\ i->y- . i'^j^LM'' CHICAGO: J. H. and C. M. GOODSELL, Publishers of The Spectator. 1869. Entered according to Act of Congress, in the year 1866, By J ADAMS ALLEN, In the Clerk's Office of the District Court of the United States, for the Northern District of Illinois. Horto.v & Leonard, printers, Chicago, III. Preface to the Fifth Edition. The exhaustion of four editions of this brief manual within a few months, sufficiently demonstrates the want which has been felt for some work of the character. The Author tenders his sincere acknowl- edgements for the kindly terms in which many of the most distin- guished Medical Examiners throughout the country have been pleased to welcome its publication. He is fully sensible of the difficulties necessarily incident to the effort to take an intermediate course be- tween the voluminous and elaborate treatise and the mere tractate. This little book is published as a chart, and not as an exhaustive volume. The effort has been to bring fairly before the Medical Examiner the salient points of his business, in as concise a form as perspicuity would possibly permit. In the present edition there has been but little change, save in the addition of an Appendix containing matter, which, it is believed, will add considerably to the value of the work, and also an Intro- ductory Chapter, calling the especial attention of Examiners to th" importance of the relations they sustain to their respective Companies; to the parties examined, and to the profession. Attention is called to the Index of the Appendix, on page 169, which indicates the general character of the additions made. The contained tables are, believed to be valuable. iv In the preparation of these additions, the Author begs leave to acknowledge the important services of I. N. Danforth, M. D., of this city—not only a medical examiner of large experience, but an accomplished professional scholar and writer. Under the pressure of his own multitudinous affairs, the Author has delayed publication of a new edition until the previous one was long out of print. Advantage has been taken of this delay to seek for the opinions and suggestions of professional Life Insurance men, both lay and professional. These have been regarded in this edition, so far as they have appeared correct and feasible. In order not to make the volume too bulky, the Appendix and Introductory chapters have been given in smaller type than used in the text. J. A. A. INTRODUCTION. It is now about one hundred and fifty years since life insurance first established itself on anything like an enduring basis. Com- mencing with the " Amicable Society," of London, it has steadily grown in public favor, until, at the present day, no form of investment is regarded with greater favor, by even the shrewdest and most sagacious business men, than the stocks of life insurance companies, and policies of insurance on their own lives. At every step of its progress, this noble institution has sought the aid and counsel of the medical profession. It has its very basis and foundation, in fact, in the established laws of mortality, as carefully and patiently worked out by medical men. The first life company was only started after Dr. Halley, of London, had made that series of observations regard- ing the duration of human life, out of which grew the " Breslau table of mortality." Every important step in life insurance has been preceded by a pioneer corps of physicians, who have carefully marked out the way; and, in no single instance, has future experience proved the falsity or unreliability of their conclusions. If all this be true, it follows that the relations of the medical profession to the interests of life insurance are vastly important; and that they are certainly quite as important to the insured party, as to the company insuring. For our present purposes, it will be conven- ient to consider the relations of Medical Examiners to life insurance, and life insurance interests, under three heads, to-wit: Their relations to the companies employing them, or to the companies' agents. Secondly, to applicants, or parties seeking insurance ; and thirdly, to the medical profession. vi First: their relations to companies, or agents of companies. It is scarcely too much to say that the ultimate safety and stability of every life insurance company rests in the hands of those who decide upon the character of its risks: for, however great may be its resources, or with however much of financial skill and sagacity its affairs may be managed, or however many or perfect may be its " tables of mortality," it is absolutely certain to come to a disastrous end, unless its risks are selected with care and discrimination. And so many, and so insidious are the diseases whereof the end is only too cer- tainly fatal, that this can only be done by the skilled and experienced Physician. To render the office of Medical Examiner to the greatest degree useful, three things seem to the writer absolutely essential: (ist) That the best talent be secured. (2d) That perfect harmony be maintained between the Examiner and the company's representative or agent. (3d) That the Examiner be appointed from the central office : that he be recognized as an officer de facto of the company, independent, and therefore self-reliant, in his sphere ; and responsible for the proper management of the interests committed to his charge. (ist.) It is an absolute and palpable wrong'for any company to appoint as its Examiners men deficient in knowledge, in high-toned honesty, in devotion to the interests of their profession, or men who are wanting in that practical wisdom which can only be acquired by actual experience. It is wrong, in that it must, to a greater or less extent, militate against, rather than contribute to, the safety of the company ; it is wrong, in that it needlessly places in jeopardy the interests of those who are entirely unable to protect themselves, namely, the policy-holders, or those who are dependent upon them ; and lastly, it is wrong, in that it must inevitably bring undeserved odium and disgrace upon the medical profession. Notwithstanding the hordes of quacks and charlatans which infest every community, competent and faithful Medical Examiners can almost everywhere be found; but while the former are forever seeking appointments, the latter must generally be sought 5 the former are only too apt to foist their services upon the unwary agent; the latter very properly regard their services as worth seeking, if worth having. Every Vll company ought to be held to a stern and rigid accountability for the character and ability of its Examiners ; it is the custodian of vastly important interests, which, from the very nature of the case, cannot be looked after by those most interested in its integrity. Its policy- holders are scattered over every State in the Union, and they, as well as the Examiners upon whose recommendation they are accepted, must of necessity be entire strangers to the Managers and Consulting Physician. But these facts furnish not the least excuse for appointing —or at all events, for retaining incompetent Examiners ; rather do they render it more imperatively the duty of those selecting them, to exercise the greatest care in obtaining honest and skilled physicians to fulfill this most important trust ; and, so perfect and complete are the means for acquiring information at the present day, that no company can plead ignorance regarding the qualifications of its Examiners, and at the same time, maintain a creditable reputation for shrewdness and good management. (2d.) Unless perfect harmony be maintained between the Exam- iner and the Agent under whom he is acting, the company's interests must necessarily suffer. The former is not unfrequently compelled to reject risks upon which the latter has expended no inconsiderable amount of time and labor, and which, in case of rejection, must go for nothing. Moreover, applicants are often rejected for reasons which are only apparent to the Examiner ; and, to the uneducated ear, or unskilled touch of the Agent, this seems an unwarranted stretch of power on the part of the former. With the Agent it is a question of commissions-, with the Examiner it is a question of safety; and these two interests sometimes stand diametrically opposed to each other. But it is for precisely this reason that the Medical Examiner is employed at all; and, unless he resolutely stands, like an alert and faithful sentinel, between the company on the one hand, and the unsafe and undesirable applicant seeking admission thereto on the other, he signally fails of fulfilling his obligations to the former, and renders his office not only useless, but positively harm- ful. This ctmrse, however, although exceedingly desirable and important so far as the company is concerned, must of course some- times array him in direct opposition to the pecuniary interests of the Vlll Agent. But with this the Examiner must and can have nothing to do ; it is no concern of his whether the Agent is remunerated by stated commissions or a regular salary : he has only to do with the safety or unsafety of the risk ; and, while he must disregard all else but this, he must, at. the same time, maintain harmonious relations with the Agent. We propose to indicate, in the next place, how, in our judgment, this can best be done. (3d.) The Medical Examiner, at least in every situation involving any considerable number of examinations, and especially in the large cities and populous towns, where almost every applicant is more tnan likely to be an absolute stranger to both Agent and Examiner, should be appointed by the authorities at the home office, after they shall have satisfied themselves that he is precisely the man for the place, and unless they are well convinced of this, he should be dismissed and another and more satisfactory appointment should be made. Whatever may be the actual merit of the Examiner, unless he is fortunate enough to possess the entire confidence of the Managers— especially the Consulting Physician—at the central office, he cannot resign too soon. For, unless the central authorities implicitly confide in him, it will be impossible for the Local Agent to respect either him or his decisions in regard to applicants—especially if they happen, as they sometimes must, to be adverse to the interests of the Agent. For this reason, the Examiner should stand in the attitude of an officer, recognized as such by the company ; his department should stand by itself, subject only to the control of, and responsible only to, the home office. He should not be a mere " tenant at will," subject to ejectment at the pleasure or caprice of the Agent; for such an equivocal position would be derogatory, not to the man only, but to the position he vainly attempted to fill. The general adoption of this course on the part of the companies, will most certainly enable them to secure and permanently retain the best medical talent, and also insure harmonious action between the Agent and Examiner— both of which conditions are exceedingly important and desirable. Secondly: The relations of Examiners to parties seekijig assurance. The Examiner is of course bound to consider the interests of the company by whom he is employed and paid, as paramount to all ix others ; else would he absolutely endanger, rather than contribute to the company's safety and stability. But while this is undenia- bly true, it is also true that the applicant has claims which he cannot properly disregard. Life insurance has now become some- thing more than a mere privilege; it has come to be almost a sacred and "inalienable" right to every person who is eligible there- to ; and no applicant should be lightly or needlessly rejected. Every applicant coming before the Examiner is entitled to a fair and impar- tial examination; if obscure or unusual symptoms present themselves, he is fairly entitled to a second examination, or even more than that if necessary to a proper understanding of the case. Frequently does it happen that some apparently grave symptom depends upon a merely temporary cause ; for example, applicants in perfect health some- times present themselves with an unusually rapid pulse, or with the respiration unaccountably frequent, or with the countenance flushed and excited — and all this may be the consequence of excitement or perhaps fear ; for, to very many people, a Physician's office is as terrible as the dungeons of the Inquisition ; and the very best insur- ance risks are those who are least familiar with the sanctums of Doctors, and therefore most likely to give full scope to their imagina- tions. Individual peculiarities or " idiosyncracies " are sometimes met with, which, though generally indicative of some grave and per- haps incurable disease, are quite normal as regards the persons pre- senting them; these exceptional cases demand a fair hearing at the hands of the Examiner ; though it must be admitted, as a general rule, that absolute strangers, presenting symptoms which are ordina- rily associated with organic disease of any important organ, must be rejected, even though they may be in other respects desirable. In making examinations preliminary to life insurance as well as in all other investigations of this character, the Physician is likely to become acquainted with matters of a strictly confidential nature, which if divulged, might prove seriously detrimental to the party. The same standard of high-toned professional honor should guide the Examiner in his relations to applicants for life insurance, as he feels constantly bound to observe in his relations to patients under his care ; no excuse can be found for disregarding this matter in the one X case, that will not apply with equal force to the other, except, of course, that the Examiner is bound to disclose to the Consulting Physician all facts essential to a correct understanding of the case. Finally, the Examiner should not forget that, however unimportant it mav be to him, individually, whether an applicant be accepted or rejected, it may be and often is a matter of vast importance to the latter. Many a man turns to life insurance as the only means by which he can provide for the necessities of those he expects to leave behind him, when he shall have passed away ; many an unfortunate man, whose life may have been one constant struggle with adversity, sees in a policy of insurance the only means by which he can protect his family from actual want, after he has ceased to live. Such cases must not be lightly rejected; they are always entitled to a careful and candid examination, made