teiVrtib^'rn r-r :* tv£\- 5sJea\tmsRr:*-v. ,rt583 .'X- -_:.r,*| ttS-K- £&r~ ARMY MEDICAL LIBRARY WASHINGTON Founded 1836 Section Number J._°..0..£L_^j#- Fobm 113c, W. D.. S. G. O. ipo 3—10543 (Revised June 13. 1936) OFFICE OF THE :£wh;crtov&ev pEtfe NwmmM^n .New York, April, Is07. My dear Doc for: * I tat lie pleasure in sending you a copy of this Book In doing so, liowever, I assume no need, of instruc- tion for any one holding the important post of Medical E.va miner to the KNICKERBOCKER. I value the work for its hints and suggestions of kuoivledge a I read y acquired. ,lnyn.™>e of us may find his way along a bei^S^M and fami/i . path, even in darkness. Still, no one objects if the icay is lighted. This Book may light your way. Favor me by its aceciij~-ai.ee, its careful perusal, and an acknowledgement of its :is j-ipt.. -..—-» .,■ Very resjteeffnl^J.. GEO. T. SHIPLEY, M. D.. ? - Consulting Physician Knhk- rboefar Life Ins. t , MEDICAL EXAMINATIONS FOR LIFE INSURANCE. BY J. ADAMS ALLEN, M. D , LL. D., Prof. Principles and Practice of Medicine and Clinical Medicine in Rush Medical College; Formerly Prof. Physiology and Pathology in the University of Michigan. SECOND EDITION---REVISED. ( (I0057V- CH ICAGO: HORTON & LEONARD, BOOK AND JOB PRINTERS, 104 & 106 Randolph Street. MDCCCL^VII. Entered according to Act of Congress, in the year 1S66, By J. ADAMS ALLEN, In the Clerk's Office of the District Court of the United States, for the Northern District of Illinois. Note Prefatory. Life Insurance is rapidly growing in public favor, and it is not avagant to say that the time is coming when it will be more gen- even than Fire Insurance. All men have lives — not all have houses, stores, or barns. The system of endowments, non-forfeiting policies, etc., has gone far toward making what before was consid- ered extra-prudential and exceptional, a matter of ordinary business caution and common usage. That the Insurance Companies and the holders of their policies should have the highest possible advantage, it is clearly necessary that none but lives selected with great care should be assured. Hence the Medical Examiner becomes their indispensable agent. To aid him in the performance of his important work, is the object of this little Manual. It is not its intention to be argumentative, statistical, or rhetorical. Neither originality in substance nor method is sought after—but only that more clearness, definiteness, and certainty may be achieved, by attention to the suggestions herein contained. A prime object has been to concentrate to the smallest possible bulk. Hence, conclusions only are given — reasons and authorities are rarely alluded to. Justice to myself compels me to add that, while the urgent press- ure of professional duties has obliged me to write during brief and scanty intervals only—nevertheless, the ideas advanced are the re- sult of matured convictions, strengthened by several thousand personal examinations of applicants for life insurance. Chicago, 1867. J. A. A. THE APPLICATION. The Medical Examiner should first read carefully, point by point, the interrogatories proposed by the Company for which he is acting, and the answers of the applicant. This will save time, and indicate those circumstances which require especial investigation. The form generally adopted, proposes twenty-five questions — twenty-three of which demand the scru- tiny of the Examiner. For the purpose of brevity, we adopt the order of the form. I. Name, Residence, and Occupation.—The name identifies. The residence will suggest at once the na- ture of the causes of the diseases prevalent, and the relative salubrity of the locality. The moist atmos- phere and variable temperature prolific of phthisis ; ochlesis, the products of animal decomposition, and foul air, fertile in typhoid fevers and cachexia:; ma- larious districts involving endemic diseases which may especially prove noxious to the party, etc., etc. The Occupation—healthful or pernicious? Sta- tistics show the relative longevity of the different occu- pations of men, but the Examiner should superadd to 4 these the inquiry: What is the probable effect upon the applicant himself?—for that which is salutiferous to one, is often prejudicial to another. Statistics establish certain general propositions, to which, it must be recollected, many exceptions can be taken. Professional Men.—Teachers exhibit the greatest longevity. Next come Clergymen, who are subject to few diseases save those incident to sedentary habits. Contrary to the vulgar opinion, they are not more liable than others to pulmonary affections. Dyspep- sia, with its incidents, is their principal affection. Lawyers rank next. Then professional Lecturers, and next, Physicians. Of the latter, it may be said, as a class, they have not the ordinary expectation of life, by from one-third to one-fifth subtraction. Nev- ertheless, the variety of exposure and habits is such that each case requires isolated investigation. Artists.— Painters and Sculptors rank among the best risks, particularly when the former sketch from nature, and the latter merely model. Portrait paint- ers, and sculptors who cut marble themselves, are not as good risks. Photographers and Daguerreotypists rank second class. Artisans and Mechanics.— Painters using lead and oil are undesirable risks, yet need not be wholly rejected. Workers in phosphorus and quicksilver stand upon the same level. Stone cutters and millers, and similar occupations, where insoluble or irritant particles find constant access to the pulmonary surface, are less desirable, but improved methods of ventila- tion, now in vogue, render them less objectionable than 5 formerly. Glass blowers are poor risks. Compos- itors in printing offices signally demand caution in acceptance. Blacksmiths, Furnacemen, Carpenters, Coopers, and Cabinet Makers range among the most healthy operatives. Shoemakers and Harness Makers, mainly from their sedentary habits, are second class risks. The same remark may be made of Tailors. Butchers and Market men, aside from the chances of accident, (to the former particularly,) are good risks. Machinists, Plumbers, Tinsmiths, Tallow Chandlers and Barbers, and similar occupations, are generally good risks. Engravers, Jewelers, and the like, are liable to the diseases of sedentary life, but are other- wise unobjectionable. Brewers, Confectioners, Dyers, Hatters, Bakers, and others whose business involves constant exposure to warm vapors, often impregnated with medicinal or poisonous substances, are not as desirable. Chemists, Assayers, Gilders, Tobacconists, etc., are liable to the same objection. Day Laborers, unless exposed to accident, are equally as good risks as mechanics. Agricultural Laborers, in salubrious localities, are the highest order of desirable applicants. The best lives, other things being equal, are those of persons engaged in out-door and yet protected em- ployments, where the occupation is somewhat seden- tary, and yet combined with a certain amount of mus- cular exercise, with pure air, and variation enough to secure a stimulating impression upon the system. Inertia, indolence, and absolute uniformity of me- teorological influences, are as prejudicial as over- exertion and atmospheric vicissitudes. 