LIFE INSURANCE EXAMINATION EDITED BY FRANK AV. FOXWORTHY, Ph.B., M.D. Indianapolis, Indiana FORMERLY CHAIRMAN MEDICAL SECTION, AMERICAN LIFE CONVENTION, PRESIDENT OF THE AMERICAN ASSOCIATION OF MEDICAL EXAMINERS, CHIEF SURGEON INDIANA NATIONAL GUARD, MAJOR AND SURGEON U. S. -V. ; AT PRESENT ON STAFF METHODIST EPISCOPAL AND CITY HOSPITALS. ASSOCIATE EDITOR ' ' MEDICAL INSURANCE. ' ' FOR MANY YEARS A MEDICAL DIRECTOR, A MEDICAL REFEREE, AND A MEDICAL EXAMINER. ONE HUNDRED FIFTY-SIX ILLUSTRATIONS ST. LOUIS THE C. V. MOSBY COMPANY 1924 Copyright, 1924, by The C. V. Mosby Company (All rights reserved) Printed in U. S. A. Press of The C. V. Mosby Compay St. Louis TO THE MEDICAL EXAMINER COLLABORATORS HENRY ANTHONY BAKER, M.D. Medical Di l ector, Kansas City Life Insurance Company CHARLES II. BECKETT Actuary, The State Life Insurance Company W. W. BECKETT, M.D. Vice-President and Medical Director, The Pacific Mutual Life Insurance Company EDWARD B. BIGELOW, M.D. Assistant Medical Director, State Mutual Life Assurance Company T. W. BLACKBURN Secretary and Counsel, American Life Convention DAVID N. BLAKELY, M.D. Assistant Medical Director, The New England Mutual Life Insurance Company ALBERT C. BRODERS, M.D. Section on Pathology, Mayo Clinic RACHEL H. CARR, M.D. Medical Director, The Peoples Life Insurance Company LARUE D. CARTER, M.D. Medical Director, Norways Sanatorium; Associate Professor Nervous and Mental Diseases, Indiana University School of Medicine; Colonel, Med. 0. R. C. JOHN M. CONNOLLY, M.D. Chemist, Metropolitan Life Insurance Company HENRY WIREMAN COOK, M.D. Vice-President and Medical Director, Northwestern National Life Insurance Company G. E. CRAWFORD, Pll.D., M.D. Medical Director, Cedar Rapids Life Insurance Company GEORGE W. CRILE, M.D. Cleveland Clinic WM. G. EXTON, M.D. Director of Laboratories, The Prudential Insurance Company of America J. W. FISHER, M.D. Medical Director, The Northwestern Mutual Life Insurance Company 5 6 COLLABORATORS PAUL FITZGERALD, M.D. Associate Medical Director, The Prudential Insurance Company of America J. H. FLORENCE, M.D. Ex-Vice President and Medical Director, Great Southern Life Insurance Company; Ex-State Health Officer of Texas HOMER GAGE, M.D. Medical Director, State Mutual Life Assurance Company FRANK L. GROSVENOR, M.D. Medical Director, Travelers Insurance Company W. F. HAMILTON, M.D. Consulting Medical Referee, Sun Life Assurance Company of Canada WALTER C. HILL Vice-President, Retail Credit Company ROBERTSON G. HUNTER Second Vice-President and Actuary, Equitable Life Insurance Company of Iowa FRANK L. B. JENNEY, M.D. Medical Director, Federal Life Insurance Company, and Secretary of the Medical Section of the American Life Convention GEORGE EDWARD KANOUSE, M.D. Assistant Medical Director, The Prudential Insurance Company of America WILLIAM ROSS KING Editor, The Legal Bulletin HAROLD F. LARKIN Secretary, The Connecticut Mutual Life Insurance Company JOHN MASON LITTLE, M.D. Assistant Medical Director, The New England Mutual Life Insurance Company D. C. MacEWEN Junior Vice-President, The Pacific Mutual Life Insurance Company geo. g. McConnell, m.d. Medical Examiner in Chief, Insurance Department, Supreme Lodge Knights of Pythias C. NAUMANN McCLOUD, M.D. Medical Director, Minnesota Mutual Life Insurance Company JAMES C. MASSON, M.D. Section on Surgery, Mayo Clinic WM. MUHLBERG, M.D. Medical Director, Union Central Life Insurance Company COLLABORATORS 7 J. BERGEN OGDEN, M.D. Assistant Medical Director and Chemist, Metropolitan Life Insurance Company J. ALLEN PATTON, M.D. Medical Director, The Prudential Insurance Company of America WM. EVELYN PORTER, M.D. Medical Director, The Mutual Life Insurance Company of New York FRANCIS M. POTTENGER, M.D., F.A.C.P. Medical Director of Pottenger Sanatorium OSCAR H. ROGERS, M.D. Chief Medical Director New York Life Insurance Company ROBERT LEE ROWLEY, M.D. Medical Director, Phoenix Mutual Life Insurance Company EUGENE F. RUSSELL, A.B., M.D. Associate Medical Director, The Mutual Life Insurance Company of New York, Lecturer on Life Insurance Medicine, University and Bellevue Medical College S. B. SCHOLZ, JR., M.D. Associate Medical Director, Massachusetts Mutual Life Insurance Company ALBERT SEATON, M.D. Vice-President and Medical Director, The Century Life Insurance Company MARION SOUCHON, M.D. Medical Director, Pan-American Life Insurance Company SAMUEL C. STANTON, M.D. Chief Medical Director, Farmers National Life Insurance Company of America GEORGE S. STRATHY, M.D. Assistant Medical Director, Canada Life Assurance Company; Lieut. Colonel, Canadian Army Medical Corps HARRY TOULMIN, M.D. Medical Director, Penn Mutual Life Insurance Company JOHN H. WARVEL, M.D. Pathologist, Indianapolis Methodist Episcopal Hospital FRANKLIN C. WELLS, M.D. Medical Director, Equitable Life Assurance Society WILLIAM CHARLES WHITE, M.D. Chairman Medical Research Committee, National Tuberculosis Association; Ex- Medical Director, Tuberculosis League of Pittsburgh M. C. WILSON, M.D. Assistant Medical Director, The Travelers Insurance Company PREFACE Life Insurance has become one of the great business interests of the world. Policies aggregating over sixty billion dollars are now in force in the United States alone. Companies having more than a billion dollars of assets are no rarity. Careful business management has been combined with excellent medical selection to produce this result. The medical department of the Home Office could not have accomplished this alone. The medical examiner must be recognized as a vital causative factor. Millions of dollars are paid him each year for his examinations. The better the examinations, the greater number will he have, and with better results for the Home Office. This volume, it is hoped, will be a guide to the examiner. The senior medical student should receive competent instruction in the theory of life insurance, and in the practical methods of making life insurance examinations. This is as necessary as the courses prescribed by our medical colleges for the treatment of disease. Many young physicians start their careers as examiners for industrial, as well as ordinary, insurance. To them this volume should be a textbook. The medical director and the medical referee will find in this volume, not only able advice as to their respective duties, but also most comprehensive scientific and insurance information that should be a ready aid in every problem that arises. Dr. Oscar II. Rogers, addressing the senior class of the College of Physicians and Surgeons, Columbia University, said: "There are two fundamental facts in life insurance: first, that human beings die at certain definite predetermined rates; second, the in- terest-earning power of money. By compounding interest, money doubles itself in less than twenty years. People often insure every- thing but their lives. It is difficult for them to see the necessity and to believe that so many out of every thousand die every year. It is necessary to have agents to convince them. This is most noble work and never should be spoken of with contempt. Examiners are needed to show truthfully and accurately what the applicant may try to conceal. It is best to confine the examiner to one 9 10 PREFACE territory as lie thereby has a better knowledge of the community, and it is honest and square to the examiners in other territories. The companies often prefer young men for examiners as they are better trained and know more modern medicine. However, it should be a stepping stone to a good family practice, rather than to make it an end. A physician may examine all his life and never get anything out of it but his examinations. The agent is eternally struggling to minimize any unfavorable features. The agent's sug- gestions should be met with a smile, but don't forget to be square to the medical director. Do not wobblfe in your statements to him. His point of view is different. He is human, as a rule is square, and all you need to do is to be as square as you can be and just as human as can be. Your report to the medical director should be so clear that he should see what you have seen. Brevity and the graphic qualities make the report worth while." Agents are the salesmen of the company. Not only must they know their own stock thoroughly, but also what policy is best fitted for each case. Only an accurate knowledge of disease can place substandard business. The time is not far distant when every life will have an insurable value. Never before in the history of life insurance has such progress been made in the valuation of human lives, and every year finds more companies writing substandard business. It will not be long before all the life insurance companies will accept substandard risks. This volume should be the consultant of the agent. The enormous expansion of 'life insurance has rendered it im- possible for any one man to cover the entire subject of life insurance examination. During the past eight years the editor has consulted the leading medical directors of the United States and Canada as to the proper subject matter. Science is making daily progress, yet the mortality from cancer, syphilis, tuberculosis, heart and nervous diseases is too high. Specific remedies, as insulin in diabetes, may be waiting on our threshold. Until then, too much knowledge of these diseases cannot be acquired. While the editor did not wish to avoid responsibility, yet whenever it was necessary to make a decision, especially as to what should or should not be published, specialists in each particular subject were consulted. Each author is responsible for his own contribution. Too much credit cannot be accorded to these leaders in life insurance who ]'REFACE 11 have given freely of their time to make this volume a success. The authors of the various chapters have assisted me so greatly that it seems but a mediocre appreciation to mention the fact. Their patience, kindness and advice have been of inestimable value. I am especially under deep obligations for expert assistance to Dr. Oscar H. Rogers, Chief Medical Director of the New York Life Insurance Company; also to the Mutual Life Insurance Company, the Metro- politan Life Insurance Company, the Prudential Insurance Com- pany, the Equitable Life Assurance Society, Dr. J. Allen Patton, Medical Director, the Prudential Insurance Company; Drs. T. II. Rockwell, Medical Director, and Robert M. Daley, Associate Medical Director of the Equitable Life Assurance Society; Dr. Henry Wire- man Cook, Medical Director, the Northwestern National Life In- surance Company; Dr. E. W. Dwight, Medical Director, New Eng- land Life Insurance Company; Dr. Frank L. B. Jenney, Medical Director, the Federal Life Insurance Company; Dr. Lee K. Frankel. Vice-President, Metropolitan Life Insurance Company; Dr. Carleton B. McCulloch, Medical Director, State Life Insurance Company; Dr. Whitfield Harrel, Medical Director, Southwestern Life Insur- ance Company; Dr. Henry A. Baker, Medical Director, the Kansas City Life Insurance Company; Dr. C. Naumann McCloud, Medical Director, the Minnesota Mutual Life Insurance Company, the late Dr. M. M. Smith, former Editor "Medical Insurance," Dr. Chas. P. Emerson, Dean, Indiana University School of Medicine, and many others. Any typographical excellence of this volume must be credited to the publishers and also especially to Dr. Samuel Cecil Stanton, formerly Surgeon General of the Illinois National Guard and for many years'assistant editor of the Journal of the American Medical Association, and Dr. L. D. Carter, Medical Director, The Norways Sanatorium. Frank W. Foxworthy. Indianapolis, Ind. CONTENTS CHAPTER I A History of Life Insurance Examinations 25 CHAPTER II Examination and Inspection of Industrial Insurance 45 Configuration or Build, Nutrition, Nationality, Identity, 4G; Height, ■Weight, Complexion, Occupation, The Teeth, The Tongue, The Eyes, 47; The Throat, The Hands, The Gait, The Face, The Neck, The Abdomen, 48. CHAPTER III Group Insurance 51 CHAPTER IV Fraternal Insurance 54 Origin, 54; Growth, 58; Medical Selection, 59. CHAPTER V The Relation of the Agent to the Medical Examiner 07 CHAPTER VI Organization of Medical Department 75 The Medical Examiner, 78; Office System, 84. CHAPTER VII The Medical Director 92 Medical Referees 97 CHAPTER VIII CHAPTER IX The Medical Examiner 108 General Instructions to Examiners 113 Name, Address, and Occupation, 117; Age and Date of Birth, Married or Single, Habits, 118; Drug Habits, Insurance History, 119; Health Record, Injuries and Accidents, Asylums or Hospitals, 120; Rheuma- tism, Syphilis, Asthma, Indigestion, 121; Blood-Spitting or Chronic Cough, Voiding Urine at Night, Albumin or Sugar in Urine, Epilepsy, Habitual Headaches, Insanity, 122; Paralysis, Neuralgia, Palpitation of the Heart, Fistula, Appendicitis, Tumor or Cancer, Ulcer, Prostatic Disease, Pleurisy and Pneumonia, 123; Present Health, Gain and Loss in Weight, Comsumptive Association, Women Applicants, Insurable In- CHAPTER X 13 14 CONTENTS terests, 124; Climacteric, Miscarriages, Female Diseases, Family His- tory, 125; Physical Examinations, Disrobing, Inspection, 126; Pulse Rate, Blood Pressure, Height and Weight, Heart and Lungs, Rupture, Urine, Urinalysis, 127; Review, Signature, Classification, Report, Con- clusions, 128. CHAPTER XI The Etiquette of Medical Examinations 130 The Examination, 132; The Medical Blank, 134. The Examination of Women 137 Goiter, 138; Systemic Signs in Tuberculosis, 140; Cardiovascular Prob- lems, 141; Hypertension, 144. CHAPTER XII CHAPTER XIII The Mouth, Nose, Throat, Eye and Ear 146 The Mouth, Nose and Throat, 146; The Eye, 147; The Ear, 149. CHAPTER XIV The Respiratory System 152 Physical Examination, 153; General Rules for Examination, 153; Pos- ture, 153; Inspection, 153; Palpation, 155; Percussion, 155; Ausculta- tion, 157; X-ray Examination, 160; Repeated Examinations, 160. Tuberculosis 162 CHAPTER XV CHAPTER XVI General Consideration of Cardiac Conditions from the Life Insurance Standpoint 165 Examination of the Heart and Blood Vessels 169 Diagnosis of Cardiac Conditions, 169; Physical Examination of the Heart, Location of Heart, 172; Inspection, 172; Palpation, 174; Per- cussion, 175; Auscultation, 176; Heart Murmurs, 178; Hypertrophy and Dilatation of the Heart, 183; Nonorganic Murmurs or Functional Mur- murs, 183; Precordial Friction or Pericarditis, 184; Chronic Myocarditis, 184; Examination of the Pulse, Arteries and Veins, 191; Arterioscle- rosis, 193; Aneurysm of the Arch of the Aorta, 194. CHAPTER XVII The Abdomen . . . . ; 197 Presumptive Evidence, 199; Positive Evidence, 200; Confirmatory Evi- dence, 205; .Appendicitis, 221; Stones in Gall-Bladder, 222; Ulcer of Stomach-pr Duodenum, . 223 ; Benign Tumors, 224; Hernia, 224. CHAPTER XVIII CONTENTS 15 CHAPTER XIX The Nervous System 227 History, 227; Examination, 229; Diseased Conditions, 243. CHAPTER XX The Endocrines and Visceral Nerves in Relation to Life Insurance Examination 274 CHAPTER XXI Blood Pressure and How to Take It 279 CHAPTER XXII The Diagnostic Value of the Sphygmomanometer in Life Insurance Examinations 299 Suggestions as to Method of Taking the Blood Pressure, 301; Result of Recent Investigation Covering Only Cases of High Arterial Tension with no Other Impairment at Date of Rejection, 308; Conclusions, 312. CHAPTER XXIII Syphilis from the Life Insurance Standpoint 314 Treatment of Syphilis, 318; Metallic Poisoning, in Industry and in the Treatment of Syphilis-A Comparison, 320; Syphilis, a General In- fection, 321; Syphilis of the Circulatory System, 322; Syphilis of the Nervous System, 328; General Considerations, 331. CHAPTER XXIV Eocal Infection 335 Primary Foci of Infection, 337; Bacteria Found in Primary Foci of Infection, 337; Bacteria in Secondary Foci of Infection, 337; Secondary Localization of Bacteria, 338; Diagnosis o-f Presence of Foci of Infec- tion, 340. Goiter 342 CHAPTER XXV CHAPTER XXVI Goiter and Life Insurance 345 Postoperative Risks 356 Tuberculosis and Malignant Disease, 357; Surgeon's Certificate, 357; Appendectomy, 357; Herniotomy, 357; Gastric and Duodenal Ulcers, 357; Gall-Bladder Surgery, 359; Pelvic Operations of Women, 360; Kidney Surgery, 360; Empyema, 361; Mastoid Operation, 361; Trau- matic Surgery, 361; Sepsis, 361. CHAPTER XXVII CHAPTER XXVIII Malignant Epithelial Neoplasms 363 Pathologic Classification, 365; Squamous-Cell Epithelioma, 368; Basal- Cell Epithelioma, 371; Melanoepithelioma, 372; Nonmelanotic Melano- 16 CONTENTS epithelioma, 377 ; Adamantine Epithelioma or Adamantinoma, 377; Mixed Epithelioma, 382; Adenocarcinoma, 384; Location, 385; Degree of Malignancy, 387; Treatment and Results-Epithelioma, 388; Squamous- Cell Epitheliomas of the Skin, 390; Squamous-Cell Epithelioma of the Lip, 391; Squamous-Cell Epithelioma of the Cheek, 393; Squamous- Cell Epithelioma of the Mucous Membrane of the Jaw, 393; Squamous- Cell Epithelioma of the Tongue, 396; Squamous-Cell Epithelioma of the Nose, Nasopharynx, and Sinuses, 396; Squamous-Cell Epithelioma of the Tonsil, 397; Squamous-Cell Epithelioma of the Esophagus, 397; Squamous-Cell Epithelioma of the Bladder, 398; Carcinoma of the Genital Organs, 398; Basal-Cell Epithelioma, 402; Melanoepithelioma and Nonmelanotic Melanoepithelioma, 402; Treatment and Results- Adenocarcinoma, 404; Malignant Tumors of the Thyroid, 404; Cancer of the Stomach, 405; Cancer of the Large Intestine and Rectum, 406; Cancer of the Kidney, 410; Cancer of the Breast, 410; Cancer of the Uterus and Ovary, 411; Cancer of the Prostate, 414; Treatment and Results in Teratoma, Mixed Tumor and Chorioepithelioma, 415; Terat- oma, 415; Mixed Tumors of the Salivary Glands and Palate, 415; Chorioepithelioma, 415. Urinalysis 419 Female Applicants, 420; Condition of Specimen, 421; Appearance of Specimen, 422; Specific Gravity of Specimen, 424; Albumin Test, 425; Urea, 428; Chlorides, 428; Twenty-four Hour Specimen, 429; Sugar, 431; Ketones, 433; Bile, 434; Indican, 434; Blood Pigments, Urobilin, Microscopic Examination, 435; Functional Test, 436; Effect of Muscular Exercise, 437. CHAPTER XXIX The Examination for Albumin and Casts 440 Tests for Albumin, 440; Significance of Albumin, 444; Casts, 446; Significance of Renal Casts, 451. CHAPTER XXX CHAPTER XXXI Album[nuria and Cylindruria 454 Albuminuria, 454; Cylindruria, 458. Glycosuria 470 CHAPTER XXXII CHAPTER XXXIII Laboratory Procedures 490 The Wassermann, 490; Blood Chemistry, 491; Basal Metabolism, 492. CHAPTER XXXIV Life Insurance Examinations in the South 493 Malaria, 494; Pellagra, 495; Hookworm, 496; Tuberculosis, 497; Oc- cupational Hazards, 498. CONTENTS 17 CHAPTER XXXV Hazards of Tropical Risks 502 Climatic Conditions, 502; Life Habits of the People, 503; Problems of Accessibility, 504; Problems of Inspection, 504; Poor Mail Facilities, 506; Earthquakes, 506; Conditions Relating to Risks, 506; Race and Family History, 506; The Alcoholic Equation, 508; Diseases, 510; Revo- lutionary Hazards, 511; Conditions Relating to Examiners, 512; Selec- tion, 512; Qualifications and Equipment, 512; Political Entanglements, 513; Comparison of Premium Rates, 514. CHAPTER XXXVI Army Service as an Insurance Problem 515 Compound Fractures of Long Bones-Amputations, 520; Head Wounds and Fractures of the Skull, 522; Chest Wounds, 523; Wounds Penetrat- ing the Abdomen, 526; Nervous Disorders and " Shell Shock," 526; Pneumonia and Bronchitis, 537; Tuberculosis, 538; The Effect of Service on the Heart, 540; Trench Fever, 541; Trench Nephritis and Albuminuria, 542; Tropical Diseases, 547; Blackwater Fever, 549; Bacillary Dysentery, 549; Amebic Dysentery, 549; Sunstroke, 549; The Ex-Soldier's Opinion of His Diseases and Injuries, 550; Service with- out History of Illness, 551 ; Casualties, 552. CHAPTER XXXVII Numerical Method of Valuing Lives for Insurance 553 CHAPTER XXXVIII Insurance of Substandard Lives 558 Extra Premium Method, 565; Lien Method, 566; Rated-Up Method, 567. CHAPTER XXXIX The Relation of Build to Mortality 579 CHAPTER XL Examinations for Health and Accident Insurance 590 The Accident Policy, 592 • Specific Losses, 592; Total and Partial Dis- ability, 593; Surgical Hospital Benefits and Doctor 's Fees, 593; Op- tional Indemnity, The Health Policy, Temporary Disability, 594; Permanent Disability, Hospital Indemnity, Surgical Benefits, The Examination of Claimant, 595, Examination of Health Claimant, 599. The Selection of Risks for Disability and Double Indemnity Benefits 601 CHAPTER XLI Health Conservation G05 CHAPTER XLII 18 CONTENTS CHAPTER XLIII Insurance Welfare Work 616 CHAPTER XLIV Inspection Reports 625 Occupation, 636; Finances, 636; Reinspections, 637. Fraud 638 Fraud by the Examiner, 639; Fraud by Applicant and Examiner, 640; Fraud by the Beneficiary, 640; Fraud by the Applicant, 641; Fraud by Suicide, 642; Fraud by Substitution, 643; Fraud by Beneficiary, Agent and Examiner, 644; Fraud by Applicant and County Clerk, 646. CHAPTER XLV Legal Aspects of Life Insurance Examinations 648 The Relation of the Medical Examiner to Insurer and Insured, 648; General Rule, 648; The Exception, 648; Incompetency of Examiner, 649; Connivance with Applicant, 649; Reason for Relieving the Com- pany of Liability, 649; Interpretation of Questions by the Medical Examiner, 649; Examples, 650; Company Bound Where Examiner In- correctly Reports Answers, 650; Personal Knowledge of the Medical Examiner, 651; Medical Examiner's Knowledge of Facts in Applica- tion, 652; Examiners not Regularly Employed, 652; Ratification by Applicant of Examiner's Acts, 652; Rule as to Agents Under Iowa Statute, 652; The Medical Examinations, 653; Matters of Opinion, 653; Name and Age of Insured, 654; Statements as to General Health- Temporary Ailments, 654; Good Health, 654; Specific Disorders, 655; Colds, 656; Bronchitis, 656; Catarrh, 656; Dyspepsia, 656; Nephritis, 656; Fainting Spells, 657; Hernia, 657; Pregnancy, 657; Miscellaneous Ailments, 657; Contact with Transmissible Diseases,. 658; Medical Attendance, 658; Attendance for Serious Diseases, 658; Eczema, 659; Inflammation of the Throat, 659; Headache, 659; Statements as to Occupation, 660; Questions as to Temporary Employment, 660; Divided Employment, 661; Examples, 661; Conclusions as to Occupational An- swers, 663; Conclusion, 663. CHAPTER XLVI CHAPTER XLVII The Influence of Occupation on Life Underwriting 666 The Accident Hazard, 667; Living Conditions, 668; Degenerative In- fluences, 668; Moral Environment, 670; Liquor Business, 670; Methods of Rating, 670; Removal of Rating, 674; Disability Benefits, 675; Double Indemnity, 675; Occupational Blank, 676; Questionable Hazards, 678. Postponement in Disease 681 CHAPTER XLVIII ILLUSTRATIONS FIG. PAGE 1. Application issued in 1857. Prudential Assurance Company of' Eng- land 26 2. Application issued in 1857. Prudential Assurance Company of England 30 3. Plank in use in 1857 by the Mutual Life Insurance Company of New York 31 4. Blank in use in 1857 by the Mutual Life Insurance Company of New York 32 5. Blank in use in 1920 by the Prudential Assurance Company of England 33 6. Blank in use in 1920 by the Prudential Assurance Company of England 34 7. Blank in use in 1920. Penn Mutual Life Insurance Company ... 38 8. Blank in use in 1920. Penn Mutual Life Insurance Company ... 39 9. Blank in use in 1920. Northwestern Mutual Life Insurance Company 41 10. Blank in use in 1920. Northwestern Mutual Life Insurance Company . 42 11. Medical examination blank used by the Supreme Lodge Knights of Pythias 64 12. Answers made to the medical examiner, American Life Convention Company 80 13. Examiner's confidential report and medical examiner's report, American Life Convention Company 81 14. Card used in home office for recording examiner's work 83 15. Shows the older, still widely used, method of handling an application 88 16. Shows a diagrammatic scheme of an ideal office arrangement where the application travels in a direct line within a single room from the time it is received at the home office until the application is filed . 88 17. Shows a copy of the examination upon which the first policy was issued by the Massachusetts Mutual Life Insurance Company .... 99 18. The examining cape in use 154 19. Barrel-shaped chest, a case of long-standing pulmonary emphysema . . 154 20. Deformity of the chest due to thoracic aneurysm 154 21. Simple clubbing of the fingers 155 22. Fluid, showing massive effusion filling completely the right side of the chest 156 23. Empyema, showing encysted empyema 157 24. Artificial pneumothorax 158 25. Cavity upper right lobe showing marked fibrous capsule 159 26. Foreign body in lung without symptoms of any sort and yet offers large element of danger in insurance risks 160 27. Areas over which nonorganic sounds are heard with maximum intensity; areas over which organic heart murmurs are heard 170 28. Diagram showing approximate outline of heart on chest wall .... 173 29. Diagram showing areas over which heart sounds are heard upon ausculta- tion 177 19 20 ILLUSTRATIONS FIG. PAGE 30. Mitral regurgitation 179 31. Mitral stenosis 180 32. Aortic regurgitation 181 33. Aortic stenosis 182 34. Chart for indicating organic heart murmurs. Mutual Life Insurance Company 185 35. Chart for indicating nonorganic sounds. Mutual Life Insurance Company 186 36. Special heart blank. New York Life Insurance Company .... 187 37. Special heart blank. New York Life Insurance Company .... 188 38. Special heart letter. The Equitable Life Assurance Society .... 189 39. Special heart letter. The Equitable Life Assurance Society . . . 190 40. Regions of the abdomen 203 41. Radiogram showing normal colon and gallstones 205 42. Radiogram showing facetted gallstones 206 43. Radiogram showing retrocecal chronic appendix 207 44. Radiogram showing chronic adherent appendix holding cecum up . . 208 45. Radiogram showing cancer of cecum 209 46. Radiogram showing cancer of cecum and ascending colon with involve- ment of ileocecal valve 210 47. Radiogram showing cancer of ascending colon and hepatic flexure . . 211 48. Radiogram showing carcinoma of lower third of esophagus. Stomach normal. Duodenal cap and sphincter well shown 212 49. Radiogram showing normal tubular type of stomach showing cap and sphincter 213 50. Radiogram showing perforating saddle ulcer, lesser curvature stomach 214 51. Radiogram showing normal tubular stomach in oblique position as seen in cholecystitis. Duodenum held against liver 215 52. Radiogram showing multiple papilloma of stomach, mistaken for malignancy 216 53. Radiogram showing bismuth enema, marked ptosis 217 54. Radiogram showing bismuth enema, long pelvic type of cecum . . . 218 55. Radiogram showing ulcer of duodenum, nonobstructing 219 56. Radiogram showing obstructing carcinoma of the greater curvature side of antrum 220 57. Chart showing blood pressure, auscultatory method 280 58. Small mercurial sphygmomanometer 281 59. Large mercurial sphygmomanometer 282 60. Small mercurial sphygmomanometer 283 61. Large mercurial sphygmomanometer 284 62. Small aneroid sphygmomanometer 285 63. Large aneroid sphygmomanometer 287 64. Palpatory method 288 65. Auscultatory method. Small instrument 289 66. Auscultatory method. Large instrument 290 67. Exercising while blood pressure is being taken 292 68. Chart showing incidence of goiter and its geographic distribution . 346 ILLUSTRATIONS 21 FIG. PAGE 69. Diagrammatic representation of the original structural facts found in the mammary acinus 367 70. Squamous-cell epithelioma of the lip 369 71. Squamous-cell epithelioma of the tongue 369 72. Squamous-cell epithelioma of the larynx 369 73. Papillary epithelioma of the urinary bladder 369 74. Squamous-cell epithelioma of the cervix 369 75. Squamous-cell epithelioma of the penis 369 76. Squamous-cell epithelioma of the lip 370 77. Squamous-cell epithelioma of the temple 370 78. Squamous-cell epithelioma of the left submaxillary lymph node, second- ary to epithelioma of the lip 371 79. Squamous-cell epithelioma of the urinary bladder 372 80. Squamous-cell epithelioma of gall-bladder 373 81. Epithelioma of the skin of the nose, showing squamous cells and gland type of basal cells intimately connected (typical metaplasia) . . 374 82. Basal-cell epithelioma of the scalp 374 83. Basal-cell epithelioma of the eyelid 374 84. Basal-cell epithelioma of the nose, showing solid plugs of cells . . . 375 85. Basal-cell epithelioma of the cheek 375 86. Melanoepithelioma of the skin over the left scapula 375 87. Metastatic melanoepithelioma of the left axillary glands, secondary to growth shown in Fig. 86 376 88. Melanoepithelioma of the skin of the groin 376 89. Melanoepithelioma of the skin of the calf of the leg 377 90. Nonmelanotic melanoepithelioma of skin over left shoulder . . . 377 91. Nonmelanotic melanoepithelioma shown in Fig. 90 378 92. Adamantinoma showing solid areas and cysts 378 93. Adamantinoma showing direct connection with the epithelium of the gum 379 94. Section from center of tumor shown in Fig. 93, showing different types of cells and early cyst formation 380 95. Mixed epithelioma of the palate showing direct connection of tumor cells and epithelium 381 96. Different field in tumor shown in Fig. 95 showing squamous and gland epithelium intimately connected 381 97. Carcinoma of the thyroid 382 98. Carcinoma of the breast 382 99. Carcinoma of the breast 383 100. Ulcer of the stomach associated with carcinoma 383 101. Carcinoma of the stomach (leather bottle type) showing glandular involvement 384 102. Carcinopia of the stomach 385 103. Papillary carcinoma of the ileum 386 104. Carcinoma of the cecum 387 105. Carcinoma of the sigmoid 388 22 ILLUSTRATIONS FIG. PAGE 106. Carcinoma of the rectum 389 107. Carcinoma of the rectum showing involvement of circumference of bowel 390 108. Mortality from cancer 416 109. Immiscible balance and improved urinometer 426 109zl. Standard tubes for estimating albumin quantitatively by Exton.'s test 427 110. Doremus-Hinds ureometer 429 111. Skopometer for directly estimating cloudiness and color of liquids as used in Prudential Laboratory 430 112. Euscope set for routine microscopy as used in Prudential Laboratory . 437 113. Method for detecting minute quantities of albumin 441 114. Method of performing nitric acid contact test for albumin .... 441 115. Method for the detection of minute quantities of albumin .... 442 116. Nitric acid test for albumin 443 117. Pure hyaline casts 447 118. Fibrinous casts 448 119. Waxy casts 449 120. Hyaline and finely granular casts 450 121. Epithelial cast, blood cast, pus cast, fatty cast with compound granule and fatty renal cell adherent 450 122'. False casts or cylindroids 451 Chart. Visual albuminuria guide 458 123. Advanced dressing station in a trench 516 124. Field ambulance stretcher bearers at Passchendaele, November, 1917 . 517 125. Light railway for evacuating wounded from forward area .... 518 126. German prisoners stretcher-bearing on their way out, Passchendaele, 1917 519 127. Working in a main dressing station 521 128. German prisoners carrying a wounded Britisher 522 129. Stretcher-bearing down a trench mat track. November, 1917, Pas- schendaele front 523 130. Dressing wounded at an advanced dressing station ..*.... 525 131. Getting wounded prisoners out 528 132. The ground over which wounded had to be evacuated at Passchendaele 529 133. German prisoners carrying out their wounded 530 134. German prisoners carrying out British wounded 532 135. Mortality curves of certain companies 559 136. Chart showing ultimate rate of mortality-American Men Mortality Table, also ultimate rate of mortality-50 to 60 pounds overweight 562 137. Chart showing ultimate mortality-American Men Mortality Table, also ultimate rate of mortality-25 to 45 pounds underweight and tuberculous family history 563 138. Chart showing ultimate rate of mortality-American Men Mortality Table, also ultimate rate of mortality-locomotive engineers . . 564 139. Chart showing ultimate rate of mortality-American Men Mortality Table, also ultimate rate of mortality-free users of alcohol . . 568 ILLUSTRATIONS 23 FIG. PAGE 1-10. Chart showing rate of mortality-American Experience Table at True Age, rate of mortality-150 per cent of American Experience Table, and rate of mortality-American Experience Table at rated- up age 569 141. Basic ratings for build 571 142. Additions to basic ratings for tuberculosis in family record . . . 572 143. Chart showing additions to basic ratings for abdominal girth greater than chest expanded, deductions from basic ratings for abdominal girth less than chest expanded, and deduction from basic ratings for endowments maturing under age of 55 574 144. Health conservation methods used by the Metropolitan Life Insurance Company 617 145. Mortality organic heart disease 618 146. Mortality of tuberculosis of the lungs . 619 147. All causes of death compared with mortality of Metropolitan Life In- surance Company 619 148. Mortality from cancer 620 149. Total mortality puerperal state 620 150. Mortality of Bright's disease 621 151. Mortality of children's diseases, (measles, scarlet fever, whooping cough and diphtheria) 621 152. Typhoid fever mortality 622 153. Puerperal septicemia mortality 622 154. Influenza and pneumonia mortality 623 155. Accident mortality 624 156. Terminal reserves American Experience with 3% per cent interest twenty payment life plan preliminary term 672 LIFE INSURANCE EXAMINATION CHAPTER I A HISTORY OF LIFE INSURANCE EXAMINATIONS By Harry Toulmin, M.D., Philadelphia, Pa. Medical Director, Penn Mutual Life Insurance Company The history of life insurance examinations is indeed one of small beginnings, of gradual development, and of steady progress. Al- though life insurance, as known today, dates back to 1762 with the founding of the Equitable Society in England,1 the first exam- inations of which 1 have found a record were not made until early in the nineteenth century. The simplicity of these examinations, when contrasted with those now in use by most companies, is very striking. The Scottish Widows' Fund and Life Assurance Society, organ- ized in 1811, provided in the "Plan of the Regulations" that "the Directors shall have power to appoint one or more physicians or surgeons in Edinburgh to judge the state of health of entrants." It was not until 1814, however, that applicants were required to produce certificates from their attending physicians. About 1832 this company required examination by its (own appointed) exam- iners; and not until 1835 was any data as to family history intro- duced into the examination. I have received from the Medical Directors of other companies information of distinct value for which acknowledgment is here made. I am particularly indebted to Dr. Otto May, the Medical Officer of the Prudential Assurance Company of England, for copies of applications made to that and other life companies in England in years gone by, as well as for blank forms now in use. In a personal communication Dr. May expresses his opinion that medical examinations appear to have been instituted first about 1846, though before that time a report was obtained from medical men in some cases. Walford, however, in his "History of Life Assurance in the United Kingdom" says,2 "It is not easy to de- 25 26 LIFE INSURANCE EXAMINATION Fig-. 