under circumstances which are not unfavor- able to the applicant ; symptoms which are merely the result of trepidation or of the excitement of the occasion, should be cleared up, and, in all regards, the examiner should give the applicant a fair and impartial hearing, with the fixed resolution of rendering a decision which shall be just to both parties; and while this rule applies with peculiar force to the class of cases just cited, every applicant, whether high or low, rich or poor, fortunate or unfortunate, has the unques- tionable right to expect precisely the same kind of treatment ; and, when it is added that a needless rejection is a permanent and irrepara- ble injury, inasmuch as it must always stand as a grave objection— perhaps an insuperable bar—to the acceptance of the rejected party by other companies, it will be seen that these observations are based upon principles which cannot be lightly disregarded, without doing violence to the demands of justice and equity. Thirdly: the relations of the examiner to the Medical Profession. Every Medical Examiner is, in an important sense, a " representative man," to the company employing him, as well as to parties seek- ing insurance. He is to them the exponent of the present standard of medical excellence ; for, it cannot reasonably be supposed that a powerful corporation would deliberately appoint, or, at all events, long retain, as the custodians of its safety, inferior or incompetent men, when the best talent is quite as easily accessible, and involves xi no greater outlay of expense. Let no Medical Examiner for a moment suppose that he has a merely personal interest in acquitting himself creditably and honorably ; that his individual interests are alone to suffer if he fails to perform his duties satisfactorily ; but let him always remember that he has been selected on account of his presumed ability and acquirements ; that every blunder he commits, and every unprofessional or undignified act he allows himself to per- form reflects with damaging force not on himself only, but on the Profession as a whole. It is just as imperatively his duty to main- tain a high standard of professional honor in the discharge of his duties as Examiner for an insurance company, as it is in any other duty connected with his vocation; just as much his duty to examine an applicant carefully, as to diagnosticate a case he proposes to treat carefully ; just as much his duty to frown upon and discountenance quackery and charlatanism in this matter as in any other. And this is due to the insurance companies, no less than to the medical pro- fession ; ever since its origin, the interests of life insurance have been, to a great extent, committed to the hands of Physicians, and, from the very nature of the case, this state of things must continue ; they alone are capable of deciding as to the safety or unsafety of risks, and they alone are capable of making the observations necessary to a correct understanding of the laws of mortality. But in still another and no less important direction do the investigations of medical men subserve the interests of life insurance, namely, in observing the laws and conditions of health, and disseminating inform- ation thereupon among the people ; in arresting the progress of con- tagious diseases, and rendering them comparatively harmless, and in enforcing salutary regulations for the preservation of the public health in cities and towns. The tendency of all this is to enhance the value of human life ; to render the business of life insurance less hazardous, and therefore to bring it more directly within reach of those most likely to be benefited thereby ; thus making it not only theoretically, but really a boon and a blessing to those who are unable to make any other provision for the prospective necessities of their families. To such a work as this, the medical profession ought to yield an active and hearty support, not only in the persons of a few Xll of its members, but as a compact and united whole. To this end let Medical Examiners so discharge their duties as to increase the confidence of the companies in the profession ; let them remember that, to the companies, they are the acknowledged exponents of the standard of professional acquirement, honor and integrity, and let them remember that they have their part to perform towards making life insurance, in a larger sense, the institution of the people. Note Prefatory. Life Insurance is rapidly growing in public favor, and it is not extravagant to say that the time is coming vtfhen it will be more gen- « eral 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 i6 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 quicksilvei 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 »7 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. 2 i8 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 typnoid 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- haps, 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. *9 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- I EXPECT- AGE. AGE. AGE. AGE. ation. 18 ATION. ATION. ATION. O 3872 4Z.87 35 3I.OO 52 I9.68 I 44.68 l9 42.17 36 3°-32 53 18.97 2 47-55 zo 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 3i 40 27.61 57 I6.2I 6 51.17 24 38-59 4i 26.97 58 15-55 7 50-80 25 37.86 42 26.34 59 14.92 8 50.24 26 37-14 43 25.71 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 i3-3i u 48.04 29 35.00 46 23.82 63 12.81 12 47.27 30 34-34 47 23.I7 64 12.30 x3 46.51 3i 33 68 48 22.50 65 11.79 H 45-75 32 33°3 49 2I.8I 66 11.27 IS 45.00 33 32.36 5° 21.1 I 67 10.75 16 44.27 34 31-68 5i 2O.39 68 10.23 ii' 43-57 Other tables vary this expectation from one to two per cent. lo 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 21 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 11 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 23 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 easily 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 24 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- rhcea 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. 25 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 seq.) 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. 26 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. 27 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." 28 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. 29 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, Asthma, Fits, Fistula, Quinsy, Rheumatism Bronchitis, Consumption, Cholic, Diphtheria, Disease of the Heart, Dropsy, Gout, Insanity, Liver Complaint, Paralysis, Palpitation, Rupture, Scarlet Fever, Spitting of Blood, Diseases of the Urinary Organs. 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. 3° 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 37 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 totally independent of permanent organic disease. It 31 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 by 32 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 33 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 3 34 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 dropsical effusion, even though organic disease may not be discovered, precludes insurance. Diphtheria, aside from its immediate danger, ma) 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, 3S 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 Fistulae 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 3« 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. Fits.— 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. 37 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. Analvsis 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. 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 bv 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 38 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 39 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 4° 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 41 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 -eturn of the symptoms. 42 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 43 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 a lit popula- tion. It is about fourteen times more frequent in 44 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. 45 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. 46 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 Haemoptysis 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 De 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 47 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. Hamatemesis, a symptom often confounded with haemoptysis, is of vastly less significance, nevertheless requires, from its occasionally dangerous origin, very careful inquiry as to its real cause. The blood may have come from the nares, the throat or the lungs, have been swallowed and vomited. It may have come from aneurism above or below the stomach, from ma- lignant or non-malignant gastric ulcer ; occasionally as the result of severe gastritis; again as vicarious of menstrual or other discharges. In the vast majority of cases it occurs as the result of the local congestions of malarious diseases, or from scorbutus or purpura. The decomposed blood, or coffee-grounds vomit of yellow fever, etc., need hardly be alluded to. Diseases of the Urinary Organs.— Under this euphemistic designation are intended—nephritis, neph- ralgia, cystitis, stone in the bladder, diabetes, haema- turia, albuminuria or Bright's disease, prostatitis, spermatorrhoea, gonorrhoea, stricture, urinary fistula, syphilis, or other organic or constitutional diseases 48 involving the urinary organs, primarily or secondarily. The question is last but not least. The obscurities of diagnosis and prognosis are more frequently hidden here than in any other part of the animal frame work, and coincidently, here, the acuteness of the medical ex- aminer will be taxed even more than in the minutely studied and carefully described changes of the thoracic viscera. For the physical signs are clear to the mode- rately educated perceptive faculties, whilst both physi- cal and rational signs exhaust the skill of diagnosis when the renal and subsidiary organs come under view. Chronic nephritis rejects, and so also, chronic nephralgia, whatever their causes. Cystitis, if present, rejects, whether acute or chronic. Calculus rejects ; but the previous passage of a small concretion may not disqualify, unless the diathesis be strongly marked, and the evidences be strengthened by hereditary pre- disposition. Diabetes necessarily rejects, but doubtful cases should be analyzed. Albuminuria, or Bright's disease in any of its forms, absolutely rejects. Observe—that organic disease of the kidneys may be present without albuminuria, and albuminuria may occur without renal organic change, but either, if present, reject. Prostatitis, or the prostatic enlarge- ment of old age, if sufficient to materially interfere with the extrusion of urine, must reject. Spermator- rhoea, so-called, is usually merely a catarrh of the urinary mucous membrane, analogous to the leuchoT- rhcea of females, and of trivial importance. It is usually an evidence either of mere dyspeptic derange- ment, or of improper medication. Notwithstanding the stress laid upon it by many authorities, it is safe 49 to say that, in at least nineteen cases out of twenty, it in no wise invalidates the risk. True spermatorrhoea will manifest itself in connection with other symptoms involving the constitution as a whole, which will re- quire no reference to this as necessary to sustain an opinion. Taken as a symptom, isolated, it is of as little importance as a nasal catarrh. The previous occurence of Gonorrhoea is mainly of importance because its old time treatment, by balsamic and other highly irritant remedies, may have laid the foundation of Bright's disease ; or because it may have been followed by septic poisoning of the blood, involving gonorrhceal rheumatism, etc. This latter is capable of producing organic diseases, of equal importance with those of rheumatism from the usually more noted causes. Stricture, whether the result of gonorrhoea or acciden- tal causes, requires attention. Is it spasmodic or per- manent ? Is it permeable or impermeable ? Is it the result of merely a local or of a remote cause ? It is often times symptomatic of renal or vesical organic disease, and these disqualify. If trivial, although troublesome, it is of less importance. If it require Syme's, or other severe operation for its. relief, the insurance should be postponed. A similar remark may be made of urinary fistula. Let it be cured, whatever its cause, before insurance. All malignant diseases of the organs of course reject. In all cases of renal or urinary disease, once more, examine the heart. Syphilis.—In all cases where secondary or tertiary syphilis is clearly present the risk should be postponed. This disease is usually capable of perfect cure. In 4 5° badly managed or cachectic cases it becomes dangerous to longevity. At the present time it is better man- aged, and the chances of perfect recovery are better than heretofore. But the rule is imperative—when present, reject. Observe, historically, the distinction between the merely local sore, (however extensive its ravages) the chancroid, and the true infecting chancre— the latter only of insurance import. The best dis- posed party applying for insurance will perhaps deny its previous occurrence, and there may be no signs superficially to be observed. And yet it is easy for the moderately instructed examiner, in the majority of instances, to satisfy himself of the facts. Nevertheless, the present writer admits the loss of one risk for which he was examiner, by giving credit to the party's own statement and innocent countenance. Many cases of reported consumption, for whose de- mise the examiner is held professionally responsible, are in fact, syphilitic decline and ultimate decay. But the examiner must guard himself against such disas- trous result by stern disregard of appearances. This he can do without violating any of the proprieties. Observe whether there are any traces of cutaneous eruption—whether there is or has been alopecia— whether there is emaciation, or other signs of depraved nutrition, onychia, enlarged post-cervical glands, iritis, catarrh,white patches or tubercles, or cicatrices about the mucous membrane of the mouth, tongue or throat; whether there are nodes, or have been pains in the bones. If possible, (perhaps under excuse of exam- ining for hernia), examine for the significant indu- ration of the inguinal glands. Indeed when the 51 attention is directed to the matter, it does not require much tact or sagacity to make up one's mind safely. Fortunately doubtful cases are overrated in importance. It is perhaps necessary to call the attention of the examiner to the general physiognomy of urino-genital diseases, which is almost too unmistakable for the ex- pert ever to be deceived in—but for the inexperienced it is proper to say that it is both capable of observa- tion and indescribable. XII. Has the Party had Inflammatory Rheumatism? The repetition of this question by several compa- nies in their forms, attests the great importance attached to its satisfactory answer. But sufficient has been written upon this point upon p. 29. et seq. XIII. & XIV. Subject to Dyspepsia, Dysentery orDiarrhcea? A perfect state of health of the alimentary canal and its subsidiary organs is, of course, necessary in order that there should be perfect nutrition of all parts of the body. Temporary disturbances may arise from temporarily acting causes and yet not inval- idate the risk ; but frequently recurring, or persistent disorder, whatever the cause, throws doubt upon it, and then the case must be carefully diagnosed. Dyspepsia is primarily noteworthy because it is one of the initiatory symptoms of the tubercular diathesis. 