M LDiC'/Uv -i i-vOl1 LSSION .anD •■ «.■■>-' 1jj ■• 
THE MUTUAL INTEREST OF THE MEDICAL 
PROFESSION AND INSURANCE COMPA- 
NIES IN THE PROLONGATION OF LIFE.1 
BY CHARLES DENISON, A.M., M.D. 
DENVER. COLORADO. 
Professor of Diseases of the Chest and of Climatology, University of 
Denver; Ex-President of the American Climatological Association; 
Author of '-The Rocky Mountain Health Resorts,” “The Annual 
and Seasonal Climatic Charts of the United States;” etc. 
enjoy, it does not appear to have occurred to them 
to inquire how much it would have cost to stamp out 
a disease in preference to paying a bonus for those 
this given disease had slaughtered. Judging by the 
“possibilities” mentioned, the important question 
has not yet been entertained, namely, how 10 per 
cent, of health precaution and skillful, systematic 
and professional supervision of their risks might 
result in 30 to 60 per cent, pecuniary gain to the 
companies. 
However, admitting that the life insurance com- 
pany has thus far been an institution founded on 
money considerations only, we will at first strive to 
keep in the background the splendid humanitarian 
idea which underlies this present conception of its 
future possibilities. Then, when a broader and 
nobler course for the companies has been shown, 
not only to be comparatively inexpensive but very 
profitable considering the outlay, the beneficent pur- 
pose of prolonging life, the idea of benefits while 
living for the insured, as well as for his survivors 
after death, may be a substantial support to the more 
enlightened plan for life insurance’s usefulness. Let 
it be distinctly understood that this is not a plea for 
the insurance of invalid risks. However, the time 
may come when the better understanding of the 
classification and varying longevities of invalids 
may lead to a knowledge of their insurability. 'No, 
it is the care and improvement of the risks the com- 
panies have already taken which are prominent 
objects of this paper. 
There is undoubtedly a considerable mortality 
1 rate, which, because of deaths by accident or acute 
■ diseases, is diverted from the ratio that would other- 
■ wise belong to the consumptive class. Besides med- 
t ical officers are making particular efforts to shutout 
this one disease by skillful selection, and by the ex- 
’ elusion of heredity. Notwithstanding these influ- 
ences there are deaths enough among the insured 
■ from tuberculosis alone, to warrant the reform here- 
after suggested in this paper. If the other com- 
r panies were as painstaking in the compilation 
, of their mortuary statistics as the Mutual Life of 
• New York has been, they too would learn something 
i directly to the point and greatly to their benefit. 
I Namely, 1st: That, as to consumption, as early as 
, the third year of insurance the companies have prac- 
> tically lost most of the advantage of their selection of 
> risks. 2nd. That from the second to the tenth year 
i of insurance the mortality they have to pay for aver- 
5 ages 23 per cent, due to some form of tubercular dis- 
- ease. This ‘ is a fair inference from the following 
■ table, kindly furnished me by the medical depart- 
3 ment of the Mutual Life, taken from the mortuary 
> records of the company for its first thirty years of 
3 of experience: 
7 TABLE XV.—Proportion of Consumptive Mortality to Total Mortality and to 
Years of Life Exposed. 
This is a new inquiry, seeking to bring into better 
harmony and successful cooperation two great insti- 
tutions, i. e., scientific medicine and life insurance 
business. Those satisfied with what is already the 
rule will oppose with the argument, cui bonof the two 
callings are wholly distinct and entirely sufficient as 
they are. The argument is both fallacious and 
deceptive, besides being useless. 
We, the medical profession, are not and do not 
pretend to be perfect, We are simply on the road 
to perfection, constantly passing many things by the 
way with regretted and unregretted, if unknown, 
ignorance of their real nature. 