6 II. The Age.— Different ages predispose to particular diseases. So, also, hereditary diseases, according to their kind, may be outgrown, or not yet arrived at. During the period of increase, extending to about the twenty-fifth year, (varying, of course, in indi- viduals,) the tendency to disease and death is propor- tionately very great. One-tenth of all children born die the first month. In large towns, nearly one-half die before the fifth year. Respiratory and strumous diseases are especially fatal between puberty and the age of maturity — placed at twenty-five. None should be insured before puberty, except at extra rates. Between that period and maturity, the party demands especial investigation of the respiratory and glandular systems. Continued fevers, of the typhoid type, are also liable to be destructive during this pe- riod. The exanthems readily implant the germs of phthisis and other strumous disorders. Rheumatism, if it now occurs, in consequence, per- naps, of the excessive activity of the sanguineous system, is exceedingly liable to beget organic disease of the cardiac valves, with its subsequent results. From the twenty-fifth year to the thirty-fifth, or fortieth, or age of maturity, the best risks, ceteris paribus, are chosen. During this period, the applicant stands more, so to speak, on his own individuality. Hereditary predispositions affect him less, and external agencies are easiest resisted when tending to disease. The habits and external influences now require most careful survey. 7 From the fortieth year, at latest, decline commences. Hereditary diseases regain their dangerous tendency, and acute affections are met with less power of resist- ance. Yet, acute diseases of various forms are less to be dreaded than during the mobile years previous to maturity. The progress of changes in the system is slower, and the tendency is to congestions rather than inflammations ; to urinary diseases; to fatty degenera- tions ; to cardiac and other obstructions from undue deposits ; to dropsies, apoplexies, paralyses, and the like. The following table shows the expectations, or average duration of life of each individual, calculated from the Carlisle table of mortality: EXPECT- EXPECT- EXPECT- EXPECT- AGE. ATION. AGE. 18 ATION. AGE. ATION. AGE. ATION. O 38.72 42.87 35 3I.OO 52 I9.68 I 44.68 l9 42.17 36 3O.32 53 18.97 2 47.55 20 4I.46 37 29.64 54 18.28 3 49.82 21 4O.75 38 28.96 55 17.58 4 50.76 22 4O.O4 39 28.28 56 16.89 5 51.25 23 39-31 40 27.61 57 l6.2I 6 51.17 24 38-59 41 26.97 58 15-55 7 50-80 25 37.86 42 26.34 59 14.92 8 50.24 26 37-H 43 25.7I 60 H-34 9 49-57 27 36.41 44 25.O9 61 13.82 IO 48.82 28 35-69 45 24.46 62 I3-31 11 48.04 29 35.00 46 23.82 63 12.81 12 47.27 30 34-34 47 23.I7 64 12.30 l3 46.51 31 33 68 48 22.50 65 11.79 H 45-75 32 33-°3 49 2I.8I 66 11.27 15 45.00 33 32.36 5° 21.II 67 10.75 16 44.27 34 31.68 5i 2O.39 68 10.23 17 43-57 - Other tables vary this expectation from one to two per cent. 8 But it should be recollected that, in individual cases, the expectation of life may be increased by pass- ing beyond certain ages—a fact wholly ignored by the tables. Thus, for example, where there is clearly an hereditary tendency to phthisis—when parents, or brothers or sisters have died of the disease before twenty-five or thirty, and the party has lived, and is now in good health, at the age of forty, half the danger may be said to have passed; at fifty, three-fourths or four-fifths; and at sixty, but a mere modicum, re- mains—certainly not over one-fifteenth or twentieth, if, indeed, it may be said to exist beyond that of other persons without hereditary predisposition of any sort. On the contrary, the tendency to gout, urinary dis- eases, insanity, apoplexy, paralysis, etc., increases with the progress of declining years. It is safe to say that, when tables indicate a pro- gressive diminution of the life expectation, this idea should be modified and corrected by a full understand- ing of the hereditary, constitutional, or acquired tendency to, or relief from, special forms of disease. III. The Marriage Relation suggests hygienic influences so obvious that it is unnecessary to delay in its con- sideration. Married men are usually the most desira- ble risks. General statistics show that even with females, the dangers incident to maternity do not ma- terially impair the risk. A woman who has once borne a child with no extraordinary difficulty, is a 9 better risk than the primipara, and married women than those who are unfortunately single. The circum- stances of previous labors, if any have occurred, should be fully understood, and reference had, if possible, to the attending physician. In large towns and cities, applications are frequently made by those neither married nor single, for insurance. These applications are not infrequently made by "housekeepers," who, having passed the heyday of their years without physical impairment, save that which years may bring, become solicitous of providing by endowment for later old age, or else for the support of dependants. These cases are not desirable, neither is it necessary utterly to refuse them. But the most rigid investigation is requisite before they are recom- mended. IV. & V. Sobriety and Temperance—Use of Opium, etc.