52 Or it may evidence organic malignant or non-malig- nant disease of the stomach. It may be sympathetic of cerebral or renal, of uterine or spinal affection of more or less serious character. In the larger propor- tion of instances it indicates merely a catarrhal condi- tion of the gastric mucous membrane, or slight dis- turbance of the hepatic functions. But whatever its cause, duration or severity, whenever present, it should receive ample consideration. Dysentery, when present, rejects, and if the party is subject to its recurrence, enquiry must be made as to its cause and origin. Chronic colitis or entero- colitis reject. But many cases of supposed dysentery depend solely on haemorrhoids, local, curable ulcera- tion, or morbid growths about the rectum. Neverthe- less it is safe to say that tenesmus, discharges of blood and pus, especially with occasional febrile heat and emaciation, should reject. The condition of the liver in such cases, should be carefully observed. Diarrhoea is a term relative to the habits of the individual. It does not refer so much to the frequen- cy as to the character of the discharges. Occasional attacks of acute diarrhoea may occur in the very best risks. Such cases point to an examination into the habits of the party, whether of eating, drinking or ex- posure to vicissitudes of temperature, moisture or exercise. Ill regulated diet, imperfect mastication, improper quality of food, irregular hours, and intem- perance of drink, are among the most frequent causes,— but some form of enteritis, hepatic derange- ment, or disease of the glandular organs, subsidiary to 53 the digestive apparatus,— Bright's disease,—ochlesis, malaria, with other agencies are capable of produc ing the same result. The votary of opium or alcoholic stimulants is scarcely ever free from this symptom. In returned soldiers, or those addicted to vegetarian theories, it is frequently the result of scorbutus. When there is emaciation, a despondent countenance, dark circles around sunken eyes, a sallow, leaden or sodden skin, a sunken abdomen, a red and pointed, or a loose, pale and flabby tongue,— an undue indifference, or an augmented irritability of the nervous system, look out for diarrhoea and its cause. XV. Habitual Cough ? The significance of an habit- ual cough in life insurance examinations depends wholly on its cause; but if admitted, it requires criti- cal examination. It may depend on local causes in the pharynx, larynx, trachea, bronchia, or pulmonary pa- renchyma. It may arise from cardiac, hepatic, gastric, intestinal or spinal disease. It may be a mere morbid habit of the nerves and muscles involved in the act. Primarily, it demands physical diagnosis of the condi- tion of the lung tissue, especially at the apices of the lobes,—together with a rational account of the history and diathesis. Taken as a mere symptom, Dr. Hartshorne's statement is as brief and satisfactory as any which can be given, viz: Cough is dry and hollow, or hacking, when nervous or sympathetic. Dry and tight in early bronchitis ; Soft, deep and loose, in advanced bronchitis ; Hacking, in incipient phthisis pulmonalis ; 54 Deep and distressing in confirmed consumption ; Short and sharp in pneumonia ; Barking and hoarse in early or spasmodic croup ; Whistling in advanced membranous croup ; Paroxysmal and whooping in pertussis [and asthma.] It is needless to advert to the character of the expectoration, as that will at once command the atten- tion of the practitioner. It may be mucous, purulent, rusty, bloody and muco-purulent, nummular and heavy, putrid, etc., etc., each case giving its distinctive infor- mation of value to the examiner. XVI. Mechanical or Surgical Injury? Any wound, however trivial, makes its own demand on the powers of life. The amputation of an arm or limb, suggests inquiry as to the reason for the operation. Tuber- culous deposit, malignant disease, caries and necrosis, requiring surgical interference, clearly invalidate the risk ; whereas mere mechanical injuries, as causes, may not materially impair it. Caries, or even necrosis, from acute periostitis or external injury, even though ultimately requiring exsection or amputation, are, by no means, as serious objections to the risk as exostosis, enchondroma, osteo-sarcoma, cachectic deposit and the like. Statistics are wanting upon this point, but the , writer's general judgment, from reading and observa- tion, is, that the so-called capital operations, although recovered from, apparently, to a certain extent impair the desirability of the risk. Individual cases, it is true, may lend color to a different opinion, yet the stern proposition remains, that great injuries to the 55 system, whether accidental or surgical, tend largely to exhaust the original powers of life and, pro tanto, im- pair the insurance expectation. In the case where a limb has been amputated after a long continued dis- charge, which has become habitual, although exhaust- ing to the system, this remark is especially of impor- tance. Apoplexies, paralyses and various organic affections are not unlikely to supervene. The old ulcer iC cured," may involve new and unexpected dis- ease. Any serious mechanical or surgical injury, un- explained— with no positive evidences to the contrary lessens the desirability of the risk. Long continued confinement in the recumbent position, of itself, pre- disposes to disease; and indeed any injury, which, although not severe in itself, has necessitated sedenta- ry habits, with deficient air, exercise, etc., will leave traces of its deleterious influence on special organs or the general system. XVII. Severe Personal Injury or Disease within the last Seven Years ? This query is based on the general idea that if more than seven years have elapsed the results of previous disease are little liable to be developed The popular opinion founded, as usual, upon an antique professional idea, is that the whole body is changed in its constitution every seven years. The instructed examiner needs not to be informed that all the moving and acting parts are changed in constitution within a space of time scarcely exceeding, if reaching, the third of a year. The practical rule, however, re- mains, recent diseases require more careful scrutinv 56 as to their results than those which occurred long pre- vious. Some companies under this head require details as to the character of the disease, and a reference to the attending physician. The latter point will be alluded to further along in this essay. The former will suggest, at once, to the intelligent examiner, the vast differences of degree and danger, of immediate or re- mote disastrous consequences, which may obtain in dis- eases which, for nosological purposes, receive the same name. Whatever the name, the practical fact remains that no disease is the product of a single cause, and vary- ing with the multiplicity of influences acting upon dif- ferent persons—will be the result, immediate or remote, of any single cause which may give the present affection its scientific appellation. Some organizations sustain and oppose the specific causes of certain diseases with little derangement even of functional action — others manifest the evidences — the gravest evidences, of organic and perhaps ultimately fatal change. XVIII. Longevity of Ancestors ? In the United States, such is the character of the population, this question can, in the majority of instances, be answered only with reference to the grandparents. Yet the traditions of families, in the absence of registration statistics are worth something. The descendants of certain families are notably long-lived, and of others short-lived. Co- incident with this fact will be found certain hereditary tendencies to disease. The family record, if tolerably complete and reliable, is of the highest insurance im- portance. It is well known that hereditary diseases 57 not infrequently pass over one generation to appear in the next, or subsequent generations. The shape, capacity, and mode of action of internal organs are determined by the parentage, with as much constancy as the external likeness. These likenesses determine particular proclivities to intimate textural change, with the results of such change. Nations and tribes, clans and families have their marked peculiarities of external likeness, with almost identical tendencies toward death. This is especially true in the older countries, where rank, caste, and custom keep up the usage of inter- marriage. It is of perhaps less importance in the United States, where these distinctions are only tem- porarily recognized. Nevertheless the observation of three generations, conduces much to correctness of judgement in any case under examination. If the grandparents on both paternal and maternal sides have reached old age the risk is more desirable. Longevity of grandparents on the maternal side is to be preferred to that on the paternal side. In either instance, if possible, the cause of the death of the grandparents should be noted. If either of them was affected by phthisis, or tuberculosis in any of its forms ; by apo- plexy or paralysis, by rheumatism of gout; by organic disease of the heart, Bright's disease, cancer, insanity or epilepsy ; by syphilis, or other transmissible disease, the risk must be most carefully investigated. Mean- while it should be recollected that change of location, intermarriage and habits, etc., are capable, under the guidance of the present developed principles of hy- giene, of almost entirely controlling or obviating 58 the hereditary tendency. All causes of disease thor- oughly understood may, not only be robbed of their pernicious tendency but, be rendered subservient to the increased longevity of the race. It is to be recol lected that progressive improvements in hygiene and medical science, as a whole, have largely increased the relative duration of human life, and that the longevity of our grandparents may, ceteris paribus, be well sur- passed by this generation, and this still further increased by the next, by approximation to recognition of the great laws of health as now understood. XIX. Parents Living or Dead—Present Health or Cause of Death, respectively.— As previously re- marked, hereditary predispositions require at least three generations for their satisfactory elucidation. But as one of these, and strongly influencing the re- sult of observation, the peculiarities of parents should be studied. " When one only of the parents is the victim of constitutional disease, the tendency to sim- ilar constitutional diseases is most obviously expressed in those children who most resemble that parent in physical conformation and appearance, and it has been observed that, when both parents suffer, the tendency will sometimes be expressed more often in the daugh- ters of the family than in the sons, or more often in the sons than in the daughters." The organic peculiari- ties, derived from the parent, will determine special and peculiar results from any accidental exciting cause. 59 But it should be recollected that the incidental occur- rence of a family disease is less likely to be marked by acute, prolonged, or obstinate symptoms than when the same disease, nosologically, occurs in an individual without such hereditary predisposition. Nevertheless, its occurrence, whether severe or mild, fully deter- mines the hereditary proclivity, and impairs the risk. Family proclivities to disease are more strikingly man- ifested in brothers and sisters than between parents and children. The intermingling of opposite tenden- cies begets, so to speak, in the children, a neutraliza- tion of the peculiar aptitudes to disease existing in the parents respectively. Physiological likeness of the parents induces imperfect progeny, pro tanto, just as certainly as intermarriage within the forbidden degrees of consanguinity. En passant, we remark, the offspring of cousins, etc., must be most carefully examined, prior to any recommendation of the risk. The ques- tion involving any such relationship of parents should never be omitted. Tuberculosis, carcinoma, and other malignant form- ations, rheumatism, gout, insanity, paralysis, apoplexy, syphilitic, renal and cu aneous diseases, are especially noteworthy in this connection. In considering the influence of hereditary tendency to disease, the remarks upon p. 6, et seq., require at- tention. It may have been outgrown, or not yet arrived at. No sufficient exciting cause may have yet been presented. The individual may appear in high physi- cal health, and yet be on the brink of disease of the most fatal kind. 6o It is fortunately the case that the medical science of the present time looks largely more to individual ten- dencies towards death, and suggests prophylactic hygienic measures, rather than engages in a wild pur- suit of specifics and mysteriously operating agents, to do away with organic morbid changes already grown unmanageable and incurable. The exact influence of hereditary tendency to dis- ease can, probably, be never precisely estimated, be- cause the vice of organization inherited will always increase the mortality from other forms of disease. The latent predisposition will manifest itself in that increased mortality. Nearly nine out of ten