1.-Application issued in 1857. Prudential Assurance Company of England. HISTORY OF LIFE INSURANCE EXAMINATIONS 27 terminc when the practice of subjecting persons proposing to in- sure to a medical examination, i.e., a personal examination by a medical practitioner retained in the interest of the Assurance Office, was first adopted. Dr. Price, in his preface to Morgan's Doctrine of Annuities, 1779, said (referring to the Equitable Society), Mt would not, perhaps, be amiss to appoint a medical assistant, whose particular business it should be to inquire into the state of health of the persons who are offered to be assured.' That Society had, in its original proposal form, asked for reference to the usual medical attendant. It did not itself appoint a regular medical examiner until 1858. The early Life Offices all required the applicant to ap- pear personally before the Board; not a very bad ordeal for ordinary purposes, but in the case of latent diseases, hereditary or acquired, quite effective. "I suspect the practice of a personal examination arose with the proprietary offices early in the present century, and had, by the period at which we have now arrived, (1843) come into almost gen- eral practice." Nicoll1 is of the belief that it was "well into that Century (Nineteenth) before the requirements of a medical examination of proposers had become general with the offices." He later states that "it was probably between the years 1850 and 1860 that any- thing like the full papers we are now accustomed to were generally adopted." The London Assurance, one of England's oldest com- panies, first appointed a medical officer in 1846.3 Prior to the use of medical examiners, it was the custom, as has been stated, to require proposers to appear before the Board for inspection (a cus- tom which still exists in a few offices), or to require a statement from the proposer's medical attendant.* A copy of an application bearing date of 10th month, 1832, to the Friends' Provident Institution, is of sufficient interest and impor- tance to be quoted in full. Respected Friend, A proposal having been made to the FRIENDS' PROVIDENT INSTITU- TION, for an Assurance on the life of and reference having been made to thee for information respecting his present and general state of health, I am desired by the Directors to request that thou wilt be pleased to favor them with answers to the following queries. Permit me 'Readers who wish fuller information regarding' the early beginnings of Medical Examinations in England, and as to Life Assurance without medical examinations, are referred to Mr. Nicoll's comprehensive and interesting paper, and the discussion which followed its reading.1 28 LIFE INSURANCE EXAMINATION to add, that it is important for the party proposing the Assurance, that every question should be answered in as full and fair a manner as possible. As communications of this nature are considered to be strictly confidential, and as a reason for declining a Life Assurance is never assigned, a perfect reliance may be felt that should the tendency of thy answers be such as to induce the Directors not to accept the proposed Assurance, the purport of them will never be suffered to transpire, or to become, in any way the subject of ob- servation. I have further to solicit, that thou wilt have the kindness to return this letter with the queries answered, addressed to B. ECROYD, BRADFORD, YORK- SHIRE, by an Early Post. - I am respectfully, 1. How long hast thou known ? 2. When didst thou see him last? 3. What was his state of health at that time? 4. What has been his general state of health during the time thou hast known him? 5. Has he at any time to thy knowledge and belief, been subject to fits, hemor- rhage, severe hernia, asthma, disease of the lungs, spitting of blood, sud- den seizure of any description, inflammatory disorders, or any other dis- order tending to shorten life? 6. Is he a subject of scrofula, gout, insanity, or any hereditary disorder? 7. Are his habits sober and temperate? 8. Dost thou consider his ordinary manner of living conducive or injurious to his health? 9. Is it thy opinion that he is likely to live as long as a healthy person, aged .... years may be expected to live? 10. Is there any other circumstance within thy knowledge, with which the Direc- tors ought to be made acquainted; and if so, be pleased to state it. THE MEDICAL ATTENDANT is requested to sign his answer to the follow- ing questions in addition to signing the above. 11. Art thou the Medical Attendant of 12'. If so, hast thou long known the character of his constitution? 13. Hast thou frequently been consulted by him: and for what description of complaints? 14. When wast thou last consulted by him? Signed " Iii 1845 Hie National Provident Institution of London requested their medical referee to carefully examine as to present and general state of health of the applicant and communicate the result by answering the questions as fully as possible. The questions were as follows: 1. Have you attended professionally? If so, when, and for what complaint? HISTORY OF LIFE INSURANCE EXAMINATIONS 29 2. What is your opinion of the general state of his health? 3. Has he had fits, or a seizure of any kind, proceeding from the head or heart? 4. Has he been ruptured? 5. Has he had spitting of blood, or any disease of the lungs? 6. Is he a subject of scrofula, or any hereditary or constitutional disorder? 7. Has, any member of his family died of pulmonary disease? (If answered in the affirmative, please state particulars.) 8. Is he a subject of gout, and in what degree? 9. Is he a subject of insanity? 10. Are his habits sober and temperate? 11. Do you consider his life eligible for Assurance, and that he is likely to live as long as the generality of persons of his age may be expected to do? 12. Are you aware of any other circumstances with which the Directors ought to be made acquainted? If so, please state them. The medical report from the London Assurance Corporation dated 1846 is of interest in that the family history seems to have been considered of more importance than formerly. Reference, also, is made to the rejection of the applicant by any other company. Dr. May, having forwarded me the original of an application in the Prudential dated 1857, I have had it photographed (Figs. 1 and 2) in order to give in full the appearance of a paper used at that time. The blank in use by the Mutual Life Insurance Company of New York in the same year is also shown in Figs. 3 and 4 for com- parison. The blank at present in use by the Prudential is shown in Figs. 5 and 6 and is fairly characteristic of the blanks in use by other English companies. Life Insurance in America had its origin in 1759 when a Charter was granted for "A Corporation for the Relief of Poor and Dis- tressed Presbyterian Ministers and of the Poor and Distressed Widows and Children of Presbyterian Ministers." (Now known as the Presbyterian Ministers' Fund). Medical examinations were not required until 1870.4 Zartman, however, states that the Pennsyl- vania Company for Insurance on Lives, organized in 1809, "marks the beginning of life insurance in the United States, upon a business basis."5* The New England Mutual Life Insurance Company was chartered in 1835 but did not begin to write business until 1843. Physical examinations of applicants were not, however, required prior to *A thorough study of the original papers of the Pennsylvania Company, and a careful review of the minutes of the Board of Directors, which was very kindly made for me, indicate that physical examinations never were required. The early policies were issued on a short declaration by the proposer, and in later years a statement was obtained from the family physician. The Pennsylvania Company ceased writing life insurance in 1873. 30 LIFE INSURANCE EXAMINATION Fig'. 2.-Application issued in 1857. Prudential Assurance Company of England. HISTORY OF LIFE INSURANCE EXAMINATIONS 31 Fig. 3.-Blank in use in 1857 by the Mutual Life Insurance Company of New York. 32 LIFE INSURANCE EXAMINATION Fig-. 4.-Blank in use in 1857 by the Mutual Life Insurance Company of New York. HISTORY OF LIFE INSURANCE EXAMINATIONS 33 Fig. 5.-Blank in use in 1920 by the Prudential Assurance Company of England. 34 LIFE INSURANCE EXAMINATION Fig. 6.-Blank in use in 1920 by the Prudential Assurance Company of England. HISTORY OF LIFE INSURANCE EXAMINATIONS 35 1855.G The Mutual Life Insurance Company of New York incor- porated in 1843, did not ask for a physical examination until 1856.7 Both of these companies, however, had in use prior to this time quite full statements to be made by the applicant. Several life insurance companies were formed between 1845 and 1850, among them the Penn Mutual Life Insurance Company which was incorporated in 1847 and issued its first policies that year. The following questions were asked the applicant: Are the general habits of life of Party regular and temperate, or otherwise? Are they active or sedentary? Has the Party ever been afflicted with any disease or injury likely to impair the constitution or to shorten life; if so, state what disease or injury? Is the Party liable through influence to any serious disease? If so, name the disease. Has Party been vaccinated or had the small-pox? Is Party now in good health and generally healthy and free from influence of any circumstances which tend to shorten life? Has Party resided in tropical or otherwise unhealthy district or country, at any time within last ten years? If so, where, for how long a period, and with what effect upon the health? Is there any information respecting health and habits of Party with which this company ought to be made acquainted? Name and residence of Party's usual medical attendant. If he has none, then name and residence of some friend or physician to be referred to for in- formation as to health, etc. The questions to be answered by the applicant's physician or friend were as follows: How long have you known him? Have you seen and attended him frequently? If so, for what complaint and how long since? Is he temperate in his habits of life? Active or sedentary? Is he exposed by hereditary influence to pulmonary or other serious diseases? Has he at any time been afflicted with insanity, apoplexy, palsy, convulsions, or other serious derangement of the nervous system; with scrofula, affection of the lungs, heart, or other important organs; with aneurism, rupture or any other disease that either is or may become dangerous or may leave the general health in a precarious condition? Do you believe that his health is good at present -and that he possesses a sound constitution? Are you aware of any peculiarities; or particular circumstance not attended to above that may tend to shorten his life or render its duration unusually un- certain? 36 LIFE INSURANCE EXAMINATION As will be noted he was in no way subjected to a physical exami- nation. The questions asked by other companies in their early be- ginnings were equally simple.* In 1848 we find a "Certificate from the Physician who has per- sonally examined the applicant," was a requirement. The following questions were asked: "What is the height, complexion and gen- eral appearance: Are there any signs of affection of the head or of a predisposition to it: or of paralysis or any other nervous affection1? Are there any signs of affection of the lungs, heart, or larger blood vessels? What is character of the pulse? Beats per minute? Are there any signs of abdominal or other diseases, not included in the previous questions? Are there any signs of previous disease or me- chanical injury? Opinion on the life?" This was the company's first medical examination,-surely not a very comprehensive one. In 1849 many of the questions were amplified, especially number two of the application, so as to include most of the illnesses then known to medicine. We also find the first suggestion of a physical examination in a question to be answered by physician or friend: "Did you see and carefully examine the above named before writing out these answers? If so, please state when." In 1851 the height, weight and chest circumference were first required and the "stethoscopic character of the respiration and heart's action" were called for in these quaint questions.! "What is the stethoscopic character of the respiration as to fullness, ease, gentleness, uniformity over both lungs, and freedom from cough and expectoration? What is the stethoscopic character of heart's action as to clearness, force, regularity and freedom from unusual sounds? What is the character of pulse and rate per minute?" Possibly they were the result of the appointment in this year of the company's first medical examiners (directors). Prior to this time the medical examinations had been made by physicians not directly in the employ of the company. In the same year, 1851, the agent's responsibilities were greatly increased by his having to answer these queries: Have you seen the person whose life is to be insured? Is he in a reputable situation of life? Are you positive he is the same person who appeared before the Medical Examiner? *Russell truly says, "The early requirements for Insurance were brief and pitiful.''8 fLaennec invented the stethoscope in 1816. HISTORY OF LIRE INSURANCE EXAMINATIONS 37 Are you personally acquainted with him? If that is the case, how long have you known him? Have you ever known or heard of his being indisposed? If he has been so what was the complaint, or complaints, with which he was afflicted and when? Is he at this time, to the best of your knowledge, in perfect health? Is his manner of living temperate, and has it always been so? Are his habits active and regular? Is his complexion sallow, flesh colored, pale, florid, or brown? Is he thin, middle sized, robust or bloated? Is his neck long, short or in proportion to his body? Is his chest broad, narrow or middle sized? State any defect there may be in his person. Do his manners, conversation, or appearance indicate ill health, feeble con- stitution or irregular habits? State what you know of the longevity of his family; the diseases to which they have been most subject; and, in particular, what near relations died of pulmonary or heart disease? Do you consider him in all respects a proper person to be insured, and do you recommend him as such? In 1852 a question concerning female applicants was added: "If a female is she with child, how far gone, and whether first time or otherwise?" though the company had insured females from the first. In 1854 more definite information regarding family history sup- planted the general questions of earlier years. In 1857 the company had become aware of the fact that it was well to know something about the applicant's insurance history, as will be seen by this question: "Has a proposal been made for in- suring the life of said party at any office; and if so, state what office, and for what amount, and whether it was accepted or declined?" In 1864 the ages at which brothers and sisters died was requested, but not the causes of death. The importance of knowing an applicant's intentions as to travel is indicated by a question introduced the same year, 1864, as fol- lows: "Does the party expect to travel? If so, how much in each year and through what parts of the country?" Additional information regarding females was asked for in 1869, the questions now being, "Does she expect to he confined? Is she in good functional health in all respects or has she passed the change of life? How many children has she had? Is there any kind of uterine disorder?" In 1869 we also first find reference to 38 LIFE INSURANCE EXAMINATION Fig\ 7.-Blank in use in 1920. Penn Mutual Fife Insurance Company. HISTORY OF LIFE INSURANCE EXAMINATIONS 39 Fig'. 8.-Blank in use in 1920. Penn Mutual Life Insurance Company. 40 LIFE INSURANCE EXAMINATION the use of tobacco and opium; and to the wearing of a truss if ruptured. In 1873 the questions relating to family history were arranged as in blanks in use today, though data relating to half brothers and sisters were included. In 1875 the applicant was asked whether he has "ever resided in a tropical or unhealthy district of the United States or elsewhere within the last ten years." In 1879 an analysis of the urine for albumin, by "heat and nitric acid" was first called for.* In the following years there were certain changes made from time to time in the questions pertaining to personal history. Typhus fever was considered of importance as late as 1880, but is not re- ferred to in 1885. In the latter year we find that the occupation of the husband was desired, when applicant was a female. In this year, 1885, the analysis of the urine included the specific gravity, and tests for albumin and sugar, and the examiner was asked whether the specimen was passed in his presence. In 1890 microscopic examinations were first made but the use of the microscope certainly antedated this year in many offices. In a personal communication from Dr. Oscar H. Rogers, Medical Director of the New York Life Insurance Company, he tells me that urines were subjected to the microscope long before 1887. Stress was still placed at this time on successful vaccination, if applicant had not had small-pox or varioloid. In 1915 the blood pressure was required of the examiner, but we have been taking it at the home office since 1911 and examiners in the larger cities have been reporting it for some years. I know of two companies, The Mutual Life Insurance Company of New York and the Northwestern Mutual Life Insurance Company, whose blood pressure records go back to 1907.1 Though the questions to be answered by the family physician or * Allen in 1869 wrote as follows: "It is true, however, that, in practice, cases will rarely come before the examiner in which an examination (of the urine) 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."9 tRiva-Rocci in 1896 and Hill in 1897 brought out the first modern sphygmo- manometer. HISTORY OF LIFE INSURANCE EXAMINATIONS 41 Fig. 9.-Blank in use in 1920. Northwestern Mutual Life Insurance Company. 42 LIFE INSURANCE EXAMINATION Fig. 10.--Blank in use in 1920. Northwestern Mutual Life Insurance Company. HISTORY OF LIFE INSURANCE EXAMINATIONS 43 friend were not formally dropped from the blank until 1915, they had not been regularly required for several years previous. The blanks in general use today by the American companies have much in common, but vary greatly in certain details, reflecting the experience or general policy of the individual company. The forms now in use by the Northwestern Mutual and the Penn Mutual Life Insurance Companies are shown in Figs. 7, 8, 9, and 10. At the Tenth Annual Meeting of the Medical Section of the American Life Convention, Mr. Thomas W. Blackburn, Secretary and Counsel of the Convention, presented a paper on Applications and Medical Examinations in which he analyzed the blanks of 100 companies belonging to that Association. He states that he found 202 inquiries relating to designated diseases, and that the "blanks contain a lot of inquiries which lead nowhere." He urged the Con- vention to adopt a standard blank from which would be eliminated all useless and unnecessary questions.10 I have made a similar analysis of the examination blanks of 57 companies belonging to the Association of Life Insurance Medical Directors with the following results: In Part I, in the statements of the Applicant to the Examiner, there are about 480 questions, and in the parts signed by the exam- iner relating to physician's examination there are more than 550 questions. Of course, some of these express the same idea in dif- ferent words, yet duplicate questions were eliminated as far as possible. Sieveking has truly said, "The great difficulty in framing the queries has consisted in steering a middle course between pedantic minuteness on the one hand and too great breadth on the other. The former may prove vexatious to the applicant and irritating to the physician, but the latter may err by not suggesting subjects that a careless or much occupied practitioner may slur over and forget. ' '1X In following the development of life insurance examinations from the few simple questions of the early 40's to the somewhat compli- cated and lengthy blank of today, we find that we have followed the progress of medicine during these years. Our ideas of the impor- tance of this or that factor have been modified by a more intimate knowledge of the influence of heredity and environment. Improved laboratory methods have become of inestimable value. Instruments of precision, unknown to our predecessors, have become familiar by 44 LIFE INSURANCE EXAMINATION daily use. Above all, the study of mortality statistics, of the influ- ence of various impairments, has been of the greatest help in deter- mining what are the important points to be covered by a life insurance examination. We may not find it practical to adopt a standard blank to be used by all companies; we may be able to return to the simpler forms of earlier days, as our examiners in the field become better trained, but we shall always want to obtain from our examiners the most accurate picture of the applicant that can be drawn, in order to make a just and fair decision, to accumulate accurate data for future study and to make selection, as nearly as possible, a science. References iNicoll: Life Assurance without Medical Examination, Transactions of the Faculty of Actuaries, ii, 1904-5. 2Walford: History of Life Insurance, Jour. Institute of Actuaries, 1887, xxvi, 315. sMay: Personal Communication, 1920. < Allen, Perry S.: Personal Communication, 1920. sZartman: Yale Readings in Insurance-Life Insurance, 1909. eDwight, Medical Director, New England Mutual: Personal Communication, 1920. TWeisse, Medical Director, Mutual Life Insurance Company of New York: Per- sonal Communication,1920. 8Russell: The Selection of Lives for Insurance. Proceedings of the Association of Life Insurance Medical Directors of America, 1889-1906. o Allen: Medical Examinations for Life Insurance, Revised Edition, 1869. loProceedings of the Tenth Annual Meeting of the Medical Section of the American Life Convention, 1920. uSieveking: The Medical Adviser in Life Insurance, ed. 2, 1886. CHAPTER II EXAMINATION AND INSPECTION OF INDUSTRIAL INSURANCE By Paul FitzGerald, M.D., Newark, N. J. Associate Medical Director, The Prudential Insurance Company of America Industrial insurance in America has become such a vital part in the economy of the nation that it seems fitting to go somewhat briefly into its history. Never should this question be considered without giving credit to the pioneer of industrial life insurance in America, the late Hon. John F. Dryden, from whose fertile brain came the idea which de- veloped and became one of the greatest factors in our business and philanthropic life. Beginning as the Prudential Friendly Society in Newark, in 1875, nurtured and carried on with difficulty, culminating in the wonderful organization that is indissolubly linked with the name of its founder and later taken up by other organizations, industrial insurance is now one of the most stable of all lines of busi- ness. Briefly, its plan is to insure people of both sexes, from age two next birthday to age seventy, for a weekly payment and for various sums, depending upon the amount paid, such premiums to be collected weekly by agents of the company. Many families in time of need have blessed the day when insurance of this form was secured. It is a fact that pauper burials have become a thing of the past, and the systematic payment of a certain sum of money each week has incul- cated the idea of saving and thrift among the people and thus made them better and more reliable citizens. A doctor who becomes an examiner for one of the companies writing industrial insurance has a trust placed in his hands. He becomes a part of the great plan for aiding humanity. He should familiarize himself thoroughly with the forms of policies and with the instruc- tions promulgated for his guidance. He should realize that he be- comes one of the important factors in this great plan and, unless he is willing to call promptly upon all applicants, and to give true and loyal service, he should never undertake the work. 45 46 LIFE INSURANCE EXAMINATION When an examiner loses sight of the fee paid, and considers the needs of the agent or applicant, then only does he become a valuable examiner. When he cooperates loyally with the field force and by every effort in his power works with it for the issuing of business, then does he become invaluable to the men engaged in writing the business; but in the effort to give this aid he must never lose sight of his duty and obligation to the company that employs him and by which he is paid. Every company wants all of the good business it can secure and the examiner is lhe only man in the field who stands between the company and the field force. His selection of risks must be made impartially, for he does not want to recommend that the company insure poor risks nor, on the other hand, does he want to advise the rejection of those who are entitled to insurance. The medical examiner is required to use his eyes. He is at liberty also to call into play the tactus eruditus. Certain kinds of risks are excluded because of inspection. Others are examined because of the developments of an inspection, while the value of an inspection is in nowise affected in those cases which re- quire examinations. Every examiner for a life insurance company should get all he can from inspection of the applicant before him. He should strive to be- come proficient in this important part of his duty. An observant eye is almost equal to an acute ear. What one sees one knows, or sus- pects, whether or not an inspection is to be followed by an examina- tion. The value of a medical inspection is best determined by having the examiner submit, in part at least, the information gained, the impressions that were made and the suspicions that were aroused by a visual inspection alone. Configuration or Build.-Whether muscular, obese, erect, stooped, well-proportioned, small, large, well-developed, etc. Nutrition.-Whether good, average or pool1; whether thin, flabby, fat or firm. Nationality.-Jew, Japanese, Chinese, Mulatto, Negro, Italian, German, English, Turk, Irish, etc. Identity.-It is always of great importance that the examiner should satisfy himself beyond a doubt that he sees the right person. There are several facts bearing on this, the first of which, and most important, is the signature of the applicant as compared with the signature which appears upon his application. Next, without regard to the order of importance, may be mentioned birthmarks, business INDUSTRIAL INSURANCE 47 card or private personal card, the name on some article of clothing, the initials on jewelry, loiters in the person's possession, color of hair or eyes, deformities, abnormalities, scars, loss of limb, instru- ments or other articles of daily use in the possession of lhe person, as, for example, doctor's thermometer, carpenter's rule, clerk's scis- sors, etc. Height. Weight.-I Tnderweight, overweight, average weight. Complexion.-Ruddy, clear, muddy, pasty, bronzed, healthy, un- healthy, indicative of special disease, as, for example, Bright's dis- ease, liver disease, syphilis, heart disease, consumption, dilated venules, bloated appearance, ocular or facial paralysis. Occupation.-Whether manual or mental. 'Callosities on the hands or elsewhere frequently show exact character of work. Dr. Charles Lyman Greene mentions, as examples, carpenters, tailors, watchmak- ers or players of stringed instruments; also seamstresses and those who are accustomed to write with the pen. Plumbers, housemaids, masons, coal teamsters, blacksmiths and iron workers often give evi- dence of occupation by stains on person or clothing, resulting from their work. The Teeth may show more or less clearly the vigor of health and cleanliness of habit. Sound, white, and even teeth are usually asso- ciated with good health; evidence of skilled dental work points to scrupulous care of the person. If, on the contrary, the teeth are neg- lected, carious and offensive, it just as surely indicates lax personal cleanliness. If the teeth are peg-shaped or notched it is indicative of specific disease, probably inherited. The Tongue is another index of health or disease. Is it not safe to say that every physician examines his patient's tongue when in quest of a diagnosis? If furred or heavily coated, edematous, clean, bright red, dry, moist or tremulous, are not these regarded as diag- nostic pointers? The tongue also may protrude directly forward or obliquely. A good deal was written of this last peculiarity, in the case of the assassin of President Garfield, and it is worthy of notice. The Eyes.-It has been asserted that the eye itself is incapable of expression, that in the play of the various emotions as depicted upon the face, the eye is passive, the eyelids, the eyebrows and the facial muscles playing the important role. Others insist that the eye itself can express ('motion unaided. We also see unequal contrac- 48 LIFE INSURANCE EXAMINATION tion of the pupil, congested mucous membranes, puffiness under the eyes, and a jaundiced sclerotic eye, ptosis, exophthalmos, cataract, opacity of cornea, disturbance of vision, etc. The Throat.-We can discover enlarged tonsils, catarrhal condi- tions, ulcerative processes, mucous patches, destruction of parts by ulceration, lead poisoning, spongy gums, pallor of mucous membranes, serpiginous scars suggesting constitutional disease, scars on the border of the tongue suggesting possible epileptic seizures, etc. The Hands may be hard, horny, bronzed, calloused, club-fingered, with incurving nails, rheumatic or gouty nodules; or they may be soft, white, small, well-preserved, with nails neatly trimmed, or stained because of occupation. Nails transversely ridged may pos- sibly indicate a somewhat recent illness, longitudinal ridges indi- cating a gouty diathesis. We notice also intentional tremor, thick- ened joints, etc. It can be told at a glance whether the applicant is a laboring man or not. The Gait.-It is easy to detect the lameness of rheumatism or gout, partial paralysis, atrophy of the leg; the peculiar walk of locomotor ataxia (shuffling), paralysis agitans (trot), multiple neuritis (lifting gait), the reeling gait of intoxication, whether by drugs or alcoholics, shortening due to disease or luxation, etc. The Face entire may suggest anemia, chlorosis, jaundice, Addi- son's disease, consumption, Bright's disease, fever, heart disease, etc. As it tells of gladness, of melancholy, so it discloses apprehension, fear, or pain (anxious facies). It betrays restlessness and nervous- ness, perhaps more readily than stolidity. It is an index of ease and of health, as well as of disease and suffering. It speaks of idiocy, of imbecility, of brutish instincts, of intemperance and of a scholarly, temperate life. It betrays congenital heart disease by the peculiar duskiness of color observed, emphysema, laryngeal obstruction, apnea or dyspnea. Its wrinkles tell of old age or addiction to drugs. The saddle-nose indicates constitutional syphilis. The Neck.-Here is seen throbbing, pulsating carotids, enlarged lymphatics, scars from suppuration of glands, goiter and tremor of the head. The Abdomen.