— The habitual drinker of alcoholic spirits, or the ha- bitual opium-eater, should, as a rule, be rejected. The inquiry proposed to the applicant will rarely secure a correct answer. Very few will voluntarily admit either intemperance, gluttony, or other generally recognized vice. The Medical Examiner is expected to guard the interests of the Company and co-insurers, by ob- serving carefully the signs of excessive stimulation, as, unfortunately, too often furnished by votaries of Alcohol, Opium, Chloroform, Ether, Cannabis Indica, and the like. The consumption of other stimulants and narcotics besides alcohol, has notably — we might IO well say enormously — increased within several years past. The alcoholic breath is readily detected, but equally clear to the educated perception is the effect of other narcotics and stimulants. Too often the applicant is induced to apply for assurance, by self- consciousness of his indulgence in some pernicious method of excitement, which he knows tends to short- en life, but which he vaguely believes he can abandon or control before it is too late. Intemperance, by which we mean not merely drunk- enness, but an inordinate, pernicious habit of stimula- tion by something, is, as likely as rheumatism, gout, insanity, or tuberculosis, to be hereditary. The family history here becomes noteworthy. A tuberculous tendency may be, to a certain extent, con- trolled by hygienic influences; among which may be numbered the use of stimulants of various kinds. The rule for the Medical Examiner is this: If the stimulant taken invigorates digestion and assimilation, then it is not cause for rejection": if it merely excites the nervous system, it is an objection to the risk. Observe —invigoration of digestion and assimilation (real power) is not to be confounded with mere in- crease of adipose tissue, which is often indicative of depression of nutritive energy. Is the party an occasional or an habitual tippler? There are some men who indulge in only an infrequent debauch, and in the interim are strictly temperate. Such a habit, if ascertained, impairs materially the risk. The habitual drunkard is well described by Dr. Brinton : " The chief characteristics one can briefly II express in words, are the fiery, unctuous skin, with its secretions reeking with volatile, fatty acids; the red and ferrety eyes, with their fitful glare, rather than gleam ; the furred tongue; the fetid breath, and the trembling limbs, that often announce the impression made by the copious habitual ingestion of alcohol on the stomach and nervous system respectively." Other suggestive appearances are afforded by sunk- en eyes surrounded by dark circles ; pallid, or even waxy complexion; moist, sticky skin; emaciation ; tremulousness of the muscles, unless rendered tem- porarily tense by a full dose of the stimulant; a ner- vous restlessness of the whole person ; often abstrac- tion of mind, etc., etc. Many times the party will ' temporarily conceal the habit, or even persuade him- self it does not exist to an injurious extent; hence the necessity for great caution. The friend's certificate here becomes indispensable, and the attending physi- cian's testimony should not be overlooked. Habitual opium-eating does not show such easiljf described and unmistakable marks, yet can rarely be concealed from an observer of ordinary sagacity, whose attention is directed to the point. Notwithstanding the singular character of the testi- mony in the Earl of Mar's case, in England, in 1832, it is safe to say that opium-eating lessens the expecta- tion of life, and is, therefore, a valid reason for de- clining the risk. Undue nervous irritability; a peculiar, shuffling gait; flabby muscles ; drooping eyebrows, with dark lower lids, while the eye itself seems to sink and grow dim ; with general marks of 12 old age ; or else, while the stimulant has full effect, excitement with brilliant eyes, but contracted pupils ; quick, restless movements ; or, sometimes, in differ- ent temperaments, general dullness, lassitude, sleepi- ness, and a relaxed skin, with sticky perspiration, and husky voice. When the applicant says he has a diar- rhoea or dysenteric difficulty which requires occasional doses of opium, when the eyes are hazy, and the tongue has a whitish coat; when there is a mucous secretion from the eyes, with frequent hawking of mucus from a flabby mucous membrane of the pharynx, and perhaps of the nose. When he is a married man, and with these symptoms, has no chil- dren, carefully observe and reject him. Much must be left to professional discretion — but cave canem. VI. Vaccinated? — A person who has never been vacci- nated or had the small pox, should not be accepted. If vaccinated, the inquiry should be: Was the vacci- nation successful ? and then, how recently was the operation performed ? A successful vaccination many years previous, is not sufficient, but if it has been fre- quently repeated without infection, the case may be deemed clear. In doubtful cases, examine the cica- trix, or re-vaccinate at once. If small pox or vario- loid has occurred, it requires especial caution as to the condition of the lungs and intestinal mucous mem- brane. The date when it occurred should be given, and the fact of perfect or imperfect recovery noted. 13 VII. & VIII. Residence in a Foreign Climate.— Without ex- act reference to isothermal lines, natives of the zone extending from the thirtieth to the fiftieth parallels of latitude, may be considered as the best risks. An ac- quaintance with the meteorological condition of par- ticular localities, is of great importance. Excessive thermometrical, barometrical and hygrometrical varia- tions, in any particular locality, usually impair risks, by rendering them subject to various diseases. Thus, moist, warm situations usually involve the malarious diseases; cold, or variable, and moist re- gions are prolific of tuberculous cachexiae; dry (yet variable in temperature) districts, render rheumatic and inflammatory diseases more dangerous. On equal parallels, the temperature of Europe is higher than that of America, and excepting the influence of the changes produced by cultivation, present the diseases of lower climates in higher latitudes. General tem- peraments are varied by persistent climatic influences. (Fid. p. 61, et se'qi) Acclimation in the South.—Whilst men, almost alone of animals, can range from the Equator to the " open Polar Sea," with apparent impunity, by observ- ing certain precautions which their reason and knowl- edge suggest, nevertheless, they subject themselves, sooner or slower, to organic changes which are termed briefly "acclimation." These changes render them less liable to the acute diseases of localities, or endemics. 