If Lawson Tait had any reason to make the state- 
ment attributed to him, that “that man would be 
rash who would make a positive diagnosis of any 
given condition within the abdominal cavity,” then 
certainly every physician must appreciate the equal 
necessity of the largest possible array of evidence of 
disease within the thorax in order to reach any pos- 
itive conclusion. Time is evidence, and memory is 
unreliable, hence the great need of the systematic 
recording of the evidence in chronic cases. A com- 
plete diagnosis may be so difficult that it requires to 
be something more than “physical,” and the physi- 
cian needs all his own intuition, historical informa- 
tion and side aids, as the microscope, to come to a 
definite conclusion. 
We know so very little of the pretubercular stage 
for instance, that indefinite, indefinable condition of 
the body solids or fluids, before the bacillus of tuber- 
cle “lives, moves and has its being.” 
And as to life insurance, it can not boast of any 
greater completeness than the medical profession, 
unless on the understanding that insurance is noth- 
ing more than taking chances on those who will die 
in favor of those who survive. Life insurance had 
practically no existence previous to 200 years ago, 
when Pascal, a Jesuit priest, being appealed to to 
divide the stakes in a game of chance, in doing so 
figured out the “doctrine of probabilities,” which 
has ever since been the basis of the life insurance 
business. But, as an institution interested in life, insur- 
ance is far from the attainment of its highest suc- 
cess. To appreciate the truth of this statement one 
has only to carefully peruse the diverse views as to 
“Modern Insurance and its Possibilities,” in the 
March number of the North American Review, by 
prominent and distinguished presidents of American 
life companies. What a splendid conception of the 
“possibilities” of life insurance these excellent gen- 
tlemen would have had if they could have seen, in 
their mind’s eyes, the harmonious picture of the com- 
ing life insurance president aiding and abetting the 
physician of the future in the prevention of disease 
and the prolongation of life! Strange as it may seem, 
in view of such well rewarded business sagacity, as 
these correspondents of the North American Review, 
Duration of 
Insurance. 
Deaths from 
Consumption. 
Percentage on 
Total Mortality. 
No. of Deaths to 10,(XX) 
Years of Life Ex- 
posed. 
1st year 
57 
10.67 
7 
2d “ .... 
117 
20.07 
17 
3d “ .... 
133 
24.19 
21 
4th “ .... 
143 
25.49 
25 
5th “ .... 
116 
23.73 
24 
6th to 10th year.. 
298 
22.70 
28 
Above 10 years.. 
168 
14.33 
23 
The above are not strained estimates, but probably 
underestimates for all companies; for that the Mu- 
1 Read before the Section of Medicine of the American Medical Asso- 
ciation, June 7, 1893, at Milwaukee, Wis. 2 
MEDICAL PROFESSION AND INSURANCE COMPANIES. 
tual Life is a carefully managed company in its 
medical department is either plainly shown by the 
following table, obtained from the same source, or 
else the more numerous consumptives among the 
beer drinking Germans hang on to life much longer, 
than the consumptives in our healthier yet faster- 
living America: 
TABLE VIII.—Showbill the Annual Number of Deaths from Consumption 
Among 10,000 Insured at Each Quinquennial Period of Life. 
PROPORTION OF DEATHS FROM CONSUMPTION TO EVERY 10,000 INSURED. 
of the applicant should be included. Then, if either 
or both are below a given fair standard, (say 25 or 
30 per cent, below) for the applicant’s height, sex, 
age, etc., the exposure of the applicant’s chest and 
the taking of the semi-circumferencial measurements 
of the two sides, should in all cases be required. Jly 
these measurements the following will be shown: 
First. If an unnatural difference in the respiration 
movements of the two sides of the thorax has to ex- 
plain, by inference, a deficient spirometrical record, 
with manometer record normal for that person, then 
surely that inference is toward fibrosis or pleuritic ad- 
hesions and perhaps latent tuberculosis. Second. If, 
with similar variation in movement, a marked defi- 
ciency in manometer record has to be explained, the 
spirometrical record being all right, then the infer- 
ence is to a positive weakness, which must influence 
the applicant’s vitality. Third. If, however, defi- 
ciency below a standard of health both in the spiro- 
metrical and manometer record of an individual, 
can or can not be accounted for in deficient move- 
ment of one or both sides, there is then a suspicion of 
weakness, to possibly elucidate which a more careful 
investigation is needed before accepting the risk. 
