sex a/nd hy Age Period. Sex and Age Period. Ordinary De- partment. Intermediate Branch. Industrial De- partment. Males: Ages 25 and over 83.5 70.3 140.0 25 to 34 12.0 33.4 104.3 276.5 662.5 8.7 41.8 107.6 295.1 645.3 9.7 35 to 44 37.5 45 to 54 154.1 55 to 64 368.0 65 and over 679.2 Females: Ages 25 and over 141.6 115.1 197.7 25 to 34 31.4 71.6 213.5 353.6 313.1 25.4 87.8 206.7 422.1 1,009.8 17.8 35 to 44 98.9 45 to 54 235.8 55 to 64 429.6 65 and over 707.5 * Knight, Augustus S., and Dublin, Louis I., "The Eelation of Cancer to Economic Condition." Eead before the Association of Life Insurance Medical Dibectors of America, Worcester, Mass., October 17, 1917, Re- printed by Metropolitan Life Insurance Company, New York, 1917, 156 MOKTALITT STATISTICS OF INSURED WAGE EARNERS. In this table, clwlm rates per one hundred thousand mean in-force for the several departments are compared. Actual experience demonstrates that very little error is involved in a comparison of mortality rates based upon the number of claims reported and the mean number of policies in-force if such data are related strictly to age periods. The comparison is valid therefore as above given. Because of the heavy representation of policyholders at the ages under 45 years, with a small num*ber -of deaths, leading to aberrant cancer death rates for these ages, the Intermediate rates for both males and females at all ages are apparently the lowest. At the ages beyond 45 years, where* cancer mortality is numerically signi- ficant, the Industrial group showed the highest rate, the Ordinary the least and the Intermediate a rate between the other two. As a result of an extended consideration of the data developed in this inquiry into the possible relation of cancer and economic condition, it was concluded that: 1. The current medical opinion that there is strong association between low economic status and a low cancer death rate is in all probability unfounded. 2. The cancer mortality rate at the ages where the cancer rate is significant, decreases as we go up in the economic scale. 3. This is shown to be true for each sex where sufficient data are available. 4. This conclusion is not conditioned by the effect of varying amounts of medical selection in the three groups considered. Trend of the Cancer Death Bate. Medical literature of the past few years contains much contro- versy on the question whether mortality from cancer is actually increasing or not. One school of research holds "that the mor- tality from cancer is increasing at a more or less alarming rate throughout the entire civilized world and that this increase implies most serious consequences, present and future, to the populations concerned."* Another group of statisticians holds that "the re- ported mortality from cancer is increasing in almost every part of the world, but the real mortality, if increasing at all, is certainly not increasing with equal rapidity. . . . The cumulative evidence * Hoffman, Frederick L., ' ' The Mortality from Cancer Throughout the World," p. 218. Prudential Press, Newark, New Jersey, 1915. CANCEK. 157 that improvements in diagnosis and changes in age composition explain away more than half and perhaps all of the apparent in- crease in cancer mortality rebuts the presumption raised by the figures and makes it probable, though far from certain, that cancer mortality is not inereasing."f It is not the purpose of this section to take sides in the contro- versy. It is desired to offer the mortality records of the present investigation only as a contribution to the available supply of trustworthy data on the trend of cancer mortality. The following table shows the rates per 100,000 persons exposed in each of the color and sex classes within the scope of this inquiry for the years 1911 to 1916: TABLE 92. Mortality from Cancer, All Forms, Classified by Color and by Sex. Death Bates per 100,000 Persons Exposed. Single Years in Period 1911 to 1916. Experience of Metropolitan Life Insurance Company. Industrial Department. Persons. wmte. Colored. Year. Males. Females. Males. Females. 1911 to 1916 70.0 50.4 88.4 31.0 87.8 1916 1915 1914 1913 1912 1911 70.3 70.9 69.8 70.5 70.3 68.0 51.8 50.7 50.7 51.4 47.8 49.6 87.2 89.8 87.9 87.5 91.7 86.5 36.5 29.0 28.0 32.4 30.7 28.9 86.1 90.4 88.3 93.6 86.3 81.3 Cancer death rates in this present experience, covering six calendar years, and relating in all to fifty million years of life ex- posed to risk, show no decisive upward or downward tendency for all age classes com'bined. This is true for each color and sex group- but more decisively for the group of insured white females for whom the highest rates are recorded. The rates, by color and by sex, for the year 1911 are, to be sure, slightly lower than the fig- ures for the entire six year period; this condition may be acci- dental and without significance. Considering all ages combined, therefore, there is no evidence presented in these figures from + Willcox, Walter F., "On the Alleged Increase of Cancer, ' ' Quarterly Publications of the American Statistical Association, Sept., 1917, p. 756. 158 MORTALITY STATISTICS OF INSURED WAGE EARNERS. which an increasing mortality may be predicated with any certainty. It would be more significant perhaps in this discussion to con- sider the trend of the cancer death rate during the six year period in a definite age period, especially one in which the cancer death rate is usually high. For this purpose we have chosen the age period 55 to 64 years. The following table shows for each one of the color and sex groups, the death rates from cancer (all forms) during the six year period: TABLE 93. Mortality from Cancer (All Forms) Ages 55 to 64 Tears, Classified BY Color and by Sex. Death Bates per 100,000 Persons Exposed. Single Years in Period 1911 to 1916. Experience of Metropolitan Life Insurance Company. Industrial Department. Persona. WWte. Colored. Year. Males. Females. Males. Females. 1916 1915 1914 1913 1912 1911 386.4 380.8 390.9 384.1 381.9 368.7 358.0 336.0 385.0 370.3 334.1 353.3 427.4 427.8 423.3 414.6 443.2 400.2 218.3 175.7 167.7 195.2 176.4 158.0 339.9 394.3 351.7 368.3 325.4 373.7 This table shows very much the same trend situation in the age period 55 to 64 years as we found for all ages combined. The year 1911 was again a year of comparatively low cancer mortality. As the figures are compared for the individual years we find some variation with no clearly defined tendency toward increase or de- crease. Our data, therefore, need not serve to confirm either one of the two opposing opinions and, in fact, point out the necessity for reserve and caution in predicating any decisive opinion with regard to the real trend of cancer mortality during recent years. A longer period of time will be required to collect authentic figures upon which a definite Judgment can be based. Considerable analysis of cancer data according to age, sex, color and organ or part affected will be necessary before any final conclusions can be drawn as to the amount of increase, if any, in recent years. An- canceIr. 159 other view of our data with respect to this question of cancer mortality increase is presented in the following table: TABLE 94. Mortality from Cancer (All Forms). Percentage, Death Rate per 100,000 Persons Exposed in 1915-1916 of Death Rate in 1911-1912. Classified hy Color, Sex and by Significant Age Periods. Experience of Metropolitan Life Insurance Company. Industrial Department. Persons. White. Colored. Age Period. Males. Females. Males. Females. Ages 25 and over . . 101.0 105.2 98.3 105.1 100.7 25 to 34 35 to 44 45 to 54 55 to 64 65 to 74 75 and over. . 98.1 100.1 99.1 102.2 107.0 101.0 121.0 104.3 109.7 101.1 115.9 104.1 94.1 96.9 97.0 101.2 101.9 104.4 95.5 142.6 67.7 118.0 117.2 110.7 95.0 98.2 93.1 105.2 107.0 48.6 We have eliminated in this table any superfluous references to ages under 25 years and in order to get at the heart of the matter have presented only the percentage which the cancer death rate in two years combined, 1915-1916, was of the death rate in two prior years, 1911-1912, at each significant age period, for each color and sex class. Considering all persons in this mortality experience at ages 25 and over, there was an increase of only 1.0 per cent, in the cancer death rate between the two periods compared. This figure is a composite of a variously weighted increase of 5.2 per cent, for white males, a decrease of 1.7 per cent, for white females, an increase of 5.1 per cent, for colored males and a practically stationary rate for colored females. Considered according to age period, this in- crease of 1.0 per cent, in the cancer death rate of all persons in this experience, aged 25 years and over, was a composite of a de- crease of 1.9 per cent, between 25 and 34 years, contributed very largely out of the experience of white and colored females, a prac- tically stationary death rate between 35 and 44 years, which is, in itself, a composite of an increase for white and colored males and a decrease for white and colored females, and a slight decrease between 45 and 54 years. At this latter age period, we observe an 160 MOETALITY STATISTICS OF INSUEED WAGE EARNERS. increase of nearly ten per cent, in the white male rate, a decrease of 3.0 per cent, for white females, of 6.9 for colored females, and of 32.3 per cent, for colored males. The major influence, however, in slightly lowering the cancer death rate of all persons between 45 and 54 years was, of course, the experience of the group of white females. Between 55 and 64 years, all classes in the mor- tality experience show an increase in the rate, highest for colored males and least for white males. The age period 65 to 74 years shows an increase of 7.0 per cent, which is contributed very largely by the experience on male lives of each color group. It should be remarked that the cancer experience of colored persons exerts but slight influnce upon the ratio of increase of cancer mortality in the entire experience. In fact, for some of the age periods, the data on the increase of cancer mortality among colored persons are aberrant. It will be seen from the foregoing table that considerable analysis of cancer facts according to age, sex, color and by organ or part affected is necessary before any final conclusions are drawn as to the amount of real increase in cancer mortality, if any, in recent years. A discussion, in some detail, of the cancer mortality ex- perience according to the organs or parts follows. Cancbe* of the Stomach and Liver. The deaths classified under this heading constituted, as was shown above, the most important subordinate group of specific types of cancer. Cancers of the stomach and liver were recorded in 37.6 per cent, of all cancers in this entire experience. It should be remembered that this heading also includes cancers and other malignant tumors of the pharynx, the esophagus, and the gall bladder, f The combined total of malignant growths of the pharynx and esophagus, however, numbers less than five per cent, of all deaths recorded under this heading in general practice, and does not, therefore, seriously affect the present data. In gall bladder cancers the liver is frequently involved. We recorded 14,153 deaths from malignant growths of the stomach and liver. The death rate was 36.3 per 100,000 persons * Cancer and other malignant tumors. t The International list heading ' ' Cancer of the Stomach, Liver, ' ' is somewhat misleading, inasmuch as cancers of certain other organs of the digestive system are classified under it, as noted above. CANCEE. 161 exposed. As shown in the following table, the facts vary con- siderably according to color, sex and age period. TABLE 95. Mortality from Cancer of the Stomach and Liver, Classified by Color, Sex and by Age Period. Death Bates per 100,000 Persons Exposed. 1911 to 1916. Experience of Metropolitan Life Insurance Company. Industrial Department. Persona. White. Colored. Age Period. Males. Females. Males. Females. AU ages — one and over 26.3 24.8 29.8 16.2 18.5 lto24 25 to 34 35 to 44 45 to 54 55 to 64 65 to 74 75 and over. . .3 3.0 18.6 67.2 168.5 276.0 334.7 .3 2.9 18.1 77.0 193.3 303.6 339.1 .3 2.7 20.1 67.7 168.4 288.7 353.3 .2 3.3 13.8 44.0 108.0 125.3 164.6 .6 5.0 16.5 44.8 99.5 122.1 217.8 There is a higher death rate for this cause, without important exception, for white lives than for colored lives. Below 35 years, mortality from cancer of the stomach and liver is not numer- ically important. The death rate increases from a figure of 18,6 in the age period 35 to 44 years to the maximum in the highest age period in this series, 75 years and over. From 45 years ol age and onward, however, the death rate of white males for this disease is appreciably higher than the rate for white females, with the exception of the very highest age period, 75 years and over. Among colored persons the death rate from cancer of the stomach and liver is higher for males than for females between 55 and 74 years only. At the ages under 55 years, colored females show higher death rates from this cause than do colored males. Comparison of Data for Cancer of the Stomach and Liver among Insured Wage Earners and among the Population of the Expanding Registration Area of the United States. For both males and females at the ages where death rates from this cause are at all significant, a higher death rate is recorded 12 162 MORTALITY STATISTICS OF INSUEED WAGE EAENERS. among the group of insured wage earners than is observed in the Eegistration Area of the United States. Beginning with the age period 35 to 44 years, there is an excess of over nineteen per cent., between 45 and 54 years, an excess of thirty-two per cent., and between 55 and 64 years, an excess of twenty-nine per cent, over the rates for males prevailing in the expanding Eegistration Area of the United States. The excess in the death rate of cancer of the stomach among insured females is not so great as in the case of insured males. In the following table, a comparison of the foregoing facts is given: TABLE 96. Mortality from Cancer of the Stomach and Liver. Death Bates per 100,000 Persons Exposed, Classified by Sex and hy Age Period. Insured White Lives in Experience of Metropolitan Life Insurance Company, Industrial Department (1911 to 1916) and General Population Experience of Expanding Eegis- tration Area of the United States {1910 to 1915). "" Males. Females. Age Period. M.L.I. Co. (White). U. S. Reg. Area. Per Cent. M.L.I. Co. of Reg. Area. M.L.I. Co. (Wlilte). gU. S. Reg. Area. Per Cent. M.L.I. Co. but no great significance can be attached to the figures. There are obvious reasons why the death rate among insured children should be higher than for chil- dren in the general population. In the first place, insured children are almost entirely urban residents and the urban death rate is about douhle the rural rate for this disease. The population of TABLE 109. Mortality from Measlbs. Death Bates per 100,000 Persons Exposed. Classified hy Sex and hy Age Period. Insured White Lives in Experience of Metropolitan Life In- surance Company, Industrial Department (1911 to 1916) and General Population Experience of Expanding Eegistra- tion Area of the United States {1910 to 1915). Males. Females. Age Period. M.L.I. Co. (White). U. S. Reg. Area. Per Cent. M.L.I. Co. of Reg. Area. M.L.I. Co. (White). V. S. Reg. Area. Per Cent. M.L.I. Co. of Reg. Area. AH ages — one and over 10.5 6.8 154.4 8.6 7.1 121.1 lto4 5 to 9 10 to 14.... 15 to 19.... 20 and over. 84.1 10.5 1.3 1.0 .3 63.4 7.7 1.9 1.8 .7 132.6 136.4 68.4 55.6 42.9 80.0 11.4 1.9 .9 .6 59.8 7.8 2.5 1.8 1.2 133.8 146.2 76.0 50.0 50.0 PEINCIPAL COMMUNICABLE DISEASES OF CHILDHOOD. 181 the Registration Area is about equally divided between the urban and rural communities. Another factor favoring the Eegistra- tion Area is the inclusion in the latter of a small proportion of colored lives whose death rates from measles are lower than those for whites. The table on page 180 permits a more detailed com- parison of the two sets of figures by age and sex. The mortality from measles has been showing marked fluctua- tions in recent years. This tendency has been observed in both the general population and the insured group. The year 1915 marked the minimum death rate for this disease in both experi- ences. For that year the rate was 5.7 per 100,000 exposed for Metropolitan Industrial policyholders aged one year or more and 5.4 per 100,000 exposed for the general population at all ages. In this comparison the rates include both white and colored children among the insured. The year 1915, it may be remarked, showed the lowest death rate recorded for measles for the general popu- lation since the beginning of the period covered by the annual mor- tality reports relating to the expanding Eegistration Area. The year 1916, however, showed a pronounced increase in both experi- ences, although this was not as marked among the insured group as it was for the expanding Eegistration Area, in which the death rate more than doubled. The following table shows the trend of the mortality among white and colored policyholders by sex during the period 1911 to 1916: TABLE 110. MORTAIilTT PROM MEASLES, CLASSIFIED BY COLOE AND BY SeX. Death Rates per 100,000 Persons Exposed. Single Years in Period 1911 to 1916. Experience of Metropolitan Life Insurance Company. Industrial Department. Persona. White. Colored. Year. Males. Females. Males. Females. 1911 to 1916 8.9 10.5 8.6 5.2 4.8 1916 1915 1914 1913 1912 1911 9.9 5.7 6.9 12.3 7.6 11.4 12.2 6.5 8.1 14.2 9.3 13.0 9.4 5.9 6.5 12.1 7.2 10.5 4.0 2.3 4.8 7.6 3.9 9.4 3.5 2.4 4.0 6.5 3.6 9.2 182 MOETALITY STATISTICS OF INSURED WAGE EAENEES. Comparisons of the death rate for this disease covering long periods of years should be made only with certain reservations. In fatal cases usually the complications and sequelae are the im- mediate causes of death. Only a few years ago there was very great understatement of this condition on reports of causes of death. This situation has been gradually improved through the efforts of National, state and corporate bureaus interested in mor- tality statistics. Year after year increasing numbers of physicians have learned the importance of stating primary conditions instead of sequelae and terminal complications as determining causes of death. Measles is one of the diseases the published death rates for which have been very materially affected by this influence. No doubt there is still some understatement but the condition has shown very great improvement. Those who make comparisons and analyses based on the published death rates for this disease should make due allowance for the influence of these factors. (&) SCAELET PeVER. Probably there have been few more gratifying evidences of the effectiveness of public health activity in this country than the con- sistent decrease in scarlet fever mortality. The attention given by public health officials to prophylaxis, the increasing rigidity of school inspection, the education of the public on the necessity of care and precaution against the spread of the disease, have all been potent factors in lowering the mortality from scarlet fever. There has also been more widespread public appreciation, not only of the more or less immediately fatal results, but of the serious sequelae of the disease. There were 4,638 deaths from scarlet fever among Metropolitan Industrial policyholders during the period 1911 to 1916. The death rate was 8.6 per 100,000 exposed. The death rate among white policyholders, both male and female, was about four times as high as that for the colored policyholders. This- is a condition which has also obtained, year by year, for the population of the expanding Eegistration Area. The comparative immunity of colored persons to this disease has long been recog- nized. The sex incidence for the insured shows a heavier com- parative death rate for males over females among white policy- holders than among colored ones. The colored experience, how- ever, is small, and this comparison is, possibly, not significant. PEINCIPAL COMMUNICABLE DISEASES OP CHILDHOOD. 183 The age period of heaviest mortality, in the Metropolitan experi- ence, is the period 1 to 4 years, during which ages 2,210 deaths or 47.6 per cent, of the total of 4,638 deaths occurred. The follow- ing table gives the death rates by age period for each color and sex class : TABLE 111. Mortality from Scarlet Fever, Classified by Color, Sex and by Age Period. Death Bates per 100,000 Persons Exposed. 1911 to 1916. Experience of Metropolitan Life Insurance Company. Industrial Department White. Colored. Age Period. Persons. Males. Females. Males. Females. Ail ages — one and over 8.6 10.6 8.6 2.5 2.2 1 to4 5 to 9 10 to 14 15 to 19 20 to 24 25 and over. . 49.0 22.5 6.4 2.8 1.6 .5 53.5 24.3 5.8 3.0 1.2 .4 48.8 23.4 7.5 2.9 2.2 .6 16.0 8.8 5.1 1.0 .2 22.2 6.4 2.5 2.3 .5 .3 The sex and age characteristics brought out by examining the comparable figures for the expanding Eegistration Area (with the population under one year eliminated) do not differ materially from those shown above for the Metropolitan experience. It is true that the slight excess which is recorded among insured males over females is not in evidence for the general population. In the latter experience the mortality rate for the period 1910 to 1915 for males was 7.1 per 100,000 population; this corresponds closely to the rate shown for females (7.5). For the age period 1 to 4 years the insured white male children show a higher rate (53.5 per 100,000 exposed) than is in evidence for those of the same age group in the general population (45.8) ; the insured females of this age group show about the same excess over the females in the general population (48.8 as compared with 42.8). In the age period 5 to 9 years the insured white males registered a higher death rate than did the males of the general population and the insured white females also showed a very slight excess. It must be borne in mind, however, in making this comparison, that 184 MOKTALITY STATISTICS OF INSUEED WAGE EAENERS. the colored population in the expanding Eegistration Area is in- cluded, and that on account of the extremely low incidence of scarlet fever among colored people it is probable that their in- clusion in the exposure accounts for a considerable share of the excess which is shown for the insured white children. Another element which should be considered in comparing the mortality from this disease among insured children and those of the general population is the far higher proportion of urban exposure among the policyholders. The mortality reports covering the general population show, year after year, considerably higher death rates for scarlet fever in the cities than in the rural communities, and the rates for the insured do not have the benefit of much rural ex- posure. The following table shows, side by side, the figures for males in the expanding Eegistration Area compared with those for white insured males; also the figures for females in the Eegistra- tion Area compared with those for white insured females: TABLE 112. Mortality from Scarlet Fever. Death Bates per 100,000 Persons Exposed. Classified hy Sex and hy Age Period. Insured White Lives in Experience of Metropolitan Life In- surance Company, Industrial Department (1911 to 1916) and General Population Experience of Expanding Eegistra- tion Area of the United States (1910 to 1915). Males. Females. Age Period. M. L. I. Co. (White). U. S. Reg. Area. Per Cent. M. L. I. Co. of Reg. Area. M. L. I. Co. (White). U. S. Reg. Area. Per Cent. M. L. I. Co. of Reg. Area. All ages — one and over 10.6 7.1 149.3 8.6 7.5 114.7 lto4 53.5 45.8 116.8 48.8 42.8 114.0 5 to 9 24.3 22.0 110.5 23.4 23.1 101.3 10 to 14.... 5.8 6.0 96.7 7.5 7.1 105.6 15 to 19.... 3.0 2.8 107.1 2.9 3.1 93.5 20 to 24.... 1.2 1.6 75.0 2.2 2.2 100.0 25 and over. .4 .6 66.7 .6 .7 85.7 The highest death rate during the period for Metropolitan In- dustrial policyholders was that for the year 1911 (13.1) ; the death rate for 1913 was 12.7; for 1914, 9.8; for 1912, 9.0. For the yeai 1915 there was a decrease to 4.6 and this was followed by a further decline in 1916 to 4.1. PRINCIPAL COMMUNICABLE DISEASES OF CHILDHOOD. 185 This experience corresponds closely to that of the Registration Area. The trend of the mortality due to scarlet fever during the period 1911-1916 among Metropolitan Industrial policyholders is shown by the following table: TABLE 113 Mortality from Scarlet Fever Classified by Color and by Sex. Death Bates per 100,000 Persons Exposed. Single Years in Period 1911 to 1916. Experience of Metropolitan Life Insurance Company, Industrial Department. Persons. White. Colored. Year. Males. Females. Males. Females. 1911 to 1916 8.6 10.6 8.6 2.5 2.2 1916 1915 1914 1913 1912 1911 4.1 4.6 9.8 12.7 9.0 13.1 4.7 5.8 12.1 16.0 11.1 16.2 4.0 4.3 9.7 12.7 9.1 13.6 2.2 1.9 3.3 3.0 1.7 2.8 1.8 2.2 2.9 2.3 2.4 1.3 It is not necessary to comment in this report, at length, on the greatly decreased and almost continuously decreasing mortality from scarlet fever as shown both by the experience among Metro- politan Industrial policyholders and by the reports of the Bureau of the Census since the year 1900. Inasmuch as the mortality from this disease is of such great interest from a public health standpoint, one cannot fail to be impressed by the great saving of life which these reports show — especially when we examine the annual Census mortality volumes beginning with the year 1900. Special emphasis should be laid on this point: great as is the de- crease in the mortality as indicated by the published death rates for the Registration Area, there has been a still greater actual decrease. The published death rates for scarlet fever have been materially increased by the educational work of public and corporate registra- tion offices in securing increased precision of statement of causes of death. In a recent study of the mortality of childhood,* it was shown that scarlet fever, while unimportant as a cause of death in the * * ' The Mortality of Childhood, ' ' Dublin, Louis I. Read at the Seventy- ninth Annual Meeting of the American Statistical Association, Philadelphia, December 27, 1917. Published in Quarterly Publications of the American Statistical Association, March, 1918. 186 MOETALITY STATISTICS OF INSUKED WAGE EARNERS. first year of life caused 1.7 per cent, of all the deaths between one and two years of age in the Eegistration Area during the period 1910 to 1915; 4.7 per cent, between two and three years; 7.0 per cent, between three and four years and 7.6 per cent, during the fifth year of life. During the second quinquennium 7.1 per cent, of all of the deaths were ascribed to scarlet fever. This percent- age dropped to 3.0 during the third quinquennium. (c) Whooping Cough. Like measles, whooping cough is seldom fatal when uncom- plicated. When whooping cough causes death it is usually through terminal pulmonary conditions, bronchopneumonia in particular. Because of its very wide prevalence it is, like measles again, a very dangerous disease and one which stands high among the fatal affections of children. In all, 3,075 deaths were caused by whoop- ing cough among policyholders during the period 1911 to 1916, corresponding to a rate of 5.7 per 100,000 exposed at all ages. The disease is limited almost entirely to the ages of childhood. Of all the deaths, 98.2 per cent, occurred among children between one and nine years old, and 86.7 per cent, of the decedents were between one and four years of age. There is, therefore, very little room for a discussion of whooping cough mortality by age period apart from the first two quinquennia of life. The following table shows the facts for the ages under 10 years for each color and sex group : TABLE 114. Mortality from Whooping Cough, Classified by Color, Sex and by Age Period. Death Bates per 100,000 Persons Exposed. 1911 to 1916. Experience of Metropolitan Life Insurance Company. Industrial Department. Persons. White. Colored. Age Period. Males. Females. Males. Females, All ages — one and over 5.7 4.7 5.6 9.2 9.3 lto4 5 to 9 10 and over . . 59.1 4.9 .1 42.0 3.0 .1 60.9 4.9 .1 151.3 12.7 .2 173.9 17.3 .4 PEINCIPAL COMMUNICABLE DISEASES OF CHILDHOOD. 187 Unlike the other communicable diseases of children the death rate for whooping cough is considerably higher among colored than among white children. In fact in the age period of 1 to 4 years, the mortality from whooping cough among colored boys and girls is approximately three times as high as among white children of the same ages. The disease is also more prevalent among females than among males. This is true for each of the significant age periods and for each race. Similar relations are found to exist in the data for the population of the Eegistration Area. The following table which is limited to the significant age periods will serve as a basis for comparison of the mortality from this disease in the two experiences: TABLE 115. Mortality from Whooping Cough. Death Bates per 100,000 Persons Exposed. Classified ty Sex and hy Age Period. Insured White Lives in Experience of Metropolitan Life In- surance Company, Industrial Department (1911 to 1916) and General Population Experience of Expanding Eegistra- tion Area of the United States {1910 to 1915). Males. Females. Age Period. M.L.I. Co. (White). U. S. Reg. Area. Per Cent. M.L.I. Co. of Reg. Area. M.L.I. Co. (White). V. S. Reg. Area. Per Cent. M.L.I. Co. Of Reg. Area. lto4 5 to 9 10 and over. 42.0 3.0 .1 40.0 3.2 .1 105.0 93.8 100.0 60.9 4.9 .1 55.6 4.6 .2 109.5 106.5 50.0 In all comparisons between the mortality experience of Metro- politan Industrial policyholders and of the expanding Eegistration Area, for whooping cough, we should not lose sight of the fact that of the four chief epidemic diseases known as " children's diseases," namely, measles, scarlet fever, diphtheria and whooping cough, the last named is the only one for which the mortality is higher in rural than in urban districts. The fact that the rural population in the Eegistration Area is large and that among the Industrial policyholders of the Company it is small, must, therefore, always be considered in comparing the two experiences. The trend of whooping cough mortality has been downward since 1911. The variations in the rate from year to year are largely accounted for by the epidemic character of the disease. The rate for 1916, for example, rose very appreciably over that for 1915 but 188 MORTALITY STATISTICS OF INSURED WAGE EARNERS. is nevertheless much lower than the rate for 1911. The trend corresponds closely with that in the expanding Eegistration Area, but for both experiences it may safely be said that a large measure of mortality^ entirely unnecessary and subject to ready control, would be eliminated if the necessary steps were taken to impress upon the public the truly dangerous character of the disease and to prevent children from coming in contact with those afflicted. The following table shows the figures for whooping cough for each of the six years: TABLE 116. MOKTALITY FROM WHOOPING COUGH, CLASSIFIED BY COLOB AND BY SEX. Death Bates per 100,000 Persons Exposed. Single Years in Period 1911 to 1916. Experience of Metropolitan Life Insurance Company. Industrial Department. Persons. WUte. Colored. Year. Males. Females. Males. Females. 1911 to 1916 5.7 4.7 5.6 9.2 9.3 1916 1915 1914 1913 1912 1911 5.8 4.7 5.8 5.9 5.1 7.1 4.9 4.3 4.7 4.5 4.3 5.5 6.3 4.6 5.6 5.8 4.9 6.8 7.3 6.8 10.0 10.5 7.9 13.3 6.5 6.6 10.6 11.1 8.3 13.5 As with all epidemic diseases there is, among physicians, a tend- ency in fatal cases to report on death certificates the terminal com- plication to the exclusion of the primary cause. The fact that the profession has been less prone to do this in later years than in earlier ones affects very materially the comparability of a series of death rates for whooping cough extending over a long period of years Unless the compiling offices, which publish figures for different areas, have been equally assiduous in their efforts to correct these careless statements of cause of death, the compara- bility of one set of death rates with another is extremely question- able. When allowance is made for this factor, it is evident that there has been a considerable decrease in the mortality in the ex- panding Eegistration Area of the United States since 1900, although the published figures themselves, if not competently and critically analyzed, do not indicate this. Thus, the published annual average death rate in the expanding Eegistration Area for PRINCIPAL COMMUNICABLE DISEASES OF CHILDHOOD. 189 the period 1901 to 1905 was 10.9 per 100,000 population, which is but little higher than the 10.2 in that area for the year 1916. There has been, however, as a matter of fact, a greater decrease in the actual mortality from whooping cough than these figures indi- cate, because the earlier compilations are not based on so high a proportion of accurate statements of the primary cause of death as are the later ones. (d) DiPHTHEEIA AND CeOUP. The deaths included under this title are very nearly all certified in modern practice as due to "diphtheria." The former usage of the words " croup " and " membranous croup " as synonyms for diphtheria is no longer current. It is believed that the statistics on diphtheria in this report are especially accurate, first, because of the characteristic and, for the most part, unmistakable clinical picture in fatal diphtheria and, second, because of the care taken in this ofBce to secure as accurate a statement of the cause of death from the physician as possible. TABLE 117. Mortality from Diphtheria and Croup, Classified by Color, Sex and BY Age Period, Death Bates per 100,000 Persons Exposed. 1911 to 1916. Experience of Metropolitan Life Insurance Company. Industrial Department. Persons. White. Colored. Age Period. Males. Females. Males. Females. All ages — one and over 24.3 29.8 23.8 9.6 8.6 lto4 5 to 9 10 to 14 15 to 19 20 to 24 25 to 34 35 to 44 45 and over. . 152.2 66.1 13.8 3.0 1.6 1.3 .9 .8 165.3 68.1 12.6 3.0 1.5 .8 1.0 .7 149.2 70.0 16.0 3.1 1.5 1.5 .9 .8 90.4 31.8 8.2 2.2 2.3 .7 1.0 .7 75.5 35.2 10.3 3.2 1.6 2.3 1.0 1.1 Diphtheria begins to assume importance as a cause of death in the second year of life. In the third year of life, between two and three years of age, it is the third cause of death in numerical im- portance. Between three and four years, between four and five 190 MOKTALITT STATISTICS OF INSUEED WAGE EAENEES. years and in the age period five to nine years, diphtheria is the first cause of death in order of numerical significance. In the five year age period ten to fourteen years, this disease constitutes the third cause of death in numerical rank. There is an appre- ciable death rate from the disease at the various ages in adult life. The age statistics for the disease are given in the table on page 189. As was the case for scarlet fever and measles, both colored males and females show very much lower death rates for diphtheria than do white males and females. Between one and four years of age, the death rate of females from diphtheria is lower than that for males among both the white and colored race groups in this experi- ence. Beginning with the age period five to nine years, however, and up to twenty years of age the mortality for females from diph- theria is significantly higher than for males. This applies to both the white and colored groups. Death Rate from Diphtheria among Insured Children of White Wage Earners and among Childr&n in the Population of the Expanding Registration Area Compared. At the ages under 15 years, the diphtheria death rates of both male and female children of insured wage earners are higher than TABLE 118. Mortality from Diphtheria and Croup. Death Eates per 100,000 Persons Exposed. Classified hy Sex and hy Age Period. Insured White Lives in Experience of Metropolitan Life In- surance Company, Industrial Department (1911 to 1916) and General Population Experience of Expanding Registra- tion Area of the United States (1910 to 1915). Males. Females. Age Period. M. L. I. Co. (White) . U. S. Reg. Area. Per Cent. M. L. I. Co. of Reg. Area. M. L. I. Co. (White). U. S. Reg. Area. Per Cent. M. L.I. Co. of Reg. Area. All ages — one and over 29.8 17.2 288.8 23.8 17.3 137.6 lto4 5 to 9 10 to 14.... 15 to 19.... 20 to 24.... 165.3 68.1 12.6 3.0 1.5 127.3 48.7 11.4 3.4 1.7 129.9 139.8 110.5 88.2 88.2 149.2 70.0 16.0 3.1 1.5 113.8 51.8 13.1 3.7 2.2 131.1 135.1 122.1 83.8 68.2 PEINCIPAL COMMUNICABLE DISEASES OF CHILDHOOD. 191 the corresponding rates among children in the expanding Eegis- tration Area of the United States. Between one and four years the excess amounted to practically 30 per cent., and between five and nine years, to practically 40 per cent, for insured males, and to 35 per cent, for females. The table on page 190 gives a compari- son of the chief facts of diphtheria mortality at the ages under 35 years for both the insurance and the population experience. Trend of the Death Rate for Diphtheria. Barring two years in this experience, 1911 and 1913, there has been a slightly downward general tendency of the death rate from diphtheria. This corresponds fairly well to the tendency observed in the experience of the expanding Eegistration Area of the United States. The various methods employed in the control of diph- theritic infection and in the reduction of case mortality have been productive of results in those countries which have fairly well TABLE 119. Mortality from Diphtheria and Croup, Classified by Color and by Sex. Death Bates per 100,000 Persons Exposed. Single Years in Period 1911 to 1916. Experience of Metropolitan Life Insurance Company. Industrial Department, Persons. White. Colored. Year. Males. Females. Males. Females. 1911 to 1916 24.3 29.8 23.8 9.6 8.6 1916 1915 1914 1913 1912 1911 21.0 21.4 25.7 27.2 24.5 27.3 25.4 26.3 30.8 33.3 30.5 34.0 20.4 20.7 25.8 26.7 23.5 26.6 8.5 8.5 7.1 11.7 11.2 10.7 7.8 8.4 10.6 8.8 7.8 7.9 organized systems of preventive medicine. In the United States, for instance, the death rate of the Eegistration Area was 43.3 per 100,000 persons in 1900, and 15.7 in 1915, the latter rate being the lowest recorded in any of the years since 1900. It may be ex- pected that from time to time epidemics of this disease will serve to raise the rate somewhat, but, in the long run, the various pre- ventive measures employed, especially the administration of diph- 192 MOKTALITY STATISTICS OF INSURED WAGE EAENEES. theria antitoxin, the extension of school medical inspection, the effective quarantine of cases and the detection of atypical carriers, may be depended upon to still further reduce mortality from this cause. The table on page 191 gives the facts for each calendar year, 1911 to 1916, in this experience. CHAPTER XII. DiAEEHEA AND EnTEEITIS. The data for diarrhea and enteritis presented in this report do not distinguish between infantile diarrhea as classified under Title No. 104 of the International List, and diarrhea and enteritis (affecting persons two 3-ears of age and oyer) as compiled under Title No. 105. The largest proportion of the deaths from infantile diarrhea and enteritis occurs in the general population under one year of age. Since no persons under one year of age are included in this insurance experience, a distinction in our figures of the type of diarrhea would affect only those deaths between ages one and two. These have no great significance. This accounts for the decision to combine the two titles. There were included under the title, thus understood, all forms of inflammatory, ulcerative or catarrhal conditions of the intestines or of the gastroenteric tract where the intestines were chiefly involved, except those definitely reported as due to tuberculous, cancerous, dysenteric or other primary factors. It should be remembered that this cause of death may be either primary or secondary. Only the presumably primary cases are listed in this experience, and these cases result, especially among children, from the use of improper food, from various toxic sub- stances produced in the decomposition of food, from the extreme heat of summer ; or, as in senility, from changes in the constitution of intestinal secretions. These constitute the larger proportion of the cases in the insurance experience. The secondary cases of diarrhea and enteritis follow certain infectious diseases such as true dysentery and typhoid fever; they also follow circulatory disturb- ances which cause a catarrhal enteritis of chronic character, and they are common in diseases of the liver and in chronic conditions of the heart and lungs, as well as in cachectic conditions such as cancer, pernicious anemia and Bright's disease. None of the above is included in the present discussion. The total number of deaths assigned to the combined title during the period between 1911 and 1916 was 14,173. These deaths ac- 14 193 194 MORTALITY STATISTICS OF INSURED WAGE EARNERS. counted for 3.2 per cent, of the entire mortality and corresponded to a rate of 26.3 per 100,000. The rates according to color, sex and age are shown in the followinsr table: TABLE 120. Mortality from Diarrhea and Enteritis, Classified by Color, Sex and BY Age Period. Death Bates per 100,000 Persons Exposed. 1911 to 1916. Experience of Metropolitan Life Insurance Company, Industrial Department. Peraona. White. Colored. Age Period. Males. Females. Males. Females. AU ages — one and over 26.3 28.2 24.6 26.4 27.7 1 to 4 5 to 9 10 to 14 15 to 19 20 to 24 25 to 34 35 to 44 45 to 54 55 to 64 65 to 74 75 and over. . 208.7 8.8 2.4 1.9 2.8 4.5 7.7 10.9 28.2 80.3 182.5 210.6 8.2 2.1 1.2 1.8 4.4 8.0 10.1 25.6 63.8 180.2 197.1 8.4 2.0 1.4 2.9 3.6 5.7 8.9 25.1 86.8 183.3 298.0 10.1 3.8 7.0 3.6 5.9 10.8 14.7 43.2 76.8 150.9 249.4 16.9 6.8 6.7 6.3 8.7 14.5 24.3 51.9 117.4 208.7 The highest death rates in this experience are recorded in the first and last age periods, namely, 1 to 4 years and over 75 years. The minimum rate is in the period 15 to 19 years among the whites and in the period 20 to 24 years among the colored. There is con- siderable variability in the rates for the colored race by age period. From the minimum at 20 to 24 years the rates rise regularly and, after age 45 is reached, very rapidly, to their maximum in advanced old age. The period 65 to 74 years is an important one from the point of view of mortality from diarrhea and enteritis. Colored persons, especially when considered for specific age periods, show higher rates than do white persons. The single ex- ception is for males 75 years and over. It is quite possible that even this exception would be eliminated if the figures for colored males 75 and over were based on a larger experience. A feature of the colored experience is the maintenance of a comparatively high rate in the period of early adult life when the very lowest figures prevail for the whites. Thus, in the period between 15 to DIARRHEA AND ENTERITIS. 196 19 years, the rate for colored lives is more than four times as high as for white lives. The ratios of the death rates of the sexes vary for the two races. Among insured white lives the total rate is higher for males than for females but this is due principally to the higher mortality in the period of early childhood. In the period of old age the rates are higher for females. Colored females have higher rates than the males virtually throughout life with the exception of the period under five years. The excess in the rate of females is especially marked in the ages after 65 years. Comparison of Mortality from Diarrhea and Enteritis among In- sured Wage Earners and among the General Population of the Expanding Registration Area. At the important age periods, that is, under 5 years and at 75 years and over, insured lives show lower death rates from these causes than are found in the population of the Eegistration Area of the United States. The single exception is found among the males 75 and over, but even there the difference is not marked. At TABLE 121. Mortality fkom Diakbhea and Enteritis. Death Bates per 100,000 Persons Exposed. Classified by Sex and hy Age Periods. Insured White Lives in Experience of Metropolitan Life Insurance Company, Industrial Department {1911 to 1916) and General Population of Expanding Registration Area of the United States {19 W to 1915). Males. Females. Age Period. M. L. I. Co. (WMte) . U. S. Reg. Area. Per Cent. M. L. I. Co. of Reg. Area. M. L. I. Co. fWhlte). U. S. Reg. Area. Per Cent. M. L. I. Co. of Reg. Area. All ages — one and over .... 28.2 28.0 100.7 24.6 28.9 85.1 lto4 210.6 232.3 90.7 197.1 210.0 93.9 5 to 9 8.2 8.0 102.5 8.4 8.0 105.0 10 to 14.... 2.1 2.2 95.5 2.0 1.9 105.3 15 to 19.... 1.2 1.5 80.0 1.4 1.7 82.4 20 to 24.... 1.8 1.9 94.7 2.9 2.9 100.0 25 to 34. . . . 4.4 3.2 137.5 3.6 3.6 100.0 35 to 44. . . . 8.0 5.4 148.1 5.7 5.6 101.8 45 to 54. . . . 10.1 9.1 111.0 8.9 9.9 89.9 55 to 64. . . . 25.6 19.2 133.3 25.1 22.9 109.6 65 to 74.... 63.8 48.8 130.7 86.8 63.9 135.8 75 and over 180.2 173.6 103.8 183.3 223.3 82.1 196 MOETALITY STATISTICS OP INSURED WAGE EARNERS. the age periods beyond 25 years there is, generally speaking, an ex- cess among the insured over the general population, which is marked in the ages after 35 years among males. For the females the two sets of figures are not very different. When the urban character of the insured industrial population is considered with the fact that death rates from diarrhea and enteritis are uniformly higher in such areas than in rural communities, the generally favorable conditions found to prevail in the insurance experience at the youngest ages are even more remarkable. The table on page 195 exhibits the figures for the two groups. Trend of the Death Rate from Diarrhea and Enteritis. In general there has been a reduction in the death rate from this condition during the six year period but it has not been marked. There was hardly any change in the rate during the first three years ; a reduction then occurred for the next two years and in 1916 an increase was registered. The rate in that year was not as high as during the first three years of experience in the present series. The reduction is much more consistent and noteworthy among colored males and females than among white. A similar tendency is ob- servable in the figures for the expanding Registration Area but before any detailed comparisons can be made it must be remembered that the insurance figures do not include infants under one. The following table presents the figures for the trend of the death rate from diarrhea and enteritis among the insured wage earners: TABLE 122. MORTALITT FROM DiARRBEA AND ENTERITIS, CLASSIFIED BY COLOR AND BY SEX, Death Bates per 100,000 Persons Exposed. Single Tears in Period 1911 to 1916. Experience of Metropolitan Life Insurance Company. Industrial Department. Persons. White. Colored. Year. Males. Females. Males. Females. 