14 but they are fraught with much significance to the insurance examiner. More than two thousand years ago, the naturalist Pliny noticed that " those who are seasoned can live amid pestilential diseases." The reason of this may be a matter of speculation, but of its essential truth there can be no doubt. The organic changes thus brought about express themselves in the larger phase of different races of men, begotten through the opera- tion of ages of similar influences acting on parent and progeny. Without descending to .minutiae, it may be said the Northerner going South may become, to a certain ex- tent, acclimated by physical changes in the skin, liver and spleen, especially involving their heightened ac- tivity of interstitial change, and, usually, increase in bulk. Increased activity of any organ, according to a well known natural law, involves greater tendency to disease. If, instead of more energetic action of the skin, there is less, from any temporary or permanent cause, then the mucous membrane of the intestine will be called into excessive activity, and the acute or chronic diarrhoea of tropical climates be produced. Else there are the " bloated belly, distorted features, dark yellow complexion, livid eyes and lips ; in short, all the symptoms of dropsy, jaundice and ague, united in one person." Coming North, the comparatively healthy Southron falls an easy victim to tuberculous, nephritic, and in- flammatory diseases. The rule is to observe the rela- tive activity and development of each organ or apparatus involved — whatever the cause of variation. *5 Acclimation to the so-called malarious fevers, etc., of the South, gives no immunity to yellow fever, any more than does typhoid fever from variola at the North. Yellow fever is a disease of cities and towns, epidemic usually, and requires its especial prophylaxis — not gained by any mere acclimation. As Dr. Nott emphatically writes : " The citizen of the town is fully acclimated to its atmosphere, but cannot spend a single night in the country without serious risk of life; nor can the squalid, liver-stricken countryman come into the city during the prevalence of yellow fever, without danger of dying with black vomit." The immunity from second attacks of yellow fever is nearly complete, yet the constitution is liable to permanent impairment from its ravages, and in all cases organic diseases are carefully to be looked for. The immunity from diseases prevalent in particular localities often exhibited, in exceptional cases, is due principally to two causes : First, The peculiar organi- zation of the individual himself; and, Second, The care with which he adapts his life, manners and cus- toms to his changed surroundings. As Dr. Ham- mond remarks : " For an Englishman or an Ameri- can to attempt a residence in latitude 8o° without changing his food, clothing or habits, by making them conform to the climate to which he has come, would lead to but one termination — death. But if he studies the conditions by which he is surrounded, and profits by the experience of those to whom it is nat- ural, he becomes habituated to the new order of things, and lives in health and comfort." i6 The same law holds good with reference to a change to hot climates. Hence, he who has shown, by actual experience, that he has maintained good health in either extreme of latitude, may be more safely in- sured, or, if already insured, be granted permission, more readily, to take up a Northern or Southern residence. Nearly the same law holds good with regard to yel- low fever or other epidemic disease — the best pro- phylaxis is for the individual so to shape his habits as to keep well—and he who will attempt this, is the best risk. IX. & X. Employed in the Army or Navy ? — The careful examination to which the recruit is ordinarily subjected before being mustered into the service, is a point in his favor, if he was received. Questions then arise as to the influence of the service upon him. The diseases to which he has generally been exposed are principally " typho-malarial fever," rubeola, camp diarrhoea, dysentery, rheumatism, scorbutus, pneu- monia, catarrh, cardiac changes, Bright's disease, and not least, venereal affections. An individual who has escaped permanent systemic or organic disorder, from these various causes, may generally be put down as a good risk, even though his personal or family history is not every way satisfac- tory. Nevertheless, the obscure results, often capable of discovery on rigid examination, require more than usual care, before accepting the applicant. 17 In my own experience, I have often found cardiac and renal diseases, and the secondary or tertiary forms of syphilis in returned soldiers, discoverable only after most careful scrutiny. The exposures and ex- igencies of the service involve the most potent causes of organic disease, even though the elasticity of many systems prevents immediate manifestation of striking symptoms. Previous Employments, and their Effect on Health.—The present occupation may be ordinarily innoxious, but the previous employments have left lasting traces of injurious influence. So, again, the present business may be such as to endanger the health generated by previous healthful engagements. The peculiarities of the individual here require cau- tious investigation. ( Fid. Occupation.) XI. Has the Party had any of the following Diseases? Apoplexy, Fits, Quinsy, Asthma, Fistula, Rheumatism Bronchitis, Gout, Rupture, Consumption, Insanity, Scarlet Fever, Cbolic, Liver Complaint, Spitting of Blood, Diphtheria, Paralysis, Diseases of the Urinary Disease of the Heart, Palpitation, Organs. Dropsy, Seriatim. — A party who has had a decided attack of Apoplexy should be rejected. Evident tendency thereto also should disqualify. Asthma is but a symptom — it may or may not be a cause of absolute rejection. Each case requires specific examination. i8 Observe—Asthma may occur merely from local irritants applied to the respiratory surface, and the causes of such local irritation may depend upon mere idiosyncrasy. Or it may depend upon blood poison- ing of various kinds. Thus particles of hay, soot, excessive moisture, atoms of certain gases, animal emanations, ipecacuanha and other medicinal substances are capable of producing more or less severe spas- modic asthma. Such cases, irrespective of organic lesion, do not necessarily disqualify from insurance. Some persons always have asthma in certain locali- ties—never in others. Thus C. cannot stay a single night in Ann Arbor, Mich., without a severe par- oxysm of asthma ; yet he has lived years in Detroit, only 21 miles distant, without a single attack. A., well known to me, lives in California with perfect health and freedom from the disease, whereas, in the Northern United States, he is a constant sufferer. These individual peculiarities, and the suffering they generate, are the best guarantee that the party will himself protect the interests of the Company. Nearly the same remark may be made with reference to asthma from blood poisoning—prominent among the causes of which we may mention malaria, or such other causes as promote