Gentlemen, these are new points for life insurance 
examinations which I believe I have the honor to 
present for the first time. Whether their observance 
will shut out 10 or 20 per cent, of the consumptive 
mortality, which is now borne by the companies, I 
do not know, but I am sure they will account for 
many doubtful cases not usually made plain by an 
ordinary physical examination. These rules are the 
outgrowth of my personal investigations with the 
spirometer and manometer, samples of which are 
here presented as made for me by Messrs. Truax, 
Age. • 
Mutual Life 
Insurance Co. 
12 German Life 
Insurance Co’s 
21 to 25 years 
23 
19 
20 to 30 “ 
23 
39 
31 to 35 “ 
22 
42 
36 to 40 “ 
17 
37 
41 to 45 “ 
17 
30 
46 to 50 “ 
16 
38 
51 to 55 “ 
15 
35 
56 to 60 “ 
16 
32 
61 and upwards 
18 
32 
All ages 
18.6 
35.7 
Note.—It should be borne In mind that the above table is influenced 
by the younger life which obtains in a company’s experience during the 
first 30 years of its existence. 
What, is needed is a similar computation up to date 
of the mortality experience of all the companies, not 
only like the above two tables, but also another giving 
the ratio of deaths in this class to all deaths for each 
year's age of policy. 
Then in comparison with general mortality sta- 
tistics, obtained without reference to insurance, the 
companies would know two important facts; first, 
the quality of work their agents and physicians are 
doing for them; second, the great importance and 
tremendous expense of the consumptive class on their 
lists. They would incidentally learn the great value 
to the companies of climatic change and close super- 
vision or individualization in these cases. This 
needed list should comprise deaths from consump- 
tion, fibroid phthisis, chronic pneumonia, chronic 
pleurisy and bronchitis, tuberculosis, asthma, scrof- 
ula, “wasting” etc. My experience, in an effort to get 
these data from the companies, is that they haven’t 
them, or if they have they are not of such a nature as 
to be given to the public. Of course we must admit 
a certain untrustworthiness of mortality statistics, 
the insidious and usually complicated existence of 
tuberculosis furnishing one excuse for a flexible esti- 
mate, but broadly it can be stated that the cost in 
death losses paid by life companies, in the past fifty 
years, has been between $350,000,000 and $600,000,000. 
In view of the importance of this consumptive 
class to the company’s welfare, and the, to me, 
undoubted fact that latent tuberculosis is at the 
bottom of more failures in health than that subtle 
condition ever was credited with, I recommend to 
medical directors of life insurance more exact and 
systematic safeguards against the entrance of such 
impaired lives on an equal footing with selected 
healthy risks. There is not time and so it is not 
here my purpose to fully discuss the intimate rela- 
tions which should always exist between the medical 
director and the medical examiner of a life insur- 
ance company. The confidence which is reposed in 
these two by the unprofessional officials of the com- 
pany is as yet insufficient to offset the excessive in- 
terest the agent has to insure anybody regardless of 
risk, or the desire of many applicants to be rated 
higher than their physical condition fairly warrants. 
In a carefully constructed entrance examination 
paper, among the physical conditions required to be 
stated, I think the spirometrical and manometer record 
In the winter and spring of 1873, when, after pul- 
monary hemorrhages, night sweats, etc., I was myself 
health seeking in San Antonio, Texas, I met Dr. M. 
Slocum, a physician whose experience so well illus- 
trates a plan I had already conceived that I will here 
relate his case : Some sixteen years before this time 
of my meeting Dr. Slocum he found himself a health MEDipAL PROFESSION AND INSURANCE COMPANIES. 