con- sumptive patients will be found, on investigation, to have lost one or two out of the immediate family connexion by phthisis. A single instance in a family of a disease, usually hereditary, need not invalidate the risk. The party is thrown on his own personality. Both father and mother being of consumptive tendency, the risk should be declined. But either may have died of some accidental intercurrent disease or injury. Hence the personal peculiarities shonld be ascertained. The mother transmits disease more certainly than the father. But the likeness of organization, if it can be deter- mined, affords the best method of general judgment. When, in addition to one, or both, of the parents, a brother or sister has died of an, usually, hereditary disease, the risk should be declined. The author repeats his carefully considered and matured conviction, from the evidences, that brothers 6i and sisters are more likely to manifest hereditary pro- clivities to disease than are parents and children. They inherit respectively the faults and virtues, as well physical as mental, of each of the parents. How far these may counteract each other, and produce a well balanced mental and physical organization, it *s the duty of the Medical Examiner cautiously to consider. In addition to general resemblance of external and internal organization, it should be recollected, mem- bers of the same family are likely to have acquired similarity of habits of living, diet, dress, exercise, exposure, etc., which cannot fail respectively to im- press upon them similar tendencies to health or disease. In this relation, also, it is well to bear in mind the physiological fact that half-brothers, or half-sisters, mav indicate individual tendencies to organic change which may throw light on the constitutional peculiari- ties of the party under examination. The second husband may not solely be responsible for the organi- zation of his own children. This point, it must be confessed, is one surrounded by obscurity, but the indefatigable medical agent of a life insurance society may derive, from the most unexpected quarters, evidences to guide him in forming an unexceptionable and reliable opinion. XX. Family Physician. — The Examiner should never neglect observance of this query. First, that he may have t^e testimony of the attendant medical man as 62 ' to any peculiarities observed in previous diseases. Clear-headed medical men, in cases treated by them, gain cognizance, not only of present severe symptoms, but, what is of more importance, of the tendencies towards a particular form of death. Some physicians, and a great deal of cheap rhetoric has been expended upon this point, complain that insurance companies do not pay them for the information conveyed in their certificate. This is simply absurd* The family physi- cian is the friend of the party applying, and, it is fair to presume, has relations with the party not altogether of the eleemosynary kind. The trouble of filling out the certificate is merely trivial, being altogether his- torical in its nature. Yet it is of value — not solely to the company. Doubtful points may be thereby explained, and difficulties cleared up. The professional character of the physician, it is needless to say, lends much of confidence to the examiner in making up his opinion. Aside from his certificate, his attendance upon the party may lessen (or increase) the dangers of accidental disease. One or two companies adver- tise a reduction of rates, even so much as ten per cent., provided a particular species of family "physician" is employed. This would be startling to life companies. and examiners generally, were it not so clearly an advertising device — the expense to be defrayed by diminished dividends to the insured. XXI. Intimate Friend Referred to. — There may be cir- cumstances affecting the prospects of longevity which &3 the applicant is either ignorant of, or wilfully with- holds. Thus, habits of intemperance are most fre- quently of all denied by the party himself, and these may be made known by his acquaintances. The solicitor ought not to neglect inquiry upon this point, and submit to the examiner the friend's certificate. Again, the applicant may have had "fits"—epileptic or apoplectic seizure, etc., the real significance of which may, for prudential or other reasons, have been with- held from his knowledge. For these and similar reasons, the corroborative evidence thus gained, should be laid before the examiner. XXII. Previous Rejection or Assurance.—The fact of previous insurance should never be permitted to lessen the care of inspection. The previous examiner may have been inexpert or careless, or have inadvertently overlooked some important point. Or, again, acute or chronic, or even hereditary diseases, may have since been developed, involving organic changes of imme- diate or remote danger. Previous rejection demands employment of all the physician' s skill in diagnosis. The real cause for such rejection should be discovered, if possible. It may have been in consequence of* the applicant's then habits, and some other reason assigned to spare personal feeling. It may have been from some temporary ailment present, or not yet fully re- covered from. It may have been from misapprehen- sion of the applicant's answers on certain points, or from misinterpretation of symptoms observed. Or, 64 again, because the company to which application was made, excluded a particular class of cases which other companies accept. Or, by the baldest hypothesis, it may have been from the human weakness of attempting to gain credit for remarkable professional skill and acumen, at a cheap rate. But when the previous examiner and the attendant circumstances are fully known, nothing but positive demonstration will warrant the medical man in recom- mending the risk. It must be demonstrated that the previous disease is fully recovered from; that the hereditary taint is absent; that bad habits do not exist; that the heart or lungs, or other organ blamed, are respectively free from lesion. Whilst a needless rejection does permanent injustice to both the appli- cant and the company, every medical examiner must avoid the imputation of making the company by whom he is engaged, a hospital for invalid risks. XXIII. Is the Applicant fully Aware of the Purport of the Questions he has Answered and Subscribed? He may be of limited intelligence, or unfamiliar with the language, the names of the diseases alluded to, etc. The solicitor may have been careless in his method, and thus periled the party's subsequent rights, as well as tending to mislead the examiner. Wherever there is the slightest cause to apprehend any negligence or mistake in this matter, the exam- iner should himself again propound the necessary questions. THE EXAMINATION. In order that no point may be overlooked, the Medical Examiner should adopt a regular method of personal examination of the applicant — the form adopted by the company for which he acts being care- fully adhered to, but, nevertheless, considered merely as suggestive, not exhaustive. All the considerations noticed in the Applicant's personal history, must be given full weight in the proposition of further ques- tions, and still more careful observation. Although not in accordance with the usual mode of systematic general diagnosis, the purposes of this essay will, perhaps, be better subserved by adhering to the more generally adopted formulae furnished by the insurance companies. Be sure that the .person examined is the one whose application has been read over. Mistakes here occa- sionally occur, especially when parties have the same names, or several applications are received at once. These blunders might be deemed merely ludicrous, were they not so important in their probable results. 5 65 66 I. Height and Weight.— Whilst the general propor- tions are, perhaps, of the most importance, yet the rule is, that the medium height is endowed with the greatest endurance. Five feet and eight inches may be taken as the medium in this country, for adult males. The average of adult females is, of course, considerably below this — but statistics are wanting Upon the subject. Probably five feet and one and a half inches is the approximately correct standard. Emigrants from Continental Europe average a little less than five feet six inches, if we except certain races, as the Hungarians, Poles, and Sclaves, who reach the American standard. Emigrants from the British Islands average about five feet seven inches. In this country, the average height of persons bred and living in large towns and cities, is something less than that of those living in rural districts, whilst in Europe, the reverse is claimed to be the case. This fact is important, as to a certain extent indicating the general hygienic influences which have operated on races, families, and, ultimately, the individual. The better developed having been from a better nourished stock, and physically superior lineage. Very tall men are usually of less muscular power, less respiratory activity, with a greater tendency to cardiac and pulmonary diseases. They are more liable to hernia, varicose veins, and ulcers of an obstinate kind upon the extremities. Acute diseases attacking them are more disposed to assume the chronic form, with general breaking down of the constitution. On 67 the other hand, short persons are apt to be dispropor- tionately developed ; their muscular power, and ca- pacity for physical endurance are small, and they become the ready victims of acute, and especially epidemic diseases. The relation of age to the height ahould never be overlooked, but this will be alluded to a little further along. The Weight is of moment, relatively to the height. The simplest statement of the due relation is that of Dr. Brinton : "As a rule, it may be laid down that an adult male, in good health, 66 inches in stature, ought to weigh rather more than ten stones, or 140 pounds avoirdupois. And for every inch above and below this height, we may respectively add and subtract about five pounds." Individuals may present a wide range of variation from this; "But as a rule, twenty per cent., or one- fifth, is almost the maximum variation within the limits of health." The annexed table is introduced for convenience of reference : HEIGHT. WEIGHT. MEDIUM CHE3T 5 feet 1 inch Should weigh 120 Bbs 34.06 inch. 5 " 2 " (t tt 125 tt 35-I3 " 5 " 3 " tt tt 130 tt 35.70 *« 5 " 4 " tt tt 135 tt 36.26 " 5 " 5 " tt " 140 tt 36.83 « 5 " 6 " tt n H3 " 37.50 " 5 " 7 " ft tt H5 tt 38.16 « 5 " 8 " tt it 148 a 38-53 " 5 " 9 " ft tt »55 tt 39.10. » 5 " 10 " ft tt 160 The Phlogistic, usually engrafted upon the Sanguine Temperament, where acute inflammation, with active symptoms, readily supervenes upon slight causes. Here there is generally great activity of the blood making processes, with some imperfection of structure of the excreting organs. The Typhoid, when with rapidity of textural changes, easily exaggerated by disturbing influences, there is feebleness of nutrition and repair with inactivity of the excretories. In fine, the acute physician may recognize a great number of these general proclivities to disease, yet each consistent with present health, which, being known, must enter into his well compacted decision as to the real character of the risk. The Cachexia, unlike the Temperament or Diathe- sis, determines the presence of disease,— not, perhaps, involving any particular organ, but pervading, in its malign influence, each and all. It may be the diathesis developed into an existent disease. The diathesis, being known, may never find development into ca- chexia or local disease, being prevented by appropriate hygienic influences. But the cachexia may originate without the previous existence of the diathesis, and, in this case, is usually more amenable to therapeutics. When both co-exist, the prognosis is thereby rendered vastly more grave than it would be even with greater severity of local symptoms. The noticeable cachexiae are those connected with the developed diathesis, as above suggested, and to these may be added, as requiring attention, the Syphilitic, ISO Erysipelatous, Anaemic or Chlorotic, Albuminoid, Haemic, Haemorrhagic, Rachitic, Cancerous, etc. The sum total, so to speak, of the power of carry- ing on the processes of life, ministering to repair, and resisting morbific influences, derived by the system as a whole, is expressed by the term the Constitution. This word is significant of the Vital Force, or indi- vidual capacity for living. It measures, for the Exam- iner, the Life-Expectation. Deviations from the typical standard of formation and action, as arbitrarily established for purposes of scientific comparison, may be found present to an indefinite extent, and yet the capacity for living be fully equal to, or even above the Insurance Average. Poetical descriptions, or ideas, of the mens sana in corpore sano, may differ as widely as men themselves, and it is idle to set up either Apollo or Vulcan as types of Methuselah. Nay, the educated intellect, by adapting the frail body appropriately to its surround- ings, may cause its years to surpass those of the most symmetrical and well developed athlete. APPENDIX. Note to page 15. (Occupation.) Occupation has, of course, a more or less direct bearing on health and longevity : in some vocations there is constant danger of accident or violent death even, while in others the danger on this account is so slight as to be quite unworthy of consideration at all. Again, a particular calling may involve not the least risk on account of phys- ical danger, and yet be extremely prejudicial to health and longevity. The following table indicates approximately the relative influence of the various callings and professions on the duration of life; Class I being considered most dangerous, Class IV least so: Brakeman on Freight Trains. Buzz Sawyer. Circular Sawyer. CLASS I. Powder Maker. Seaman. CLASS II. Bridge Builder. Boatman. Barber on Steamboat. Brakeman on Mail Trains. Cartridge Maker. Clerk on River Steamboat. Captain of Lake or Sea Vessel. Car Coupler. Conductor on Freight Trains. Cooper. Dock Laborer. Engineer on River Steamer, Farrier. Fireworks, Maker of. Fireman (Locomotive). Grinder of Edged Tools. Horse Shoer. Laborer, (Wharf, Warehouse, Grain Elevator.) Lighterman. Lumberman. Master or Mate of Vessel. Match Maker. Mail Agent, (Traveling). Mate of River Steamer. Miner (underground). Nightman. Pilot. Quarrier. Quarryman. Raftsman. Railroad Engineer. Race Horseman. Sailor. Steward on Steamboat. Switchman. Stevedore. Slater. Steel