portal venous congestion. Alcoholic stimulants, and sometimes even unexpected articles, as sugar, will occasionally produce the same result. Here the persistence of the cause must gov- ern the judgment. None of these cases wholly preclude acceptance of the risk. Again, asthma may depend upon reflex causes totall/ inde endent of permanent or ank disease. It l9 may alternate with ague, or other periodical disorders. It may depend on uterine, vesical, rectal, or even gastric disorder. It may be dependent solely on an excitable temperament and emotional influences. The gravity and permanence of the excito-motor cause here must be sought out, and only its due importance attached. But Asthma, which is the symptom of cardiac obstruction—of tuberculosis—of emphysema—of acute or chronic bronchitis — of thoracic tumors — or, perhaps, aneurism — of hepatic venous obstruction from thoracic disease, or parenchymatous change in the liver itself— or from organic cerebral or spinal change, should utterly preclude insurance. Bronchitis.—A proclivity to attacks of bronchitis should disqualify, not only from the dangers of un- complicated bronchitis, but because it is so often symptomatic of the tuberculous diathesis. Again, as indicative of nephritic, cardiac, gastric, or other dis- eases of remote organs, or those from septic causes, (typhoid, syphilis, etc.) It may be observed, how- ever, that bronchitis may, and often does, leave a condensation of a portion of the pulmonary vesicular structure, simulating tubercular deposit, and again, that it may leave behind dilatations of the tubes, which simulate very closely excavations from tuber- cular softening. Resulting emphysema should be carefully searched for, and its fallacious resonance not confounded with healthy lung-vesicular structure. Popularly, simple pharyngitis, and all slight or severe catarrhal inflammations, are merged in the general term bronchitis; so that the information conveyed bv 20 the patient's own statement is of very little practical value. Consumption.—The rule is absolute that consump- tive cases should be rejected. Physical investigation is always to be exact, for the healthiest external ap- pearance may but hide the germs of the disease. Cholic—This term indicates but a symptom, the significance of which depends solely upon its cause. Taken in its widest sense, we may say that at the present time, improved methods of diagnosis and treatment, have robbed the disease of its formerly dangerous character, and. unless proceeding from peculiar causes, it need not be considered a cause for rejection. The well known forms are the gastric, intestinal, hepatic, nephritic, and that from lead, or, perhaps, also, copper poisoning. The cholic of flat- ulency, or temporary dyspepsia, does not particularly enhance the risk — neither does the so-called bilious cholic, unless the patient is peculiarly subject to it. If, however, the latter evidently depends upon the passage of gall-stones, and frequently recurs, it is a cause for rejection. Where painter's, or other metallic cholic has occurred, it is not, alone, to be considered cause for rejection, unless it has recurred, and partic- ularly, the same occupation has been continued. The lead worker who has had this cholic, and continues in the business, should be rejected. A single attack of nephritic cholic need not reject — recurrence, even at a distant interval of time, should exclude. Many so called cases of cholic are really enteritis, and may in- dicate marasmus. The local and general evidences of 21 tuberculosis of the mesenteric glands, must be inves- tigated. Cardiac Disease.— Organic disease of the heart positively excludes. Physical diagnosis is indispensa- ble here, but it should be recollected that, as a rule, while the healthy heart may, from accidental causes, give an abnormal sound temporarily, the heart dis- eased to such an extent as to reject, can not, for any continuous period, give forth healthy sounds. Ab- normality in rhythm or impulse may depend solely upon temporary causes, and so, also, may abnormality of sound — but when these are present, the parts should always be re-examined. Variations in rhythm or impulse may be individual peculiarities, and there are evidences that varied sounds may also depend upon idiosyncrasy, but the safer rule is never to accept the party, unless the natural sounds may be heard. When, from any cause, cardiac disease has frequently occurred, and abnormalities are present, the party should be turned over to invalid companies. Dropsy.— This is another symptom which may, or may not, be of importance. If present at the time of examination, no chances should be taken, but the party advised to postpone the application. It may have been a sequence of malarious disease — as often from ague — if there be not now malarial cachexia, it is no cause of rejection — but if hepatic or splenic parenchymatous disease remain, the applicant should be rejected or postponed until that is cured. It may have been left behind by scarlatina, or other zymotic disease — if it has not recurred, and the evidence of 22 nephritic, cardiac, or other organic disease do not re- main, it is not cause for rejection. It may have resulted from peritonitis, which has been entirely re- covered from — if so, the party may be received. If from chronic peritonitis, it is cause for rejection. If it occurs from renal (Bright's) disease, from perma- nent hepatic, cardiac, or pulmonary organic affection, the party cannot be assured. The dropsy from drunkard's liver, (cirrhosis) vitiates the application. Aside from constitutional causes, the effusion into the pericardium is more grave in insurance prognosis, than that into the pleural cavity. The latter than ascites, and ascites than that into the areolar tissue, oedema, anasarca, etc. But local anasarca always ne- cessitates the greatest care, lest albuminuria be present or impending, or lest some permanent organic disease is its origin. Any constitutional cachexia, as syphilis, in connection with the dropsic-1 effusion, even though organic disease may not be discovered, precludes insurance. Diphtheria, aside from its immediate danger, may lay the foundation of tuberculosis — may be followed by albuminuria or dropsical effusions, or more or less permanent paralysis. It is not usually mentioned in the list of diseases about which the party is ques- tioned, but its grave sequelae entitle it to thorough consideration. Fistula.