3 
seeker in San Antonio, Texas, two years after his 
wife had died of consumption in New Orleans. For 
her health he had moved from the North to the 
South. Whether his was a case of infection or not 
I am not certain; but he was really in a serious 
condition, emaciated and having several hemor- 
rhages in the streets of San Antonio, excited even 
by the effort of walking a block. He was also broken 
in finances, and naturally thought of utilizing the 
then present value, to the company carrying it, of his 
life insurance. Pie had a $5,000 policy on his own 
life in his wife’s favor. I believe this was either in 
much good thus came to this man, why not to all in- 
sured under similar circumstances? Might I not have 
been insured myself, and the medical fraternity of my 
then home, Hartford, Conn., justly conclude that a 
hundred, such as I then was, would average to live not 
over three years, i. e., to remain in the Connecticut 
valley. Now, twenty years afterward, when a policy 
on my life would have more than trippled itself in 
value, I survive and am permitted to disturb the con- 
tented insurance man with these vexing conundrums ! 
The country of southwestern Texas, New Mexico, 
Arizona, Southern California and Colorado is full of 
illustrations of this kind, so that it would be possible 
to assert with approximate accuracy, that classes of 
tubercular invalids who would have averaged to live 
two to four years, in their Eastern homes, have al- 
ready lived from five to fifteen years in their newly 
chosen residences. The significance of this is plain 
enough when one considers that a prolongation of 
life nine years for a man of forty, doubles the value 
of his policy to the company holding it, through the 
incoming premiums and the use of the money which 
would otherwise have been paid out because of his 
death. 
Twenty years ago I hoped to be able to present the 
exact data that would serve as a basis of this life 
prolongation, i. e., a classified table of climates and 
classes of invalids, together with the different longev- 
ities of these invalids, residing thereafter in the 
several climates. But over 3,000 physicians, care- 
fully selected by prominent medical friends to repre- 
sent the whole United States and Canada, to whom 
my circular of inquiries was then sent, had not the 
requisite uniformity of mental training, nor habits 
of studying or recording disease, to make their com- 
bined replies of real value. There was not then, and 
there is not yet among medical men, enough system 
of disease investigation nor uniform expertness in 
diagnosis to formulate a table of disease longevities. 
There is knowledge enough of both climate and con- 
sumption within the great body of medical men, but 
it is so often nullified by individual peculiarities, 
experiences and environment, that collectively it is 
practically valueless. Success must come largely 
from individual effort and proficiency. This conclu- 
sion brings us to the most important and final part 
of my paper. The remedy for professional incom- 
petency lies in some appropriate system, and a better 
familiarity with every diagnostic means. The sys- 
tem which I here present may not be the one in all 
its features which will be eventually endorsed by the 
medical profession as the best, but it is very much 
better than none at all. 
“ The Chest Diagnosis Chart and aid to climate 
selection,” which is the main feature of this plan is 
the outgrowth of much study. By a two years’ use 
it has enlisted my confidence. It tends to avoid the 
omission of any important part of a critical clinical 
or physical examination. It stimulates accuracy in 
defining and graphically illustrating thoracic disease. 
It favors an earlier detection of enfeebled or diseased 
states, through this accurate association of changed 
physical conditions. It refreshes and strengthens 
the memory as to previous investigations of a given 
case. The chart has been submitted for criticism 
and correction to some of the leading physicians in 
the United States, and very generally received their 
approval. The severest criticism is thought, by two 
distinguished physicians, to be the great difficulty in 
a New York or New England company. Three of 
the best physicians in San Antonio critically exam- 
ined him and made a written report of the facts, 
recommending to the company to pay Slocum at least 
50 per cent, of his policy for its surrender. The 
company sought to parley with their man, and of- 
fered him $1,500. That was worth a thousand times 
as much to him living as to him dead, and he accepted 
the offer quickly, the more so as the indications were 
even then apparent of a disruption between the North 
and the South. He took this money and resolved 
that he would not go inside a house for six months, 
and kept his resolve. My oldest brother, then a res- 
ident of San Antonio, used to go out to Slocum’s tent 
on the prairie to play chess with him under the mes- 
quite bushes. Well, sixteen years afterward, when 
I met the doctor, he was clerk and recorder of Bexar 
county, a hale and hearty man of 160 lbs. weight, 
though his voice was yet husky and he relied consid- 
erably on stimulants. 