1911 to 1916 26.3 28.2 24.6 26.4 27.7 1916 1915 1914 1913 1912 1911 26.3 24.4 24.8 27.7 27.6 27.9 28.7 26.3 26.7 29.9 28.7 29.2 24.9 22.5 23.1 26.0 25.3 26.4 22.2 25.6 24.7 26.2 32.3 28.0 24.3 25.4 25.4 28.3 32.5 31.0 CHAPTEE XIII. Diseases and Conditions Incidental to the Mateenal State. A study of the mortality of women from the causes and condi- tions incidental to childbearing is of singular interest and import- ance at the present time in view of the nation-wide campaign for the conservation of civilian life during wartime. Deaths of women from these causes affect the community deeply because they are for the most part preventable, and because they occur at periods of life when each death involves serious social loss. The amount of such loss is very considerable. Between the ages of 15 and 45 years, the diseases and conditions incidental to child-bearing account for more deaths of women than does any other disease or class of diseases except tuberculosis. An examination of the available facts on maternal mortality should, therefore, assist materially in directing the plans which may be developed to control these causes of prevent- able death, distress and family disintegration. The statistical study of these causes of death may be undertaken in a number of different ways. The first and usual method is to consider these diseases and conditions in a manner similar to other causes of death; namely, to relate the deaths to the total popula- tion. The rates obtained in this way serve to indicate the proper place of puerperal mortality among the several important conditions causing death in the whole population. Such mortality rates are, however, limited in their utility ; for the deaths are of females alone, while the total population contains both males and females. Another method often used, is to relate the puerperal deaths to the total number of females in the community. This gives another and higher rate than the one noted above. The figure thus obtained has this limitation: the population refers to all females, whereas the deaths are those of women within a limited range of ages. We have, therefore, in our treatment followed a third method and have presented specific death rates which are limited to females of the childbearing ages, namely, 15 to 44 years. In every case we have attempted to give the facts for five and ten year age groups during this puerperal period. The rates are, therefore, based on deaths 197 198 MOETALITY STATISTICS OF INSUEED WAGE EARNERS. and on exposed lives homogeneous with respect to sex and age. A very sensitive measure of puerperal mortality is thus obtained. In this investigation there were recorded in all 10,056 deaths from the diseases and conditions incidental to childbirth in the age period 15 to 44 years. This covers the six-year period from 1911 to 1916 inclusive. These deaths, when related to the 14,694,360 years of life exposed of women 15 to 44 years of age, correspond to a death rate of 68.4 per 100,000 women at these ages. Of the total deaths, 8,288 occurred among white females and 1,768 among colored females ; the rates per 100,000 for the two races being 66.1 and 82.3 for the white and colored women respectively. It is, thus, shown at the outset that colored females suffer much more seriously than do white women from the diseases and conditions incidental to childbearing. TABLE 123. Mortality from Puerperal Diseases and Conditions. Classipied by Color. Deaths in Age Period 15 to 44 Years. Experience of Metropolitan Life Insurance Company, ment, 1911 to 1916. Industrial Depart- White and Colored. White. Colored. Puerperal Disease or Condition. i Q 1^1 1 Q ■^2 f o • Total puerperal dis- eases and con- ditions 10,056 100.0 68.4 8,288 100.0 66.1 1,768 100.0 82.3 Accidents of pregnancy Puerperal hemorrhage. . . Other accidents of labor Puerperal septicemia .... Puerperal albu- minuria and convulsions Other puerperal diseases and conditions 874 779 1,020 4,321 2,654 408 8.7 7.7 10.1 43.0 26.4 4.1 5.9 5.3 6.9 29.4 18.1 2.8 704 670 827 3,494 2,233 360 8.5 8.1 10.0 42.2 26.9 4.3 5.6 5.3 6.6 27.9 17.8 2.9 170 109 193 827 421 48 9.6 6.2 10.9 46.8 23.8 2.7 7.9 5.1 9.0 38.5 19.6 2.2 The 10,056 deaths were due to a considerable number of diseases and conditions complicating or characteristic of the puerperal state. The most important of these is septicemia, which alone was respon- DISEASES INCIDENTAL TO MATERNAL STATE. 199 sible for 4,331 deaths, or 43.0 per cent, of the total. This condition was followed in order, by albuminuria and convulsions with 2,654 deaths, or 26.4 per cent, of the total. Together, these two definite conditions account for 69.4 per cent, of the fatal puerperal cases, but it is realized that the actual proportion is even higher. Many deaths from puerperal septicemia and puerperal albuminuria are, unfortunately, still reported under the disguise of one or another of these terms, without qualification, which results in their assign- ment to conditions which are not classified under the puerperal total. The table on page 198 shows the number and percentage of deaths as well as the rates per 100,000 exposed from the several conditions incidental to childbirth; distinction is made as to the color or race of the decedents. It would be interesting to classify these deaths according to the period of their occurrence, that is, whether during pregnancy, at confinement or during the puerperium. Unfortunately, present methods of certification and classification of these diseases make it impossible to draw such distinctions. To be sure the accidents of pregnancy occur in the antepartum period. The deaths from puer- peral hemorrhage and from " other accidents of labor " are clearly associated with labor. On the other hand, such titles as puerperal septicemia and puerperal albuminuria and convulsions, which relate to the largest number of deaths, may cover all three periods in the puerperal state. Puerperal septicemia is most often a complication of labor and of the postpartum period, although a considerable number of deaths are associated with pregnancy as complications of abortion, miscarriage, etc. Fatal puerperal albuminuria and con- vulsions occur most frequently as complications of labor, less fre- quently during pregnancy and least of all during the puerperium. Comparing the mortality of the two races, we find but few excep- tions to the rule that the death rates of colored women are con- siderably higher than those of white women for each of the diseases and conditions mentioned. The largest disparity between the two races is to be noted for septicemia for which the white and colored rates are 27.9 and 38.5 per 100,000 respectively. It is interesting to observe that the mortality rate for puerperal hemorrhage is slightly lower for colored women as is also the case in the miscella- neous group entitled "other puerperal diseases and conditions." Even for these conditions the figures require further study before 200 MORTALITY STATISTICS OF INSURED WAGE EARNERS. conclusions can be drawn. It is a question, if our figures related back to the total number of pregnancies rather than to the total number of women, ages 15 to 44, whether the rate would show up as favorably for colored as for white women. Age Incidence of Principal Causes of Maternal Mortality. The foregoing observations on maternal mortality are of greater import when considered according to the principal age periods. Let us first study all of the causes of maternal mortality taken together. TABLE 124. Mortality from Puerperal Diseases and Conditions. "White and Colored Females. Death Bates per 100,000 Women Exposed, Ages 15 to 44 Years, 1911 to 1916. Experience of Metropolitan Life Insurance Company. Industrial Department. Age Period. White Female3. Colored Females. All ages — 15 to 44 years 66.1 82.3 15 to 19 20 to 24 24.3 72.1 93.0 62.2 93.4 100.7 25 to 34 88.3 35 to 44 56.7 Considering white women alone, the least death rate for all dis- eases and conditions incidental to childbirth was registered in the age period 15 to 19 years, namely 24.3 per 100,000. The rate rises rapidly to a maximum of 93.0 in the age period 25 to 34 years and then declines to 62.2 for the ten year period 35 to 44 years. Among colored females, however, we observed markedly different age characteristics of maternal mortality. The rate of mortality among colored females between 15 and 19 years was 93.4 per 100,000, the same rate, practically, as was observed in the period of maximum incidence, 25 to 34 years, among white females. From this high and damaging rate in the fourth quinquennium of life, the rate of maternal mortality among colored females rises to a figure of more than 100 per 100,000 exposed between 20 and 24 years and declines to a rate of 88.3 per 100,000 exposed in the age period 25 to 34 years. It is of singular interest to observe that whereas the colored female rate for maternal mortality is practically four times that of white females for the age period 15 to 19 years and prac- DISEASES INCIDENTAL TO MATERNAL STATE. 201 tically one-third greater than the rate of white females between 20 to 24 years, for the ages after 25 years and up to 44 years, the mortality rates of colored females for all puerperal diseases and conditions combined are significantly lower than the rates for white females. The table on page 200 shows the death rates per 100,000 women exposed in each of the color groups in this study, according to age periods. These data suggest rather than answer inquiry. They call for a further display of obstetrical statistics to show the number of births to white and colored women at the several age periods of life and in relation to these data, the deaths from the various diseases and conditions associated with childbearing. Is the high death rate from puerperal diseases among j-oung colored females due primarily to a very high birthrate or to improper care of parturient colored women in the early ages of adult life? Has the factor of ille- gitimacy had an effect upon the high mortality of colored mothers ? These and other questions could be readily answered by a further display of birth and mortality data. PuEEPEKAL Septicemia. We may now consider the facts for each of the principal puerperal diseases in relation to age period. Puerperal septicemia, for white women, shows its highest mortality rate between 25 and 34 years, and its least rate between 15 and 19 years. Among colored women, there is an almost uniform and very high rate between 15 and 24 years with only a slight decline during the period 25 to 34 years. For the age group 35 to 44 years, the rates for white and colored women for puerperal septicemia are practically the same. The outstanding feature of mortality from puerperal septicemia there- fore is the gradually rising rate among white females to the maxi- mum in the age period 25 to 34 years and the very high and prac- tically stationary rate for colored females for nearly twenty years of life between the ages 15 and 35. In the age period 15 to 19 years, puerperal septicemia shows a rate very nearly four and a half times as high among colored as among white women, although at the older ages the rates for the two races approximate each other. These facts are shown in Table 125 following: 202 MORTALITY STATISTICS OF INSUEED WAGE EARNERS. TABLE 125. Mortality from Puerperal Septicemia. White and Colored Females. Death Bates per 100,000 Women Exposed, Ages 15 to 44 Years, 1911 to 1916. Experience of Metropolitan Life Insurance Company. Industrial Department. Age Period. White Females. Colored Females. All ages — 15 to 44 years 27.9 38.5 15 to 19 10.7 32.8 40.7 21.9 46.3 20 to 24 49.4 25 to 34 42.5 35 to 44 22.2 Puerperal Albuminuria and Convulsions. A somewhat similar relation is also to be noted with reference to the facts for puerperal albuminuria and convulsions, under which title-heading deaths from puerperal nephritis and puerperal uremia are also counted. Among white women, the rate is lowest between the ages 15 and 19. The rate rises rapidly to its maximum, 22.6. This remains stationary between 20 and 35 years of age. Colored females show the maximum rate in the first age period under obser- vation, 15 to 19 years, namely, 36.9 per 100,000, with a gradual decline to a minimum at the latest age period, 35 to 44 years, 13.0. It should be noted that, in the age period 15 to 19 years, colored females show a death rate for this cause nearly four times that for white females. Table 126 gives the facts for puerperal albuminuria and convulsions: TABLE 126. Mortality from Puerperal Albuminuria and Convulsions. Colored Females. White and Death Bates per 100,000 Women Exposed, Ages 15 to 44 Years, 1911 to 1916. Experience of Metropolitan Life Insurance Company. Industrial Department. Age Period. White Females. Colored Females. All ages — 15 to 44 years 17.8 19 6 15 to 19 9.5 22.6 22.6 14.9 36 9 20 to 24 23 25 to 34 15 7 35 to 44 13 DISEASES INCIDENTAL TO MATERNAL STATE. 203 Accidents of Peegnanct. Many conditions are included under this head the more impor- tant of which are abortions, accidental and self induced, premature birth, and extra uterine or tubal gestation. The death rate among white women is comparatively low until age 25 is reached. The maximum rate, 8.7 per 100,000 is found in the age period 25 to 34 years. The rate declines appreciably thereafter. Among colored women, however, it is uniformly higher at every age than among white women but this is especially marked at the ages under 25. Between 20 and 25 years the death rate (10.3) is more than twice the white rate. The figure declines somewhat between the ages 25 and 34 and more markedly between 35 and 44 years. It is a matter of some interest that a very large proportion of these fatal cases are the direct result of attempts at abortion. In spite of the many efforts to cloak this condition, we have record of 67 such fatal cases in the Industrial mortality experience of 1917 alone. Many more cases certainly occurred but were not reported. The facts would appear to indicate a wide prevalence of this dan- gerous and criminal practice. Our data comparing the two color or race classes according to age periods are shown below : TABLE 127. Mortality from Accidents op Pregnancy. White and Colored Females. Death Bates per 100,000 Women Exposed, Ages 15 to 44 Years, 1911 to 1916. Experience of Metropolitan Life Insurance Company. Industrial Department. Age Period. White Females. Colored Females. All ages — 15 to 44 years 5.6 7.9 15 to 19 1.3 4.7 8.7 6.0 2.1 20 to 24 10.3 25 to 34 9.9 35 to 44 7.0 Pueeperal Hemoeehage. The deaths under this title include those reported from placenta previa and retained meiribranes provided there is no evidence of septicemia as a complication. The mortality rate is least at the youngest ages. Among white women, the rate reaches its maxi- mum at the oldest ages, i. e., 35 to 44 years, when it is 8.1 per 204 MORTALITY STATISTICS OF INSURED WAGE EARNERS. 100,000. Among colored women the highest rate is found between 25 and 34 years. It is an interesting fact previously observed by obstetricians that colored women at the older ages of the child- bearing period suffer from puerperal hemorrhage much less fre- quently than do white women. Table 138 gives the facts for puer- peral hemorrhage: TABLE 128. Mortality from Puerperal Hemorrhage, White and Colored Females. Death Bates per 100,000 Women Exposed, Ages 15 to 44 Years, 1911 to 1916. Experience of Metropolitan Life Insurance Company. Industrial Department. Age Period. White Females. Colored Females. AH ages — 15 to 44 years 5.3 5 1 15 to 19 .8 3.3 7.5 8.1 .9 20 to 24 6 1 25 to 34 64 35 to 44 5.1 Other Accidents of Labor. This title covers such deaths as are due to breech presentation, Caesarian section, and forceps operations and those attributed to dystocia, " injury at birth " and to " childbirth " or " confinement," with no further description. In the period 15 to 19 years, the first age period for which we have figures for these causes, among colored females the rate was five times that of white females, the figures being 6.7 and 1.4 per 100,000 living, respectively. Thereafter, the rates for the two races are not so divergent; in fact, after age 25 they are nearly identical. The maximum rate among white women is found in the age period 25 to 34 years when it is 9.4 per 100,000 and the maximum among colored women in the earlier age group 20 to 24 years, when the rate is 10.8. The data for these "other accidents of labor " are displayed in Table 129 on the next page. Comparison of Insurance data, 1911 to 1916, with Population Data, 1910 to 1915. The above facts relate to a large group of female Industrial policyholders. For purposes of comparison we may turn profitably to the figures for women in the expanding Eegistration Area of DISEASES INCIDENTAL TO MATERNAL STATE. 205 TABLE 129. mortai.ity from "other accidents op labor." white and colore Females. Death Bates per 100,000 Women Exposed, Ages 15 to 44 Years, 1911 to 1916. Experience of Metropolitan Life Insurance Company. Industrial Department. Age Period. White Females. Colored Females. All ages — 15 to 44 years 6.6 9.0 15 to 19 1.4 6.1 9.4 7.8 6.7 20 to 24 10.8 25 to 34 10.3 35 to 44 7.3 the United States, This is, in fact, the largest group in the gen- eral population of the United States for whom death rates may be prepared from the published data now available. A number of limitations, however, should be pointed out which interfere some- what with the complete comparability of the data for insured women with those for the general population. The figures for the expand- ing Eegistration Area cover the six-year period, 1910 to 1915; the Metropolitan figures are for the six-year period, 1911 to 1916. The population of the Eegistration Area includes a small proportion of colored in addition to the white, whereas the insurance figures are for each of the two races taken separately. For the comparison, the figures for white insured women alone will be used. There are also differences in the geographical areas covered by the two groups. The Eegistration Area still excludes most of the southern and a number of western states ; the Metropolitan policyholders are repre- sented in nearly all of these states. It is clear nevertheless that these several differences are not sufficiently important to vitiate the comparisons of the mortality rates which we shall make. In the six-year period 1910 to 1915, there were 57,013 puerperal deaths recorded among women in the Eegistration Area, ages 15 to 44 years. This corresponded to a death rate of 63.1 per 100,000 exposed at these ages.* The rate is therefore somewhat less than * The aggregate number of years of life of women ages 15 to 44 in the Eegistration Area exposed during the six year period 1910 to 1915 inclusive was estimated at 90,301,312, from data furnished by the Bureau of the Census and by the Prudential Insurance Company of America. 206 MORTALITY STATISTICS OF INSURED WAGE EARNERS. that fei the insured women which was 66.1. The slight excess in the rate of mortality from diseases and conditions connected with maternity among insured women should not be interpreted too closely as an indication of worse conditions respecting childbirth among the wage earning element of the population, in view of the higher birth rate which prevails among the policyholders than among the population at large and for other reasons. As was the case among the insured women, the most important single items included in this mortality study of the general population are puerperal septicemia and puerperal albuminuria ; the former being responsible for 44.4 per cent, and the latter for 23.9 per cent, of all the puerperal deaths. Together, these two conditions are respon- sible for 68.3 per cent, of the puerperal deaths ; among the insured white women they accounted for 69.1 per cent. The accidents of pregnancy occurred in 9.3 per cent, of the cases; among insured white women they occurred in 8.5 per cent. The similarity in the two sets of figures is marked indeed and serves to confirm the gen- eral reliability of the returns in the two series. Comparative Age Characteristics of Maternal Mortality. The data for the puerperal diseases and conditions in the two series are also very similar when studied by age period. Consider- ing first all the puerperal causes combined, we find that the death rates reach a maximum in both groups in the age period 25 to 34 years. The mortality among insured women is lower between ages 15 to 19 years by 10 per cent. In the age group 20 to 24 years and in the age periods thereafter up to 44 years of age, maternal mor- tality among insured white women is from five to ten per cent, higher than among the female general population. For puerperal septicemia, the figures are slightly more favorable for the insured women. Thus, between the ages 15 to 19, insured white women show a death rate from puerperal septicemia which is only 83 per cent, of the rate among women in the general popula- tion. In the period 20 to 24 years the advantage in favor of the insured women is close to 5 per cent, of the population rate. Be- tween 25 and 34 years, the rate for the insured women shows an ex- cess of nearly 7 per cent. In the last period 35 to 44 years, the death rate is practically the same for the two groups. The figures for puerperal albuminuria and convulsions are differ- ent in several respects from those for puerperal septicemia, the rates DISEASES INCIDENTAL TO MATERNAL STATE. 207 being on the whole more favorable for the women in the general population than for the industrial group. Virtually the same mor- tality rates are observed in the two experiences at ages 15 to 19 years but thereafter, mortality of the insured is considerably higher than for women in the Eegistration Area. It is 25 per cent, higher at the age period 25 to 34. TABLE 130. Mortality fkom Ptjerpeeal Diseases and Conbiticns. Death Bates per 100,000 Women Exposed. Classified by Age Periods between 15 and 44 Years. Insured White Lives in Experience of Metropolitan Life Insurance Company, Industrial Department (1911 to 1916) and General Population of Expanding Eegistration Area of the United States (1910 to 1915). Total-Puerperal State. Puerperal Septicemia. Puerperal Albuminuria. Age Period. M. L. I. Co. (White). u. s. Reg. Area. p. c. M. L. I. Co. or Reg. Area. M. L. I. Co. (WUte). u. S. Reg. Area. p. c. M. L. I. Co. of Reg. Area. M. L. I. Co. (WWte). Reg. Area. p. c. M. L. I. Co. Of Reg. Area. All ages — 15 to 44 years . 66.1 63.1 104.8 27.9 28.1 99.3 17.8 15.1 117.9 15 to 19... 20 to 24. . . 25 to 34... 35 to 44... 24.3 72.1 93.0 62.2 27.0 68.9 84.2 58.4 90.0 104.6 110.5 106.5 10.7 32.8 40.7 21.9 12.9 34.4 38.1 21.7 82.9 95.3 106.8 100.9 9.5 22.6 22.6 14.9 9.6 18.3 18.1 12.9 99.0 123.5 124.9 115.5 Table 130 presents the essential rates for the two series by age period not only for the total puerperal state but also for the two most important single conditions in this disease group. The rates for the other puerperal conditions are comparatively low in both groups and do not justify any extended comparisons be- tween the insured and the general populations. Relative Improvement in Maternal Mortality among Insured Women and in the General Population. If the composite death rate among insured white women appears to be somewhat higher than that for women in the population gen- erally it should also be noted that this difference is being progres- sively overcome. Thus, in 1911, a death rate of 70.1 per 100,000 insured white females ages 15 to 44 years was recorded and in 1916, 208 MORTALITY STATISTICS OF INSURED WAGE EARNERS. a rate of 62.6 per 100,000. This represents a decline of 10.7 per cent, in the rate of maternal mortality in the insured group. When we compare the 1910 rate among females in the general population of the Registration Area, 63.4, with the 1915 rate, 61.6, we find a decline of only 2.8 per cent, in maternal mortality. In 1911, the rate among the insured women was 9 per cent, in excess of the population rate; in 1915, this excess was reduced to only 3 per cent. A comparison of the two series of rates annually from 1911 to 191 5< the latest year for which these figures are available at this time for the Eegistration Area by age, is shown in the following table : TABLE 131. Mortality from Puerperal Diseases and Conditions. Death Bates per 100,000 Women Exposed, Ages 15 to 44 Years. Single Years in Period 1911 to 1916. Experience of Metropolitan Life Insurance Company, Industrial Depart- ment, and of Expanding Eegistration Area of the United States. Females, Ages 15 to 44 Years. Year. Death Rates per 100,000 Women Exposed. Insured White Women. Women In Popula- tion, Reg. Area. Population, Reg. Area Rates. 1916 62.6 63.3 68.6 70.5 62.4 70.1 * * 61.6 64.4 64.1 60.7 64.5 63 4 * 1915 1 03 1914 1 07 1913 1912 1.10 1 03 1911 1 09 1910 * * Data unavailable. There is, therefore, a general tendency for the rate of total maternal mortality among insured white females to approximate that of females in the general population. A greater relative reduction in mortality is also observed for puerperal septicemia among insured white females than among females in the general population. Thus, in 1911 among insured white females, aged 15 to 44 years, we recorded a death rate from this condition of 30.6 per 100,000 and in 1916 a rate of 25.3 per 100,000. This represents a decline of 17.3 per cent. In the ex- perience of the Eegistration Area there was a decline in the six years between 1910 and 1915 from 29.2 to 25.4 per 100,000 or 13.0 DISEASES INCIDENTAL TO MATERNAL STATE. 209 per cent. In 1915, the rate of mortality from puerperal septicemia, the chief cause of death of women in the maternal state, was actually lower among insured white females than among females in the gen- eral population. The following table gives the chief comparative facts for puerperal septicemia in both experiences : TABLE 132. Mortality from Puerperal Septicemia. Death Bates per 100,000 Women Exposed, Ages 15 to 44 Years. Years in Period 1911 to 1916. Single Experience of Metropolitan Life Insurance Company, Industrial Depart- ment, and of Expanding Eegistration Area of the United States, Females, Ages 15 to 44 Years. Year. Death Rate per 100,000 Women Exposed. Ratio, Insurance Insured White Women. Women in Popu- lation, Reg. Area. to Population, Reg. Area Rates. 1916 25.3 24.8 28.6 31.9 26.9 30.6 * * 25.4 28.7 29.2 26.3 29.9 29.2 * 1915 .98 1914 1.00 1913 1.09 1912 1.02 1911 1910 1.02 * * Data unavailable. We have found from our previous inquiry that the conditions classified as puerperal albuminuria and convulsions are second in importance among the total causes of maternal mortality. For this cause of death we have recorded a steadily rising rate with but one exception year by year between 1910 and 1915 for women aged 15 to 44 years in the experience of the Registration Area and a fluctuating rate among white females in the insurance experience. The table on page 210 presents a comparison of the data available for these conditions among white insured women and among women in the population between the ages of 15 and 44 years. This is a discouraging picture in view of the well established opinion among obstetricians that the largest part of the mortality from these conditions may be prevented through adequate medical and nursing service carried on during the period of pregnancy. The figures clearly indicate a fruitful field for the extension of such service to women. This, in fact, is the reason for the general ex- 15 210 MORTALITY STATISTICS OF INSURED WAGE EARNERS. tension of the Company's nursing service to women during preg- nancy. Through such service the nephritic and hepatic cases will undoubtedly be brought earlier under medical observation and many cases which would under ordinary circumstances terminate fatally as puerperal albuminuria and convulsions will thus be carried safely through their confinement. TABLE 133. Mortality fkom Puerperal Albuminuria and Convulsions. Death Bates per 100,000 Women Exposed, Ages 15 to 44 Years. Single Years in Period 1911 to 1916. Experience of Metropolitan Life Insurance Company, Industrial Depart- ment, and of Expanding Eegistration Area of the United States. Females, Ages 15 to 44 Years. Year. Death Rates, per 100,000 Women Exposed^ Ratio of Insurance to Insured White Women. Women In Popula- tion, Reg. Area. Population, Reg. Area Rates. 1916 18.3 16.9 18.0 19.0 17.3 17.1 * * 16.1 16.1 15.4 14.6 14.3 13.7 * 1915 1.05 1914 1.12 1913 1.23 1912 1.18 1911 1.20 1910 * * Data unavailable. Accidents of Labor. The registered mortality from these causes of death for the group of white insured females, shows a general and substantial downward trend from 1911 to 1916. The Eegistration Area mortality rates show the peculiar phenomenon of a steady downward trend up to 1913 and a gradual rise in the rate between 1913 and 1915. It is not possible to indicate how much of the general decline in mortality from this cause among insured white females is due to the work of the Visiting Nurse Service. Under the rules of that service, the work of the visiting nurse is confined very largely to after-care of mothers after childbirth. It is believed, however, that the amount of prenatal work already extended to insured women in the Indus- trial Department tends in a measure to correct during pregnancy the remediable mechanical difficulties which may be encountered during labor. The work of the public health nurse for pregnant DISEASES INCIDENTAL TO MATERNAL STATE, 211 women would necessarily be in the direction of insuring proper medical care for women in childbirth. "We show the comparative mortality facts for accidents of labor below : TABLE 134. Mortality from "Other Accidents op Labor." Death Bates per 100,000 Women Exposed, Ages 15 to 44 Years. Single Years in Period 1911 to 1916. Experience of Metropolitan Life Insurance" Company, Industrial Depart- ment, and of Expanding Registration Area of the United States. Females, Ages 15 to 44 Years. Year. Death Rates per 100.000 Women Exposed. Ratio of Insurance Insured White Women. Women In Popu- lation, Reg. Area. to Population, Reg. Area Rates. 1916 6.2 6.1 6.2 7.1 6.1 8.2 * * 5.9 5.6 5.4 5.6 6.2 6.1 * 1915 1.03 1914 1.11 1913 1.31 1912 1.09 1911 1.32 1910 * * Data unavailable. Puerperal HemorrJiage. It has been assumed in obstetrical literature generally that mor- tality among women in the wage earning groups of the population from puerperal hemorrhage was more common than in general unse- lected populations. Our data show, however, a lower death rate except in one year, 1914, from this cause among white insured fe- males in the families of wage earners than among females in the general population of the Eegistration Area of the United States. The figures indicate an uncertain tendency in the mortality of both groups. Table 135 on page 212 gives a view of the data available. Accidents of Pregnancy. Comparative mortality from this cause of death shows higher death rates in 1913, 1914 and 1915 among insured white females than among females in the general population. There seems to be, in general, higher mortality from the accidents of pregnancy among white females in wage earners' families than among females 212 MORTALITY STATISTICS OF INSURED WAGE EARNERS. TABLE 135. Mortality from Puerperal Hemorrhage. Death Bates per 100,000 Women Exposed, Ages 15 to 44 Years. Years in Period 1911 to 1916. Single Experience of Metropolitan Life Insurance Company, Industrial Depart- ment, and of Expanding Registration Area of the United States. Females, Ages 15 to 44 Years. Year. Death Rate per 100,000 Women Exposed. Insured White Women. Women In Popula- tion Reg. Area. to Population, Reg. Area Rates. 1916 1915 1914 1913 5.2 5.7 6.2 4.6 4.9 5.3 * * 6.0 6.1 6.3 6.2 5.8 5.6 * .95 1.02 .73 1912 .79 1911 1910 .91 * * Data unavailable. in the general population. Such data as we have available are given in the following table : TABLE 136. Mortality from Accidents of Pregnancy. Death Bates per 100,000 Women Exposed, Ages 15 to 44 Years. Years in Period 1911 to 1916. Single Experience of Metropolitan Life Insurance Company, Industrial Depart- ment, and of Expanding Registration Area of the United States. Females, Ages 15 to 44 Years. Year. Death Rates per 100,000 Women Exposed. Insured White Women. Women in Popula- tion, Reg. Area. Population Reg. Area Rates. 1916 4.6 6.1 6.2 5.9 4.8 6.1 * * 5.7 5.5 5.5 5.8 6.2 6.6 * 1915 1.07 1914 1.13 1913 1.07 1912 .83 1911 .98 1910 * * Data unavailable. diseases incidental to maternal state. 213 Prevention of Maternal Mortality, The figures presented in the above tables disclose a large and profitable field for intensive public health work. It is no light matter that with the present development of sanitary science and of preventive medicine there should still be one fatal termination in from every 100 to 200 cases of pregnancy and childbirth. Yet this is the situation in a number of large centers of population for which adequate data are available. As we have pointed out, the puerperal conditions in their entirety represent a hazard to the life of women, which is second only to that from pulmonary tuberculosis at these childbearing ages. The serious social losses resulting from the many deaths of women at these ages are now more thoroughly realized. Deaths of wives and mothers mean, in most instances, the destruction of family ties with their incalculable consequences to the community. These facts explain the recent efforts for the care of women in pregnancy. Prenatal work is fast becoming an integral part of the routine of preventive work of the departments of health of many American cities. In some communities, like Boston and New York, private agencies cooperating with the visit- ing nurse associations, have specialized in the nursing of women throughout the period of pregnancy, confinement and after-care. Thousands of cases are being cared for each year in prenatal clinics and through follow-up and instructive visits by specialized nurses. In Boston, the work has been brought to the point where definite life saving of both mother and child on a large scale already appears evident. Other communities will undoubtedly show similar results as their work becomes better established. It is among insured women that the best results of a policy of life conservation have been obtained. Prom the very beginning, in 1909, the nursing service of the Metropolitan Life Insurance Com- pany considered the care of women after childbirth a major function of the service and this has been the policy of the Company since. In 1916, out of a total of 160,843 female policyholders visited dur- ing illness 41,572 or 25.8 per cent, were cases resulting from diseases or conditions of the puerperal state. While the majority of these cases involve care of women after normal childbirth, there are many cases each year of the abnormal and acute conditions requiring intensive nursing care. Thus, in 1916 there were 967 cases of puerperal septicemia, 308 cases of albuminuria and convulsions and 214 MOETALITT STATISTICS OF INSURED WAGE EARNERS. 3,469 cases of abortion and miscarriage. In all, a total of 243,738 nursing visits were made in 1916 to these women either before or after their confinement. It is not surprising, therefore, that we should find a very favorable course in the mortality of these insured women from nearly all the conditions incidental to ehildbearing. In the six year period be- tween 1911 and 1916, the death rate among white female policy- holders* from these causes fell 10.7 per cent., the figures for 1911 and 1916 being 70.1 and 62.6 per 100,000 respectively. The per cent, reduction is greater in this period for colored women, namely, 20.4 pea- cent. The decline in mortality from puerperal septicemia is especially marked among white women in this period, being 17.3 per cent. With the exception of accidents of pregnancy, the saving in mortality between 1911 and 1916 is greater among insured women than among women in the population at large between 1910 and 1915 as represented in the Eegistration Area data. These com- parisons, therefore, serve as a strong endorsement of the Company's programme for the care of parturient women through public health nursing. * Ages 15 to 44 years. CHAPTER XIV. We shall now depart from the practice of discussing in a separate chapter the mortality statistics of individual diseases. In each of Chapters XIV, XV and XVI we shall group a number of causes of death, otherwise unrelated, into chapters of convenient length, and shall consider the respective diseases in the order of their decreas- ing numerical importance. This seems advisable because the dis- eases and conditions thus discussed are not of sufficient numerical importance to justify the extensive treatment accorded to those in the preceding chapters. This grouping must not be considered as an expression of any relation between the diseases ; our arrangement is determined only by a consideration of the size of the chapters. The present chapter will deal with the following diseases: 1. Diseases of the Arteries, Atheroma, Aneurism, etc. 2. Typhoid Fever. 3. Cirrhosis of the Liver. 4. Influenza. 5. Diabetes. Diseases of the Aetekies, Atheeoma, Anetjeism^ etc. The deaths registered under this title include those certified as due to arteriosclerosis, and to other arterial diseases such as fatty degeneration of the arterial wall (atheroma) and aneurism of various types. The larger proportion of the 9,142 deaths under this title, however, relate to general arteriosclerosis. In all, 1.4 per cent, of the deaths in the total experience are included. Reports on mortality from arteriosclerosis must be accepted with caution because of inherent defects in the statistics. It is only in recent years that physicians have paid serious attention, in pre- paring death certificates, to the arterial diseases as causes of death. Increasing popular interest in these diseases has carried with it, at the same time, neglect on the part of physicians to specify, in many cases, the associated impairments of the heart and kidney, which, if they were stated as they should be, would result in the assignment of the cause of death to other than arterial disease. There is still, 215 216 MOETALITY STATISTICS OF INSURED WAGE EARNERS. therefore, considerable uncertainty as to the full significance of the figures on arterial disease mortality submitted in this report. The following table shows the death rates from the arterial dis- eases, arranged by sex, color and age : TABLE 137. Mortality kbom Diseases of the Arteries, Atheroma, Aneurism, Etc. Death Bates per 100,000 Persons Exposed. 1911 to 1916. Experience of Metropolitan Life Insurance Company. Industrial Department. Persons. White. Colored. Age Period. Males. Females. Males. Females. All ages — one and over 17.0 18.8 15.1 21.3 15.8 1 to 24 25 to 34 35 to 44 45 to 54 55 to 64 65 to 74 75 and over. . .1 1.6 5.8 16.0 66.0 298.7 888.8 .1 1.4 6.6 21.0 87.8 392.7 1089.5 t .6 1.7 8.7 50.3 249.8 804.5 .3 7.2 25.8 38.8 79.8 287.3 686.0 .4 2.9 8.1 24.1 67.8 210.2 653.3 f Less than .05 per 100,000 exposed. We find, as in a number of the other degenerative diseases, a marked difference in the two races. Colored males, especially at the earlier ages of adult life, show much higher mortality rates than do white males. Colored females, likewise, up to 64 years, show exces- sive rates from this cause. After age 55, there is a reversal of this condition and the rates for white lives exceed those for the colored. Males show higher rates than females in each race. A comparison of the death rates prevailing among the insured lives with those in the population of the Eegistration Area shows a marked excess in the former group during the significant age periods. Thus, between 65 and 74, white insured males have a rate nearly 68 per cent, in excess of that of the male population, and insured females a rate 63 per cent, in excess of that for females in the Eegistration Area. The following table gives a few of the comparative facts in the two experiences: DISEASES OF THE ARTERIES, 217 TABLE 138. Mortality from Diseases of the Arteries, Atheroma, Aneu^-ism, Etc. Death Bates per 100,000 Persons Exposed. Classified by Sex and Age Periods. Insured White Lives in Experience of Metropolitan Life In- surance Company, Industrial Department (1911 to 1916) and General Population of Expanding Begistration Area of the United States (1910 to 1915). Males. Females. Per Cent. Per Cent. M. L. I. Co. U. S. Reg. M. L. I. Co. M. L. I. Co. U. S. Reg. M. L. I, Co. (White). Area. of Reg. Area. (White). Area. Of Reg. Area. 25 to 34.... 1.4 1.7 82.4 .6 .7 85.7 35 to 44.... 6.6 5.8 113.8 1.7 2.2 77.3 45 to 54.... 21.0 17.6 119.3 8.7 8.2 106.1 65 to 64. . . . 87.8 61.3 143.2 50.3 35.4 142.1 65 to 74.... 392.7 234.1 167.7 249.8 153.3 162.9 75 and over 1089.5 983.4 110.8 804.5 743.7 108.2 As already pointed out, it is very doubtful whether we have con- clusive figures as to the true incidence of these diseases at the pres- ent time. The trend of the death rates between 1911 and 1916 may, therefore, be no real indication of the general tendency of the dis- ease during the period. The uncertainties of diagnosis and certifi- cation are still too dominant to warrant drawing any far reaching conclusions. The sudden decline in the death rate both among white females and white males subsequent to 1914 was clearly the result of changed office practise in assigning cases where arterio- sclerosis was reported Jointly with a number of other conditions such as bronchopneumonia, chronic bronchitis, endocarditis, and many other causes. Following the practise of the Census Bureau, such cases were, after 1914, assigned not to arteriosclerosis but to the accompanying condition. Among insured colored persons, there is shown a fairly marked increase in the rates from year to year despite the influence of this factor. The figures for the population of the Eegistration Area are different in that they show a condition of increased incidence from year to year. The following table shows the figures for the individual years between 1911 and 1916 differentiated by color and sex: 218 MOKTALITY STATISTICS OP INSUKED WAGE EAENEES. TABLE 139. m'^ktality from diseases of the arteries, atheroma, aneurism, etc., Classified by Color and by Sex. Death Hates per 100,000 Persons Exposed. Single Yea/rs in Period 1911 to 1916. Experience of Metropolitan Life Insurance Company. Industrial Department. Persons. White. Colored. Year. Males. Females. Males. Females. 1911 to 1916 17.0 18.8 15.1 21.3 15.8 1916 1915 1914 1913 1912 1911 15.2 14.4 18.9 19.0 17.6 17.4 16.5 14.5 21.2 21.0 20.5 20.1 13.2 13.2 17.2 17.2 15.3 15.3 21.8 21.5 21.0 23.1 20.5 19.9 16.9 16.9 16.2 15.7 15.0 13.9 Typhoid Fever. Typhoid fever, according to Sir William Osier, " is everywhere an index of the sanitary intelligence of the community." It is encour- aging, with this statement in mind, to find that typhoid fever shows ' during the six year period under investigation a very large per- centage of decrease in its incidence. It is still a cause of much con- cern, however, in its wide distribution and in the considerable num- ber of deaths that annually result from it. A wide gulf still sepa- rates sanitary knowledge from sanitary accomplishment over a large area of the United States. It will be possible, through the examina- tion of the data of this experience, to determine the comparative incidence of the disease in the two color or race groups constituting the American working population. This will throw light on the different sanitary surroundings of the white and colored people respectively. Of perhaps equal interest to the medical profession will be the variable incidence of mortality from the disease by sex, and in the several main age periods of life. Typhoid fever caused 9,011 deaths during the period between 1911 and 1916. The rate of mortality was 16.8 per 100,000 living, the disease accounting for 1.4 per cent, of all the deaths. The following table will be the basis of our discussion of the inci- dence of the disease in the two race and sex groups according to age period : TYPHOID FEVER. 219 TABLE 140. Mortality from Typhoid Fever, Classified by Color, Sex and by Age Period. Death Bates per 100,000 Persons Exposed. 1911 to 1916. Experience of Metropolitan Life Insurance Company. Industrial Department. Persons. White. Colored. Age Period. Males. Females. Males. Females. All ages — one and over 16.8 15.8 12.8 35.6 34.2 1 to 4 5 to 9 10 to 14 15 to 19 20 to 24 25 to 34 35 to 44 45 to 54 55 to 64 65 to 74 75 and over. . 