— Fistulae are of importance, as indicative of local or general disease, or both. Locally, they may indicate the presence of a foreign substance at the bottom, as more particularly a bit of dead bone, 23 or cartilage. In each of these instances the surgical pathology becomes the prime point of inquiry. The cause and extent of the necrosis whether of bone or cartilage. The location of the bullet, or splinter, bit of cloth, or whatever it may be. The surgical curability of the salivary, faecal, urinary, etc., false outlet, with the question of its cause. So also of the mechanical action of muscles. The import- ance of the organ reached by the fistulous opening may have much to do with the decision of the case, e. g. bone, gland. Some Life Companies vaguely in- struct their examiners that Fistulas are a positive cause of rejection. In this case Fistula in ano is, evi- dently, the difficulty intended. But whether fistula in ano should reject depends wholly upon its cause and extent. First — If it is among the signs of tuberculosis, it should certainly reject — whatever opinion may be entertained as to its hastening or retarding the tuberculous development. Second—If it has proved obstinate under correct treatment, it should disqualify. Third—If it is large, burrowing, and exhausting, it is ample cause for rejection. But if it is traceable to ulceration of the part from merely local or temporary causes, as haemorrhoids, acute dysentery, or direct mechanical injury—without evidences of the tuberculous diathesis, or remote or- ganic disease—if it has proved amenable to appropri- ate treatment, and is no longer a cause of exhaustion, it should not reject the risk. Personally, the opinion 24 of the writer is that, with the improved surgical methods of the present time, too much significance has been attached to this usually strictly local difficulty. pITS.— Under this general and vague designation, the insurance forms prominently intend Epilepsy in its various phases. When Epilepsy is clearly present, whatever its degree or frequency of manifestation, it utterly disqualifies. Not that it necessarily shortens life per se, but because even without this usual result it may impair the mental faculties, or dispose to acci- dents, which essentially impair the risk. The epilepti- form convulsions of primary dentition, and the changes incident to that epoch, if they have not man- ifested a disposition to return, or injured the mental faculties, or involved paralyses, in later life do not disqualify. The irregular muscular contractions of simple Hysteria, unless connected with organic dis- ease, or general cachexia, do not prevent acceptance. Males of nervous temperament sometimes manifest symptoms very like those of Hysteria with its queer symptoms—such cases should be carefully investigated, but these symptoms do not necessarily disqualify. Youths of both sexes about and after the age of puberty for several years may exhibit mild or severe epileptiform symptoms, or even decided periodical convulsions, yet if these either spontaneously, or under treatment subside, it may be laid down as a rule that if after several years they do not recur, the risk is a good one. The age of twenty-five in the male, and twenty-three in the female may be considered critical in this regard. *5 Chorea, in all particulars, may be regarded as identical with the "fits," of the formulary, so far as its pathology and influence upon longevity is concerned. Gout, of chronic character, and particularly, if in any degree hereditary, disqualifies. But it does not follow that all sore toes are gouty. Analysis of in- dividual cases is indispensable. The habits of life, and surroundings, will attract the attention of the examiner. The Dyspepsia and general malaise discoverable by examination are of more significance to the cautious medical agent of the Company. a Insanity does not always tend to shorten life directly, but if present disqualifies on account, first, of disease of central nervous organs which it indi- cates : and, second, because of the greater liability to accidental death which the withdrawal of healthful reason involves. It is to be distinguished from the delirium of temporary disease, and from mere eccen- tricity. Malarious diseases are not infrequently fol- lowed by an interval of insanity, sometimes of the most active character, and yet which recovered from tends not an hour to shorten life. Of this the writer's personal experience has given him abundant evidences. Such cases need not necessarily be rejected. The puerperal state often, also, involves this condition with similar prognosis ; but if puer- peral insanity have occurred, it is better not to insure unless the grand climacteric has been passed. Hered- itary insanity, and a single attack in the individual, or marked proclivity thereto, or where it is as evident 26 in the family connection as other hereditary diseases adverted to should reject. The well balanced mind cannot contemplate suicide without horror, but the evidences are abundant that oftentimes murder and suicide may be the only manifestations of the hered- itary taint of insanity, and, therefore, although preg- nant signs of mania in any of its forms may be absent, and general good health apparent, the risk should nevertheless, in such cases, be declined. Yet justice to applicants requires, when insanity is men- tioned as having occurred in the connection, that the particulars of the case be inquired into. It may occur that the instance was one from some incidental, and not hereditary cause. It may have arisen from local injury, from septic poisoning of the blood, or, per- haps, have been merely senile mental decay, etc., in either instance, not invalidating the risk. Other things being equal, the actual presence of insanity will lessen the chances of longevity to one-fifth or one-sixth the healthy standard. Liver Complaint. — Hepatic diseases are to be looked for in those who are, or have been residents of malarious districts ; in spirit drinkers ; and those of the technical bilious temperament, i. Enlargement of the liver, if from portal venous congestion, may not in- validate the risk ; if from hepatic venous congestion, it is a sign of disease pregnant with danger, and while pres- ent should absolutely reject. The hobnail or drunk- ards' liver (cirrhosis) should reject. As an isolated symptom, the contracted or small liver is more sus- picious than the enlarged one. Persistent hepatic 27 disorder, points prominently to tuberculosis, fatty degeneration, cirrhosis, or malignant diseases, either of which will disqualify. Adjacent tumors may, more or less, permanently, obstruct the passage of bile, or directly interfere with the action of the organ. Of course, these