It can almost truthfully be said it is not consump- 
tion that kills, but worry. The money the life insur- 
ance company sent saved that man’s life. The offi- 
cers of the company made a good bargain, and they 
need not reproach themselves because they did not 
hold on to that policy in order to save the over 
$20,000 which, in value to them, it would have 
amounted to if it had been kept in full force up to 
the time Dr. Slocum eventually died, about twenty- 
five years from the time the company made the set- 
tlement with him. 
Was it not perfectly natural for me to ask, if this 4 
MEDICAL PROFESSION AND INSURANCE COMPANIES. 
getting the ordinary physician to go into the amount 
of detail required to properly fill out the document, 
and also his natural hesitancy to make any kind of 
an exact statement as to internal chest conditions. 
If this criticism is just, it is one of the greatest com- 
mendations the chart could receive. Accuracy and 
truth can nowhere be of more value than in regard 
to diseased conditions within the human body, and 
that means, be it a diagnosis chart or a professor of 
physical diagnosis in a medical school, which will 
teach the ordinary physician to knoiv xchat he says 
and say what he knows, is a great blessing to humanity. 
Let it be understood, if you like, that the practice 
of such innovations will hardly be established among 
the older men in the profession, who are almost un- 
changeably fixed in their ways of investigating and 
combating disease. It is the younger men in the 
profession whom I hope to gain as friends and cola- 
borers in this new field. I would that every teacher 
of physical diagnosis in the land would do with their 
students as I have and shall hereafter do with mine; 
namely, drill them in this system of clinical research 
and physical diagnosis, and present them with copies 
enough of some such a chart as this that they will 
get into correct habits of recording their chronic 
cases at the start of their professional career. As to 
the too little interest among physicians to attend to 
the required detail, a knowledge on the part of the 
public of the benefits to result will bring a healthful 
demand for such services. However trivial, prolix 
or exacting an ordinary life insurance examination 
may be, the details are all attended to before the 
application is considered complete. This influence 
in favor of accuracy as to detail gives me the 
strongest hope for the chart’s utility. What a won- 
derful educator of the medical profession such an 
agency would be,if adopted and generally utilized by 
all the great life insurance companies! All this 
increase of labor on the part of medical men would 
be in the direction of greater proficiency in the diag- 
nosis and description of disease. Besides it would 
be productive of more uniform and correct informa- 
tion of the healing effects of different climates than 
obtains at present. 
The chart is here presented for your inspection, 
with the directions for its ordinary and special uses 
printed on the first page. Besides its use for pre- 
serving a record in chronic pulmonary cases, direc- 
tions are given for carrying on a consultation between 
widely separated physicians, and for an intelligent 
inquiry as to the suitableness of a given climatic 
change, before a suspected or known invalid under- 
takes a journey to a distant health resort. The plan 
I should like to see the life insurance companies 
adopt, and one I am sure they could afford to carry out 
with great credit and profit to themselves,is as follows : 
Each company uses its own force of selected med- 
ical examiners, or if preferred designates a smaller 
force of physicians, skilled in physical diagnosis, to 
represent the principal centers where their policy- 
holders reside. Besides these they designate their 
own expert referee physician or physicians; perhaps one 
specially skilled in the climatic treatment of respir- 
atory diseases—at the headquarters of the company 
or elsewhere—or several such representing most 
prominent health sections of the country. The com- 
pany then notifies all its policyholders that under 
specified premonitor3T or actual symptoms of disease, 
such as pulmonary hemorrhage, night sweats, pro- 
gressive wasting of flesh, etc., they will send the 
chest diagnosis chart, have a critical inquiry made 
by their chosen local and referee physicians and re- 
turn the written report and advice of these physicians 
for the policyholders’ benefit and final decision. The 
company may do less, or even more than this much. 