12.7 12.9 16.2 24.6 23.4 18.5 15.1 13.1 12.3 11.8 10.6 10.8 8.6 12.4 20.8 24.3 20.7 17.1 15.1 15.2 11.6 9.9 11.6 11.5 13.4 20.0 17.7 13.2 10.9 8.7 7.5 7.9 9.2 28.8 41.6 35.4 59.5 46.7 29.3 26.4 28.7 27.6 48.4 35.5 44.8 58.4 60.0 38.8 28.8 20.7 20.2 22.0 20.0 36.3 It is evident that typhoid fever death rates show very pronounced differences for the two races. Those for the colored persons are greatly in excess of those for whites. This holds true for every year of the six year period. The rate for colored males (35.6) is considerably more than double that for white males (15.8) ; that for colored females (34.2) is almost three times that for white females (12.8). These differences between the races are even more marked when we consider certain of the age periods, especially the years of childhood. Thus, between the ages of five and nine, the colored children show rates between four and five times as high as those for white children at the same ages. It is impossible from the above data to say definitely to what extent these race differences indicate a varying degree of resistance to the disease. A much more plausible explanation is that the great body of the colored policyholders reside in those areas of the country and in certain definite localities of cities where typhoid fever is much more prevalent than in areas inhabited by the white policyholders. It is possible, of course, that the factor of resistance plays a part also, but this can be determined only by future research which will take into consideration all of the local sanitary surroundings of the two races. 220 MORTALITY STATISTICS OF INSURED WAGE EARNERS. The variations in the incidence of typhoid fever mortality in the two sexes are less pronounced, but are, nevertheless, in evidence. Taking all ages together, males show higher rates than females, the differences being more marked among the whites than among the colored. On further analysis, we find that this difference results from a considerably higher death rate among males beginning with the age period 20 to 24, the male excess increasing with advancing age. In the earlier ages, that is, under age 15, there is a pronounced excess in the rate of females of both races. Eeference has already been made to the varying incidence by age in this condition. We may summarize the facts as follows : the highest mortality occurs in the age group 15 to 19 years, although among white males, this maximum figure is attained in the next age period, 20 to 24 years. TABLE 141. , Mortality from Typhoid Fever. Death Bates per 100,000 Persons Exposed. Classified by Sex and Age Periods. Insured White Lives in Experience of Metropolitan Life In- surance Company, Industrial Department {1911 to 1916) and General Population of Expanding Registration Area of the United States (1910 to 1915). Males. Females. Age Period. M. L. I. Co. (Wliite). U. S. Reg. Area. Per Cent. M. L. I. Co. of Reg. Area. M. L. I. Co. (White). U. S. Reg. Area. Per Cent. M. L. I. Co. of Reg. Area. All ages — one and over . . . . 15.8 20.7 76.3 12.8 14.7 87.1 lto4.... 10.8 10.1 106.9 11.6 10.0 116.0 5 to 9 ... . 8.6 11.0 78.2 11.5 12.3 93.5 10 to 14... 12.4 12.7 97.6 13.4 15.7 85.4 15 to 19... 20.S 26.6 78.2 20.0 22.9 87.3 20 to 24... 24.3 34.2 71.1 17.7 21.0 84.3 25 to 34. . . 20.7 27.5 75.3 13.2 15.2 86.8 35 to 44... 17.1 21.3 80.3 10.9 12.4 87.9 45 to 54... 15.1 18.3 82.5 8.7 11.8 73.7 55 to 64... 15.2 18.0 84.4 7.5 11.3 66.4 65 to 74... 11.6 15.2 76.3 7.9 12.1 65.3 75 and over 9.9 10.3 96.1 9.2 10.0 92.0 A comparison of the above data with those for the population of the Eegistration Area of the United States confirms the several important relations which have been described. We find again a higher incidence of the condition among males than among females at all ages combined, and more especially in the ages after early TYPHOID FEVER. 221 adolescence. We find also that the periods of maximum mortality are in exact agreement in the two experiences. Among males in the Eegistration Area for example, the highest death rate for any period is that for the age group 20 to 24 years and, for females, in the period 15 to 19 years. The same general contour of the curves of mortality by age period for each of the two sexes is to be noted, that is, a maximum mortality in the period of early adult life tapering down to a minimum at the two extremes of life. The table on page 220 presents a comparison of the death rate by age and sex for insured lives with corresponding figures for the population of the Eegistration Area. The general correspondence between the two sets of figures is very marked and yet there are important differences to which reference should be made. Beginning with the period 5 to 9 years, the rates are uniformly higher for the population of the Eegistration Area, the most marked difference being found in the age period 20 to 24 years. For each sex there is a decided advantage, apparently, in favor of the insured white lives as compared with the general population. It is undoubtedly true that the Eegistration Area figures are somewhat higher because of their inclusion of a small proportion of colored lives, but perhaps a more significant factor is the fact that a large proportion of the population of the Eegistration Area is rural in character whereas, the insured lives are almost entirely limited to cities and their immediate environment where typhoid fever rates are nearly always lower than in the country. On the other hand, it should not be overlooked that a considerable proportion of the policyholders of the Company reside in certain of the non-registration States of the country where typhoid fever is more prevalent than in those States which constitute the Eegistra- tion Area. All things considered, typhoid fever is not as favorable a condition for purposes of comparison as are some others. The figures submitted do, however, confirm the essential relations of the disease in both groups and serve to show that wage earners and their families do not suffer unduly from its effects. The decreasing death rate from typhoid fever is one of the very gratifying features of this mortality experience. There was a con- tinuous and marked decrease in the mortality rate year by year, beginning with 1911 and closing with 1915. A slight increase is in evidence for 1916 as compared with 1915, but the significance of 222 MOETALITY STATISTICS OF INSURED WAGE EAENEES. this cannot be evaluated at this time. The following table gives the figures for each of the six years in the period by sex and by color : TABLE 142. Mortality from Typhoid Fever, Classified by Color and by Sex. Death Bates per 100,000 Persons Exposed. Single Years in Period 1911 to 1916. Experience of Metropolitan Life Insurance Company. Industrial Department, Persons. White., Colored. Males. Females. Males. Females. 1911tol916 16.8 15.8 12.8 35.6 34.2 1916 1915 1914 1913 1912 1911 13.0 12.9 16.1 18.4 19.1 22.8 12.1 12.1 15.5 17.7 17.9 21.2 10.1 9.8 12.1 14.2 14.6 17.7 27.1 31.8 35.5 38.0 37.5 45.8 28.0 25.4 31.5 35.5 40.5 46.5 A comparison of the above figures with those for the Eegistration Area shows a number of coincidences. The rate for 1911 in the Registration Area was also the highest for the quinquennium 1911 to 1916; that for 1915 was the lowest for the same period. Again, a slight rise is shown for 1916 over 1915 in the population data. In other words, the fluctuations in the insurance experience serve here as a very sensitive index of the fluctuations in the general popula- tion experience. Mortality from Sequelae of Typhoid Fever. Before closing this section, it will be well to refer to one additional feature of typhoid mortality which the data under consideration make possible, namely the sequelae of typhoid fever. A study made in 1914* of a group of more than 1,000 persons who had recovered from an attack of typhoid fever in 1911 showed clearly that in the three year period following the disease the mortality was slightly more than double what might be normally expected from persons in the same age and sex classes. It was found that during the first year after recovery close to three times the expected number of deaths * Dublin, Louis I., * ' Typhoid Fever and Its Sequelae, ' ' Metropolitan Life Insurance Company, 1914, CIRRHOSIS OF THE LIVER. 22? occurred (384 per cent). During the second year, the ratio of actual to expected mortality was 217 per cent, and, during the third year, the ratio was only 80 per cent. This would indicate that the effect of an attack of typhoid fever continues over a period of two years, during which time there is a marked increase in the mortality from certain conditions which apparently are induced by typhoid fever. These are tuberculosis, diseases of the heart, and diseases of the kidney, which all appear in exaggerated proportions as causes of death in the group of survivors. In considering typhoid mortality, therefore, it is well to remember that, in addition to the death rate from the disease, there is also the added element of impairment which follows in the track of recovered cases, taking a toll of approximately double mortality during the period of from two to three years after "recovery" from typhoid fever. It is estimated that in the period from 1911 to 1916, when 9,011 deaths from typhoid fever occurred in the Industrial experi- ence of the Metropolitan Life Insurance Company, an additional 3,600 deaths occurred among those who had been attacked by ty- phoid fever but who had recovered — evidently a significant addi- tion to the mortality due to any cause of death. Cirrhosis of the Liver. Eight thousand and sixty-four (8,064) deaths of Metropolitan policyholders were recorded as due to cirrhosis of the liver during the six year period 1911 to 1916. The death rate was 15.0 per 100,000 exposed. Included under this title are deaths from alcoholic cirrhosis, but not those in which the disease is definitely reported as a sequela of syphilis. Alcoholism is recognized as the chief cause of cirrhosis of the liver. It must be clear, therefore, that a large num- ber of cases of alcoholism are not reported in the published statistics where cirrhosis of the liver is registered as the cause of death. All statistics in any way related to mortality from alcoholism are still understatements. Color, Sex and Age Incidence of Mortality from Cirrhosis of the Liver. The death rate for white policyholders was higher than that for colored policyholders for each sex group. This applies to the four ten-year age periods of heaviest mortality from the disease extend- 224 MORTALITY STATISTICS OF INSURED WAGE EARNERS. ing from age 35 to age 75. After age 75, the rate for white males was also higher than for colored males, but, among females, the color relation was reversed. This may well be due to the unre- liability of the data for colored females at this advanced age period of life. The following table presents the facts by color, sex and by age: TABLE 143. Mortality from Cirrhosis of the Liver, Classified by Color, Sex and BY Age Period. Death Bates per 100,000 Persons Exposed. 1911 to 1916. Experience of Metropolitan Life Insurance Company. Industrial Department. Persons. White. Colored. Age Period. Males. Females. Males. Females. All ages — one and over 15.0 20.7 10.6 18.8 9.6 1 to 19 20 to 24 25 to 34 35 to 44 45 to 54 55 to 64 65 to 74 75 and over. . .4 1.0 6.7 24.4 48.8 66.8 98.6 102.8 .4 1.1 9.8 39.9 87.8 114.8 145.7 124.8 .3 .4 4.1 16.5 29.0 40.6 71.3 91.2 1.2 3.3 10.7 28.6 47.6 73.8 111.9 82.3 1.3 2.4 5.3 11.1 22.2 27.7 64.6 99.8 The rates are also much higher for males than for females. This applies to both white and colored policyholders at all of the signifi- cant age periods. The mortality is low in early life. Beginning with the age period 25 to 34 years, the rate becomes important, and, after that, rises rapidly, reaching the maximum, for significant age groups, at the period of 65 to 74 years. Both white and colored males show a decrease in the death rate after age 75, while females of both races show significant increases in the rate. It is possible that these variations are accidental as the result of the small num- ber of lives exposed at the advanced periods of life. Comparison of Mortality from Cirrhosis of Liver among Insured Wage Earners 1911 to 1916 and among the Population of the Expanding Registration Area, 1910 to 1915. Comparison with available data by sex and age for the expanding Eegistration Area shows that the mortality among insured white CIRRHOSIS OF THE LIVER. 225 males exceeds very slightly that for the males of the general population (20.7 per 100,000 exposed as compared with 18.0 per 100,000 population). For the females, the corresponding rates are 10.6 and 8.9. In each experience, it will be noted that the mortality among males is about double that among females. As might be expected, the death rates for the lower age periods are not signifi- cant in either experience. It is not until age 35 is reached that cirrhosis of the liver becomes a serious factor in mortality. From that age on, the death rate for cirrhosis of the liver is very much higher among white insured men and women than it is in the Registration Area. At the age period 35 to 44 years, for males, the death rate for the policyholders is 39.9 as compared with 19.2 for males of the general population. For those 45 to 54 years of age, the corresponding rates are 87.8 and 44.1. While the excess is smaller in the three highest age groups, it is, nevertheless, very pro- nounced in each case. For the females, practically the same rela- tions are in evidence, although the rates are lower. In each age period, there is found a markedly higher rate among the Industrial policyholders. It is believed that in the case of cirrhosis of the liver, as with many other diseases in which the death rates for the insured exceed those of the general population, the explanation is TABLE 144. Mortality from Cirrhosis of the Liver, Death Rates per 100,000 Persons Exposed. Classified hy Sex and by Age Periods. Insured White Lives in Experience of Metropolitan Life In- surance Company, Industrial Department (1911 to 1916) and General Population of Expanding Begistration Area of the United States (1910 to 1915). Males. Females. Age Period. M. L. I. Co. (White). U. S. Reg. Area. Per Cent. M. L. I. Co. of Reg. Area. M. L. I. Co. (White). U. S. Reg. Area. Per Cent. M. L. I. Co. of Reg. Area. All ages — one and over . . . . 20.7 18.0 115.0 10.6 8.9 119.1 ltol9.... .4 .4 100.0 .3 .4 75.0 20 to 24... LI .9 122.2 .4 .7 57.1 25 to 34.... 9.8 5.3 184.9 4.1 3.0 136.7 35 to 44.... 39.9 19.2 207.8 16.5 9.8 168.4 45 to 54.... 87.8 44.1 199.1 29.0 19.5 148.7 55 to 64.... 114.8 74.9 153.3 40.6 31.5 128.9 65 to 74.... 145.7 104.7 139.2 71.3 53.9 132.3 75 and over 124.8 108.7 114.8 91.2 73.9 123.4 226 MORTALITY STATISTICS OF INSURED WAGE EARNERS. found in part in the different distribution of the exposure with reference to rural and urban residence. Examination of the gen- eral population mortality reports, year after year, shows that for this disease the urban mortality is in the neighborhood of 50 per cent, in excess of the rural. The fact that the insured exposure is almost entirely urban in character is undoubtedly an important element in their higher death rate. The special circumstances which give rise to a higher urban rate for this disease are at present unknown. The table on page 225 presents a comparison of the death rates for cirrhosis of the liver by age and sex in the general population and among the Industrial policyholders. Trend of the Death Rate from Cirrhosis of the Liver. The highest mortality during the six year period was encountered in the year 1912 (16.7) while the lowest was for the year 1916 (13.6). There were no marked fluctuations in the mortality, although the trend in both the Metropolitan experience and that of the expanding Eegistration Area was downward. Influenza. True epidemic influenza is a specific infectious disease. Several times within the last two decades of the nineteenth and in the second decade of the present century it has been epidemic or en- demic in this country, notably in 1889, 1890 and in 1915 and 1916. From the statistical standpoint, however, it is still necessary to exercise great caution in considering this disease. The word " in- fluenza " is a term which is very loosely used by physicians and in many cases in which it is given as the cause of death it is in error, the true cause being some other condition accompanied with respira- tory symptoms. It is very necessary to bear this in mind in com- paring the death rate for influenza for a period of years and in fact in evaluating the extent of the mortality from the condition at the present time. It should not be lost sight of, however, that the tendency to use the term correctly is becoming more and more marked as the years go on. The 8,056 deaths which were ascribed to influenza during the period 1911 to 1916 were therefore an over-statement of the num- l)er, although it is impossible to determine the element of error. The death rate based on this number of deaths was 15.0 per 100,000 INFLUENZA. 227 living. During the six year period the highest rate was for 1916 (23.8) ; the minimum rate was observed in the year 1914 (11.3). The incidence, therefore, more than doubled in a short span of two years, showing clearly the epidemic character of the disease. In the expanding Eegistration Area of the United States also, much the same condition prevailed. The mortality in 1916 reached a rate of 26.4 per 100,000, Ijy far the highest rate in the history of the United States Eegistration Area and exceeding by 65 per cent, the rate for the year before. The disease was especially prevalent and virulent in various parts of the country during the latter part of 1915 and in the early months of 1916, which accounts for the marked increase shown in the death rates, both in the reports of the United States Census Bureau and in the Industrial experience of the Metropolitan. The following table presents the data for each of the six years between 1911 and 1916 by color and sex: TABLE 145. Mortality from Influenza, Classified by CoiiOR and by Sex. Death Bates per 100,000 Persons Exposed. Single Years in Period 1911 to 1916. Experience of Metropolitan Life Insurance Company. Industrial Department. Persons. White. Colored. Year. Males. Females. Males. Females. 1911 to 1916 15.0 11.3 14.0 26.5 33.6 1916 23.8 18.7 24.2 34.9 44.1 1915 13.0 9.4 12.1 28.3 29.0 1914 11.3 8.3 10.7 20.6 25.8 1913 12.3 9.4 11.4 23.9 25.9 1912 12.3 8.9 10.0 25.5 35.8 1911 15.9 11.9 14.2 25.3 41.3 Influenza Mortality According to Color, Sex and Age. The mortality from this disease is most prominent at the two extremes of life, especially at the older ages when very high death rates are attained. The lowest rates are observed between the ages 5 and 35 years. Prom age 35 onward the incidence rapidly in- creases, more than doubling with each successive age period. The above facts with regard to age period are generally true for both sexes and both races. The death rate for colored policyholders 228 MORTALITY STATISTICS OF INSURED WAGE EARNERS. is more than double that for white persons for each sex. This dif- ference between the two race groups becomes very marked in some of the lower age periods, when the rate for the colored is more than three times that for the white. Females show uniformly higher rates than males in both race groups. This is especially marked in the period of middle life and of old age when the death rates are highest. The following table presents the facts for influenza by color, sex and age period during the six year period : TABLE 146. Mortality from Influenza, Classified by Color, Sex and by Age Period. Death Bates per 100,000 Persons Exposed. 1911 to 1916. Experience of Metropolitan Life Insurance Company. Industrial Department. Persona. White. Colored. Age Period. Males. 1 Females. Males. Females. AH ages — one and ■over 15.0 11.3 14.0 26.5 33.6 lto4 5 to 9 10 to 14 15 to 19 20 to 24 25 to 34 35 to 44 45 to 54 55 to 64 65 to 74 75 and over. . 13.1 3.5 2.4 3.6 4.7 6.7 11.2 22.2 53.9 '148.0 315.0 12.6 2.9 1.8 2.7 3.4 5.0 10.8 18.9 44.9 121.2 235.5 11.8 3.4 2.2 2.6 3.5 4.7 7.6 17.5 45.7 142.4 329.0 28.8 7.5 4.1 9.3 10.5 16.3 23.8 40.4 94.8 230.5 397.9 20.3 5.8 8.4 13.2 15.3 15.9 21.3 49.7 124.1 285.4 617.0 That very similar relations in the death rates by sex and age pre- vail in the general population of the "United States is shown by the data for the expanding Eegistration Area, 1910 to 1915. It will not be necessary, however, because of the element of uncertainty in the rates for influenza to give the actual figures for the Eegistration Area. It should be noted nevertheless that the mortality rates from &is condition are much higher among the white urban policy- holders than in the population of the Eegistration Area for each sex and at virtually every age period. DIABETES. 229 Diabetes. The data on diabetes in this experience of insured wage earners are, so far as we can determine, original in the literature of Ameri- can vital statistics. In spite of the intense interest of the medical profession in the subject in recent years, little has been done so far to determine the extent to which the condition is responsible for mortality. The figures herein submitted are not only accurate measures of the incidence of the disease as a cause of death in gen- eral, but, what is perhaps more important, they give a picture of the history of the condition in relation to sex, color and age period. To the clinician and the laboratory student of the disease, the relations presented may well serve as a clue in directing further diabetes research. Another element of interest inherent in these figures is that, referring, as they do, to the industrial population, they may throw light on the probable effect of social and economic condition upon the incidence of diabetes. This is still a mooted question in the medical literature. There is a tendency in some quarters to re- gard the disease as more prevalent among the prosperous elements of the population. On the other hand, certain exciting causes in- herent in the harsher conditions of life and work have been identi- fied in the case-histories of diabetes mellitus. It will be important, TABLE 147. Mortality from Diabetes, Classified by Color, Sex and by Age Period. Death Bates per 100,000 Persons Exposed. 1911 to 1916. Experience of Metropolitan Life Insurance Company. Industrial Department. Persons. White. Colored. Year. Males. Females. Males. Females. All ages — one and over 14.4 10.8 18.5 9.5 11.4 lto4 5 to 9 10 to 14 15 to 19 20 to 24 25 to 34 35 to 44 45 to 54 55 to 64 65 to 74 75 and over. . 1.8 1.7 3.4 4.0 4.0 5.4 9.3 30.4 80.1 127.2 134.9 1.9 1.6 3.1 4.5 5.0 6.5 10.6 25.4 56.6 95.5 102.1 1.9 1.8 4.1 4.0 3.7 4.9 8.8 34.3 102.1 161.4 158.2 2.3 .3 2.6 3.3 4.7 9.6 20.8 48.6 55.1 109.8 1.9 .6 2.5 1.5 .8 4.3 7.7 33.5 53.7 57.5 108.9 230 MOETALITY STATISTICS OF INSUEED WAGE EARNERS. therefore, to see later how the figures here presented compare in detail with those in the general population whose economic status is altogether more favorable. If the number of deaths in this ex- perience (7,762) are not as many as for other conditions which have been discussed, it should be remembered that this number is by far the largest aggregation of cases of this disease which have as yet received extended statistical treatment. The table on page 229 presents the death rates per 100,000 persons exposed with respect to color, sex and age period. The death rate increases with age. Under 35 years, there is no very appreciable incidence of the condition. Between ages ten and fourteen, a rate of 3.4 deaths per 100,000 persons living is the first indication of a significant distribution in the population of the disease in its malignant form. Between 25 and 34 years, the rate, 5.4, accentuates the earlier finding. Beyond 35 years, there is a rapid rise in the slope of the curve for diabetes. The highest point is observed in the last age period, namely, 75 and over. But, even in the more significant age period of 65 to 74 years the rate is not far from its maximum. In fact, among white females, the maxi- mum is reached in this period. There is a lower death rate among colored persons at each of the age periods, and this is especially true of colored females as com- pared with white females. The difference in favor of colored lives becomes more important beyond age 55, when diabetes is an im- portant condition. It should be noted also that diabetes has a very marked sex incidence, the rates beyond age 45 being for both white and colored women higher than for males of the corresponding race. There is only one exception and it is not a significant one. Prior to age 45, the condition is reversed. This suggests the inter- esting question whether the menopause may not have some influence in changing the sex ratio of diabetes mortality after 45 years of age. Diabetes Mortality Among Insured Wage Earners and Among the General Population of the United States {Expanding Registrar tion Area) Compared. Among males, under 20 years of age, and, among females under 35 years of age, in this insurance experience, the diabetes death rates are, almost without exception, lower than the corresponding rates for the population in the Registration Area of the United DIABETES. 231 States. Beyond 20 years of age, however, there is an excess in the rate among insured white males which increases up to the period 35 to 44, Beyond this age, the ezcess declines to a point where the rates for the two groups are much the same. Among the females, there are significantly higher rates for insured women than for those in the general population. Beginning with the age period 45 to 54 years, the amount of excess varies somewhat from 25 to 30 per cent. The following table presents a comparison for the disease in the two series, that is, the insured group and the general Eegistra- tion Area population : TABLE 148. MOETALITY FROM DIABETES. Death Bates per 100,000 Persons Exposed. Classified hy Sex and hy Age Periods. Insured White Lives in Experience of Metropolitan Life In- surance Company, Industrial Department (1911 to 1916) and General Population of Expanding Registration Area of the United States (1910 to 1915). Males. Females. Age Period. Per Cent. Per Cent. M. L. I. Co. U. S. Reg M. L. I. Co. M. L. I. Co. U. S. Reg. M. L. 1. Co. (White) . Area. of Reg. Area. (White) . Area. of Reg. Area. All ages — one and over . . . . 10.8 14.5 74.5 18.5 17.5 105.7 1 to4.... L9 2.2 86.4 1.9 1.8 105.6 5 to 9 ... . 1.6 3.0 53.3 1.8 3.0 60.0 10 to 14... 3.1 4.2 73.8 4.1 4.8 85.4 15 to 19... 4.5 4.8 93.8 4.0 4.1 97.6 20 to 24... 5.0 4.8 104.2 3.7 3.8 97.4 25 to 34... 6.5 5.6 116.1 4.9 5.2 94.2 35 to 44... 10.6 8.6 123.3 8.8 8.3 106.0 45 to 54... 25.4 22.6 112.4 34.3 27.5 124.7 55 to 64... 56.6 57.4 98.6 102.1 78.4 130.2 65 to 74... 95.5 95.0 100.5 161.4 127.9 126.2 75 and over 102.1 112.8 90.5 158.2 121.2 130.5 Trend of the Death Rate from Diabetes. In this experience for insured wage earners, there is a slight tendency toward increase in the recorded death rate for diabetes mellitus There is some significance attached to this increase in mortality from the disease. There are no important nosologic con- siderations confusing the statistics for diabetes as was observed for several other diseases and conditions, notably, cancer. Fatal dia- betes is well reported in this mortality experience and the certifica- 232 MORTALITY STATISTICS OF INSURED WAGE EARNERS. tion of the disease has probably not improved materially during the period covered by this experience. The minimum rate was observed in 1911, 13.3 per 100,000 persons exposed. The group of insured white females, as in other years, was very largely responsible for the high figure shown in 1916 for the entire experience. In 1911, in- sured white females registered a diabetes rate of 16.5 per 100,000 exposed; in 1916, the figure was 20.2 per 100,000. In the experience of the Eegistration Area of the United States, there has been also observed since 1900 a gradual increase in the death rate of diabetes mellitus. The figures for the individual years are shown herewith by color and sex : TABLE 149. MORTALITT rROM DIABETES, CLASSIFIED BY COLOR AND BY SeX. Death Bates per 100,000 Persons Exposed. Single Years in Period 1911 to 1916. Experience of Metropolitan Life Insurance Company. Industrial Department. White. Colored. Year. Persons. Males. Females. Males. Females. 1911 to 1916 14.4 10.8 18.5 9.5 11.4 1916 1915 1914 1913 1912 1911 15.9 15.1 14.2 13.9 13.7 13.3 11.5 10.3 10.5 10.8 10.3 11.3 20.2 20.0 18.4 17.5 17.7 16.5 11.6 8.1 10.0 8.9 9.7 8.1 14.8 14.4 10.4 10.9 9.2 7.7 CHAPTER XT. This chapter will deal with the following diseases: (1) Appendicitis. ~ (2) Hernia, Intestinal Obstruction. (3) Syphilis. (4) Chronic Bronchitis. (5) Rheumatism. (6) Acute Bronchitis. (7) Alcoholism, Acute and Chronic. Appendicitis. Interest attaches to the statistical treatment of appendicitis in view of the increased accuracy of the returns in recent years for this condition. Many deaths are now classed properly as due to appen- dicitis which some years ago would have been charged to "peri- tonitis." Fortunately, the many deaths classified as due to appen- dicitis in this experience covered a period during which every effort was made to assign these deaths to their proper cause. The total number of deaths from appendicitis during the period 1911 to 1916 was 6,345, corresponding to a death rate of 11.8 per 100,000 exposed. The death rate for colored insured persons is slightly higher than that for white lives. This is true for each sex, although the difference between colored females and white females is the more marked. The rate for males is slightly higher than for females among both white and colored policyholders. A more careful examination of the mortality curve shows some very interesting characteristics by age period. Thus, the age period of maximum incidence is at 15 to 19 years. This is true, with the exception of the white female group, for each one of the race and sex categories in this experience. From this age period onward, txie rates decline for a period of twenty-five to thirty-five years. The rates then increase somewhat only to decline again. The sug- 233 234 MORTALITY STATISTICS OF INSURED WAGE EARNERS. gestion of Stouman* that the curve of mortality for this disease is, in fact, a combination of two curves, both skew, appears to be confirmed by our figures. Only additional medical research can clear up the true meaning of this characteristic. The following table presents the death rates for appendicitis by color, sex and age period : TABLE 150. MOKTAIilTY FROM APPENDICITIS, CLASSIFIED BY COLOE, SeX AND BY AGE PeEIOD. Death Bates per 100,000 Persons Exposed. 1911 to 1916. Experience of Metropolitan Life Insurance Company. Industrial Department. Persons. White. Colored. Age Period. Males. Females. Males. Females. An ages — one and over 11.8 13.2 10.2 13.9 12.8 lto4 5 to 9 10 to 14 15 to 19 20 to 24 25 to 34 35 to 44 45 to 54 55 to 64 65 to 74 75 and over. . 4.7 10.1 13.9 15.7 12.9 12.4 11.6 11.8 11.3 10.8 11.0 4.8 10.6 15.6 18.3 15.6 13.6 13.2 12.4 14.2 13.3 17.0 4.8 9.9 12.6 12.4 9.9 10.9 9.3 11.1 9.4 9.2 9.2 5.8 9.7 15.8 18.5 14.1 13.5 14.4 16.3 12.0 13.4 .6 7.0 9.0 19.0 15.9 15.0 15.8 10.2 11.0 9.4 There are no pronounced differences between the death rates of the Industrial experience and those for the Eegistration Area of the United States when considered by sex and age period. The characteristics above described are observed also in the population data. The death rates for the individual years between 1911 and 1916 do not show any definite tendency toward increase or decrease. The figures for white males on their own account would indicate a condition of slight increase; for white females there is very little variation, while for colored males there is a slight decrease. The rates for colored females vary too markedly from year to year to permit any conclusion to be drawn. The facts are shown m the following table: * Stouman, Knud, "An Analysis of Appendicitis Statistics," American Journal of Public Health, Vol. 6, July, 1916. HEENIA AND INTESTINAL OBSTRUCTION. 236 TABLE 151. Mortality from Appendicitis, Classified by Color and by Sex. Death Bates per 100,000 Persons Exposed. Single Years in Period 1911 to 1916. Experience of Metropolitan Life Insurance Company. Industrial Department. Persons. White. Colored. Year. Males. Females. Males. Females. 1911 to 1916 11.8 13.2 10.2 13.9 12.8 1916 1915 1914 1913 1912 1911 12.3 11.8 12.0 12.0 11.5 10.9 14.2 13.3 13.5 13.7 12.1 12.2 10.0 10.1 10.7 10.1 10.6 9.6 13.1 15.6 12.1 13.5 14.7 14.1 16.8 11.7 12.6 14.3 11.6 9.7 Heenia and Intestinal Obsteuction. Hernia and intestinal obstruction caused 5,519 deaths among Metropolitan policyholders during the period 1911 to 1916. The death rate was 10.3 per 100,000 exposed. Of these deaths, 2,357 were caused by hernia with a rate of 4.4 and 3,162 by intestinal obstruction with a rate of 5.9. Color, Sex and Age Incidence. Considering the conditions jointly, the mortality is found to be higher among colored policyholders than among white policyhold- ers; the death rate for colored males is 12.4 per 100,000 exposed, as compared with 8.5 for white males; that for colored females is 12.2 as compared with 11.2 for white females. Among white poli- cyholders the mortality among females is higher than that among males. The highest rates occur among the higher age groups, the maximum being for the period 75 years and over. It is significant that the rate for the lowest age period, 1 to 4 years, is higher than the rates for the succeeding age periods up to age 35. There is considerable difference, however, in the color incidence of the dis- ease in the different age groups. Among white males, the rates for the first five age periods, that is, up to age 24, are higher than the corresponding rates for females. In the periods from 25 to 74 years the males have decidedly lower rates. For ages 75 and over the male rate is asrain in excess of the female rate. Colored males 236 MORTALITY STATISTICS OF INSURED WAGE EARNERS. show rates in excess of those for colored females for the first four age periods, from 1 to 20 years. From 24 to 54 years the female rates are higher. For the age period 55 to 64 and 65 to 74, the male rate is about double that for females ; while for the group 75 years and over the male rate is about four times the female rate. These facts are presented in the following table : TABLE 152. Mortality feom Hernia and Intestinal Obstruction, Classified by Color, Sex and by Age Period. Death Bates i)er 100,000 Persons Exposed. 1911 to 1916. Experience of Metropolitan Life Insurance Company. Industrial Department. Persona. White. Colored. Age Period. Males. Females. Males. Females. All ages — one and over 10.3 8.5 11.2 12.4 12 2 1 to4 5 to 9 10 to 14 15 to 19 20 to 24 25 to 34 35 to 44 45 to 54 55 to 64 65 to 74 75 and over. . 7.7 2.3 1.5 2.3 3.2 5.4 10.2 20.6 40.4 75.5 145.0 9.6 2.6 2.0 2.4 3.4 4.3 7.0 17.9 34.7 70.9 160.3 5.6 1.6 .9 1.6 2.5 4.6 10.9 22.4 44.7 81.9 141.5 9.6 5.2 3.2 5.8 4.9 8.0 10.2 17.9 51.0 83.5 205.8 8.9 2.9 1.6 4.4 5.0 11.8 16.8 21.2 28.2 41.1 45.4 Trend of the Death Rate from Hernia and Intestinal Obstruction. The general tendency during the period has been toward a lower death rate from these causes. The highest rate was that for 1911 (11.0), the lowest that for 1915 (9.6). The rate increased in 1916 to 10.1. Compared with the experience in the Eegistration Area it will be noted that the rates for the two conditions combined were higher for each year in the Eegistration Area than for the Indus- trial policyholders of the Company. A closer analysis, however, shows that this was due to a much higher mortality in the Area for intestinal obstruction, which is common among children under one year of age. Since there are no Industrial policyholders at this earliest age period, the rate for the Company's experience is not affected by this high mortality from intestinal obstruction. SYPHILIS. 237 Syphilis. Syphilis as the chief and determining cause of death was returned in 4,659 cases in the Industrial experience of the Metropolitan Life Insurance Company during the six year period 1911 to 1916. This figure corresponds to a death rate of 8.7 per 100,000 living. In common with other statistical returns on this condition, these figures represent an utterly inadequate measure of its true inci- dence. In fact, the statistical discussion of the mortality from syphilis is still subject to the gravest reservations because of the tendency of physicians to conceal this disease in their reports of causes of death. A wide gap separates the meager returns of mor- tality compilations from what clinicians know to be the wide dis- tribution and the serious consequences of syphilitic infection. Nevertheless, the data at our disposal are worthy of consideration, if only because they show an unmistakable tendency in the direc- tion of more accurate certification of this cause of death. A com- parison of the rate for the year 1916 in this Industrial experience with that for 1911 would, in itself, indicate a most alarming in- crease. Thus, in the first year, the figure is 3.4 per 100,000 and, in the last year, 11.9. The apparent rate has more than trebled in the short period of six years. The truth is, however, that each year more effort was expended in identifying suspicious reports as true cases of syphilis. For years to come, the published death rates for syphilis are certain to increase; but many years will elapse be- fore the mortality figures will present an approximate picture of the ravages of this disease. Fundamentally, the statistics of syphilis suffer from a defect in the system of classification. Conditions clinically known as due to syphilis, such as locomotor ataxia, general paralysis of the insane, and certain cardiovascular, renal and hepatic affections can not, as yet, be assigned to this cause because of the prevailing rules of international compiling practice. For the time being and until the International List of Causes of Death is revised, these diseases must continue to be assigned to conditions of various local tracts, and not to the general disease, syphilis, which classification present medical knowledge demands. Combining syphilis, locomotor ataxia and general paralysis of the insane, there would be not 4,659 deaths from syphilis in this experience, but a total of 7,680. The com- bined death rate is thus raised to 14.3 per 100,000; but even this 238 MORTALITY STATISTICS OF INSURED WAGE EARNERS. figure is far from the truth when we consider the large number of fatal cases of true syphilis which are reported as due to cirrhosis of the liver, aneurism, myelitis, cerebral tumor, and others. It is hoped that the future will clear up the uncertainty and indefinite- ness which still affect our statistical knowledge of syphilis mor- tality. The following tables show first, the mortality incidence by color and sex of syphilis, definitely so reported or identified, and second, for the group — syphilis, locomotor ataxia and general paralysis of the insane combined. Distinction is made for the individual years between 1911 and 1916 in both tables. TABLE 153. MOKTAIiITT FEOM SYPHILIS, CLASSIFIED BY COLOE AND BY SEX. Death Bates per 100,000 Persons Exposed. Single Years in Period 1911 to 1916. Experience of Metropolitan Life Insurance Company. Industrial Department. Persons. White. Colored. Year. Males. Females. Males. Females. 1911 to 1916 8.7 9.3 3.9 32.4 18.7 1916 1915 1914 1913 1912 1911 11.9 11.4 9.8 6.0 8.1 3.4 13.2 12.2 10.8 5.9 8.8 3.0 5.2 5.4 4.2 2.7 3.8 1.5 47.1 44.8 37.8 21.5 25.3 13.9 24.6 22.4 20.2 16.1 18.2 9.5 TABLE 154. Mortality fbom Syphilis, Locomotor Ataxia and General Paralysis of THE Insane, Combined, Classified by Color and by Sex. Death Bates per 100,000 Persons Exposed. Single Years in Period 1911 to 1916. Experience of Metropolitan Life Insurance Company. Industrial Department. White. Colored. Year. Persona. Males. Females. Males. Females. 1911 to 1916 14.3 16.6 7.3 43.3 25.2 1916 1915 1914 1913 1912 1911 15.7 16.0 14.6 13.7 13.7 11.0 17.7 17.9 16.9 16.5 16.2 13.8 7.6 8.5 7.2 6.9 7.4 6.1 55.3 55.0 47.8 37.0 35.3 25.9 30.6 27.1 26.7 25.4 24.6 15.7 SYPHILIS. 239 Even these tables, defective as they undoubtedly are, serve to indicate some important relations (of syphilis mortality) in the several color and sex classes. The death rate among colored lives is consistently higher than among whites. The rates are about three to one. The rates are much higher for males than for females in each one of the color groups. If we consider the figures for 1916, we will find a death rate of 55.3 for all ages combined for colored males. This is a mortality figure which must be consid- ered seriously, because it is higher than the rate for many other causes of death which are viewed with much alarm. More inter- esting relations, however, are brought out in the two following tables which give the death rates by age period both for syphilis so reported or identified, and for syphilis combined with locomotor ataxia and general paralysis of the insane. TABLE 155. Mortality from Syphilis, Classified by Color, Sex and by Age Period. Death Bates per 100,000 Persons Exposed. 1911 to 1916. Experience of Metropolitan Life Insurance Company. Industrial Department. Persona. White. Colored. Age Period. Males. Females. Males. Females. All ages — one and over 8.7 9.3 3.9 32.4 18.7 lto4 5 to 9 10 to 14 15 to 19 20 to 24 25 to 34 35 to 44 45 to 54 55 to 64 65 to 74 75 and over. . 2.6 .6 .6 1.3 3.3 10.2 22.0 24.1 20.1 15.3 13.0 2.0 .5 .6 .7 2.6 10.4 29.8 34.9 28.5 21.0 22.7 1.4 .4 .3 .9 1.6 4.2 9.0 10.1 8.3 7.0 4.2 12.8 2.3 3.2 4.2 11.8 35.2 60.8 71.0 74.4 60.1 54.9 14.6 2.6 1.6 7.0 12.4 21.3 31.3 33.0 26.8 24.7 18.1 A comparison of Tables 155 and 156 shows, as might be ex- pected, that for the earlier age periods no significant changes in the rates are caused by combining deaths reported from syphilis with those reported as due to locomotor ataxia and general paralysis of the insane. In the age groups which cover middle and old age, however, the death rates are raised very materially by the addition of deaths certified as due to these other causes but which are caused. 240 MORTALITY STATISTICS OF INSURED WAGE EARNERS. TABLE 156. Mortality from Syphilis, Locomotor Ataxia and General Paralysis op THE Insane, Combined, Classified by Color, Sex and by Age Period. Death Bates per 100,000 Persons Exposed. 1911 to 1916. Experience of Metropolitan Life Insurance Company. Industrial Department. Persona. White. Colored. Age Period. Males. Females. Males. Females. All ages — one and over 14.3 16.6 7.3 43.3 25.2 1 to4 5 to 9 10 to 14 15 to 19 20 to 24 25 to 34 35 to 44 45 to 54 55 to 64 65 to 74 75 and over. . 2.6 .7 .7 1.4 3.5 12.6 32.9 41.6 43.6 49.8 74.9 2.0 .6 .7 .9 2.7 13.8 48.2 65.0 64.0 65.1 112.1 1.4 :t 1.0 1.7 5.5 14.2 18.2 21.7 32.2 51.9 12.8 2.3 3.2 4.8 12.5 38.9 79.8 102.9 117.1 120.3 137.2 14.6 2.6 1.6 7.0 12.4 24.3 40.6 48.7 51.9 66.9 45.4 primarily, by S3rphilitie infection. The figures for the first age period, 1 to 4 years, do not constitute an adequate illustration of the well known fact that syphilis causes a very high mortality in early childhood. This experience does not cover the mortality of the first year of life; if it did the figures would be many times higher. After the first age group there is a decrease, but beginning with the period 15 to 19 years there is a continuous increase throughout the period of middle and old age. This continuous increase is shown, with one or two minor exceptions, for both males and females among white and colored policyholders. Attention is directed to the extremely high figures representing the mortality from syphilis among colored males at the period between 45 and 65 years. No reference is made here to the figures for the Eegistration Area because of the dissimilarity in the two experiences with respect to reporting practice, age and color factors. Syphilis is very common as a cause of death in the first year of life and this infant mortality finds no place in the insurance experience. The situation is further complicated by the uncertainty of the returns in the published mor- tality figures for the Eegistration Area and nothing can be gained by further comparison. CHEONIC BRONCHITIS. 241 Cheonic Beonchitis. Chronic bronchitis caused 4,224 deaths among Metropolitan In- dustrial policyholders during the six-year period 1911 to 1916 ; the death rate per 100,000 living was 7.9. This rate is much higher than that for acute bronchitis in the same experience, which is con- trary to the condition found in the expanding Registration Area of the United States. The difference is clearly due to the differing age distribution of the two populations. The disease has a marked color, sex and age incidence. The rates among colored persons are higher than among the white group for each of the two sexes. The highest mortality is attained in the latest age periods in this series, namely, 65 years and over, although the rates between 55 and 64 years are also significant. Unlike acute bronchitis, there is no high mortality in the earliest age periods of life. It is noteworthy also that the excess pointed out for colored lives does not continue into the advanced ages. From age 65 onward, the rates for white males and females are much in excess. It is not clear just what this reversal of the inci- dence in the two races indicates. The following table presents the facts for chronic bronchitis by color, sex and age : TABLE 157. MOETALITY FEOM CHRONIC BRONCHITIS, CLASSIFIED BY COLOR, SeX AND BT Age Period. Death Bates per 100,000 Persons Exposed. 1911 to 1916. Experience of Metropolitan Life Insurance Company, Industrial Department. Persons. White. 1 Colored. Age Period. Males. Females. Males. Females. All ages — one and over 7.9 6.8 8.1 9.4 11 4 lto4 5 to 9 10 to 14 15 to 19 20 to 24 25 to 34 35 to 44 45 to 54 55 to 64 65 to 74 75 and over. . 