Polisher. Telegraph Builder. Timber Cutter. Train Starter. Wood Carver and Turner. Yard Master. M2 CLASS III. Agricultural Implement Maker. Bar Keeper. Blacksmith (working). Blast Furnace (working in). Block, Oar and Mast Maker. Boiler Maker. Bolt Maker. Brass Founder (working). Bricklayer. Broker in Cattle and Horses. Baggage Master on Trains. Baggage Master at Station. Canal Boatman. Captain on River Steamer. Car Driver. Carman (Drayman). Carpenter and Joiner. Caulker (Ship). Coachman. Cork Cutter. Cooper. Coal Heaver. Carpenter (Railroad). Chief Engineer. Car Repairer. Car Cleaner. Conductor on Passenger Trains. Distiller. Driver of Express Wagon. Drover. Detective (Railroad). Express Agent (not on trains). Express Agent on trains. Engineer on Stationary Engine. Express Messenger on Trains. Foundry (employee in). Fireman (Engine, Hose, Hook and Ladder). Freight Agent (station). Freight Laborer. Hod Carrier. Horse Breaker. Hostler. Inspector of Wood and Timber. Knife and Instrument Maker. Lead Pipe and Tube Maker. Lighthouse or Lightship Keeper. Lightning Rods (one who puts up). Livery Stable Keeper. Lumberman, manufacturer. Laborer, common. Locomotive Superintendent. Limestone Ouarrier or Burner. Master Mechanic. Mason. Machinist. Metal Turner. Miner (surface). Naval Architect. Operative in Saw and Planing Mills Painter. Prison Office Keeper. Puddler. Rolling Mills. Saw Mill (employee). Shooting Gallery Keeper. Scythe and Sickle Maker. Ship Carpenter. Shipsmith. Slate Quarrier. Stable Keeper. Stage Driver. Sugar Refinery (workman in) Station man. Signal man. Ship Inspector. Stone Cutter and Dresser. Track Laborer. Track Superintendent. Track Foreman. Track Inspector. Teamster. Turpentine Manufacturer. Watchman. Wood Chopper. CLASS IV. Actor, Actress. Ale or Beer Manufacturer. Apothecary, Druggist. Architect. Armorer. Artificial Limb Maker. Actuary. Artist, Painter. Attorney, Lawyer. Auditor. Army or Navy Officer (not in service). Author, Writer. Bookseller. Broker in mdse., stocks, or gold. Bank Officer or Clerk. Book-keeper, Accountant. Baker. Barber. Basket-maker. Bell-hanger. Boat Builder. Bookbinder. Boot and Shoe Maker. Box and Trunk Maker. Brass Polisher, Finishei. Brewer. Brickmaker. Builder, not Laborer. Cabinet Maker. Cap or Carpet-bag Maker. Carpet Weaver. Chair Maker. Chemist and Druggist. Chiropodist. Civil Engineer. Clock Maker. Coach Maker. Coffee-House Keeper. Commercial Agent. Clergyman. Minister. Clerk, (generally). Clothier. Commission Merchant. Captain of lake or sea steamer. Chemist, manufacturing. Coal Miner (underground). Confectioner. Cook (professional). Coppersmith Copperplate Printer. Cornice Moulder. Cotton Dyer. Cotton Packer and Presser. Cotton Printer. Cow-keeper, Milk Seller. Currier. Custom-house Officer. Cutler. lS3 CLASS IV.—Concluded. Draughtsman. Dressmaker. Dentist. Die Engraver, Mould Maker. Drug Grinder. Eating-House Keeper. Embosser. Embroiderer. Engraver. Editor, Reporter. Engineer, Mining. Fisherman. Farmer, owner, Farm Laborer. File Maker. Fish Curer. Fish and Oyster Dealer. Furrier. Gardener. Gas Fitter. Gas Works, service, G auger. General Trader, (traveling). Glazier. Glover. Gold Beater. Glass Blower. Gold or Silver Refiner and Worker. Grocer (general). Grain Measurer. General Trader, storekeeper. Grave Digger, Sexton. Gunsmith. Harness Maker, Saddler. Hat and Cap Maker. Hollow Ware Maker. Hoop Maker. Hoop Skirt Maker. Hotel or Tavern Keeper (country). House Decorator. Huckster. Hotel Keeper, proprietor. Insurance Officer and Clerks (not traveling). Ivory Cutter and Worker. India Rubber Manufactory, employee in. Ink Maker. Instrument Case Maker. Japanner. Jeweler, worker. Lithographer (not working). Leather Dyer. Locksmith. Looking Glass Maker. Last Maker. Machinist, not in employ of railroad. Marble Cutter. Marble Mason. Marketman. Medical Student. Metal Refiner. Miller, grain and flour. Morocco Dresser. Millwright. Manufacturer (not working). Milliner. Musician. Moulder. Naval Officer, in service. Nail Maker. Nurseryman, working. Oil Dealer, petroleum. Operative.in Cotton or Woolen Mills. Organ Builder. Oyster Dealer. Phonographer. Photographer. Physician. Postmaster. P. O. Clerk (not traveling) Packer of Hay, Cotton, Pork, Beef. Packing Case Maker (not using circular saw). Painter, house, ornamental. Paper Hanger. Paper Box Maker. Pastry Cook. Pawnbroker. Pencil Maker. Picture-frame Maker. Percussion Cap Maker. Plasterer. Plater. / Plumber. Porter. Potter. Pressman. Printer, compositor. Pump Maker, President or Secretary of Corporation. Publisher. Purser, steamship. Policeman. Railroad Employees. Rectifier. Rope Maker. Surgeon. Ship Rigger. Soap Boiler. Sail Maker. Saloon Keeper. Sausage Maker. Segar Maker, Scourer, Dyer. Ship Broker, agent. Ship Builder, contractor. Steward on vessel or steamer. Smelter. Soda Water Manufacturer. Shovel Maker. Silversmith. Spindle Maker. Spring Maker. Steel Pen Maker. Stereotyper. Surgical Instrument Maker. Surveyor. Tanner. Tinman, tinker. Traveling Agent. Type Founder. Tailor. Teacher. Telegraph Operator. Tool Maker. Turner, Wood and Ivory. Umbrella Maker. Upholsterer. Varnish Maker. Vitriol Manufacturer. Watchmaker. Weighing Machine, Scale Maker. Wharfinger. Wheelwright. Whip Maker. Whitesmith. Wig Maker. Wire Maker. Wood Dealer. Watchman. Weaver. Weigher. 154 Note to page 16, The popular idea that the affection known as " clergyman's sore throat" predisposes to consumption is, to a great extent, erroneous. On the other hand, it is probably safe to say that consumption finds fewer victims among the clergy, than among any other class of people—the exercise of public speaking tending rather to develope and strengthen the lungs than otherwise. As a general rule, public speakers are safe and desirable risks. Note to page 16. (Professional men.) It must be adrnitted, as an exception to the general rule, that under-teachers in city schools are most unfavorably situated as regards health and longevity. Confined for six or eight hours a day in close, ill-ventilated rooms, which are crowded with children in all stages of uncleanliness ; with both body and mind wrought up to the highest pitch of exertion, and all this for many consecutive weeks or even months, it is scarcely to be wondered at that their standard of health is low as compared with that of the great majority of teachers in the colleges and higher schools, or of teachers in common schools in country towns. It is probable that statistics would show a marked difference in the average duration of life, between city and country physicians, and that the difference would be in favor of the former. The terribly exhausting life of the country practitioner, together with his unavoidable irregularity of habits and of hours of rest, cannot be otherwise than unfavorable to long life. As regards other professions, it does not appear that any marked difference obtains between city and country. But the popular belief, that the opportunities for the enjoyment of vigorous health, are, on the whole, better in the country than in the city, is probably true, though a series of observations on this point are much needed. The actual difference, however, is not so great as has been supposed ; owing perhaps to the increasing popularity of gymnastic and other exercises intended to develop a high state of physical health ; the improved methods of constructing dwelling houses as regards warming and ven- tilation, and the improved notions of society as regards diet and *55 dress; fashionable society having now learned to tolerate warm attire, however ridiculous or preposterous its form may be—another reason for the improved hygienic condition of cities is, that modern science has at length developed the fact that contagious and zymotic diseases may be, to a great extent, prevented by the enforcement of sanitary regulations ; consequently every city of any considerable size has its " Board of Health," clothed with ample powers, and held rigidly accountable for their employment, both by public opinion, and by an exacting and critical newspaper press. Note to page 19. (Table of Mortality.) In the first of the annexed tables, is shown the mortality from all diseases usually mentioned in Life Insurance Applications, for the year i860, together with the rates they severally bear to 10,000 deaths, from all known causes of mortality. The second table shows the proportion of deaths to 10,000 from all causes, in the several "census districts" of the United States, from the same diseases, and for the same year. The States and Territories comprising the several districts will be found in connection with the table on page 16. It will be observed that the deaths from "colic," "palpitation" and "spitting of blood" are not given ; this is simply because they are very properly regarded as being symptoms only ; and therefore entitled to no place in a classified arrangement of diseases for scientific purposes. (Compiled from the Census Report for i860). As Life Insurance Companies have multiplied, and operations on a more extended scale have been made, tables of mortality have also multiplied. The Carlisle table is given on page 7, of this work; below will he found the "American," " Combined Experience" and "English" tables — the latter being that generally known as " Farr's table." i56 SHOWING THE DEATHS IN THE UNITED STATES, AND THE RATIO TO 10,000 DEATHS, FROM DISEASES USUALLY MEN- TIONED IN LIFE INSURANCE APPLICATIONS, FOR THE YEAR i860. DISEASE. Apoplexy............... Asthma................. Bronchitis............... Cancer.................., Consumption............ Colic..................... Diphtheria............. Disease of the Heart. Dropsy.................. Fits, (Epileptic)....... Fistula.................. Gout...... ............. Intemperance.......... 3>o83 669 1,919 3»292 49,082 44 1,663 6,53° 12,090 501 37 4i 93' 86 18 53 92 ,379 1 46 183 355 «4 26 DISEASE. Insanity................. Influenza................ Liver Complaint...... Paralysis.......... ..... Palpitation............. Quinsy................... jRheumatism........... [Rupture................. Scarlet Fever........... Spitting of Blood...... Dis. of Urinary Organs Syphilis................., 452 385 2,633 4,637 o 3 £*> 730 1,881 360 26,402 2,112 *33 73 130 23 52 IO 741 56 6 SHOWING THE PROPORTION OF DEATHS TO 10,000 FROM ALL CAUSES, IN THE "CENSUS DISTRICTS" FOR THE YEAR i860. DISTRICTS. PROPORTION TO 10,000 OF ALL DEATHS. Apoplexy............................ Asthma............................... Bronchitis........................... Cancer................................ Consumption....................... Colic................................. Diphtheria.......................... Diseases of the Heart............ Dropsy.............................. Fits, (Epileptic).................... Fistula................................ Gout.................................. Intemperance...................... Insanity.............................. Influenza........................... Liver Complaint................... Paralysis............................. Palpitation.......................... Quinsy............................... Rheumatism....................... Rupture.............................. Scarlet Fever....................... Spitting of blood................. Dis. of the Urinary Organs... Syphilis.............................. log 17 140 2,162 II. III. IV. V. VI. VII. VIII 81 ',535 141 25 "5 107 i'793 62 15 46 79 1,29s 78 26 60 95 i,»95 71 492 no 37 51 47 1,214 4 135 286 73 236 369 3° 126 258 '4 96 601 46 8 766 45 i,°93 1,085 18 45 9 1,112 31 59 9 766 116 215 241 15 5 7 102 92 59 '9 965 to i- 0 no oovi onu<4>w >o " 0 no oovi LO LO LO LO ONt»t 4* lo lo lo to 1-1 0 no OOVl ONLn 4> LO to i-i O NO OOVJ ONLn 4. Lo to 1-c O Age. On On On "-a VI OONO O OO 00 O0V) +■+■ Ow -« to 4* ►" vivivivivivjvjvivjvivi oo m tJ w 4. ^ Ln On^J 00 OONO 0 On4> lo n vo sj 01 w im 00 Onlo to no 4* ^4 00 00 On4> 0 On m Ln N) NJViUHfl fc> "^4 •-• ONki HW 00 00 00 00 M l-l |0 LO 0 OOLn to ^O y Ifl v] 0 N w O 00 00 00 4> 4- <-n O ^4 4» O K> 4* 0 « M 00 OO OO OO OO OONO NONONONONONONONONONONONO 0 ON On*-4 oonono O *-* i-i to LO 4. 4* Ln ON vl vl oon£ 0 11 OOLn LO ONJ4k Mifl Onlo O OOLn (J OMlfl tl 0 ONVl NO HWl^vlNO MOO OvOOMU! OOtO ONOLn O 0 00 ON4* tlHHtlJ>N|UVOMOlAt>|JUlHO American Table. Number Living. ON On On-v1 vi oo-o 0 C + UlW UN o m oo w\o "] O vavivivivl-vlvjvjvivi 0000 » f ul +-ui On--4 ^J OOno 0 >-i onui Ln 4- LO m 0 00 on4* N 0 0 00 to LO 1-1 ^1 H UJ Ui Ul IA U) M to ONLn ONLO to OOLO OOLO 00 00 00 00 00 00 00 00 ** JO lo 4. 4* 01 On 00U1 M OOOOl |1 hh oolo OOlo Onno 4* 1- NO NO M^ fc) 00 "o to 00 OO 00 OONO nonononovononononononononc o VI OONO NO O I- l-i 10 LO LO 4* Ln Ln ONVl ~J OONO O vl 4> h "oOLn "to NO Ln to no On^o no Onlo no Onlo 0 10 lo LO LO to M 0 00CN4* tONO ONLO C -^1 Ln to O ON4. vj Ln NO NO Ln 00 OOLn 0 LO Ln Onv) 00 O 4* O Combined Experi-ence. Number liv-ing. "o "o no no 4* O On to J> « to ^4 00 OO 00 00 OOVI Ms)M vj v)v] NO vl 4. to 11 no oovj ONLn 4* 4» OnO M » (J v)U\ 4.U1 OnnO (0 ^NJVlN)V)N) lo lo *o to to to vl to NO Onlo ^ "J ~-4 to « 0 no vlvlvjvlvjvjvlvjvlvlvlvlvlvlvjvlvjvlv] MMl-iMI-itOtOtOtOtOtotOLOLOLo4*4.4*4. OO OO 00 OONO 0 1-1 tOLOLn^JNO tocnvl OLtO ONNO American Table. Number Dying. p m m 0 O Ln O 0> VI ON OOLO ONONONO OOOOO0OOO0 OOM NJVJ-4SJ v] to 004>. O OOLn LO to l-t O NO OOV] ONLn Ln m h ^\vo n s] vo ONLn Ln Ln Ln OnvI 00 0 -4 V] 4- OO to 4- ^4 ^4 n] nj nJ sj OnOnOnOnOnOnOnOnOnOnOnOnlTnOnOnOn to IH O ONONONO OOMOO'ONIMnJnIM^nIvjsj 0 4* OOLO O04> 0 Onlo O^LnLOtO»HiHWt04>ON Combined Experi-ence. Number dy-ing. h u H u NO 0 O 1H tJ W W 4^^iOi ON ^4 00 OONO 0 w w w w H M (J W LO LO lo 4* Ln LO On U1DLOL1LOJ>4>4>4.4>4>4>0>0>0>0>410>0> ON^I OO OONO 0 0!-it0tJLo4k4kLnON ONVl 00 OO American Table. Expectation of Life. 4- H NO ON NO O « LO LO O OOLn (J^O v] 4. *. NO ONLO O\00 O 4» NJ VO kO Ln OOO to Ln ^J MO H NO Onlo to to lo 0 vl 4* ih 004* w OOLn to OOLn 1-4 OOLn 1-1 004. 0 *-J LOLO 1-c MVONJUHJ O^JLONOLn 0 ON f +> OON OONO O O M to t^U ^lAOt On ^4 OO OONO OOLn »-i OOLn to NO On4^ m OOLn IJ 0nJ4» to 0 oo^a on-^j vi no O *> 4». onooo *o 4* LO OO LO LO O O l-c »0 w OOLn 00 Ln vi 00 0 LO LO LO LO 0 -4 LO 4" 4" LO LO Ln Ln LOLOLOLOLOLo4.4.4.4».4i.4i.4.4i.4i.4>4»4>'4h Ln Onvi v] OONO O O >-< M ULO 4> 4.U1 on-J ~J OO OOLn to no onlo O ^4 4. 11 ocLn to no Onlo 0 onlo On On^J OOOO NO NO NO NO NO 00 OO v) On 4. LO 1- OO ON Combined Experi-ence. Expectation of Life. M M 1- *0 CO OONO 0 tO NO O. HI MO + N4 Ht>»Ub>|lM)lDDMU|0 MWU 0 >- to mu 4»4>ui on on^J 00 ocno 0 0 004* 1-1 ^1 4. O^J w 0 s w ovJ4' 0 ^4 to On>h On »» ^4 lo no On to no Onlo 0"1 + l>0 CO H. (J J> 0 to NO LO LO H LO vj 4* Onlo U1UWDLJLOWI>)L14>4>4>0>4>0>4>4>4>0> 4»4»Ln OnOn*-4 OOOONO O O ih to LO LO 4. Ln ON"-! NNl^i 1-IV14,. 