One physician suggests that the company should have 
a reexamination of all their insured at stated periods ; 
another that all impaired lives only need be so reex- 
amined. The company, however, could well afford to 
promise to loan the insured a given per cent, (based 
on his disability), of the amount named in his 
policy at a small rate of interest, in case this aid was 
needed to help bear the expense of the advised change 
of climate or occupation. The applicant, with all 
these benefits so well and gratuitously furnished 
him, should not and probably would not refuse to 
obey the proffered advice. The company would reap 
the reward in the resulting prolongation of life. 
This return would be great for the outlay, accordiug 
to how early in chronic lung affections the needed 
change would be inaugurated. The longer it is be- 
fore the breaking down of lung tissue, the better. 
Hence the great advantage of an early inquiry like 
the one here proposed. If, as statistics prove that 
there are over 100,000 who die annually of consump- 
tion in the United States, and 200,000 who are already 
more or less affected for every 100,000 who die, the 
proposition is how to reach the new cases so that 
they will average eight to ten years of life thereafter, 
instead of only two. 
The whole matter is now presented in a form 
which, I trust, will meet your approval, and coming 
to public light through you, representative men of 
the medical profession, is freely and unreservedly 
given, with the hope that this method of recording 
cases, and this beneficent plan for life companies, 
will receive your hearty endorsement. 
In conclusion, I crave your indulgence for this 
fragmentary treatment of so many questions, each 
of which is of importance enough for a separate 
thesis. This method of presentation seemed to be 
warranted by the mutual interdependence of these 
various interests. 
I shall be gratified if even this much shall prove 
a help to those who will hereafter take up the work 
and more completely present and elaborate the dif- 
ferent phases of this important subject. 
[After the reading of the above, a committee of the Sec- 
tion of Medicine was proposed to "consider the suggestions 
embodied in the essay.” This committee reported : 
“That the adoption by the medical profession of a definite 
and comprehensive plan of recording, with explicit and 
accurate statement, the results of examinations of persons 
affected with chronic pulmonary disease, as proposed by 
Dr. Denison, is a consummation earnestly to be desired, 
encouraged and hoped for, since it would be conducive to 
the early recognition and to the prompt and effective treat- 
ment of such disease, and to a correct appreciation of its 
course and tendencies, besides affording the best possible 
basis of consultation between widely separated physicians.” 
The financial features, as to life insurance companies 
undertaking to aid their consumptive insured to seasonably 
profit by climatic change, etc., were advised “to be referred 
for their advancement to the physicians connected with 
each insurance company.”! THE CHEST DIAGNOSIS CHART. 
AND AID TO CLIMATE SELECTION. 
By Charles Denison, A. M., M. D., Denver, Colorado, Professor of Diseases of the Chest, and of Climatology, University of Denver, Author of “The Rocky Mountain Health Resorts/' 
“The Annual and Seasonal Climatic Maps of the United States/' Etc. 
The objects of this examination record are, first and chiefly—To afford tho physician a suitable means of preserving the ex- 
act data of liis examinations in chronic pulmonary cases, and incidentally to foster among physicians the habit of accurateness and 
tnoroughness in physical diagnosis. 
Second—To furnish a basis of intelligent correspondence between widely separated physicians when a consultation is desired. 
Third—To insure success and prevent useless expenditure on the part of invalids journeying for health, by intelligently canvass- 
ing tho whole subject beforehand by means of this chart, which is meant to be a physical photograph of a patient’s real condition, presented 
for tho judgment of a physician expert in such matters. 
Fourth—To present to Life Insurance and Beneficiary Associations a means for the early detection of respiratory and other 
associated diseases largely controlled by climate and a basis for the prolongation of these lives at a time when a more or less complete 
restoration to health is quite possible. 