1.7 .9 .5 .9 1.7 2.4 3.6 9.1 29.5 113.2 304.4 1.4 .7 .2 .3 1.1 1.7 4.0 10.8 32.1 111.4 309.3 1.2 .8 .4 .5 .6 1.2 2.3 6.6 27.3 120.3 317.3 6.4 1.9 2.2 2.9 5.3 7.0 6.2 17.9 28.2 85.2 150.9 7.6 3.2 1.9 7.3 9.5 7.9 7.3 11.3 34.3 82.2 235.9 17 242 MORTALITY STATISTICS OF INSURED WAGE EARNERS. As in the case of acute bronchitis, we are not justified in compar- ing the above figures with those for the expanding Eegistration Area of the United States. The rates, as we have seen, are important only after age 65, and it is at these ages that the proportion of policyholders to total persons insured is much lower than in the general population. There has been a marked decline in the death rate in the insur- ance experience from chronic bronchitis since 1911 in each one of the color and sex classes. The same condition is to be observed in the figures for the expanding Registration Area. It is probable that the same cause has been at work to bring about this result, namely, improved reporting of causes of death by physicians. Many vital statistics offices in the country have for a number of years made a special effort to advise physicians against the use of the term "chronic bronchitis" when tuberculous bronchitis was meant. Undoubtedly the effect of this effort is shown in the rap- idly reducing figures for this cause of death. Rheumatism. Deaths from rheumatism are classified, according to the detailed International List of Causes of Death, under two distinct headings. The first is acute articular rheumatism and the second chronic rheumatism and gout. Unfortunately so many deaths are still re- ported as due to " rheumatism," without any qualification, that it is impracticable to determine which of these two conditions actually caused the deaths. The report of "rheumatism" is frequently made in cases where the deaths were due to the acute infection, rheumatic fever, a disease which has epidemic prevalence. This is the condition which the present title No. 47 of the International List (acute articular rheumatism) was intended to cover. Unfor- tunately, however, the same term "rheumatism" is also returned for many cases of arthritis deformans, which is a disease of the joints of doubtful etiology, but which ordinarily pursues a chronic course. It is also used in cases in which physicians intended it as the equivalent of "chronic rheumatism," a term used loosely for all sorts of long standing painful conditions of the joints, nerves, bones and other parts of the body. Any attempt at this time to show separately the mortality actually due to acute rheu- matic fever on the one hand and to chronic rheumatoid arthritis RHEUMATISM. 243 and to gout, on the other must, therefore, necessarily fail under present conditions of reporting and tabulation. This conclusion is fully demonstrated by an analysis of the age distribution of the deaths charged to acute articular rheumatism in the Metropolitan experience during the period 1911 to 1916. There were 3,409 deaths assigned to acute articular rheumatism during this six-year period, of which 1,023, or 30 per cent., were those of persons over 45 years of age. When these figures are con- sidered in connection with the fact that young adults are the ones principally affected by rheumatic fever and that considerably less than 10 per cent, of the cases, based on authentic experience, might be expected to affect those over 45 years of age, it is readily seen that it is very improbable indeed that the majority of these deaths in the higher age periods are correctly classified. This condition is even more pronounced in the reports of the general population, for according to the annual mortality report of the Census Bureau for 1915, out of 3,274 deaths charged to acute articular rheuma- tism, 1,383 or 42.2 per cent, were those of persons over 45 years of age. This is contrary to clinical experience. TABLE 158. Mortality from Eheumatism (Acute and Chronic), Classified by Color, Sex and by Age Period. Death Bates^per 100,000 Persons Exposed. 1911 to 1916. Experience of Metropolitan Life Insurance Company. Industrial Department. Persona. White. Colored. Age Period. Males. Females. Males. Females. All ages — one and over 7.4 6.8 7.2 9.4 11.3 1 to 4 5 to 9 10 to 14 15 to 19 20 to 24 25 to 34 35 to 44 45 to 54 55 to 64 65 to 74 75 and over. . 2.8 7.9 7.6 5.5 4.0 4.4 5.8 9.4 16.3 35.5 57.6 3.3 8.0 6.8 5.7 3.6 4.0 5.8 9.8 13.7 28.3 41.1 2.4 8.2 8.8 5.1 3.9 3.9 4.3 7.2 14.8 35.5 56.9 3.8 5.5 5.1 5.1 6.2 5.0 10.2 15.6 26.4 41.8 178.4 1.3 5.8 7.1 7.0 5.5 7.4 9.9 16.2 30.8 71.6 90.7 In this discussion, for the reasons noted above, it has been decided to combine the two International List titles and to consider them 244 MORTALITY STATISTICS OF INSURED WAGE EARNERS. as one statistically with the full knowledge that different clinical entities are included. Only the future will determine what the true incidence of these separate diseases is. The number of deaths from these two diseases combined among Metropolitan Industrial policyholders during the period 1911 to 1916 was 4,007 and the death rate was 7.4 per 100,000 exposed. Of these deaths 3,409 were classified under " acute articular rheu- matism " with a corresponding death rate of 6.3 ; 598 deaths, with a rate of 1.1, were charged to "chronic rheumatism and gout." Of the 598 deaths charged to the latter, 502 or 83.9 per cent, were those of persons over 45 years of age. " Eheumatism," analyzed in this way, shows a higher death rate for females than for males among both white and colored policy- holders; it shows quite a pronounced excess in the death rate of colored persons over whites. This same excess is also exhibited in the reports for the general population. The higher death rates for the females, however, are in evidence chiefly during the three high- est age periods, and it will be observed that during the chief wage- earning periods, among white policyholders at least, the death rates for the males are somewhat greater. The table on page 243 pre- sents the mortality during the period 1911 to 1916 among Metro- politan Industrial policyholders by color, sex, and age. TABLE 159. Mortality from Eheumatism (Acute and Chronic), Classified by Color and by Sex. Death Bates per 100,000 Persons Exposed. Single Years in Period 1911 to 1916. ExperieDce of Metropolitan Life Insurance Company. Industrial Department. Persons. White. Colored. Year. Males. Females. Males. Females. 1911 to 1916 7.4 6.8 7.2 9.4 11.3 1916 1915 1914 1913 1912 1911 5.9 6.9 7.3 7.8 8.2 8.9 6.2 6.5 6.4 7.2 7.3 7.7 5.6 6.8 7.2 7.4 7.8 8.9 6.4 7.5 9.4 9.7 14.1 9.6 7.8 10.1 11.2 12.4 11.6 15.3 The general trend of the mortality charged to these diseases is downward, the maximum for the period 1911 to 1916 among the ACUTE BEONCHITIS. 245 insured having been the rate of 8.9 per 100,000 exposed in 1911 and the minimum, that of 5.9 in 1916. A continuous decrease is shown throughout the intervening years. This downward tendency is observed for both white and colored policyholders. Table 159 shows the trend of the mortality from "acute articular rheuma- tism" and "chronic rheumatism and gout" combined during the period 1911 to 1916. Acute Bkonchitis. There were 2,636 deaths among Metropolitan Industrial policy- holders from acute bronchitis during the six-year period 1911 to 1916. This corresponds to a death rate of 4.9 per 100,000 living. The deaths are concentrated at the two extremes of life, that is, under age 5 and over age 65. Taking the experience as a whole, 70 per cent, of all the deaths from acute bronchitis are found in these age periods. During the remaining years of life the deaths are so few as hardly to justify any particular comment. The death rate from acute bronchitis is considerably higher among colored than among white persons; the rate for females in each group is higher than for males. The highest rate in the total experience is found in the age group 75 years and over, 100.4 per 100,000. The next highest rate is in the period 65 to 74 years, 31.9 per 100,000. The age period 1 to 4 years follows with a rate of 27.0. These age characteristics, however, are very different when we consider the white and colored races. Among colored males and females, about one-half the deaths from acute bronchitis are found in the period 1 to 4 years ; this results in very high death rates for this early period of life ; in fact, the rate for colored males was over two and one-half times that for white males and that for colored females three and one- third times the rate for white females. The table on page 246 presents the facts by age period and for each sex and color group. It is impossible to make a fair comparison between the death rates referred to above and those for the expanding Kegistration Area of the United States. The reason is that acute bronchitis is a dis- ease which causes death chiefly in infancy and old age but more especially in early infancy. In the Eegistration Area over one- half of the deaths charged to this disease are of infants under one year of age and a very considerable number relate to persons over 246 MORTALITY STATISTICS OF INSUEED WAGE EARNERS. TABLE 160. Mortality feom Acute Bronchitis, Classified bt Color, Sex and by Age Period. Death Bates per 100,000 Persons Exposed. 1911 to 1916. Experience of Metropolitan Life Insurance Company. Industrial Department. Persons. White. Colored. Age Period. Males. Females. Males. Females. All ages — one and over 4.9 4.4 4.8 6.4 7.5 1 to4 5 to 9 10 to 14 15 to 19 20 to 24 25 to 34 35 to 44 45 to 54 55 to 64 65 to 74 75 and over . . 27.0 2.0 .5 .6 .6 1.0 1.5 2.3 8.1 31.9 100.4 23.5 1.9 .5 .3 .4 .7 1.3 3.0 8.0 26.8 68.1 23.9 1.7 .2 .4 .4 .4 .9 1.7 8.7 37.4 123.1 62.8 1.9 2.2 1.0 2.6 3.4 3.8 4.2 6.6 8.4 68.6 80.0 5.1 2.5 4.1 2.1 2.8 3.4 2.6 5.7 29.4 81.7 70 years of age. In the first of these age groups there are no Metro- politan policyholders at all, and for persons over 70 a far smaller proportion of Industrial policyholders were observed than were esti- mated to be in the general population. It is, therefore, not at all surprising that the crude rate for acute bronchitis in the general population is very much higher than that for the Industrial expe- rience but no significance can possibly be attached to these dif- ferences. There have been slight and unimportant changes in the death rate in the Industrial experience in the period between 1911 and 1916^^.-- y-^-"""^^ Alcoholism, Acute or Chronic. There were 2,555 deaths among Metropolitan Industrial policy- holders during the period 1911 to 1916, which, on the basis of descriptions of causes of death on death claims, were classified as due to alcoholism. The death rate was 4.7 per 100,000 exposed. There were no marked variations in the mortality, as compiled, during the six-year period, the maximum rate for the period being that for 1912 (5.3) and the minimum for the year 1911 (4.0). Compared year by year with the death rates for the expanding Eeg- istration Area, it will be noted that those for the latter were, in ALCOHOLISM^ ACUTE OK CHKONIC. 247 general, a little higher than those for the policyholders, the single exception being the year 1912 when the rate was the same for each experience (5.3). Color, Sex, and Age Incidence. The death rate per 100,000 for white males (8.8) was higher than for colored males (6.8) and that for white females (1.6) was slightly in excess of the rate for colored females (1.5). The heaviest mortality was registered in the age period 35 to 44 years (14.2 per 100,000 exposed), with a rate in the following age period, 45 to 54 years, but slightly less (13.9 per 100,000). In these two age groups occurred 1,529 deaths or 59.8 per cent, of all the deaths reported from this cause among the insured group. Considerably more than half of the mortality from this cause occurs, year after year, in the experience of the expanding Eegis- tration Area between the ages of 35 and 55 years. The mortality under 25 years of age from alcoholism is negligible. For white males the rate for the period 45 to 54 years is slightly higher than in the preceding period ; for white females and for colored persons of each sex the rate at this period is either slightly lower than or identical with that for the preceding period. After age 54, how- ever, there is a uniform decline. The following table gives the rates per 100,000 exposed by color, sex, and by age period: TABLE 161. Mortality from Alcoholism, Classified by Color, Sex and by Age Period. Death Bates per 100,000 Persons Exposed. 1911 to 1916. Experience of Metropolitan Life Insurance Company. Industrial Department. Persons. White. Colored. Age Period. Males. Females. Males. 1 Females. All ages — one and over 4.7 8.8 1.6 6.8 1.5 ltol9 20 to 24 25 to 34 35 to 44 45 to 54 55 to 64 65 to 74 75 and over. . .1 1.0 6.2 14.2 13.9 10.2 8.4 4.8 t 1.7 12.8 32.2 32.4 24.0 18.4 12.8 t .3 2.4 4.7 4.1 2.2 2.3 .3 1.6 6.0 16.6 14.7 13.8 16.7 13.7 .4 1.1 1.5 3.1 3.1 1.3 f Less than .05 per 100,000 exposed. 248 MORTALITY STATISTICS OF INSURED WAGE EARNERS. Unreliability of the Data for Alcoholism. Published reports of deaths and death rates for alcoholism are not regarded seriously by those who compile them. The difficulties which beset the path of the vital statistician in obtaining figures covering mortality from this condition are many and serious. The same trouble is encountered as is found in dealing with the venereal diseases: physicians often hesitate and, in fact, wilfully refuse to write on death certificates the name of the primary cause of death when such cause is one which might cast a certain degree of odium on the family of the deceased. In such diseases as this many phy- sicians reason that if they cannot comply with the requirement of the law and at the same time have what they consider due regard for the confidence of patients and the positions of their families, they will disregard the spirit of the law and report as causes of death terminal or complicating conditions rather than primary causes. There is little question that each year thousands of deaths occur in which alcoholism was a factor but which are never re- turned as due to this cause. Many of the deaths reported as due to "cirrhosis of the liver" are deaths of which alcoholism was the primary and causative factor. Many that are ascribed to "menin- gitis " are caused by that variety known as alcoholic serous menin- gitis. Many reported as caused by "apoplexy" or "cerebral edema" are in reality cases of alcoholic cerebral apoplexy' or alco- holic cerebral edema, or what is commonly known as alcoholic " wet brain." The death rates in the table on page 247 are not presented, therefore, as figures representing the actual or approximate mor- tality from alcoholism among the Company's Industrial policy- holders. They represent reported conditions — not actual condi- tions. The rates would be much lower than they are if it were not for the fact that special inquiries by the Statistical Bureau have brought out the fact of the existence of alcoholism in many cases where no mention of it was made by the physicians in their state- ments to the Company or on certified copies of the death certifi- cates. Many years will elapse before even approximate death rates covering the mortality from this disease can be presented by any statistical office. CHAPTEE XVI. This chapter will deal with the following diseases : (1) Pellagra. (2) Malaria. (3) Angina Pectoris. (4) Ulcer of Stomach. (5) Acute Poliomyelitis. Pellagra. The facts for pellagra mortality in this investigation of insured wage earners are of special importance, first, because the areas rep- resented in this inquiry cover a large part of the region of pellagra incidence in the United States, and second, because the figures refer to the wage earning group of the population among whom pellagra is more prevalent than in populations generally. Furthermore, adequate data on the race or color, sex and age incidence, in rela- tion to persons exposed, are also available from this study and these may aid the laboratory and clinical experts in their researches into this disease. The published population mortality statistics do not, at present, offer such opportunities for the detailed examination of pellagra mortality. The table on page 250 gives an idea of the geographic distribution of pellagra in the several districts of the South and Southwest where most of the pellagra deaths in this experience were recorded. The color incidence is also shown. It will be observed upon comparison of the following table with the one for malaria (shown on page 256) that, in general, where malaria death rates are high, pellagra death rates are low. This does not, of course, indicate any relation between the two diseases. It does emphasize the fact, however, that the chief sanitary problem of the coast, gulf and river plain of the South is malaria and that of the Southern Appalachian Plateau, supporting a considerable factory population, is pellagra. Malaria and pellagra are two of the outstanding diseases and conditions which still constitute a serious menace to the efficiency of the Southern wage earner — more so for the negro than for the white man. Both diseases, when of 249 250 MORTALITY STATISTICS OF INSURED WAGE EARNERS. TABLE 162. MOETALITY FEOM PELLAGRA IN SELECTED SOUTHERN DISTRICTS. Classified hy Color. Years 1914, 1915 and 1916 Combined. Bates per 100,000 Exposed. Experience of Metropolitan Life Insurance Company. Industrial Department. Area and District. Rate per 100.000. White. Colored. 3.3 17.9 27.5 57.6 16.0 28.7 16.5 63.1 68.8 106.0 67.7 101.0 176.6 293.9 102.3 108.5 33.4 70.4 5.4 19.1 11.4 8.7 81.4 102.4 53.1 98.1 35.1 127.3 167.5 167.9 83.8 117.8 51.5 57.5 29.5 61.2 68.8 56.8 22.3 109.3 41.4 40.3 24.2 19.6 56.2 52.3 Entire Metropolitan Experience Southern districts combined . . Birmingham, Ala Little Rock, Ark Atlanta, Ga Augusta, Ga Columbus, Ga Macon, Ga Savannah, Ga New Orleans, La Poplar Bluff, Mo Charlotte, N. C Greensboro, N. C Raleigh, N.C Columbia, S. C Spartanburg, S. C Chattanooga, Tenn Jackson, Tenn KjioxvUIe, Tenn Memphis, Tenn Nashville, Tenn Richmond, Va Roanoke, Va the chronic type, involve long periods of disability for work and in certain areas of intensive incidence, are the cause of heavy pre- ventable mortality at the productive ages of life. Among the white industrial population in certain sections of the South, malaria and pellagra, together, often assume more importance as causes of death than does tuberculosis. Before drawing any conclusions on the comparative color, sex and age incidence of the disease it should be remarked that the exposure upon which the death rates reported in this study are based, comprises all of the Company's policyholders in the United States and in Canada. A very large proportion of this exposure, therefore, was located in nonpellagrous territory. In the discus- sion of malaria it will he remarked that 20 per cent, of the Com- pany's total exposure to risk was located in the Southern and PELLAGRA.. 251 Southwestern sections of the country. In order to have death rates best constituted for purposes of investigating the true color, sex and age incidence of the disease it would be desirable to confine the exposure and deaths to pellagrous portions of the country. This is, however, quite impracticable at the present time both for population and insurance data. The rates are presented with this reservation as to the lack of homogeneity in the geographic areas of the exposures and of the deaths. The figures have considerable value, nevertheless, as will be seen in the following table: TABLE 163. Mortality pkom Pellagra, Classified by Color, Sex and by Age Period. Death Bates per 100,000 Persons Exposed. 1911 to 1916. Experience of Metropolitan Life Insurance Company. Industrial Department. Persons. White. Colored. Age Period. Males. Females. Males. Females. AH ages — one and over 4.3 1.6 3.9 6.4 20.7 lto4 5 to 9 10 to 14 15 to 19 20 to 24 25 to 34 35 to 44 45 to 54 55 to 64 65 to 74 75 and over. . .4 .3 .6 .9 2.8 5.5 8.9 9.2 13.0 11.9 10.1 .2 t .2 .3 .3 1.4 2.9 4.1 10.9 10.3 9.9 :5 .2 .5 .9 2.5 4.8 8.4 8.1 10.1 8.8 5.0 2.3 2.3 2.7 1.3 2.3 4.6 8.8 15.3 19.2 21.7 41.2 1.5 3.5 3.4 6.2 19.8 24.5 31.1 30.9 39.2 41.1 45.4 ■{■Less than .05 per 100,000 exposed. There is a constantly rising death rate with advancing age. The disease has its lowest incidence as a cause of death in the ages of childhood. In fact, the number of deaths of white children under 15 is negligible; colored children show a larger number of cases. After age 15, the rates increase regularly with age until the age period 55 to 64 years is reached. From this point onward the rates fall slightly among white lives but continue to increase among the colored The death rate among colored persons is higher than among white persons. This is true at every age period and for both sexes. In fact, the rate is four times as high for the colored males as for the white males, all ages combined, and more than five times as 252 MORTALITY STATISTICS OF INSURED WAGE EARNERS. high for the colored females as for the white females. This con- dition is largely the result of the different geographic distributions of the white and colored policyholders. The latter reside for the most part in the Southern States where pellagra is common, whereas the majority of white policyholders reside in the Northern States where pellagra is still very rare. There is, nevertheless, a real excess in the mortality rate among the colored as is shown by the figures in the first table of this section for a number of representa- tive southern cities and towns where pellagra has been prevalent for a number of years. The rate for females is higher than for males both among the white and among the colored. This is found at virtually every age period. From ages 25 to 54 years the pellagra death rate of white males is only from 30 to 50 per cent, that of white females. Begin- ning with the age period 55 to 64 years and continuing to the end of the table, white males, however, show a higher pellagra mortality than do white females. Colored males at all age periods show lower death rates for pellagra than do colored females. It would be very interesting to learn why females in this country have the higher rates since no such relation between pellagra death rates of the sexes has been observed in a number of other countries where the disease is prevalent. Comparison of Pellagra Mortality Among Insured Wliite Persons and Among the General Population of the Expanding Registration Area of the United States. A comparison of pellagra mortality among this group of insured wage earners and among the population of the expanding Regis- tration x\rea in the United States is possible under certain limiting conditions. It must be remembered, in the first place, that the exposure to risk in the insurance experience covers a very much larger proportion of persons in the pellagrous region of the South and Southwest than does the population included in the expanding Registration Area of the United States. This fact in itself would account for the great excess in pellagra death rates of insured white persons. Thus, between 25 and 64 years for both white males and white females, there is, practically, a constantly rising rate of excess in the pellagra death rate of insured white persons over the rates for the general population of the Registration Area. The excess is PELLAGRA. 253 more marked for insured white males than for insured white females. In view of the difference between the two sets of data as to geo- graphic area and as to the social status of persons included in both experiences, it would be well not to stress comparison of the figures too far. The pellagra mortality experience of the Eegistration Area, 1910 to 1915, and of insured white persons, 1911 to 1916, according to sex and age period is shown comparatively in the fol- lowing table: TABLE 164. Mortality from Pellagra. Death Rates per 100,000 Persons Exposed. Classified by Sex and Age Periods. Insured White Lives in Experience of Metropolitan Life Insurance Com- pany, Industrial Department (1911 to 1916) and General Popula- tion of Expanding Registration Area of the United States (1910 to 1915). Males. Females. Age Period. M. L. I. Co. (Whit*). U. S. Keg. Area. Percentage M. L. I. Co. of Reg. Area. M. L. 1. Co. (White). U. S. Reg. Area. Percentage M. L. I. Co. of Reg. Area. All ages — one and over. . . 1.6 1.1 145.5 3.9 2.8 139.3 1 to 4 .2 .2 100.0 .5 .3 166.7 5 to 9 t .3 10.0 .2 .3 66.7 10 to 14... .2 .2 100.0 .5 .4 125.0 15 to 19.... .3 .2 150.0 .9 1.0 90.0 20 to 24.... .3 .5 60.0 2.5 2.4 104.2 25 to 34... 1.4 .9 155.6 4.8 3.7 129.7 35 to 44.... 2.9 1.4 207.1 8.4 5.2 161.5 45 to 54.... 4.1 2.3 178.3 8.1 4.9 165.3 55 to 64.... 10.9 3.8 286.8 10.1 5.4 187.0 65 to 74.... 10.3 3.8 271.1 8.8 4.9 179.6 75 and over 9.9 3.4 291.2 5.0 3.7 135.1 f Less than .05 per 100,000 exposed. An examination of the above table will show some interesting similarities in the two experiences. In the first place, females in both cases show higher rates than do males; there are only a few unimportant exceptions. Secondly, the rates increase with ad- vancing age. In spite of their differences, therefore, the two sets of data confirm one another in essential respects. If they do not correspond more closely in actual rates it is because they refer to different geographic areas. The above conclusion is confirmed by the similar distribution of the deaths from pellagra by age in the two experiences as is shown in the following table : 254 MORTALITY STATISTICS OF INSURED WAGE EARNERS. TABLE 165. Number and Percentage Distribution of Deaths from Pellagra. 1911 TO 1915. Classified by Age Period. Insured White Lives in Experience of Metropolitan Life Insurance Company, Industrial Department, and General Population of Expanding Eegistration Area of the United States. Metropolitan Experience. V. S. Registration Area. Age Period. Per Cent, of Per Cent, of No. of Deaths. Total. No. of Deaths. Total. All ages — one and over 1942 100.0 6694* 100.0 ltol4 74 3.8 264 3.9 15 to 19 52 2.7 193 2.9 20 to 24 136 7.0 491 7.3 25 to 34 394 20.3 1326 19.8 35 to 44 453 23.3 1565 23.4 45 to 54 355 18.3 1214 18.1 55 to 64 340 17.5 947 14.1 65 to 74 120 6.2 516 7.7 75 and over 18 .9 178 2.7 * Known ages only. The two distributions are much alike. It is only after age 55 that differences make themselves felt and these are the result in all probability of the very different age constitution of the living in the two groups; the proportion of policyholders after age 65 is very much lower than the proportion in the corresponding age group of the general population. For the ages preceding this period of life, however, there is virtual correspondence. Trend of the Death Rate from Pellagra. The death rate from this disease may be expected to vary accord- ing to the greater or less intensity of the factors which produce the disease in the first place, and which aggravate the disease and re- tard recovery in the second place. It has been fairly well estab- lished by recent research work of the U. S. Public Health Service that pellagra is a deficiency disease, the result of a persistent ab- sence in the diet of meat, eggs, milk, beans, peas and other proteins. The every-day diet of the wage earning element in the South is characterized by this deficiency and is conditioned primarily by the state of industry, the regularity of emplojrment and the wage-level. An important secondary fact not to be overlooked, however, is the general status of some parts of the industrial population of the South as regards efficiency in personal and home life, and whether PELLAGKA. 255 or not there is disregard of the plain facts of hygiene, diet and order in the home. In the following table are shown the facts of pellagra mortality for the six year period 1911 to 1916, distinguishing single calendar years : TABLE 166. Mortality feom Pellagra, Classified by Color and by Sex. Death Bates per 100,000 Persons Exposed. Single Years in Period 1911 to 1916. Experience of Metropolitan Life Insurance Company. Industrial Department. Persona. White. Colored. Year. Males. Females. Males. Females. 1911 to 1916 4.3 1.6 3.9 6.4 20.7 1916 1915 1914 1913 1912 1911 3.6 6.7 5.3 3.3 2.8 3.6 1.4 2.1 2.2 1.3 1.2 1.7 2.7 5.9 4.7 3.4 2.6 4.1 6.2 12.2 6.9 4.6 4.1 3.4 22.4 36.6 26.7 13.1 12.5 10.5 The possible effect of economic conditions upon the incidence of pellagra may be seen from the foregoing data. Late in 1914 and in 1915, when the economic situation in the South was exceedingly grave, the pellagra mortality rates were high. In 1916, following a period of economic revival, characterized by an extraordinary movement of raw and manufactured cotton products, resulting in prosperity for both employers and wage earners alike, the pellagra death rate dropped to a figure of 3.6 per 100,000 exposed. These economic facts affected both the white and colored groups in this experience, and likewise, probably, the pellagra death rates of these groups. It must be remembered that pellagra manifests itself mainly in two clinical forms, an acute type and a chronic recurrent form. It is probable that an improvement in the industrial situation which results in better wages and regular employment and consequently in a more generous family diet reduces the number of acute cases and that it modifies the severity of the chronic recurrent form of the disease. 256 MORTALITY STATISTICS OF INSUEED WAGE EARNERS. Malaria. No infection, except perhaps tuberculosis, compares with malaria in the extent of its geographic distribution or in its importance as a cause of physical disability among mankind generally. Fifty years ago, in the United States, malaria seriously affected nearly every state then fairly thickly populated. Noteworthy epidemics were recorded in Michigan, New Jersey, Pennsylvania and Massa- chusetts, as well as in the South, where the disease still lingers as a cause of considerable and preventable loss. The advance of sani- tary engineering, the growth of populations and the subsequent filling-in of swampy areas have gradually eliminated the breeding grounds of the anopheles mosquito and have thus almost eradicated malaria from the northern tier of states. The very largest regis- tration of malaria in this mortality experience of wage earners was drawn from the group of persons insured in the southern and southwestern portions of the United States. It is significant to TABLE 167. Mortality from Malaria in Selected Southern Districts. Classified by Color. Years 1914, 1915 and 1916 Combined. Bates per 100,000 Exposed. ExperieDce of Metropolitan Life Insurance Company. Industrial Department. Area and Diatxict. Rate per 100,000. Entire Metropolitan Experience Southern districts combined . . Birmingham, Ala Little Rock, Ark Augusta, Ga Columbus, Ga Macon, Ga Savannah, Ga Cairo, 111 Paducah, Ky New Orleans, La Poplar Bluff, Mo St. Louis, Mo Charlotte, N. C Raleigh, N. C Columbia, S. C Jackson, Tenn Memphis, Tenn NashviUe, Tenn L4 9.3 5 33 32 12, 28, 11, 44, 54, 4, 106, 2, 4. 15, 17, 51, 33, 2, 15.8 41.6 35.9 160.7 34.5 S4.5 36.2 130.3 54.2 73.2 36.4 60.9 9.4 46.5 50.9 21.7 89.0 105.9 17.6 MALAEIA. 267 observe also that most of these malaria deaths occurred in the coastal, gulf and river plain of the South and nominally few of them on the Appalachian Plateau. The table on page 256 shows the geo- graphic distribution of the malaria deaths in this mortality expe- rience for the combined years 1914, 1915 and 1916, the only three years for which the data are fully available with respect to geo- graphic incidence. The 2,295 deaths from malaria in the experience of the six year period correspond to a death rate of 4.3 per 100,000 persons exposed. It should be remembered in considering this rate that whereas most of these deaths from malaria came from territory in the southern and southwestern sections of the United States, the exposure upon which the death rates are based covers all of the Company's policy- holders in the United States and Canada. The southern and south- western business of the Company in 1916 constituted approxi- mately 20 per cent, of the total exposure. The total rate is there- fore devoid of much meaning although the figures for the incidence by color, sex and age do show interesting interrelations and these are given in the following table : TABLE 168. MOETAIilTY FROM MALARIA, CLASSIFIED BY COLOR, SEX AND BY AGE PERIOD. Death Bates per 100,000 Persons Exposed. 1911 to 1916. Experience of Metropolitan Life Insurance Company. Industrial Department. Persons. White. Colored. Age Period. Males. Females. Males. Females. All ages — one and over 4.3 2.1 1.9 17.8 22.1 1 to 4 6.5 3.7 3.7 42.9 44.4 5 to 9 3.2 2.2 1.7 16.6 17.3 10 to 14 1.9 1.1 1.1 5.4 13.4 15 to 19 1.9 .9 .7 9.9 12.9 20 to 24 2.8 1.2 1.2 13.8 14.5 25 to 34 3.4 1.4 1.1 12.4 14.7 35 to 44 3.8 2.0 1.3 11.2 16.1 45 to 54 6.5 3.3 2.6 24.4 29.0 55 to 64 10.0 3.9 4.5 41.4 54.6 65 to 74 16.0 8.4 7.0 81.9 89.3 75 and over. . 15.4 9.9 4.2 123.5 99.8 Comparisons between the white and colored malaria death rates should be made with special caution. Most of the colored policy- 18 258 MORTALITY STATISTICS OF INSURED WAGE EARNERS. holders in the Company's experience are located in the South and Southwest, and this fact alone would conduce to a much higher malaria death rate than was recorded among white persons, the majority of whom are located in northern areas not affected to any great extent by malarial infection. The comparative malaria death rates presented in the introductory table to this section will give some idea, however, of the relative color incidence at least of deaths from malaria. According to the age statistics, malaria mortality was nearly eight and one-half times as frequent among colored males and nearly 12 times as frequent among colored females as among the corresponding sex groups of the white population. Males of the white experience showed a malaria death rate practically eleven per cent, higher than did females of the same race group. Colored males, on the other hand, showed a malaria mortality practically twenty per cent, more favorable than the rates for colored females. It is not possible to account for this reversal of the sex ratio of malaria mortality from the facts at hand. The age characteristics of the malaria mortality curve are well defined. The highest rates are found at the two extremes of life, the minimum being reached at the period of adolescence. From age 20 onward the rates increased fairly regularly with only here and there an exception. A high mortality figure for the period of early childhood is to be noted. TABLE 169. MOETALITY FROM MALARIA, CLASSIFIED BY SEX AND BY AgE PERIOD. Death Bates per 100,000 Persons Exposed. 1910 to 1915. Experience of the Expanding Eegistration Area of the United States. Age Period. All ages — one and over . 2.4 1 to4 5 to 9 10 to 14.... 15 to 19.... 20 to 24 25 to 34 35 to 44.... 45 to 64 ... . 55 to 64 ... . 65 to 74.... 75 and over. 2.4 4.4 4.9 1.7 1.6 1.0 1.2 1.2 1.3 1.5 1.7 1.5 1.6 1.8 1.7 2.7 2.3 4.5 3.6 5.9 6.0 13.1 11.6 MALARIA. 259 Because of the sharp differences in geographic distribution of the two groups of exposed lives it is not deemed desirable to make a direct comparison between the death rates of insured wage earners and those for the general population in the expanding Registration Area of the United States. It may be of interest, however, to observe the very similar conformation of the curve of mortality by age and sex in the Eegistration Area during the period 1910 to 1915. This is offered on page 258. At some of the age periods the death rates of the insured expe- rience are higher and at others they are lower than those shown for the Registration Area considered by sex, but no significance may be attached to these ratios. The population mortality figures for the disease, however, are valuable in that they confirm the relation previously outlined in the death rates by age period, namely, a crest at each end of the mortality curve and a minimum point between 10 and 20 years of age. Trend of the Malaria Death Rate — 1911 to 1916. The malaria death rate of 1911 was the highest and the rate of 1916 was the lowest in the Industrial experience. During this period the rate declined without exception, the figure for 1916 being less than one-half that recorded for 1911. The decline was more pronounced for white than for colored persons and greater for females than for males in each color group. The facts are shown below for each of the single calendar years : TABLE 170. MOETAUTY FROM MALARIA, CLASSIFIED BY COLOR AND BT SEX. Death Bates per 100,000 Persons Exposed. Single Years in Period 1911 to 1916. Experience of Metropolitan Life Insurance Company. Industrial Department. Persons. White. Colored. Year. Males. Females. Males. Females. 1911 to 1916 4.3 2.1 1.9 17.8 22.1 1916 1915 1914 1913 1912 1911 2.9 3.5 3.7 4.5 5.4 6.1 1.4 1.7 1.7 2.1 3.1 3.2 1.3 1.8 1.6 1.8 2.4 3.0 14.4 14.3 16.2 20.5 20.9 21.2 15.1 17.7 21.0 23.5 26.6 30.6 260 mortality statistics of insured wage earners. Angina Pectoris. Two thousand two hundred and eighteen (2,218) deaths from angina pectoris were reported in this experience during the six year period 1911 to 1916, corresponding to a death rate of 4.1 per 100,000 exposed. In no year was the mortality from this cause noticeably high as compared with other years. The maximum death rate was observed in 1913 (4.4) and the minimum in 1916 (3.8). The death rates for the expanding Eegistration Area of the United States showed the same general uniformity but were con- siderably higher than those for the Metropolitan experience. The maximum rate for the Eegistration Area during the sexennium was 7.7 per 100,000 population in 1915 and the lowest was that for 1911 (7.1). The higher mortality in the Eegistration Area as compared with the Metropolitan experience was due almost alto- gether to the age distribution of the two experiences. About 40 per cent, of the deaths due to angina pectoris are those of persons over 70 years of age and the exposure at these ages is very much smaller among the Industrial policyholders than in the population of the Eegistration Area. Color, Sex and Age Incidence. The death rates for Metropolitan policyholders were identical for white and colored males (4.6), but showed a rather marked excess for colored females (5.8) over white females (3.5). Among white policyholders, the death rate for males was higher than that for females, but among colored policyholders the contrary was true. Among white decedents, the excess of mortality of males over fe- males was very marked for the age groups in which the greatest number of deaths occurred, namely, 45 to 54, 55 to 64 and 65 to 74 years. Among colored persons the rates for females for the age periods 45 to 54 years (15.7) and 65 to 74 years (38.8) were much higher than those for males at these age periods (10.1 and 30.1) ; for the period 55 to 64 years, however, the male rate (21.0) slightly exceeded the female rate (19.8). The following table presents the facts by color, sex and age : ANGINA PECTOEIS. 261 TABLE 171. Mortality from Angina Pectokis, Classified by Color, Sex and by Age Period. Death Rates per 100,000 Persons Exposed. 1911 to 1916. E-Tperience of Metropolitan Life Insurance Company. Industrial Department. Persons. White. Colored. Age Period. Males. Females. Males. Females. ■ All ages — one and over 4.1 4.6 3.5 4.6 5.8 1 to 24 25 to 34 35 to 44 45 to 54 55 to 64 65 to 74 75 and over. . .2 1.2 3.4 8.3 21.4 49.4 70.1 .1 1.2 3.5 12.0 28.9 68.8 73.8 .2 .9 2.2 4.6 16.8 39.8 73.7 .5 2.0 7.6 10.1 21.0 30.1 .3 2.8 6.4 15.7 19.8 38.8 54.4 In the analysis of these figures, it should be borne in mind that the number of deaths involved among colored policyholders was only 353 and that this number is quite too small to use as a basis for important conclusions. Another point should be remembered, namely, that the term " angina pectoris " is used loosely in this country. It is still a favorite expression, especially with coroners, in cases of sudden death. Ulcer of the Stomach. Ulcer of the stomach caused 2,159 deaths among Metropolitan Industrial policyholders during the six year period 1911 to 1916, corresponding to a death rate of 4.0 per 100,000 exposed. Ex- amination of the rates for the different years shows that there were no fluctuations of importance, the rate for 1915 (3.8) showing the greatest deviation from the average for the period. The death rate for ulcer of the stomach in the Eegistration Area showed a slight upward trend; in fact this has been continuous during the period, the maximum (4.6) being that for the year 1916. Color, Sex and Age Incidence. The crude death rates for the Metropolitan Industrial policy- holders indicate a higher incidence for colored persons than for white persons, and a preponderance of mortality of males among 262 MOETALITT STATISTICS OF INSURED WAGE EARNERS. the white, but of females among the colored. Among the males, the highest rates were found at the age period 75 and over, 21.3 per 100,000 for the white and 41.2 per 100,000 for the colored. There was a continuous increase throughout the lower age periods until the maximum was reached at the age period 75 years and over. Females had the highest rates at the age period 65 to 74 (17.9 and 28.2 per 100,000 white and colored policyholders respectively). Beginning with the earliest period, they also showed a continuous increase throughout the lower age groups. The following table shows the color, sex and age incidence of ulcer of the stomach among Metropolitan Industrial policyholders : TABLE 172. -Mortality from Ulcer of the Stomach, Classified by Color, Sex AND BY Age Period. Beath Bates per 100,000 Persons Exposed. 1911 to 1916. ExperieDjce of Metropolitan Life Insurance Company. Industrial Department. Persons. White. Colored. Age Period. Males. Females. Males. Females. All ages — one and over 4.0 4.3 3.1 6.2 6.4 ltol9 20 to 24 25 to 34 35 to 44 45 to 54 55 to 64 65 to 74 75 and over .4 2.0 3.9 7.6 9.7 12.9 19.7 18.7 .3 1.8 4.6 10.3 15.3 17.4 19.1 21.3 .4 1.8 2.8 5.0 6.0 9.3 17.9 15.9 .4 2.3 5.5 11.8 11.1 16.2 35.1 41.2 1.1 4.0 6.3 9.1 10.7 15.0 28.2 18.1 Acute Poliomyelitis. With the exception of the single year 1916, acute poliomyelitis has caused only between 100 and 150 deaths per annum in the en- tire mortality experience of insured wage earners under review. The death rate varied from 1.2 to 1.8 per 100,000 persons exposed between 1911 and 1915. In 1916, however, an epidemic of the disease occurred and the rate rose to 12.2 per 100,000. The cases in that year were, for the most part, confined to the Middle Atlantic and to a few of the New England States. The City of New York showed by far the largest number of cases recorded. Out of the total of 1,245 cases registered in 1916, 456 or 36.6 per cent, were ACUTE POLIOMYELITIS. 263 reported from that city. There was also a noteworthy representa- tion of deaths from the cities of Newark and Philadelphia. Poliomyelitis has a very marked color, sex and age incidence. In this respect, it is very similar to the other acute infectious dis- eases of childhood already considered. This is made evident in the following table, which displays the color, sex and age incidence of this disease for 1916 alone: TABLE 173. Mortality from Acute Poliomyelitis, Classified by Color, Sex and by Age Period. Death Bates per 100,000 Persons Exposed. Year 1916. Experience of Metropolitan Life Insurance Company. Inidustrial Department. Persons. White. Colored. Age Period. Males. Females. Males. Females. All ages — one and over 12.2 16.9 10.2 6.2 3 5 lto4 5 to 9 10 to 14 15 to 19 20 to 24 25 and over. . 86.4 26.9 4.8 2.4 1.2 .4 99.7 31.8 5.7 3.2 1.0 .9 75.3 23.5 4.9 1.6 1.2 .3 79.4 19.1 1.9 3.6 53.0 15.1 1.7 White males and white females suffer much more acutely from poliomyelitis than do the same sex groups among colored people. It should be recalled, though, that in this mortality experience colored and white persons were very unequally exposed to the dis- ease. Males show higher mortality rates than do females at every age period with the exception of the age period 20 to 24 years. The disease takes its highest toll in the earliest years of childhood. In fact, the rate for white males under five, 99.7 per 100,000, was higher than the death rate for measles (84.1 per 100,000) and for scarlet fever (53.5 per 100,000) in the corresponding age period of life. The same fact was observed for the age period five to nine. The rates decrease rapidly beginning with age ten years, and the deaths are very few after age 25. Only 100 deaths after age 25 occurred out of the total of 1,889 deaths in the six year period. CHAPTEE XVII. Miscellaneous Diseases and Conditions. In addition to the major diseases and conditions discussed in the foregoing text there are a number which have played a not incon- siderable part in this mortality experience. Some of these justify brief discussion because of their importance as public health prob- lems, irrespective of the relatively small number of deaths due to them; others claim attention because they illustrate recent tenden^ cies in the technique of mortality statistics. The figures represent- ing the number of deaths from these minor conditions should be accepted in most cases with some reservation. In practically all instances there has been an apparent decline in the death rate for these causes of death during the six year period. This, we believe, is due, in large part, to improved certification of the causes of death by physicians. The increasing interest of physicians in preventive medicine, the circulation, by various vital statistics offices, of educa- tional literature on the certification of causes of death, and the many letters written to physicians asking them for more definite state- ments of causes of death, have resulted in reducing by many thou- sands the registration of deaths under these titles and correspond- ingly increasing the numbers assigned to the more approved and reliable headings of the International List. These diseases and conditions of miscellaneous order will be considered according to their International List position. Dysentery. Under dysentery were classified 2,039 deaths during the expe- rience period, corresponding to a death rate of 3.8 per 100,000 exposed. There has been a practically continuous decline in the death rate during the sexennium. The maximum rate is that for the year 1911 (4.8). The minimum rate was recorded in 1916 (3.1). The term "dysentery" is used by physicians very loosely in this country. True amebic dysentery, caused by the ameha dysen- teriae, is comparatively rare in North America with the exception 264 MISCELLANEOUS DISEASES AND CONDITIONS. 