should reject. Abscesses present reject; but, if formerly existent, and now fully recovered from, are to be judged of from their causes and effect upon the system. The abscess, from local or acci- dental cause, has less significance than that from pyaemia; the latter than that from abnormal deposit, as of tubercle, cancer, etc. Recurring abscesses dis- qualify, whatever the cause. A tendency to the forma- tion of gall-stones, with ileus or jaundice, if recurrent, should be an obstacle to approval. Jaundice, while present, postpones acceptance. If dependent on hepatic venous congestion, it rejects. If it depended simply on portal congestion, as occuring in malarial or other fevers, it is comparatively trivial. Observe, it is only a symptom, and its real meaning necessitates examination and judgment. Thus it may appear as a consequence of a catarrhal condition of the bile ducts ; or as the result of impaction of gall-stone, or the mechanical pressure of tumors ; faecal accumula- tions in the colon; from lumbricoid worms in the common duct, etc. Or it may be an evidence of ma- lignant degeneration, or of permanent organic disease, as tuberculous, fibroid, fatty or amyloid degeneration, etc. From the largely more frequent causes of this symptom being temporary, and not permanent in ope- ration, the isolated symptom may be considered as 28 suggestive of investigation, and not as a reason by itself for rejection. Paralysis, whether simply local, paraplegic, or hemiplegic, demands the most scrupulous examination. Hemiplegia or paraplegia, if present, totally disqualify. But if formerly present, as clearly the result of some merely temporarily acting cause, and this cause has been entirely removed, e. g. infantile neurosis, acci- dental lesion, hysteria, etc., it may be passed over. When combined with cardiac disease, or the apoplectic diathesis, even though there be apparent health, it should reject. The import of the local cause is the important point of inquiry. Local paralysis may oc- cur from local injury, local tumor, or similar cause, and not disqualify. When present, and not clearly explicable as the result of a removable or innoxious local cause, it should reject. Palpitation of the heart is a symptom of little sig- nificance. Always noted among the list of symptoms about which the patient is questioned, it really is of no importance, save as directing attention toward or- ganic disease of the heart, or toward dyspepsia or dis- orders of innervation. Taken by itself, it is a symptom which attracts attention to its possible cause, but neither accepts nor rejects. Quinsy, or Tonsillitis. This local affection is prin- cipally important as one of the evidences of the tuber- culous diathesis. It is capable, it is true, of producing death by mechanical occlusion of the respiratory pas- sages, but this is so rare an accident that, practically, it may be neglected in calculating the chances of the 29 risk. The same remark may be made as with refer- ence to the danger of lancing the swollen tonsils. By this little operation, branches of the carotid artery may be wounded, and death result, just as death may result from choking while eating. But when the party ad- mits being subject to this difficulty, local examination should be made with the tongue spatula, or better still, the laryngoscope. Rheumatism.—Frequent and aggravated attacks of rheumatism, even though important internal organs may not have been previously involved, should dis- qualify. Hereditary rheumatism impairs the risk. It is a disease, so far as danger is concerned, character- ized by its tendency to affect particularly the white fibrous tissues. Thus, the cardiac valves, the pericar- dium, the dura mater, etc., become liable to fatal change. Uric and sulphuric acids are largely abundant in the secretions, and the blood becomes abnormally fibrinous. The real danger of this diathesis is, in the first place, from acute changes which may involve speedy dissolution, or from deposits which necessitate grave organic disease which may, later, cause sudden or gradual death. It is capable also of so exhausting the blood itself, as to render the risk a bad one, irrespective of organic change. In judging of the effects of the organic diathesis, the atmospheric vicissitudes, and the habits of life of the party must be noted ; next, the ordinary condition of the skin and kidneys ; then, most assiduously, the irritability, or actual organic change of the heart structures ; then, the continuance and frequency of return of the symptoms. 3° Most patients when questioned with regard to the presence of rheumatism, will refer to occasional pains in the muscles, or stiffness in the joints, of a quasi rheumatic character, as being true rheumatism ; the Examiner must observe that these are not intended by the question, else, no person could be considered as exempt. Acute rheumatism, or a decidedly rheu- matic diathesis, is what is to be looked after. A single attack of even inflammatory rheumatism may not disqualify, although it may have been severe. But if metastatic, it should militate against the risk. If recurrent, as well as metastatic, it should reject. If the case has been progressive, and without being metastatic, has passed on from point to point, and ultimately involved the heart, the insurance prognosis is more grave than in case of mere temporary metastasis. Mere thickening of fasciae or stiffening of the joints from long previous, but not recurrent rheumatism, need not impair the risk—neither lumbago, nor even, so-called, sciatica of a clearly chronic rheumatic origin ; but when local paralyses, or temporary or permanent symptoms of apoplexy have resulted, the risk should be rejected. Coagula may be condensed on the roughened cardiac surfaces, and their detachment from time to time determine local paralysis, apoplexiae or even mor- tification, to the extreme astonishment of the superfi- cially informed. Chronic Catarrhal Affections—sometimes paroxys- mal in character, are often of rheumatic or gouty origin, so also, sclerotitis and even meningitis and maniacal delirium. The quasi rheumatism of mala- rious districts requires particular examination, and so 31 also, those varieties resulting from gonorrhoea and syphilis — each of which may puzzle the practitioner, but must be isolated to judge of its influence upon longevity. Metastatic rheumatism rejects; syphilitic rheuma- tism rejects ; especially does recurrent rheumatism of hereditary character reject; chronic sciatica of intense character rejects — so also, does severe lumbago, tic doloureux, etc. Whenever rheumatism is acute or chronic, long continued, recurrent, hereditary or accompanied with cachexia, the insurance company must have the benefit of the doubt which naturally arises, and the party be declined. Rheumatism is liable to be confounded in diagnosis with erysipelas, gout, trichinous disease and neuralgia; especially is it liable to be mistaken for phthisis, pleurisy, etc., when occurring in the intercostal mus- cles. Scorbutic pains are very liable to be mistaken for chronic rheumatism. In prognosis, not more than one or two per cent, prove fatal, directly or remotely, and half of these of the latter result. At the present time, from improved methods of treatment, it may be confidently asserted that the disease has been robbed of half of its individual terror, and in its insurance, direct or remote, prognosis, of three-quarters of its significance. Rupture.