-A large abdomen in a small man means either tardy digestion with the flatulency of constipation and possibly im- pacted feces or an enlarged liver or spleen, possibly chronic recurrent appendicitis, or an abdominal growth; enlarged superficial veins warn INDUSTRIAL INSURANCE 49 of liver disease. A colored line in the middle of the abdomen points to a distended abdomen in the past, cither from disease or from other well-known physiologic cause. Cicatricial tissue over the site of a surgical operation may be observed, also the presence of hernia and evidence of the fact that a truss has been worn. It should be a cardinal rule with an examiner to require every ap- plicant 1o walk toward him. Never pass on a risk that is in bed or sitting down, for often the failure to rise is due to some disease or deformity. In his manner of making examinations a man shows his ability as a diagnostician, for he is called upon to bring every faculty into play. In the candidate for insurance remember that a private patient is uot being examined. The patient is willing to give a full history of his life, some features important and some of not much use, but the doctor gathers from the patient sufficient data upon which to make a diagnosis. With the insurance applicant the reverse obtains. In- stead of free and full explanation, unwilling and evasive answers are frequently given. The applicant wants the insurance and it is the examiner's duty to find out whether he is entitled to it. Tactful questions may result in eliciting a personal history that will at once put the examiner on his guard, or it may bring forth the information that the family his- tory is poor. 4'Don't know" should never be accepted as an answer to any question until every means to secure a definite answer has been exhausted. The error of thinking that because a man is robust look- ing he is therefore a good risk should never be made. Many a robust individual is a very poor risk, while a lean man who it would appear ought to be a poor risk may pass a better examination. An examiner's work must never be done hurriedly or in a slip-shod manner. In examining, as in other things, what is worth doing at all is worth doing well. When conducting a medical examination, care should be taken to obtain exact information; an examiner should never express doubt or indecision in any report he may transmit to the home office. He should give a pen picture of the applicant, and the details of his examination should be so complete that the reviewer will have a comprehensive idea of the value and desirability of the risk. Any doubtful report clouds the issue, for if an examiner is in doubt when he completes his examination, with the applicant before him, it readily can be understood that there will be confusion and doubt in 50 LIFE INSURANCE EXAMINATION the mind of the man who is called upon to determine whether or not the risk is acceptable. Unnecessary correspondence results, which de- lays the issue of the business and ofttimes causes its loss simply because the examiner did not spend time enough to clear up every doubtful point. Incorrect or incomplete answers to questions are the bane of every life insurance company's existence. Reports of such a character are delayed in order that a careless examiner may complete his work, to say nothing of the expense attendant upon such carelessness. All correspondence should be promptly answered and letters should be carefully perused to determine just what is wanted. For example: an examiner reported a history of rheumatism. No other explanation accompanied the report. Of course, he became the recipient of a letter asking for details, character of the attack, whether articular or mus- cular, if the former, what joints were involved, the duration and severity of attacks and date of last attack. This was the compre- hensive answer received: "I am glad to say that Mr. has had no attack of rheumatism prior to the first nor subsequent to the last attack." Additional correspondence was, of course, necessary. This case is cited as an instance of the trials of a reviewer. It is an ex- treme case, but illustrates the point admirably. Tact is essential in dealing with all applicants, for umbrage is readily taken if an examiner is brusque or overbearing in his manner. It makes considerable difference how a delicate question concerning personal or family history is asked. The tactful examiner will have his questions fully answered, while the tactless one may be shown the door. Many a case has been lost because an examiner did not appre- ciate the necessity of care and tact in his handling of applicants. Such an examiner is of no value to a company and should be replaced. He should be unbiased in his recommendations, for he is paid by the company and his first duty is to it. Cooperation is the oil that insures the smooth running of the machinery. An examiner must be pre- pared for hard and laborious work, but if he proves worthy in the examining of industrial risks he will become qualified for the exam- ining of larger cases. CHAPTER III GROUP INSURANCE By Franklin C. Wells, M.D., New York City Medical Director, Equitable Life Assurance Society* Group insurance is a new development in the life insurance world, and its beneficent purpose and the practical success it has already met with commend it to a permanent place in its own particular field of usefulness. Therefore, it is well that a brief presentation of the subject should be included in a modern treatise on life insurance. Group insurance has come into existence at a time in the history of our industry, when it is of vital importance that the integral parts of the structure should be strengthened and cemented. It is a new form of cooperation, which is clearly in line with the spirit of modern in- dustry, since it is a concrete demonstration of the employer's interest in and for his employees, their homes, and families. This form of insurance may be called popularly, "Wholesale Insur- ance," because it deals with all of the employees or members of an industrial plant in a wholesale way, i. e., in one single blanket con- tract; although attractive individual certificates, bearing the name of the employee and his beneficiary, are issued in each case. There have been many definitions originated to express the exact meaning of this "Employer-Employee Mutual Benefit" proposition, but, it is best explained by the strictly legal definition, now embodied in the Statutes of the State of New York, as follows: "Group Life Insurance is that form of Life Insurance, covering not less than fifty employees, with or without medical examination, written under a policy issued to the employer, the premium on which is to be paid by the employer, or by the employer and employees jointly, and insuring only all of his employees, or all of any class or classes thereof, determined by conditions pertaining to the employ- ment, for amount of insurance based upon some plan which will pre- clude individual selection, for the benefit of persons other than the employer, provided, however, that, when the premium is to be paid by the employer and employees jointly, and the benefits of the policy *Dr. Wells died in December, 1923. 51 52 LIFE INSURANCE EXAMINATION arc offered to all eligible employees, not less than 75 per cent of such employees may be so insured." Ever since it has been established, the plan has more than justified itself, largely because it benefits both employer and employee. Just as it is sometimes said that a community is "wealthy" in proportion to the number of healthy people it contains, so, likewise, a community of industrial employees is "efficient" in proportion to the number of contented workers. It is clear that this modern form of protection for the home and family does a great deal to produce contented em- ployees, because it lessens worry, and increases loyalty to the em- ployer. The result is a reduced labor turnover, which becomes more pronounced as the plan is better understood. Every one in a certain given group is included in the plan, regard- less of age or physical condition, for no medical examination is neces- sary, except in certain states whose laws so require. An important feature of this service is thus seen, for many are protected, who could not be insured, if they were submitted to a rigid physical examina- tion, or to the standards of a life insurance company. New incoming employees are automatically included under the plan, and outgoing employees automatically cease to be protected upon termination of service. The amount of insurance issued to each individual is usually a fiat sum, or an amount equal to a year's salary, with a fixed minimum or maximum. Sometimes the amount is graded according to length of service, and is subject to a yearly increase, up to a certain figure. The cost of group insurance is paid by the employer, and must be considered as a plus proposition to the expense of plant operation, for it cannot be viewed as a substitute for other forms of benefit. It is distinctly an addition to other means of service which may and which should be rendered, and does not take the place of wage increase, or even a bonus distribution. Life insurance looks ahead into the future, and against that day, when a home may be without the bread-winner-when the pay en- velope shall cease, and stern necessity appear at the door. The plan stands for the protection of the wife and mother who is, after all, the power behind the worker, and who by right claims protection, which is so much needed for herself and those dependent upon her. While this plan does not, or should not exempt any person from making full provision for the maintenance of dependents, still, it does furnish GROUP INSURANCE 53 a wonderful means of immediate help, and a so-called "tiding over," when death comes to the bread-winner. The preliminary inspection of the plant is important, because, in this respect, a group case is treated as an individual, and inspected in its entirety, as follows: the number of males and females, with the average age, is ascertained; also, the physical condition of the plant, which embraces the general health of employees, their appear- ance, their record of recurring illnesses, etc., the average amount of morbidity and mortality, and the provision made in the plant for accidents, temporary illness, etc., and whether a physician is acces- sible all, or a part, of the time. The plant itself is examined and described, to ascertain whether it is provided with adequate fire-escapes, clean toilets, washrooms, lock- ers, etc. The condition of the drinking-water, and the details of loca- tion in the city or the country are also noted. The general hazard is important and warrants minute description. Especial attention should be given to the material used in manufac- ture, the hazard in manufacture, the processes of operation, and all factors having a bearing upon conditions affecting sickness, accidents, or mortality. In addition to this form of inspection, when the statutes of a state so require, employees are examined physically. In this case, physical examination is made by a designated physician, and the results are passed upon in each individual case. By means of this form of insurance protection, the employer is enabled to render to his body of employees a service, which otherwise might be too expensive, or entirely impossible for them to obtain, and, by so doing, he increases and extends the spirit of loyalty and coopera- tion. CHAPTER IV FRATERNAL INSURANCE By Geo. G. McConnell, M.D., Indianapolis, Ind. Medical Examiner in Chief, Insurance Department, Supreme Lodge Knights of Eythias Origin The spirit of fraternal insurance is of such antiquity and the mists of time have rolled over the events of the past, obscuring them so completely, that the only conception we get is by combining the meager data, which has come down through the ages, with a lively imagination. The fraternal principles of brotherhood, friend- ship, cooperation and protection are almost or quite as old as time itself. It requires no great stretch of the imagination to picture the early caveman as an ardent fraternalist, although it is quite likely from all that we know of his nature, that he did not call it fraternal- ism or insurance either. However, even in those primitive days, there was the necessity of providing something to eat and wear, and as the clothing consisted almost wholly of skins, it must have been promptly demonstrated that some were more "apt" in the capture of the wild game than others, and that some were much more skillful in the preparation of the skins for wearing. Hence we visualize the more successful hunters bringing in the game and the more skillful tanners preparing the skins. Thus a cooperative fraternal insurance brotherhood was established. As time measured by centuries went on, this same principle was applied to other common interests and while each successive step was taken wholly for convenience and with no thought of com- mercial profit, the ground work was slowly but surely being laid for the wonderful fraternal organizations of today. The Rev. T. De Witt Talmage, in one of his famous sermons called attention to what was probably the first life insurance com- pany. It was during the reign of Pharaoh in Egypt and the king was very much distraught over a dream which he had had and 54 FRATERNAL INSURANCE 55 called upon Joseph to decipher the dream and tell him what was best to do and Joseph advised him in this wise: "And let them gather all the food of those good years that come and lay up corn under the hand of Pharaoh and let them keep food in the cities. "And that food shall be for store to the land against the seven years of famine which shall be in the land of Egypt, that the land perish not through the famine," Genesis XLI: 35, 36. Mr. Talmage said of this: "These words were the words of Joseph, President of the first Life Insurance Company the world ever saw. It had in it all the advantages of the 'Whole Life Plan,' of the 'Tontine Plan,' of the 'Endowment Plan,' and all the other good plans." The term "guild" signifies worship, feast, contribution. Inas- much as the English social guilds are generally conceded to be the forerunner of the fraternal societies, a short history of these or- ganizations may be of interest. There is some record that Roman trade guilds were numerous as early as 700 B.C. They included practically all of the trades such as weavers, dyers, tanners, shoemakers, smiths, goldsmiths and many others, but there is little evidence to prove the continuity of the Roman guild, and it is doubtful whether they survived the barbarian invasion or were in any way connected with the guilds of the middle ages. A theory that has been widely accepted connected the early Germanic or Scandinavian sacrificial banquets with the medieval guilds. This view does not seem to be tenable, for the old sacrificial carousals certainly lacked two of the essential elements of the guilds: cooperative solidarity or permanent association and the spirit of Christian brotherhood. No theory on this subject can be satis- factory which wholly ignores the influence of the Christian Church. The social guild was an institution of English origin. The mem- bers were brothers. They gave their "wed" or pledge to each other to stand together as brethren of the same family; they under- took to pay their "gylde" or stated contributions to the common chest, and to perform the duties required of them by the regulations of the guild. Long before the associations of a similar nature ap- peared on the continent of Europe, the existence of these guilds was recognized in English laws and records. 56 LIFE INSURANCE EXAMINATION In the latter part of the seventh and the beginning of the eighth century, a code of Anglo-Saxon laws was formed, among which were found two concerning the liability of the brethren of the guild in case of slaying a thief. A hundred years later the laws of Alfred recognized the guild. When a kinless man committed man- slaughter the guild helped him to pay the decreed price of blood. When a man without relatives was slain, the guild had a claim on part of the blood money paid by the slayer. A body of laws for the city of London, dating in the time of the Athelstan, in the first half of the tenth century, contained ordinances for the keeping up of social duties in the guilds. The agreement of one of the old Anglo-Saxon guilds runs thus, the original being in Anglo-Saxon: "This assembly was collected in Exeter for the love of God, and for our Soul's need, both in regard to our health of life here, and to the after days which we desire for ourselves by God's doom. "Now we have agreed that our meeting shall be thrice in twelve months-once at St. Michael's Mass, the second time at St. Mary's Mass after mid-winter, and the third time on All-Hallows Mass day, after Easter, and let each guild brother have two cesters of malt, and each young man one cester and one sceat of honey, and let the mass priest, at each of our meetings, sing two masses, one for living friends, the other for the departed. "And each brother of common condition, two psalters of psalms, one for the living, and one for the dead. "And at the death of a brother, each man six masses or six psalters of psalms, and at a death, each man five pence, and at a house burning each man one penny. "And if any one neglect the day for the first time, three masses, for the second, five, and at the third time, let him have no favor unless his neglect arose from sickness or his lord's need. "And if any one neglect his contributions at the proper day, let him pay two-fold; and if anyone of this brother-hood mis-greet another, let him make amends with thirty pence. Now we pray, for the love of God, that every man hold this meeting rightly, as we rightly have agreed upon it. God help us thereunto." These features or their equivalents are to be found in nearly all of the later guild ordinances. Another Anglo-Saxon guild added to the customary articles of association, provision for the members FRATERNAL INSURANCE 57 standing by each other with money and weapons when occasion required. The guilds were recognized by an act of Parliament in 1388 and the picture presented to us in the reports to the Parliament is of an organization of middle-class citizens, based mainly on the prin- ciples of good fellowship and mutual assistance. They helped each other when sick or distressed, buried their dead with due solemnity and stood by each other when in any way wronged. These social guilds survived the Civil strife that overthrew Richard II and lasted through the reign of his successor. They were unshaken by the French wars of Henry V and lived through the Wars of the Roses but were utterly crushed by Henry VII who seized their moneys and properties under pretense of necessities for the maintenance of wars. However, the old guild spirit gradually came to life again and the result was the rise of the English Friendly Societies for coopera- tion among the people in moderate circumstances. They endeav- ored, in a self-respecting way, to forefend the ills of life and the mischances of affairs by provision for sharing the hazards among themselves, a principle which is still the predominant feature of fraternal insurance. The earliest known policy of Life Insurance was made in the Royal Exchange, London, 18th of June, 1583 for £883, 6s, 8d for twelve months, on the Life of William Gibbons. Sixteen under- writers signed it, each severally for his own share, and the premium was 8 per cent. The age of the insured was not referred to, nor was it considered in fixing the premium. Gibbons died May 29th, 1584, or within the first year of membership, therefore establishing a mortality rate of 100 per cent of the entire membership, a rate that would prove disastrous to even more modern companies. While the London experience was most unprofitable it was un- doubtedly the beginning of the vision that insurance might be issued for the benefit of the insured and at the same time for the financial profit of the insurer, thus giving us our first conception of present day commercial insurance. Between the time of the Revolution and the Civil War, some of the old English Friendly Societies, such as the Odd Fellows, Ancient Order of Hibernians and the Ancient Order of Foresters, had been transplanted to America from Great Britain, and certain native 58 LIFE INSURANCE EXAMINATION societies, like the Red Men, the Good Templars, the Sons of Tem- perance and a number of others had come into existence, all of which afforded a measure of charitable relief to their members. The first fraternal insurance society was founded at Meadville, Pa., in 1868, by John Jordan Upchurch (lovingly called "Father Upchurch" by all fraternalists). Father Upchurch started this great effort with one dollar. This society was the Ancient Order of United Workmen and was the beginning of a new class of fraternal orders that was to make the provision of a substantial death bene- fit a primary object; and I may say in passing, that this is still the fundamental object of all life insurance, whether commercial or fraternal. The earliest orders called for a uniform contribution from each member to meet benefit claims as these arose. This was pure char- ity, in essence if not in form, and loft the future without provision, under the assumption that there would always be members enough and willing to meet the demand on call. However, this proved to be an inefficient financial plan because it left the younger members to pay the inevitably increasing claims of the older members. The early fraternal benefit societies soon learned from experi- ence that was often costly, that the crude idea of a uniform contri- bution must be changed,, and a gradual development took place wherein the contributions were graded according to the member's attained age at entry, and a more careful medical selection was required. But even this plan lacked some of the essentials for permanence, because the rates were fixed to meet the current losses and gave no heed to reserve accumulation to meet future obligations. As time went on it was found necessary, in order to provide for these future obligations, to make additional changes. These changes have been made and the permanence and stability of the Fraternal Insurance Societies of today were estabished. Growth When it is taken into consideration that the first fraternal insur- ance organization came into existence less than sixty years ago, that it had its inception in a very small way, that it was a venture into uncharted fields and that there was absolutely no established prac- tice to guide "Father" Upchurch in his work, the record of the FRATERNAL INSURANCE 59 enormous growth and development of fraternal insurance reads like a fairy tale, and is proof beyond question that there was a real need for this form of insurance. Combining as it does the practice of friendship, charity and benevolence with a safe protection to relatives and dependents, the fraternal insurance societies have done as much or more than any other movement to weld the American people into a harmonious whole. It would be quite impossible in the space allotted to me to trace the various changes that have taken place since "Father" Upchurch organized the first fraternal beneficiary society. Suffice it to say that the fraternal leaders gradually profited by the early experi- ences and the fraternal orders have been an acknowledged educa- tional influence that has made America of today the best insured portion of the world. While statistics do not usually make interesting reading, there is no more impressive way to show the growth of fraternal insurance than by quoting a few figures: Total amount of insurance in force, $10,158,369,169 Total number of members, 8,816,285 Paid to beneficiaries in 1922, $122,711,363 Paid to beneficiaries since organization, $3,051,531,737 Amount of insurance issued in 1922, $1,199,334,570 Medical Selection If under the heading of medical selection I am able to say some- thing that will add to the fraternal spirit which should exist between the examiner and the medical director, it will more than repay me for many years of serious thought on the subject. With several years' experience as a local insurance examiner, and with twenty-four years' experience as a medical director, I feel that I can speak with some authority on the difficulties encountered in both positions. To definitely understand the situation in the medical department of the fraternal societies, it will be necessary to draw a picture of past happenings. Organized less than sixty years ago, without the benefit of previ- ous experience, the fraternal societies came into existence with no fixed policy regarding the need of careful medical selection. In fact, 60 LIFE INSURANCE EXAMINATION probably little or no thought was given to this subject. However, it soon developed that some care in the medical selection of appli- cants was desirable, but the requirements under the early examina- tions were so meager and the fee of the medical examiner was so small that the results were far from satisfactory. Out of these conditions grew the method of "group" examina- tions. When a lodge was ready for installation and the prospective candidates were on hand, the doctor who had been selected as ex- aminer (by the local members) lined the whole class up in a row and conducted the examinations about as follows: The Doctor: "Number one man in line, are you in good health?" Answer: "Yes sir." Doctor: "Number two man in line, are you in good health?" Answer: "Yes sir." Doctor: "Number three man in line, are you in good health?" Answer: "Yes sir." Doctor: "Are any of those present in poor health?" Answer: "No, sir." Doctor (turning to Lodge Officers): "Mr. Lodge Officers, I find all present in good health." This was an actual occurrence, and took place in my presence many years ago. I am not citing this instance in a jocular mood, nor in criticism of the doctor or the lodge members, but to show how a very dangerous impression was developed that fraternal examinations were not a serious ordeal, an impression which still prevails to some extent. This system is no longer tolerated and I want to urge with all the emphasis at my command that medical examiners forget this obsolete method, and that they not only erase it from their minds but that they make a special effort to eliminate from the minds of agents and, the public the impression that medical examinations for fraternal insurance do not amount to much. The fraternal examination of today is expected to be, and is, on a par with the best, and the examiner who slights it or makes any dis- tinction between the examinations for fraternal and commercial in- surance, is doing a rank injustice to the fraternal societies. The physician who makes a careless examination or who passes over some apparently slight physical ailment in the applicant may be jeopar- dizing that applicant's insurance and is inevitably placing himself FRATERNAL INSURANCE 61 in the position where a charge of incompetency, ignorance, or fraud can be laid at his door by the home office. Probably no other work of the physician gives a wider scope for keen analysis than the insurance examination. The local examiner portrays the picture of the applicant as he appears today, and leaves the probable future of the applicant to the judgment of the med- ical director. It should be kept in mind that the medical examina- tion is a permanent record and should the death of the applicant occur in the early years of membership, the examination is sub- jected to the acid test of investigation. No examiner need be chagrined by early deaths which occur from accident or acute disease, but early deaths from cancer, tuberculosis, nephritis, arteriosclerosis, organic heart trouble, or other diseases which ordinarily run a protracted course, are never a flattering rec- ommendation, and it is in the detection of the early danger signals that the examiner establishes a reputation for carefulness. It is sometimes a strong temptation to the busy examiner to elim- inate the urinalysis from the insurance examination, especially if the applicant appears to be in good health. Nephritis causes more deaths than any other one disease and the early evidence can be detected only by an examination of the urine. Diabetes, from which there is a high rate of mortality, usually gives no evidence of its approach except by careful urinalysis. Age must not be considered in the necessity for making a urinaly- sis as either of these diseases is frequently discovered in the young as well as in those more advanced in years. It should be constantly borne in mind that specific gravity is not a reliable guide. Many samples of urine which register a normal specific gravity, contain either sugar or albumin or both; and many that register a low specific gravity contain sugar, while others that register a high specific gravity often times show albumin. These exceptions, of course, reverse the usual rule, but occur often enough to make dependence on the specific gravity a very unsafe proceeding. A letter from the medical director asking for additional informa- tion in regard to an applicant's examination is usually the cause of considerable inconvenience to the examiner. These requests could be materially reduced if the local examiner would make a complete statement in regard to anything which might be an impairment to the risk. To illustrate: An applicant frequently gives a history of 62 LIFE INSURANCE EXAMINATION a death in the family from tuberculosis, and the local examiner gives the medical director no further details. With our present knowledge and belief that tuberculosis is highly infectious, it is imperative to know when this death occurred, and whether the applicant was closely associated with the relative or member of the family who died. To further illustrate: It is often revealed in the medical ex- amination that the applicant has had asthma or bronchitis, or pneu- monia or gives a history of indigestion, or of an operation (I merely mention these ailments to illustrate my point and not because they cover the whole field) and the local examiner fails to give the dates, the duration and severity of these attacks. It is necessary for the medical director to have these details in order to take intelligent action on the application and it would save the local examiner much extra work and some inconvenience if the full data were furnished in the orginal examination. It quite frequently happens that the medical director declines an applicant wdio has been recommended for acceptance by the local examiner. Just how prevalent the idea is that this is a reflection on the judgment of the examiner, there is no w7ay of knowing, but that this view does exist is quite evident from the letters of inquiry received. In many cases there is no outstanding and evident reason, so far as the applicant's present physical condition is concerned, why fa- vorable action should not be taken, but when the law of average is consulted, the risk takes on the quality of being unsafe. Perhaps the question of overweight or underweight is as greatly misunderstood as any, and to illustrate I give a concrete case: A merchant, age twenty-four, in good health and with a good family history, is 6 feet, 1 inch in height, and weighs 240 pounds. Such a man might be rated as first class by the most careful examiner, but would probably be declined or rated up by most medical directors. The facts are these: That a man at age twenty-four, height 6 feet, 1 inch should weigh 176 pounds, or a few pounds over or under this figure; in this case the man carries an excess weight of 64 pounds and the tables of mortality show that in a large class of risks made up of exactly this type, the death rate will be at least 125 per cent of the expected. If such a risk is declined or rated up by the med- ical director, the local examiner should not feel that any reflection has been cast on his judgment even though he has advised acceptance. Most medical directors are in full sympathy with their local exam- FRATERNAL INSURANCE 63 iners and always hesitate to call on them for additional information which causes them extra work, but it lias been aptly said that the " Medical Department is the credit department of an insurance com- pany" and that the "local examiner is the eyes of the medical director," hence it must be obvious to all concerned that the local examiner holds a very important position in the insurance field. He is not expected to be familiar with, or to have ready access to tables of mortality and the laws of average, hence he has completed his duty to the society when a correct family history has been obtained, a record made of all serious past illnesses or operations, and an accu- rate picture drawn of the applicant's present condition. If a better and closer acquaintance could be had between the local examiner and the medical director, it would eliminate many mis- understandings. Therefore I would suggest that when the oppor- tunity affords, the examiner should visit the offices of the companies for which he examines and get acquainted with the medical depart- ment. One personal interview will establish a better understanding than years of correspondence. The medical director is directly responsible for the selection of risks, but in order to make a safe and sane selection, he must have the backing of his local examiners in full measure. In my judgment the average insurance examiner of today is ren- dering the most conscientious service at his command and I trust that the comments I have made will be taken in the spirit of coopera- tion and friendship. Most examination blanks are too long and this fact is realized by the majority of medical directors but these blanks were prepared to meet all requirements as nearly as possible. Often times the local examiner complains of the number of questions included in these blanks, but if the questions were not comprehensive, many mistakes would be liable to result. I am submitting a copy of the examination blank which is used by the Insurance Department, Knights of Pythias (Figs. 11-A and B). We are not contending that this is a perfect blank or that it would meet the requirements of all insurance societies, but the blank is submitted for the purpose of showing that the selection of risks by fraternal insurance societies has been practically standardized. A further word is necessary in reference to the fee for exami- nations paid to the local examiner by fraternal insurance societies. While the fee paid for an examination is very moderate, it should 64 LIFE INSURANCE EXAMINATION Part two of Application for Membership in the Insurance Department of The Supreme Lodge Knights of Pythias In Continuation of and Forming a Part of Application in the Insurance Department, Supreme Lodge Knights of Pythias ANSWERS MADE TO MEDICAL EXAMINER 1. A. Haye you ever been advised by a physician to try a change of ! climate to benefit your health? B. Has any physician given an unfavorable opinion of your physi- r cal condition with reference to life insurance? C. Have you been declined, postponed or limited to a policy differ- ent from the policy applied for by any company? (State company and details.) D. Give the name and residence of your medical adviser. (Or D. family physician to whom you. now refer for certificate if deemed necessary.) E E. Would you consult a regularly licensed physician if sick? - ' 1 F. Have you consulted a physician, or any kind of practitioner, during the last five years. F 2. State every physician Give name and address of each Dates and details Result or practitioner whom you have consulted or who has treated you in the past five years. (If none, so state.) FAMILY RECORD. In giving Cause of Death, avoid all indefinite terms. IF LIVING IF DEAD 3. Aire ! Health Ate Cause of Death Veatl/ Details * Health"* FATHER MOTHER BROTHERS Living Dead ... I SISTERS Living Dead 4-Attained age of Father's Father? Father's Mother?Mother's Father? Mother's Mother? l| 5. Have any of those mentioned under family record or any one in your household ever had Tuberculosis? Give full details. G, Haye you ever had or been No* "'J* o.t. Duration Hr.uh treated for any disease or dis-[ turbance of (answer each separately.) ------ a. Brain or Nerves? n b. Throat or Lungs? _ c. Heart or Blood Vessels? q I d. Stomach, Liver, Intestines, Kid- -: i| ney or Bladder? D. e. Genito Urinary Organs? I f. The Skin, Bones, Glands, Eye E. |l or Ear? p ; 7. a. Have you ever had Gout, Rheu- : matism, Tuberculosis or A. Syphilis? b. Have you ever had vertigo or p. dizzy spells? -- c. Have you ever raised or spit blood? C- 1 I d. Is your health impaired in any way? D. e> Have you ever had a surgical operation? P f. Have you ever had any other - illness or injury not men- |tioned above?F. | 8. a. What is your average daily consumption of Alcoholic Beverages? b. Have you used them to the extent of intoxication during the past five years? I agree that the above and foregoing answers shall be a part of my application, which shall consist of parts I and II taken together. I also agree that said answers shall become a part of my certificate contract. I also war- rant the truth of said answers and request that a certificate be issued to me based thereon. Dated at , County of , State of on theday of, 19 SIGNATURE OF APPLICANT WITNESS: M. D. (To be written in presence of Medical Examiner.) GENERAL INSTRUCTIONS TO MEDICAL EXAMINERS In the examination of