1-1 004>. m\o On4* i-tNO"JLnLO O 0 ^1 4* to no Onlo 0 OOvj O 4* 0 Oovj ON4» w Ln English Life Table No. 3, (males). Ex-pectation of Life. in NONflNONOVC O0000O0O00O0000000 OOVl vlvlvjvlvlvlvlvjvj OnOnOnONOnOnOnOnOn ONLn Ln Ln Ln Ln «0">Ln I Ape lTi -£ LO to M O NO OOVl ONUl 4* LO »0 l-i O NO OOVl ONLn 4> LO to 1- 0 NO OO "-4 ONLn 4> Lo to i- 0 NO OO vl ONLn 4» LO "B*1 to K> LO OO 1*0 LO 4- 4* 4- 4* 4> Ln Ln Ln Ln Ln On ON On ON On On American Table. 4- N LO *> Ln ON 00 0 jo 4> LO 4>. ON 00 ON NO LO as "to 00 v4 "to <1 jjn OO Ln 0 LO 00~M Ln VI NO LO LO "to 0 4-■vl ONV] LO NO NO O v4 JO lo 4^ Ln Ln ON ^ ^4 Number Living. 4* ~4 0OV] vl Onlo On LO 4- LO vl ON NO LO NO On4» 4* ON On On to to ON NO LO Ln Ln LO NO LO 4> 0 0 M vl OOLO 0 OONO 0 LO H M M 0 0 LO Ln NO 4- 4* lo On ^4 J- JO OLO OOLn M l-l M HI HI tO tO tO t3WWWW+>+N4>4>4>UllONlJNUllJNLn ONOnOnONO> 4» Ln On OONO HiLOLnvlNO h o> On OO M OO Ln OO O tO 4» ONOOOJ0 4.LnvlNO 0 10004. ON , oo 4. "o* hi "on4>. to to 00 Ln ^1 W4>"J m Ln OO m w Ui On^4v1 ONLn tONO On w on 0 4» -vl 0 — .... ...... — ^.^. ^..v.^._ ~ . .. .* ^. TvNOLn4> On 0 ~4 "-4 0 ONLnNO ON OO4» - - 1 4. vl hi Ln OO CO 0OO0 v4 NO Hi OnOO 4". 0^-1 00 M NO (0NOV1 On4»NO OOONOLn MLO r- -*. - ~3vl O NO ^4 NO 0-4 00 4> Ln OO 4* 4» HiLnLnLO O Hi 004>NOLn ON 0O0 VI NO HI ONOO -fl" U HI WJ H MJ I>l>^vj Ul^. ■> ■ no O to NO 4» ^4 OOOvNUn to 4. 4. 0~4NO oo- Combined Experi- ence. Number liv- ing. H. HI HI HI HI HI tO t> tO *JJJJ3JOj0.t)JOjOJJJOJOj0j1J"J1J1J"J-'J-!J-,J-'J-'J-'J1H' M U W 0-1 NJ (fl "b "u j> "on^nO Oh"(JL1J>4>UiLiO>4>WW tO hi ONO OOOOvl ONLn 4* OO 00 to Hi HI O M Ln LO 4. OOLn 4- LO 1- NO ~4 4» H ON NO NO NO ONOO VI O 0 004> NO to 4. Ln vl OO 00 Q M to 4* ONNO to ON NO 4- NO LO 00 OOvl ONLn Ln 4* 00 4* to O OC On4" h om- ONHiLnvl OO H HILO OOO ONO 6 LO OO {Ji OO 4. Ln O NO LO American Table. Number Dying. B H M M M » m D » tl H S (1 » M 1> l> D f f M „M ," ." ," J" M h M M M •< " M tO OO 4* Ln On OONO *M *t> 4* Ln -vl "boNO 0 Hi tOLOOOOOOOOOLO to to HI HI ONONO OOVl ON ONLn 4> 4> w W tJ LnNOLnoo t0t04*v4 MLn M On SO OOLO ON OONO v4 4. o LO Ln ONLn to NO 4* NO to OnNO hi 4. vl vo to Onno 00 VI Hi ON tOLnLn HI to VI Ln LO M OOHi OOVl to 0 On~-J 10 NO NO LO NO CCtO M ^4 Hi CM- OOHi ON14> O 00 V] Hivl ONLn ON" Combined Experi- ence. Number dy- ing. m m M hi t> to DU WW 4>o> 4.U1U1U1 On On--4 vl 00 OO OONO OOMMtotOoo4>.4vLnON ON-^1 po 00 Ln ONOONO M .k ONNO i- 4" -vl OW-4 bw-4 M J> OO 10 ON M Ln '0 4»N04» 0U1 Hi ONtO 004" 0 -Ow On14> Ovl 04» 0 OONOtONOOONO-vlvl OONO H 4. 00 4. O 0000000004" O OO 00 OO 0 4» O OOONON^4N04i.NOLn to ONONO American Table. Expectation of Life. m m hi m M to to to HUUl>moo>4.J>OtLnUi ON ON Onv) "4 po OONO NO NO O O _ hi 'to 4. On 00 m lo Ln oo'hilo O^NO hi 4» vl O 4> M m 4> bo to onwlV, b -»> NO 4> no Ln O ON 1- vj 00 NO Ln to to 00--4V4SO M Ln NO 4» 0 ONOO O OOOOOONO to ON M OOOnOnvI 0 4» 0-v< On ON~4 MLn M OOV1V1V4NO to to to LO lo -f>. 4. Ln OnON"-J 00 vl LO NO Ln to OOLn M ON 0 ON Combined Experi- ence. Expectation of Life. |4 tO to to tO t0LOLOO0LOLOO04»4i.4»'4i',-nLnLn ONON ONVl i-i to 4. Ln OnOOO MOOLnvlNO m4» onno to Ln OO m 4» 00 to On O 4» NO VINO M Ln NO 4» O 0>4» LO LO Ln vl hi ONLO m m tOLnNOLn 10 n u Ul O OO OO OONO NOOOMHitotooo4i.4.LnLn On-v1 v] 1> bo oo OCLO 0OJ> VO Ln M on to 004* b ON Onlo to to 4. vl hi o>oo O OC ON ONLn on *v( English Life Table No. 3 (males). Ex- pectation of Life 00 159 The following simple rules for the calculation of life expectation are taken from the "Agents Manual of Life Insurance." They may be relied upon as approximately correct, and will be found useful in the absence of the standard mortality tables: From 14 to 26 inclusive, deduct the age from 100: half the balance is the expectation " 26 to 30 " " " " " 98 " " " " " 31 to 40 " " " " " 96 " " " " " 41 to 4*7 I»39i 1**45 59i 5^3 1,136 RATIO MALE. 1,000 I.OOO 1,000 1,000 1,000 1,000 1,000 1,000 1,000 ? SEXES. FEMALE. I.258 J,345 I,I23 1,207 1,378 I,429 1,470 1,060 902 i65 Note to page 32. Mere Nephralgia should be diagnosticated as comparatively unim- portant ; but it is probable that, in the great majority of instances, nephralgia is symptomatic of the passage of a calculus—and is there- fore warrant for rejection, or at least a suspension of judgment. Nephralgia is also, occasionally, the expression of malarial irritation —in which case it is no obstacle to insurance. Note to pages 37 and 137. (Insanity.) Probably in no disease, liable to present itself to the Examiner, is the hereditary tendency more strongly or more uniformly marked, than in insanity. Out of 1,654 cases admitted into the Hartford " Retreat for the Insane," 304, or about one in every five cases, were of hereditary origin. Dr. Aitken gives the ratio as " varying from 26 to 69 per cent." It is also important to bear in mind that heredi- tary insanity is prone to assume the most hopeless and incurable form of this disease; namely "Melancholia:" of fifteen cases investigated by the writer, all were clearly hereditary. But there is still another point to n-hich the attention of the Insurance Examiner should be drawn : namely, that the suicidal propensity is more strongly marked in Melancholia than in any other form of the disease. The Diagnosis of some forms of "delusional" insanity is some- times exceedingly difficult. The following rules, copied from Ait- ken, as compiled by him from the admirable work of Bucknill & Tuke, are practically valuable : (1.) Learn as thoroughly as possible the antecedents and history of the patient. (2.) Estimate the value of the hereditary tendency, upon the fol- lowing principles : (A.) The insanity of one parent indicates a less degree of predisposition than that of a parent and an uncle; and still less than that of a parent and a grand-parent, or of two parents. (B.) The insanity of a parent and a grand-parent, with an uncle or an aunt in the same line, may be held to indicate even stronger pre- disposition than the insanity of both parents. (C.) The insanity of a parent occurring after the birth of a child, without predisposition, is of no value in the formation of an hereditary tendency. (D.) If several brothers or sisters, older and younger than the patient, t66 [or applicant,] have become insane, the fact tells strongly in favor of predisposition, although neither parent nor grand-parent may have been lunatic. (E.) The insanity of cousins cannot yet be deter- mined as worth anything in favor of predisposition, except in corroboration of other and weightier facts. (3.) Ascertain if there has been any change of habits or predis- position. (4.) Exercise the greatest tact and discretion in the personal exam- ination of probably insane patients. (5.) Observe any peculiarities of residence or dress. (6.) Study the appearances, demeanor, and general conduct of the patient. (7.) Notice any peculiarities of bodily condition; [as emaciation, state of the skin, bowels, pulse, tongue, etc.] (8.) Observe any peculiarities of gesture, or of countenance. As a general rule, when, upon close examination, insanity appears to be clearly hereditary—and especially if the parent whose sex agrees with that of the party under examination became insane before his or her birth, the risk had better be declined, even though it may be in other respects desirable. Note to page 40. (Palpitation.) The following list includes the chief causes of palpitation of the heart, except when dependent upon organic disease of the organ itself: (1.) Diseases or derangements of remote organs, as the stomach or liver. (2.) The use of narcotics or stimulants, as alcohol, opium, or tobacco. (3.) Gouty, rheumatic or malarial irritation. (4,) Masturbation, or excessive sexual indulgence. (5.) Excessive or prolonged mental labor. (6,) Hysteria, disordered menstruation. (7.) Anaemia or leucocythaemia. In the latter case it will probably be associated with cardiac, as well as arterial and venous murmurs ; the former best heard over the base of the heart, and the latter along the course of the carotids. Whenever these are present, the risk must be declined : First, be- cause the anaemia is of itself sufficient cause for rejection ; and, Sec- ondly, because it is impossible to distinguish with absolute certainty between the sounds caused by the watery condition of the blood, and i67 those caused by actual organic disease. Palpitation is also occasionally associated with, and dependent upon spinal irritation, "especially if there is tenderness of the upper half of the spine." When easily excited, or long continued, it is very liable to result in organic disease of the heart — and is certainly indicative of some source of trouble, which it should be the business of the Examiner to ferret out and explain, before recommending the risk. Note to page 46. (Spitting of Blood.) While the expectoration of blood is, with great propriety, gener- ally looked upon as an insuperable obstacle to insurance, it is, of course, possible that a person, who is exceedingly desirable as an insurance risk, may have sometime spat blood from the mouth ; for example, the bloody expectoration of acute bronchitis, or of pneu- monia, by no means precludes the idea of subsequent vigorous health, and therefore of insurability—and justice to the applicant demands that the cause be carefully sought out. But whenever a doubt exists, that fact alone should determine the rejection of the risk—else would the examiner impair rather than increase the safety of the company employing him. In insurance applications, the term "spitting of blood " is of course used arbitrarily, else would almost every applicant who answers this question negatively perjure himself. It is intended to ascertain whether any expectoration of blood from the lungs or bronchial tubes, or from any source indicative of organic disease has ever occurred ; and it is sometimes necessary to explain to the applicant its scope and meaniug. Every man who has had a tooth extracted must have discharged blood from the mouth, and many other causes equally trivial might give rise to the same thing ; but while this would, of course, be literally and undeniably "spitting of blood," it would not come within the limits of the technical meaning of this phrase as employed in insurance applications or medical text works. It would be better if the term, on account of its loose and unmeaning phraseology, and on account of its being so frequently and easily mis- understood, could be dropped entirely, and another of greater accuracy substituted for it. i68 The following table is intended to show the more common and dangerous sources of bloody expectoration, together with their prominent symptoms and insurance significance : SOURCE. DIAGNOSIS. CAUSE AND SIGNIFICANCE NOSE. Blood generally issues from the nostrils ; sometimes flows backwards, and is coughed up, but if the patient is made to lean forward, the blood flows from the nostrils, which estab-lishes the diagnosis. The blood can generally be seen trickling down the pharynx ; and is not usually florid. Causes are almost always easi-ly made out, and are of little importance to the Insurance Examiner. MOUTH. The soft, spongy, swollen state of the gums, with blood slowly oozing from them, and the readiness with which they bleed upon being touched, at once indicates the source. Generally indicates an im-poverished condition of the blood, as in Scorbutus; and calls for great caution. BRONCHIAL TUBES. Expectoration consists of mu-cus or muco-pus, streaked with blood, not intimately and uni-formly mixed ; quantity of blood generally quite small ; large, course rales are easily heard. Acute or chronic bronchitis ; foreign bodies, or ulceration are the common causes. Either of these reject or suspend until complete recovery takes place. LUNGS. Coincident with other signs and symptoms of phthisis ; blood in considerable quantity; florid ; generally " frothy," or containing small air bubbles, and intimately mixed with mu-co-pus ; not coagulated. Almost always indicative of tubercular deposit, and is of course an unqualified warrant for rejection. STOMACH. Sense of weight and uneasi-ness in the epigastric region ; or perhaps decided nausea ; the matter vomited consists of dark grumous blood, altered by the action of gastric juice, unless caused by the opening of an ar-tery, by ulceration ; discharges of altered blood from the bow-els ; tenderness of epigastrium. Caused by injuries — as a blow or kick ; by inflammation or "active hyperaemia"; by ulceration; by cancer; by irri-tant poisons; by an altered state of the blood itself; or it may be vicarious, as of menstru-ation. All but the last must of course reject, and that even requires careful investigation. 169 Note to page 48 and 123. (Urine.) In all cases where symptoms of obscure origin and doubtful signifi- cance are present, the urine should be carefully tested by the most approved methods, and, if possible, examined microscopically. Not every Medical Examiner, however, will be so fortunate as to possess a microscope ; but no one need be without a supply of test-tubes and reagents, or the skill and knowledge requisite for their use. It is true, however, that, in practice, cases will rarely come before the Exam- iner in which an examination will either be proper or necessary, and it should never be done when it can safely be avoided ; nor should the Examiner ever permit himself to subject the applicant to the trouble and annoyance of furnishing him with a specimen of his urine, merely for the purpose of acquiring experience for himself, or of impressing the company employing him with exalted ideas of his scientific ability. Yet cases may and do sometimes arise, when im- portant interests are at stake, and when it becomes the duty of the Examiner to at least make a chemical examination of the urine ; in all such cases, the matter should be fully explained to the applicant, that he may understand its necessity and reasonableness. The fol- lowing table, compiled chiefly from Da Costa and Golding Bird, shows the morbid elements most likely to present themselves to the Insurance Examiner, together with the best means for thtir detection MORBID ELEMENT PHYSICAL CHARACTERS. TESTS AND REACTIONS. ALBUMEN. Sp. gr. varies from 1,010 to 1.025 ; color light; a precipi-tate of a light color generally falls after a few hours Heat throws down a more or less abundant whitish pre-cipitate, which is insoluble in acid ; Nitric acid also precipi-tates the albumen, and heat fails to re-dissolve it. BLOOD, Color red, smoky or dingy ; deposits, on standing, a brown-ish or coffee ground sediment ; if in large quantity, minute coagula may be seen at the bottom o£ the test glass. The microscope at once re-veals the presence of blood globules : Sulph. acid changes the urine to a brown or reddish brown color, showing the pres-ence of haematin. 