235 of the southern states. The type known as bacillary dysentery, which occurs both sporadically and in epidemics, is also infrequent because of steadily improving sanitary conditions. It has been estimated, and, in fact, fairly well demonstrated by registration offices, that a large proportion of the "dysentery" (so reported) in the United States is really enteritis or gastroenteritis. This is true especially in cases where it is reported for infants under two years of age. Examination of the Census Bureau reports on mor- tality statistics shows that approximately one third of the mortality reported for dysentery is that of children under two years of age. Very little of this, as a matter of fact, is correctly assignable to this title. The deaths which have been "charged away" from dysentery in the insurance experience have gone to swell the totals, chiefly, of diarrhea and enteritis and abdominal tuberculosis. Erysipelas. Twelve hundred and eighty-nine erysipelas (1,289) deaths were registered during the six year period 1911 to 1916. The death rate was 2.4 per 100,000 exposed. There has been no marked change during the period in the death rate for this condition. The death rates for white policyholders are considerably in excess of those for the colored, and the mortality among males for each race exceeds that among females. In the general population experience the death rates are higher than those for the Company's Industrial policyholders. This is due chiefly to the fact that approximately one third of the mortality caused by erysipelas is among infants under one year of age, a class which does not form a part of the Metropolitan experience. Under erysipelas are classified all deaths so reported, with no information as to type or primary cause. These include cases of slight traumatism complicated by the disease, but do not include those deaths in which erysipelas supervenes nor violence cases where the traumatism, in itself, would have caused death. Purulent Infection and Septicemia. Under this heading were classified 1,083 deaths, corresponding to a death rate of 2.0 per 100,000 exposed. The general trend of mortality throughout the six year period has been downward. Sev- eral hundreds of deaths which would have been classified under this 266 MORTALITY STATISTICS OF INSURED WAGE EARNERS. heading on the basis of the original reports received from physi- cians, have been transferred to other titles on the basis of more definite data supplied by these physicians. As an illustration of the loose manner in which the term "septicemia" is used by American physicians, we may cite the result shown by 295 replies from physicians^ who reported it as a cause of death of policy- holders in this investigation during the six years 1911 to 1916. In 207, or 70.2 per cent, of these cases, the deaths, on the basis of the corrective data furnished by the physicians, were charged to titles other than purulent infection and septicemia. Of the 207 replies that were received 76 or 25.8 per cent, were assigned to puerperal septicemia alone. The remainder were scattered among various diseases and forms of violence. The published death rate in the expanding Eegistration Area of the United States has been showing a decreasing trend for many years which, also, is due to the fact that physicians are reporting under the primary diseases cases where blood poisoning was a complication of the primary causative condition. Gonococcus Infection. The number of deaths charged to this disease (200) during the six years covered by this report does not indicate that this is a factor of much importance in this mortality experience. The death rate for the period was but .4 per 100,000 exposed on the basis of the reports of gonococcus infection which have been re- turned. Low as this figure is, it is, nevertheless, a matter of in- terest that when the rate for the last year of the sexennium (.5) is compared with that for the first year (.2) it is seen that there has been an apparent increase of 150 per cent. As a matter of fact, however, this rise is only apparent and is due, in large part, to the constantly increasing care which physicians are exercising in re- porting primary causative factors on forms provided for statements of causes of death. The reports for the general population show an even greater apparent increase in the death rate for gonococcus infection. For the year 1916 the general population death rate was .8 per 100,000 population, which is double the rate for 1911 (.4) and eight times the annual average rate for the period 1901 to 1905 (.1). It is evident that published figures for this disease 1 See Appendix C. MISCELLANEOUS DISEASES AND CONDITIONS. 267 can not be taken as a reliable index of its incidence as a cause of death. Anemia, Chlorosis. One thousand seven hundred and seventy-two (1,772) deaths were charged to these diseases during the sexennium 1911 to 1916. The great majority were reported under one of the following ex- pressions: anemia (without qualification), Banti's disease, chloro- sis, pernicious anemia, and splenic anemia. The International List of causes of death does not provide for the separate tabulation of these several types. Indeed, the title itself is unsatisfactory ; the term " anemia " is very vague and is used very loosely indeed ; so much so, that it is probable that many fatal cases so diagnosed would not be reported under this title heading if blood examina- tions had been made. In many cases the deaths here tabulated result either from acute or chronic secondary anemias, and if all of the data for correct classification had been at hand, they would, doubtless, have been assigned to many other causes, prominent among which are malarial fever, rheumatic fever, syphilis, malig- nant growths, the autogenous poisonings resulting from various chronic diseases, and indeed in some cases, to traumatic agencies. It will, therefore, be understood that the title "anemia, chloro- sis" relates only in part to proved fatal cases of the two forms of primary or essential anemia known as chlorosis and pernicious anemia. It will be noted that in the Metropolitan Industrial experience there has been little change in the death rate during the six year period 1911 to 1916. A slight upward trend is shown. This cor- responds with the general population experience as shown by the Census Office reports on mortality statistics. " Other Chronic Poisonings." Only 164 deaths were charged to this title (No. 59 of the Inter- national List of Causes of Death) during the period 1911 to 1916. These deaths were cases reported as due chiefly to chronic morphin- ism, opium poisoning and coeainism. It should be understood that the chronic occupational poisonings are not classified here ; nor are any of the acute poisonings, whether occupational or not. The chief interest in the figures attaches to the fact that during the first four years of the sexennium there was little change in the death 268 MORTALITY STATISTICS OF INSURED WAGE EARNERS. rate. In 1915, however, there was a considerable increase, but in 1916 the death rate dropped very materially. This corresponds with the general population experience, and it may be presumed that the very pronounced decrease in the death rate in 1916 was due to the enforcement of legislation covering the sale of habit- forming drugs. Encephalitis. Under this vague and indeterminate heading, 519 deaths were classified. This corresponds to a death rate of 1.0 per 100,000 exposed. There has been a steady downward trend in the mor- tality charged to this disease throughout the period and the rate for the final year, 1916 (.8), represents an apparent decline of 33^ per cent, from that for the first year, 1911 (1.2). This appar- ent decline should be construed as having very little significance other than to serve as an evidence of the increasing accuracy with which causes of death are being reported year after year. Without question many deaths are being added to the totals classified as due to tuberculous meningitis and to the various forms of violence on account of the growing tendency to specify the primary factor in cases of terminal encephalitis. This downward trend in the appar- ent death rate is also seen in the experience of the expanding Reg- istration Area. Meningitis. Four thousand one hundred and seventy-one (4,171) deaths were classified under "meningitis" during the period 1911 to 1916. This title, unfortunately, is a composite one and includes not only the condition known as "simple meningitis," which is usually a terminal condition in other primary diseases, but also the epidemic cerebrospinal type which is an infectious disease. Of the 4,171 deaths, 3,348 were returned as due to the former group of condi- tions such as "simple meningitis," "meningitis," without further qualification, "cerebral meningitis," "spinal meningitis," and 823 deaths were reported as due to cerebrospinal fever. The statistical tabulation of deaths returned under the first group is hardly worth while, because such reports are but partial reports, and as such, figures relating to them are bound to be misleading. Experience and tests have shown that over three-fourths of the deaths returned in this manner were really primarily due to other conditions, chief among which are tuberculous meningitis, syphilis, MISCELLANEOUS DISEASES AND CONDITIONS. 269 cerebrospinal fever and diseases of the ears. The 3,348 deaths just referred to represent cases in which it was not possible to secure information either as to the type of "meningitis" or the name of the disease or form of violence of which it was a sequela. Cerebrospinal Fever. — The chief interest in the study of menin- gitis statistics is centered on the 823 deaths relating to cerebro- spinal fever, or to epidemic cerebrospinal meningitis as it is often called. This is an acute infectious disease caused by an organism known as the diplococcus mtracellularis meningitidis. While it is marked by fever and by inflammation of the cerebral and the spinal meninges, its place in a statistical classification should be among the specific infectious diseases rather than among those of the nervous system, where it is at present placed. In the first year of the sexennium to which this report relates, no effort was made to segregate the deaths from this disease. The two tables which follow relate, therefore, to a quinquennial period, 1912 to 1916. The first of these tables, which is given immediately below, shows the sex, color and age distribution of the mortality among the insured for this period. TABLE 174. Mortality from Cerebrospinal Fever, Classified by Color, Sex and by Age Period. Death Bates per 100,000 Persons Exposed. 1912 to 1916. Experience of Metropolitan Life Insurance Company. Industrial Department. Persons. WWte. Colored. Age Period. Males. Females. Males. Females. All ages — one and over 1.8 2.1 1.2 3.8 2.4 1 to4 5 to 9 10 to 14 15 to 19 20 to 24 25 to 34 35 to 44 45 to 54 55 to 64 65 to 74 75 and over. . 7.2 2.6 1.8 1.7 1.1 .8 .7 .8 .3 .4 8.0 2.4 1.6 2.4 1.0 .8 .7 .9 .4 .3 6.3 2.1 1.3 .7 .8 .5 .4 .2 .1 .6 9.2 7.3 4.9 5.0 3.5 2.7 1.6 3.4 .7 6.9 4.9 4.8 1.7 1.9 1.3 1.5 2.1 1.6 There were 823 deaths either originally reported or finally iden- tified in our experience during the quinquennium 1912 to 1916 as 270 MORTALITY STATISTICS OF INSURED WAGE EARNERS. due to cerebrospinal fever. Over one-third of these were deaths of children 1 to 4 years of age ; over one-half were under 10 and about two-thirds under 15. The mortality for males in both the colored and white experience was very considerably in excess of that for females and for each sex the death rate for the colored experience was heavily in excess of that for the white. The following table shows the trend of the death rate for cerebro- spinal fever during the quinquennial period 1912 to 1916. It will be noted that the decline was a continuous one for the first four years of the quinquennium, that is, from a maximum of 3.0 per 100,000 exposed in 1912 to a minimum of 1.3 in 1915. This was followed by a slight increase to 1.5 in 1916. The experience for the insured corresponds fairly well with that for the general popu- lation except that for 1916 the latter, with a rate of 2.1 per 100,000 population, shows more of an excess over the 1915 rate than is in evidence for the corresponding year in the Metropolitan experience. TABLE 175. MOKTALITT FEOM CEEEBROSPINAL FeVER, CLASSIFIED BY COLOR AND BY SEX. Death, Bates per 100,000 Persons Exposed. Single Years in Period 1912 to 1916. Experieiice of Metropolitan Life Insurance Company. Industrial Department. Persons. White. Colored. Year. Males. Females. Males. Females. 1912tol916 1.8 2.1 1.2 3.8 2.4 1916 1915 1914 1913 1912 1.5 1.3 1.5 1.7 3.0 1.9 1.8 1.8 1.8 3.1 1.2 1.1 1.1 1.4 1.5 2.0 .9 2.7 3.4 10.4 1.4 .8 1.1 2.3 6.6 Locomotor Ataxia. * The most important causative factor in locomotor ataxia is syph- ilis, and, in fact, some of the best authorities now say that the disease never originates without syphilis. On this account deaths certified as due to locomotor ataxia should be considered in relation to syphilis, and in Appendix C there will be found quotations of the number of deaths charged to syphilitic in- fection in which it had been definitely certified by physicians that the syphilitic origin of locomotor ataxia had been attested by *See also syphilia, page 237. MISCELLANEOUS DISEASES AND CONDITIONS. 271 Wassermann reactions. On account of the growing tendency of physicians to certify primary causes, and on account of the practise among some statistical offices of requesting physicians to certify definitely to the luetic origin of deaths ascribed to locomotor ataxia, the death rate for locomotor ataxia is showing an apparent decline. This decline has been continuous in the present experience for in- sured wage earners throughout the last four years of the six year period covered by this report. This is not in agreement with the death rates shown for the expanding Eegistration Area in which for four of the six years there was no change. There was a decline, however, from 2.6, the 1915 rate in the general population, to 2.4 per 100,000 population in 1916. The Eegistration Area death rates are considerably higher than those for the insured. This is accounted for, in part, by the age distribution of the two popula- tions. Well over one-third of the deaths from the disease occurs in the higher age periods where the policyholders do not comprise a very high proportion of the total number insured. Softening of the Brain. Under this heading, 488 deaths of Industrial policyholders were classified during the six year period 1911 to 1916. The death rate for the period was .9 per 100,000 exposed. Examination of the apparent trend of the death rate shows a practically continuous downward trend during the six years and the rate for 1916 (.7) is 58.3 per cent, of that for 1911. Softening of the brain is an extremely unsatisfactory statement of cause of death in that it is a secondary condition rather than a primary cause. This explains the apparent downward trend in the mortality which the figures for the years of the sexennium show. The fact is that in the later years registration offices have been querying this return, with the result that many deaths originally certified as due to softening of the brain have been registered, instead, under arteriosclerosis, em- bolism, thrombosis, and other diseases, as a result of more definite information so secured. The apparent decrease shown for the in- sured group corresponds to that shown for the general population. General Paralysis of the Insane. Two thousand two hundred and twenty-four (2,224) deaths of Metropolitan Industrial policyholders were classified as due to 272 MOETALITY STATISTICS OF INSURED WAGE EARNERS. this disease during the six year period, 1911 to 1916. The death rate was 4.1 per 100,000 exposed. In view of the fact that the antecedent cause of general paralysis of the insane is now believed by the best authorities to be syphilis, a separate statistical treat- ment of the mortality from general paralysis is of little value. It has been decided, therefore, to treat it in connection with the study of syphilis, page 237. When this condition is reported jointly with syphilis, the death is classified as one primarily due to the latter, but very frequently indeed, physicians simply report "general paralysis of the insane," "dementia paralytica," "paresis," or "general paralysis" without stating specifically that these condi- tions occurred as the result of initial syphilitic infection. Since the International List of Causes of Death provides a separate title for general paralysis of the insane we have (in keeping with stand- ard practise) classified under general paralysis all deaths in which syphilitic origin was not definitely stated by physicians, except that in very many cases letters of inquiry were sent to physicians asking them whether they had knowledge of the existence of syphilis as a predisposing cause and, if so, whether its presence was shown by history or by tests. The replies in a great many instances gave us information on the strength of which many deaths originally cer- tified as due to general paralysis of the insane were ultimately classified under the heading of syphilis. Analysis of the apparent trend of the death rate among the Company's policyholders shows a very pronounced decrease for general paralysis of the insane. The death rate for 1916 (2.7 per 100,000 exposed) is less than half that for 1911 (5.7) and with one exception there was a continuously declining death rate throughout the period 1911 to 1916. The declining rate shown for the Metropolitan experience is in marked contrast to the increasing mortality shown by the reports of the Census Bureau for the ex- panding Registration Area of the United States throughout the same period. It was not the custom in the Census Bureau during the period 1911 to 1916 to query reports of general paralysis for specific statements of the existence of syphilis. The color and sex incidence of the death rates for general paral- ysis of the insane is about the same as for sjrphilis. The death rates for males exceed those for females in the colored as well as in the white experience, and the rate for colored persons is very much higher for each sex than that for the whites. MISCELLANEOUS DISEASES AND CONDITIONS. 273 Convulsions. Five hundred and fifty-nine (559) deaths were charged to "con- vulsions '' in this experience. The International List of Causes of Death devotes two title headings to this subject, one of which is confined to deaths of children under 5 years of age and the other to persons 5 years of age and over. The 461 deaths of children under 5 years classified under this cause are assigned thereto only in cases where it was impossible to secure more definite iniorma- tion which would justify the inclusion of such deaths under more definite and satisfactory statistical headings. Convulsions in young children represent a symptom-complex of some other condi- tion — in the majority of cases such diseases as diarrheal complaints, the pneumonias, and the several forms of meningitis. Only 98 deaths of persons 5 years and over were charged to convulsions during the six year period. These also represent cases which were assigned to this title only when it was not possible to obtain defi- nite data which would justify their classification elsewhere. When such information is obtained, these deaths are usually transferred, in cases of women of childbearing age, to puerperal causes, and in adult males to the various nervous diseases or to some form of traumatism. The death rate for convulsions is declining, which is a manifesta- tion of improvement in statements of cause of death rather than an indication of changed condition as to the incidence of fatal cases of "convulsions." " Other Diseases of the Nervous System/' Under this heading of the International List of Causes of Death are classified a very considerable number of nervous diseases which are not covered statistically by any other title relating to the vari- ous diseases of the nervous system and the organs of special sense. The title, therefore, is a residual one and many of the diseases listed under it are so dissimilar to others so listed, that the only relationship lies in the fact that they all affect the nervous system. Under this heading the following, chiefly, were reported as causes of death: acute hydrocephalus, anemia of brain, cerebral tumor, cretinism, disease of brain (nature not specified and unobtainable on inquiry), idiocy, imbecility, Jacksonian epilepsy, nervous ex- haustion, nervous prostration, neurasthenia, sclerosis of brain, 19 274 MORTALITY STATISTICS OF INSURED WAGE EARNERS. tetany and a few others. Many of the diseases listed under this title are really of syphilitic, or more or less remote traumatic, origin. These deaths would have been so classified if accurately reported. The death rate from this group of causes in the present experience shows a slight downward trend. This is due to increasingly specific statements of cause of death resulting from the widespread cam- paign carried on by practically all registration offices with a view to securing accurate reports from physicians. The tendency in the expanding Eegistration Area is also a downward one, which is attributable, doubtless, to the same cause. The number of deaths recorded under this residual title during the period 1911 to 1916 was 1,349, corresponding to a death rate of 2.5 per 100,000 exposed. Diseases of the Ears. In the great majority of the fatal cases of ear disease otitis media is the primary factor. There were 962 deaths charged to ear dis- eases in the Metropolitan Industrial experience during the period 1911 to 1916. The death rate was 1.8 per 100,000 exposed. The prevailing rate throughout the years of the sexennium has changed very little from year to year. This corresponds with the expe- rience in the expanding Eegistration Area of the United States, although in the latter experience group the rate in recent years has been much higher than in the years covering the first quinquennium of the present century. There has not been an actual increase in the fatal cases of ear disease, probably, to the extent indicated by these rates. On the other hand, hundreds of physicians who, in earlier years would have certified fatal cases of otitis media as due to the terminal condition, meningitis, have been returning such cases in more recent years, under the stimulus of educational propa- ganda, as "otitis media." Pericarditis. Under this heading the deaths of 634 Metropolitan Industrial policyholders were recorded during the period 1911 to 1916. The corresponding death rate was 1.2 per 100,000 exposed. The trend of the death rate is downward. In 1911 the rate was 1.4, in 1912 and 1913 it was 1.3 and for each of the three remaining years of the sexennium it was 1.0 per 100,000. The apparent downward MISCELLANEOUS DISEASES AND CONDITIONS. 275 trend of the death rate in the Metropolitan experience corresponds fairly well to that in the Eegistration Area. Probably the decline in each experience is more apparent than real. Secondary pericarditis is, more and more, being recorded under the primary infection. The disease is usually the result of pyogenic infection or it arises by extension of inflammation from contiguous organs. As a primary condition it is extremely rare. It is caused, in addition to the lesions noted above, by rheumatism, traumatism, and indeed in some cases, by tuberculosis. The more frequent mention of pri- mary rheumatic fever and other causative factors on forms pro- vided for reporting causes of death is perhaps the chief factor in the apparent decline of the pericarditis death rate. Under this heading are also classified certain other diseases of the pericardium, namely, hydropericardium, hemopericardium and pneumopericardium. Acute Endocarditis. Under this heading are classified first, all deaths reported defi- nitely as caused by acute endocarditis or acute myocarditis ; second, all deaths of persons under 60 years of age for whom "endocar- ditis" (without qualification) or "myocarditis" (without qualifi- cation) were returned as the cause of death;' third, cases of in- fective endocarditis, malignant endocarditis and septic endocarditis reported with no additional information as to primary causative factors. The title heading "acute endocarditis" as used in the International List of Causes of Death is a distinct misnomer, since under this title are classified also deaths from myocarditis which is an inflammation of the myocardium or muscular walls of the heart, whereas endocarditis is an inflammation of the endocardium or lining membrane of the heart. A better title heading for the conditions included here would be acute infectious endocarditis and myocarditis. Nevertheless, 5,080 deaths of Metropolitan Industrial policy- holders were classified under this heading during the sexennium 1911 to 1916. The death rate for the period was 9.4, and although there has been no pronounced change from year to year, there has been a slight upward trend in the rate. The annual average for the last three years of the six year period is much higher than that for the first three years. This is difficult to account for in view of the fact that for almost all of the other unsatisfactory and indefi- 276 MOKTALITY STATISTICS OF INSUEED WAGE EARNERS nite titles we have observed a tendency toward an apparent decrease in the death rate. This title is unsatisfactory because instances are very rare indeed in which acute endocarditis occurs as a pri- mary disease. Consequently, whenever it is reported without state- ment of any other morbid condition, the presumption is that the name of the etiological entity which was responsible for this condi- tion was not mentioned by the physician. In the expanding Regis- tration Area of the United States since 1911 there has been a slight upward trend also in the death rate for acute endocarditis. Know- ing as we do that we should expect the opposite trend in common with that for other indefinite statements, the reason for the increase in the rate must be sought elsewhere. It is possible that the num- ber of forms of the disease which are encountered as primary fac- tors is actually increasing. This may be true especially of cases in which malignant or infectious endocarditis is in evidence as a pri- mary disease of the heart lining or valves. However this may be, we are face to face with the situation that this is almost an isolated instance of an apparent increase in the death rate for an unsatis- factory title. Embolism and Thrombosis. Under this heading are classified reports of embolism and of thrombosis which appear with no statement as to primary cause. It should be distinctly understood, however, that deaths from puer- peral embolism and from embolism due directly to postoperative conditions are not classified under this heading, but in the first in- stance under the puerperal state, and in the second under the title representing the cause for the relief of which the operation was performed. One thousand one hundred and ninety-two (1,192) deaths were classified as due to embolism and thrombosis in this experience during the period 1911 to 1916. The corresponding death rate was 2.2 per 100,000 exposed. The general trend of the mortality throughout the period has been upward. There has been no pro- nounced change, however. The same trend is observed in the fig- ures for the expanding Eegistration Area during the corresponding period. In the Metropolitan experience the death rate for the colored exposure for the period as a whole (2.7) was in excess of that for white policyholders (2.1) ; the rate for white females (2.4) was higher than that for white males (1.8) ; for colored lives, how- MISCELLANEOUS DISEASES AND CONDITIONS. 277 ever, the mortality among males and females was about the same, namely, 2.8 for the former and 2.7 for the latter. Diseases of the Larynx. The greater part of the 594 deaths which were classified under this heading during the period 1911 to 1916 were reported either as due to laryngismus stridulus, laryngitis, edema of glottis or spasmodic croup. The death rate for the period was 11 per 100,- 000 exposed and the general trend throughout the sexennium has been slightly downward. This is also true of the expanding Eegis- tration Area experience. It frequently happens that deaths re- ported by physicians under the several terms classified under " dis- eases of the larynx" represent cases which were actually of diph- theritic origin. This applies particularly to deaths reported from " laryngitis " which were caused actually by diphtheritic, fibrinous, membranous or pseudomembranous laryngitis, but which were not so stated in the original return of the physician. Much of the apparent decline in the death rate for diseases of the larynx is doubtless due to the growing tendency of the medical profession to give more explicit statements of these causes, thus enabling statis- tical ofiices to classify them as deaths caused by diphtheria. Pulmonary Congestion, Pulmonary Apoplexy. Under this heading 939 deaths of Metropolitan Industrial policy- holders were classified during the period 1911 to 1916. The death rate for the sexennium was 1.7 per 100,000 exposed and the appar- ent trend, as shown by the figures relating to each year of the period, is distinctly downward. The same apparent downward trend is in evidence for the figures relating to the general popula- tion. In fact, it is more pronounced in the latter group than for the insurance experience. "Pulmonary congestion, pulmonary apoplexy" is an extremely unsatisfactory title from the standpoint of mortality statistics, be- cause the terms listed under it stand for conditions which are, almost altogether, mere complications or terminal symptoms of other diseases. It is, as a matter of fact, unfortunate that the rather considerable bulk of deaths reported in this way should be- come a part of the grand total recorded as due to diseases of the respiratory system. Many of these reports are received for cases 278 MORTALITY STATISTICS OF INSURED WAGE EARNERS. in which the return is "pulmonary edema" or "pulmonary con- gestion/' and in which these conditions were terminal to cases of cardiac, renal or other diseases. The apparent decline in the death rate both among the insured group and in the general population experience is accounted for largely by better certification of primary diseases. The great majority of the deaths charged to this title were re- ported as due to pulmonary apoplexy, pulmonary congestion, pul- monary edema, hypostatic pneumonia and terminal pneumonia. Asthma. Under this title were classified the very considerable total of 1,594 deaths during the sexennium 1911 to 1916. This corre- sponds to a death rate of 3,0 per 100,000 exposed. There has been a continuous decline in the rate throughout the years which con- stitute the period covered by this experience. The rate for the final year, 1916 (2.5), represents a decline of 30.6 per cent, from that shown for the earliest year, 1911 (3.6). This decline is not in evidence in the published figures for the general population, for which an almost uniform death rate is exhibited throughout the sexennium. The apparent decline shown in the figures for the insured group is due, in considerable part, to the rather rigid cen- sorship exercised concerning reports of " asthma " from the mining districts, with the result that many of these returns have been iden- tified as relating to cases of miners' asthma. These deaths are classi- fied under another title of the International List of Causes of Death. A number of these reports, moreover, would have been classified as cardiac asthma and assigned to organic diseases of the heart, and still others would have been assigned to Bright's disease as cases of renal asthma, if strictly accurate returns had been made. The deaths, therefore, which go to make up this total of 1,594 fatal cases represent, for the most part, reports of "asthma," without qualifi- cation, and also returns of " bronchial asthma " concerning both of which no additional data were available. The title is very unsatis- factory because it is intended to be limited to the disease known as bronchial or spasmodic asthma. Unfortunately the term "asthma" is used loosely by physicians in other conditions associated with dyspnea. In the Metropolitan experience the death rate for the MISCELLANEOUS DISEASES AND CONDITIONS. 279 colored exposure (6.0) is more than double that for white persons (2.5). There is no marked sex incidence shown among the insured. " Other Diseases of the Respiratory System." Under the above heading are classified a considerable number of terms which are not assignable to any of the diseases of the respira- tory system for which a separate statement of mortality is provided in the International List of Causes of Death. It is known as a " residual " title, and like all others of this kind, it provides for the classification of a number of vague and indeterminate reports. It should be understood that tuberculous conditions, if known, are not classified under this title heading. In the Metropolitan experience the majority of the deaths classified here were reported as follows, there being no further definitive data available : abscess of lung, chronic pneumonia, " disease of lung," hemoptysis, hemor- rhage of lung, interstitial pneumonia, miner's asthma, and pneu- mokoniosis. Under this heading 888 deaths of Metropolitan Industrial policy- holders were registered during the period 1911 to 1916, correspond- ing to a death rate of 1.7 per 100,000 exposed. Comparison of the death rates for the several years constituting the six year period shows a marked downward trend, to which no significance whatever should be attached except as an evidence of the increasing accuracy of reporting causes of death and of the greater care with which these reports are inspected from year to year. The result is that reports of the very vague and indeterminate conditions listed under this title are being to a greater extent, year after year, transferred to more specific and satisfactory headings. This apparent down- ward trend in the death rate is also shown in the Census reports covering the mortality of the general population. Diseases of the Pharynx. One thousand one hundred and fifty-three (1,153) deaths of Industrial policyholders were reported from diseases of the pharynx during the six year period 1911 to 1916. The death rate for the sexennium was 3.1 per 100,000 exposed. The general trend of the mortality among the insured during the sexennium was upward. This was practically continuous. The minimum was shown for the earliest year, 1911 (1.6), and the maximum for the latest year. 280 MORTALITY STATISTICS OF INSURED WAGE EARNERS. 1916 (2.6), The same rising tendency of the death rate is shown by the figures for the general population. There was no pro- nounced color incidence in the Metropolitan experience although the rate for colored policyholders (3.4) exceeded slightly that for the white (2.1). The number of deaths of colored persons in- volved, however (159), was rather too small to be significant. Among the white insured the death rate for males (2.5) exceeded that for females (1.7) ; among the colored policyholders the rate for the females (2.6) was, on the other hand, higher than that for males (2.1). The greater part of the deaths charged to diseases of the pharynx were reported as follows: ^''disease of throat," Ludwig's angina, pharyngitis, quinsy, tonsillitis, or Vincent's angina. "Other Diseases of the Stomach {Cancer Excepted)."' The very considerable total of 4,921 deaths of Industrial policy- holders was reported as due to the various diseases and conditions which must be classified under the above title heading according to the stipulations of the International List of Causes of Death. This number of deaths corresponded to a death rate of 9.1 per 100,000 exposed. There has been a continuous decline, however, through- out the six years covered by this report, from a maximum of 11.0 for 1911, the earliest year, to a minimum of 7.6 for 1916, the latest one. An even more pronounced downward trend has been shown by the figures for the general population during the same period. The apparent decrease in the death rate is due to more accurate reporting of causes of death in the later years as compared with the earlier ones, together with more rigid questioning of the reports on the part of registration offices. Under this title are listed such terms as: gastritis, gastric ca- tarrh, " disease of stomach," " acute indigestion," " indigestion " and a number of others which, as a rule, are worse than worthless as statements of the primary cause of death. These terms are used carelessly when they relate to various fatal affections in which in- flammation or irritation of the stomach is a complication. Deaths so reported are found on investigation, very frequently, to be charge- able to such conditions as alcoholism, organic heart disease, gastric ulcer, gastroenteritis, and other diseases and conditions rather than to the above title. As is apt to be the case with these residual MISCELLANEOUS DISEASES AND CONDITIONS. 281 titles., where careless and incompetent reporting of cause of death is so important a factor in influencing the death rate, the rate for colored policyholders is very greatly in excess of that for whites. In the Metropolitan experience the actual number of deaths of col- ored persons assigned to " other diseases of the stomach " was 1,563 with a corresponding death rate of 23.3 per 100,000 exposed. There were 3,358 deaths of white insured with a rate of 7.1 or less than one third the rate for the colored. There was no marked dif- ference in the rates for males and females among the whites, the rate for the former being 6.9 and for the latter 7.3. Among the colored policyholders, however, the mortality among the females was considerably in excess of that among the males (25.6 as com- pared with 20.6). The terms which follow will indicate the manner in which the majority of the deaths charged to this title were reported in the Metropolitan experience. It should be understood that in each case no further information was available on the basis of which it could be classified under a more definite and satisfactory title: abscess of stomach, catarrh of stomach, catarrhal gastritis, conges- tion of stomach, "disease of stomach" (unqualified), dyspepsia, gastritis, hemorrhage of stomach, indigestion, acute indigestion, and pyloric stenosis (noncancerous or unqualified). Although it is plainly indicated in the title heading that cancer of the stomach is not included here, it is, perhaps, well to emphasize the fact by restating it and to direct attention to Title No. 40 (cancer and other malignant tumors of the stomach and liver) under which deaths from malignant gastric growths are classified. It is possible only to speculate as to how much unrecognized cancer is concealed under the title " other diseases of the stomach." Biliary Calculi. Under the above title were classified 1,591 deaths in the Metro- politan Industrial experience during the six year period 1911 to 1916. The corresponding death rate was 3.0 per 100,000 exposed. A very slight upward trend was shown throughout the six year period. This same upward trend was shown for the general popu- lation experience. In both experiences it is accounted for, in all probability, by increasing precision in statement of causes of death rather than by any actual increase in deaths caused by biliary cal- 282 MOETALITY STATISTICS OF INSURED WAGE EARNERS, culi. For this disease the death rate of white persons is consid- erably higher than that for the colored, while the rate for females in both the white and colored experiences is very much higher than for males. White females show a death rate of 4.9 per 100,000 exposed for the period 1911 to 1916, which is almost five times that for white males (1.0) ; for the colored the female rate (3.4) is double that for the males (1.3). The greater part of the deaths charged to biliary calculi were reported in the Metropolitan experience under the following terms : biliary calculus, biliary colic, cholelithiasis, and gall stones. "Other Diseases of the Liver." Under this heading the very considerable total of 3,181 deaths were classified during the sexennium 1911 to 1916. The death rate was 4.1 per 100,000 exposed for the period. Included here are the various noncancerous, nontuberculous and nonsyphilitic hepatic and gall-bladder affections for which the International List of Causes of Death does not provide a separate classification. The causes of death assigned to this title were reported, in the main, as follows: abscess of liver, atrophy of liver, cholemia, cholangitis, cholecystitis, disease of liver (unqualified), hepatitis, hypertrophy of liver, icterus, and jaundice. There has been a fairly consistent decline in the death rate throughout the period covered by this report. A similar downward tendency is shown in the reports covering the mortality for the gen- eral population experience although the downward trend there is not as marked as that shown for the insured. In each case the decline in the death rate is doubtless due more to increasing accu- racy in reporting than to any change in conditions covering actual fatal cases resulting from the diseases classified under this title. In the Metropolitan experience the colored exposure shows a death rate considerably in excess of the white. The sex incidence, how- ever, is different for the two races. Among white insured wage earners the rate for females was 4.4 per 100,000 exposed, as com- pared with 3.0 for white males. Colored lives, however, show a higher rate for males (6.4) than for females (5.8). Simple Peritonitis (Nonpuerperal) . Under this very unsatisfactory heading 1,013 deaths were re- ported in the Metropolitan experience during the six year period MISCELLANEOUS DISEASES AND CONDITIONS. 283 1911 to 1916. The death rate was 1.9 per 100,000 exposed. It is desired at this point to emphasize the fact that no case was classi- fied under this heading until every possible effort had been made to ascertain the primary cause of the "peritonitis." Experience shows that a very large majority of the deaths which physicians certify as due to "peritonitis" are, in fact, primarily caused by tuberculous peritonitis, appendicitis, traumatism, and both non- puerperal and puerperal diseases of the female genitals. Primary, idiopathic peritonitis is rare and each report of "peritonitis" is a suspicious one for which vital statisticians usually seek a correction before tabulating the death under this heading. The 1,013 deaths charged to this title, therefore, represent, in the main, a residue of those originally certified as caused by "peritonitis" and concern- ing which no more definite information could be obtained. No significance is to be attached to the declining death rate shown for the insured in the later years covered by this report as compared with the earlier ones. The decline registers simply the increasing tendency to report cases complicated by peritonitis under the pri- mary cause rather than under the terminal symptom. A corre- sponding apparent decline in the death rate of the general popula- tion is shown in the reports covering its mortality. The decrease is traceable, to a very great extent, to the same cause. Colored lives show a mortality more than triple that in evidence for the whites (4.7 per 100,000 exposed as compared with 1.5). In the white experience the rate for females (1.9) is nearly double that for males (1.0) ; in the colored experience the mortality assigned to this cause for females was Q.&, which is almost treble that for col- ored males (2.4). Acute Nephritis. Numerically, acute nephritis is an important cause of death in the Industrial experience of the Metropolitan Life Insurance Com- pany, no less than 5,120 deaths having been charged to it during the sexennium 1911 to 1916. The corresponding death rate was 9.5 per 100,000 exposed. This is another one of the causes of death for which the International List provides a separate title heading, but which by no means constitutes a satisfactory statement of cause of death. In the majority of deaths in which acute nephritis is a factor, it is a secondary condition. When it appears as the sole statement of cause of death the report is always more or less sus- 284 MORTALITY STATISTICS OF INSURED WAGE EARNERS. picious, the strong presumption being that the primary causative factor has been omitted in the statement of the physician. Among the principal causes of acute nephritis are exposure to cold, as well as typhoid fever, malaria and syphilis. Acute poisonings also often bring on this disease. Whenever it is reported, without qualification, in connection with the death of a woman of child- bearing age it is more than probable that the death is one that should, in reality, be classified under the head of those due to puer- peral causes. In children it is a frequent complication of the acute contagious or infectious diseases such as scarlet fever, measles, diphtheria and even chicken pox. The 5,120 fatal cases which are here ascribed to this disease represent a mere residue of those origi- nally reported as having been caused by "acute nephritis." During the latter half of the experience period particularly, there has been rigid inspection of such reports and many letters of inquiry for the primary cause have been sent out to physicians. The replies which have been received together with the growing tendency to report primary conditions are, more than any other factors, respon- sible for the decline in the death rate which is shown when com- parison is made of the rates for the first three and the last three years of the sexennium, 1911 to 1916. A similar apparent decline in the death rate is shown by the published figures for the general population; but this decline, like that for the Metropolitan Indus- trial experience, evidenced better reporting and improved methods of compiling causes of death rather than an actual decrease in the number of cases in which " acute nephritis " was the primary cause of death. On the basis of the 5,120 deaths that remain registered under this cause, the death rate for the colored exposure (17.9 per 100,000 exposed) was more than double that for the whites (8.3). For white insured lives the mortality among males (9.2), was consid- erably higher than that for females (7.6). Among colored lives, however, there was little difference in the rates for the sexes, 18.0 for males, as compared with 17.8 for females. "" Other Diseases of the Kidneys." Eight hundred and sixty-one (861) deaths of Industrial policy- holders were charged to "other diseases of the kidneys" during the period 1911 to 1916. This corresponds to a death rate of 1.6 MISCELLANEOUS DISEASES AND CONDITIONS. 