applicants for membership the Medical Examiner is responsible for a strict compliance with the laws of this department and a faithful performance of duty to the Board of Control which makes the appointment in all cases and issues the commission of authority. The applicant's answers to all questions should be fully and clearly expressed. In the examination answer every question explicitly and clearly. In determining the character of the risk the Insurance Department must always be given the benefit of a doubt, and if anything is known which affects the same the Examiner must immediately make a SPECIAL confidential report to the Medical Examiner in Chief direct. The medical examination fee shall under no circumstances exceed $3.00. Medical Examination by a relative is not permissible. Medical Examiners will not be paid for examining applicants over GO vears of age. Fig. 11-A FRATERNAL INSURANCE 65 INSURANCE DEPARTMENT OF THE SUPREME LODGE KNIGHTS OF PYTHIAS INDIANAPOLIS, IND. 9. This examination must be made in private, answers must be in black ink, the examiner to record in his own I handwriting the answers of applicant to every question and have the applicant sign full name. 10. a. How well do you know the a- e. Exact height in shoes FtIn. applicant? b. Is he related to you by blood b Exact weight (coat and vest off)Lbs. c. Any uXtS,' deformity or - Did you weigh applicant? hernia? (Describe in de- h. Girth of chest, full inspiration In. tail.) . z c. d. Any recent gain or loss in i. Girth of chest, full expiration In. weight? (State amount t and cause.) <*• J- Girth of abdomen at umbilicus In. 11. a. State rate of pulse b. Is it intermittent or irregular? (If so, describe fully.) * c. State Blood Pressure: Systolic Diastolic Do you find upon examination any ab- Describe fully any abnormality, normality of d. The Arteries (atheroma or undue d. thickening) ? e. The Heart (abnormal action, e murmurs, hypertrophy, degen- eratton J ? f. The Respiratory System (lungs, -- nose, throat)? g. The Nervous System (brain, spinal 8* cord, nerves)? h. The Abdomen (stomach, intestines, h. * liver, spleen)? i. The skin, middle ear, eye or other i, part of body? : - j 12. a. What is the specific a- 13. If any abnormality or history of same forward gravity of the urine? specimen to Home Office. c Is s^igar1 present'114' e- Have y0U forwarded a Portion of the specimen as d. LvegVu Knowledge Cabove to the Home Office? that the urine exam- f. Is there any evidence of Genito-urinary diseases, ined was authentic? d* past or present? (Describe fully.) • 14. a. Does applicant look older than stated age? a. (If so, state how many years and why)? - L b. Is there anything unfavorable in the general appearance such as delicate or sickly appearance or full habit? b. c. Is there any undue hazard to life or health from occupa- ' tion or pastime which might affect the risk as to life insurance? c> d. Was there any one present other than the applicant and i yourself while making the examinations and recording the declarations? d. e. Do you know or suspect that the applicant ever has or now uses alcoholic beverages to excess or any narcotic? f. Has the applicant ever had, in your opinion, symptoms of e. hepatic or renal colic, appendicitis, gastric or intestinal - ulcer, tuberculosis or any disease not already mentioned? g. Do you know of anything in connection with the moral f. x character, physical condition or past health record not - already detailed which would unfavorably affect his insurability? (If so, give details under 15.) g 15. REMARKS AND ADDITIONAL DATA: I certify that I have made the above examination at City, State on thisday of, 19 m. d. ; P. 0. Address | County I State j MEDICAL EXAMINER PLEASE FILL BOARD OF CONTROL, INSURANCE DEPARTMENT, SUPREME LODGE KNIGHTS OF PYTHIAS. To Doctor DR. P. O. Address County State . In the sum of Three($3.00) Dollars for the examination of Application Number Approved by Paid by Voucher Number (Medicul Examiner Chief.) ' Fig. 11 -B 66 LIFE INSURANCE EXAMINATION be kept in mind that the whole structure of fraternal insurance is of very recent origin. At the outset it was not realized that any medical examination would be necessary. When it was found that an examination would be required, it was made a very perfunctory affair. However, as the requirements have been gradually increased the compensation has followed suit to some extent. It is safe to say that most officials of fraternal societies feel that the fees now customary are not in keeping with the price of living, but as added expense is always a problem it must necessarily be approached slowly and with caution. However, there is a con- stantly developing tendency to harmonize the examining fee will other rising expenses and if the medical men will continue to be patient, the situation will undoubtedly be adjusted to their satis- faction. It must be taken into consideration that the entire aim of the fraternalists has been to furnish insurance at actual cost and that every cent of increased cost must necessarily come from the pockets of the members. It should also be considered that many who could afford it do not take insurance, while thousands and thousands who in reality cannot afford to carry insurance, do so at the expense of other real necessities in order that their families may be pro- tected. Medical men might well carry in mind the thought that although the compensation may seem inadequate, the situation is slowly but surely improving and meanwhile the deficiency is a direct contribu- tion to the general welfare of the fraternal system. I want to close this chapter with a quotation from one of George G. Halpine's poems. The noble sentiment expressed in these lines will ever be the cornerstone in the success of fraternal insurance societies: "Comrades known in marches many, Comrades tried in dangers many, Comrades bound by memories many, Brothers let us ever be. Wound or sickness may divide us, Marching orders may divide us, But whatever fate betide us, Brothers of the heart are we." CHAPTER V THE RELATION OF THE AGENT TO THE MEDICAL EXAMINER By Harold F. Larkin, Hartford, Conn. Secretary, The Connecticut Mutual Life Insurance Company "It has done more than all gifts of impulsive charity to foster a sense of human brotherhood and of common interests. It has done more than all repressive legislation to destroy the gambling spirit. It is impossible to conceive of our civilization in its full vigor and progressive power without this principle which unites the funda- mental law of practical economy, that he best serves humanity who best serves himself, with the golden rule of religion, 'Bear ye one another's burdens.' " Thus are briefly summarized by the Encyclo- pedia Brittannica some of the accomplishments of life insurance. One may ask to what factor may be attributed the growth and ex- pansion of the business of life insurance to the importance it oc- cupies in the economic life of today. The answer seems to be, the agent. Life insurance companies obtain their business through the efforts of their agency organizations. Experience has clearly demonstrated that men do not voluntarily seek life insurance to any appreciable extent; for while they may recognize the manifold benefits it con- fers, and realize their need of such protection in event of death to care for their families and to safeguard their business enterprises or to provide for themselves in old age, yet it requires the services and efforts of the agent to induce them to act. A loving and in- dulgent father will labor to give his family all the comforts and pleasures of life within his means; yet were it not for the energetic and persuasive solicitation of an active insurance agent, he would fail to provide after his death for the maintenance of his home, the support of his widow and the education of his children. So it is to the agent that the public is largely indebted for the extension of the benefits of life insurance. Life insurance salesmanship is constantly attracting on the whole men of a higher type and better calibre than ever before. The per- 67 68 LIFE INSURANCE EXAMINATION sonnel so engaged today far surpasses that of the past in character, ability, knowledge of the business and training for their work. More and more are graduates of our colleges and leading institu- tions of learning taking up the selling of insurance as a life work. Our colleges and schools are offering courses in insurance designed to acquaint students with the underlying fundamental principles upon which the institution of insurance rests. In addition, insur- ance companies, through their own schools of training and courses in salesmanship or in conjunction with established universities like Carnegie Institute, New York University, and others cooperating with the Associations of Life Insurance Agents, are conducting courses with the same basic idea of educating the agent to fulfill his responsibilities to the public as its insurance advisor and counselor, to teach him to prescribe professionally rather than to peddle pro- miscuously the policies his company offers best designed to fit the varying needs of the insuring public. The life insurance agent is becoming recognized more and more in his community as a leader in its civic and religious life, foremost in public service, a man to be counted upon to aid in public welfare or any movement for civic betterment. The World War revealed the agent as a patriotic con- tributor to his country's needs, those unfitted for the burdens of active military service making heavy sacrifices of time, strength and energy in conducting the campaigns for the Liberty Loans, the Red Cross, and other kindred relief organizations utilizing their selling experience to bring such campaigns to a successful conclusion. To- day the progressive life insurance agent is recognized by business men as an expert qualified by ability and training to advise them how to buy life insurance whether it be to cover federal and state inheritance taxes, costs of administration of their estates, funeral and doctor's bills, incomes for widows and children or other de- pendents, educational plans for children, mortgages or other indebt- edness, incomes for themselves upon retirement, or any of the vari- ous purposes which the modern life insurance contract will serve. The development of a competent selling force is one of the most difficult problems confronting insurance executives; but every live company is bending its energies toward the building up of such an organization, recognizing that only through that channel can it secure new business and so fulfill its mission of usefulness to the public generally. The rates charged by a company for insurance are based on the RELATION OF AGENT TO MEDICAL EXAMINER 69 mortality experienced among normal healthy lives. It is presup- posed that none but standard lives will be granted such insurance, for the admission of persons of impaired physical condition or of poor family history indicating a lack of longevity in the family would naturally result in heavier death losses than contemplated by or provided for in the premiums charged, and so would prove dis- astrous financially to the company. Hence to determine that in- dividuals presented by its agents as applicants for admission to the company measure up to its standards of physical fitness, and to detect any impairments of health or condition, an examination by a physician as the medical representative of the company is re- quired. Accordingly a company appoints medical examiners throughout the territory from which it is seeking to obtain new business. In selecting a corps of medical examiners, a company aims to pick men of high character and integrity, men of the best professional standing, men of tact and of sound judgment, keen to size up an applicant for insurance, quick to perceive any impair- ments, and withal, men who will present to the company for the consideration of its Medical Directors and underwriters a clear, accurate and reliable description of the applicant's condition, and men who, in the performance of this duty, will act without fear or favor, uninfluenced by personal prejudice or pressure from others, stating their honest opinions based on their knowledge of, and training for, examination work. In his capacity as its trusted medical representative appointed to safeguard the company's interests, it becomes the duty of the ex- aminer to study the application and medical blanks in use by his company; to acquaint himself with the questions therein, their sig- nificance and purpose; to familiarize himself with the company's special requirements in different types of cases; and then to examine carefully and thoroughly each applicant presented, reporting his findings impartially in the realization that his obligations and re- sponsibilites are to the company he represents and call for the high- est professional skill and training for the work which he can supply. The agent represents the producing side of the business, desirous of securing insurance for every applicant properly insurable. The examiner represents the underwriting side, desirous of granting insurance to every applicant presented, but mindful of the com- pany's welfare, which demands that unsound risks be excluded. 70 LIFE INSURANCE EXAMINATION At times their interests will appear to clash. Their opinions may differ. Their work calls for a sympathetic understanding by each, of the problems and difficulties the other is facing. Each should make an honest effort to cooperate with the other and to work har- moniously for the interests of the company they represent. Tact is required in their dealings; personal feelings should not be al- lowed to exist and prejudices must be overcome. An earnest and sincere attempt by each at all times to aid the other will facilitate their work and make for more pleasant and satisfactory relations than if petty antagonisms and friction are allowed to develop The agent can assist the examiner in various ways. First, let him learn the hours most convenient for the doctor to devote to examina- tion work. Then let him arrange, if possible, an appointment for the applicant to conform. This will secure prompt service, for if the physician knows the applicant is coming at a certain time, he will endeavor to save time for the case. But be sure the applicant is there to keep his appointment. If this becomes impossible, ordi- nary courtesy demands that the examiner be notified, for it is not unlikely that there are other demands on his time which can be used to advantage. Second. When the applicant lives in the country or a long distance from the examiner, the agent can often assist the examiner by ar- ranging to have the applicant meet the examiner half way between points, or else by having several applicants in the same neighbor- hood, thus making necessary only one trip for the doctor to examine all. Third. The handling of his case will be expedited if the agent will make certain that the examiner is supplied with proper blanks, and if he will also inform the examiner of any special requirements as to microscopic examination of the urine or sending of a specimen to the home office, or similar requirements which can readily be met if attended to at the outset but which may cause troublesome delays if overlooked. Such thoughtful acts of courtesy will well repay the agent by the prompter service secured. Fourth. The agent should employ for examinations the physician regularly appointed by his medical department as its examiner. An agent going into new fields should procure from his company a list of the examiners for that territory, and then endeavor always to employ the company's appointee. The more examinations there are to be made, the greater will be the physician's income from this RELATION OF AGENT TO MEDICAL EXAMINER 71 source, and thus the more interested will he become in the work of the agent. If the examinations are given to several different physi- cians, very likely there will not be sufficient compensation involved to arouse any particular interest of any of the examiners; whereas if the one physician is employed to make a goodly number of exami- nations, he will recognize the value to him of encouraging and as- sisting the agent to build up a good volume of business. Fifth. The agent should never attempt to influence the views or judgment of an examiner or to suggest or dictate to him what his report on an applicant should show. The agent is at liberty to present his own views to his company's Medical Directors or other officials direct, and he may rest assured that any facts or informa- tion he can supply as to the insurability of his client will have due consideration. The examiner likewise owes certain obligations to the agent. In fact, only as the agent is successful in his efforts to secure appli- cants, are there any examinations to be made, and so any fees payable to the examiner. The agent's compensation is not earned until he has delivered the policy and secured settlement therefor. He is vitally concerned in getting an interested prospect examined and the business issued because his earnings depend upon placing that business in force. Most persons are prone to postpone securing life insurance. Although they recognize its economic value and intend to secure it, they defer action. In fact, payment of premiums to provide insurance protection for others dependent upon him constitutes an unselfish act of personal sacrifice on the insured's part, and accordingly to induce others to purchase life insurance requires salesmanship of a high order. The agent may have worked on a prospect for a long period before arousing interest in his proposi- tion; but when the prospect is won over and consents to be exam- ined, no time should be lost in arranging for a prompt examination. The importance of quick action is apparent. Change of mind on the prospect's part, competition by representatives of other com- panies, opposition on the part of the prospect's wife, sudden illness or accident, are all factors liable to upset a sale unless the applicant is speedily gotten before the examiner. Hence the examiner's co- operation with the agent by a prompt examination while the appli- cant is in the mood will prove of material assistance and mutual advantage to all concerned. The examiner's office furnishes in general the best place for mak- 72 LIFE INSURANCE EXAMINATION ing an examination, but obviously this oftentimes cannot be ar- ranged. Some applicants may wish to be examined at their homes or at their places of business, and willingness of an examiner to accommodate prospect and agent in this respect helps. The exam- iner should, however, insist on privacy and a room large enough, light enough and quiet enough to enable him properly to examine the applicant. Again, some prospects are required to observe cer- tain hours at their places of employment, and consequently must arrange for examination in the evening, perhaps outside the physi- cian's usual hours. Here, too, is his opportunity to cooperate with the agent. One physician reports having made an examination at midnight at the Union Station in his city. Another took an ap- plicant from his work to a neighboring fire house to secure quiet and privacy. Such cases, while infrequent in practice, denote a recognition by the examiner of the agent's problems. Many companies permit their agents by collecting the initial premium when taking the application to bind the company on the risk from the date of the medical examination provided the com- pany upon its receipt of the application is satisfied that on the day of the medical examination, the applicant was an acceptable risk. In that event, the company's liability dates from the time of the medical examination. Obviously not merely the interests of the agent but those of the proposed beneficiaries suffer when time is allowed to elapse between the signing of the application and the making of the examination. How costly such a delay might have proved in one case is well illustrated by the following recent ex- perience of one company. This insured signed his application and paid the initial premium for the insurance on Friday morning; was promptly examined at lunch time that same noon; the papers were in due course forwarded to the home office, and on the following Wednesday night, while the papers were in transit, the insured was killed in an automobile accident; but he was protected under the application, and the policy was duly issued the next day. "Make the examination within twenty-four hours after securing the appli- cation" is an excellent rule for examiner and agent to observe. In the conduct of the examination, the physician should carefully refrain from any comment that may upset the agent's sale, for in many cases, at the time of the examination the applicant is not yet persuaded to accept a policy if issued. He may be only too eager to find some excuse for not buying, and so a tactless remark by RELATION OF AGENT TO MEDICAL EXAMINER 73 the examiner may offer the opportunity. On the other hand, the examiner may often help the agent to close a hesitating prospect. Man proverbially underinsures. He is apt to think in terms of the face amount of his insurance rather than of the income which it will yield. As death will terminate his income-producing power, he should strive to provide an income adequate for the proper sup- port of the family. The physician is often in a position to judge of the applicant's financial needs and ability to maintain insurance, and so his suggestions to the applicant in the course of the exami- nation may result in persuading the applicant to accept a greater amount than was first contemplated. The examiner, especially in rural districts, frequently has an intimate acquaintance with the personal condition and circum- stances of many of his neighbors, and so his suggestions as to likely prospects to engage the agent's attention will prove very helpful to the solicitor, for his knowledge may cover both the physical and financial aspects of the case. Such assistance enables the agent to utilize his time advantageously and with beneficial results for him- self and the examiner. The examiner should remember that the medical board of his company has had broad experience in dealing with large numbers of risks; that the members of the board look at cases as belonging to different classes or types, and are cognizant of the results produced by these classes; and that consequently their decisions must be based on the light of the knowledge and experience they have gained. Some- times an examiner, viewing only the individual applicant before him, may be inclined to minimize the effect of some defect in physical con- dition or personal history, and hence to recommend acceptance of the risk. If the company's decision differs, he should not criticize its ac- tion, nor should he create rfurther dissatisfaction with the company's declination in the mind of the agent in an attempt to justify his own recommendation. Let him remember that the company aims to accept every risk safely insurable, and that it is the company which must stand the loss if premature death occurs. The company will gladly receive any information regarding a case which the examiner may have to present, and oftentimes he may prefer to write confidentially rather than to put his comments in the applica- tion papers. Any such communications are helpful and welcomed by the medical directors; and in this way the examiner is enabled 74 LIFE INSURANCE EXAMINATION to place before the company facts which it is entitled to receive; yet he avoids arousing the agent's displeasure. In their callings, both examiner and agent are serving humanity. Each is contributing his part toward making the lot of others better, brighter and happier. Each may have the consciousness of a world of good accomplished, measured not by the material re- wards he may receive; but still he has the realization that many owe to him thanks for benefits received through his efforts. Con- fidence in each other and cooperation with each other are needed to make their work most effective. CHAPTER VI ORGANIZATION OF MEDICAL DEPARTMENT By Henry Wireman Cook, M.D., Minneapolis, Minn. Vice-President and Medical Director, Northwestern, National Life Insurance Company As the entire practice of medical selection has been a development of the past half century, it is not surprising to find that there were no medical examiners prior to 1860, and that applicants for insurance were accepted upon the casual approval of the president of the com- pany or the board of directors after a persona] interview or a brief written recommendation from some local policyholder. As gradually expert medical opinion was required, first, that of the family physician, and later, that of a carefully selected company examiner, the role played by medical science in the life insurance business has been increasingly important, until today it involves an intricate machinery, vital to the company's success and directly related to almost all the company's major activities: selecting, training and educating a corps of physicians, reviewing, rating, classifying and analyzing their work; determining the company's mortality experience (the largest single factor in its financial success) ; promoting health conservation, both among the policyholders and the general public; applying medical selection to the choice of employees as well as policyholders; render- ing medical service and welfare work to employees; and, perhaps as important as any other function, offering a sound, convincing, cordial and yet firm basis of cooperation with the agency organization. It is readily seen that the conduct of a modern medical department in- volves far more than a sound medical training and clinical experience. This, it is true, is an essential background, but it must be supple- mented by effective business methods and an enlightened social con- sciousness. The medical organization in a life insurance company may, for pur- poses of analysis and study, be divided under two general headings -first, personnel; second, office machinery-and both are essential to effective and scientific operation. The medical personnel consists of one or more medical directors and laboratory technicians, and the field medical examiners. Though 75 76 LIFE INSURANCE EXAMINATION in the early stages of the development of most companies the medical director's position is only part-time and in the nature of a consultant or adviser, ultimately, and better from the very beginning, the medical director is not only a full-time officer, contributing clinical knowledge as a guide to medical selection, but also the responsible head and business executive of a department in which arc centered all the data pertaining to the selection of risks: the medical, the inspection, the training of agents in selection, the appointment, control and educa- tion of examiners, statistical data furnished from all sources, but principally actuarial, and the control of all the office machinery con- cerned with the receipt, action and issuance of new business, and, in addition, such other company and employees' medical service as has been previously enumerated. Too great care cannot be exercised in the choice of the officer who is to hold this responsible position, as much of the success of the com- pany depends on both his professional and business ability. He must be thoroughly grounded in the science of medicine and should have had a certain degree of experience in the practice of his profession. If he has not had the benefit of the best medical education, he will not only not have had the necessary scientific background, but will be unable to distinguish the relative values of different prospective ex- aminers. He should have some special course or experience in biom- etry and the statistical side of medicine and be able to apply the data furnished by medico-actuarial investigation. He must be able to meet men easily and deal with them successfully under trying and difficult conditions. He must be able to formulate reasonable, not necessarily ideal, standards and to maintain a firm stand when he has reached the best decision possible. He must understand office system and be receptive to newer business methods. In brief, he must be both a scientist and a capable executive. The medical director must have one or more medical assistants, enough so that he is not buried in routine and so that the department may function normally when he is absent. In addition to the clerical personnel of the medical department, which will be taken up under office machinery, the medical director should have a laboratory tech- nician for the urinalysis work. The urinalysis, which is a rather constant routine, can be not only more economically but also better done by a trained, intelligent lay girl. A physician who has spent eight or ten years in preparation for his profession cannot be expected ORGANIZATION OF MEDICAL DEPARTMENT 77 to do interestedly, and therefore well, routine specific gravities, albumin and sugar tests and microscopic examination. In addition to the work associated with his own department, the medical director must be in intimate and sympathetic relationship with the other officials and departments of the company. A spirit of fellowship based on association and effort in a tremendously worth- while enterprise is essential, but should be supplemented and culti- vated by regular meetings when matters of mutual interest are openly and frankly discussed and when the different viewpoints inherent in the variety of training and experience of men of medical, legal, mathe- matical, financial, executive and salesmanship specialization can be broadened and correlated into an effective and united whole. Here, and in equally important periodic visits to agency meetings, the medical director learns that life insurance salesmen as a whole are earnest, conscientious men, attempting to earn an adequate living for themselves and their families and having a real sense of the social obligation of their calling, and are not using their entire time and effort in putting over bad risks on the company. Here also the agency directors and the agents themselves learn to know the medical director as a trained, earnest worker who is trying faithfully to apply his scientific equipment to the advancement of the business of life insurance in such a way as to insure protection to the largest propor- tion of the risks submitted on an equitable basis, consistent with fair treatment of the applicant and a reasonable mortality experience for the company, not as a narrow technician who takes secret delight in thwarting the agent's efforts and depriving him of his hard-earned commission. Of all the grotesque misconceptions arising in social and business life from conflicting desires and ambitions, none is more absurd than this, that the ultimate aim of the medical department and the agency department is not the same. Both want growth, ex- pansion, favorable mortality, low net cost. Neither wants unnecessary restriction on production or excessive mortality. No medical director would want to stay with a company which was not expanding, and did not have an active, aggressive agency force. No agent would want to be associated with a company which accepted impaired risks at inadequate rates and so experienced a high and unfavorable mor- tality. It is entirely possible and logical that these two departments should work in complete accord and with a mutual understanding and respect. 78 LIFE INSURANCE EXAMINATION The Medical Examiner The medical examiner has been spoken of as the eyes of the medical department. However that may be, the department is certainly groping in the dark if it has not the benefit of a corps of well-trained, keen, alert and interested medical examiners. High grade officials, stacks of statistics and an efficient office system will not overcome the deficiency caused by ignorance, carelessness or dishonesty on the part of the medical examiner. Upon his professional and personal attain- ments and qualities depends the reliability of the data upon which is based the action on the individual risk, the statistical data, and the aggregate mortality experience of the company. Important as home office knowledge and statistical analysis are, the relative time and thought spent upon them are excessive as com- pared to the care spent in selecting an unprejudiced, capable exam- iner, in furnishing him a well-considered blank for his reports, in educating him and cultivating his interest, and in safeguarding his service from all undue influence or bias. No matter how much we may study and argue about the significance of albuminuria, we are not much better off in the individual case if the examiner has not re- quested a specimen for examination, if he is incapable of examining it when obtained, or if the applicant or agent is allowed co exercise his preference for the physician who cannot or will not report the facts. The quality of service rendered the company by the medical exam- iner depends on: 1. Care in his selection. 2. His protection in rendering unbiased opinions. 3. The blank upon which he makes his report. 4. His continued education and cultivation. 