That is, to furnish a critical inquiry—(a) By a competent Examining Physician at or near the patients home, (b) By a Micro= 
scopist, if the sputum is to be stained and examined, (c) By a Referee or Consulting Physician in a distant city or health resort. 
While no restrictions are placed on the use of this chart or system by any invalid, yet the family physician is most likely to first con- 
ceive the idea of a necessary change: therefore, if tho attending or family physician makes the first examination, it is preferrable that the 
choice of Referee Physician, and the final acceptance of the plan proposed, be largely left to him. The Referee Physician, returns to the 
home physician (or to the patient, if so desired) his own written opinion, answers to questions, advice about living expenses, and such ad- 
ditional information, or published documents, (about climate, diet, exorcise, etc.) as he thinks needed, and also if requested, this chart. 
Then the enquirer has all the available facts before him for his study, and for his own or his doctor’s conclusions. 
Additional Inquiries and Explanations. 
(To be filled out by the patient or first examiner.) 
The financial question—An important consideration is the ability of the enquirer to follow the advice which may be given. Under 
which head (1, 2, 3 or 4) is the patient to be classed? 
1. Financially fully able and willing to live as required and devote himself to getting well, 
2. Do what ever is best at moderate expense for one year or 
3. After four months or sooner, if physically able, will be compelled to take up occupation. What 
outdoor work would he bo willing to substitute? 
4. Has no money and would be compelled immediately to depend upon his trade, herein stated, or upon 
for a livelihood. 
If tho patient prefers, he, or his physician for him, can state his preference as to the climatic change to be made, giving his reason 
therefore, whether financial, social, business or pleasure. 
The life insurance problem, if it is to be considered, requires—1. Does the patient desire the insurance company interested 
in his longevity to investigate the needs of his case, and docs he intend, as nearly as possible, to abide by tho decision reached? 
2. In what company or companies is the patient insured, giving age of policies and amounts?. 
3. Would tho financial aid of a loan secured by this insurance be nooded in order to carry out any recommended trial or adoption 
of a now climate or chango of life from that existing at present? 
The examination fees—In the original examination the fee for such a critical diagnosis should be ~5 to $10 or more, according’ to the custom of the exam- 
iner in such cases; depending also upon whether or not a microscopic examination of the sputum is made. The final consultation fee, if the Referee Physician 
gives a full written report of his own opinion, etc., should also be $10, which should accompany the request for consultation. Where, because of the limited cir- 
cumstances of the applicant, the first examiner so requests, the fee of the Referee Physician may be considered as $5, as also when only the decision of a single 
question is desired not involving a consultant’s usual responsibilities, 
lCopyrighted by the Author.] put>lishesd and for sale by Chas. Truax, Greene & Co., Chicago. Price, $1.00 per 100; $4.00 per 500; $7.50 per 1,000.] THE CHART. 
Note—In answering, those portions printed in light type cnn be written over; nnd all conditions nre to be considered ns Normal which nro not otherwise) specified, crelsew 
in the chart shown to bo disoused. 
Examination mado by Dr P. O. Address, 1S!)._ 
Patient’s name? Present address Former residence? 
Age? Occupation?.. Married or single? Height, ft? In? 
Inheritance to Consumption or what chronic ailment? 
Does patient resemble father or mother more? Exposuro to infection, explain if any probable? 
Condition of health or life previous to present illness? 
FAMILY HISTORY. 
Commencement, date and cause? 
Times of severe sickness since then? - 
JT “ " ------------------------ 
First appearance of night sweats when? Blood spitting? Profuse yellow expectoration?. 
(2 to 4 ounces in 24 hours.) 
After occurrence of night sweats, when? Blood spitting? Profuse yellow expectoration? 
When, if at all, did dyspnoea commence? - 
Weight (pounds) in health, at best, when was it? At least since sickness, when? Now? 
COURSE OF DISEASE. 
PAST CLIMATIC EFFECT. 
Changes in Residence since sickness and what periods? 