285 per 100,000 exposed. No pronounced change is shown for any year of the period as compared with other years, the death rate being fairly stationary. This is also true in the general popula- tion experience, although the death rate for this group of diseases is slightly higher in the general population than among the insured. Comparison of color and sex rates among the policyholders shows that the mortality in the colored exposure, 2.4 per 100,000 exposed, was rather in excess of that for the white group (1.5). For white lives, however, the death rate for females (1.6) was a little higher than that for males (1.4) ; this is contrary to the experience in the colored exposure, for which the male rate was 2.8 as compared with 2.0 for the females. Diseases of the Bladder, Under this heading 611 deaths of Metropolitan policyholders were classified during the period 1911 to 1916. The death rate for the period as a whole was 1.1 per 100,000 exposed; a fairly con- tinuous downward trend is in evidence throughout the period. It should be stated that this title does not include cancer of the blad- der, tuberculosis of the bladder, bladder conditions of gonococcic origin, nor vesical calculus. A decline in the death rate as shown for the Metropolitan experience is also in evidence, and even more pronounced, in that of the general population. This is due to the change of many reports to the titles that relate to gonococcus in- fection, to diseases of the prostate, and to cancer and tuberculosis. The great majority of the fatal cases classified under this title were reported as due to cystitis, retention of urine, rupture of the blad- der, tumor of the bladder (noncancerous or unqualified) and abscess of the bladder. The rate for colored lives (2.2 per 100,000 ex- posed) is more than double that for white lives (1.0) and for both the colored and the white experiences the death rate for males was about three times that for females. Diseases of tJie Prostate. The diseases of the prostate gland, exclusive of those certified as due to tuberculous, cancerous, syphilitic, or traumatic causes, were reported as causes of 1,162 deaths among Metropolitan Industrial policyholders during the sexennium to which this report relates. The corresponding death rate was 2.2 per 100,000 exposed. There 286 MORTALITY STATISTICS OF INSURED WAGE EARNERS. was no pronounced variation during the six year period. The rate for the period as a whole and for each of the several years which constitute it, is lower than that for the general population. This is due to the fact that a very great majority of the deaths caused by prostatic troubles are those of men in the higher age groups. Ordinarily, very close to 90 per cent, of the mortality from these diseases is among men over sixty years of age. On account of the comparatively low exposure among the insured at these ages, a higher death rate is to be expected in the general population expe- rience. The mortality among colored men for the six year period was 7.7 per 100,000 exposed, which is almost double the rate for the white insured (4.3). Uterine Tumor {Noncancerous). Under this heading are classified all uterine growths which are not reported as due to cancer. The number of deaths charged to this cause in the Metropolitan Industrial experience during the sexennium 1911 to 1916, was 1,335, corresponding to a death rate of 2.5 per 100,000 exposed. Little change is shown throughout the period when the rates for the individual years are compared. The death rate in the general population experience is lower for each year of the period, but, like that for the insured, there is little fluc- tuation from year to year. The great bulk of deaths charged to this condition occurred between the ages of 25 and 55 years — in fact, 1,103 or 82.6 per cent, of the 1,335 deaths were those of women in this age group. The difference in the rates for the Metropolitan and the expanding Eegistration Area experience is accounted for largely by the different race composition of the two populations. The death rate among colored women is much higher than among the whites — over six times as high ; the rates for the two races being 17.3 and 2.7 per 100,000 exposed respectively. The proportion of colored policyholders to the total number of policyholders is far greater than the proportion of the colored population of the ex- panding Eegistration Area is to its total population. We would, therefore, expect a higher death rate among the insured. " Other Diseases of the Uterus." Under this heading are classified deaths actually caused by non- cancerous, nontuberculous and nonpuerperal diseases of the uterus. MISCELLANEOUS DISEASES AND CONDITIONS. 287 together with certain others which, if correctly certified, would have come under cancer, tuberculosis, or puerperal causes. The latter group are placed under the unsatisfactory title, "other diseases of the uterus " because all of the information which physicians might have given did not appear in their statements. The deaths classi- fied under this heading were returned, in the main, under one of the following designations: abscess of uterus, disease of uterus (with no further qualification), endometritis, inflammation of uterus, menopause, metritis, pelvic abscess, pelvic cellulitis and prolapse of uterus. There were 786 such reports during the period 1911 to 1916, cor- responding to a death rate of 1.5 per 100,000 exposed. Rather a pronounced apparent downward trend is shown, which means that the growing tendency to make full and complete reports has brought about more certifications under the head, chiefly, of diseases inci- dental to pregnancy and childbirth. Salpingitis, Other Diseases of the Female Genital Organs. One thousand seven hundred and eighty-two (1,782) deaths of insured women were classified under this heading during the period 1911 to 1916. The death rate was 3.3 per 100,000 exposed, and there was very little variation throughout the sexennium. Com- parison with the figures for the general population shows that, while the death rate for the latter was the lower, the same absence of any material fluctuation from year to year is to be observed. The comparatively high death rate among insured women is due, largely, to the fact that there is a higher proportion of colored women among them. In the experience for the insured, the mor- tality among colored women from these diseases has been about four times that for the whites. Practically 90 per cent, of the deaths are those of women between the ages of 20 and 50 years. Under this heading are classified all deaths caused by the non- venereal, noncancerous, nontuberculous, and nonpuerperal diseases of the female genital organs for which separate headings are not provided by the International List of Causes of Death. The great majority of the deaths classified under this heading were reported under one of the following terms: abscess of Fallopian tube, ab- scess of ovary, disease of genital organs (unqualified), disease of ovary (unqualified), disease of Fallopian tube (unqualified), in- 288 MORTALITY STATISTICS OF INSURED WAGE EARNERS. flammation of Fallopian tube, inflammation of ovary, ovaritis, pus tube, pyosalpingitis, rupture of tube, salpingitis, and tubo-ovarian abscess. A large number of these were, undoubtedly, either of gonoeoccie or puerperal origin. They were not so defined by physi- cians, however, and the 1,783 cases classified under "salpingitis, other diseases of the female genital organs " are those which could not be definitely identified as deaths primarily due to gonorrhea or to puerperal causes. Oangrene. Under this very unsatisfactory heading 681 deaths of Metro- politan Industrial policyholders were classified during the six year period 1911 to 1916. This corresponds to a death rate of 1.3 per 100,000 exposed. The death rate shows an apparent decline throughout the period. This is due, largely, to improving certi- fication of causes of death whereby primary causative factors in cases of gangrene are being certified by physicians to a greater extent year after year. In consequence, deaths in which gangrene appears as a complication are being classified, more and more, under the diseases of which gangrene is a complication. The same appar- ent decline in the death rate is in evidence for the general popula- tion, and this decline is doubtless due to the same reason as that which is shown for the Industrial experience. The death rate for the general population is considerably higher, which is to be ex- pected on account of the age distribution of the two populations, if for no other reason; for a very great majority of the deaths charged to this title are those of persons over 60 years of age, and this class does not constitute as great a proportion of the Metropoli- tan exposure as it does of that of the general population. Again, a report of "gangrene" is not accepted by the Metropolitan Sta- tistical Bureau for classification, without investigation as to the primary cause. In consequence of this rather rigid censorship, a very considerable number of deaths originally certified as due to gangrene have been transferred to other titles, chief among which are diseases of the arteries, embolism and thrombosis, diabetes and many of the several titles which come under the general class head- ing " External Causes." Old Age. This is one of the most unsatisfactory title headings in the Inter- national List of Causes of Death. The several terms listed under MISCELLANEOUS DISEASES AND CONDITIONS. 289 this title, such as, " senility," " old age," " senile debility," " senile degeneration," " senile weakness " and others have too often been used in cases of old people who died of more or less well defined organic disease. Fortunately, however, this practice is steadily falling into disuse and the death rate for old age is seemingly de- clining. The decrease in the death rate in 'the Metropolitan In- dustrial experience is significant, therefore, only as it represents an improvement in the quality of the returns from year to year and in the censorship exercised in classifying causes of death. A simi- lar decrease in the apparent death rate for old age is in evidence in the mortality reports for the general population and is to be at- tributed to the same causes. The published death rate has declined in the expanding Registration Area from 50.4 in 1900 to 17.0 in 1916. Three thousand four hundred and eighty (3,480) deaths of Metropolitan Industrial policyholders were charged to this condi- tion during the six year period 1911 to 1916; this corresponds to a death rate for the period of 6.5 per 100,000 exposed. The crude death rate for old age among the insured is, of course, much lower than that shown for the Registration Area, the obvious reason being the difference in the age distribution of the two populations. A much smaller exposure proportionately of old people is found among the insured. The death rate for colored lives during the period (8.9) is higher- than that for white lives (6.1) and for each color class a higher death rate was reported for females than for males. In this connection it is of interest to note that the decrease in the death rate for old age is responsible for a considerable part of the supposed increase in the death rates of some of the " degenera- tive diseases." The explanation is that the great majority of the deaths which, under conditions of five, ten, or fifteen years ago, would have been returned as due to " old age " or its synonyms, are now being reported by more careful physicians under such head- ings as cerebral hemorrhage, arteriosclerosis, organic heart dis- ease, etc. Ill-Defined Diseases. Under this heading of the International List of Causes of Death are classified all reports which are not returned in such a way as to permit more satisfactory statistical assignment. The great ma- 20 290 MORTALITY STATISTICS OF INSURED WAGE EARNERS. jority of the deaths classified under this heading consists of cases in which either a complete diagnosis was not made or reported, or in which the cause of death was absolutely unknown or was returned as "unknown." In some instances there was no medical attend- ance. It should be definitely understood that none of the deaths classified under this title in this report was so assigned without every effort having been made to obtain a more definite report. Many hundreds of cases in which the vague and indeterminate ex- pressions listed under this class were encountered in the original certifications of physicians and coroners were ultimately classified under more definite headings as a result of corrections made by those who gave the original reports. The general improvement in cause of death certification and the yearly growing number of these corrected returns are the sole explanations for the declining death rate which is in evidence for this class, both for the insured and for the general population. The list which follows shows the manner in which the great bulk of the deaths charged to this class were reported: dropsy, cardiac syncope, "dropped dead," sudden death, asthenia, atrophy, bilious- ness, cachexia, cardiac asthenia, cardiac failure, cardiac paralysis, catarrhal fever, collapse, coma, complication of diseases, congestion, debility, decline, disappearance, dyspnea, "fever," "found dead," gastric fever, general debility, general weakness, heart failure, in- fection, inflammation, inquest pending, malnutrition, natural causes, "operation," paralysis of heart, postoperative shock, pros- tration, shock, surgical operation, surgical shock, "undetermined," "unknown," unknown disease, unspecified, and weakness. It should be understood, moreover, that not all of the ill-defined diseases and conditions are classified here. The group simply covers the worst of the type. It will be well, in this connection, to read what is said about unsatisfactory reports of causes of death in the discussions on such subjects as meningitis, peritonitis, pneu- monia, etc. Five thousand four hundred and forty-eight (5,448) deaths of Industrial policyholders were charged to "ill-defined diseases" during the period 1911 to 1916; this corresponds to a death rate of 10.1 per 100,000 exposed. SXJPPLEMElIiTT SUPPLEMENT. Mortality Statistics of Insured Wage Earners During 1917. It is possible at the present time to present a general statement on the mortality experience of the year 1917, although we can show only the facts for the combined experience without distinc- tion for the color, sex and age classes. The death rate in the aggre- gate during 1917 was 11.61 per 1,000 exposed. This is based upon a total of 125,955 deaths and an exposure of 10,847,852 years of life. The mortality experience of 1917 according to causes of death, classified under the titles of the detailed International List, is displayed in Table 176, page 294. The death rate from all diseases and conditions, combined, de- clined slightly in 1917 from the figure recorded for 1916 ; the rates being 11.61 and 11.68 per 1,000 persons exposed, respectively. The nine months of war in 1917 did not, therefore, result in any increase in the total mortality. Observation will show also that there were not many deaths of persons in military or naval service from causes incidental to military operations. Such deaths as oc- curred among the mobilized American forces were virtually limited to the acute infections in camps in the United States. Tuberculosis was the chief cause of death, being responsible for 16.3 per cent, of all deaths in 1917. The death rate for all forms of tuberculosis was 188.9 per 100,000, and for tuberculosis of the lungs alone, including acute miliary tuberculosis, 172.3 per 100,- 000 This was the lowest rate recorded for this disease in the mortality experience since 1911. In 1916, the rate was 172.8 per 100,000. The difference between the rates for these two years, however, was the smallest of any between any two years in this experience, which indicates a slackening in the downward tendency of the mortality in recent years. Organic diseases of the heart followed tuberculosis in order of numerical importance. The rate was 142.0 per 100,000, which is higher than the rate for the six year period 1911 to 1916, 140.1. It was only in 1912 that the death rate reached a higher point, 143.8. 293 294 MOKTALITY STATISTICS OF INSUEED WAGE EAENERS. 1-^ S ^ f?i ^ o ^ H < % M =c W y to <« r^ H 1—1 C>q ft H o 1-1 B ^ r>i < ^ H ^ s 1 -T< s W »-H P 2? fe ■f* o K r/) Kl .s 42 O ts H iHi-HTj*i-irH I a«BN«0iHt(5«t^(MW«0iH OJ l> N ft «5 t» O (N lO 00 •* .O |l>'-HiOOOO'*(M03i-iOfO TtiTtiiOi-iO-* rt lO Tj000t^(>^ ' otvi-T i-T i> cj r-T (N 1-1 € as QJo I 2 (u O o3 a ■ 03 S O cS 3 .3 ^ 03 P m S-i (D d O "iJ /S ^ -t^ ■" -U> |>,^ Jh -" S =? 4> il? 03 H > > 03 UJ S > •" O 3 S ■ iH O 03 n ft «J -S ft-^ s b = -s ^ o -e 111 43 03 T! O ■ftt jh-c srsTa s-th sj- 5 o:+j^ ^ ^-S 03 rt 03 03 -£3 ft''^ :a -a 2 I* Ml ^ to M-H K ^ >>,2 » -- a >i-q jH 03 SUPPLEMENT. 295 « w o H o CD OOOI>l>05lOOCOOrHTjHCO(NOT ' oJ (N ■* o e4 l> CClTtO5'-HlfflC0C0CO'-lTtH-*i-Hr-H OS ■t>t-t^l>t^l^ 00 <1pq o » -So H g 05=0. ■^_CD(M_i-HCv5|>.co-^C0(NO5(N-l— (N 05 r-J lO CO I-H O ' 00 CO ■^' 1-H iri S O c^ rHOl r-llC00O3CO00^i-l'*fflTtHU5Ti(^ OS CD i-H »C t- CO 05 b- 00 Ol T-H O 00 CO Tfi tH CD T3 .2 3 o 03 rt a ;3 3 r" td £ "5 J2 IB P " o s q !«! 0) S 03 03 S bo® o3 u cl oo'^g o 03 O s -s g 3 o3 o3 tn o3 o IS s S3 O .2.1-2 13 M ^.2 go Soft u S H . S .2 •S'S S <=" H cl G OD !C O O p. - ^ 'H ° o s> ^5 t^00050i-HiMCOTt(iCicOl>OOOJ O 1-1 --I i-H (M CO CO CO CO CD CO CO 296 MORTALITY STATISTICS OF INSURED WAGE EARNERS. i- fe) ^A o O 3 (=) ~ ft 2 ag , 13 iz; 3 » ° X S 2 So a g a o ■§ CO ' T-H T^' Tt ccoc^»oinc 05 C<5 I 00 lO lO oi 00 00 lo X 00 CO .-I 03 ; 03 «3 o J3 ■ I ^ a:: H g c -3 m r; 03 32 < §^ to S H H IB Eh << as m aj cj (B q, y 01 S S ^ ft aj ;3 J3 _2 S "^ SoQccO ID (U .»H CO c3 4) a S3 •oat, M ^ * o p 03 +^ «« .2 < •- 03 J^ aj ^42 >— to OOOQ lO CO l^ 00 o> Ol o o o o o o o i(M00-*U5Ot^00 '^ i-Hi— *i-Hr-l»-Hi-Hi— ti— »T-H^^i— tt—t >S i-iO5'*CO(N(N00»O^C^-* t~ IN rH M OJ CO -* CO IN a! a a> 0) 0) '■§ -S ■*^ -^ -^o § 'o'o'o o ^ OQ 03 OQ fe -, 03 03 03 -^ 2 5 00 m ., 3 03 03 03 3^ g tn CD 00 fJ 3 •J? a "JS «3 ,j3 S 03 So a '3 o M C3 ,„ >>0 03 O 03 * d « m a "^ 03 m 1^ 03 a s 3 +3 X 03 c 03 -o : ID o _S o c a 03 03 03 03 ^ .U -ci +i -t^ -fj o o o 'i O 3 C3.fi .1; o3 -(J h i o-s 03 03 ^ .2 03 BT3 S S Q Q P O Q SUPPLEMENT. 297 5) S o M S Z M M (35 <-j »o 'i; OJ (N rH 1-J ' (N t> CO O rH t^ (N O ■* ^ CI »o C<) i-H CO ■* CO O (N IN r-l rt IN ^ a CO CO !> lO t-J T-( fH rH t^ lO IN ^ IN t^ ■* t^ t^ 00 1-H lo 1-1 rH ^ X lO C3 -^ 3 p, 0) m -a j3 ^ o"o £ OD 00 2 V 4) fl a: ai m e3 c3 > 0) 4) C .2 .2 O 5 «; 2 * S S 53 5 g In o o s s s « K g t) m M 2 f^ ^ C5 — < 2 25 vi lU O O ^ -O ? fl .-. a m c3 • .2 S M c ; +j ^ 3? 4j , 4^ -3 Q.T5 ' o « a; T3 03 M OOt» .-£ IK '- B a "-3 "-3-3-3 "« M ■+J o3 o o3 o3 ^ rt Sh rt» >H fn tn m § oj '^ ^ t> h o o « j3 o) « m S -< Ph OPLipLi Ah a O & OS O « 02 J P Ph Of^ 1-1 6 ■2,-2 I .2 .2 2 ^ ^ ft 15 M i-:i 298 MORTALITY STATISTICS OF INSURED WAGE EAENEES. ^S o f ■*§ i'g OS a> . i"! £ . a H CS <) «> Ph ^ a< fl M W to f ) H g rff fl Q ■+0 rrl H c ^H tJ lU 1 1— 1 ^ a ^ ft ts. lo CD •>* •)- ic i> (N b. 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AH agea — 1 yr. and over. 1 to 4 5 to 9 10 to 14. 15 to 19. 20 to 24. 39 Of the buccal cavity White males 1353 989 240 75 49 14153 5309 7674 494 676 4482 1414 2701 103 264 7882 6499 1383 3579 31 3004 9 535 938 478 409 25 26 5279 2563 2209 240 267 6 3 2 1 20 7 13 22 14 6 2 4 4 3 3 114 51 58 4 1 4 2 11 12 9 3 5 5 5 2 3 72 31 37 2 2 5 3 2 7 2 6 13 9 3 1 3 3 1 1 5 1 4 57 31 24 2 4 2 1 1 16 6 7 2 1 18 8 8 1 1 16 14 2 1 1 2 1 1 112 58 45 3 6 12 4 White females Q Colored males 1 Colored females 1 40 Of the stomach, liver White males 35 17 White females .... Colored males 10 1 Colored females 7 41 Of the peritoneum, intes- tines, rectum 42 White males 18 White females 21 Colored males 1 Colored females 2 42 Of the female genital organs White males 30 White females 25 Colored males Colored females 5 43 Of the breast 4 White males White females 3 Colored males Colored females 1 44 Of the skin 4 White males 3 White females 1 Colored males Colored females 45 Of other organs or of organs not specified . . . White males 97 57 White females 31 Colored males 1 Colored females 8 APPENDIX A. 317 Condition. Classified by ColoRj Sex and by Age Period. Mortality Experience, 1911 to 1916. Age Periodf . Int'l List 25 to 30 to 35 to 40 to 45 to 50 to 55 to 60 to 65 to 70 to 75 and Number. 29. 34. 39. 44. 49. 64. 59. 64. 69. 74. over. 4 11 30 72 117 168 218 222 229 152 99 39 2 5 20 44 86 120 157 173 180 114 74 1 4 5 18 15 25 40 29 39 30 22 1 2 6 15 12 14 11 6 3 2 1 1 3 4 1 11 7 9 4 5 1 71 186 417 745 1184 1907 2436 2716 2183 1522 697 40 30 56 123 236 436 715 933 1085 837 580 239 26 84 217 416 613 1021 1301 1427 1241 868 422 7 13 29 40 53 82 84 96 45 30 12 8 33 48 53 82 89 118 108 60 44 24 73 110 213 276 393 624 643 700 653 462 228 41 22 26 52 68 119 176 210 245 217 160 61 35 57 116 161 238 385 394 424 410 284 156 5 6 10 10 7 16 12 10 10 7 7 11 21 35 37 29 47 27 21 16 11 4 143 325 727 1022 1212 1277 1169 903 598 320 128 42 95 229 96 547 816 992 220 1078 199 988 181 785 118 523 75 283 37 112 16 48 180 206 25 108 256 412 506 553 500 416 396 256 145 43 1 3 2 2 7 9 5 2 18 86 202 346 421 470 429 342 332 223 130 2 1 2 1 2 1 5 22 52 64 81 79 69 67 54 28 13 7 9 21 27 41 67 99 154 172 180 142 44 1 5 11 15 22 39 52 83 94 80 66 5 3 6 8 14 20 39 59 74 97 75 1 1 4 3 3 4 5 1 2 1 1 3 2 5 4 7 3 1 99 161 227 312 472 609 718 802 670 492 265 45 48 64 77 115 185 294 357 414 360 283 138 39 74 112 150 221 248 297 303 263 192 115 4 7 21 24 26 40 32 37 25 8 6 8 16 17 23 40 27 32 48 22 9 6 318 MORTALITY STATISTICS OF INSURED WAGE EARNERS. Number of Deaths from Each Specified Disease or Metropolitan Life Insurance Company Industrial Cause of Death. Age Periods. Infl List Number. AH ages — 1 yr. and over. lto4. 6 to 9. 10 to 14. 16 to 19. 20 to 24. 46 Other tumors (tumors of the female genital organs excepted) 293 51 161 9 72 3409 1303 1511 245 350 598 159 336 41 62 21 11 8 1 1 7762 2305 4754 289 414 743 40 692 8 103 164 66 103 2 3 7 4 3 126 70 48 6 2 1 1 11 7 4 83 41 39 3 3 1 2 570 266 269 17 18 3 2 1 1 1 122 53 60 7 2 1 1 1 1 2 1 1 497 202 256 16 23 4 4 1 1 224 94 121 i 8 6 1 6 2 1 1 1 1 322 150 133 15 24 9 3 6 1 1 1 242 120 109 8 5 46 7 35 4 8 4 3 1 5 White males I White females 2 Colored males Colored females 2 47 Acute articular rheumatism .... White males 209 74 White females 98 Colored males 17 Colored females 20 48 Chronic rheumatism and gout. . White males 10 6 White females 2 Colored males 2 Colored females 1 49 Scurvy 1 White males White females Colored males Colored females 1 60 Diabetes 218 White males 109 White females 96 Colored males 10 Colored females 3 51 Exophthalmic goiter 66 White males 8 White females 51 Colored males Colored females 7 52 Addison's disease 14 White males 9 White females 5 Colored males Colored females APPENDIX A. 319 Condition. Classified by Coix)Rj Sex and by Age Period. Mortality Experience, 1911 to 1916. Age Periods. Int'l List 25 to 30 to 35 to 40 to 45 to 50 to 55 to 60 to 65 to 70 to 75 and Number. 29. 34. 39. 44. 49. 54. 59. 64. 69. 74. over. 14 16 27 44 28 18 27 32 32 30 7 46 3 2 1 2 4 2 4 8 7 9 1 9 6 13 15 17 13 17 17 23 18 6 1 1 3 3 1 1 7 13 24 4 "'3 5 "7 2 3 166 166 147 183 170 176 192 160 168 100 57 47 53 51 48 58 57 72 60 46 48 30 18 75 70 54 66 64 59 85 81 82 49 22 13 15 24 24 18 24 17 12 13 5 9 25 30 21 35 31 21 30 21 25 16 8 16 21 15 17 44 41 64 81 108 101 63 48 7 8 4 6 10 8 18 19 26 28 11 6 9 5 9 23 28 31 43 64 64 46 1 2 2 1 4 2 6 9 4 3 4 3 2 4 1 7 3 9 10 14 6 2 1 2 1 1 1 49 . . . 1 1 1 1 1 1 215 239 250 333 541 859 1191 1257 1066 641 281 50 95 95 90 120 150 229 291 300 261 185 72 94 106 120 158 304 525 787 867 753 426 189 11 18 22 26 34 30 49 32 18 15 8 16 20 18 29 53 75 64 58 34 15 12 68 90 86 100 80 62 49 51 27 8 3 51 4 3 2 3 5 2 3 1 54 70 2 74 80 1 62 2 48 38 3 41 25 6 '3 io 15 10 16 11 12 8 "7 1 2 14 14 16 14 22 16 12 11 16 3 1 52 4 4 6 5 4 1 5 5 6 2 10 10 9 1 9 16 1 1 14 1 7 6 10 1 1 320 MORTALITY STATISTICS OF INSUKED WAGE EARNERS. Number of Deaths from Each Specified Disease or Metropolitan Life Insurance Company Industrial Cause of Death. Age Period* iDfl List Number. All ages — 1 yr. and over. lto4. 5 to 9. 1 10 to 14. 15 to 19. 20 to 24. 53 Leukemia 762 378 309 39 36 1772 507 1103 49 113 426 160 213 18 35 2555 1889 405 207 54 191 168 5 18 9 6 1 2 164 69 71 8 16 70 44 22 1 3 63 29 29 5 112 58 51 2 1 3 1 1 1 88 57 27 1 3 44 27 14 3 38 17 19 2 1 1 1 1 52 30 19 3 53 13 25 1 14 22 11 10 1 2 2 58 34 14 5 5 90 30 48 2 10 35 14 16 3 3 8 2 1 2 3 2 2 6 5 1 67 36 23 4 White males White females Colored males Colored females 4 54 Anemia, chlorosis 65 White males 9 White females 44 Colored males 3 Colored females 9 65 Other general diseases 24 White males 8 White females 12 Colored males 2 Colored females 2 66 Alcoholism (acute or chronic) . . White males 64 37 White females g Colored males 6 Colored females 4 67 Chronic lead poisoning White males 3 s White females Colored males Colored females 58 Other chronic occupation poisonings 1 White males White females 1 Colored males Colored females 69 Other chronic poisonings White males 17 11 White females 3 Colored males Colored females 3 APPENDIX A. 321 Condition. C1,assified by ColoRj Sex and by Age Period. Mortality Experience, 1911 to 1916. Age Periods. 25 to 29. 30 to 34. 22 5 13 2 2 208 150 36 16 6 10 7 1 35 to 39. 34 14 14 3 3 78 16 54 2 6 17 5 9 1 2 315 227 61 21 18 40 to 44. 5 7 2 2 454 323 70 50 11 21 19 1 1 14 105 123 45 to 49. 50 to 54. 16 22 11 1 4 435 317 77 33 31 41: 49 9ll i! 10 6 14 1' 1 1 3 1 2 1 15 14 5 4 7 9 1 1 2 57 12] 20 24 32 2' 2 3 3 I 15l! 193 50 124 7 12 22 22 345 295 55 to 59. 26, 23 20 23 '61 ... 15 51 26 22 2 1 232 157 5 4 198 255 229 167 59 40 17 27l 18 12 4' 8 2 60 to 64h 14 6 6 1 1 40 23 14 1 2 193 61 126 4 2 12 4 4 1 3 114 84 18 11 1 15 14 1 70 to 74. 75 and over. 32 162 49 19 11 14 11 8 18 5 1' 1 2 .. . 31 13 4 12 4 1 2 1 1 10 Infl List Niimber. 63 54 65 56 67 58 59 322 MORTALITY STATISTICS OF INSURED WAGE EARNERS. Number of Deaths from Each Specified Disease or Metropolitan Life Insurance Company Industrial Cause of Deatb. Age Periods. Int'l List Number. All ages — 1 yr.and over. 1 to 4. 5 to 9. 10 to 14. 15 to 19. 20 to 24. 60 to 76 II. Diseases of the Ner- vous System and of the Ohgans of Special Sense 57606 21801 26150 4184 5471 3961 1950 1645 195 171 1865 899 766 114 86 989 435 409 79 66 1034 480 373 104 77 919 White males 392 White females 326 Colored males 100 Colored females 101 Encephalitis 60 519 214 200 53 52 4171 1907 1663 336 265 823 378 275 97 73 797 513 191 59 34 4049 1846 1716 239 248 1889 990 768 69 62 83 37 36 4 6 1705 834 716 82 73 279 146 112 12 9 1149 602 473 42 32 1095 574 453 40 28 61 27 21 7 6 799 370 327 58 44 160 70 58 19 13 2 2 555 286 228 19 22 510 265 209 16 20 38 11 18 6 3 404 164 172 35 33 101 42 33 13 13 5 4 1 133 71 53 4 5 102 53 45 1 3 40 17 20 2 1 327 165 101 40 21 90 55 17 13 5 1 1 106 58 34 5 9 55 34 17 2 2 37 White males 20 White females 10 Colored males 2 Colored females 5 61 Meningitis (total) 182 White males 71 White females 59 Colored males 30 Colored females 22 *A61 Cerebrospinal fever White males 50 18 White females 17 Colored males g Colored females 6 62 Locomotor ataxia 3 White males 1 White females .■ 1 Colored males 1 Colored females 63 Other diseases of the spinal cord (total) 83 White males 35 White females 36 Colored males 8 Colored females . 4 A63 Acute anterior poliomyelitis White males 27 11 White females 13 Colored males 3 Colored females * Includes only deaths reported as due to cerebrospinal fever during the APPENDIX A. 323 Condition. Classified by ColoRj Sex and by Age Period. Mortality Experience, 1911 to 1916. Age Periods. Int'l Llat 25 to 30 to 35 to 40 to 45 to so to 55 to 60 to 65 to 70 to 75 and Number. 29. 34. 39. 44. 49. 54. 59. 64. 69. 74. over. 1013 1400 1831 2569 3522 5090 6173 7716 8052 6895 4577 60 to 76 392 554 653 898 1149 1701 2215 2821 2955 2614 1693 395 490 676 996 1515 2168 2757 3612 3991 3537 2494 118 181 236 302 361 513 488 515 437 286 155 108 175 266 373 497 708 713 768 669 458 235 40 26 22 31 27 31 29 19 17 9 9 60 19 12 5 17 6 15 8 5 6 4 5 13 2 9 9 14 12 13 10 6 4 3 4 7 1 1 4 2 6 3 3 1 4 5 7 4 3 2 2 1 2 1 135 126 90 100 85 75 44 52 25 14 8 61 59 40 34 41 36 31 21 23 7 8 3 60 52 28 41 30 28 16 20 16 4 3 18 17 15 14 9 8 3 4 1 1 1 8 17 13 4 10 8 4 5 1 1 1 33 26 19 19 17 15 3 6 4 1 61 12 7 5 7 4 5 6 5 1 1 3 1 4 1 12 7 4 5 9 2 5 3 6 1 4 5 6 2 4 3 1 2 9 23 47 86 90 126 149 116 68 46 26 62 4 13 25 55 58 84 94 79 42 32 20 3 7 15 20 18 27 38 25 19 13 4 1 1 3 8 8 10 10 7 6 1 2 1 2 4 3 6 5 7 5 1 64 90 87 122 143 248 234 320 339 244 132 63 25 36 37 37 53 83 85 129 148 107 54 28 36 38 52 61 106 110 148 146 105 62 5 11 8 18 11 26 21 14 26 15 6 6 7 4 15 18 33 18 29 19 17 10 9 16 4 7 7 7 12 11 17 5 5 A63 5 8 3 5 1 6 7 3 11 3 1 3 4 1 2 1 4 5 6 1 4 1 1 3 2 4 1 3 1 period 1912 to 1916; such deaths were not tabulated separately in 1911. 824 MORTALITY STATISTICS OF INSURED WAGE EARNERS. NuMBEE OF Deaths from Each Specified Disease ok Metropolitan Life Insurance Company Industrial Cause ol Death. Age Periods. Inf 1 List Number. All ages — 1 jT. and over. lto4. 5 to 9. 10 to 14. 15 to 19. 20 to 24. 64 Cerebral hemorrhage, apoplexy 36638 12886 17855 2347 3550 488 193 215 38 42 2773 758 1066 358 591 2224 1056 691 274 203 757 195 389 82 91 1869 864 689 181 135 98 28 49 6 15 138 54 60 12 12 1 1 19 11 7 1 2 2 59 26 26 4 3 54 23 20 9 2 3 2 1 17 9 5 3 1 1 76 38 33 2 3 30 14 13 1 2 51 25 14 5 7 4 3 1 19 5 8 4 2 2 "2 116 59 40 12 5 11 7 1 1 2 96 31 39 9 17 8 4 2 1 1 18 7 6 2 3 7 4 2 1 28 6 14 4 4 215 99 75 28 13 9 "7 1 1 160 55 69 Colored males 18 Colored females 28 65 Softening of the brain 5 White males 1 3 Colored males Colored females 1 66 Paralysis without specified cause 12 White males 1 White females 2 Colored males 6 Colored females 3 67 General paralysis of the insane. White males 4 2 White females 1 Colored males 1 Colored females 68 Other forms of mental alienation 51 White males 16 White females 21 Colored males 7 Colored females 7 69 Epilepsy 220 White males 108 White females 72 Colored males 20 Colored females 20 70 Convulsions (nonpuerperal) . . . White males 8 1 White females 7 Colored males Colored females APPENDIX A. 325 Condition. Classified by ColoRj Sex and by Age Period. Mortality Experience, 1911 to 1916. Age Periods. 25 to 29. 30 to 34. 35 to 39. 40 to 44. 45 to 49. 50 to 54. 55 to 59. 60 to 64. 70 to 74. 75 and over. lat'l Llat Number. 248 80 80 47 41 62 17 32 6 7 229 104 92 20 13 10 506 176 185 69 76 133 69 33 20 11 21 31 8 15 188 96 58 27 7 10 1 4 1 4 861 263 334 109 155 10 5 2 2 1 56 16 11 15 14 249 133 52 47 17 75 68 18 32 9 9 162 55 75 14 18 1378 410 555 165 248 17 104 26 26 23 29 300 152 78 37 33 86 15 54 7 10 159 75 57 12 15 3 3 2308 668 1067 230 343 23 12 3 172 27 68 18 59 311 164 78 49 20 74 21 34 8 11 104 48 39 9 3698 1173 1676 340 509 30 7 14 5 4 260 43 72 58 87 277 144 73 31 29 78 19 43 10 6 71 34 24 9 4 4805 1688 2245 332 540 35 12 17 2 4 325 90 101 50 84 234 103 76 34 21 63 6172 2252 2988 373 559 71 24 33 9 5 441 112 172 54 103 6575 2410 3363 306 496 95 79 20 24 74 21 36 9! 69 24i 29 i 'I 5753 2160 3049 206 338 101 100 525 160 221 50, 94; 69 79 19 18 48 19 22 3 4 51 31 14 2 4 1 426 137 186 39 64 218 185 163 3835 1418 2121 117 179 300 90 158 19 33 103 43 53 4 3 31 8 19 3 1 35 20 8 2 5 17 3 12 25 12 11 1 1 64 65 66 67 68 69 70 326 MOKTALITY STATISTICS OF INSURED WAGE EAENERS. Number of Deaths from Each Specified Disease or Metropolitan Life Insurance Company Industrial Cause of Death. Age Periods. Inf 1 List Number. All ages — 1 yr. and over. ito4. 5to9. 10 to 14. 15 to 19. 20 to 24. 71 Convulsions of infants White males 461 204 186 34 37 98 26 65 3 4 310 102 164 15 29 1349 632 592 108 117 43 16 18 2 7 962 461 401 49 51 94415 34636 43556 7257 8966 458 204 184 34 36 6 4 1 1 2 1 1 88 50 32 6 14 8 6 237 118 101 9 9 563 265 229 35 34 3 2 1 11 4 7 1 1 92 46 37 7 2 6 3 2 1 154 74 70 7 3 1583 657 810 49 67 21 6 16 3 2 1 73 39 25 6 3 1 1 108 39 57 6 6 2096 808 1098 81 109 18 2 14 1 1 2 1 1 67 33 25 5 4 3 1 2 89 63 31 3 2 2201 923 1011 115 152 White females Colored males Colored females 72 Chorea 9 White males 2 White females 7 Colored males Colored females 73 Neuralgia and neuritis White males 9 1 White females 5 Colored males 1 Colored females 2 74 Other diseases of the nervous system 78 White males 38 White females 29 Colored males 4 Colored females 7 75 Diseases of the eyes and their annexa White males White females Colored males Colored females 76 Diseases of the ears 58 White males 40 White females 14 Colored males 2 Colored females 2 77 to 85 III. Diseases of the ClRCULATOKY SySTEM . White males 2060 757 White females 964 Colored males 125 Colored females 214 APPENDIX A. 327 Condition. Classified by Coloe^ Sex and bt Age Period. Mortality Experience, 1911 to 1916, Age Periods. Infl List 25 to 30 to 35 to 40 to 45 to 50 to 55 to 60 to 65 to 70 to 75 and Number. 29. 34. 39. 44. 49. 54. 59. 64. 69. 74. over. 71 7 1 2 1 2 3 7 1 6 3 72 2 1 3 3 6 1 1 1 2 4 i 6 1 3 23 32 36 29 31 33 34 26 21 12 16 73 8 12 11 10 9 10 13 7 8 5 6 13 15 19 17 19 18 16 12 9 7 10 2 1 2 4 3 1 2 5 4 2 2 3 1 4 4 71 95 111 122 115 107 90 101 71 44 24 74 29 33 38 40 32 41 40 39 12 16 6 32 39 50 62 63 51 35 39 38 19 16 6 6 8 13 10 7 7 8 11 3 1 4 17 15 7 10 8 8 15 10 6 1 1 1 1 2 6 4 2 2 75 . ... 1 1 1 1 4 1 2 1 1 1 1 1 1 1 1 47 35 27 31 32 52 34 22 20 10 6 76 26 21 12 11 17 17 11 7 8 6 1 16 11 9 15 8 23 16 12 10 4 4 4 2 2 2 3 5 3 1 1 1 4 3 4 7 4 3 2 2457 3170 4260 6129 6331 8134 9782 12811 13687 12132 8019 77 to 85 835 1047 1316 1654 2188 2791 3628 4811 5264 4687 3005 1072 1212 1597 1944 2459 3431 4294 5995 6793 6255 4392 257 440 616 707 737 853 850 897 709 638 248 293 471 731 824 947 1059 1010 1108 921 652 374 328 MORTALITY STATISTICS OF INSURED WAGE EARNERS. NuMBEjR OF Deaths from Each Specified Disease or Metropolitan Life Insurance Company Industrial Cauae of Death. Age Periods. Int'l List Niimber. All ages — 1 jrr. and over. 1 to 4. 5 to 9. 10 to 14. 15 to 19. 20 to 24. 77 Pericarditis 624 197 252 73 102 5080 1871 2269 412 528 75345 26923 35225 5830 7367 2218 977 889 141 211 9142 4020 3894 651 577 1192 380 628 84 100 455 118 267 24 46 11 2 7 2 150 75 63 6 6 328 150 133 • 22 23 2 2 10 6 3 1 2 1 1 42 15 22 2 3 302 110 169 8 15 1182 503 600 35 44 8 5 2 1 1 1 12 5 7 4 3 1 31 10 17 2 2 271 98 149 10 14 1754 683 917 63 91 5 1 3 "l 4 3 1 9 4 4 1 1 1 23 12 7 3 1 280 110 133 13 24 1833 774 848 92 119 14 6 4 2 2 12 6 3 1 2 17 6 9 1 1 5 2 2 1 25 White males 9 White females 9 Colored males Colored females 7 78 Acute endocarditis 268 White males 96 White females 124 Colored males 19 Colored females 29 79 Organic diseases of the heart . . . White males 1667 620 White females 787 Colored males 98 Colored females 162 80 Angina pectoris 25 White males 7 White females 12 Colored males 4 Colored females 2 81 Diseases of the arteries, atheroma, aneurism, etc. . . . White males 15 7 White females 2 Colored males 2 Colored females 4 82 Embolism and thrombosis White males 34 8 White females 22 Colored males Colored females 4 83 Diseases of the veins (varices, hemorrhoids, phlebitis, etc.) White males 9 2 White females 4 Colored males 1 Colored females 2 APPENDIX A. 329 Condition. Classified by Color, Sex and by Age Period. Mortality Experience, 1911 to 1916. Age Periods. Infl List 25 to 30 to 35 to 40 to 45 to 50 to 55 to 60 to 65 to 70 to 75 and Number. 29. 34. 39. 44. 49. 54. 59. 64. 69. 74. over. 37 36 42 35 45 49 63 62 47 53 23 77 8 10 10 15 13 20 18 20 18 14 ■i 18 6 9 8 18 15 22 27 20 30 17 6 10 11 4 6 5 9 6 4 3 5 10 12 8 8 9 14 9 5 6 3 293 352 443 431 580 645 714 178 81 67 25 78 90 137 139 143 230 244 282 65 24 19 9 135 138 185 173 215 278 322 89 43 38 15 29 28 65 55 58 51 51 10 4 4 1 39 49 54 60 77 72 59 14 10 6 1970 2561 3403 4202 5089 6571 7790 10702 11055 9390 5848 79 696 824 1035 1354 1711 2161 2794 3898 4083 3499 2138 860 1008 1309 1602 2018 2838 3450 5085 5622 4919 3229 191 359 447 559 578 699 705 770 588 431 193 223 370 612 687 782 873 841 949 762 541 288 39 65 95 120 166 216 286 368 386 277 146 80 7 27 37 33 72 107 145 157 189 132 52 19 16 26 42 45 67 110 162 163 128 88 7 5 18 20 16 15 16 19 12 6 6 17 14 25 33 27 15 30 22 11 6 45 88 170 195 271 463 751 1267 1873 2136 1851 81 15 26 60 72 115 199 332 584 882 951 768 10 14 18 36 68 141 295 520 803 1022 961 14 30 67 62 58 61 57 76 88 84 50 6 18 25 25 30 62 67 87 100 79 72 41 38 52 83 113 118 110 143 168 154 90 82 10 13 21 19 32 35 40 57 46 50 28 19 15 25 49 55 58 55 66 94 91 56 3 4 3 2 16 14 7 9 12 9 3 9 6 3 13 10 11 8 11 16 4 3 14 18 42 40 50 50 49 66 53 29 23 83 4 5 9 7 10 18 13 19 14 7 4 7 11 21 27 33 27 31 33 33 19 17 2 1 2 1 3 3 2 6 1 1 1 1 10 5 4 2 3 8 6 3 1 330 MORTALITY STATISTICS OF INSURED WAGE EARNERS. Number of Deaths from Each Specified Disease or Metropolitan Life Insurance Company Industrial Cause of Death. Age Periods. Infl List Number. All ages — 1 yr. and over. 1 to 4. 5 to 9. 10 to 14. 15 to 19. 20 to 24. 84 Diseases of the lymphatic sys- tem (lymphangitis, etc.) . . . 165 83 56 15 11 194 67 76 27 24 71345 29140 29443 6642 6120 57 32 17 5 3 3 3 13887 6208 5611 1026 1042 27 14 7 2 4 5 2 1 1 1 2888 1218 1195 206 269 14 6 5 3 7 2 3 1 1 1168 435 478 121 134 6 2 2 1 1 11 6 3 1 2 1786 697 563 248 278 8 3 3 Colored males 1 Colored females 1 85 Hemorrhage; other diseases of the circulatory system 9 6 1 Colored males 3 86 to 98 IV. Diseases of the Re- spiratory System .... 2200 812 White females 666 377 345 Diseases of the nasal fossae . . . 86 72 33 26 9 4 594 305 227 34 28 188 26 130 5 27 2636 943 1224 196 273 12 7 2 3 300 167 111 9 13 4 2 2 1218 500 494 98 126 6 5 1 119 64 51 4 5 2 3 143 64 57 6 16 7 4 3 24 12 10 2 13 5 7 1 35 14 6 7 8 5 3 2 7 3 2 1 1 15 5 5 1 4 37 8 12 3 14 2 White females 1 Colored males 1 Colored females 87 8 3 2 2 1 88 Diseases of the thyroid body. . . White males 16 3 12 1 89 35 9 White females 10 8 Colored females 8 APPENDIX A. 331 Condition. Classified by ColoRj Sex and by Age Period. Mortality Experience, 1911 to 1916. Age PerlodE . Infl List 25 to 30 to 35 to 40 to 45 to 50 to 55 to 60 to 65 to 70 to 75 and Number. 29. 34. 39 44. 49. 54. 59. 64. 69. 74. over. 7 4 5 6 2 4 6 6 5 6 2 84 4 1 3 5 2 1 5 3 2 1 2 2 1 2 1 4 1 2 4 "2 1 1 1 1 1 11 8 8 17 15 18 13 19 19 20 11 85 1 4 2 6 6 5 3 6 5 13 3 3 2 2 6 5 6 5 12 13 4 7 - 4 2 3 4 2 4 3 1 1 3 1 1 3 3 2 1 2 1 2572 3048 3484 3876 4111 4883 5550 6285 6358 5524 3725 86 to 98 991 1297 1513 1742 1879 2140 2302 2468 2333 1929 1176 781 855 989 1212 1344 1814 2362 2928 3334 3065 2246 480 515 586 557 533 519 413 440 288 217 116 320 381 396 365 355 410 473 449 403 313 187 3 1 3 1 6 2 1 9 7 7 86 3 1 2 3 3 2 1 2 1 1 4 3 5 2 1 1 1 i 1 2 16 17 14 14 13 10 11 7 19 9 6 87 3 4 8 6 6 2 6 6 9 5 1 4 11 4 3 2 3 5 1 10 4 4 5 2 2 3 2 2 4 2 3 3 1 10 12 13 12 15 15 21 12 13 8 4 88 1 1 1 2 1 2 1 9 7 2 10 11 8 11 16 1 9 9 "l 4 2 2 1 5 3 4 1 3 1 42 39 49 44 49 59 103 146 197 231 209 89 10 10 15 11 24 21 30 54 59 66 48 10 7 14 13 11 29 62 79 124 149 147 13 8 9 10 10 3 6 5 3 2 5 9 14 11 10 4 6 5 8 11 14 9 332 MORTALITY STATISTICS OF INSURED WAGE EARNERS. Number of Deaths from Each Sphkjipted Disease or Metropolitan Life Insurance Company Industrial Cauae of Death. Age Periods. Int'l List Number. All ages — 1 yr. and over. lto4. 5 to 9. 10 to 14. 15 to 19. 20 to 24. 90 Chronic bronchitis 4224 1453 2070 286 415 16224 6338 7505 1152 1229 41707 17659 16185 4318 3545 1985 853 740 213 179 939 319 456 85 79 171 100 53 11 7 1594 607 583 182 222 75 29 24 10 12 7007 3096 2896 514 501 4874 2203 1930 375 366 246 145 86 12 3 95 35 48 4 8 3 1 2 36 19 8 1 8 63 22 25 6 10 972 387 426 77 82 1430 605 575 101 149 92 41 39 7 5 21 10 7 2 2 3 2 1 15 7 3 2 3 30 5 12 7 6 220 82 90 19 29 754 286 316 72 80 54 18 22 8 6 10 4 2 2 2 4 2 1 1 4 2 1 1 57 9 14 9 25 222 69 79 39 35 1263 524 398 164 177 112 46 38 17 11 17 6 6 3 2 8 3 1 2 2 9 6 1 2 92 White males 24 White females 16 Colored males , Colored females 16 36 91 Bronchopneumonia 216 White males 60 White females 86 Colored males 31 Colored females 39 92 Pneumonia — lobar and iindefinpid , 1608 White males 630 White females 463 Colored males 286 Colored females 229 93 Pleurisy 128 White males 53 White females 41 Colored males 20 Colored females 14 94 Pulmonary congestion, pul- monary apoplexy 21 White males 7 White females 6 Colored males 3 Colored females 5 95 Gangrene of the lung 11 White males 3 White females 6 Colored males 2 Colored females 96 Asthma 13 White males 2 White females 5 Colored males I Colored females 5 APPENDIX A. 333 Condition. Classified by Color, Sex and by Age Peeuod. Mortality Experience, 1911 to 1916. Age Periods. Infl List 25 to 30 to 35 to 40 to 45 to 50 to 55 to 60 to 65 to 70 to 75 and Number. 29. 34. 39. 44. 49. 54. 59. 64. 69. 74. over. 96 110 105 122 168 250 365 537 722 798 634 90 22 28 44 36 64 97 135 200 253 267 218 25 24 26 45 58 101 176 266 395 484 379 22 21 12 19 26 29 21 26 29 22 11 27 37 23 22 20 23 33 45 45 25 26 268 282 313 384 466 614 803 1100 1270 1218 889 91 91 107 118 161 188 246 308 370 419 389 247 96 93 115 143 180 260 383 598 754 727 579 35 41 48 44 43 53 47 68 33 35 25 36 41 32 36 45 55 65 64 64 67 38 1922 2315 2664 2939 2992 3426 3687 3894 3559 2732 1648 92 788 1053 1215 1387 1418 1533 1563 1575 1349 984 646 675 630 713 883 971 1266 1528 1766 1778 1444 949 352 384 458 418 386 359 286 291 192 133 61 207 248 278 251 217 268 310 262 240 171 92 111 119 134 146 136 160 140 141 127 84 55 93 35 45 45 58 65 69 65 63 51 33 21 37 33 51 52 43 63 56 51 61 42 25 21 24 16 26 17 16 7 9 8 3 2 18 17 22 10 11 12 12 18 7 6 7 26 36 40 48 41 43 83 88 112 139 120 94 5 9 16 21 10 17 34 26 38 47 34 10 16 9 15 19 11 33 44 64 85 82 8 8 7 7 6 9 8 10 5 1 3 2 4 8 5 7 6 8 8 6 6 1 7 13 13 13 20 19 20 15 8 12 2 95 2 8 5 9 14 14 12 9 5 10 1 3 6 7 4 6 3 6 5 3 1 1 1 1 1 1 1 1 1 1 2 29 62 67 76 123 166 186 236 243 223 116 96 12 7 18 20 41 72 67 95 104 94 41 3 18 28 28 30 42 72 83 105 95 62 8 14 9 13 19 28 22 24 16 17 7 6 13 12 15 33 24 25 34 18 17 6 334 MOKTALITY STATISTICS OF INSURED WAGE EARNERS. Number of Deaths from Each Specified Disease or Metropolitan Life Insurance Company Industrial Cause of Deat . Age Periods. Int'l List Number. All ages — 1 yr. and over. 1 to 4. 5 to 9. 10 to 14. 15 to 19. 20 to 24. 97 Pulmonary emphysema White males 123 60 39 18 6 888 444 205 133 106 49146 19862 21433 3526 4325 17 4 8 5 11153 5356 4730 565 502 1 1 18 8 7 1 2 2245 1029 944 131 141 13 1 8 3 1 1562 735 605 115 107 3 2 1 31 13 6 7 5 1649 738 594 139 178 3 2 White females 1 Colored males Colored females 98 Other diseases of the respira- tory system (tuberculosis excepted) 47 White males 16 White females 17 Colored males 6 Colored females 8 99 to 118 V. Diseases of the Digestive System .... White males 1676 649 White females 659 Colored males 138 Colored females 230 Diseases of the mouth and annexa 99 200 73 90 15 22 1153 545 449 65 94 124 70 45 5 4 2159 929 806 189 235 45 28 15 1 1 277 149 105, 9 14 16 1 8' 8 16 7 7 1 1: 22 10 12 293 144 124 10 15 5 4 1 16 6 7 3 7 3 3 1 116 45 54 7 10 3 2 1 14 6 5 3 4 3 1 82 43 34 1 4 51 18 25 3 5 10 White males 5 White females 3 Colored males 1 Colored females 1 100 Diseases of the pharynx White males 70 32 White females 20 Colored males 6 Colored females 12 101 Diseases of the esophagus White males 2 1 White females 1 Colored males Colored females 02 Ulcer of the stomach 108 White males 39 White females 47 Colored males 7 Colored females 15 APPENDIX A. 336 Condition. Classified by ColoRj Sex and by Age Period. Mortality Experience, 1911 to I&IG. Age Periods. Int'l List 25 to 30 to 35 to 40 to 45 to 50 to 55 to 60 to 65 to 70 to 75 and Number. 29. 34. 39. 44. 49. 54. 59. 64. 69. 74. o-'er. 4 3 6 7 5 10 16 21 16 16 12 97 1 2 2 7 9 10 7 9 8 1 2 1 1 2 6 7 8 7 3 3 1 4 3 2 1 1 2 1 1 2 1 1 49 49 63 70 87 109 114 88 63 47 23 98 19 24 28 30 43 61 73 58 35 22 9 9 11 9 14 14 22 18 19 19 18 6 12 10 18 14 21 17 13 4 2 3 2 9 4 8 12 9 9 10 7 7 4 6 1943 2145 2644 2919 3140 3626 3501 3694 3225 2520 1504 99 to 118 670 699 886 1094 1239 1468 1394 1392 1127 871 515 782 '836 1075 1159 1300 1534 1555 1742 1670 1389 859 182 231 311 307 268 284 258 245 194 105 53 309 379 372 359 333 340 294 315 234 155 77 14 15 13 4 10 14 9 2 12 4 7 3 5 2 7 2 6 2 99 2 2 4 7 "9 7 4 6 3 6 3 3 2 4 4 2 2 1 1 1 2 1 4 2 2 3 3 1 1 1 53 48 40 41 32 20 23 20 17 10 11 100 22 17 12 26 13 8 7 10 6 5 6 20 19 16 7 10 8 10 8 6 4 4 5 3 7 3 4 3 4 2 1 6 9 5 5 5 1 2 2 3 1 1 2 4 9 9 13 15 11 12 15 7 101 1 2 5 6 11 8 6 8 6 4 "i 1 2 2 2 2 1 2 4 2 1 5 4 7 1 1 3 165 168 241 234 224 224 212 182 176 89 39 102 62 72 97 107 114 115 ^ 100 82 61 28 15 59 55 86 70 70 74 79 72 85 46 19 17 17 28 31 21 13 14 13 14 7 3 27 24 30 26 19 22 19 15 16 8 2 336 MORTALITY STATISTICS OF INSURED WAGE EARNERS. Number of Deaths from Each Specified Disease or Metropolitan Life Insurance Company Industrial Cause of Death. Age Periods. mt'i Last Numbe-. All ages — 1 yr.and over. 1 to4. 