5. A systematized grading and gauging of his work. The information he gives should be kept strictly confidential. A physician who jeopardizes the friendship and influence of a local, per- haps prominent, acquaintance, by giving the company some vital information and who then finds that this information is later detailed through some- officer of the company or clerk to the agent, and by him all over town, can readily be excused for not laying himself open twice to the same misuse. Such a company does not deserve to get the facts, and does not often get them twice from the same doctor. The examination should never be handed over to the local agent, but should be mailed in direct by the examiner. ORGANIZATION OF MEDICAL DEPARTMENT 79 Tlie permanence of the examiner's position must be preserved throughout the continuance of good service, absolutely independent of whether his care, his integrity and his skill have earned the favor or the dislike of the agent or the prospective policyholder. When the first examiners were appointed, little or no choice was exercised by the company, the preference resting with the agent or the applicant. Undoubtedly the greatest single improvement in methods of medical selection has been the appointment by the medical director of the company's examiners, and the insistence that the com- pany's chief examiner in each community must be used if available, or in his absence, the first and second alternates in the order named by the company. Analysis of records, forms of blanks, etc., are of relatively small importance to the prior necessity that examiners be chosen who are competent to report the facts and, who are acting in the interests of the company, and not chosen by impaired applicants for the very reason that they will not report the facts. No mistake in medical selection is more disastrous than to give the agent or the applicant the privilege of discontinuing and penalizing a painstaking and honest physician in favor of the incompetent, careless, or dis- honest examiner. This is vital. The number of reasons some agents can think up for discontinuing a regular examiner and appointing a new one is limited only by their ingenuity. The regular man is too young, too old, too slow in his examinations, not a booster, is indiffer- ent, incompetent, etc., the physician recommended is more alive, more active, will suggest prospects, and-most important-will take a policy. You cannot receive loyal service without being loyal. Always give the examiner a chance to state his side of the case and in addi- tion make a full investigation. It is astonishing how the stories dis- agree. An agent has the right to demand prompt and efficient serv- ice. He should be encouraged to report facts and his complaints should be investigated immediately, but if any stability or real value is to be expected of the medical reports submitted, the examiner's appointment should never be subject to the caprice or ill will of an agent. Further, he must be guaranteed, in return for the kind of service required, the first choice for all examinations in his territory, if he is not ill, absent, or absolutely unavailable. Nothing will more quickly impair the quality of the average examination received than to give the agent a choice between two, three, or four examiners. One can usually be found who will cultivate the good will of the agent at the 80 LIFE INSURANCE EXAMINATION [Part II] This examination most be made In private. Answers moat be written In BLACK ink« the examiner to record in hie own handwriting the answers of applicant to every question. and have applicant sign full name. ANSWERS MADE TO THE MEDICAL EXAMINER Id continuation ot and forming part al application for Insurance in the AMERICAN LIFE CONVENTION COMPANY, of Chicago, Illinois PERSONAL HIST OR Y: 5. What, if any, changes in occupation or residence have you made, been 1. Date of birth? advised to make, or contemplate making on account of your health? ®Ace "d nationality? g Have you ever been in any way connected with the manufacture or 3. Have you ever occupied the same house or room with a tubercular gaje alcoholic liquors? person?7- Give details of present occupation (If so. state date, and relationship of patient.) 8. Have you ever been declined or postponed or limited by any insur- 4. State whether single, married, widowed, or divorced. ance company? HABITS: 11. Do you, or have you ever used opium, cocaine, or any other narcotic 9. Do you now use, or have you ever used whiskey, wine, beer, or other n ,, . „ or habit-forming drug? alcoholic beverage? _If so, to what extent? 12. Have you ever taken or been advised to take treatment for liquor or 10. Have you ever used them to excess or intoxication? drug habit? HEALTH: (The examiner ia expected to use care and interested effort in developing all sign* and symptoms, and admissions of previous illness or impaired health.) 13. Name below all causes for which you have consulted a physician in the last ten years: Illness Number of Attacks Date Severity and Duration Any Remaining Effects? Attending Physician's Name and Address 14. Are you now in good health, as far as you know and believe?18. Has your weight increasedor decreased 15. Has any medical examiner or physician, formally or informally, in the past three years? expressed an unfavorable opinion as to your insurability ** 9O' "ow much, and cause? or health? 19. Are you ruptured?(If so, give location and describe 16. Have you ever had, or been advised to have, any surgical opera- fully) - tion? ja proper truss constantly worn? 17. Have you ever been under observation, care, or treatment in any 20. Have you ever had any of the diseases mentioned in item 4 of hospital, sanitarium, asylum, or similar institution?Part III? 21. Have you now, or have you ever had, any other diseases or any injury?-- Give details, dates, etc., of any history noted above: FAMILY RECORD: In giving caase of death or ill health, avoid indefinite terms. 24. If Applicant is a woman the following questions must be answered. Living Dead '' ====^=============== ====. 22~ Are Health Are Caure oi Death Ho. Lona sick? a Give date of birth of / [h anyone dependent Fathar your last child. - - • upon you for support? (If so, give particulars.) Moth«r|b Are you now pregnant? c Have you ever had any * Occupation of huabandT miatyuriagea? .... (Give dates and details.) h Health of husband? Sisters d Are the menstrual funo- » Has he applied for insur- tions now regular? • •ance in this Company? I 23. Have there ever been any cases of insanity, e Have you ever bad a tu- j In what other compan.es tuberculosis, epilepsy, or suicide in your mor or disease of breast, does he carry insurance, family? If so, give details:womb or ovaries?and in what amount? 1 hereby declare that all statements and answer* as written or printed herein and in Part I of thia application are full, complete and true, whether written by my own hand or not. and I agree that they are to be considered the basis of any insurance issued hereon. I hereby authorise any physician or other person who has or may attend me to disclose to said Inaurance Company any information thus acquired. Dated atthisday of 192 Witness M.D. Applicant. Signature of Medical Examiner. Signature of Party Examined. IMPORTANT Examination of Thia itatement must be detached by Addreae - the Examiner and sent to the Medical Authorixed by AgentDate192 Director at the Home Office the same . day the examination i* made. Under AMERICAN LIFE CONVENTION COMPANY, Dr. no circumstance* should it be deliver- Chicago, Illinois ed or shown to any agent of the Com- pany The Examiner's Confidential ToM.D. Report on the reverse side of this sheet must be filled in as a part of the For examination of medical examination. party made192 Fig. 12. ORGANIZATION OF MEDICAL DEPARTMENT 81 EXAMINER'S CONFIDENTIAL REPORT Give your personal opinion of general physical condition,-(appearance, figure, color, vigor, general health, etc.): - Give detailed opinion of moral hazard,-(habits, insurable interest, social status, etc.): (Specify whether applicant has ever been intemperate) Do you unreservedly recommend this applicant as a first class risk? Or do you rate the risk as medium? Or poor?If other than first class, give reasons -M. D. Medical Examiner. [Part III] MEDICAL EXAMINER'S REPORT. N. B.-Examiners are requested to make a very careful examination of heart and lungs with stethoscope against the bared skin. 1. a How long have you known ap- a 11. a Is the respiratory murmur clear a plicant? --- and distinct over every part of b Are you related to him? b both lungs? b Are the lungs free from every b 2. a Does applicant impress you as a indication of disease? healthy and vigorous? - b What is his apparent age? b 12. a Give location and character of a ~ apex beat. 3. a Physical defects or deformities? a Indicate with an (X) on diagram the , position of the apex beat in all cases. b Impairment of sight? b b Are the heart sounds and b c Impairment of hearing or dis- "c rhythm regular and normal? charge from ear? c Describe any evidence from c d Have you found, after careful ex- d percuBsion or auscultation of amination.any evidenceof goitre, 2phy °rother <hsease °f enlarged glands or other tumor?heart- 4. Has applicant ever had syphilis, stricture or any venereal disease? 13< Waa your examination of heart 5. Is there any alteration in the and lungs made with stetho- reaction or in knee scope against bared skin? 6. a What is his exact weight? a 14 URINALYSIS: a Specific Gravity? b Exact height? b in Reason? c Clear or cloudy when voided? c Girth of abdomen? c in. d Albumin? e Tests used? d Girth of chest under vest? d Expirationin. f Sugar? g Tests used? Forced inspiration in Make note of sllfthteat trace of albumin or auOar found at any examination. h The specimen examined e Did you weigh applicant? e was voided in my presence, ata. mp.m. / Did you measure him? f i Has any one ever claimed to have found casts, 7? What is his temperature? (under albumin or sugar in the applicant's urine? tongue)degrees. 8. a Rate of pulse? a i Are you forwarding a specimen of the applicant's urine? b Is pulse irregular or intermittent? £ nunute' A specimen of urine must be forwarded to the Home Office Give details below. for microscopical examination in every case when applicant isyears 9. Are the arteries thickened or of age, or over, or when amount applied for is or over, or when sclerosed?specific gravity is under or over~, or when there is previous history of kidney disease. Send specimen in case of any abnormal mm' Hg- finding. Five grains of boric acid per ounce is recommended as a 10. What is the blood pressure?Diastolicmm. Hg. preservative. REMARKS AND EXPLANATIONS: 15. Are you satisfied as to the applicant's identity, and the I 16' ~»Uon?( substantial correctness of all answers?Iterpreter ia required.) I Certify that I have carefully examined ofin private, at this... day of_„_192_ : that the statement of applicant on other siae of this sheet is in my handwriting, and is exactly as made by the applicant to me, and that it was signed by said applicant in my presence. (Signature of Examiner) M. D Examiner's Postoffice address Fig. 13. 82 LIFE INSURANCE EXAMINATION expense of his colleague and the company. An agent is more than human if he prefers the best rather than the easiest examiner. The character of the service rendered by the examiner will depend somewhat upon the form and arrangement of the blank furnished to him for his report. The first reports used were merely statements attesting that in the examiner's opinion the risk was acceptable. While in the case of a few well-trained and thorough examiners this might be all that is necessary to make the individual risk safely in- surable, it certainly would not guarantee a thorough examination at the hands of the average examiner, nor would it permit, even in the case of the best examiners, records which would be of any value for comparison or classification. From a realization of the inadequacy of the simple approval of the risk, the blanks became more and more complicated until they mentioned every known disease, and thoroughly confused and bewil- dered the examiner in a maze of clerical detail. During the past few years the reaction has been towards a simplified blank which shall concentrate on vital points and omit all nonessentials. An example of this tendency has been the attempt to develop a uniform blank acceptable to all companies, with the requirements of which all ex- aminers will become familiar, so that their entire attention can be concentrated on obtaining the facts necessary to intelligent and safe selection. The aim of the uniform blank was towards simplifying the ques- tions, reducing their number to the minimum required to give essen- tial information, and conserving the examiner's time occupied in clerical detail so that he might be able to devote more time to the physical examination and a thoughtful summary and recommenda- tion of the risk. A copy of the examination blank adopted by the Medical Section of the American Life Convention is here appended. (Figs. 12 and 13.) In any business relation, interested service is far more valuable than routine service, and particularly is this true in the case of medical examiners. An examiner who has had personal relations or acquaintance with the medical director is much more free and helpful in his reports. Where this personal acquaintance cannot be reached, much can be done by correspondence. Many companies send out each month, with the checks, a letter giving some pointers in the physical examination, or some note of interest in connection with medical selection. Some companies go further and send periodically ORGANIZATION OF MEDICAL DEPARTMENT 83 NameState P. O Credential mailed Received A&e Date Graduation CollegeCommission mailed Remarks: Form 309c 5-19 (19674) Fig. 14-A Omissions Remarks: Errors Drums Urinalysis Credits Delays Fig. 14-B 84 LIFE INSURANCE EXAMINATION to their examiners and agents pamphlets or reprints relating to the problems of medical selection. The doctors of this country who graduated prior to 1905 were largely taught the use of the sphyg- momanometer by insurance companies, and their present equipment to make competent urinalyses comes in great part from the same source. In the routine correspondence much can also be done to cultivate a friendly relation and keep the interest of the examiner, thanking him scrupulously for evident care, explaining why the company's action may vary from his recommendation, checking care- lessness or incompetence, and showing' him the importance of his work. It is most important that the work of the examiner should be watched carefully, and recorded in some convenient form for refer- ence and grading. An alphabetical examiner's card has been adopted in various modified forms by many companies, and is handy and easy to keep up (Fig. 14-A). The back of the card (Fig. 14-B) is ruled into spaces in which the checking clerk makes notation of omissions, mis- takes, death losses, carelessness, inattention to correspondence, etc. The general impression one gains of an examiner's work will fre- quently be unjust or too lenient if not controlled in this way, and such data are invaluable in deciding how much confidence to place in a recommendation, especially of a borderline risk, or in deciding on a change or ranking of examiners. Office System Given an ideal organization from the point of view of medical per- sonnel, the service will fall far short of effectiveness if the decisions are based upon the vague impression in regard to prognosis gathered from a general medical education and individual experience, and if the execution of the technical decision is not governed by modern office system. Medical departments are so accustomed to the use of a numerical height and weight table in medical selection that it is diffi- cult to realize that only thirty years ago Mr. Macauley presented his paper on "Weight and Longevity" and that before that time medical directors were compelled vaguely to estimate what was overweight and underweight, just as we still have only a vague impression of the proper action towards many conditions, which as yet have not been studied and analyzed sufficiently in the light of actual experience to permit exact ratings. The Medico-Actuarial Investigation added immensely to the accuracy ORGANIZATION OF MEDICAL DEPARTMENT 85 of our knowledge along this line, and many other examples of indi- vidual contributions, such as the work of Dr. Fisher of the North- western Mutual on blood pressure, Dr. Rogers and Mr. Hunter on occupational ratings, and, more recently, on heart murmurs, are familiar to all of us. The value of the best scientific medical train- ing, wisdom, common sense, and experience as the necessary basis of medical selection should not be minimized, but actuarial science has added a most efficient instrument of precision to supplement, control and guide what has been thought of as the special domain of medicine. Recently, although rather late, even clinical medicine is recognizing the necessary part that scientific prognosis should play in clinical practice. The really advanced surgeon or physician is no longer satis- fied with lhe incorrect and misleading reports that were formerly given as results of treatment and operation. Surgeons have long realized that reports of "cures" from operations for cancer must be given guardedly, especially since Halstead attempted a scientific follow-up of results in operations for carcinoma of the breast, but the same study has been applied to but few other surgical or medical conditions. Data on results of treatment at the Trudeau Sanatorium furnish a notable exception. To say that a man is "cured" after a stone has been taken from the pelvis of his kidney, without recognizing the excess mortality that follows from this disease throughout the life expectancy of the class, and not only an excess mortality but a mortality which increases with the length of time elapsed since the period of symptoms, is to give a very erroneous impression both of the effect of treatment and of the pathologic background. No degree of accuracy can be gained from the medical textbook or clinical paper in regard to an exact prog- nosis in mitral insufficiency with or without marked hypertrophy and as a sequel to rheumatism, or independent of it. Yet, life insurance experience has supplied very accurate data on those questions as it has also on peptic ulcer, gastroenterostomies, etc. The sooner the time comes when hospitals and clinics control their records and ex- perience by sound actuarial analysis, the sooner shall we add to the knowledge which is equally necessary for accurate medical selection, correct clinical prognosis, and sound judgment in regard to the effect of treatment. The modern medical director must, therefore, supplement his med- ical training and experience with all of the information which has come and is daily coming from an analysis of actual experience in 86 LIFE INSURANCE EXAMINATION homogeneous groups. There is no reason why he should use such experience and percentages blindly and narrowly any more than why this should be done in the case of any other instrument of precision. The fact that some physicians try to bring every patient's blood pres- sure to a normal average by the use of stimulants or vasodilators does not constitute a valid argument against the use, but only against the misuse, of the sphygmomanometer, Having obtained the technical medical and actuarial background for scientific medical selection, it is equally necessary to develop and maintain a modern, scientific business-like office system to give effec- tive expression to this knowledge. Business success is a far more complicated process today than it was a generation ago, and this is true of all lines. The wasteful, care- less, disorganized methods of mining, manufacturing, financial, agri- cultural and professional enterprises, which then allowed an excellent margin of profit, would today spell speedy ruin. The margin of profit is smaller, competition is keener,-and slip-shod methods cannot stand the pace. Unfortunately, our universities in this country do not cor- relate their scientific courses with practical business training, and our scientific men are unfamiliar with modern methods of business system and efficiency. The medical man who attempts to handle his office clerks and routine and his outside examiners in such an orderly and prompt manner as to give -the sort of service that the company and the agents have a right to demand, must familiarize himself with the principles and practice of business routine. In such a business con- cern as a life insurance company, it is as serious a criticism of a de- partment's efficiency to cause an unnecessary delay in correspondence, in the issuing of policies, in paying examiners, in advising agents of medical appointments, or to fail to keep an intelligent record of the examiner's work, his omissions, his promptness, his mistakes, and to grade and classify physicians systematically according to school of graduation, hospital training, etc., as to be unable exactly to time a cardiac murmur, or to be ignorant of the extra mortality suggested in the various groups of the medico-actuarial investigations. This grade of service can be obtained only by the use of the best system and the latest physical adjuncts in filing, card indexing, etc., and by the em- ployment of educated, intelligent and loyal clerks. The system that combines speed, exactness and minimum work is the most efficient. Some systems are so complicated and involve so much duplication of work that they are extravagant and impair ORGANIZATION OF MEDICAL DEPARTMENT 87 rather than aid real efficiency. System must be the means rather than the end. Some men who pride themselves on their system and have every act, no matter how immaterial, indexed, cross-indexed, charted and illustrated on intricate diagrams, lose sight of the end in their enthusiasm over the means. This is not the place to attempt a detailed description of filing cases, card systems, etc. This physical side of the organization can be obtained from textbooks on business management, from firms manufacturing and selling office equipment, and by study of the methods of other life insurance companies and other business organizations. A modern office is constantly modify- ing its system in order to conform to newer ideas and altered condi- tions. Habit and a limited experience are serious obstacles to a re- sponsive and modern system. The clerks who have become accustomed to an obsolete method and who have had a narrow experience naturally do not readily see the virtues in the proposed innovations. But the constant minor changes in the larger offices and the great changes be- tween the methods separated by a single decade, should make us all alive to the need for watching the newer suggestions and for utilizing those that appear to have permanent value and to fit in with the gen- eral office scheme already adopted. Sweeping changes too suddenly made without due regard for the established routine in any office are generally ill-advised and costly. Under the older method the medical department was often situated in a remote part of lhe plant, and applications were carried there and then carried back, after being held long enough for the prelimi- nary check by the medical director and for obtaining inspections and answers to omissions and other necessary data to permit final action. Then, after visiting the auditing, filing, actuarial, agency and other departments, all assembled papers were again presented to the medi- cal director to be earfully rechecked and approved or declined, and then sent to the files or the policy department. This traveling of the application back and forth around the building for review, record, approval and issuance necessitated much lost motion and un- necessary delays and expense. The general tendency has been to con- centrate all activities related to the receiving, acknowledgment, check- ing, approval and issuance of applications and policies into a single department, known as "New Business Department," where lost mo- tion can be eliminated and valuable time saved. Fig. 15 shows the older, still widely used, method of handling an application. 88 LIFE INSURANCE EXAMINATION /. /Entered or, amt. Pay doctors s< date cor. -ZAte'ana prem. checked and app- backed. App. photographed. 3. Previousms. and impairments looked up- 9. /ssued. A EEnter ed in app ■ regist er. IO. Take record as to settlement. 5. Por action. II Cards made. A Policy to sec. for signature. 6. Por approval. 12. App filed. £>. Policy mailed. Fig. 15. Fig. 16. ORGANIZATION OF MEDICAL DEPARTMENT 89 Fig. 16 shows a diagrammatic scheme of an ideal office arrangement where the application travels in a direct line within a single room and through the different processes necessary to all stages of its handling from the time it is received at the home office until the applica- tion is filed. The left half of Fig. 16 shows a diagrammatic arrange- ment which could take care of all second year and subsequent pre- miums, correspondence, etc., in a similar way, with the same relation to the files. This arrangement is not always possible in the emer- gency quarters in old-fashioned office buildings occupied by many com- panies, but is the scheme towards which companies will trend more and more as they build and occupy new buildings suited to the require- ments of the business. This contemplates a single open office which can be easily arranged to accommodate 500 or more clerks. All factors- heating, lighting, ventilating, noise, supervision, speed, accuracy, and economy-are better managed in the large office than in the small divided offices. Contrary to the popular belief, the noise from type- writers, adding machines, etc., is greatly reduced in the large office where the more distant walls do not as insistently reflect the sound, especially if, as in modern offices, the walls are deadened by felt and canvas covering. The application, in the diagram, travels a direct route from files and from desk to desk, rendering messenger service unnecessary and permitting each stage to be completed in the mini- mum time and with least effort. This route from 1 to 7 can be traveled in two or three hours, and lhe policy can be issued without difficulty the same day the applica- tion reaches the home office. One of the most valuable features of the later method of selection is the substitution of lay checkers, to relieve the medical directors of routine clerical work which trained girls really do more accurately and better, and at less expense. The extent to which these trained clerks can be used to check and rate applications depends upon the stage in the development of a numerical rating system in that company, or upon the extent to which the opinion of the medical department has been reduced to writing, so as to be available for the use of both clerks and medical directors. There is no more helpful, even necessary sys- tem in the medical department than to put every opinion and rating into writing, preferably in the form of percentages. If an applicant with a certain history or physical sign deserves to be rejected today or rated to a certain percentage, it is obviously obligatory from every viewpoint-fairness, accuracy and consistency-that another appli- 90 LIFE INSURANCE EXAMINATION cant tomorrow or next year with the same impairment should receive the same action, or else that the same action should be intelligently modified in the light of subsequent experience. Even if one man could see every case, it would be humanly impossible for his memory to be sufficiently exact to maintain absolute uniformity, and with several different men, any uniformity of action is the more impossible. The only possible way is to continue to put the opinions and actions down in writing, and to modify and correct these notations from time to time in accordance with the new knowledge and experience. This not only is fair to the applicant, but it satisfies the agent as he rec- ognizes a reasonable uniformity instead of snap-shot varying stand- ards, and it tends greatly to clarify and standardize the knowledge and opinion of Hie medical director himself. Care must be exercised, however, in the development of the numer- ical system and rating by clerks, that this tendency is not carried to an extreme. Medicine is not, and never can become, an absolutely exact science. We shall never see the time when sound and experi- enced medical judgment can be entirely replaced by a mechanical system. Borderline, complicated and unusual cases should always be referred to the medical director for decision, and some cases will require a conference in which more than one medical opinion com- bined with an actuarial point of view will be necessary to do the in- dividual factors justice. As the tendency in the past in medical selection has been to give too much weight to individual opinion and experience, we must be sure that in the immediate future the pendulum does not swing too far in the opposite direction, for tables, charts and percentages must not be expected to supplant experience, judgment and common sense. Neither the financial interest nor the moral responsibility of the company in the health of the prospect ends with his becoming a policy- holder; in fact, they begin with the formal approval and issuance of the contract. An insurance company is so peculiarly situated as to wield a wide and authoritative influence in matters of individual and public health, and, in so doing, will be benefiting its own financial standing by improving both the insured and the general mortality, and, in addition, by contributing another and important phase to its service to the public. Medical information, health bulletins, periodic examinations, urin- alyses on request, medical and nursing service to industrial and group policyholders, specific advice in substandard and rejected cases, active ORGANIZATION OF MEDICAL DEPARTMENT 91 support and participation in public health movements-all constitute a triple obligation, to the policyholder, to the company, and to the community. Life insurance has become a monument to sound financial policy, and one of our national economic bulwarks. It must now take its place as a great humanitarian power, utilizing to the full its excep- tional opportunities in the field of public health, and so bringing nearer the complete practical expression and realization of Glad- stone's aphorism, "In the health of the people lies the strength of the nation. ' ' CHAPTER VII THE MEDICAL DIRECTOR By Frank L. Grosvenor, M.D., Hartford, Conn. Medical Director, Travelers' Insurance Company The medical director must be a physician of ability, conversant with the history and art of medicine and its science as existing during the period of his activity. In addition he should have qual- ifications fitting him for his special work. His responsibilities bring him in contact with many individuals on a basis differing from that of patient or fellow-physician with whom the physician ordinarily deals. The medical director in the course of his duties is necessarily in close relation with those who view problems which arise from a business standpoint, and is re- lied upon to coordinate the business and medical principles through the application of which a life insurance company may attain success. It is necessary that the medical director have the personal qual- ifications of strong character, fair-mindedness and good judgment so that he may have the confidence of his staff at the home office and his examiners in the field as well as that o-f his executives and their assistants with whom he is brought in daily contact. His direct responsibilities include the maintenance of a competent clerical organization, which shall handle the details of the medical depart- ment so that the medical officers may be able to devote their entire time to the problem of medical selection, the organization and guidance of a home office corps of assistants and the maintenance in the field of a large corps of qualified medical examiners. The medical director is deficient in his duty unless he is able to provide for the use of himself and his staff a library which is kept abreast of the progress in medicine and so to systematize the work that all concerned may have the opportunity for the use of this library. At least in the larger companies it is necessary that a well- equipped laboratory be maintained. In addition to being an aid in 92 THE MEDICAL DIRECTOR 93 selection, a laboratory is important to the work of such companies as an attempt to increase the longevity of their policyholders by con- servation work among their insured. The use of the laboratory is also of value in the matter of the conservation of health of com- pany employees, a work of very great importance from many as- pects and which lies in the province of the medical director. He is called upon to maintain an efficient organization for the carrying on of this work in the companies which now undertake it and in those which may not be doing so at present, to bring to the atten- tion of his executives the value of such work to the company. The purpose of the medical organization of a life insurance com- pany is that of selection of risks which shall attain a longevity with resultant mortality such as is desired by the company and necessary for its continued operation. This can be accomplished only by the employment of competent examiners. The picture of the applicant which they render must be the basis upon which action is taken and consequently must serve as the rock upon which the house must be built if it is to stand. Having received the report of the examiner, it is necessary to construe the facts as presented and to determine how they may be applied to the underwriting prac- tices which govern the company in its selection. It is necessary for the medical director and those who assist him to have knowl- edge as to the effect upon longevity of disease, heredity, build, en- vironment and occupation as it may affect health or constitute an occupational hazard. A knowledge of histology and pathology and consequent ability in prognosis is especially important, as is diagnostic ability, and not the least necessity is the ability to inter- pret the findings of other physicians as rendered in their reports. The medical director is called upon to cooperate with the Claim Department in the investigation and settlement of claims in which there is a question whether or not insurance was obtained through misrepresentation. The medical director and his assistants find it necessary to review such death losses as occur during the select period, that is, within five or six years from the date of appli- cation, from the standpoint of the cause of death, in connection with which he must observe first, whether there is any reason to suspect that the examiner reporting on the case was inefficient and if so to take the necessary steps in the matter-perhaps discon- tinuance, suggestion or advice, depending upon the degree of ineffi- 94 LIFE INSURANCE EXAMINATION ciency; second, a review of the papers acted upon at the home office, whether there is anything in the case to indicate that the risk should not have been accepted. It is necessary in reviewing death claims to bear in mind the general experience of the company and likewise to consider that a death from a given cause in a given type of case may indicate that such an application should not have been accepted. Such a conclusion should not be reached, except in cases of evident error, without a knowledge of the number of similar cases to which the company is exposed in its experience and the results in this class as a whole. Statistical study is of primary importance. Statistics based on the experience of life insurance companies are again dependent upon the physician in the field, as it is he who finds and reports the conditions which are made a matter of record and enter into the statistics. This also applies to statistics with regard to causes of death which are based upon the