170 MORBID ELEMENT PHYSICAL CHARACTERS. TESTS AND REACTIONS. SUGAR. Color light; sp. gr. high ; very peculiar odor ; rarely de-posits sediments ; contains large excess of water. Fill a test tube about one third full of urine; add a few drops of solution of sulphate of copper, or just sufficient to color the urine a light tinge of blue; add liquor potassae in large excess ; the mixture now assumes a deep blue color if sugar be present, and upon be-ing heated, it changes first to a brownish color, then yellow, and finally a reddish brown precipitate of sub-oxide of cop-per falls to the bottom, which establishes the presence of sugar. PUS. When the urine contains pus, it deposits an opaque, creamy sediment, or a gelatinous mass, is generally alkaline and always slightly albuminous. Upon microscopic examina-tion, pus cells are readily dis-covered ; a drop of acetic acid should be added to the speci-men under examination for the purpose of developing the nu-clei. The chemical test for pus is liquor potassae, which forms therewith a gelatinous precipitate of a light straw color. BILE. Color very dark ; sp. gr. not materially changed ; generally coincident with other symp-toms of hepatic derangement. Pour a small quantity of urine on a white plate, or other porcelain surface ; a drop of nitric acid is then added ; a play of color shortly takes place, commencing with green and blue, passing to violet and red, and often finally to yellow and brown. MUCUS. Color light; a more or less abundant flocculent deposit takes place ; putrefactive changes commence very early, the urine rapidly becoming ammoniacal. Upon the addition of acetic acid, the fluid part of the mucus coagulates into a thin semi-opaque, corrugated mem-brane, which at once estab-lishes the difference between mucus and pus. 171 Note to page 76. (Pulse.) The rapidity of the heart's action is considerably modified by the position of the body ; possibly to a greater extent than is commonly supposed. This subject has been carefully studied by Dr. Guy, and with the following results : In ioo healthy males, averaging 27 years of age, in a state of rest, and of freedom from excitement, the aver- age frequency of the pulse was, when standing, 79 ; when sitting, 70 ; and when lying, 67 beats per minute;—or a difference of 9 beats between sitting and standing. In 50 healthy females, of the same mean age, and under the same circumstances in other regards, the average pulse when standing, was 89 ; when sitting, 81 ; and when lying, 80 beats per minute ; —or a difference of 8 beats between stand- ing and sitting. In my own examinations, I have generally found a difference of from 4 to 8 beats per minute, between the standing and sitting posi- tions ; and a difference of less than 6 beats is the rare exception. Yet the difference is very frequently stated, in the reports of Exam- iners, as being no more than one or two beats — which is, at best, but a very unskillful "guess," and of no value whatever to the com- pany. The pulse should be counted a. full half minute, by the watch, in both positions, and the result should be carefully noted down at the time. But to the Insurance Examiner, the pulse is, in general, little more than an indication of the condition of the nervous system at the time of the examination. The mere fact that they arc being examined is sufficient, with many people, to cause a marked acceleration of the heart's action, or even to produce violent palpitation. It is often the case that the applicant has walked rapidly from his place of business to the office of the Examiner, in which case he is almost certain to present an unusually rapid pulse. Many an excellent risk has been needlessly rejected, on account of an unusual rapidity of pulse, which probably subsided before the applicant reached his own home. And this is an act of injustice to both company and applicant. In all cases in which the pulse is merely rapid, without symptoms of cardiac or other organic disease, the party should be allowed to sit until the heart shall have had time to resume its normal action'; or if this fails 172 of accomplishing the object, he should be re-examined on a subse- quent occasion, after having learned by experience, that an examin- ation for life insurance is not the fearful ordeal his imagination may have pictured it. I have frequently found it necessary, in my own experience, to make several examinations, and have even found some applicants so exceedingly " nervous" that I have been obliged to resort to the strategy of amusing them for awhile, by cheerful con- versation or otherwise, before getting at the real character of the heart's action, and have thereby received some most desirable risks which must otherwise have been rejected; and this is precisely the experience of many Medical Examiners. In fact, the pulse is very like an unreliable witness: it must be sharply "cross-examined," before full credence is given to its testimony. Note to page 127. (Locomotor Ataxy.) It is by no means impossible tha"t cases of Locomotor Ataxy, in its incipient stage, may present themselves to the Medical Examiner, and its early detection is both very important and very difficult. The symptom first complained of is generally pain, or rather pains. The patient generally supposes himself to be troubled with rheumatism or neuralgia ; and careful inquiry will often develop the fact that he has been repeatedly '\doctored" for one or the other or both of these diseases. But the anomalous character of these pains ought always to arouse the suspicions of the alert Examiner; the party describes them as "boring," or "stabbing," or "cutting," or "shooting' pains, and ofttimes seems vainly to rack his brain in search of a word of sufficient force and intensity to express his meaning; they are generally aggravated by sudden changes of temperature — especially by cold, damp weather; they seldom last longer than from a few seconds to a minute, but are liable to recur at very brief intervals— sometimes as often as "ten, fifteen or twenty times/an hour;" they are limited to no particular part of the body, though rather more likely to affect the lower extremities than otherwise. "Often a first sign is reeling about upon getting out of bed in the dark." At this stage, even, while the party admits no deterioration of his general health, careful observation will often detect defective co-ordination: if he is made to walk with his eyes closed, the gait will become 173 unsteady and staggering. Nocturnal incontinence of urine, and noc- turnal emissions of semen are also premonitory symptoms of loco- motor ataxy ; though these are less constant than the peculiar pains and uncertainty of locomotion above alluded to. But when these symptoms are present, the risk should be unhesitatingly declined, and the existence of any one of them suggests great caution, and probably a suspension of judgment. Note to page 129. (Vertigo.) Some companies inquire as to previous attacks of vertigo (dizzi- ness). This is a mere symptom, and its true character is usually misapprehended. It is safe to say that it is ordinarily but an evidence of dyspeptic derangement. It is not a precursory symptom of apo- plexy, paralysis, or organic diseases of the nervous centre of any sort. (Flint.) It is not an evidence of disease of the heart even. It is sometimes evidence of " nervous asthenia," but under such circum- stances concurrent symptoms will readily determine the true char- acter of the case. So also it may occur from sexual excesses, or the inordinate use of tobacco—cessation from the use of narcotics or stimulants, etc. Taken alone, its previous occurrence can scarcely be considered of sufficient importance to materially impair the risk. Note to page 134. (Softening of the Brain.) It is unfortunately the case that we have no symptom or group of symptoms which are pathognomonic of softening of the brain in its early stages — the only time at which it is at all liable to come before the Examiner; and this fact gives an additional importance to the disease, in its relation to life insurance. In the first place, softening of the brain occurs most frequently in those persons whose health has been for some time more or less impaired' without any assignable cause being apparent; the symptoms complained of are vague and unmeaning, being indicative of general debility or diminished vital power, rather than of any organic dis- ease ; in another class of cases, some " distinct chronic and exhaust- ing disease may be present"—but such cases will rarely or never come before the Insurance Examiner, the evidences of disease being sufficiently marked to attract the attention of the solicitor. The following remarks are intended to apply only to those cases which 174 are "developed slowly and insidiously," and which are not preceded by inflammation, hemorrhage, or acute ramollissement; in fact to cases of "chronic idiopathic ramollissement," and to these, even, only in their earliest stages. In the great majority of instances, the symp- tom first attracting attention, is a " torpor and prostration of intellect." The patient himself is generally aware that his powers of mind are gradually becoming weaker and weaker ; he finds himself unable to attend to his business — or at least to do so costs him a constant and painful effort; tasks which have seemed to him but trifles heretofore, now assume immense proportions; and he especially laments his inability to undertake and successfully prosecute any task requiring sustained mental effort. Sometimes a sudden inability to. prosecute some employment requiring unusual perfection of motor power first excites the patient's alarm; for example, a flutist of celebrity, fifteen months prior to the manifestation of any marked symptoms of cerebral disease, became suddenly unable to " finger " and blow his instru- ment with his accustomed skill, and this turned out to be a typical case of softening of the brain. "Softening of the cerebral hemis- pheres," says Andral, "induces alteration in motion much more con- stantly than in intelligence ;" but this rule is certainly not without its exceptions; for it is by no means unfrequently the case that mem- ory, or the power of retaining mental impressions and recalling them at will, is one of the early—indeed the earliest—symptoms of cere- bral softening. Occasionally the patient notices a slight impairment of the power of controlling the muscles of the lips and tongue, or perhaps of the cheeks and lips, or of the tongue alone ; he is sur- prised to find that he cannot eject his saliva with certainty and accuracy, or that he cannot fix his lips as in the act of whistling; his tongue becomes slightly tremulous, and when protruded turns slightly to one side. Another very important symptom, sometimes observed, is an unaccountable inability to write as well as usual; the patient cannot form letters, or guide his pen with accuracy ; he complains that "his hand trembles," and calls the attention of his friends to the fact, and to his inability to account for it; words are sometimes spelt wrong, or one word substituted for another, or the patient some- times writes and dispatches to distant friends, letters which are but *75 the merest muddle of nonsense — and yet, at this very time, he may converse rationally and coherently, and even attend to plain, simple matters of business. Among the prodromic symptoms of softening, may also be mentioned headache, "usually dull in character," numb- ness, obscure pain, weight or indescribable sensation of "something wrong," in the extremities, a stooping gait, and tendency to cramp in the limbs. When an applicant admits the presence of these symp- toms or of any one of them ; and especially when to this is super- added a general appearance of debility, let the risk be unqualifiedly rejected. Note to page 144. (Female applicants.) Extreme longevity is but rarely reached by women; yet the average duration of life among women is longer than among men, probably because they are less exposed to causes of mortality—and this even, with the perils incident to maternity added to other causes. In fact, other things being equal, the woman who is happily a wife and mother is far preferable, as an insurance risk, to the unfortunate spinster, upon whom age and decrepitude are only too certain to creep prematurely. The following tables are self-explaining, and therefore require no comment: TABLE SHOWING THE COMPARATIVE MORTALITY OF FIRST AND SUBSEQUENT LABORS. Authority. No. of Primi-fira. No. of Deaths. Or 0 ne in every No. of Multi-firte. No. of Deaths. Or one in every Hardy & McClintock Matthews Duncan.... Johnson & Sinclair... 2,125 3,722 4,535 35 5° 83 60 74 54 4,5IQ 12,671 9,213 30 103 80 150 123 "5 10,382 168 62 26,394 213 124 176 SHOWING THE MORTALITY FROM PUERPERAL FEVER IN DIF- FERENT PREGNANCIES.—(Matthews Duncan.) No. of Pregnancy. No. of Mothers. No. of Deaths. Percentage of Deaths. Or one in 2,253 4,031 ',563 189 97 85 47 9 4.30 2. II 3.OI 4.76 23 47 33 Fifth to Ninth......................... SHOWING THE RELATIVE LONGEVITY OF MARRIED AND UN- MARRIED FEMALES. At the age of-— 25. 30., 35- 40., A married female has to live— Tears. Mo nths. 40..................4 36..................° 32.................. 5 28.................11 *5..................7 An unmarried female has to Hue— Tears Mo nths. 3°..................8 30..........v......6 28.................11 26..................4 *3..................5 Diffe; Tears. 9..... 5..... 