5 to 9. 10 to 14. 15 to 19. 20 to 24. 103 Other diseases of the stomach (cancer excepted) 4921 1480 1878 628 935 6684 3199 2928 314 243 7489 2830 3402 491 766 12 5 4 1 2 57 14 25 7 11 6345 2832 2622 423 468 2357 788 1287 170 112 545 249 206 42 48 6684 3199 2928 314 243 2736 1284 1151 151 150 2 1 1 37 12 12 4 9 212 103 99 9 1 36 25 4 6 1 154 54 60 18 22 638 278 276 31 53 2 1 1 13 1 8 3 1 734 358 324 30 22 15 13 2 75 16 20 20 •19 157 64 59 12 22 2 1 1 2 1 1 916 470 367 50 29 13 10 1 1 1 64 14 20 15 15 117 33 39 22 23 2 2 954 493 338 58 65 18 9 4 4 1 122 21 41 20 White males White females Colored males Colored females 40 104 Diarrhea and enteritis (under 2 years) White males White females Colored males Colored females 105 Diarrhea and enteritis (2 years and over) 150 White males 40 White females 75 Colored males 11 Colored females 24 106 Ankyln.qtoTnin.sis 1 White males 1 White females Colored males Colored females 107 Intestinal parasites 1 White males White females 1 Colored males Colored females 108 Appendicitis and typhlitis White males 700 340 White females 257 Colored males 43 Colored females 60 A109 Hernia 40 White males 23 White females 5 Colored males 9 Colored females 3 APPENDIX A. 537 Condition. Classified by Colx>r.. Sex and by Age Period. Mortality Experience, 1911 to 1&16. Age Periods. 30 to 34. 35 to 39. 195 280 45 j 46i 381 200 59 80 20 41 25 22. 14 6 71 56 65 40 to 44. 318 74 95 67 82 245 82 90l 26 47 i 470 384 157 133 201! 157 43 i 40 69 54 I 67 98 32 47 11 237 77 90 28 42 339 129 135 32 43 157 43 89 11 14 347 92 101 219 63 90 22 44 265 93 129 22 21 217 52 138 9 18 60 to 54. 1391 135! 63 110 284 124 23 49 277 92 139 28 18 297 174 16 18 55 to 59. 447; 430 128 139 62 101 355 122 149 39 45 179 82 73 9 15 297 78 188 21 10 60 to 64. 608 145 257 33 73 1 166 79 11 10 369 118 215 24 12 65 to 69. 515i 510 166 211 63 95 165 241 44 60 626 138 303 29 66 1 I 1 80 371 341 t 318 109 180 19 10 70 to 74. 75 and over. 450! 288 136 261 19 46 160 331 17 44 65 26 33 4 3 226 78 134 10 3 79 173 12 24 552! 380 127 219 11 23 23 163 69 76 7 1 Int'l List Number. 103 104 106 106 107 108 A109 338 MORTALITY STATISTICS OF INSURED WAGE EARNERS. Number of Deaths from Each Specified Disease or Metropolitan Life Insurance Company Industrial Cause of Death. Age Periods. Infl List Number. All ages — I yr. and over. 1 to 4. 5 to 9. 10 to 14. 15 to 19. 20 to 24. B109 Intestinal obstruction 3162 1039 1580 209 334 1006 316 437 99 154 236 75 122 12 27 11 2 7 1 1 8064 4426 2715 574 349 1591 217 1250 36 88 2181 652 1122 195 212 313 180 111 9 13 54 30 16 4 4 5 2 3 1 1 19 11 4 1 3 2 "l ■l 78 36 26 8 8 152 75 54 14 9 29 11 11 4 3 6 4 2 25 10 9 3 3 1 1 55 29 14 9 3 86 49 24 9 4 20 13 5 1 1 8 4 4 29 11 11 4 3 2 1 1 35 13 13 3 122 55 39 14 14 39 18 16 2 3 4 1 1 1 1 29 9 9 5 6 3 1 1 1 42 13 16 8 5 133 White males 50 White females 61 Colored males 6 Colored females 16 110 Other diseases of the intestines White males 43 14 White females 20 Colored males 5 Colored females 4 111 Acute yellow atrophy of the liver 30 White males 7 White females 18 Colored males Colored females 6 112 Hydatid tumor of the liver .... White males White females Colored males Colored females *113 Cirrhosis of the liver 55 White males 25 White females 11 Colored males 10 Colored females 9 114 Biliary calculi 18 White males 2 White females 8 Colored males 3 Colored females 5 115 Other diseases of the liver White males 74 26 White females 31 Colored males 9 Colored females 8 * Includes alcoholic cirrhosis of the liver. APPENDIX A. 339 Condition. Classipieb by ColoRj Sex and by Age Period. Mortality Experience, 1911 to 1916. Age Periods. 25 to 29. 30 to 34. 35 to 39. 40 to 44. 45 to 49. 50 to 54. 55 to 59. 60 to 64. 65 to 69. 70 to 74. 75 and over. Int'l Ll3t Number. 176 48 71 14 43 73 13 41 3 16 21 4 12 1 4 3 ' 3 186 92 54 24 16 38 5 26 3 4 95 35 39 8 13 180 38 86 12 44 69 17 24 5 23 24 3 13 2 6 377 196 112 42 27 69 9 48 4 8 139 39 64 19 17 198 29 108 17 44 87 19 38 11 19 21 3 12 1 5 2 i 1 633 321 216 71 25 91 10 65 5 11 174 38 85 26 25 182 35 98 15 34 82 22 36 11 13 16 6 6 4 2 1 1 890 473 302 72 43 136 22 103 2 9 152 45 70 19 18 179 44 98 11 26 88 27 34 9 18 17 9 7 1 1072 608 346 67 51 171 28 133 3 7 203 64 95 25 19 252 82 132 19 19 89 23 37 12 17 17 6 10 1 1 1 1170 704 353 79 34 222 22 181 6 13 224 64 119 18 23 260 77 146 18 19 58 22 25 4 7 12 2 7 1 2 1093 645 354 59 35 32 207 5 7 230 60 132 16 22 309 89 175 22 23 92 28 44 10 10 20 8 9 3 949 553 304 64 28 235 30 193 1 11 229 67 131 12 19 265 82 158 15 10 70 16 37 8 9 9 4 4 1 791 408 303 44 36 167 23 136 1 7 225 59 141 11 14 206 62 126 6 12 66 26 29 8 3 18 9 9 2 2 532 272 218 23 19 115 17 93 2 3 141 37 91 4 9 149 44 93 8 4 47 17 24 2 4 8 3 5 214 88 109 6 11 70 16 53 1 85 27 55 ■3 B109 110 111 112 113 114 115 340 MORTALITY STATISTICS OF INSURED WAGE EARNERS. Number ar Deaths prom Each Specified Disease or Metropolitan Life Insurance Company Industrial Cause of Death. Age Periods. Infl List Kumber. All ages — 1 yr. and over. 1 to 4. 5 to 9. 10 to 14. 15 to 19. 20 to 24. 116 Diseases of the spleen 77 39 34 2 2 1013 210 490 74 239 304 121 140 16 27 64919 24602 28216 5335 6766 6 4 2 65 27 29 5 4 4 1 1 1 1 618 294 219 60 45 4 2 1 1 75 28 36 I 6 2 4 693 274 246 37 36 3 1 2 64 23 28 7 6 10 5 4 1 484 171 244 35 34 2 2 104 23 45 4 32 12 5 4 1 2 933 305 437 52 139 3 White males 2 White females 1 Colored males Colored females 117 Simple peritonitis (non- puerperal) 105 White males 17 White females 64 Colored males . 7 Colored females 27 118 Other diseases of the digestive system (cancer and tuber- culosis excepted) 11 White males 4 White females 5 Colored males 1 Colored females 1 119 to 133 VI. NONVENEREAL DIS- EASES OF THE Genito- urinary System and Annexa 1634 White males 505 White females 814 Colored males 90 Colored females 225 Acute nephritis 119 5120 1969 1954 549 648 52067 20762 22650 4234 4421 3 2 1 316 146 117 28 25 259 124 91 29 15 246 118 94 19 15 312 141 137 15 19 1 1 130 43 65 9 13 321 114 164 24 19 201 79 88 18 16 524 209 240 31 44 315 White males 147 White females 121 Colored males 21 Colored females 26 120 Bright's disease 835 White males 321 White females 367 Colored males 63 Colored females 84 121 Chyluria White males White females Colored males Colored females APPENDIX A. 341 Condition. Classified by Color, Sex and by Age Period. Mortality Experience, 1911 to 1916. Age Periods. Infl List 25 to 30 to 35 to 40 to 45 to 50 to 55 to 60 to 65 to 70 to 75 and Number. 29. 34. 39. 44. 49. 54. 59. 64. 69. 74. over. 6 5 8 7 6 7 7 4 5 1 3 116 2 3 3 5 2 4 5 2 1 1 4 2 5 1 1 3 2 2 2 5 2 1 1 105 89 90 64 47 45 44 49 28 21 18 117 7 7 12 7 10 11 10 16 2 6 5 61 44 40 29 21 24 24 20 17 11 7 4 7 13 5 6 1 2 2 2 2 3 33 31 25 23 11 9 8 11 7 3 3 22 27 33 43 29 28 23 28 20 5 3 118 9 11 17 16 10 8 12 13 7 1 7 9 11 21 16 16 10 14 12 4 2 1 3 2 3 1 1 1 1 5 4 3 3 2 3 1 i 2184 3016 4048 4841 5614 6437 7367 8374 8205 6541 4030 119 to 133 610 884 1214 1562 1926 2416 2923 3472 3430 2858 1758 1040 1347 1715 2049 2481 2717 3089 3466 3596 2886 1870 132 237 363 456 506 617 698 732 646 479 195 402 548 756 774 701 687 657 704 533 318 207 330 367 41'4 439 429 450 446 397 312 219 109 119 133 153 154 146 148 143 166 150 123 82 38 122 127 148 174 175 178 144 152 121 87 41 30 41 50 53 50 51 59 47 33 28 12 45 46 62 66 56 78 77 48 35 22 18 1187 1883 2719 3605 4472 5491 6435 7424 7252 5776 3572 120 442 691 1001 1371 1709 2174 2590 3039 2934 2417 1485 630 770 1088 1427 1859 2282 2751 3158 3335 2699 1752 79 176 286 367 420 507 569 613 524 375 156 136 246 344 440 1 1 484 528 525 614 459 1 1 285 179 121 342 MOETALITY STATISTICS OF INSUKED WAGE EARNEKS. Number of Deaths from Each Specified Disease or Metropolitan Life Insurance Company Industrial Int'l List Number. Cause of Death. Age Periods. All ages — 1 yr. and over. 10 to 14. 15 to 19. 122 123 124 125 126 127 128 Other diseases of the kidneys and annexa White males White females Colored males Colored females Calculi of the urinary passages White males White females Colored males Colored females Diseases of the bladder White males White females Colored males Colored females Diseases of the urethra, urinary abscess, etc White males White females Colored males Colored females Diseases of the prostate White males White females Colored males Colored females Nonvenereal diseases of the male genital organs White males White females Colored males Colored females Uterine hemorrhage (non- puerperal) White males White females Colored males Colored females 861 302 401 86 72 322 174 116 24 611 320 141 109 41 202 110 13 77 1162 928 234 56 35 21 67 53 14 16 23 APPENDIX A. 343 Condition. Classifikd by Color^ Sex and by Age Period. Mortality Experience, 1911 to 1916. Age Periods . Int'l List 25 to 30 to 35 to 40 to 45 to 50 to 55 to 60 to 65 to 79 to 75 and Number. 29. 34. 39. 44. 49. 54. 59. 64. 69. 74. over. 49 46 75 76 66 83 75 76 82 60 44 122 14 14 23 21 19 23 26 29 36 28 17 27 25 40 34 36 43 32 32 31 25 21 3 1 8 14 8 10 10 9 5 6 3 5 6 4 7 3 7 7 6 10 1 3 15 21 30 18 22 29 37 43 29 25 12 123 9 11 17 5 11 13 18 24 18 13 7 4 7 13 10 10 13 15 15 8 7 4 2 2 1 3 1 1 2 4 4 2 1 5 1 19 13 15 21 37 36 50 87 113 121 74 124 3 6 4 6 13 13 27 48 68 78 43 6 4 5 6 10 12 7 17 20 23 23 7 2 4 5 9 9 11 17 21 16 5 3 1 2 4 5 2 5 5 4 4 3 15 20 21 12 29 20 31 20 21 2 5 125 5 8 2 8 2 4 13 14 18 2 16 15 2 3 1 1 1 3 9 10 11 7 12 1 6 10 1 4 6 1 3 2 6 14 16 61 108 200 282 284 181 126 2 5 8 11 30 77 163 229 236 164 1 2 1 6 "5 31 31 '37 53 48 17 3 4 4 4 2 8 5 4 9 3 1 127 2 1 1 1 1 6 1 3 7 2 1 1 3 3 3 1 2 4 1 2 1 9 11 9 8 7 4 3 3 2 1 2 128 7 "9 "e 6 6 "3 "3 3 "2 2 2 3 2 1 1 2 1 344 MORTALITY STATISTICS OF INSURED WAGE EARNERS. Number of Deaths from Each Specified Disease or Metropolitan Life Insurance Company Industrial Int'l List Number. Age Periods. Cause of Death. All ages — 1 yr.and over. 10 to 14. 15 to 19. 20 to 24. 129 130 131 Uterine tumor (noncancerous). White males .... White females . . Colored males . . Colored females. Other diseases of the uterus. . . . White males. . . . White females . . Colored males. . Colored females. Cysts and other tumors of the ovary White males. . . . White females . . Colored males . . Colored females. 132 Salpingitis and other diseases of the female genital organs. 133 134 to 141 134 White males. . . . White females . . Colored males. . Colored females. Nonpuerperal diseases of the breast (cancer excepted) . White males. . . . White females . . Colored males. . Colored females. VII. The Puerpebal State White males. . . . White females . . Colored males. . Colored females. Accidents of pregnancy . White males. . . . White females . . Colored males. . Colored females. 1335 705 630 786 600 186 608 400 108 1782 1151 631 37 2 30 5 10151 8359 1792 885 712 173 6 1 103 54 49 979 660 319 17 9 8 72 60 12 30 27 3 282 196 86 1 2246 1865 381 161 122 39 APPENDIX A, 345 Condition. Classified by ColoRj Sex and by Age Period. Mortality Experience, 1911 to 1916. Age Periods. 25 to 29. 30 to 34. 35 to 39. 40 to 44. 45 to 49. 50 to 54. 55 to 59. 60 to 64. 65 to 69. 70 to 74. 75 and over. Int'I List Number. 53 139 253 265 270 123 85 56 30 24 12 129 18 56 89 128 178 84 58 37 17 20 9 35 83 164 137 92 39 27 19 13 4 3 112 110 101 97 83 52 39 28 25 7 8 130 76 82 75 74 69 41 32 21 23 6 "7 36 28 26 23 14 11 ■7 7 2 1 1 52 56 76 67 60 39 29 24 39 18 9 131 33 40 53 52 51 26 28 22 ■33 18 9 19 16 23 15 9 13 1 2 6 332 342 318 210 117 37 21 8 7 132 211 223 '"' 134 82 31 14 6 6 121 119 127 76 35 6 "7 2 1 5 2 7 4 4 4 3 4 1 1 1 133 * 6 2 1 5 1 3 1 1 2 1 4 '3 3 1 1 1 1 2357 2171 1644 659 76 6 1 134 to 141 1986 1822 1392 563 62 3 i 371 349 252 96 14 3 218 220 173 59 9 1 134 178 179 141 48 7 40 41 32 11 2 1 246 MORTALITY STATISTICS OF INSURED WAGE EARNERS. Number of Deaths from Each Specified Disease or Metropolitan Life Insurance Company Industrial Cause of Death. Age Periods. Infl List Number. All ages — 1 yr. and over. 1 to 4. 5 to 9. 10 to 14. IS to 19. 20 to 24. 135 Puerperal hemorrhage 791 681 110 1036 838 198 4348 3512 836 2675 2249 426 369 327 42 43 36 7 4 4 3 2 "l 4 1 3 4 i 3 25 22 3 61 38 23 449 291 158 385 259 126 13 12 1 2 1 1 1 1 109 White males White females 86 Colored males Colored females 23 130 Other accidents of labor White males 200 White females 159 Colored males Colored females 41 137 Puerperal septicemia 1036 White males White females 849 Colored males Colored females 187 138 Puerperal albuminuria and convulsions 671 White raales ....•• White females 684 Colored males Colored females 87 139 Puerperal phlegmasia alba dolens, embolus, sudden death 61 White males White females 57 Colored males Colored females 4 140 Following childbirth (not otherwise defined) 8 White males White females 8 Colored males Colored females 141 Puerperal diseases of the breast White males White females Colored males Colored females APPENDIX A. 347 Condition. Classified by ColoRj Sex and bt Age Peeiod. Mortality Experience, 1911 to 1916. Age Periods. 25 to 29. 30 to 34. 35 to 39. 40 to 44. 45 to 49. 50 to 54. 55 to 59. 60 to 64. 65 to 69. 70 to 74. 75 and over. Int'l List Number. 171 188 199 87 11 1 135 147 160 176 79 10 1 24 28 23 "8 1 233 235 196 95 10 3 136 193 191 ■ 162 '84 7 2 40 44 34 11 3 1 1087 926 602 221 22 1 137 896 771 502 185 16 1 191 155 100 36 6 542 509 383 164 17 •- 138 484 439 70 327 56 140 15 58 24 2 92 82 85 29 6 1 139 76 74 79 23 6 16 "8 6 "e 1 12 11 5 4 1 140 10 8 4 4 1 2 3 1 2 1 141 2 1 348 MORTALITY STATISTICS OF INSURED WAGE EARNERS. Number of Deaths from Each Specified Disease or Metropolitan Life Insurance Company Industrial Cause of Death. Age Periods. Inf 1 List Number. All ages — 1 yr. and over. 1 to4. 5 to 9. 10 to 14. 15 to 19. 20 to 24. 142>to 145 VIII. Diseases of the Skin and of the Cellular Tissue White males 1529 632 602 134 161 84 35 45 2 2 41 13 24 3 1 23 11 9 2 1 37 23 7 5 2 41 19 White females 11 Colored males 5 Colored females 6 142 681 248 278 73 82 215 133 70 3 9 360 176 126 37 21 273 75 128 21 49 1266 649 480 64 73 23 10 12 1 8 4 4 41 15 24 2 12 6 5 1 148 77 62 3 6 18 4 11 3 19 7 11 1 4 2 2 180 78 92 4 6 3 1 1 , 1 10 6 4 8 3 4 1 2 1 1 180 112 61 3 4 5 2 3 9 7 1 1 22 14 5 1 2 1 1 126 90 27 6 3 12 White males 5 White females 3 3 Colored females 1 143 Furuncle 7 4 White females 1 Colored males Colored females 2 144 Acute abscess White males 16 9 White females 3 Colored males 2 Colored females 2 145 Other diseases of the skin and 6 White males 1 White females 4 Colored males 1 146 to 149 IX. Diseases of the Bones AND OF the Organs OF Locomotion White males 58 29 White females 21 2 6 Diseases of the bones (tuber- 146 1109 576 415 58 60 140 73 58 3 6 169 74 85 4 6 168 104 58 3 3 116 81 26 6 3 53 White males 27 White females 20 Colored males 2 Colored females 4 APPENDIX A. 349 Condition. Classified by ColoRj Sex and by Age Peeiod. Mortality Experience, 1911 to 1916. Age Periods. Infl List 25 to 30 to 35 to 40 to 45 to 50 to 55 to 60 to 65 to 70 to 75 and Number. 29. 34. 39. 44. 49. 64. 59. 64. 69. 74. over. 32 67 55 82 103 125 128 182 183 204 142 142 to 145 15 28 25 34 49 53 46 69 63 82 67 11 19 18 28 34 41 50 75 82 88 60 10 4 12 9 17 12 15 15 15 8 6 10 8 8 11 14 20 23 23 19 7 2 38 14 18 26 62 47 99 109 136 99 142 1 5 6 9 8 18 19 33 32 50 45 1 6 5 4 11 16 15 43 49 60 41 3 1 2 3 11 4 10 10 12 7 4 2 3 4 7 9 13 18 14 6 6 10 11 19 25 33 21 18 18 13 7 143 5 6 7 10 15 16 14 11 11 12 5 1 4 3 1 8 1 7 3 15 2 5 1 1 7 7 1 2 11 31 17 31 28 24 27 38 19 17 11 144 6 16 9 12 21 14 6 19 10 7 8 4 6 5 11 3 5 14 14 7 8 2 6 1 7 2 4 6 3 1 1 1 3 2 1 2 1 1 2 1 1 1 13 8 13 14 24 16 33 27 37 38 25 145 3 1 3 3 5 5 7 6 10 13 9 6 3 5 5 13 5 16 11 19 19 15 1 1 3 4 2 1 2 4 2 1 5 3 4 3 2 4 9 8 4 4 74 50 51 50 64 55 62 54 49 37 28 146 to 149 39 18 19 20 35 23 27 28 22 21 11 28 19 20 23 18 20 25 20 21 10 13 4 7 8 4 5 3 5 3 3 3 1 3 6 4 3 6 9 6 3 3 3 3 58 43 43 42 54 44 49 42 38 27 23 146 32 16 16 17 30 18 21 23 18 18 9 20 16 16 19 15 16 20 15 14 6 11 4 7 7 3 5 2 4 3 3 1 1 2 5 4 3 4 8 4 1 3 2 2 350 MORTALITY STATISTICS OF INSURED WAGE EARNERS. Number of Deaths from Each SPECiFiia) Disease or Metropolitan Life Insurance Company Industrial Cause of Death. Age Periods. Int'l List Number. au ages — 1 yr.and over. lto4. 6 to 9. 10 to 14. 15 to 19. 20 to 24. 147 Diseases of the joints (tubercu- losis and rheumatism ex- 120 53 53 5 9 6 5 1 31 15 12 1 3 320 177 121 15 7 6 2 4 2 2 181 103 63 11 4 9 3 6 2 1 1 66 32 30 3 1 12 8 3 1 21 14 6 1 7 6 1 1 1 2 2 15 10 5 4 2 Colored males Colored females 2 148 Amputations White males White females 149 Other diseases of the organs 1 White females 1 ' Colored females 150 X. Malformations 7 6 1 Congenital malformations (still- births not included) 150 320 177 121 15 7 3480 994 1889 220 377 181 103 63 11 4 66 21 321 14 15 10 7 6 White females 30 3 1 6 1 6 1 164 XII. Old Age White males White females Colored males 164 3480 994 1889 220 377 . . . Colored females APPENDIX A. 351 CoNorriON. Classified by Coloe, Sex and by Age Period. Mortality Experience, 1911 to 1916. Age Periods. 25 to 29. 30 to 34. 35 to 39. 40 to 44. 45 to 49. 50 to 54. 65 to 59. 60 to 64. 65 to 69. 70 to 74. 75 and over. Infl Llat Number. 13 5 8 3 2 1 6 3 6 3 2 1 1 1 11 3 8 8 3 4 1 4 3 1 7 2 4 1 1 1 3 1 9 6 2 2 1 1 3 1 8 3 3 1 1 3 2 1 1 1 10 4 5 1 3 2 1 8 4 3 1 1 1 3 2 1 1 6 2 4 5 2 3 5 4 1 1 1 4 2 1 1 2 1 1 3 1 2 1 1 147 148 149 160 2 1 1 1 2 6 3 2 1 11 3 8 4 3 1 3 1 1 1 3 1 2 6 1 1 2 2 1 1 20 6 9 4 1 72 16 33 8 15 1 1 287 65 132 32 58 605 159 317 48 81 1167 344 652 71 100 1 1 1323 403 745 55 120 160 154 6 1 1 2 2 20 6 9 4 1 72 16 33 8 16 287 65 132 32 58 605 159 317 48 81 1167 344 652 71 100 1323 403 745 55 120 154 362 MORTALITY STATISTICS OF INSURED WAGE EARNERS. Number oi Deaths from Each Specified Disease or Metropolitan Life Insurance Company Industrial Cause ol Death. Age Periods. Int'l List Number. All ages— 1 yr. and over. 1 to4. 5 to 9. 10 to 14. 15 to 19. 20 to 24. 155 to 186 XIII. External Causes*: White males 50712 31381 11618 5610 2103 4259 2160 1662 238 199 3788 2344 1064 216 164 2809 2004 444 281 80 4113 2717 712 556 128 4847 3174 White females 747 670 Colored females 256 Suicide (total) 165 to 163 6542 4309 1748 308 177 2352 1280 874 89 109 1040 633 386 14 7 761 626 106 24 5 316 176 109 16 15 1519 1210 152 129 28 27 15 8 2 2 8 1 6 1 2 1 1 7 7 1 1 8 6 1 1 364 135 195 16 18 199 45 137 4 13 26 12 14 23 16 3 3 1 20 4 14 1 1 81 60 23 6 2 707 White males 391 White females 226 45 Colored females 45 155 Suicide by poison 338 White males 145 White females 152 9 32 156 Suicide by asphyxia White males 47 29 White females 16 2 157 Suicide by hanging or strangulation 42 White males 30 White females 7 Colored males 5 Colored females 158 Suicide by drowning White males 24 9 White females 7 4 4 159 Suicide by firearms 225 159 White females 38 24 4 * Includes war deaths (1,149). APPENDIX A. 353 Condition. Classified by ColoEj Sex and by Age Period. Mortality Experience, 1911 to 1916. Age Periods. Int'l List 25 to 30 to 35 to 40 to 45 to 50 to 55 to 60 to 65 to 70 to 75 and Number. 29. 34. 39. 44. 49. 54. 59. 64. 69. 74. over. 4245 3813 3460 3189 2983 2968 2722 2574 2177 1692 1073 155 to 186 2598 2303 2183 2106 2004 1969 1811 1600 1210 797 401 622 615 521 524 544 628 634 742 774 780 605 784 676 600 432 329 281 205 154 108 54 26 241 219 156 127 106 90 72 78 85 61 41 724 711 666 640 598 620 527 431 304 152 71 155 to 163 421 401 425 429 433 466 413 347 254 118 61 218 235 170 173 139 128 97 72 44 33 10 52 48 48 26 19 20 14 12 6 33 27 23 12 7 6 3 1 337 314 227 240 157 178 135 113 68 30 8 165 159 157 134 147 98 126 98 86 59 19 6 142 115 67 76 54 43 34 26 9 11 2 16 22 12 12 4 6 2 1 20 20 14 5 1 3 1 87 103 122 122 115 129 113 77 57 33 7 156 60 50 59 66 71 85 82 57 45 22 4 33 51 60 54 43 43 29 17 11 11 3 3 1 2 1 1 2 3 1 1 1 1 1 1 40 51 58 58 74 86 91 97 76 35 23 157 34 36 51 44 60 73 71 85 67 32 20 4 13 2 14 13 10 15 10 9 3 3 1 2 3 3 5 2 1 2 1 31 33 29 25 30 37 20 31 22 8 5 168 20 14 14 15 18 23 13 23 13 5 6 7 17 11 7 8 14 6 7 9 2 2 1 2 3 2 1 2 1 2 2 1 1 175 156 162 132 152 130 122 80 52 29 15 159 128 109 122 111 134 113 113 73 49 28 15 , 14 25 13 14 9 7 5 2 1 1 j 26 18 24 4 8 8 3 6 2 7 4 3 3 1 2 1 354 MORTALITY STATISTICS OF INSURED WAGE EARNERS. Number cf Deaths from Each Specified Disease or Metropolitan Life Insurance Company Industrial Cause of Death. Age Periods. Infl List Number. All ages — 1 yr. and over. lto4. 5 to 9. 10 to 14. 15 to 19. 20 to 24. 160 Suicide by cutting or piercing instruments 346 272 47 24 3 107 58 38 7 4 33 25 5 3 68 29 31 2 6 39268 24794 9356 3705 1413 622 265 248 45 64 1144 515 475 82 72 4228 2149 1644 236 199 183 94 73 7 9 357 162 147 30 18 3740 1 1 2720 3 1 1 1 5 3 2 3 2 1 4 2 1 1 3241 2308 459 412 62 24 8 12 1 3 49 14 32 1 2 15 11 3 Colored males 1 .161 Suicide by jumping from high places 4 2 1 Colored males 1 Colored females 162 Suicide by crushing White males 6 4 White females 1 1 163 6 White males 2 White females 1 Colored males Colored females 3 Accidents or undefined vio- lence (total) * 3027 White males 2323 1963 10481 420 209 264 160 73 1 87' 38 42' 18 36j 14 4 3 5, 3 2170 White females 427 333 97 164 Poisoning by food 28 White males 11 White females 10 5 2 165 Other acute poisonings 61 34 16 9 91 30 16| 5 7\ ... 44 6 Colored females 4 ' , 2 11 * Includes titles 164 to 181 inclusive, 185 and 186, but excludes "war APPENDIX A. 355 Condition. Classified by ColoRj Sex and by Age Period. Mortality Experience, 1911 to 1916. Age Periods. Infl List 25 to 30 to 35 to 40 to 45 to 50 to 55 to 60 to 65 to 70 to 75 and Number. 29. 34. 39. 44. 49. 54. 59. 64. 69. 74. over. 25 28 42 46 53 44 30 21 20 10 9 160 18 22 35 37 42 35 23 17 14 9 8 , 4 3 4 4 6 7 5 4 4 1 1 3 3 3 4 . 1 3 2 2 2 2 16 13 18 11 9 9 5 5 7 4 1 161 7 9 6 6 6 7 3 2 6 1 1 7 4 9 2 2 2 2 3 1 3 1 2 1 1 1 1 1 2 3 2 3 1 2 3 6 2 2 1 162 2 2 2 1 2 6 2 2 1 1 1 1 1 1 10 11 5 6 6 4 6 6 3 2 163 3 2 2 3 3 2 6 2 2 1 6 7 1 3 2 3 1 1 1 3 1 1 1 1 2574 2327 2274 2195 2175 2203 2105 2089 1843 1532 995 1787 1582 1546 1522 1482 1434 1347 1226 940 675 340 324 317 304 307 383 475 527 659 726 743 593 369 339 340 284 227 220 169 132 94 64 23 94 89 84 82 83 74 62 72 83 60 39 25 37 23 33 26 30 27 21 20 12 8 164 10 12 7 13 10 10 9 10 6 4 1 9 15 8 8 10 9 11 8 13 6 7 2 3 3 4 2 6 4 1 4 7 5 8 4 5 3 3 1 2 104 86 67 66 60 47 43 41 24 23 9 165 38 33 19 31 35 29 21 29 11 15 6 49 41 38 21 19 12 19 10 12 6 4 11 4 6 7 2 3 3 2 6 8 4 7 4 3 2 i deaths" (x-186). 356 MORTALITY STATISTICS OF INSUEED WAGE EARNERS. Number of Deaths from Each Specified Disease oe Metropolitan Life Insurance Company Industrial Cause ol Death. Ali ages — 1 yr. and over. Age Periods. Infl List Number. 1 to 4. 6 to 9. 10 to 14. 15 to 19. 20 to 24. 166 676 257 185 62 72 4714 1545 2393 255 521 1431 843 485 69 34 5757 4310 661 708 78 1029 637 89 248 55 93 51 15 21 6 6917 4021 2297 405 194 101 45 30 12 14 1977 912 828 116 121 46 21 21 2 2 280 194 74 9 3 39 19 11 4 5 9 3 6 454 249 159 31 15 64 28 24 1 11 760 227 410 29 94 48 24 23 1 742 627 77 33 5 100 63 14 18 5 10 8 1 1 311 204 78 23 6 30 7 15 5 3 174 35 108 8 23 53 36 13 2 2 915 717 79 110 9 209 162 9 33 5 10 8 2 201 145 32 16 8 24 10 11 3 130 29 73 8 20 68 31 32 3 2 1031 737 128 157 9 244 161 23 58 2 5 2 1 2 208 158 27 17 6 34 White males 11 White females . 13 Colored males 6 Colored females 4 167 Burns (conflagration excepted) 162 White males 38 White females 86 Colored males . g Colored females 29 168 Absorption of deleterious gases (conflagration excepted) 97 White males 59 White females 28 Colored males 5 Colored females 5 169 Accidental drowning White males 694 479 White females 113 Colored males 92 Colored females 10 170 Traumatism by firearms. . . White males 136 77 White females 4 Colored males 41 Colored females 14 171 Traumatism by cutting or piercing instruments White males 9 4 White females 1 Colored males 4 Colored females 172 Traumatism by fall White males 241 191 White females 24 Colored males 17 Colored females g APPENDIX A. 357 Condition. Classified bt Color, Sex and by Age Period. Mortality Experience, 1911 to 1916. Age Periods. Infl List 25 to 30 to 35 to 40 to 45 to 50 to 55 to 60 to 65 to 70 to 75 and Number. 29. 34. 39. 44. 49. 54. 59. 64. 69. 74. over. 25 35 42 33 34 31 31 27 28 24 13 166 12 18 27 20 19 18 15 6 9 10 2 8 5 9 8 7 6 10 11 9 10 9 3 6 3 2 7 4 2 5 3 1 2 7 3 3 1 3 4 5 7 3 2 145 123 133 135 140 170 146 159 149 124 87 167 28 29 36 28 33 36 32 29 17 24 12 84 66 65 79 81 99 88 96 93 78 59 9 11 10 13 6 6 4 9 9 5 3 24 17 22 15 20 29 22 25 30 17 13 94 100 97 113 123 127 132 127 96 68 42 168 47 57 55 81 77 74 83 80 58 40 20 34 27 30 22 34 44 46 46 35 28 22 8 9 10 8 9 8 2 1 2 5 7 2 2 3 1 1 1 432 328 224 259 184 241 232 197 154 156 134 109 88 82 68 40 34 19 16 169 299 188 167 42 28 20 17 27 20 11 10 9 3 3 84 71 47 31 30 20 8 9 4 3 7 5 8 5 8 3 3 2 1 82 69 58 34 10 17 7 13 7 4 170 38 35 27 17 5 13 5 8 6 1 3 3 8 2 3 2 4 1 2 34 28 17 9 2 2 1 1 7 3 6 6 2 12 7 6 6 4 5 4 4 1 1 171 4 6 2 3 2 2 3 4 1 1 1 1 1 7 2 2 1 2 1 -2 3 267 341 410 419 457 504 549 653 687 707 508 172 199 257 304 318 313 324 330 338 289 255 147 30 49 52 58 98 136 169 271 356 414 344 26 28 46 35 35 33 35 27 22 9 6 12 7 8 8 11 11 15 17 20 29 12 358 MORTALITY STATISTICS OF INSURED WAGE EARNERS. Number of Deaths from Each Specified Disease or Metropolitan Life Insurance Company Industrial Cause of Death. Age Periods. Int'l List Number. All ages — 1 yr. and over. 1 to 4. 6 to 9. 10 to 14. 15 to 19. 20 to 24. A173 Traumatism in mines White males 612 505 3 104 48 40 1 7 905 720 32 148 5 4485 3598 301 527 59 1600 1130 312 124 34 2507 1737 585 139 46 1658 1226 242 170 20 7 4 2 1 48 32 15 1 120 63 51 3 3 165 96 61 6 2 170 97 66 4 3 1 1 10 7 2 1 171 132 27 11 1 186 120 52 10 4 625 423 160 32 10 273 202 50 17 4 15 9 1 5 1 1 30 26 1 2 1 228 185 19 22 2 104 78 17 6 3 335 257 53 20 5 107 83 14 9 1 100 89 11 8 8 140 112 9 16 3 508 409 32 62 5 96 66 14 14 2 177 132 33 11 1 112 82 13 14 3 79 70 White females Colored males 9 Colored females B173 Traumatism in quarries. . . . White males 2 2 White females Colored males Colored females 174 Traumatism by machines . . White males 113 97 White females 2 Colored males 14 Colored females A175 Railroad accidents and injuries 4 644 White males 546 White females 18 Colored males 76 Colored females 4 B175 Street-car accidents and injuries 75 White males 58 White females 10 Colored males 6 Colored females 1 C175 Automobile accidents and injuries 176 White males 129 White females 38 Colored males 6 Colored females 3 D175 Injuries by other vehicles. . White males 110 88 White females 14 Colored males 8 Colored females APPENDIX A. 359 Condition. Classified by Color^ Sex and by Age Period, Mortality Experience, 1911 to 1916. Age Periods. 25 to 29. 30 to 34. 35 to 39. 40 to 44. 45 to 49. 50 to 64. 55 to 69. 60 to 64. 65 to 69. 70 to 74. 76 and over. Infl List Number. 80 61 58 50 48 45 37 21 14 3 A173 69 48 39 39 40 38 30 19 12 1 1 3 ii 13 19 11 "8 "7 "7 2 3 6 6 3 5 6 3 2 2 1 B173 2 6 4 1 1 3 3 5 3 2 1 1 2 "i 1 1 69 93 93 73 82 67 59 34 24 7 4 174 49 1 19 68 3 21 1 69 2 22 64 9 69 13 46 4 17 50 I 30 1 3 21 2 1 7 1 2 1 557 396 344 323 261 258 228 250 149 83 37 A175 471 312 17 60 7 279 9 50 6 251 210 195 28 33 2 181 20 25 2 187 39 21 3 117 17 11 4 67 13 3 24 7 3 3 13 67 6 14 49 9 13 33 5 101 74 101 93 105 121 130 110 85 53 46 B175 84 4 13 61 3 8 2 77 9 12 3 72 8 11 2 74 15 10 6 92 20 6 3 92 29 8 1 68 33 7 2 60 21 3 1 36 11 5 1 29 15 2 153 101 97 103 108 94 109 115 79 49 21 C175 114 23 13 3 73 19 5 4 65 22 9 1 66 27 9 1 76 26 3 3 60 23 7 4 67 31 9 2 80 28 4 3 52 19 4 4 35 14 12 8 1 89 114 101 98 107 103 75 78 63 47 11 D175 79 3 7 87 9 17 1 80 4 15 2 74 7 15 2 75 14 16 2 76 10 17 60 6 9 59 8 11 46 10 6 1 29 13 4 1 9 1 1 360 MORTALITY STATISTICS OF INSURED WAGE EARNERS. Number of Deaths from Each Specified Disela.sb or Metropolitan Life Insurance Company Industrial Int'l List Number. Cause of Death. Age Periods. All ages — 1 jT. and over. 1 to4. 5 to 9. 10 to 14. 15 to 19. 20 to 24. E175 176 177 178 179 180 181 Landslide, other crushing. White males. . . . White females . . Colored males . . Colored females. Injuries by animals. White males. . . . White females . . Colored males . . Colored females. Starvation . White males .... White females . . Colored males . . Colored females. Excessive cold. White males. . . . White females . . Colored males . . Colored females. Effects of heat . White males. . . . White females . . Colored males. . Colored females. Lightning . White males. . . . White females . . Colored males . . Colored females Electricity (lightning excepted) White males. . . . White females . . Colored males . . Colored females. 381 299 20 58 4 233 188 10 35 217 128 27 45 17 1247 720 336 132 59 96 71 11 14 452 421 16 12 27 27 21 15 1 o 6 1 1 1 1 15 17 9 12 3 3 1 2 2 14 14 10 13 2 1 2 34 68 31 64 2 2 1 2 APPENDIX A. 361 Condition. Classified by ColoRj Sex and by Age Period. Mortality Experience, 1911 to 1&16. Age Periods. Infl List 25 to 30 to 35 to 40 to 45 to 50 to 55 to 60 to 65 to 70 to 75 and Number. 29. 34. 39. 44. 49. 54. 69. 64. 69. 74. over. 39 38 29 33 30 35 19 13 6 2 2 E175 27 29 20 23 23 31 15 12 4 2 2 1 1 2 1 9 9 7 8 7 4 4 1 1 2 1 11 15 19 20 16 14 13 10 16 6 2 176 7 14 16 15 14 12 11 8 14 5 2 1 1 1 3 1 2 6 2 2 2 2 2 3 1 3 3 2 1 2 177 1 1 1 2 1 1 2 1 1 1 1 1 1 13 22 14 16 20 23 22 24 18 13 5 178 5 15 9 6 15 12 16 18 9 5 1 2 2 3 5 4 1 2 8 2 4 1 4 4 3 2 4 3 3 5 3 3 1 1 1 1 2 2 1 41 70 122 104 120 128 130 107 125 101 66 179 25 44 81 71 82 82 68 54 69 36 26 3 14 13 18 17 27 40 39 43 56 32 10 8 21 10 14 14 15 10 10 7 4 3 4 7 5 7 5 7 4 3 2 4 13 8 5 5 6 4 5 1 2 1 1 180 10 6 3 3 4 3 3 1 1 1 2 1 1 1 1 1 2 2 2 1 1 1 66 49 45 33 14 12 11 3 1 181 63 46 41 30 12 11 8 3 1 1 1 1 1 2 4 2 1 1 2 1 1 362 MOKTALITY STATISTICS OF INSURED WAGE EARNERS. Number of Deaths from Each Specified Disease or Metropolitan Life Insurance Company Industrial Cause of Death. Age Periods. Infl List N»unber. All ages — 1 yr. and over. lto4. 5 to 9. 10 to 14. 15 to 19. 20 to 24. 185 Fractures (cause not specified) 806 414 316 57 19 1722 1146 298 228 50 1149 1130 14 6 3753 1148 500 1592 513 2435 691 292 1132 320 616 167 43 297 109 702 290 165 163 84 12 8 4 176 96 72 8 3 1 2 28 10 16 2 8 3 4 1 5 2 3 15 5 9 1 27 16 9 2 160 87 52 15 6 3 2 1 45 19 15 7 4 16 9 4 2 1 5 1 2 2 24 9 9 6 1 20 15 3 2 123 84 26 11 2 2 2 60 24 16 15 5 37 15 7 12 3 7 3 1 2 1 16 6 8 1 1 14 12 2 144 112 7 22 3 156 155 1 352 119 58 127 48 238 83 42 92 21 60 20 3 22 15 54 16 13 13 12 20 White males 16 White females 1 Colored males 3 186 Other external violence. . . . White males 123 98 White females . 12 Colored males 10 Colored females 3 (x-186) War deaths* 431 429 White females 1 Colored males 1 Colored females 182 to 184 Homicide (total) 682 White males 184 White females 93 Colored males 291 Colored females 114 182 Homicide by firearms White males 459 125 White females 62 Colored males 207 Colored females 75 183 Homicide by cutting or pierciag instruments White males 125 33 White females '. 4 Colored males 62 Colored females 26 184 Homicide by other means. . White males 98 26 White females 37 Colored males 22 Colored females 13 Includes the two years 1&15 and 1916 only. APPENDIX A. 363 Condition. Classified by OoloRj Skx and by Age Period. Mortality Experience, 1911 to 1916. Age Periods. Infl List 25 to 30 to 35 to 40 to 45 to 60 to 55 to 60 to 65 to 70 to 75 and Number. 29. 34. 39. 44. 49. 54. 59. 64. 69. 74. over. 36 36 47 57 50 54 68 91 90 118 76 185 28 25 36 39 38 35 31 41 24 37 13 5 6 6 8 14 23 42 60 75 60 6 6 5 11 3 3 3 5 2 5 1 2 1 1 2 1 3 4 1 2 115 118 97 104 117 108 108 74 75 44 36 186 78 78 66 67 86 75 79 50 46 29 15 9 11 5 6 8 17 17 12 17 10 17 20 25 22 26 20 14 11 10 9 3 2 8 4 4 5 3 2 1 2 3 2 2 200 170 100 62 14 5 1 1 1 (x-186) 194 168 99 60 14 3 1 1 1 5 2 1 1 1 1 1 1 747 605 420 292 196 140 89 63 29 8 7 182 to 184 196 152 113 95 75 66 50 26 15 4 75 61 46 43 22 24 10 11 4 4 "2 362 289 212 121 83 40 22 10 8 3 114 103 49 33 16 10 7 6 2 2 539 405 277 190 114 69 45 21 10 3 4 182 135 100 64 58 34 26 25 10 3 1 49 34 27 28 16 15 3 6 2 2 1 272 204 160 83 65 22 13 2 6 2 83 67 26 21 9 6 4 3 1 121 98 67 52 29 16 17 8 3 2 1 183 36 17 21 10 7 6 8 2 1 2 6 5 7 3 2 4 1 65 66 29 28 15 7 4 5 1 _ 1 18 19 12 7 4 1 1 3 87 102 76 50 53 55 27 24 16 3 2 184 25 35 28 27 34 34 17 16 10 2 24 21 14 8 3 7 3 5 2 1 1 25 29 23 10 13 11 6 3 2 13 17 11 6 3 3 2 2 1 t Does not include war deaths (1,149). 364 MORTALITY STATISTICS OF INSUEED WAGE EARNERS, Number of Deaths from Each Specified Disease or Metropolitan Life Insurance Company Industrial Cause of Death. Age Periods. Infl List Number. AU ages — 1 yr. and over. lto4. 5 to 9. 10 to 14. 15 to 19. 20 to 24. 187 to 189 XIV. Ill-Defined Diseases 5448 2591 1504 731 622 404 173 132 59 40 90 35 31 11 13 71 30 23 12 6 109 40 35 17 215 White males 72 White females 60 Colored males 40 Colored females 43 Ill-defined organic disease White males 187 261 46 69 64 82 131 59 54 7 11 5056 2486 1381 660 529 5 1 2 2 1 1 398 171 130 57 40 4 1 1 2 86 34 31 10 11 5 2 2 1 2 2 64 28 19 11 6 6 4 1 1 2 2 101 38 31 16 16 6 White females Colored males 2 Colored females 4 188 Sudden death 3 White males White females 2 Colored males Colored females 1 189 Not specified or ill-defined White males 206 72 White females 58 Colored males 38 Colored females 38 APPENDIX A. 365 Condition. Classified by ColoBj Sex and by Age Period. Mortality Experience, 1911 to 1916. Age Periods. | ■ Int'l List 25 to 30 to 35 to 40 to 45 to 50 to 55 to 60 to 65 to 70 to 75 and Number. 29. 34. 39. 44. 49. 54. 59. 64. 69. 74. over. 307 406 483 450 465 466 493 538 470 323 158 187 to 189 151 210 264 242 263 238 237 239 200 130 67 72 65 88 100 105 106 131 175 191 128 62 52 86 64 63 56 69 55 62 39 31 15 32 45 67 45 41 53 70 62 40 34 14 3 9 16 15 20 26 35 44 26 27 14 187 1 4 2 3 2 8 7 7 5 3 1 3 4 6 8 7 11 9 7 5 3 2 3 6 9 9 8 7 8 2 2 6 7 6 5 7 11 18 3 7 4 4 3 8 5 14 15 22 17 20 13 2 188 2 1 2 7 7 11 6 9 9 2 2 1 4 2 1 2 6 1 6 9 10 7 2 4 1 2 ... "2 2 1 2 300 394 459 430 431 425 436 477 424 283 142 189 149 208 260 238 253 229 218 226 184 116 62 69 64 81 95 93 92 115 154 175 117 57 52 83 60 58 49 6C 46 54 30 23 13 30 39 58 39 36 44 57 43 35 27 10 366 MORTALITY STATISTICS OF INSUEED WAGE EAENEKS. 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I> CO N- CO ■«JJ (N q IN IC q rH X ,H q q (N X +3 CD Ui ^ N CO 00 CO (N rH CO ' ■ ' IN ■ r- -* rH 05 d CO OS rH to l> >* Q '^ 2^ 00 ifl U5 q i-H 05 (N —1 Ti; q IN q N cc q rH X lO IN T}< .-1 rH (D t>^ ^ CO ^ 00 lO ■* rH CO ' * ' Ci ' r- »o rH 05 d T)i -1 OS CO t^ Tf OS « rH 03 ^ CO X O CO O TjH CO -* IN i> uo u: rH t>. r- •* X (N O rH >^ Tti lO (N O O 05 ^ ^ ■^ i> (N o ^ w: IN ■<* o O IN lO O »-* 05 r-l ,-1 CO O 00 ^ rH IN rl (N — X rH t^ O CO OS lO CO rH 05 05 (N .-H to l^ -H 00 iO CO 00 to ■* oc 00 to O O IC O rH t^ N O T-H lO lO l> 05 t^ Tfl rH 00 rl t^ rH Tt 1^ 1- 05 O t^ (N »0 *-* X rH T-l CO t^ ■* CO ^ IN (N rH t> rH t^ X CO OS o ■* 05 CO to o r- 00 Tj* O (N to !N IN 05 QC (N to IN CO 1> X tH rH rH Tjt C IN CO OS lO lO (N 1 rH CO lO O O -H t^ CO »o rjH to lO CO t^ N IN O 05 X t^ to O X Q • 05 (N rH 1> O O CO IN iO 05 rH HO rH Tl- O 1-11^ Tt* 05 (N 1^ 1^ ^ lO t-i — 1 CO ■* CO CO ^ IN IN rH (N 05 r* CO 1 OS CO to (N »H 00 CO CO O -H ,-( _ ■* IN CO iC iC t- »o 1> Tfl X (M t^ ■* l^ to IN a ui ■* (N i-H ■ -* o t-H I^ 05 O 00 00 CO Tt* l> 05 00 rH X C 05 CO IM »o •* O lO X ^^ t^ 05 00 to CO 00 1:^ IN lO to 05 to C5 r- ■*■<*( CO rH IN X ■* rH rH t^ 00 tH CO Tfl t^ (N t^ X ■* y. P5 05 ■* CO O OO IN rt OS ■* "H (N CO (N IN i-t y—^ Tt* lO lO (N OSrt CO 05 t^ i Q o i "5 'c 1 t5 O ft ■ -S .2 ft M S 4D If ill -►^ > hi cS ft a (0 a a "o TO c > CO g 1 •: &^ PiC4H c S o " in to C fl .2 .2 s'S 'S a a c a -a c8 3 1 to ID t a "o to 03 II '53 m 03 "o i g OQ rH cS 0. ID "o c3 p : D « : li B PS 2 ^ Q a. 1 1 a C TJ 03 s 1 : rCl • « s 10 o lS O CJ 4^ 00 05 O rH IN CO T|H lO to s 1^ X 05 o 36 CD to CO CD to to CD CO to CO t^ t^ l> t» t- t^ 1^ 3 t^ t^ t^ X d 370 MORTALITY STATISTICS OF INSURED WAGE EARNERS, H Tjl r-( CO IM CO ■* rHTlJINCOOSrH. (Nl> m; -* CO IN ,-1 t-^ (N ' ■ Tl? ' rH * lO 05 CD OS CO (N " ' d * rH ■ Tt* 00 00 O CO rH ' CO " a CO rH IN l> CO O t^ Oi CO «o CO (NrHlOOrH--* t-TJt 00 CO IN IN OS .-H ■ ' 7-i * rH ■ irf 00 00 l> CO rH ' CO ' OJ 1-( CO IN t^ & '^ 7-t ■* OS : ,h" 00 CO rH ■ IN ' o OS i-H IN CO CO o u o. rH •o ^ ^ O CO ^ rH rHrHlOlOC^SrH ■^"S CO CO q (N ■*' c4 * ■ OS ' r-I * Tj5 CO ci -^ c6 rH ■ (N ' s s T-H IN CO t^ '^ '"' A to (N t^ O CO CO O rHoscoqt>o xo Ti; CO i« CO cd lO d rM I> ■ id CO co' d Ti5 r-i ■ IN * g Ol rH CO CO 00 « "^ tH «2 q c i> CO q IN t> IN ■ ' (N ■ rH ■ ■*■ t> d t> CO r-i ' 00 ' 1-1 OJ CO CO t> OSrt tH 00 lO CO J> lO CO rH|>cOC0ININ COIN O ■<*< OS 00 f-f lO CO CD 1-1 (N •* tHOrHrHt>00 "^OS OS CO t^ rH CO I-H IN tH rj< 1> O OS (N rH (N IH rH tH (N CO OS CO ^ (N IM CO osos(Ne^iNt>. 00-* 00 CO ■* OS IN Tt* CO CO CO CO ■^ 00 IN O CO O CO IN IN tH IN '"' o rH IN CO 00 O lO OS rH 00 00-^OrHCOO COOS 00 00 OS o CO ■* lO t- (N ■* Tt< rH05-^C0Ot> lOOS iC IN t> IN CO rH ■* ■^ t> rt< t^ IN 7^ IN a> T-l j-t IN CO i ^ '-' OS in CO m 00 -* lOrHOSlOOOO t^OS 00 lO o o fl yH Tt* O 1> (N (N 00 rHrHIN-rJHlOO CO-* lO IN CO IN O IN ■* rH rfi CO OS CO CO IH (N Oi (N CO 1 "^ '"' CO O lO rH CO 'S" OSTjHCOOSrHlN OSIN O l> J> rH ^ u5 OS CO 00 CO CO t- o Tt* CO i> o 00 ■* CO (N ■<* IN ^ CO (N -^ y-t Ttl CO rH rH CO tH (N ^ OS rH (N CO l> '"' 7-1 t^ OS 00 '^ IC OS tH ■* 00 ■''tD Tti OS »0 CD OS ■* t^OSOOCOININ ox CO l> OS (N rH rH tP rH T- CO lO rH CO (N IN 1> OS OS rH lO rH r-l OJ OS rH IN ■* CO tH rH 1^ OJ-H t^ ,-1 ■* ■ «« , • , 1 02 • CI 1 3 "3 ."^ 5 g P5 Oi 'ro >J 01 g >J • T3 O H |£| P a >> ■> CI o _S fin ^ m glj a o a J 00 ' ' rH IN CO ■* lO OS CO^»OOOSOrHlN CO'* lO CO l> Jo 00 00 00 00 00 o 00 00 00 M OS OS OS OS OS OS OS o i^ ■u a CO H 00 1 APPENDIX B. 371 , 00 »o eo CO eo o o q q -l-rH OliO'*Ol'<*4-C0OlQ0 ^ i-< ^ i-i t-I • rH ' TjH rH CO id *d-*cdrH' cdiM-*' CO ■o 0) 05 rH (N iC eo 00 (N rH (N 00 00-l-rH»OiOI>00-*-!— t^t^OiM I-H IN d ■^ ■ rH ■ TJH 6 c* d CO -*■ ■ IM •* id rH ■ CO IM -^ ' rH o> 05 r^ ^^ ^^ T-^ rH 1 , O CD •* Ti; rH W -H q q CO rHOTfiooiio-1— qqqe^ K> O Tt< ^ 00 ■ c4 ■ -^ 00 rH IN ■ (N -^ CO rH ■ CO CO CO ' rH o o OS X 7-\ ^ rH O Ci •^ ■^ OQ 00 00 CO fH i-40qrHlOt^CCH— OrHCii-H q 0. >o >-! lO ' (N ■ CO t> ^ CO 1-H^lOr-i ■^COCO rH 1 5 Oi 00 '" rH rH . ^ q lO CO IM O CO »o t^-f-H— COCOOOrHUfSH— COrH0q(M lO CO ^ d * d * "*■ j> d CO (m'-^ion' cocdcd I-H Oi 1-4 00 ^ rH rH i-i s . t-; ■* ■<*< rH (N O rH ■* Ol-I— rHOq-^OlOlriJH— qqrHrH q *^ to rH rH 'in ' ■* OJ im' Co' ■ rH T^ id rH ' id CO "^ rH « 03 a> rH rH rH T-K C5'-l y^ (N (N IM T)< rH 00 C^ lOCOOOCOrHlOlOCOCOt^TjtO" 1_4 ^ •* Ol (N IM -* rH I-H lO rH CO 00 o ^ cocoiOrH cqiNco (N O O Ol IM l0-Tt(C0rH01(NOC0 CO (N X CO (N >0 (M ■* CO lO rH ■^COCO-<* rH j-{ rH IN o rH lO CO -"IH ■* CO IMrtrHTt4COOCO t^ • ir. lO CO 00 iM ■* t^ -* CO rHrtlOli-llOCO Ol-TjHlOrH Ifl rH c; rH CO 00 rH IM OCOlOrH COlMCO rH o> 00 1-i rH rH i-H a t^ CO ■<^ CO CO O IM CO CO C^TflQ0COi«iOC0(MlM00lO o ■* ■* l> eo Ol rH 00 IM o 00 rHrHOlOt^'* OOOOlOlH ■* i-i rH CO 00 rH rH rHT^lOrH IMIMCO tH ,^ 05 00 rH rH rH o O IM rHCOlOrH COCOCO Ol 00 7-i rH rH CO CO l> lO O iM CO l> C0rHTt<01C0t>00rHlMC0Tf r-( • IC ■>* CO IM rH |> b- Oi TtlCOOOrHlCl OOrHOlrH lO 2 J— o (M •* l> (M CO IM-^IOIM COCOCO rH 05 c y-f rH rH i-H o cc cc O CO ■* Ol rH ^ 01IMt^lCir>.IMC0CDTHTl4rHrH|> CO «2 00 ^ O lO IM lO iM QC OOrHlO-^lOCOOCOrHC00100I> rH CO s m i; ft ■ 1 Q .J5 _ra m O o O (U Q O 5 a c3 73 a; C 03 tr-( O jr 4 '■5 1 73 e .c ,„ • '3 o C 2? K^ "^ ;- a c a a I; .2 ■ 'd ■ o O S S m "^ g^ O ^ S " tn g ftS s s-g Jl^ ^ ^ O 03 9 o o O^ « ^^ 03 o3 ^ tj Jr! 1- > m (D aj 4} o h " CO CO m o rC o3 OQ PQQPOQ <0 73 o3 (h ""^ "S i» °^ 5 .2 — < 05 "c , o • 03 '^ O ^03 aj o -H Tl 03 > -s ^ -2 ■lull -3 .2 "3 ^ .2 g .2 ^ llllllll h3o«JiWomoP 1 : ft . ft §3 S ft a 00 00 rH Ol O rH IM CO -# lO COt^OOOlOlOrHIMCOTfllOCC i> 3d 05 l-H Ol o o o o o O O O O O O rH tH rH rH rH rH r- 4^ 5 ^^^^^^^^^^^^ rH 1 M 05 1 05 r^ '^ S h:i 372 MOETALITY STATISTICS OF INSURED WAGE EARNERS. . to O O 1 CD CO ^ lO O- c: rH CO O o a o n d d d r-i ■ r4 ■ ^ ' (N rH rH S (N -< 03 Ut i-i & «0 iO >0 Tf O l^ C^ (N IC "^ IN lO (N rH § If! 00 CO lO rH ■ rH ■ IN ■ IN rH rH o o> Ol u •■* r-( fe »o 03 05t>;-t- loioqcooc 1- rH CO rH q Oi us OS t-^ 00 lO 1-5 ■ rH ■ ^ 05 " (N tH cd "-1 rt J3 lO r-l i>o-i- cqiooo-*i- T— 1 rH CD IN 00 i 05 00 d 1-1 ■ ■ ■ IN * IN tA T-l -« CO l> looq-f— cocoi-H-^(N "il^ rH IC IC q CO d di <6 rH ' rH ' e< ' e O ^ O CO CO lO •-* IQ CO C^ Ol CO ■^ O CO t^i rH Oi lO t^ OS m 05 CO 1— 1 rH a> l> . o- ■* Tfi IN U5 rt O IN CO X O Oi "3 ss N CO X t^ ■* CO !N CO OS rH IN (N (D 03 (N O rt IN rH O X 1 y—i 1> CD ■* o lo CO 00 •^ o "^ O CO CO t^ CO iC 00 t^ lO CO »0 05 •* cc OS CO X ■^ 00 CO T-l i- T-l 7-1 OS O 00 5 i (M IN 03 OS 1— 1 1-1 lo CO c<; o- X l> CO rH ■<(! 10 <0 X rH ■* CO ^ CO cc rH (N tH o t^ 00 1-1 rH CJ (N 1-1 rH o 1 OS o X T-H 1> CO iNCOi-i MXXOSO "^ (N CO lO Tf ■<* OS IN 1> rH IN O OS 3 CO X (N —1 r^ IN rH Z s 1-1 1-1 OS u: CO (M^Cq cOfOt>t^X Ic O lO t* o «5 ir: M X t^ CO "3 t^ CO — rH CO IN X CO X O 1-1 (M CO rH s !N o '"' '"' o Ttl a> OIVCO i-ilNr^(N!N Ic O IC CO 29 CD c IN CO CO (N rH O CD ": CO CO X o cc CT> r-l O X CO CD IN 1- CO t^ U5 -< OS -* i« • PS .-o . 03 a "o 1 £ 3 a o c 1 1 1 u in "o a o 5 Q o 1 m 1 « s S ^5 fc O O OB •J i 0) a V, o DQ a) .see -3 if •1- o: >- I "c 1 "a ^2 O 3 o a Q i ■3.2 ' 03 T3 b. « ^ ii.^ 5 t. c-B § Ji c > C _c S.S '- w o3 01 t. "S M"^ 2 PI «^ n^ 3^ «■ § a ) ^ (B >- 2 O -* CO 00 l>; (>. rH -1— o IN 00 CO "? 03 CO 05 rH ^ (N 00 •<<< CO IN •a r-J ^ -* IC rJJ O O 00 ■O V ^ e>3 00 ^ ^' o '^ CO ■*~ '^ I> CO O •-< CO lO r-J IN CO tH CO CO iH CO o I-H r-H Oi Oi "5 00 rA ' ' a> (N 1^ & CO ,-J 00 t>; l> O) •* -1 05 >-;■<— 50 O TjJ CO to ^ CO 05 r-H ^ ^ 00 UJ IN rH 1 s ^ a lO ^. p 00 O l> (N 00 00 >-;■«- IN 00 ^ CO "^ U3 CO 00 ^ ^ -i |> Tli oi d « ^ «» " 1-1 ■*" ^ •rh rl< 00 C^ O i> .-; '^ t>; «0 00 "^ rt to CO b- ^ .-H --J l> id (N S OS i-H fi '^ °» CO rH 05 O lO 05 I-H O ^ rH 1— X CO ■* r^ >c CO CO* 00 rH rH -H 00 id (N r-J 11 OS »-H OS It ■* lo (M CO S^ 05 t^ o CO CO c^ CO iC lO ■^ 05 y-t t^ -* CO — 1 t- 00 t- >o X «> IN ■* CO OS M uo ^ rH ^ O CO c» to 00 o 1 CO t> CO rti t- t^ CO 00 rH O O "ca IN lO I-H CQ .-H CO »o Ol ■* J> CO CO l> •* iM lO ^ ^ rt CO CO M Oi 1-1 05 "^ 00 1 05 O 00 CO 00 CO t^ IN rH U5 CO CO CO X CO -!*< -H O 05 lO '^ X ■^ 00 >o kO (M (^ ^ ,-H rt t> rj< (N OS T-H 1 ^ Oi CO 1 Ol O CO 00 «o 03 lO tH rH rH CO X 05 >* O CO lO CO 1> I> N, l> 'Jt^ 0> CO lO «Q CO 00 ,-H ,-1 ^ !> -^ c^ o OS 03 CO "o I—* 1 05 05 iH o lO O X t^ ^^ o 00 s lO rt Th 1 t^ lO CO Ol CO I> s CO t^ — 1 rH T-H CO -* IN ;z; OS o lo" t- 1 TjH 00 03 O .-H 00 o o X IN t^ CO CD (N 00 -* CO l> CO -H CD rH ^ CO lO t^ ■* CO t> ^ _ ,.H t- lO IN OS I-H o (N T^ -H 1 lO oH CO 00 lO 05 CO "^ Oi rH lO O 00 ^i 00 CO lO 1 00 05 CO •* t^ CO TJH IN X rH CO t- o T-H 00 t> O CO CO CO to CO IN CO IN rt OS .-1 o ^ Tt< > il 11 as 0-a o S 'a 03 ft -a _3 "o a 4J o 03 < ■ Ed «< 1-3 a "o m 33 o ■ail * a a J2 ai -1 o -:- -3 -H -+J OT o '^ ^ ?3 g 03 '^ fe fe O o 00 03 O rH (N 00 tH o J ~ 00 CO o CO CO CO CO CO CO ^ rp 2 ^ ■* •* ■* ^ o i-H 1-1 ^ rH I-H I-H rH rt r-t rH ^-t T-^ r-t r^ a ■* C<1 H CO ■* rl 1 374 MOKTALITY STATISTICS OF INSUEED WAGE EAENEES. O 5 ^ f» fi H f^ h-l f^ m w ^ tu H M N HI E-1 P . Eh <1 rH 00 IN H- -1- CO CO (N IN 05 CO TjH N. lO CD O t^ •^ CO IC rH rH ' CO a> Oi 1-1 . ^ CO q INH- -H- to CD lO "? 05 •^ X t^ ■* CD 05 CO IN (N ^ t-i IN (N Tl5 rH r-i 'in s Ol OS rH ■^ (N O IN 1 -1- «0 "? rH r-* CO lO rH rH «Cl t>- rH b; d CO (N N ■ 1 l> t> 00 CO IC IN rH ■ CO 0) C5 05 i-i P^ o lO (N IN tH CO CO (N IN (N CO 00 05 >0 lO l> CO o o ■* e4 IN " CO CD Cft M ^' rH rH ' IN o o OS 00 t-l -^ fl "? IN CO 4- -H t>; b. CO CD IN IN 00 CO lO J> 00 CO -^ 0) OJ IN IN iO "5 00 IN CO IN rH "in rH T^ ■§ o3 9 ^ i-H CO 1-J t> J> 03 05 lO 00 00 05 (N •«*i "3 CO fi to IN C^ ■ ■^ ^ oi OJ IN rH r-i ' Ci OJ O) Ol 's tl 2 • '^ r-i (N -1- tH CO CO iO 10 CO (N ■* 05 -^ CO 00 CO CO ^to IN (N CD CD -* (N Tji rH rH ' (N E3 n3 S2 05 iH 05 '"' PI '-' M (N (N CD C^ IN Tfl •* "oo" "oo lO Ol rH 00 CD J O Tj< 1-1 (N IN CO CO IN CO IN CO rH 10 CO 10 a i-H 1-1 CO CD CD •* rH rH (N 05 I> '"' Ph T-H lO O CO CO c5" "cT" ~cO~ "cO CO 00 lO CO 10 00 0: S N Ol CO IN lO "5 rH CO rH 05 CO rH T^ CO «o tH 1-1 CD CD CD CO rH rH IN o OS 1 1> '"' (N ■* CD (N <0 lO "T^ t^ 1—4 00 'i* t^ l> CO CO 03 05 1> rH Tfl !■>* rH T^ lO l> -^ 00 IN iC l> CD CO OS i-H CD CO rH ■>* rH rH IN 1 "^ 1 g Ol Tfi lO o o O ~^ OS lO Tjl rH IN 00 05 CO CO pl IN O t-i 1-1 CD CO CO CD Ttl CO Tti l> CO It* ifl 10 l-H Tt< IN (N »C lO IN rH TJH rH rH IN ^H a 00 T-t o o"" ~iO lO l-H -^ O Th 00 (N ^ 10 01 IN h-l 3 ■* 1-1 IN 1> 1> -# ■* IN 1> t^ CO W3 IN IN lO IC in rH CO IN rH IN iz; OS 00 "" -S O O CO C ^ 03 lO ^ y^ 10 Ttl CO 00 CO IN tH o ■^ 1-1 IN »H CD CD C31 O" CO 05 00 05 rH rt< IC CO ^ OS 5! o . to 05 O CO 1- O 'o" "o" c IN IN IN rH CO a CO 1^5 CO O IN OC IN (N 00 OC rH ■TtH lO rfl CD rH r- ■* CO IN CO CO ■* -* I> 10 CO l> CO IC CO 0) S2 OS t-* 1-1 CO CO o CO (N rH r- -4J 1 O o . "o n • .a ; IS 1 i H 1 ; ^5 * h o m 'A O a .2 § 2 « 7 H W -£ O H c H X +■ 1 f^" a 'i 1 .a : g • ft ■ H o O O 02 H 05 ' c c > c or I a: to D E a cE u ■ . .s g ,>s"^ Q =3 c« S 5s E © aj ft 2 r PQ>>,>>>>> el o O .2 m pq pq fQ PC P5 05 CD ■* 00 S CD t> 00 05 o ^4 rH lO CO t- 00 C J A 3 tJ^ ^i ^I ^1 lO ir - lO iCl lO »o IC ^ rH rH tH rH r- CO a tH i-H 1-1 rH rH r-t o »o >~i ■* "3 1-1 '"' APPENDIX B. 375 ■1 03 ■ r-J (N 1-5 CO (N I> IN d rH iH N CO »-J 00 ' CO r-i ' tA OOCOCOr-J rH 0(Np '^t^^'^*> CO >-! (n" 1-H oi CO c5 e4 * ei i-J * i-! <0 CO N IN b^ i-H irq 1-4 lO 1-; cq (N (m' N (N t>. (N i-H O ' CO rH ■ eq OS e (N0505H— rJH (N r-i tH ■ rH ■ tA 00 rH q 00 (N rH rH 01l>05 NrHOrHt-. IN Oi rH * CO rH ' rH rH (N rH rH id rH IN rH Cq d r-i ■ rH O r-l rH t^ 00 «5 0> IX) O 00 00 O tH rH OlOOlN OI>l>lNi£) ■*C0CO rHT;J rH rH rH 1> Ttiouo ^'Cot^^»«D rH lO 05 tH 05 O t>. (N O rH rH rH I-H K5 O ■<*< to to rH Tt< rH ^ rH (N rH lOOlN 00-*lOrHO !O(N00 rH l> rH Ol Ol 00 05 00 0 00 1> CO i> IV (N rt< CO rH (N Tj< t^ .._.,, rticOrHiO 1> -^itvO O rH <* rH IC l> 05 CO l> IN X lO CO^OlN OlrHrH-^O a .g "3 S s " >i >>^ mmo 0:2' a a' -CC fl S ft § S TS 1° -i3 S i3 Ti -43 S a 5? CO bc S.2 ■ H -5 (H » S el yn ^ a a '^ ,K1 ^02 SJ 4-3 V> ^:h " § m m ;3 aj C o 2 a cs C3 rg s §-S o s a s CD 02 m ^ ^ ^ a a a. 3 d =) ,_ ^ ^ ^ h tH f-t M tH •" a a M.;2 .2 •■7! ^ ^ § s a ft c3 03 . TT T3 ■ fl fl . 