Effect of such change or treatment? 
Has health been better winters or summers? — 
Any experince in high altitudes? — 
Accustomed to what systematic exercise? 
Sputum—Color? Approximate quantity per diem in ounces? — - Bacilli present? 
When examined and by whom? Skin moist, dry or sallow?.* 
Afternoon Hectic? Cough? Pain, whore? Hands or feet cold? 
Bowels formerly? Now? Hemorrhoids or any rectal trouble? 
Patient’s habits. Smokes? Chews? ... Use of stimulants? Can walk how far without resting? 
Appetite? Digestion? Any previous avoidance of fatty food?.. Sleep? 
Pulse, sitting? Respiration Temperature, F? Time of day? What daily range if known?.: 
Spirometrical record, cu. in? Manometer M. M.? - 
Complications? Nervous state? Kidneys and bladder? Liver? 
Women—Menses? Childbearing? Female disease, etc.? 
(Any history of rheumatism, constitutional taint, glands enlarged or ulcerated, skin disease, or unusual drain on patient, s vitality, as pre- 
vious sexual excesses, explained here or by separate letter as desired.) 
I - 
PRESENT SYMPTOMS. 
Nose and Throat.—Describe, if they exist, any obstruction to nasal breathing and the cause? 
Any Rhinitis? Otitis? —- Pharyngitis?.... 
Laryngitis?! - Aphonia? Hoarseness? — 
Locality and extent of any ulcers, tubercular or adenoid growths, etc PHYSICAL EXAMINATION. 
(Made on bare chest.) 
Inspection—Emaciation? Irregularities? Depression? Clubbed fingers?--, 
Mensuration—Circumference inspiration in inches? Expiration? 1 - 
Movement—Measure of two sides—Right, inspiration? Expiration? Left, insp? Exp? 
Heart—Normal? Murmurs? Size? - 
Lungs and Pleura. —Percussion, stethoscopic percussion and auscultation? 
Draw lines from signs named to diseased areas, or indicate by marking these abbreviation letters over the diseased spots or at the ends of lines drawn outward 
from them. Also encircle excavations—approximate size.) 
Vocal Fremitus increased—F. I. 
Vocal Fremitus diminished—F. D. 
Vocal Fremitus absent—F. A. 
Dullness, slight—D. 
Dullness, decided—D. D. 
Flatness—F. 
Tympanitic Reso- 
nance—T. R. 
“Cracked metal” 
on stetlioscopic 
percussion—C. M. 
Hollow sound on 
same—H. S, 
Cavity—0. 
Honey-combed— 
H. 0. 
Bronchiectasis— 
Br. 
Pleuritic Friction 
-P. F 
Pleuritic Adhesion 
-Ad. 
Pleuritic Eilusion 
-Ef. 
Retraction of Intercostal 
spuces—It. I. 
Apex Beat—X 
Succession—S. 
Does coughing bring out 
rales not otherwise heard 
and where Y 
Are they superficial or 
deep-seated t 
V. S.—Vesicular suppressed. 
B.—Bronchial respiration, 
B. V.—Broncho-Vesicular. 
P. Ex.—Prolonged Expi- 
ration. 
B. Ex.—Blowing Expira- 
tion. 
O. B.—Cavernous 
Breathing. 
0. W. It.—Cogged- 
wheel ltespira- 
tion. 
M, R.—Mucous 
Rales. 
Q. Gurgles. 
O. R.—Crepitant 
Rales. 
S.C.R.—Sub-Cre- 
pitant Rales. 
Sib. It.—Sibilant 
Rales. 
So, It.—Sonorous Rules. 
W. Ex.—Whisper Exagger- 
ated. 
V. B.—Voice Bronchofonic. 
Pq.—Pectoriloquy. 
C.V.—Cavernous Voice. 
(Draw lines to any uumen- 
tioned condition from ex- 
planations to be added above 
or below these diagrams.) 
Diagnosis:. 
Treatment, climatic change recommended, etc.