3..... Mas. ..8 ..6 ..6 ■•7 2........2 From the "Insurance Guide and Hand Book." Symptoms referable to Tobacco. Medical examiners, especially in the United States, will meet with many cases presenting symptoms of somewhat obscure origin, which may without doubt, be fairly attributed to the excessive use of tobacco. It is peculiarly prone to disturb the heart's action, render- ing its contractions weak and uncertain, and even, in some instances, producing marked irregularity of its rythm. A noticeable feature in such cases, is, that the most trifling causes will sometimes bring on violent attacks of palpitation; a few minutes of rapid walking; climbing several pairs of stairs hastily ; the presence in the stomach of indigestible articles of food ; any sudden mental excitement, even though trivial in its nature, and a variety of equally simple and unimportant causes, are often sufficient to provoke severe attacks of palpitation, which may also prove quite obstinate, "According to the experiments of Sir Benj. Brodie, tobacco causes paralysis of the heart, through the medium of the nerves " — and this conclusion gives additional importance to the facts above detailed in their relation to insurance. Mr. Lizars gives an account of an excessive smoker who was subject to terribly severe attacks of mgina pectoris ; after an 177 unusually severe and prolonged attack, which came near proving fatal, he abandoned smoking altogether, and the disease disappeared without any treatment. Severe dyspepsia is a very frequent result of using tobacco, and is in general very obstinate when dependent upon this cause ; obstinate constipation is another of its evil results ; from these two evils result emaciation and general debility, laying the foundation for various nervous diseases. A disorder very much resembling delirium tremens was several times witnessed by the late Dr. Chap- man, and by him attributed to this potent agent ; the patients recov- ered on abandoning their pipes. In the reports of nearly every' Insane Asylum in the United States, may be found several cases of insanity charged to the account of tobacco. In the form of snuff it sometimes becomes poisonous, on account of being contaminated with lead during the process of manufacture — thus producing lead colic or lead palsy. It would be easy to extend this list of symptoms to very much greater length, but sufficient has already been said to indicate its more general and prominent effects. Does the use of tobacco tend, materially, to shorten life ? Candid, unprejudiced observations on this point are very much needed. As yet we have no data upon which to found an opinion — much less to base a statement of facts. Several American " Counterblasts " have been launched against this persecuted weed; each as valueless and impotent as that of the Royal fop of England ; the clergy, the press and the medical profession, have severally waged war against tobacco, and yet it remains and will remain the delight of millions. There can be no doubt that an excessive use of tobacco__espec- ially by a person of feeble constitution—does tend, materially, to shorten life. Moreover, a person whose blood is already poisoned by nicotine, is thereby rendered less capable of surviving severe attacks of acute diseases, and this is a proper matter for the examiner to consider. Severe and obstinate dyspepsia, angina pectoris, or oft- recurring palpitation — especially if they exist in persons excessively addicted to the use of tobacco — demand rejection. For, even if it cannot be clearly shown that tobacco is the underlying cause, its use most assuredly adds one more element of danger in the case, and one much more likely to remain permanently, than to be removed by a resolute effort on the part of the applicant. I 2 INDEX. A Page. Artists.................................... 16 Artisans.................................. 16 Age.....................................18, 73 Acclimation.............................. 25 Army Employment..................... 28 Asthma.................................29, 83 Apoplexy............................29, 131 Ancestors Longevity..................;. 56 Answers of Applicant.................. 64 Appearance, General.................... 69 Aspect of Countenance................. 70 Age, Apparent........................... 73 Aphonia.................................. 83 Aneurism of Heart.....................101 Aneurisms................................108 Angina Pectoris.........................101 Adhesions, Heart........................101 Atrophy, Heart........... ..............101 Aortic Obstruction .....................105 Aortic Regurgitation....................105 Abdominal Organs....................109 Atrophy of Liver........................112 Atrophy of Mucous Membrane......116 Albuminuria.............................119 Addison's Disease....'....................123 Atrophy of Brain........................133 Asthenia, Nervous......................136 Abscesses.................................143 Amputations........................54, 146 B Bronchitis.............................. 31 Bones, Size of............................ 81 Bilious Temperament.................. 74 Blood Murmurs..........................107 Blood Vessels, Disease of..............108 Bright's Disease................. .. .....119 Brain, Disease of........................130 Brain Chron. Poisoning................136 Blanks, Filling up of...................150 C Page. Climate................................... 25 Consumption............................. 32 Cholic.................................... 32 Cardiac Diseases......................... 33 Chorea..................................... 37 Catarrh.................................... 42 Cough, Habitual........................ 53 Chest Measurement..................... 67 Complexion.............................. 71 Color of Hair and Eyes................. 71 Congestion of Lungs.................... 84 Cyanosis..................................102 Congestion, Liver...................... ill Cirrhosis of Liver.......................112 Calculus...................................122 Cystitis, Chronic........................122 Cerebro-Nervous System...............124 Convulsions..............................126 Co-ordination, Defective...............127 Coup de Soliel...........................135 Cutaneous Affections...................143 Climacteric, Female....................145 Constitution..............................147 Cachexia.................................149 Certificates, Duplicates.................151 D Diseases, Previous....................... 29 Dropsy.................................... 33 Diptheria................................. 34 Dyspepsia................................. 51 Dysentery................................ 52 Diarrnoea.............................52, 114 Disease within Seven Vears........... 55 Dyspnrea.................................. 85 Deposits, Pulmonary................... 85 Deposits, Signs of Pulmonary......86-88 Degenerations, Heart...................102 Dilatation, Heart........................102 I 79 i8o INDEX. Degenerations, Liver....................112 Digestion, Importance of...............116 Diabetes..................................122 Duchenne's Disease.....................126 Deposits, Brain..........................133 Delirium Tremens..................22, 137 Diathesis.................................148 E Employment, Previous................. 29 Eyes....................................... 72 Emphysema.............................. 89 Empyaemia............................... 91 Epilepsy...............................36, 126 Encephalitis..............................130 F Fistula.................................... 34 Fits...................................36, 126 Friend, Reference to.................... 62 Furunculi.................................143 Female Applicants......................144 G Gout....................................... 37 Gonorrhaa............................... 49 Growths, Intracranial..................133 H Heart Disease..................33, 93, 101 Hernia...............................43> z44 Haemoptysis.............................. 46 Haematemesis............................ 47 Hereditary Disease............18, 59, 138 Height.................................... 66 Hair....................................... 7' Hydrothorax.............................. 91 Heart—Signs of Disease : Location............................... 94 Bulging or Depression............... 94 Impulse................................ 94 Area of Dullness..................... 95 Pulsation............................. 96 Sounds................................. 9^ Location of Sounds..................100 Non-organic Disease of..............106 Hypertrophy, Heart.....................102 Hepatitis, Chronic.....................113 Haemorrhoids............................116 Hysteria..............................36, 126 Hypertrophy of Brain.................'.133 Hip Disease..............................144 I Intemperance........................22, 136 Insanity........................37, 13°. J37 Injury, Traumatic....................... 34 Page. Insurance, Previous..................... 63 Identity of Applicant................... 65 Idiosyncrasy.............................. 76 Inspection................................ 80 Intestinal Tube..........................114 Intellection, Derangement.............1 30 J Jaundice.................................. 39 Joints.....................................144 K Kidneys, Disease of.....................118 " Enlargement of...............118 L Life Expectation........................ 19 Liver, Disease of....................38, m Longevity of Ancestors................ 56 M Mechanics............................... 16 Marriage................................. 20 Muscles, Contour of, etc............... 72 Mensuration.............................. 78 Movements, Respiratory............... 80 Malformations, Heart..................103 Myocarditis..............................103 Mitral Regurgitation,..................105 " Obstruction.....................105 Motion, Derangement of...............125 Menstrual Functions....................145 Metritis, etc..............................146 N Name..................................... 15 Nervous Temperament................. 74 Neuralgia, Intercostal.................. 92 Nutrition.................................117 Nephritis, Chronic......................118 Nephralgia..............................118 Nervous Asthenia.......................136 o Occupation............................... 15 Opium Eating.......................... »3 P Professional Men........................ 16 Paralysis.......................4°> I28> J42 Palpitation................................ 4° Parents, Living or Dead, etc........... 58 Physician, Family....................... 61 Phlegmatic Temperament............. 74 Pulse...................................... 76 Pneumothorax........................... 91 Pleurodynia.............................. 91 INDEX. 181 Page. Pericarditis.............................103 Pancreas..................................11 3 Prostate, Enlarged.......................122. Poisoning of Brain......................136 Pregnancy and Parturition............144 Phlegmasis Dolens......................146 Q Quinsy................................... 4° R Residence................................. 15 Residence, Foreign..................... 25 Rheumatism................ .........41, 51 Rupture................................... 43 Rejection, Previous..................... 63 Respiratory Organs..................... 78 Respiratory Organs, Diseases of....... 82 Rigidity of Muscles.....................128 Ramollissemeni, Brain.................134 Ramollissement, Spina) Cord.........142 Risk, General Character...............147 S Sobriety................................... 21 Scarlatina.......... ..................... 45 Spitting of Blood........................ 46 Syphilis.................................... 49 Stricture..............................49> I22 Skin....................................... 7" Page Sanguine Temperament................ 73 Stomach..................................1 1 1 Spleen....................................114 Sensation, Derang. of..................129 Spasms....................................126 Softening of Brain......................134 Softening of Spinal Cord...............142 Sunstroke.................................135 Spinal Diseases..........................141 Senses Special, Loss.....................144 T Temperance............................. 21 Temperament.......................73, 147 Tumors, Intrathoracic................. 92 Tremor...................................125 Tumors...................................144 u Urinary Organs, Disease of............ 47 Ulcers....................................143 V Vaccination.............................. 24 Valvular Changes, Heart..............104 Varicose Veins...........................143 w Weight................................... 66 INDEX TO APPENDIX Page. Acclimation..............................162 Alcohol, Effects of.....................162 Applicants, Female.....................175 Brain, Softening of......................173 Blood, Spitting of.......................167 Consumption.............................163 Clergyman's Sore Throat..............154 Colored Races, Mortality of.....160, 161 Diarrhoea, Camp.................. .....163 Females, Longevity of..................176 Insanity...................................165 Intemperance............................161 Inebriates, Safety of....................162 Locomotor Ataxy.......................i7a Labor, Mortality from..................175 Page. Mortality, Tables of..............157, 158 Mortality, from various Diseases......156 Nephralgia..............................1 65 Occupation, Effects of..................151 Public Speakers, Safety of.............154 Professional Men........................154 Physicians................................154 Puerperal Fever, Mortality from.....176 Palpitation...............................166 Pulse......................................171 Sexes, Mortality of.....................159 Teachers.................................154 Tobacco, Effects of.....................176 Urine, Examination of..................169 Vertigo...............................173 « 3 > NOI1VN 3N I3I03W JO ASVUBIl IVNOIIVN 3 N I 3 I 0 3 W J O A II V D S IT 1 V N O I 1 V N 3N I 3 I 03W JO A«V« ■DICINE NATIONAL LIBRARY OF MEDI CI NE N A T I O N A L L I B R A R Y O F M E D I C I N E N A T I O N A L L I B II A R Y nuiivn ini^iusn iu Aavaaii ivnoiivn 31 •T \ - r .NOI1VN 3NI3I03W JO AlVigil IVNOIIVN 3NI3I03W JO AXVmil IVNOIIVN 9NDI03W JO AIVII "/ : v !< EDI CINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY / , \je\S I NOI1VN 3N I3I03W JO AHVIHn IVNOIIVN 3NI3I03W JO A « V 8 fl I 1 TVNOUVN 3 N I 3 I 0 3 W JO A a V « J DICINE N ATION AL -LI BR ARY OF MEDICINE NATIONAL L \/%&l IBRARY OF MEDICINE NATIONAL LIBRARY s I J> \ vv • fly. \ ^ ■Sk £ ^ ^r^ia :*•'jk/^ „ v BRARYOF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATION i / Ad V BB IT TV NOUVN 3NI3I03W JO A B V 11 8 I 1 TVNOUVN 3NI3IQ3W JO A B V II 8 I T TVNOUVN 3NI3IQ ABVBBIT TVNOUVN 3NI3I03W JO A »V II8 IT TVNOUVN 3NI3IQ3W JO AdVdBIT TVNOUVN 3NI3I0 > AdVBail TVNOUVN 3NI3IQ3W JO AdVdaiT TVNOUVN 3NI3IQ3W JO ABVdaiT TVNOUVN 3NI3IC