diagnosis of the attending physi- cian. For this reason medical knowledge is necessary to the proper interpretation of experience. Precedent also enters very largely into the matter of selection. Medical directors of recent years are enabled to rely very largely upon the statistics which have developed with the growth of the life insurance business in this country within the last few decades, an advantage which their predecessors did not enjoy. Yet here, as in the practice of medicine, the art of medicine cannot be re- placed by the science of medicine which in life insurance work is constituted by statistics. Science is not yet sufficiently exact. In years past the medical director was like a ship at sea with- out chart or compass so far as statistical evidence was concerned, yet the medical directors of that time established precedents by means of their professional ability, many of which have since been shown by statistical evidence to be correct, while on the other hand many precedents which have not been established as correct by statistical evidence have not been successfully controverted by such evidence. Depending somewhat upon the method of operation in his individual company the medical director must also have a thor- ough knowledge of underwriting practices other than medical which are applied in selection, consisting of elements of specula- tion, overinsurance, moral hazard and habits. The medical director is brought into the problems of the field THE MEDICAL DIRECTOR 95 officers and solicitors through correspondence and personal con- tact. He must be able to instill a belief in his professional ability and in his fair-mindedness when he is called upon to settle ques- tions which arise in connection with the efforts of solicitors. He must not permit himself to become unduly suspicious and antag- onistic and, while it is frequently necessary for him to sift evi- dence until he can obtain a true idea of the facts in connection with any complaint which may be made to him by the company's agents with regard to examiners, or by examiners with regard to agents, this should always be undertaken with the intent to do justice to those concerned and not in the hope of fixing the blame on anyone in particular. This is very necessary in order that exam- iners in the field and agents as well shall have complete confidence in the medical department. Personal contact between the exam- iners in the field and the medical director and his assistants by means of visits in the field and visits to the home office by exam- iners located at important points serve to coordinate the work of the home office medical department and its examiners in the field to a greater degree than can be accomplished by other methods. Occasionally complaints with regard to examiners are made by agents shortsighted as to their real interest, to the effect that com- petent examiners are incompetent because of agency reasons. It may happen that an examiner very competent medically may be decidedly criticizable from a business point of view. Before such an instance can be admitted, however, the medical director must be assured that such is, in fact, the case and that the examiner is negligent of the company's interests and not the victim of allega- tions resultant upon his having given satisfactory medical service. The loyalty of examiners to the home office which is essential can- not be maintained unless unjust criticism of them be not recognized. At the home office the work of the medical director is intimately related to that of the actuary upon whom he depends to furnish and to interpret from an actuarial standpoint the experience of his own company and that of other companies which may cooperate with his own in the development of a combined experience, by which means a larger exposure and consequently more exact ex- perience become available. The study of small classes does not furnish the accurate guide which is obtained by the study of large classes, yet a study of small 96 LIFE INSURANCE EXAMINATION classes is worth while, in that it may indicate a trend which is of decided moment. The medical director and actuary must be closely affiliated in all such matters. The medical director is also called upon to give and to accept advice from the underwriters who may share with him the responsi- bility of selection. In his relation with executives a much needed qualification is that of mental honesty. In order that he may have their confidence, he must be able to substantiate his position on problems under consideration by his knowledge of the art of medicine. Medical science is not in itself sufficient evidence. CHAPTER VIII MEDICAL REFEREES By S. B. Scholz, Jr., M.D., Springfield, Mass. Associate Medical Director, Massachusetts Mutual Life Insurance Company It is of interest in connection with our studies of medical refer- ees to give some thought to the development of the medical side of life insurance to a point where medical referees were regarded as a factor in the selection of lives to be insured. We, of course, are all more or less familiar with the guilds which existed in ancient Greece and Rome. It is believed that some of these guilds required some kind or form of examination. Friendly societies seem to have exercised more or less influence in England's development. The friendly organizations were incor- porated for the protection of widows and orphans; these societies were frequently used to provide business insurance, as we under- stand it today, and other assurances for peculiar indemnities inci- dent to the state of civilization at the time; many were promotive, speculative, or social in nature, and none required any evidence of good heath. From the friendly societies developed what we today regard as true life insurance companies. A truly mutual life insurance company, the Mercers' Annuity Life Insurance Company, was founded in 1698 but was not suc- cessful. The Amicable Society, founded in 1706, was the second early life insurance company the practices of which were rational. This society required that an applicant certify that he was in good health. No examination or reference to a physician was required in the early history of the company. Applicants who lived within fifteen miles of London were required to appear in person before a court of directors and declare good health with no impairment tending to shorten life, as well as to answer any questions which might be put by any of the directors. If the proposer for insurance lived at a greater distance than fifteen miles from London, he was 97 98 LIFE INSURANCE EXAMINATION required to swear before a Justice of the Peace resident of the place in which he resided, as to his health record. It was not until 1762, when the Equitable Society of England was founded, that life insurance, "as we now understand it, was entered upon." The Equitable Society was the first organization to require "reference to two persons of good repute (one, if pos- sible, of the medical profession) to ascertain the present and gen- eral state of health of the life to be insured." By this requirement the Equitable introduced a procedure which was uniformly fol- lowed by all life insurance companies. No physical examination was required, but the applicant had to present himself before a board of the officers of the company to determine whether or not it was advisable to accept him for insurance. The Equitable fur- ther provided that "persons who do not appear before the Court of Directors or who cannot refer to a person of the medical pro- fession, are required to give a reference to three persons for an account of the present and general state of health." So much satisfaction resulted from the Equitable's court of directors that, in 1765, applicants not appearing before this "Court" but who were accepted upon satisfactory reports from the three persons referred to, were accepted at an advanced premium rate. In 1779 Dr. Price urged upon the directors of the Equitable the importance of preventing the intrusion of bad lives and suggested that "it would not perhaps be amiss to appoint a medical assistant whose particular business it would be to inquire into the state of health of the persons who were offered to be assured." The practice of medical selection, however, was not introduced by the Equitable until 1858. American life insurance companies have made more progress in the principles and practices of life insurance than have any of the European companies. Fig. 17 shows a copy of the examination upon which policy No. 1 was issued by the company with which I am associated. In addi- tion to this examination a statement was required from the appli- cant's attending physician as well as from one of his friends. Both these certificates 'were completed on forms issued by the company. The first interrogation in reference to the urinary system was introduced October 28, 1864: "Are the functions of the abdominal and urinary organs in a healthy condition?" Whether an exam- iner completed a chemical urinary examination or not seems to MEDICAL REFEREES 99 Fig. 17 have been left more or less to his discretion, as the first question in the company's examination forms, September, 1873, shows. "Are there any indications whatever of any past or present disease of the genitourinary organs? (If any doubt exists in the mind of the medica] examiner, as to this question, the urine must be exam- 100 LIFE INSURANCE EXAMINATION ined.) " Following this requirement it is interesting that it was not until March, 1881, that the company's examination form re- quired in some cases a chemical urinary examination. The latitude given the examiner is of interest. "If the history of the applicant suggests disease of the urinary organs, and in every case where the amount applied for is $10,000 or over, and the applicant is 40 years of age or upwards, the urine must be examined." Both European and American life insurance companies for many years disregarded the family history in connection with the con- sideration of a subject for insurance. The Massachusetts Mutual first inserted a question in the medical examination form as to family history October 28, 1864. I do not know of any company which required a family history earlier than 1863. The Massachu- setts Mutual's first question regarding family history included full details as to parents, brothers and sisters. The first American companies were incorporated in the larger cities and relied upon their own medical officers in the capacity of inspector, medical examiner, and medical director. As the com- panies grew and more subjects were induced to purchase life insur- ance, examinations were permitted by physicians selected by the applicant or the agent. It is difficult to determine exactly when some discretion began to be exercised in the selection of examiners and rules were promulgated as to the use of examiners. So far as I can learn, it was not until about 1865 that any reasonable dis- cretion was exercised as to the qualifications of the medical exam- iners. The Civil War may have had an influence in forcing the attention of life insurance officers to the fact that the standards of medical efficiency varied greatly even among the successful physi- cians. The medical directors, in the early years of their experience (because of the small number of examinations), had no great diffi- culty in learning who were the desirable physicians to be used as examiners, and there ensued a slow elimination of those physicians whose examinations showed that they were not competent. As the companies grew, the territories producing business became so large that it was not possible for a medical director to acquire knowl- edge of the desirability of the physicians in the territory. Some companies adopted a system of medical nominators. These nom- inators were appointed for counties, groups of counties, or states, according to the particular requirements. Their function was that MEDICAL REFEREES 101 of recommending examiners at various points within their juris- dictions. Gradually the system developed so that a nominator was expected to attend medical society meetings, conventions, etc., for the purpose of becoming acquainted in person or by report with the physicians in his territory. The selection of medical examiners by the early life insurance companies was indeed unsatisfactory. The license requirements of many of the states were nil and in others very poor. A few states had good medical practice laws. The many medical schools located throughout the country graduated innumerable physicians of al- most as many degrees of education, and it was not until the agita- tion by the American Medical Association, and the publication of the studies of the Carnegie Foundation for the advancement of teaching in 1910 that medical directors had an opportunity to learn the possible qualifications of physicians graduated from the vari- ous medical colleges. As the life insurance companies grew, it became imperative to develop some method whereby the original medical selection would be good. Many systems were devised to assure a good medical examining staff and the first method perhaps was the travel of various lay officers of the companies, who, in addition to their agency and other duties, called upon the medical examiners, inspecting and instruct- ing them. As the companies grew and medical officers gave their entire time to the work, they naturally did some traveling and com- pleted a considerable number of field examinations. Lay traveling medical inspectors were employed, as well as physicians, whose duties were purely those of inspection and instruction. As the companies grew and good producing agencies were established in the larger cities, salaried examiners were employed. In 1903, Dr. Brandreth Symonds, Medical Director, of the Mutual Life Insurance Company decided that his company was justified in establishing, at the headquarters of every managing agency, a phy- sician trained by the home office, whose duties were quasi home office in nature and, in fact, included details usually accomplished at the home office. From 1903 to 1906, Dr. Symonds completed his scheme of medical referees which today is an important factor in the Mutual Life's medical organization. After the successful inauguration of Dr. Symond's medical ref- eree system, it required but a short time to demonstrate the value 102 LIFE INSURANCE EXAMINATION of this office, and his scheme, in part or in whole, modified to the company's organization, has been followed by other companies. The companies, of course, devised different- plans as to their medical referees. Some referees devote all of their time to the work, others only a few hours a day. All are supplied with offices and the necessary equipment. The Mutual Life trains each medical referee at its home office from periods of two weeks to a month, has a very complete manual of instructions, and, I believe, is the only company consistently to follow this plan. Other companies publish detailed instructions to medical referees and may cause them to come into the home office for a few days for instruction; or, the medical referee may be some selected examiner who is vis- ited by some member of the home office medical staff and instructed as to his duties, subsequent instruction being given by correspond- ence from the home office. To my mind, the most important function of a medical referee is that of instruction of the agency force with which he is associ- ated, the education of that agency force as to the character of risks desired by the company, and information to the agency as to the factors causing declinations or ratings. The expense of a medical referee is justified because of the exam- inations he completes. Local examinations generally occupy the larger percentage of his time. Because he lias been trained by a home office medical department officer and because that officer has a positive knowledge of the particular referee's ability, examina- tions by the medical referee are more valuable to the company than if made by an examiner with whose ability and work the home office is not familiar. A medical referee, of course, makes examina- tions for reinstatement of policies, for the reduction of ratings (if the company does a substandard business), examinations for the disability clauses and reexaminations of declined applicants. He also supervises the city examiners where he is located and is re- sponsible for the distribution of examinations to them. If the company by which he is employed issues group policies, he makes surveys and examinations of the groups presented. Applicants from his field are frequently brought before him in order that he may make a preliminary examination; and he is also called upon to examine for new insurance and to review cases where the ap- plication of a rated or declined applicant is, with the authority of the company, to be reconsidered. MEDICAL REFEREES 103 Some referees complete microscopical urinal examinations from the field. Many referees complete their own microscopic examina- tions instead of forwarding specimens to the home office laboratory. The medical referee is responsible for the organization of the examiners in his particular territory, which may include a number of counties, one state, or a group of states. Some companies do not grant their medical referees authority of final appointment, but other companies authorize their referees to appoint examiners. A referee will develop professional lines of inquiry so he may be in a position to secure information from competent professional sources as to the medical ability and professional standing of any physician located in his territory whom he may wish to consider for an examinership. The referee assembles what professional ref- erences he has secured, a commercial inspection report, the physi- cian's credentials, and other pertinent papers and forwards the complete file to the home office. The referee may have made a final appointment of the physician in question or may have nominated him for an examinership. This, of course, depends upon the cus- tom of the particular company. The medical referee is constantly in touch with the agency force and supplies examiners in places where there are none appointed previous to the time of agency activity, thus preventing the delay incident to the consideration of a strange physician used as an examiner. Most companies have their organizations so arranged that all inspection reports, criticizing an applicant in a medical way, are referred to the medical referee, who, upon receipt of the report, exercises his discretion in the case, either permitting the report to be forwarded to the home office without any correspondence, or covering the impairment in detail with the examining physicians. Possibly a referee will request a more detailed inspection, or a sec- ond inspection from a different source. In these instances he for- wards to the home office a carbon copy of his letter to the exam- iner covering the criticism, and otherwise reports his action. Some companies permit their referees to exercise their own discretion as to subsequent action upon an applicant with a criticized inspec- tion report, the policy being issued and forwarded to the referee's agency to be held there awaiting completion of the additional data, when the policy may be released by him, or held for final home office instructions. A referee reviews all examination reports which pass through his 104 LIFE INSURANCE EXAMINATION agency for the purpose of learning the ability of his examiners and eliminating the undesirable. The review of the examination re- ports also makes it possible for the referee to complete, by cor- respondence with the examiner, personal or family histories, not sufficiently extended in the report. This is a very important func- tion, as it saves considerable delay in home office final action upon a given case. For instance, an applicant may give a history of some renal impairment which would require a microscopical ex- amination of the urine. The examiner not having forwarded a specimen, the referee calls for one, either to his office, or the home office. Another valuable service a referee performs is that of relieving the home office medical department of considerable correspondence with examiners along educational lines. Some companies require their referees to communicate with an examiner in every instance where the examination report shows the examiner's lack of appre- ciation or knowledge of some particular phase of his examination not fully covered by him. As typical of these instruction letters, the average examiner on finding an organic cardiac murmur ordi- narily reports it as a heart murmur, giving no further information. Companies accepting heart murmurs must have information as to the location, time, transmission of the murmur, whether there is any hypertrophy or not, and, if possible, the cause of the murmur. Other companies, not doing a substandard business, wish this in- formation for statistical reasons. The duties of some referees include the tabulation of records oF each examination completed by every examiner in his territory. These records are generally kept by cards so that a review of the card will give a good criterion of the efficiency of the examiner. The record in general includes the name of each applicant exam- ined; the doctor's recommendation, whether accepted or declined by the home office; the number of omissions and clerical errors in a report; whether medical history not included by the examiner is developed by inspection; as well as notes concerning the particular examiner's mortality. Some companies also include a record of the recommendation made by the examining physician whether or not he considers the subject a first-class risk. The systems of the companies vary as to the referees' office methods in regard to exam- iners. Some companies require their referees to have a very com- plete list of examiners, as well as data concerning disapproved MEDICAL REFEREES 105 physicians, including the reasons, etc. Some companies place the responsibility for the safekeeping of the examiner lists in the hands of the agency manager or agency cashier, so that whenever a change in the organization is made, the referee notifies the agency manager or cashier. A company may have appointed examiners at a given point, and yet a physician not an examiner may be used for an examination. Full details are developed, the physician is investigated, and, if ac- ceptable, the examination may be accepted. If not, a reexamina- tion may be required, either by the referee or by the home office, dependent upon the authority vested in the medical referee. A referee travels more or less. Some companies require that he make joint examinations of applicants in his territory who apply for insurance over a specified amount. Should examiner condi- tions requiring a survey develop anywhere in his field, he may visit the point, make an investigation and whatever changes are necessary in the interest of efficiency and harmony. It is presumed that a medical referee soon acquires, after as- signment to a territory, an intimate knowledge of the general health situation in his district. The morbidity, mortality, and birth records of a county or state are all factors of interest and value to his company, particularly so in those states not in the Census Bureau registration district. As an illustration: a medical referee's suspicions may be aroused by some abnormal public health condition in his territory and he may visit the section involved, make the necessary studies, compile data, and forward a complete report of the conditions to the home office for consideration. As typical of these reviews, I cite a group of counties of a medical referee's territory which became known for their malarial morbid- ity. The referee visited these counties, made a study of their topography, drainage, death registrations, birth registrations, meth- ods of enforcement of public health laws, and other factors bearing upon the mortality of the district. The executives of the com- pany, after carefully studying the findings, discontinued business in the area because of the abnormal conditions. Here is another ex- ample of a referee's study of his territory. A referee observed the rather constant appearance of reported deaths from childbirth in the family histories of applicants, who were residents of a group of counties. He made some inquiries from his office, later visiting the counties. His studies conclusively showed the average ability 106 LIFE INSURANCE EXAMINATION of the physicians, practicing in this group of counties, to be below the state's average. Obviously, there followed a careful consid- eration of the company's examiners and rather radical changes in the personnel. The referee's duties as regards these studies are sometimes very complete. I know of companies who have detailed referees for exhaustive studies of states; the referee visiting every county of the state interviewing examiners, and public health and registration officers, so as to gain accurate knowledge of general health conditions; he also, of course, investigates, meets, and in- structs as many medical examiners as possible, thus strengthening that corps. New occupational hazards are constantly developing because of the fabrication of things new to the world, the improvement of old manufacturing processes, the production of articles requiring the use of chemicals, etc. The referee should keep himself informed of new occupational hazards occurring in his territory, make what- ever study of them is necessary, and report his findings to the home office. Governmental supervision, in addition to the other elements constantly at work, is improving industrial conditions and occu- pational hazards, which have required a considerable extra pre- mium. As a result these may become, through the installation of safety appliances and other changes, less hazardous. A referee may be required to make complete surveys of a manufacturing plant, or of a given occupation, so that, if justified, the company may modify its premium charge for an occupation which has be- come standard or less hazardous. Occasionally a policyholder dies whose insurance has been in force a very short time. There may be circumstances concerning the death which are not easily determined or explainable. There may be a doubt whether the examiner made a competent examination. Very rarely a question arises whether or not the agent should have solicited the particular subject. In a small num- ber of death claims the intent of the applicant at the time of appli- cation may be questioned, so it is sometimes necessary for a med- ical referee to make an investigation of the applicant's health condition previous to the date of examination, the causes of death, and all other factors having any connection with the claim. Occa- sionally medicolegal questions are involved, which the referee may be called upon to cover. The review by the referee of all the examination reports from MEDICAL REFEREES 107 his territory, the tabulalion of the omissions and errors of the examiners, make it possible for him readily to determine those examiners who are lacking in ability, etc. When an examiner is found unsatisfactory, he is dropped and a successor appointed. Business varies from the different points so that an examiner may be active for a few years and then arrive at a period when, be- cause of the lack of agency production, he is not called upon to make examinations. It is therefore necessary that, at stated in- tervals-three to five years--the medical referee review all of the examiners in his territory, retiring the ones who have reached the company's age limit, replacing those removed, making new ap- pointments in those places where the examiner has disqualified himself because of specializing, habits, becoming obsolete, declin- ing practice, etc. European companies early adopted the title "Medical Referee" for medical officers intrusted with the selection of business. This custom still obtains largely in Europe and in Canada. United States companies usually designate their Home Office medical selec- tion officers as "Medical Directors." A medical refereeship is a very desirable training for a home office medical department position. Those referees who show exec- utive and administrative abilities are quickly determined and, as vacancies occur in the assistant medical directorships of their com- panies, they are often given the preference for these appointments. References The Insurance Cyclopaedia-Walford. Transaction of the Faculty of Actuaries. Journal of the Institute of Actuaries. The Value of the Medical Examiner's Opinion-Dr. Brandreth Symonds. Records Massachusetts Mutual Life Insurance Co. CHAPTER IX THE MEDICAL EXAMINER By W. F. Hamilton, M.D., Montreal, Canada Consulting Medical Hefeiree, Sun Life Assurance Company of Canada "If your work is first with you, and your fee second, work is your master, and the Lord of work, who is God. But if your fee is first with you, and your work second, fee is your master, and the Lord of fee, who is the Devil. ' '-Ruskin. To achieve success in any great undertaking an efficient service is necessary in every branch. In the business of life assurance, while there is much energy and time spent in securing risks, there is also much thought given to making them safe. If the risks are not chosen and accepted on a sound basis, there can be little hope for stability and permanence in any other part of the undertaking, and as a result the company falls short of success. The medical examiner plays no small part in the selection of risks. It is quite true that the agent does very much in this respect but the decision in most instances rests with the medical depart- ment, the final opinion at the home office depending largely on the report furnished by the company's physician in the field. Certain life assurance business is selected without medical ex- amination while group and industrial plans call for a very super- ficial inspection indeed. It may be well to bear in mind that there obtains today an opinion slowly gaining ground, that some risks, of necessity not large, may be safely assumed without a physi- cian's report. It does not appear, however, that any life company when seeking to assure individual lives for large amounts, has any serious idea of dispensing with the medical examinations, although they are secured at an annual cost of hundreds of thousands of dollars, and in prospect yet more costly. One may add that in certain American states legislation forbids the issuance of policies unless a medical examination of the applicant shall have been made by a qualified examiner. The assurance company asks of the medical examiner that he give a faithful report of the applicant's condition so that the med- ical referee may be able to decide in the best interests of the 108 THE MEDICAL EXAMINER 109 company. Before dwelling upon the essential qualifications of the examiner, one may mention in passing a few characteristics or conditions which, while not essential, may be considered most de- sirable and important. For example, legibility of the doctor's handwriting with no omissions, makes mistakes difficult and saves much loss of time and expense in correspondence. Courteous deal- ing with the prospective risk and the agents in the field tends to prevent friction. Then the examiner should show that he has reflected on the case before him by the logical conclusion based on the facts already secured and set down in his report. Turning now to consider the qualities regarded as essential to make a good examiner, all will agree that a good training should have first place,-a good medical degree and at least one year of hospital service. In the work under consideration the physician must secure facts and make out a case report in a manner much the same as that which he has been accustomed to make in the hospital. Apart from the training in getting the facts of disease and recog- nizing the physical signs of a malady which he acquires first- hand in an hospital service, he enjoys at the same time an occa- sion for studying human nature, so necessary in insurance work. Since as wide a view as possible of disease and impaired states should be acquired, a hospital service as a qualifying experience would seem invaluable. It is not possible for all companies to secure well-trained hospital men. Moreover, many men so trained are not capable of becoming good medical examiners, but the fact remains that a hospital service goes a long way towards making for efficiency in life assur- ance work. In addition to this, many companies prefer at least two years in general practice as a qualifying condition. When the physician trained with patients only, begins to act in the capacity of an insurance examiner, he at once experiences a change. The applicant is not of the same sort as the patient. He requires a different treatment. The purpose of this applicant is to make the very best of every point on which he is examined in order that he may secure a first-class standing and a policy at the lowest rates. But when the consultation is between the patient and the physician, then there are few if any hidden things,-the family history is revealed, the personal history is usually an open chapter, the habits are discussed with few denials of excess. Smith, a candidate for insurance, and Smith, ill before his physician, are 110 LIFE INSURANCE EXAMINATION scarcely to be identified in much more than the date of birth and the age of the grandparents. It must not be forgotten that the applicant feels that the company's medical officer is looking for his weak points. To discover these without displaying one's method is most desirable and possible only when the examiner, besides be- ing well trained, is endowed with tact. "Beware of entrance to a quarrel" is a bit of advice which may well be followed in this relationship. The heated argument, the rough insistence on strip- ping to the skin, the untactful question regarding habits, get one nowhere on the way to a good understanding and a complete re- port. All necessary matter must be acquired tactfully or not at all. Tact in dealing with a proposed risk is as essential as the oil to the machinery-and the medical examiner without it, trained to the highest degree, is a failure in the eyes of the agent and the com- pany. He repels where he should attract. To the qualifications already mentioned which are among the first essentials, must be added equipment. It is quite true that modern physicians already will have the greater portion if not all of the equipment required for assurance work. The thermometer, the stethoscope, the tape