03 03 . 1=1 g 03 03 • 4) ■ |£ f4 a a H 3 S fl ° c ^H 'rH rj .pH <1 <1HEh HEhHHH «H 3 O M W o H O o Pi o rn O C5 y, ^ o o 1^ o I-l S &< ■< < Eh «> M t— < a W a> S <5 ft O H a Q ^ o -«i M rHoqcOH— C^t>-C4 00 t>«p (N CO -"t -4 rH* T)5 IN a> rH ^ r)Joq-*-l— "Ot-IN Ol pT)* |1>T)< rH CO 03 00 CO 00 (U IN CO ' ' ■ -H IN CO CO ■* rH r.; d oi o o> 1-H o S ^ ■^oqtOrHcoqiN p copiNp -H iq 03 •O 00 rH CO 00 * ■ ■ ■ N .-H rl CO t- Tjt -J rH t>; l> g a>ooT)<-i— looiN r- io>-i |o»o IN CO »0 ■^ IN Oi O o o" o 03 d ■ ■ 'l-H rl CO t^ ■<1< r-; r^ 00 t> fe 0>OTt<-)— ■^(>rH 1> TtlC0Q0O5»O IN (N 00 IN IN 00 Qc »o CO * ■ l-H -^ ,-( CO T)< rH rH (N rA 1 Ol '^ rH OOCOCOH— cDtOC^ O IMQ05OO5CO rH CO 05 CO Ol ■* o3 CO (N ' " ■ e4 l-H ^ IN 05 CO Tt rH rH |> l> o> 1—1 *-4 o . ^ t^ Tt< •(- -ci< CO ei 00 lo CO r^ o ": ^ CC ^ »q IN ^ i-< 2 CO ' ' ' ci 1-1 »0 (N 1> -^ r^ p.; d oi rt a rH OS rt ^ 05 ■* ■* r-l CD O "" O "O ^ 00 l> CO ir 00 ■* O Tl* F-( CO CO •* l-H (M I- CO CO 00 la ur. 03 C 00 CO IN O •-* (M "3 rH C^ »0 K o O Oi r-l OS -^ fl l> ■£! CO r)< CO --^ IN CO 00 1^ ^^ «> cc OJ -^ cc » eq t> CO l> IC CD X c 05 CD cq o o> (N '-' rH (N «0 OC 00 00 O) "-t O "3 CO 'H O >0 03 O CO l> 00 OC 00 >C IN rH • 0> b- '* (N I> cq 00 O rH IN Oi 0> IN 00 Tt< IN (N 2 (M >-< rH 00 to OC '" CO CD 1 a l^ (M lO CO lO O O 05 00 00 CO «c ~o^ CO ■* 1-1 X ■* CO l>. CO -i< 03 tH CO CO 00 Tj< rH rH IN 00 00 IN IN (N rH IN CO -* ^^ rH i> t^ o t4 OS CO CO oi'co ■* CO 00 CD O CO CO Ol l> t^ iC CD CO •># Ol a lO 00 »0 CO CO CO CO TJH T-H t^ CO CO ^^ rH 00 IN IN CO s iM rH -^J* rH CO •* rH rH rH 1^ ;? " T-{ 00 t~ Tj< CO CO --1 -H O r-H rH CO CO 00 00 o Tt* rH CO t> CO 00 >0 CO lO CO (N O (N O l> O CO O CO o CO rH lO IN IN i-i rH CO 05 l> Tj^ t-H rH 00 l> Ol T—i '^ o 00 ^ CO CO lr» t> CD (N CO rH Oi CO >D CD IN 00 rH rH CO ■" CO IC 00 CO r-l rH ■^ 03 "5 O l> ■* lO CO rH O ^ CD CO »0 CO CO (N (N (N Tt< 00 00 rH t^ Tt CO «> '^ IN rH O l-H 05 rH l-H eq rH CO (N >o "5 OJ -H ■^ (D •pi ai T3 . yd . :a-s & 33 5P s '3 03 S bll o d 2 ro a> ■ 5 cj a "3 1 a "o 1 •(-1 p. CO ft • 02 • O • a ■ Q o 3 03 .2 ^ -^ .= 2^ g=o^ IP "3 ci +^ a !«! r o If »H i °1 ■5 xJ OS QJ T3 tc| o 3 fl .2 ^ is p 'r? c3 b r* ID tJ t: 3 3 ^ fe S . >> §1 « > J, §^ o^ Oi 00 rH t> 00 Oi s lO «0 CO l> OO 03 c rH lO CO (N 00 ■* h) 6 i> t- t> t> t- t> a 00 00 00 OC 00 OC Q 00 00 00 4^ T-^ T-l 1-t rH rH QW So 1-( * APPENDIX C. Effect of System of Inquiry to Physicians upon Death Eates of Principal Diseases and Conditions. There are two general sources of error in the statistics of causes of death. The first source is the inherent inaccuracy and uncer- tainty of the diagnoses in a fairly significant proportion of the deaths certified. This element of defect in the statistics has been found upon recent inquiry, however, not to assume as much im- portance for the chief diseases and conditions as was at one time thought to be the case. Some committee work on behalf of the American Public Health Association by a group of pathologists, clinicians and statistical workers, has shown that the statistics of the causes of death represented in contemporary American regis- tration practice are, for the most part, reliable for the practical purposes of public health work, and that they are worth the time, effort and expense required for the proper collection, tabulation and publication of the same.* This conclusion, based upon the deliberations of a representative committee, should go far to off- set the suspicions and the doubts as to the accuracy of the statis- tics of certified causes of death which have appeared in recent vital statistical literature. The second important source of error in the statistics of causes of death arises from the failure of certifying physicians to report all the morbid conditions known to them and which had any bear- ing upon the cause of death. Physicians often report only condi- tions such as " acute nephritis," " peritonitis," " septicemia " and other merely terminal incidents in the course of the last illness. This practice is perhaps excusable in view of the fact that the terminal condition is uppermost in the physician's mind, probably because it required the largest part of the physician's effort on behalf of his patient. These incomplete statements of causes of death account for a quite significant proportion of the total amount * See reprints 363 and 440, from Eeports of the United States Public Health Service, 1917 and 1918. "The Accuracy of Certified Causes of Death and its Relation to Mortality Statistics and the International List." 377 878 MOKTALITY STATISTICS OF INSURED WAGE EAENERS. TABLE 178. Effect of System of Inquiry to Physicians upon Death rates of Im- portant Diseases and Conditions. Number of Deaths before and after Inquiry and Percentage Change in Death rate. Experience of Metropolitan Life Insurance Company. Industrial Depart- ment. 1911 to 1916. Inf 1 List Number. Disease or Condition. Number of Deatlis. Before After Inquiry. Inquiry. 2280 806 5052 2773 1725 1013 3341 2224 6010 4171 402 293 1091 797 6500 5120 2148 1722 1082 939 1239 1083 5800 5279 45084 41707 52260 52067 93351 93526 13052 13089 6518 6542 8981 9035 13957 14153 8882 9011 2310 2352 1324 1353 8899 9142 2995 3075 4505 4638 3054 3155 4338 4482 4619 4776 6118 6345 7588 7882 2334 2435 3418 3579 894 938 34443 36638 1237 1318 Percentage, Deatlis After of Deaths Before Inquiry. 185 66 117 67 B61 46 62 119 186 94 20 45 92 120 28 9 156-163 29, 32-35 40 1 155 39 81 7 31 41 6 108 42 182 43 44 64 183-184 Fractures (cause not specified) Paralysis without specified cause Simple peritonitis — nonpuerperal General paralysis of the insane Simple meningitis Other tumors (tumors of the female genital organs excepted) Locomotor ataxia Acute nephritis Other external violence (excl. war deaths) . . Pulmonary congestion, pulmonary apoplexy Purulent infection and septicemia Cancer and other malignant tumors of other organs or of organs not specified Pneumonia (lobar and undefined) Bright's disease Tuberculosis of the lungs Diphtheria and croup Suicides (except suicide by poison) Other forms of tuberculosis Cancer and other malignant tumors of the stomach Typhoid fever Suicide by poison Cancer and other malignant tumors of the buccal cavity Diseases of the arteries, atheroma, aneur- ism, etc Whooping cough Scarlet fever Abdominal tuberculosis Cancer and other malignant tumors of the peritonetun, intestines, rectum Measles Appendicitis and typhlitis Cancer and other malignant tumors of the female genital organs Homicide by firearms Cancer and other malignant tumors of the breast Cancer and other malignant tumors of the skin Cerebral hemorrhage, apoplexy Homicide (except homicide by firearms) . . . 35.4 54.9 58.; 66.6 69.4 72.9 73.1 78.8 80.2 86.8 87.4 91.0 92.5 99.6 100.2 100.3 100.4 100.6 101.4 101.5 101.8 102.2 102.7 102.7 103.0 103.3 103.3 103.4 103.7 103.9 104.3 104.7 104.9 106.4 106.5 APPENDIX C. 379 TABLE 178 (Continued). Int'I List Number. Disease or Condition. Number of Deaths. Before After Inquiry. Inquiry. 15126 16224 1945 2160 7247 8056 4129 4647 629 743 2124 2555 5558 6917 2345 4659 83 200 290 823 Percentage, Deaths After of Deaths Before Inquiry. 91 B63 10 30 51 56 172 37 38 A61 Bronchopneumonia Other diseases of the spinal cord Influenza Tuberculous meningitis , Exophthalmic goitre , Alcoholism (acute or chronic) . . . Traumatism by fall , Syphilis , Gonococcus infection Cerebrospinal fever 107.3 111.1 111.2 112.5 118.1 120.3 124.4 198.7 241.0 283.8 of error in mortality statistics of the several diseases and condi- tions. The remedy for the first cause of error lies largely with the forces of medical education and diagnostic progress. The amount of absolute error due to the second important element of incom- plete statement can be quite readily controlled by a system of cor- respondence with certifying physicians. By means of such a pro- gramme, each certification by a physician which is obviously or probably an understatement is subjected to scrutiny and becomes the occasion for a letter asking for all the facts as to diseases and conditions contributing to the death. A plan of this kind was inaugurated at the beginning of the present mortality investigation and was carried out in principle, with necessary additions in the scope of the inquiries, throughout the entire six-year period. In Table 178 on pages 378 and 379, we show the effect of this system of correspondence upon the death rates of the more important diseases and conditions represented in this experience. From the foregoing tabulation, it will be seen that as a result of correspondence with physicians the number of deaths certified as due to "fractures" (cause not specified) was reduced from 2,280 before inquiry to 806 after inquiry, or a reduction of 64.6 per cent. Another equally unsatisfactory certification was " paraly- sis," without specified cause. The number of such registrations in our final tables was reduced from 5,052, the number which was originally reported by physicians, to 2,773, after inquiry, or a re- duetion of 45.1 per cent. Inspection of the table will show other important alterations in the death rates of certain causes of death, 380 MORTALITY STATISTICS OP INSURED WAGE EARNERS. the reduction being due solely to the persistent scrutiny of death certificates for incomplete statements, and the subsequent effort to secure complete and satisfactory reports from the physicians. A number of causes of death such as Bright's disease, tuberculosis of the lungs, diphtheria and croup, cancer of the stomach, and typhoid fever were affected, so far as their death rates were con- cerned, only to a very limited extent by this system of inquiry. Certain other causes of death such as whooping cough, scarlet fever and cancer of the peritoneum, intestines and rectum, which one might expect to be affected by masked returns of "broncho- pneumonia," "acute nephritis" and "peritonitis," respectively, show sbmewhat greater percentages of alteration in the recorded death rates. Cerebral hemorrhage and apoplexy, influenza, alcohol- ism, traumatism by fall, syphilis, gonococcus infection and cerebro- spinal fever were quite emphatically influenced in their death rate^ by this programme of correspondence with certifying physicians. The table on pages 381 to 384 shows what disposition was made of certain of the terms originally certified under obviously incom- plete statements. Thus, out of 295 "purulent infection and septicemia," replies received, most of which were originally returned as " septicemia," 76 cases or 25.8 per cent, were finally classified in our statistics as " puerperal septicemia." Cancer cases, where the organ or part was not specified by the physician, in 223 cases, or 25.3 per cent., out of an original total of 883 replies, were subsequently registered as "cancer of the female genital organs," and 126 cases, or 14.3 per cent., as " cancer of the breast." Returns of " meningitis " were found to have been due to tuber- culous meningitis in 17.1 per cent, of the cases and to cerebrospinal fever in 19.1 per cent, of the total number of replies received. Terminal cardiac states such as "acute cardiac dilatation" and "cardiac insufficiency" were found to have been pneumonia cases in 11.9 per cent, of the replies received. "Peritonitis" without further definition was finally registered as " appendicitis " in 17.3 per cent, of the cases and as " puerperal septicemia " in 14 per cent. The statistics of accidental, homicidal and suicidal violence were affected in an important degree by the clearing up process applied to cases which were simply certified as " fractures." Out of 1,637 fracture eases, 1,011, or 61.8 per cent, of the total number, were APPENDIX C. 381 TABLE 179. Number op Deaths where the Causes of Death were Originally Speci- fied IN Ill-defined Terms, showing also the Number and Per- centage OF SUCH Deaths Definitely Certified after Inquiry to Physicians. Experience of Metropolitan Life Insurance Company. Industrial Depart- ment. 1911 to 1916. Ill-defined Term Reported Belore Inquiry to Physician. Purulent infection and septicemia Total replies — 295 Unchanged by inquiry : 88 or 29.8 percent. Cancer and other ma- lignant tumors of other organs, or of or- gans not specified Total replies — 883 Unchanged by inquiry : 246 or 27.9 percent. Meningitis Total replies — 2560 Unchanged by inquiry: 701 or 27.4 percent. Locomotor ataxia Total replies — 596 Unchanged by inquiry : 294 or 49.3 percent. Paralysis without speci- fied cause Total replies — 2598 Unchanged by inquiry : 302 or 11.6 percent. Cause of Death Ascertained by Inquiry to Physician. I Changes In State- I ment ol Cause of Death. Total changes from "purulent infection and septicemia" to cause of death specified below "Other diseases of the uterus" . Puerperal septicemia Acute abscess Other titles Total changes from ' ' cancer . . . , organs not specified" to cause of death speci- fied below Cancer. . .of the buccal cavity Cancer ... of the stomach Cancer. . .of the peritoneum, intestines, rectum Cancer . Cancer . Cancer . .of the female genital organs. . of the breast . of the skin Other titles . Num- ber. Tuberculous meningitis Cerebrospinal fever Pneumonia — ^lobar and undefined Diarrhea and enteritis — 2 years and over Other titles Total changes from ' ' locomotor ataxia ' to cause of death specified below Syphilis Other titles Total changes from "paralysis without specified cause" to cause of death specified below "Other diseases of the spinal cord" . . . . Cerebral hemorrhage, apoplexy General paralysis of the insane Other titles 207 70.2 76 9 114 637 27 113 100 223 126 42 Total changes from "meningitis" to cause of death specified below 1859 439 489 108 94 729 302 282 20 2296 2.7 25.8 3.1 38.6 72.1 3.1 12.8 11.3 25.3 14.3 4.8 .7 72.6 17.1 19.1 4.2 3.7 28.5 50.7 47.3 3.4 88.4 322 12.4 1613 62.1 149 5.7 212 8.2 382 MOETALITT STATISTICS OF INSURED WAGE EAKNEES. TABLE 179 (Continued). lU-deflned Term Reported Before Inquiry to Physician. Cause of Death Ascertained by Inquiry to Physician. Changes In State- ment of Cause of Death. Num- Percent- ber. age. General paralysis of the insane Total replies — 2076 Unchanged by inquiry 761 or 36.7 percent. Organic diseases of the heart* Total replies — 1175 Unchanged by inquiry: 697 or 59.3 percent. Diseases of the arteries, atheroma, aneurism, etc.f Total replies — Q53 Unchanged by inquiry : 493 or 51.7 percent. Pneumonia Total replies — 5493 Unchanged by inquiry: 1595 or 29.0 percent. Pulmonary congestion, pulmonary apoplexy Total replies — 245 Unchanged by inquiry: 84 or 34.3 percent. Peritonitis — non-puer- peral Total replies — 901 Unchanged by inquiry: 179 or 19.9 percent. Total changes from "general paralysis of the insane" to cause of death specified below Syphilis Other titles Total changes from "organic diseases of the heart" to cause of death specified below Cerebral hemorrhage, apoplexy. . . Pneumonia — ^lobar and undefined. Other titles Total changes from "diseases of arteries, etc." to cause of death specified below Syphilis , Cerebral hemorrhage, apoplexy , Other titles , Total changes from "pneumonia' cause of death specified below. . . . Influenza Bronchopneumonia Lobar pneumonia Other titles to Total changes from "pulmonary conges- tion, pulmonary apoplexy" to cause of death specified below Organic diseases of the heart Chronic bronchitis Pneumonia — lobar and undefined Bright's disease Other titles Total changes from "peritonitis" to cause of death specified below Abdominal tuberculosis Diarrhea and enteritis — 2 years and over Appendicitis and typhlitis Salpingitis and other diseases of the fe- male genital organs Puerperal septicemia Other titles 1315 1257 58 478 140 252 460 175 172 113 3898 529 1076 1692 601 161 32 8 16 11 94 722 69 33 156 76 126 262 * Most of the terms included under the title ' ' organic diseases of the heart" are fairly definite. However, certain expressions such as "acute cardiac dilatation ' ' and ' ' cardiac insufficiency ' ' are often reported when they are only terminal symptoms of other diseases. It is these expressions which are covered by our inquiry. t Practically all of the inquiries related to reports of ' ' aneurism, ' ' APPENDIX C. 383 TABLE 179 (Continued). lU-deflned Term Reported Belore Inquiry to Physician. Causa oj Deatli Ascertained by Inquiry to Physician. Changes In State- ment of Cause of Death. Num- Percent- ber. age. Acute nephritis Total replies — 3271 Unchanged by inquiry : 1852 or 56.6 percent. "Other diseases of the uterus" Total replies — 280 Unchanged by inquiry: 85 or 30.4 percent. Traumatism by fire- arms Total replies — 157 Unchanged by inquiry: 35 or 22.3 percent. Fractures (cause not specified) Total replies — 1637 Unchanged by inquiry: 151 or 9.2 percent. "Other external vio- lence" Total replies — 708 Unchanged by inquiry : 132 or 18.6 percent. Total changes from "acute nephritis" to cause of death specified below Scarlet fever Influenza Alcoholism (acute or chronic) Bright's disease , Other titles Total changes from "other diseases of the uterus" to cause of death specified below Gonococcus infection Cancer and other malignant tumors of the female genital organs Uterine tumor (noncancerous) Cysts and other tumors of the ovary . . . Salpingitis and other diseases of the fe- male genital organs Puerperal septicemia Other titles Total changes from traumatism by fire- arms to cause of death specified below . Suicide by firearms Homicide by firearms Other titles Total changes from "fractures (cause not specified) " to cause of death speci- fied below Traumatism by fall Traumatism by crushing — electric rail- way Traumatism by crushing — steam rail- way Traumatism by crushing — automobiles. Traumatism by crushing — other vehicles Traumatism by other means Other titles Total changes from "other external violence" to cause of death specified below Purulent infection and septicemia Traumatism by fall Traumatism by machines Traumatism by crushing — steam rail- way Traumatism by crushing — electric rail- way Traumatism by crushing — automobiles. Traumatism by crushing — other vehicles Other titles 1419 95 156 341 118 709 195 1486 1011 53 576 43.4 2.9 4.8 10.4 3.6 21.7 69.6 23 8.2 12 4.3 25 8.9 6 2.1 38 13.6 53 18.9 38 13.6 122 77.7 9 5.7 110 70.1 3 1.9 90.8 61.8 3.2 44 2.7 61 3.7 89 5.4 60 3.7 168 10.3 81.4 22 3.1 218 30.8 41 5.8 43 6.1 21 3.0 26 3.7 58 8.2 147 20.8 384 MORTALITY STATISTICS OF INSUEED WAGE BAENBR8. TABLE 179 (Continued). Ill-defined Term Eeported Cause of Death Ascertained by Inquiry to Physician. Changes In State- men t of Cause of Death. Num- ber. Percent- age. Total changes from "ill-defined dis- eases" to cause of death specified below Malaria 422 70.6 Total replies— 598 15 22 107 27 251 2 5 Unchanged by inquiTy: ( Tuberculosis of the lungs 3 7 176 or 29.4 percent. Organic diseases of the heart 17 9 Bright's disease 4 5 Other titles 42.0 identified as deaths due to falling; 3.3 per cent, were caused by electric railway accidents, 2.7 per cent, by steam railway accidents, 3.7 per cent, by automobile accidents and 5,4 per cent, by other vehicular accidents. " Gunshot wound," in 157 replies, was found to have been homicide by firearms in 110 cases, or 70.1 per cent., and suicide by firearms in 9 cases, or 5.7 per cent. Original certi- fications of " injury," " violent death," and other ill defined terms for violence classified under Title 186 of the International List, were found to have been made for falls in 30.8 per cent, of the cases; in machinery accidents in 5.8 per cent.; in steam railway accidents in 6.1 per cent, of the original number of returns. From this brief review of an extensive programme for improv- ing the validity of the statistics of the causes of death shown in this present report, it will be seen that incomplete and understate- ment of the morbid conditions contributing to death is highly significant to students of the medical statistics of mortality. It is evident that some allowance must be made in all published statistics of mortality from causes of death, for this factor of possible under and incomplete certification of diseases and conditions. The fore- going tables and the appended text will show in a measure the extent of this specialized problem in medical statistics. It is hoped that the value of a systematic programme of inquiry to physicians in cases of doubtful certification has been established by the fore- going display of the facts for the basic material of this report. They supplement the conclusions published in recent Census Bu- reau mortality reports under the caption of " Accuracy of Statistics of Causes of Death." APPENDIX D. Standakdized, or Coreected, Death Eates. A judgment on the comparative healthfulness of two popula- tion or exposure groups, in terms of a single expression, is often necessary in the analysis of public health statistics. For instance, we may wish to compare, in the aggregate, white males of the in- surance experience with males of the Eegistration Area experi- ence. No direct comparison of the death rates for the total, ages one and over, is valid, however, without proper allowance for dif- ferences in the age composition of the two groups. On page 23 we gave a comparison of the death rates of the insurance andi "popu- lation groups, and showed that for all ages one and over, insured white males had a crude mortality rate 95.2 per cent, of the rate among males in the general population, and that insured white females registered a death rate 93.9 per cent, of the rates for females in the population of the expanding Eegistration Area of the United States. Apparently, there was a more favorable bal- ance of mortality for the group of insured wage earners. But in- spection of the table on page 5 shows that the average age of the insured group is much lower than that of the population exposure. A considerable bulk of the insurance white male experience con- sists of lives under twenty years of age (50.3 per cent.), as com- pared with 36.2 per cent, in the population experience. These dif- ferences in age constitution account for the apparently more favor- able ratio of mortality in the total white male and white female insured groups. A convenient means for eliminating the influence of variable age constitution is available. The " specific death rates," or death rates relating to specific sex and age classes in the two groups to be compared, can be multiplied into an assumed " standard popu- lation" by sex and age to produce an "expected" number of deaths. For this purpose we chose the age groups (for ages one and over) of the " standard million of population, England and Wales, 1901j" and by multiplying the sex and age death rates of 385 386 MOETALITT STATISTICS OF INSURED WAGE EAENEES. the insurance and population experiences, respectively, into the numbers in each of the corresponding sex and age classes of the "standard" or "norm" population, we produced for each experi- ence and sex class, an "expected total number of deaths." The ratio of the expected number of deaths based upon the rates for insured white males to the expected number of deaths for popula- tion males, is an accurate measure of the relative healthfulness of the two groups, so far as we may determine this fact from the mor- tality statistics of the two groups. A tabular display of the results of this correction process is given below : TABLE 180. Expected Number of Deaths, Ages One and Over, in ' ' Standard Million OF Population in England and Wales, 1901" According to Specific Death Rates op (a) Metropolitan Industrial White Experience, 1911 to 1916 AND (&) Expanding Eegistration Area Experience, 1910 TO 1915, BY Sex. Expected Number of Deaths In "Stand- ard Population," According to Specific Death Rates In : Percentage, M. L. I. Sex. Co. of Reg. Area M. L. I. Co. White Reg. Area (U. S.) Expected Deaths. Experience, 1911 Experience, 1910 to 1916. to 1915. Males 7,107 6,264 5,561 127.8 Females 5,602 111.8 From the foregoing table we may conclude that the total mor- tality of insured white male wage earners is in reality 28 per cent, higher than mortality among males in the general population and that the group of insured white females shows an excess of 12 per cent, in mortality. If the numbers of expected deaths in the foregoing table are divided by the total corresponding "standard population" at ages one and over the following "corrected" death rates are produced. A comparison with the crude rates is shown in the table on page 387, together with the standardization or correction factor. In other words, the process of correction produces an increase of 27.7 per cent, in the death rate for insured white males, of 19. o per cent, in the death rate of insured white females, a decrease of 4.8 per cent., and an increase of .3 per cent, in the death rates of males and females, respectively, in the general population. APPENDIX D. 387 TABLE 181. Crude and Standahdized Death rates pee 1,000, all Causes of Death, compaeed. Standardization factor: (Eatio of Standardized to Crude Rate). Experience Group; Sex. Crude Rate. Standardized Rate. Factor. Metropolitan Ind. White Experience, 1911 to 1916. Males 11.82 10.40 12.41 11.08 15.09 12.43 11.81 11.11 1.277 Females 1.195 Registration Area Experience, 1910 to 1915. Males .952 Females 1.003 INDEX. Abdominal tuberculosis, 62 , and "dysentery," 265 Abortions and miscarriages, 203 Absorption of deleterious gases, 119 Accidental drowningj 104 Accidental poisoning, 117 Accident death rate, improving, 125 Accident problem in the United States, and in England and Wales, 94 Accidents, 94 , according to means of injury, 100 Accidents of labor, 204 , decline in mortality, 210 , prenatal nursing in prevention of, 210 Accidents of pregnancy, 203 Accuracy of certified causes of death, 30, 377 , increasing deathrates from " degenerative diseases," 70 , communicable diseases of child- hood, 188 Acute accidental poisonings, 117 Acute articular rheumatism, 242 Acute bronchitis, 245 , in children, 245 Acute endocarditis, 275 Acute nephritis, 283 , following infectious diseases, 283 , and scarlet fever mortality, 185 Acute poliomyelitis, 262 Adolescence, suicide in, 131 Adolescent women and suicide, 131 After-mortality of typhoid fever, 222 Age composition of insured group, comparison with United States Registration Area, 5 389 Ages, mortality by, from certain diseases — see particular disease Albuminuria, during pregnancy, childbirth and the puerperium, 199 Albuminuria in the maternal state, 202 Alcoholism, 246 , and cirrhosis of the liver, 223 , defective and unreliable sta- tistics, 223, 248 AH causes of death, number of deaths or death rates by color, sex or age,, 11, 13, 14, 34, 304 , in 1917, 293 , 1911 to 1916, by single calen- dar years, 366 Anemia, 267 , chlorosis, 267 Aneurism, 215 , and syphilis, 238 Angina pectoris, 260 Anterior poliomyelitis, 262 Antitoxin in diphtheria, 191 Ajipalaehian Plateau, malaria in the, 257 , pellagra in the, 249 Appendicitis, 233 Areas included in this study, 2 Arteries, diseases of the, 215 Arteriosclerosis, 215 , and softening of the brain, 271 , as "degenerative disease," 216 Arthritis deformans, 242 Asphyxiation, accidental, 119 , suicidal, 136 Asthma, 278 Atheroma, 215 Atlanta, Ga., pellagra in, 250 Augusta, Ga., pellagra in, 250 , malaria in 256 390 INDEX. Automobile accidents and injuries, increasing death rate, 109 Biliary calculi, 281 Birmingham, Ala,, pellagra in, 250 , malaria in^ 256 Birthrate in relation to maternal mortality, 201 Bladder, cancer of the, 171 , abscess of the, 285' , diseases of the, 285 Boston, Mass., prenatal nursing in, 213 Bright 's disease, 87 , and carddo'-vascular disease, 87 , classification difficulties in, 87 — — , increasing deathrate from, 91 Bronchial asthma^ 278 Bronchitis, acute, 245 Bronchitis, chronic, 241 Bronchopneumonia, 78 — ■ — , as unsatisfactory statement of cause of death, 30, 379 , reliability of mortality sta- tistics of, 86 Brownlee, John, 51 Buccal cavity, cancer of the, 170 Burns, 106 Csesarean section, 204 Cairo, 111., malaria in, 256 Calculus, biliary, 281 Campaign against tuberculosis, 59 Cancer, problem in the United States, 147 , by organs or parts, 148 > stomach and liver, 160 female genital organs, 163 breast, 165 peritoneum, intestines, rectum, 168 buccal cavity, 170 skin, 170 male genital organs, 171 , in relation to economic con- dition or social status, 155 Cancer, continued ; increasing! mortality rates from, 156 , increasing mortality in cer- tain age periods, 159 , and tuberculosis of abdom- inal organs, in relation to child- bearing, 168 Cardiac disease — see Heart disease , ill-defined, 290 Cardio-vascular-renal disease and cerebral hemorrhage, 173 Cardio-vascular-renal diseases — see Heart disease. Bright 's disease, Cerebral hemorrhage and apo- plexy, 65, 87, 173 Causes of death, improved state- ments of, 377 Cerebral hemorrhage and apoplexy, 173 Cerebral softening, 271 Cerebral tumor, 273 — ■ — , and syphilis, 238 Cerebrospinal fever, 269 Cerebrospinal meningitis, 268 Certification, of diseases causing death, 264 f of cerebral hemorrhage, 173 ■ , of alcoholism, 248 , improvement in, by system of inquiry, 377 Changes in deathrates, following in- quiry to physicians, 377 Charlotte, N. C, pellagra in, 250 , malaria in, 256 Chattanooga, Tenn., pellagra in, 250 Child-bearing in relation to cancer and tuberculosis of the abdominal organs, 168 Childbirth, mortality in, 197, 213 Children, in wage earners' families, mortality ofj 3 , under one year of age, 7 , automobile accidents among, 110 , communicable diseases of, 178 , diarrhea and enteritis in, 193 , convulsions in, 273 INDEX. 391 Chlorosis, 267 Cholelithiasis, 282 Chronic bronchitis, 241 , and certification of tubercu- losis, 242 Chronic pneumonia, 279 Chronic poisonings, 267 Chronic recurrent pellagra, 255 Cirrhosis of the liver, 223 Classification of causes of death, 9, 32 Classification procedure in relation to increased deathrate from ' ' degene- rative diseases," 70 Coastal plain of the South, malaxia in the, 257 , pellagra in the, 249 Cocainism, 267 Codification processes, 9 Color or race composition of insured group, 4 Colored males and females, by causes of death, see Eaeial mor- tality Columbia, S. C, pellagra in, 250 , malaria in, 256 Columbus, Ga., pellagra in, 250 , malaria in, 256 ' ' Confinement, ' ' deaths in, 204 Convulsions, 273 , puerperal, 202 , in children, 273 Corrected deathrates, 385 Correspondence with physicians to in- crease accuracy of certified causes of death, 30, 377 Cystitis, 285 Deaths, by color^, sex or age, 11, 12, 34, 304; by single years, 366 Deathrates — see entries for each cause of death , by single calendar years, 1911 to 1916, and by causes of death, 366; by color and sex, 34 "Debility," 290 ' ' Degenerative diseases ' ' — see Heart disease, Bright 's disease, Cerebral hemorrhage and apoplexy, 65, 87, 173 Dementia paralytica, 272 Dementia precox and suicide in ado- lescence, 131 Diabetes mellitus, 229 , relation to working conditions, 229 , and menopause, 230 , increasing deathrate from, 232 Diarrhea and enteritis, 193 , and "dysentery," 265 Diet in causation of pellagra, 254 Diphtheria, 189 Disability among Southern wage earners, resulting from pellagra, 250 Diseases of the arteries, 215 Diseases of intestines, 193 Disseminated tuberculosis, 64 "Drink habit," statistics of, 248 "Dropsy," 290 Drowning, accidental, 104 , suicidal, 137 Drunkenness, mortality from, 248 Dublin, Louis I., 155, 175, 185, 222 "Dysentery," 264 Ears, diseases of the, 274 Eastland disaster, Chicago, 111., 1915, 105 Eclampsia, puerperal, 202 Economic aspects of homicide, 145 Economic condition, and cancer, 155 , and diabetes mellitus, 229 Economic loss, from tuberculosis, 43 , from heart diseases, 65 , from diseases of puerperal state, 197 Economic revival in the South, 1916, in relation to pellagra mortality, 255 Elevator accidents, 115 Embolism and thrombosis, 276 Encephalitis, 268 Endocarditis, acute, 275 Endometritis, 287 Enteric fever, 218 392 INDEX. Enteritis, 193 Epidemie cerebrospinal meningitis, 268 Epidemiology of tuberculosis, 51 Erysipelas, 265 Erysipelas, puerperal — see puerperal septicemia, 201 Estimating number of policyholders exposed to risk, 8 External causes, 93 , classification by, 93 , by class of violence, 94 Extra-uterine gestation, 203 Ealling, deaths from, 102 Eallopian tubes, cancer of the, 163 , diseases of the, 287 Family disintegration and maternal mortality, 213 Fatal accidents, 99 Fatality rate of childbirth, 213 Fatigue, and diabetes mortality, 229 Female genital organs, cancer of the, 163 , diseases of the, 287 I'irearms, accidental deaths from use of, 121 , suicide by, 138 Floods, mortality from, 105 ' ' Follow-up work ' ' of prenatal clin- ics, 213 Forceps delivery, 204 Frankel, Lee K., iv Frequency curves of tuberculosis mortality, 51 Gall stones, 282 Gangrene, 288 Gases, accidental absorption of, 119 "Gastritis," 280 Gastroenteric tuberculosis, 62 Gastroenteritis, 193 General paralysis of the insane, 272 General paralysis of the insane, and syphiliSj 237 Glottis, edema of the, 277 GoDococcus infection, 266 Gonorrhea, 266 Gout, 242 Great Britain, types of tuberculosis mortality in, 51 , accident problem in, 94 Greensboro, N. C, pellagra in, 250 Habit poisonings, 267 Hanging, suicides from, 137 Health conditions of wage earners, 25 Heart disease, among adult males, 65 , disability resulting from, 65 , burden upon wage earners' families, 65 — • — , classification ofj 70 , increasing deathrates for, 70 , unsatisfactory reports of, 71 "Heart failure," 290 Hepatitis, 282 Hernia, 235 Hoffman, Frederick L., 23, 156 Homicides, definition, 93 , statistics, 139 , problem in the United States, 139 Hours of labor, a factor in wage earners' mortality, 26 Hypostatic pneumonia, 278 Icterus, 282 Ill-defined diseases, 290 Illuminating gas poisoning, acci- dental, 119 Immunity in negroes Measles, 179 Scarlet fever, 182 Improvement in wage earners' mor- tality All causes of death, 26 Compared with Eegistration area, 27 Tuberculosis of the lungs, 55 Abdominal tuberculosis, 63 , Communicable diseases of child- hood, 178 Diarrhea and enteritis, 196 Puerperal diseases, 208 Typhoid fever, 222 INDEX. 393 Improvement in wage earners' mor- tality, continued Pellagra, 254 Malaria, 259 Improvement of statistics of causes of death through supplementary inquiries to physicians, 31, 377 Increasing death rate, for ** de- generative diseases," 70 , for lobar pneumonia, 77 , for automobile accidents, 109 , for diabetes mellitus, 232 "Indigestion," 280 Industrial accidents, 115, 123 Industrial conditions and pellagra, 249, 254 Industrial hazards and mortality, 123 Industrial hygiene, a factor in wage earners' mortality, 26 Industrial insurance, 25 Industrial insurance mortality ex- perience as influenced by visiting nursing, 214 Infantile diarrhea, 193 Infants, mortality of, 7 Infectious diseases of childhood, 178 Influenza, 226 Inguinal hernia, 235 Injuries at birth, 204 Inquiry system to improve certifi- cation of causes of death, 377 Intensity of labor, a factor in wage earners' mortality, 26 Intestinal diseases, 193 Intestinal obstruction, 235 Intestines, cancer of the, 168 International List of Causes of Death, 9, 32 , Number of deaths classified by color and sex (34)^ by age (304), and by single calendar years, 1911 to 1916, (366) Ireland, tuberculosis mortality types in, 51 Jackson, Tenn., pellagra in, 250 , malaria in, 256 Jaundice. 282 Jointly returned causes of death, classification of, 9, 32 Kidneys, cancer of the, 171 , diseases of the, 284 Knight, Augustus S., 155 Knoxville, Tenn., pellagra in, 250 Kopf, Edwin W., iv Labor (in childbirth), mortality dur- ing, 199 Laryngismus stridulus, 277 Laryngitis, 277 Larynx, diseases of the, 277 Life consei'vation resulting from prenatal work, 213 iLife insurance companies, public health statistics of, iv Little Eock, Ark., pellagra in, 250 , malaria in, 256 Liver, abscess of the, 282 • -, cancer of the, 160 , diseases of the, 282 Lobar pneumonia, 73 , increasing death rate from, 77 Locomotor ataxia, 270 , and syphilis, 237 , Wassermann reaction in, 271 Ludwig's angina, 280 I-ues, see syphilis Macon, Ga., pellagra in, 250 , malaria in, 256 Malaria, 256 Malaria and pellagra, and the effi- ciency of iSouthern wage earners, 249, 254 Male genital organs, cancer of the, 172 Malignant disease and anemia, 267 Massachusetts, malaria in, 256 Maternal mortality, 197 , methods of studying, 197 , in relation to age, 200 , prevention of, 213 Measles, 179 , immunity in negroes, 179 394 INDEX. Medical selection in relation to tuberculosis mortality, 53 Membranous croup, 189 Memphis, Tenn., pellagra in, 250 , malaria in, 256 Meningitis, 268 Menopause, 287 , ia relation to diabetes mortal- ity in women, 230 Mental diseases in adolescence, 131 Michigan, malaria in, 256 Middle Atlantic States, poliomyelitis ■epidemic in, 1916, 262 Miners' asthma, 278, 279 Miscarriages, 203 Morphine habit poisoning, 267 Mortality among wage earners, im- provement in, 26 — — , during 1917, by causes of death, 293 Mortality from occupational causes, 123 Mortality of childhood, 185 Mosquito problem and malaria, 256 Murder, 139 Nashville, Tenn., pellagra in, 250 , malaria in, 256 Negroes, cerebral hemorrhage certi- fication in deaths of, 175 , immunity among from measles, 179 from scarlet fever, 182 , higher typhoid fever death- rate among, 219 , and pellagra, 249 , deathrates among, see Eaeial mortality Negro women, and puerperal mortal- ity, 199 , illegitimacy a factor in ma- ternal deathrate of, 201 , puerperal hemorrhage in older, 204 Nervous system, diseases of the, 273 Neurasthenia, 273 Newark, N. J., poliomyelitis epi- demic in, 1916, 263 New England States, poliomyelitis epidemic in, 1916, 262 New Jersey, malaria in, 256 New Orleans, La., pellagra in, 250 , malaria in, 256 New York City, poliomyelitis epi- demic in, 1916, 262 New York City, prenatal nursing in, 213 Nomenclature and classification of diseases, 9, 32 Northern States, pellagra in, 252 , malaria in, 256 Number of insured wage earners, estimating, 8 Occupational and industrial hazards, 123 Occupations, classification of, 9 , causes of death in, 10 Occupational hazard in industrial in- sura-nce mortality, 2 Occupations of insured wage earn- ers, 2 Ohio Eiver floods, 1913, 105 Old age, 288 Old age, cerebral hemorrhage mortal- ity in, 175 "Old Age," deathrate from, and "degenerative diseases," 289 Opium poisoning, 267 Organic diseases of the heart — see Heart disease, 65 Osier, William, 218 Otitis media, '274 Ovaries, cancer of the, 163 Ovaritis, 288 Paducah, Ky., malaria in, 256 "Paralysis," deathrate from, 176 Paresis, syphilis in relation to, 237 Pellagra, 249 , an economic problem in the South, 249, 254 , and diet, 254 , in relation to economic and so- cial conditions, 249, 254 Pennsylvania, malaria in, 256 INDEX. 395 Pericarditis, 274 Peritoneum, tuberculosis of the, 62 , cancer of the, 168 "Peritonitis," 283 , unsatisfactory statement of cause of death, 31 — , and appendicitis, 233 Pernicious anemia, 267 Pharyngitis, 280 Pharynx, diseases of the, 279 Philadelphia, Pa., poliomyelitis epi- demic in, 1916, 263 Physicians helping to complete data on wage earners' mortalityj iv, 378 Placenta previa, 203 Pneumokoniasis, 279 Pneumonia, 72 Pneumonia — ^lobar and undefined — see Lobar pneumonia, 73 * ' Pneumonia, ' ' unsatisfactory report ■of cause of death, 77 Poisoning, accidental, 117 Poisoning, suicidal, 135 Poisonings, chronic, 267 Poliomyelitis, 262 Poplar Blufif, Mo., pellagra in, 250 , malaria in, 256 Pregnancy index, for maternal mor- tality study, 200 Pregnancy, mortality in, 198 Premature birth (death of mother), 203 Prenatal clinics in control of ma- ternal mortality, 213 Prenatal nursing, in control of mor- tality from puerperal albuminuria and convulsions, 209 , in relation to accidents of labor, 211 , in public health work of Amer- ican cities, 213 Prolapse of the uterus, 287 Prostate, cancer of the, 172 , diseases of the, 285 Proteid diet in pellagra, 254 Prudential Insurance Company of America, 23 Public health administration and typhoid fever control, 218 Public health movement and the dis- eases of children, 178 Public health statistics of wage earners, 1 Public health work in relation to tuberculosis, 59 Puerperal albuminuria and convul- sions, 202 , and renal and hepatic dis- eases, 210 Puerperal diseases, 197 , prevention of, 213 Puerperal eclampsia, 202 Puerperal hemorrhage, 203 Puerperal hemorrhage, lower mortal- ity rate from, among wage earning population, 211 Puerperal septicemia, 201 , as affecting periods of the puerperal state, 199 , and "septicemia," unquali- fied, 266 Puerperium, mortality during, 199 PiUmonary apoplexy, 277 Pulmonary congestion, 277 Purulent infection and septicemia, 265 Pylorus, diseases of the, 281 Pyosalpingitis, 288 Q-uinsy, 280 Race composition of insured group, 4 Race factors in industrial insurance mortality, 3 Racial mortality from certain dis- eases, see particular disease. Railroad accidents and injuries, 107 Raleigh, N. C.^ pellagra in, 250 ; malaria in, 256 Rectum, cancer of the, 168 Registration Area of United States, age composition of population of, 5 Registration Area of United States Mortality by sex and by age in 396 INDEX. United States and among in- sured wage earners compared. All causes of death, 23 Tuberculosis of the lungs, 52 Tuberculous meningitis, 61 Abdominal tuberculosis, 64 Organic diseases of the heart, 68 Lobar pneumonia, 76 Bronchopneumonia, 85 Bright 's disease, 90 Accidents, 99 Traumatism by falling, 103 Suicides, 132 Homicides, 144 Cancer, 154 of the stoma,ch, 162 of the female genital or- gans, 164 of the breast, 167 Cerebral hemorrhage and apo- plexy, 176 Measles, 180' Scarlet fever, 183 Whooping cough, 187 Diphtheria and croup, 190 Diarrhea and enteritis, 195 Puerperal diseases, 204 Eenal disease in causation of puer- peral eclampsia, 210 Eheumatic fever^ 242 " Eheumatism, " 242 Eichmond, Va., pellagra in, 250 Eoanoke, Va.^ pellagra in, 250 Salpingitis, 287 Sanitary index, typhoid fever as, 218 St. Louis, Mo.j malaria in, 256 Savannah, Ga., pellagra in, 250 , malaria in, 256 Scarlet fever, 182 , immunity of negroes, 182 , in urban communities, 184 Sclerosis of brain, 273 Self -induced abortion, 203 Senility, 289 Sequelae of typhoid fever, 222 Sepsis, puerperal — see puerperal sep- ticemia, 2U1 Septicemia, 265 Septicemia, puerperal^-see Puerperal septicemia, 201 Sex composition of insured group, 4 Sex, mortality from certain diseases by, see particular disease Shooting, accidental, 121 Simple meningitis, 268 Simple peritonitis, 282 Skin, cancer of the, 170 Social conditions in relation to dia- betes mortality, 229 Social research into wage earners' family problems, 26 Social statistics of insured wage earners, 1 Social status and cancer, 155 Softening of the brain, 271 South, pellagra in, 249, 254 , malaria in, 257 Southwest, pellagra in, 249 , malaria in, 257 Spartanburg, S. C, pellagra in, 250 Spasmodic asthma, 278 Spasmodic croup, 277 Spinal meningitis, 268 Standard million of population, 385 Standard of living in wage earners' families, 26 Standardized, or corrected death rates, 385 States included in this study, 2 Steam railroad accidents and in- juries, 107 Stomach, cancer of the, 160 , diseases of the, 280 , ulcer of the, 261 Stouman, Knud, 234 Street car accidents and injuries, 112 "Sudden death," 290 Suicide statistics, 126 — — , problem among wage earners 127 , in adolescence, 131 ■ — — , by means of injury, 135 poison, 135 INDEX. 397 Suicide statistics, continued asphyxia, 136 drowning, 137 firearms, 137 hanging or strangulation, 137 Suppurative otitis media, 274 Syphilis, 237 Syphilis, and cirrhosis of the liver, 223 , as a cause of locomotor ataxia and general paralysis of the in- sane, 237 , certification, 237 , and softening of the brain, 271 , and general paralysis of the insane, 272 Tabulating machines, 10 Technical processes of compiling wage earners' mortality statis- tics, 8 Thrombosis, 276 Tonsillitis, 280 Tonsils, diseases of the, 280 Traumatism, by falling, 102 , by firearms, 121 , by machines, 115 Tubal gestation, 203 Tuberculosis, 43 , disability resulting from, 43 , campaign in United States, 43 , need for wage earners' mor- tality statistics of, 43 , burden upon wage earners' families, 43 , by organs or parts, 44 , among negroes, 45, 46 , type curves, 51 , in wage earners' children, 53 , in rural areas, 53 , effect of campaign against, 57 , of abdominal organs in fe- males, and ehildbearing, 168 ■ , and maternal mortality, 197 , and the pellagra' problem in the South, 250 Tuberculous meningitis, 59 Tuberculous peritonitisj 62 Tuberculous peritonitis, and "peri- tonitis," 283 Tumor, uterine, 286 Types of tuberculosis mortality curves, 51 Typhlitis, 233 Typhoid fever, 218 , in childhood, 220 , sequelEB, 222 Ulcer of the stomach, 261 Unknown causes of death, 290 Urban life, factor in wage-earners' mortality, 7, 25 Uterine tumor, 286 Uterus, cancer of the, 163 , diseases of the, 286 , abscess of the, 287 Van Buren, George H., iv Vehicles, accidents from other, 113 Venereal disease mortality, 237, 266 Verifying punched cards, 10 Vincent's angina, 280 Violent deaths, classification, 93 Visiting Nurse Service, Metropoli- tan Life Insui^iice Company, ma- ternity nursing, 213 Vital statistics of old age, 175 Wage earners' efficiency in relation to pellagra and malaria, 249, 254 Wage earners' mortality statistics, factors influencing, 25 , uses of, in public health movement, iii Wage earners' suicide problem, 132 War deaths, .classification, 93 , during 1917, 298 Wassermann reaction in locomotor ataxia, 271 White insured wage earners, mortal- ity, 3 Whooping cough, 186 , mortality among negroes, 187 WiUcox, Walter F., 157 Women in wage earners' families, mortality of, 3 Work-accidents, 123 LIBRARY OF CONGRESS II 013 738 825 A