— The frequency of Hernia in its differ- ent forms, and its inherently dangerous nature, renders this point one never to be overlooked. According to the most general statistics, hernia is to be found in an average of one to every fifteen of the adult popula- tion. It is about fourteen times more frequent in 32 males than females, although in the latter it is more dangerous, as they are more subject to the crural form, and again, because from motives of delicacy, they do not as early apply for relief. Hernia progressively diminishes in frequency from birth till puberty, and then progressingly increases with advancing age. Viz : First year— i in 21 ; second year — 1 in 29 ; third year—1 in 37 ; until at the thirteenth year it falls to 1 in 77. Shortly after this, its frequency rises again; thus, at the twenty-first year there is 1 case in 32 ; at the twenty-eighth year — 1 in 21 ; at the thirty-fifth year— 1 in 17 ; at the fortieth year— 1 in 9 ; at the fiftieth year—1 in 6; from sixty to seventy years 1 in 4; from seventy to seventy-five years—1 in 3. In women it occurs most frequently during the child bearing years. Umbilical and direct hernia are less dangerous than the inguinal or crural forms; the latter more so than the inguinal. The irreducible is more objectionable than the reducible; and always, where a truss, of suitable construction fails to prevent descent of the intestine, the risk should be rejected. Cases of double hernia should always be rejected. Observe — Occasionally parties suppose they have hernia, when there is simply an enlarged gland, or a fatty tumor, retained testis, hydrocele, etc. Accuracy of diagnosis is here indispensable to protect the rights both of the company and the applicant. Hernia, whether single or double, which has been operated upon and apparently cured, it should be remembered, is liable to recur on gradual absorption of the new formation. This fact will have weight in properly classifying the risk. 33 Scarlet Fever.— The larger proportion of cases of scarlatina occur before the insurable age. When it occurs in the adult, its secondary results demand most cautious examination. These not rarely involve breaking down of the constitution, or serious local organic changes, which imperil the risk, and this, al- though the primary attack may have been apparently mild. Taking all the cases together, the mortality from scarlatina is scarcely exceeded by that of any other single form of disease. Consumption and typhoid fever, (including typhus,) only outrank it in fatality. It is said to be even more fatal in Europe than in this country. Fatal as it is in the onset, the medical examiner has more to do with its subsequent ravages upon the system; and these, it is found, principally depend on primary obstructions to the functional action of the kidneys. Hence, uraemia, albuminuria, anasarca, dropsy, etc. Again, its local affection of the eustachian tube, and ear may ultimate in destructive caries of the bones, and eventually prove fatal by lesion of the brain. Thus a chronic ottorrhoea, originating from this cause, militates against the risk, although it may not alone positively reject. Of course albuminuria, etc., reject. If the party has had scarlet fever and fully recovered from it, the risk is improved thereby. Many of the Continental Eu- ropeans reply to the examiner that they have had scarlet fever, or that some of their family have died of it, when on careful questioning, it will be found that "maculated typhus" is the disease intended. j 34 Again, many cases of slight roseolar eruption are con- founded with it. Such cases render it necessary for interrogation to be minute and exact in all doubtful instances. Spitting of Blood.— Unexplained Hemoptysis is one of the most pitilessly exclusive of historical symptoms. Primarily, because it is one of the earliest precursors of phthisis, and, again, because it tokens its actual existence. So large is the proportion of those exhibiting this symptom whose lives, sooner or later, terminate by consumption, that it is unnecessary to argue from recorded experience, or to appeal to the abundant statistics which have accumulated. Absence of the tubercular taint in the family history, or of concurrent signs in the individual, will not explain it away. Absence of physical signs is scarcely more to be regarded, under such circumstances, than those of the rational sort. The proof must be positive that the spitting of blood came from other cause than in- cipient or present tuberculosis of the lungs. Negative evidences are in no case sufficient. It must be proved that the blood came from the gums, the nares, the pharynx, the oesophagus or stomach. Or it must be proved that it came from the accidentally abraded larynx, trachea or bronchi; or that it depended solely on mechanical or surgical injury of the vesicular lung structure ; or that it depended solely on vicarious causes. Dr. Aitken emphatically observes : " Cases are recorded of its so-called idiopathic occurrence, as from variations (suddenly) of atmospheric pressure, ascending high mountains, or descending in diving bells, violent 35 straining efforts, or from plethora ; but in such cases, according to the experience of Drs. Fuller, Walshe and others, ' there is usually some latent mischief in the chest — some local cause of pulmonary conges- tion— some mechanical interference with the capillary circulation through the lungs.'' Finally—we observe that it may depend upon disease of the heart, especially with mitral regurgitation; upon aneurism; upon intra-thoracic tumors, either malignant or non-malig- nant ; or upon non-tubercular abscesses. But, in either case, it rejects as decidedly as though dependent on tuberculosis. H