measure, the scales, the blood pressure apparatus, the urinometer, clean test tubes, fresh reagents and a microscope, are necessary in every physician's office and they are constantly required in making a complete report for any modern life company. Even today one may find on the medical sheet in- stead of an answer to a certain question, "no apparatus," "no instrument," "not weighed," "not measured," phrases giving an excuse or no excuse, but clear evidence of indifference. Such excuses should disappear entirely from our medical reports, for not only are all the instruments mentioned above available at moderate cost, but there are men with a knowledge of how to use them and an eagerness to do so, awaiting only the opportunity, an appointment to the service. Competition in all lines of business has recently become so very keen that the agent in the field and the officials at the home office ask for promptness of service in all departments. In no depart- ment does promptness count for more than in the medical depart- ment. Since so much depends upon the report of the medical examiner, delay in getting the applicant before the doctor, due to the examiner's other engagements, or his dilatoriness or indiffer- ence, or perhaps on account of the very nature of the physician's THE MEDICAL EXAMINER 111 life-other things demanding his attention-react badly on the client, local manager and the doctor. The client changes his mind, the agent and local manager are very much disgruntled and the doctor is blamed. While it is not good policy for any self-respecting physician even to appear to lie in wait for such appointments, it is most desirable that the company's official should strive to serve the company with all possible promptness and dispatch. This quality of a company's medical representative in the field is gen- erally greatly appreciated. A complete report returned with promptness pleases alike all those interested in the business. The medical examiner should be self-reliant and decisive. He will have a great many types of men to deal with from the applicant before him to the agent and the officers in the home office. Con- ditions under which examinations are asked for may be wholly unsuited to the work. An attempt may be made to present a fact in the history in a certain light or to suppress it altogether. These are but a few of the many instances when he should rely upon his own judgment of what is needful and make the decision accord- ingly. It is expected of a man holding such a post that he show independence and ability to decide such matters as pertain to the case in hand so far at least as concerns the substance and form of the report. Now to these qualities, each so important in itself and all so very important in the making of the man for the job-to these must be added honesty and loyalty without which, so far as the company's interests are concerned, all others are in vain. To work out a good case history a man must give honest effort to it; he must search for the truth regarding the case before him, he must see the applicant and examine him according to the questions set down in the form before him. He must identify the man, the urine, and when asked regarding the weight and height and girth, he must use scales and rod and tape to find out. The company wants to know. The company does not pay a fee for a guess. Anyone may guess. Then again the examiner's loyalty is often peculiarly tested. A physician holding appointment under several companies must re- member that he serves only one at any one time, i.e., that company whose application form is already signed and before him. No un- favorable criticism of the plan or the ways of the company, will pass the lips of the man in whom this quality is found. This is 112 LIFE INSURANCE EXAMINATION one aspect of loyalty and the other is equally important. Though he serves all departments, indeed the whole company, he is ac- countable alone to the medical department. That examiner faith- ful to the company, on learning important facts, even though not directly asked for on the form, will promptly forward a statement to the home office for the information and protection of the com- pany. In short these two qualities, honesty and fidelity, make for safety in the selection of risks. Having thus enumerated the qualifications essential to the best work, it may be said in closing that if the medical examiner dili- gently adds to his training, tact, and to tact, equipment, and to equipment promptness, and to promptness self-reliance and de- cision and to self-reliance and decision honesty and loyalty-these qualities as surely as those enumerated by the Apostle centuries ago, will make him that he shall be neither barren nor unfruitful in his work either for the company or in his own behalf. CHAPTER X GENERAL INSTRUCTIONS TO EXAMINERS By Frank L. B. Jenney, M.D., Chicago, III. Medical Director, Federal Life Insurance Company, and Secretary of the Medical Section of the American Life Convention A physician is appointed or designated as a medical examiner of a company solely on his professional attainments and qualifica- tions. Agents of companies are furnished with lists of physicians to whom they must take their applicants to be examined. The agents have no concern in the appointment or selection of exam- iners, except in very rare instances, and therefore examiners are responsible only to the medical department of the company, and hence owe their allegiance to the company and not to the agent. If a physician accepts an appointment as an examiner of a com- pany he should give that company the very best service of which he is capable. He should examine each applicant conscientiously and thoroughly, and make a comprehensive report to the medical director. At the end of most examination blanks, just above the place provided for the examiner to sign his name, is a statement to the effect that the examiner has examined the applicant carefully and thoroughly, and that he has found the condition of the applicant to be as stated in the report. This statement will not be signed by a self-respecting physician unless he has really made a con- scientious examination of the applicant and carefully recorded the findings. Experience shows that there are physicians who will record the analysis of the urine without having made the analysis, and will similarly fill out a full report of the examination of the applicant without having made more than a desultory examination. This is a serious reflection upon a physician and also upon the medical profession. If a physician does not feel that he can examine an applicant in such a way as to do justice to himself and to the company, he should not accept the appointment. The company relies upon his report, and pays an adequate fee therefor, and is 113 114 LIFE INSURANCE EXAMINATION entitled to an honest examination. Such physicians are sooner or later found out and their services discontinued, so that if he cares to remain in the service of the company he should give it the best that is in him at all times. The physician who gives good service is always recognized by the medical director, his work is highly prized, and his services sought. It is only fair that the examiner should understand the position of the medical director and the difficulties under which he some- times has to work. He has to deal with all sorts of physicians from all walks of life, of all grades of education, and with gradu- ates of all grades of medical colleges. Many times he has to review examination reports so poorly written that the words can hardly be deciphered, with execrable spelling, and an appalling lack of medical knowledge. In his experience at the head of the medical department, he too frequently receives evidence showing the gross negligence, careless- ness or dishonesty of an examiner. Many intelligent physicians seem to be indifferent to the importance of an examination for life insurance, assuming the attitude that the company is rich and that the beneficiary will probably need the money. In line with this process of reasoning, he sees to it that his report upon the applicant is entirely favorable. The other picture is more pleasant to contemplate. Many of the examiners have received good preliminary educations, are graduates of "Class A" medical colleges, are earnest and conscientious in their work and make honest and comprehensive reports. The sad thing is that these examiners are all too few in number. Then there is a large number of examiners that have received only a high school education, are graduates of only fair medical colleges and have been too busy in active practice to keep in touch with the rapid march of progress in their profession. These men give the medical director the greatest annoyance and cause him the most concern. Such physicians comprise the majority of the exam- iners of a company, especially in the rural districts, and are the best available men in their communities. Often the medical director selects an able, well-educated physi- cian as examiner for a certain locality, and feels satisfied that he is going to receive efficient service, only to learn later that the agent can do nothing with him. lie is very busy; will not stir GENERAL INSTRUCTIONS TO EXAMINERS 115 from his office to make an examination; is overbearing in his atti- tude towards any applicant brought to him for examination. This brief outline is given to show some of the difficulties under which the medical director must work. To those of you who wish to undertake the work of examining applicants for life insurance, and to those who desire to continue in that work, it is urged that you give real and earnest thought and study to the subject of insurance medicine, and to the subject of clinical and physical diagnosis. The position of medical examiner for a life insurance company is remunerative, and is well worthy of your thought, care, study and consideration. There are many physicians in this country who make large incomes from life insurance examining alone. If a man wishes to enter this field and remain in it, he should see to it that he gives his company a square deal in every case examined, and does not stultify himself by signing his name to a report that is not the result of a careful, conscientious examination. A good examiner observes and studies each applicant carefully, and makes a mental note of any defect or deformity, any earmark of disease, or any deviation from the normal man. He questions each applicant closely and records all answers carefully, fully ex- plaining and elucidating all questionable points. It is to be remembered that the examination, as written, is part of the contract between the applicant and the company, and that many times a large sum of money is involved. It is therefore very important that the work be done well, and that the physician keep in mind that he is in the employ of the company and not in that of the applicant or agent, and that the company pays him to ascertain all the facts pertaining to the applicant's past and present health, habits, mode of life and present physical condition. Many examiners seem to feel that they have done their duty when they have answered all of the questions in the blank. This is not true. A real examiner does much more than is actually called for. lie notes the color and condition of the lips and gums, the skin, the clearness of the eyes, the gait and build. He looks at the tongue, teeth, throat, looks for tremors; tests the reflexes; notes the condition of the muscles, and looks for signs of recent loss or gain in weight. He observes the neck of the applicant for goiter, or for signs of past or present enlarged cervical glands, and searches the applicant for any evidence of syphilis. If he has knowledge, 116 LIFE INSURANCE EXAMINATION or even suspicions concerning the applicant, that he feels would be of interest to the company, he should always make record of the same in his report, or set forth the facts before the medical director in a personal letter. He sometimes advises the company to investi- gate the applicant's habits carefully, or to write to a certain doctor for information concerning the past or present health of the applicant. Such an examiner is a delight to a medical director, and he is sure to retain his commission as long as he cares to do examining. The examiner should remember that the medical director does not see the applicant, and that he has to rely upon the examiner's re- port, so that an accurate pen picture of the applicant should always be given, elucidating all points bearing on the personal and family history, habits, environment and physical condition. All obscure terms such as "Don't Know," "Moderately," "Not Often," "Occa- sionally," and the like should be avoided. Failure to answer every question set forth in the examination blank is a common fault of examiners, and this necessitates corre- spondence and causes considerable delay, which might have been avoided had the examiner carefully read over the report before mailing it. Do not use dashes or "ditto marks" in the place of answers to questions, as they are not answers. If corrections or erasures are made in the report, they should be acknowledged by the examiner writing his initials above the correction. The report should be dated and signed, and if a confidential slip is asked for, in addition to the report, that slip should be filled out and mailed to the medical director as soon as the report is completed. The examiners should not delay in making an examination, or in mailing a report to the company, as delays are dangerous and may cause the company to lose the business, and the agent to lose his well-earned commission. The report should be written legibly, as every word in it is to be read by many different persons, and plain writing saves much time and annoyance. Most examination reports are now photographed and the photograph attached to the applicant's policy, hence the examiner is requested to use black ink in filling out his report. The, foregoing is a general outline of what constitutes a com- petent and satisfactory examiner, and contains a few of the mistakes and omissions of many physicians, who, from force of circum- GENERAL INSTRUCTIONS TO EXAMINERS 117 stances, the companies are compelled to employ to examine their applicants. I shall now take up the filling out of the blank and the making of the physical examination in detail. Name, Address, and Occupation.-Write the name of the appli- cant very plainly, giving the full name, and being very certain that it is correctly spelled. A misspelling of the name leads to confusion in the home office, and causes delays, because the correct name must be ascertained before the policy can be written. Give the correct address of the applicant, giving the town or city and the street number. If in a rural district, give the rural route number and his post office address. State the occupation of the applicant correctly and outline briefly his duties. If he has more than one occupation be sure to state them all. In certain occupations the amount and kind of insurance is limited, an extra premium is charged, or the age is advanced to cover the extra hazard. For these reasons the examiner should set down carefully the exact occupation and duties of the applicant. If general terms, such as clerk, salesman, merchant, mechanic, driver or teamster, etc., are given, the line of business in which the applicant is engaged invariably should be stated. When a technical term, that designates the duties of the appli- cant, such as rougher, polisher, presser, cutter, roller, electrician, etc., is used, the exact duties should be carefully explained. The applicant may be employed in one line of work at one time of the year, and in an entirely different line at another. I recall, in this connection, a case in point in which a man in a northern city applied for a small policy, and gave his occupation as hotel porter, an occupation which carries no extra hazard, and which entitles him, if otherwise a good risk, to insurance at regular rates. On investigation it was learned that the applicant really was a hotel porter in the winter months, but that in the summer he was employed as a high diver in a circus. This case illustrates the necessity of getting all the facts concerning an applicant's occupa- tion. The examiner should also learn whether the applicant intends to change his occupation in the near future, or to make a journey. He may contemplate engaging in a more hazardous occupation than the present one, or may have the intention of moving to an unfavorable 118 LIFE INSURANCE EXAMINATION locality, to a foreign country, or to the tropics. He may have been advised, because of his health, to change his occupation or place of abode, and the company should be acquainted with the facts so that it can act intelligently upon the application. Age and Date of Birth.-Get the correct date of birth of the ap- plicant (this means the day, month and year), and give the correct age. Some blanks call for the age at the nearest birthday, and others at the last birthday, and it is necessary that the date and age as given agree. If the application, as written by the agent, is at hand at the time of the examination, see that the date of birth and the age as given to you agree with the application. If the agent has made a mistake in the age, his attention should be called to it at once so that he can correct his mistake and avoid delays. Married or Single.-State whether the applicant is married or single. If divorced, a widow, or widower, it should be so stated, and if the latter, the cause and date of death of husband or wife. Habits.-Question the applicant closely regarding the amount of liquor consumed. It is desirable to learn the average daily amount consumed and the greatest amount he is likely to take in any one day. Now that prohibition is in quite general effect throughout the coun- try, there is a tendency on the part of applicants to claim abstinence, but they may have private stocks of liquor on hand, or be in the habit of making their own wine or beer, so that close questioning as to the use of liquor is important. The examiner should inquire into the applicant's past habits in the use of liquor, and a real attempt should be made to learn whether or not he ever has used liquor to excess habitually. If the examiner finds that the applicant has, he should set down the full details, giv- ing the length of time he was so addicted to excess, the frequency of such excesses, and the dates or years of the addiction. If he has reformed the date of reformation should be given, and a statement made whether or not he has been a total abstainer since that date. If he has taken a so-called liquor cure, or undergone any sort of treatment for the cure of the liquor habit, it should be so stated, with the date of the cure or treatment given, whether or not he took the treatment voluntarily, and whether or not he has been a total ab- stainer since that date. To find out from the applicant just what his habits in the use of GENERAL INSTRUCTIONS TO EXAMINERS 119 liquor are, or have been, and to obtain this information without giv- ing offense is one of the most important, and at the same time, one of the most delicate duties of an examiner, and sometimes calls for the exercise of the greatest amount of tact and diplomacy. The examiner is particularly warned against employing such terms as "moderate," "temperate," "drinks when he wants to," "takes an occasional drink," etc. The examiner is requested to get as nearly a specific statement as possible regarding what he drinks now, what he has drunk in the past, how much and how frequently, and also full particulars concerning past or present excesses, cures, etc. He should ever bear in mind that an excessive drinker will rarely admit the fact. If the examiner has personal knowledge, or has information con- cerning the applicant's past or present use of liquor, he should im- part it to the medical director by letter, or in the blank space pro- vided for additional information. Drug Habits.-If an applicant has ever been addicted to a drug habit, state the kind of drug used, the amount and the date. If there has been a cure, state whether it is complete, whether any ill effects have remained, and give the date of taking the cure. If suspicious of drug addiction, it would be well to notice the arms for the sears of hypodermic injections, and other evidence of addic- tion. It might be well also to inquire whether the applicant is in the habit of taking patent medicines, particularly those containing alcohol or habit-forming drugs. Remember, that as in the case of liquor, drug-users seldom admit the fact. Insurance History.-If an applicant has been previously declined by any company, association, or society, or if the application for re- instatement of a lapsed policy has been refused, state by whom, give the date, and, if possible, the cause. If tho applicant has ever had issued to him a policy for a smaller amount than that applied for, or has been issued a policy at a higher premium or on a different plan than that applied for, give the date and the name of the company and if possible, the cause. A certain proportion of applicants will refrain from admitting adverse action by any company, and it is therefore wise to put the question to the applicant carefully and in a direct manner, and note his actions when making reply. If he is not direct in his answers, 120 LIFE INSURANCE EXAMINATION or seems evasive or ill at ease, it would be well to record your sus- picions. If you have examined the applicant before for another company, and believe the policy was not issued, or if issued, was modified, you should record the fact. Some companies inquire whether the applicant has ever applied for or received a pension, or whether he has ever received compensa- tion under any accident or health policy. If the answer is affirma- tive, state from what company, when, for what disease, accident or disability, and the amount received. Health Record.-Each ailment, symptom or condition listed on the examination blank should be made the subject of specific inquiry, the examiner slowly reading each question to the applicant. Do not accept as final a sweeping statement from the applicant that he has never been ill or under a doctor's care, because there are many con- ditions or symptoms that have a bearing on insurability that are not ordinarily counted as constituting an illness, such as piles, stricture, discharge from the ear, enlarged prostate, or even spitting of blood. These may have been forgotten by the applicant until a direct inquiry is made. When the answer to any one of the health questions is "yes," the examiner should inquire into the clinical history of the case and record the details briefly in the proper place on the blank. If, in the course of the inquiry, the examiner becomes acquainted with any health history of importance, bearing on matters not men- tioned on the blank, or if he lias personal knowledge or hcar-say information of such a character, he should not hesitate to acquaint the company therewith. Injuries and Accidents.-Incident to the health history of the applicant, information is asked as to previous injuries, accidents or surgical operations he may have sustained or undergone. Full in- formation is necessary relative to either or both, such as the date of the injury or the operation, its nature, the duration of disability, and the results. The full name and address of the physician who treated him or operated on him should be given. Asylums or Hospitals.-Inquiry is made whether the applicant has ever been an inmate or patient in any infirmary, asylum, or hos- pital. If an affirmative reply is received, give the name and location of the institution or hospital, the date when there, the reason therefor and the treatment received. Also record any consequences. GENERAL INSTRUCTIONS TO EXAMINERS 121 Rheumatism.-If the applicant admits ever having had rheuma- tism, state whether articular or muscular, give the number of at- tacks, the dates and duration of the attacks, the joint or joints affected, then state specifically whether at the time or following any attack he had any shortness of breath, pain in the chest, swelling of the feet or face, or any symptom of heart involvement. By so doing much time and correspondence will be saved. In such cases examine the tonsils, gums and teeth and make note of their condition. If the applicant has had his tonsils or teeth removed since the illness be sure to so state. Syphilis.-If the applicant admits having or having had syphilis, give the date of the infection, the name and addresses of the physi- cians who treated him, the duration and extent of the treatment, and state as accurately as possible the date of the last symptom that could be attributed to the disease. If the applicant has had salvarsan injections, be sure to so state, giving the name of the physician and the date. If any Wassermann or other tests have been macle, give the dates of such tests and state whether the results were positive or negative. It is rare that an applicant will admit syphilitic infection, and the examiner is especially requested to put this question to the applicant directly and to note his manner of making reply. If anything in the applicant's condition or appearance causes suspicion, do not fail to impart the same to the medical director, remembering the extent of the ravages of this infection in the human body and the numerous deaths that are caused thereby. If the syphilitic applicant is married, state how many children he has had and how many are living; if any have died give their ages at death; if any were stillborn, so state and mention the condition of his wife's health. Asthma.-If the applicant gives a history of asthma, record at what age it first occurred, and give some indications of the frequency, duration, and severity of the attacks and the date of the last attack. State whether the attacks are increasing or decreasing in frequency and severity, differentiate between spasmodic asthma and hay fever, and if possible, give the cause. Be careful in the physical examina- tion to note any emphysema, cardiac disease or Bright's disease. Indigestion.-A history of indigestion or dyspepsia seems trivial and unworthy of particular inquiry, but there are numerous cases that are forerunners of gall-stones or disease of the gall bladder, ulcer 122 LIFE INSURANCE EXAMINATION of the stomach or duodenum or appendicitis. Especial inquiry should be made to determine whether or not his digestive disturbance is really trivial and due to errors of diet, or is a possible symptom of impending serious trouble. Do not pass such cases by until you have carefully inquired into the history, and in such cases always palpate carefully in the region of the gall bladder, stomach and appendix for tenderness, rigidity or other signs of disease. Blood-Spitting or Chronic Cough.-If the candidate gives a his- tory of ever spitting blood, having had a chronic cough or expectora- tion or pneumonia, or ever having had shortness of breath, complete details should be recorded as to the date, number of attacks, their severity, duration, cause, etc. In such cases an exceedingly careful examination of the lungs should be made, both front and back, and the usual signs of incipient tuberculosis should be sought. Voiding Urine at Night.-If the applicant is in the habit of rising at night to void urine, state how long the habit has existed, the usual number of times he has to get up each night, and whether the num- ber of times or the amount of urine is increasing or diminishing. Learn, if you can, whether it is merely habit, or due to an enlarged prostate, diabetes, renal disease, excessive drinking of fluids at bed- time, etc. Albumin or Sugar in the Urine.-Inquiry should be made whether albumin or sugar has ever been found in the applicant's urine. If so, state when and by whom found, and how long the condition has existed. In these cases at least two very careful examinations of the urine should be made, and a specimen should be sent to the home office. Epilepsy.-If the candidate has or has had epilepsy, fits, convul- sions or attacks of loss of consciousness, a careful inquiry into the case should be made and full details conveyed to the medical director. It is necessary to know the frequency and severity of the attacks, the probable cause, and whether or not they were accompanied by dizziness, nausea, vomiting, ear trouble, etc. Habitual Headaches.-A similar explanation is required when ap- plicant gives a history of habitual headaches. Insanity.-Insanity is seldom admitted by applicants for insur- ance, but they will sometimes admit having had attacks of what they are pleased to call "nervous breakdown," "overwork," and the like. In all such cases it is well to question the applicant carefully, learn all the facts possible, and convey them to the medical director, being GENERAL INSTRUCTIONS TO EXAMINERS 123 sure to give the date of the attack and the names and addresses of the physicians by whom he was treated. Paralysis.-If a history of paralysis is obtained, learn whether it was partial, hemiplegic, and whether of central or peripheral origin. Give full particulars, including names of physicians consulted, etc. Neuralgia.-In cases of persistent neuralgia the examiner should obtain a history of the entire trouble from its inception to the date of examination, stating the cause and the nerves affected. It is very desirable to learn whether or not opiates were used in the treatment.' Palpitation of the Heart.-In cases of palpitation of the heart state whether the attacks arc slight or severe and accompanied by dyspnea or fainting. Try to determine the cause, and examine the heart carefully, both before and after exertion. Fistula.-If the applicant gives a history of having had a rectal fistula, state whether or not an operation has been performed; when, and with what results. If the fistula exists describe fully. Appendicitis.-If the applicant admits having had appendicitis state how many attacks, and give the date of each attack. State whether it was a simple case, or whether there had been an abscess formation, and whether or not the appendix was removed. Give the date of the operation, and examine the locality for the presence of rigidity, pain or tenderness and a scar indicating an operation. State whether there is hernia at the site of the operation wound. Tumor or Cancer.-If tumor or cancer is admitted, give location, date and name of operating surgeon, or if not operated upon, state what treatment has been taken. Ulcer.-If an ulcer is admitted, describe fully, and indicate its location and character, whether indolent or otherwise; give the cause, and state the nature of the treatment, with results. Prostatic Disease.-If disease of the prostate is admitted, give a full history showing the nature and extent of the trouble; its dura- tion, and the amount of inconvenience or suffering occasioned. State whether operation has been performed, giving the result, and the name and address of the surgeon. Pleurisy and Pneumonia.-In cases where a history of pleurisy or pneumonia is obtained, be sure to state the date of the attacks, the severity, whether or not there was effusion into the pleural cavity or whether there was a formation of pus. If an operation was per- formed, give a full history including the name and addresses of the physician or surgeon and the amount of chest capacity left. 124 LIFE INSURANCE EXAMINATION Present Health.-A large number of examination blanks ask the applicant to state whether he is in good health; whether he has been ill or attended by a physician in the last three or five years, and the name and address of the last physician consulted, when and for what cause. These questions should all be answered in full, and de- tailed information given if any of the questions are answered in the affirmative. Gain and Loss in Weight.-The applicant is also asked whether he has gained or lost in weight in the preceding one or two years. If he has he should state which, how much, and give the cause, if possible. It should also be stated whether the change in weight is continuing, particularly in the case of loss, and in such cases it is especially important to inquire into the cause, as the loss may be due to disease or to intentional dieting. A loss in weight of any extent may be easily detected by the ex- aminer by noting the condition of the applicant's skin, the fit of his clothes, and his appearance. Consumptive Association.-Consumptive association is an impor- tant factor in determining the insurability of an applicant. The examiner should make close inquiry as to whether or not the' candi- date, during the last three years, has lived with or associated with, anyone suffering from consumption. If the answer is affirmative full information should be given. Women Applicants.-Women applicants are subjected to a par- ticular line of inquiry which is outlined by a specific set of questions on the blank. Some companies do not insure women, others accept them for small amounts on certain forms of policies, and still others insure them at the same rates and for the same amount as men. Insurable Interest.-All companies inquire closely into the insur- able interest, and are practically desirous of knowing the motive for the insurance, and who is to pay the premiums on the policy. If the applicant is to pay the premiums herself out of her own funds, the company desires to know the amount and source of her income. As a general rule, a woman at, or past middle age, with grown or self-supporting sons and with married daughters is not entitled to insurance, and companies look askance at such cases. A self-supporting woman is, of course, a good subject for insur- ance, as is also a woman whose husband is uninsurable, and who has minor children. GENERAL INSTRUCTIONS TO EXAMINERS 125 The examiner should inquire tactfully why application is made; he should ascertain who, if anyone, is dependent on her. If married, her husband's occupation should be given, and whether he already is insured in her favor, and for how much. She should state how many children she has had and give the ages of the oldest and the young- est, and state whether she is pregnant. Climacteric.-The examiner should also inquire whether the ap- plicant has passed the climacteric and when. Miscarriages.-The applicant should be questioned as to mis- carriages, and if it is learned that she has miscarried, the date should be given, the cause of the miscarriage ascertained, and inquiry made as to whether she has since given birth to a child at full term. If she has had several miscarriages, inquiry should be made to try to determine the cause, with especial reference to the condition of the husband's health. Female Diseases.-The candidate should be closely questioned regarding illnesses peculiar to her sex, and if any such are admitted full particulars should be given; in some cases a special examination is necessary. In the examination of a woman applicant the examiner is always at a disadvantage, as he cannot always secure or insist on a disrobing as complete as in the case of a man. A tumor of the breast or a cancer of the uterus may escape detection unless the examination is carefully made. If the examiner is suspicious of some hidden ailment he should use all the tact in his possession and en- deavor to make such an examination as will remove all doubt and still will not offend the applicant. Family History.-The applicant should be asked whether any member of his family, including parents, grandparents, brothers, sisters, uncles and aunts, has ever had tuberculosis, insanity, epilepsy, fits or convulsions. If the examiner receives an affirmative answer, he should give full particulars and in the case of tuberculosis, state when the relative in question died, and whether or not the applicant was associated with or lived with that relative during the illness. If he lived with the member of the family so afflicted, learn whether he still lives in the same house, and if so what precautions were taken to prevent spread of the infection. This same information is required if applicant has been associated with anyone other than a blood relative who has, or has had, tuber- culosis. In recording the family history of an applicant, give the age of the 126 LIFE INSURANCE EXAMINATION living members of the family, and the condition of their health. Give the exact age, if possible or the approximate age, at least. In giving the condition of health, if it is learned that any member of the family is in "fair" or "poor" health, give full explanation as to the health impairment. It is often difficult to get the exact age at death of deceased mem- bers of the family, but the examiner should endeavor to arrive at as near the exact age as possible. The predisposition of the family to longevity or early death is very important in determining the insurability of an applicant. The cause of death should also be carefully inquired into, particularly in those who died before reaching seventy years of age. In recording the age and the cause of death, try to avoid using the term "don't know." If you are compelled to give the answer, an explanation should be made stating why the applicant is unable to give a better answer. The date and duration of last illness should also be given. Some companies ask for the year of death of parents, brothers, or sisters, particularly when they died of some hereditary disease. Physical Examination.-Having secured from the applicant all the information he is able to impart, or obtained after close questioning, attention can be given to the physical examination. This requires all the skill and judgment an examiner possesses. The examination should be made in private, in a good light, and should be thorough and exhaustive, no matter how well you may be ac- quainted with the applicant, nor how good a risk he may appear to be. Disrobing.-The applicant should remove his clothing to the waist, further disrobing to be at 1he discretion of the examiner. [See Chap- ter on Examination of Women.] Inspection.-Inspect the applicant carefully without exciting his suspicion; note the color and condition of his hair and look for alo- pecia, or other evidence of disease; look for syphilitic dermatoses, enlarged occipital or cervical glands or scars; observe the complexion and note whether healthy, ruddy, pale, sallow, waxy, etc.; note the color and appearance of eyes; look for jaundice, signs of dissipation and arcus senilis, and test the ocular reflexes as to light and accom- modation ; note the ears and examine for discharge, or other evidence of disease; examine the mouth and throat, observe the teeth, gums and tongue, and note the condition of the tonsils; examine the neck GENERAL INSTRUCTIONS TO EXAMINERS 127 closely for goiter; look carefully for any tremors; observe the gait and carriage of the applicant and note any defects or deformities. The trained examiner will make such an inspection of an applicant in a very short time, and practically without his knowledge. Pulse Rate.-Count the pulse of the applicant for a full minute, or longer if any deviation from the normal is detected; take the tem- perature carefully. If the pulse is ninety or above, sitting, recount on another day; if the temperature is above normal take again on another day, preferably in the late afternoon or evening. In taking the pulse, feel the radial artery, and note whether there is any atheroma. The temporal arteries should also be observed. If any signs of disease are detected they should be carefully recorded. Blood Pressure.-All companies require a report on the reading of the blood pressure, and every examiner should provide himself with a good instrument, and become proficient in the taking of blood pressures, and the interpretation of the findings, both systolic and diastolic. Height and Weight.-Measure and weigh the applicant carefully, and record the exact height and weight. If the applicant is at all corpulent be particularly careful in measuring the abdominal girth. If the abdomen is pendulous it should be so stated. Heart and Lungs.-By careful inspection, palpation, percussion, and auscultation, ascertain whether there is any deviation from the normal in the heart or lungs. Examine also for signs of disease of the liver, stomach or spleen. Rupture.-Examine any rupture, and observe the site of any pre- vious operation. Urine.-Obtain a sample of the applicant's urine, being sure to collect it in such a way that you can be certain it is authentic. It is always well, in the case of a man, to have the urine passed in your presence. If this cannot be done, note whether or not the bottle is warm when handed to you. If you are suspicious, see the applicant again, on some pretext and collect another sample. If he is unpre- pared for your second visit, you will undoubtedly secure an authentic sample. Urinalysis.-Make a very thorough analysis of the urine, and record your findings carefully. It may be necessary to make a microscopic examination, or to forward a sample to the home office of the company. If so, do it promptly; delays, as before stated, are dangerous. 128 LIFE INSURANCE EXAMINATION The medical director may request you to see the applicant again for reexamination with special attention to certain points, or for another urinalysis, etc. When so requested, be sure to give the mat- ter your very earliest possible attention. Review.-While the candidate is putting on his clothes, look over the examination paper and correct any vague answers, errors, and omissions. Signature.-Be sure to have the applicant sign the examination with his full name. If perchance, lie is unable to write, witness his mark. Classification.-Generally the examiner is asked to classify the quality of the risk, and is asked to state whether, in his opinion, the applicant is a "First class," "Good," or "Doubtful" risk. For guidance, the following is given as a basis for classification: First Class.-Applicants in perfect health, who never have had a serious illness; of good habits, healthful surroundings and vocations and free from hereditary predisposition to disease. Good.-Those applicants who have had serious illness, but have re- covered; those in whom hereditary taints are suspected, though not manifested, and those subject to slight ailments. Doubtful.-Those applicants with impaired health, hereditary pre- disposition to disease, bad habits, or whose health is liable to be in- jured by their occupation or environment. Report.-As soon as completed the report should be mailed to the home office of the company, or wherever the medical director in- structs that it be sent, and should never be shown to the agent or anyone else. Some companies have the application attached to the medical ex- amination paper. In such cases the examiner is requested to return the entire paper to the agent, but in such event there is usually a confidential report slip attached to the examination which is to be torn off, filled out, signed, and mailed direct to the medical director. On this slip the examiner gives his confidential opinion and any other information of interest regarding the risk. This slip should be mailed at once in every case, as the application cannot be acted upon at the home office until this slip is received. Conclusions.-The examiner should be careful to make thorough examination and comprehensive reports in all cases, as he may be called upon to reexamine the applicant at a later date for additional insurance, and if the two reports do not agree, his position will be GENERAL INSTRUCTIONS TO EXAMINERS 129 embarrassing. The applicant may be examined later for additional insurance by another physician and if his report does not agree with the first, the company will investigate, and if the first examiner's re- port is found to be incorrect or incomplete, he will have difficulty in explaining the discrepancies and may be dropped from the list of examiners. A serious point and one that is the cause, many times, of an ex- aminer's being discharged, is the astonishing repetition of pulse rates, specific gravities and blood pressure readings in the reports of •some examiners. Records of all examinations are kept in the medical departments, and a review of these records shows that in a large num- ber of cases certain doctors will report a pulse of seventy, (70), a specific gravity of one thousand twenty, (1,020) and a blood pressure reading of one hundred twenty (120) mm. systolic and eighty (80) mm. diastolic. This cannot mean anything except dishonesty or gross carelessness. A good examiner makes his examinations with care and reports what he finds. These records of an examiner's work show the medical director how much confidence can be placed in his work and in his recommendations. A number of companies require a specimen of the urine to be sent to the home office in all cases or where the amount applied exceeds a certain fixed amount, or where the applicant is more than forty (40) or forty-five (45) years of age. The results of these home office ex- aminations show that in an appreciable percentage of cases albumin, casts or sugar are found that are not reported by the examiner, who had previously examined part of the specimen sent in. This is a very bad mark against the examiner, and could have been avoided by a careful examination of the urine of the applicant. Examiners are cautioned to be neat and well-groomed in appear- ance and to have clean and well-equipped offices. The impression they make upon the agents and upon the applicants who appear before them is very important. Make thorough examinations, accurate reports of your findings and be honest with yourself and the company. The foregoing are suggestions and recommendations based on an experience covering a long period of years. No details or technic or instructions in clinical or physical diagnosis have been attempted, as they will be given elsewhere. CHAPTER XI THE ETIQUETTE OF MEDICAL EXAMINATIONS By Samuel C. Stanton, M.D., Chicago, III. Chief medical Director, Farmers National Life Insurance Company of America The subject of etiquette of medical examinations naturally includes in its scope the qualifications of the individual to whom is entrusted that most vitally important detail, the making of rhe physical exam- ination for life insurance. The company must depend chiefly upon the report of the medical examiner, to safeguard it against fraud and misrepresentation, for in many cases inspections are not obtained. He should preferably be affiliated with the local medical society and be on a friendly footing with his professional brothers, for it is often necessary for the examiner to obtain additional information about points in the family or personal history of an applicant which may make clear otherwise obscure or imperfect data, or to confirm or verify the statements of applicants. This detailed information can oftentimes be furnished only by the attending physician or family physician of the applicant. The importance of the maintenance of cordial relations between the examiner and his fellow practitioners in the community is self-evident. He should possess a great store of tact and diplomacy, a keen in- sight into human nature, a pleasing presence and an unruffled and unrufflable temper. It may be claimed that such qualifications are impossible of attain- ment in persons of body, parts and passions, but the more closely the medical examiner can approximate these virtues, the greater will be his efficiency and his value to the company he represents. Due weight must be placed on the circumstances which precede the examination. In the vast majority of cases the applicant does not initiate the proceedings. He is approached by the agent who in one way or another induces, prevails upon, cajoles, or coerces the applicant into signing the application, and then arranges for his examination. The applicant, as a rule, is not anxious to have the insurance and 130 ETIQUETTE OF MEDICAL EXAMINERS 131 often feels that he has been forced or over-persuaded, and so is not in a frame of mind which tends toward harmony. Under such adverse circumstances it becomes the duty of the medi- cal examiner to attempt to establish an entente cordiale between the applicant and himself, first, that he may thereby be enabled to obtain from the applicant the information necessary, and second, that he may be able to convert the hostile, negative or neutral mental attitude of the applicant into an active friendly feeling toward the examiner and his company. To bring about this desirable and essential condition of active friendliness, oftentimes taxes to the utmost the ingenuity and diplo- macy of the examiner. Frequently the applicant may state at the outset that he does not want nor need the insurance. In such cases the examiner should enlarge upon the virtues of life insurance in genera], the advantages of the protection it affords, its excellencies as a sound and judicious investment, and the like. The most important factor in the establishment of a cordial feeling between the applicant and the examiner is to secure some point of common interest. Sometimes intimate acquaintance with the town or locality where the applicant was born or reared may be useful. In this way acquaintance with the geography of the country may serve as an aid in bringing applicant and examiner in closer personal touch. In case of foreign-born applicants, the writer has found his knowledge of foreign countries, places, languages, manners and cus- toms of great benefit. The Danish applicant will warm up to one who has been in Denmark and knows that Kjobenhavn means Copen- hagen; the Italian, to one who can speak of Firenze or beautiful Napoli; the Englishman, to one who can appreciate the difference be- tween the English as spoken in Yorkshire, the Fen country, Sussex and Cornwall. It may be that the button indicating war service or membership in a fraternal society will arouse a feeling of interest which may be most valuable to the examiner. The examiner should be ever on the alert to seize upon any such possible intersecting lines of interest. The mental attitude of the medical examiner is most important. In examinations for life insurance the ordinary professional condi- tions are reversed. The duty of the medical examiner is not that of the physician whom a sick person or one who thinks he is ill consults. The applicant, however unwillingly he may have signed his applica- 132 LIFE INSURANCE EXAMINATION tion, having taken the plunge, is desirous of appearing to the best physical advantage, even at times to the extent of withholding in- formation or of giving misinformation. Instead of dilating upon his real or imaginary ailments, the applicant is anxious to make a good appearance, to emphasize his absolute healthfulness and insurability, and so to impress the examiner that he will make a favorable report. In this attitude the applicant will have the hearty and whole-souled support of the agent, as a rule. The examiner in his report must endeavor to sift the chaff of in- complete oi* misleading' statements from the wheat of the necessary facts, and present to the medical director, who rarely sees the appli- cant, a mental picture of the applicant as he is. The Examination Aside from the analysis of the medical blank which has been dis- cussed fully in another chapter, there are certain general considera- tions which should be borne ever in mind by the examiner. Examinations should be made in private, only the examiner and applicant being in the room or within hearing. The questions to be answered by the applicant are confidential, ami must be so considered, and their value is materially impaired by the presence of other indi- viduals. A husband may have episodes in his life of which his wife is ignorant or which he does not desire her to know. It is within the range of possibility that in the past history of the wife there may have been occurrences which she does not wish disclosed to her hus- band. Every opportunity should be given the applicant to make frank and confidential statements to the examiner, and for the attain- ment of this, privacy is essential. It may be necessary to defer making an examination on account of the temporary ill health of the applicant. In this case the reasons for delay should be detailed to the medical director. Sometimes an examination cannot be completed at one session, by reason of the inability of the applicant at that time to give informa- tion regarding points of salient interest to the company, or his in- ability to furnish a specimen of urine to the examiner. An examination once made should never be suppressed, but the re- port should be forwarded promptly to the home office. Sometimes an applicant may ask the examiner not to send in the medical report, on account of unfavorable findings, or conditions which make the re- jection of the applicant probable or positive. ETIQUETTE OF MEDICAL EXAMINERS 133 The agent may urge the examiner to destroy an unfavorable medi- eal report, and may offer to pay the examiner the regular fee for the examination or even a larger fee. The examiner should never yield to this persuasion or temptation. He is bound in honor to the com- pany which employs and trusts him to transmit all information, favorable or unfavorable, about the applicant; to safeguard the com- pany in its future transactions, and to render it impossible for an undesirable applicant to obtain insurance from a sister company by withholding the fact of a previous rejection or failure 1o obtain policy as applied for, or by making false or misleading statements. Ditto marks should never be used. Every question should be an- swered individually and no group answers should ever be made. Black ink should invariably be used as every medical report must be photographed, and clear photographs may not be obtained if ink of another color, faint ink or indelible pencil be used. Examinations should never be made in a field, in cold rooms, or in noisy shops or offices, where privacy cannot be obtained. Examinations should never be hurried. The applicant who states that he can give only ten minutes to the examiner would better be advised that a full and complete examination cannot be made in that time. In the great majority of cases, when the matter is properly presented to the applicant, he will either give as much time as is necessary or will make another appointment. A medical examiner should never allow himself to examine his wife, son, daughter, or other near relative. It is well to avoid even the appearance of evil, and however fair and judicial the examiner might desire to be in his report, it is practically impossible for him entirely to ignore the personal equation. The examiner who considers that by the mere recording of answers to the questionnaire, he has fulfilled his entire duty, is of little value to his company, for this work is merely clerical and might be done by any reasonably intelligent clerk. The questions are intended to fur- nish a systematic history, and the examiner should supplement these questions, whenever necessary, in order to obtain full and complete information regarding any point about which there may be doubt. He is expected to use care, tact and interested effort in developing all signs and symptoms, and admission of previous illness or impaired health. 134 LIFE INSURANCE EXAMINATION The Medical Blank The first part of the medical blank is ordinarily devoted to the "Answers made to the Medical Examiner," by the applicant, and includes personal history, habits, and family history. While some of the questions may seem to be unimportant or unnecessarily detailed and precise, the experience of life insurance companies has demon- strated their value. Accuracy in recording the date of birth is necessary, in order to check up with the information on the application, and thus insure a correct premium rate. The question regarding race and nationality is important, as the correct answer places the applicant in the proper class for rating. It is essential that the company know whether the applicant is white, colored, or of one of the Far-Eastern races. The mortality experience among the latter races is less favorable than in the white race, and therefore, if acceptable for insurance, negroes, East Indians, Chinese and Japanese are charged a higher premium rate than Caucasians. The recent or present association of the applicant with persons suffering from tuberculosis is important on account of the contact danger in this disease. The question whether the applicant is single, married, widowed, or divorced, should be carefully considered by the examiner. If widowed the date and cause of death of husband or wife and the duration of illness should be stated in as much detail as is deemed necessary, as these facts may have a material bearing on the value of the applicant as a risk for life insurance. The personal health history of the applicant is a very important factor in the examination, and the examiner should, with the greatest tact, endeavor to elicit information which may enable him to differ- entiate an acute gastro-enteritis from an appendicitis; to distinguish between muscular rheumatism and arthritis, biliousness and gall- bladder disease, to pick out, from the applicant's history self-given, the important facts to be recorded. The questions as to the present health of the applicant, whether any unfavorable opinions as to health have been expressed; observation, care or treatment in hospital or sanatorium; recent increase or de- crease in weight, and past diseased conditions, operations, accidents or injuries are all supplemental to, and form an essential part of, the record of personal history. The questions under family history are frequently slurred over by ETIQUETTE OF MEDICAL EXAMINERS 135 the examiner, who does not appreciate the possibly important bearing the correct answers may have on the estimation of the value of the applicant as a risk for life insurance. For instance, the fact of death at earlier ages of a number of near relatives might naturally lead to the inference that the applicant might not live out his expectancy. Several deaths from pneumonia or tuberculosis in the immediate family would bring up the query whether vital resistance, especially toward respiratory diseases, might not be lowered in the case of the applicant. The history of one or more cases of insanity, mental dis- ease, or suicide might make one think of the possibility of mental unbalance in the individual under examination. Several abortions or stillbirths in the history would make the examiner suspicious of possible luetic infection. In the case of women, the history during the childbearing period and around the menopause is often very enlightening. The increasing incidence of malignant disease makes this the more important. It is also necessary to know the insurable interest. If the applicant is mar- ried, it is well to know whether her husband carries insurance in amount at least equal to that applied for by the applicant, and of which she is the beneficiary. The examiner should never fail to have the applicant sign the "Answers Made to the Medical Examiner" nor to append his signa- ture as witness. If it is necessary, on account of a rapid pulse, excessive blood pres- sure, high temperature, abnormal urine or other causes, for the medi- cal examiner to see the applicant a second time, the reason should be clearly explained to the applicant. He should be told that he is not being "turned down," but that the second visit is necessary in order that his showing may be as favorable and as complete as possible. He should also be warned that an uncompleted examination virtually places an impairment on him, which will have to be removed before he can be accepted for insurance by another company. Inspection will often reveal physical defects. The applicant may appear much older than his stated age, may not appear healthy and vigorous, may show evidence of enlarged glands, past or present, tumors or goiter. He may be lame, with one leg shorter than the other, or deformed. There may be curvature of the spine. His sig- nature may show marked tremor, but it should be remembered that this may be found in individuals, who have no nervous disease but are not accustomed to the use of a pen. 136 LIFE INSURANCE EXAMINATION The information to be derived from inspection of the body of the applicant emphasizes the necessity, at least, of removing all clothing above the waist. The examination of the heart should always include the location and character of the apex beat, the presence or absence of murmurs, the rhythm of the heart sounds and whether or not hypertrophy or other diseased conditions exist. The respiratory apparatus should be gone over carefully to be sure that the respiratory sounds arc clear and distinct over every part of both lungs, and that the lungs are free from every indication of dis- ease. It should be unnecessary to state that the examination of the chest should be made with the chest bared, by inspection, palpation, auscul- tation, by stethoscope and percussion. The urine should be voided by the applicant in the presence of the examiner, or in an adjoining room with door open so that there may be no possibility of substitution. The urinalysis should be made at once before decomposition takes place and in cases in which the amount of insurance applied for is sufficient, two ounces of the same specimen, properly labelled, should be sent to the home office in a suitable container in which a preserva- tive has been placed, for independent chemical and microscopic ex- amination. Should the examiner find abnormalities in the urine, a specimen should always be sent to the home office with an explanatory memorandum. It is an excellent routine procedure for the examiner to look over the blank carefully after it has been supposedly completed, to be certain that no questions remain unanswered or incompletely an- swered. The more carefully the blank is prepared, the less correspondence between the medical examiner and the home office will be necessary. If the medical examiner does his duty faithfully, carefully and pains- takingly, his fidelity, industry and skill will obviate a great part of the labor now unnecessarily imposed on the medical director, and the inevitable friction which arises in many cases when an examiner who has made a mistake or omission is obliged to be reminded of it by his medical director. CHAPTER XII THE EXAMINATION OF WOMEN By Rachel II. Carr, M.D., Chicago, III. Medical Director, The Peoples Life Insurance Company Under general considerations it may be said that women are subject to the same ailments as men and that they have the same congenital deficiencies. They acquire certain disabilities by rea- son of their manner of dress, habits, and occupation. From an in- surance standpoint, women make desirable risks because, as a rule, they are not engaged in hazardous occupations, they are less sub- ject to specific infections and they have been more moderate in the past in the use of alcoholics. A comparison of the hazards of life to men and to women was published by Dr. W. A. Evans in which he gives the study made by Dublin of the Metropolitan Life Insurance Company. The follow- ing is Dr. Evans' article: "In 1909, in the registration area of the United States (more than half the country), the death rates per 1,000 living were as follows: RATIO OF MALE TO AGE MALES FEMALES FEMALE MORTALITY 15-19 3.95 3.37 117.2 20-24 5.68 4.59 123.7 25-34 6.66 5.54 120.2 35-44 9.74 7.65 127.3 45-54 16.82 12.32 136.5 55-64 29.88 22.86 130.7 65-74 62.42 52.66 119.4 75-. . 152.14 138.65 109.7 "From the above it is seen that it is about twenty per cent safer to be a woman. It is almost as safe to be an old man as it is to be an old woman, but beware of being a man of fifty. "When it comes to certain diseases, the comparisons are espe- cially interesting. Women are much safer from consumption (2.19 to 3.53). They have the advantage as regards the following dis- eases: pneumonia (female rate, 1.03; male rate, 1.43), Bright's dis- ease (1.25 to 1-54), accidents (.55 to 1.99), diseases of the arteries (.22 to .32), cirrhosis of the liver (.17 to .36). 137 138 LIFE INSURANCE EXAMINATION "When it comes to heart disease there is about an even break, (1.93 to 1.98). With apoplexy there is an even break (1.07 to 1.07), while with cancer males have distinctly the advantage, the rate for females being 1.25 and that for males .79. "By referring to the table above it will be seen that women have the advantage at every age. Dublin calls attention to the fact that even in the active childbearing years women have a lower death rate than men. However, when one can choose it is well to go the limit and choose the safest. Spinsters have lower rates than married women. "In spite of all this, insurance companies do not want to insure women. Insurance companies have experience tables upon which they base their charges for insurance after adding overhead charges and other items. It has been the experience of most life insurance companies that women overrun their expected mortality. "The Metropolitan found that women insured by them had a low death rate as compared with the experience tables. Dublin's explanation is as follows: When a company goes after business actively, it gets high grade risks. When a company waits for business to go after it, the percentage of low grade risks is high. The people who hunt up insurance are often those who suspect that something is wrong. Dublin says that women are past masters at realizing intuitively that the machine sometimes misses a cog. It is his opinion, that when insurance companies actively work for business among women, they will find them much better risks than men." In a single chapter it is possible to consider only a few special problems presented in the examination of women. There are four subjects commonly regarded as of importance, namely, goiter, tu- berculosis, cardiovascular problems and hypertension. Much has been written on these subjects from a clinical standpoint, as well as from the experience of the general practitioner, yet no hard and fast rules can be set down to govern the acceptance or rejection of women who may have these impairments. I. Goiter It is estimated that five per cent of women in the Great Lakes region present goiters of varying sizes. Some companies reject them outright; others accept all but the exophthalmic type; and some make an attempt to grade this impairment. The unsolved THE EXAMINATION OF WOMEN 139 question is what goiters are simple and will remain nontoxic and what goiters are or will become toxic. This problem cannot be solved at present in an ordinary examination and any goiter may later become toxic. Goiters occurring in women not over twenty-five years of age and otherwise normal, may be divided into three classes. To the first class belong small goiters of the so-called physiologic type, without nervousness, tremor, tachycardia or exophthalmos. These symptoms and signs are given in the order of the frequency of their observance and significance. A careful history and the appli- cations of a few simple tests are required to exclude nervousness. Tremor may be tested in the extended and separated fingers, sway- ing noted when standing with the eyes closed and muscular con- trol evidenced by the attempt to approximate the index fingers when standing with eyes closed and making a semi-circle with the extended arms. Tachycardia and exophthalmos are easily detected. Normal young women with goiters of this first class showing none of the signs and symptoms mentioned may be accepted as standard. The second class includes women not over twenty-five years of age and normal except for the presence of a small goiter and slight nervousness and mild tremor. This class is entitled to term insurance or other modifications deemed advisable. The third and last class presents small goiters in young women showing definite nervousness, tremor, tachycardia and exophthalmos and is not entitled to insurance. The goiters of middle age occur in the period in which toxicity is most likely to develop. This fact and their persistence beyond the twenty-fifth year make it impossible to consider them simple or physiologic, and their acceptance involves considerable hazard. The incidence of toxicity is most common from ten to fifteen years after the appearance of a goiter. In later life, a small goiter that has never given rise to symptoms or signs is probably nontoxic, and does not of itself bar the indi- vidual from insurance. Any large goiter, whether toxic or nontoxic, is a serious impair- ment by reason of the pressure symptoms it may exert and the functional disturbance it may produce in adjacent tissues and or- gans. It is liable to give rise to a severe toxemia when degenerative changes take place in it, which allow the disintegrating goiter to flood the system with its toxic products. 140 LIFE INSURANCE EXAMINATION II. Systemic Signs in Tuberculosis Tuberculosis in women furnishes a most serious problem, a prob- lem too often not dealt with successfully or effectively. It is not my purpose to dwell on the chest examination, and the lesions dis- closed by it. The teaching of our medical schools has emphasized the importance of this procedure, and in general practice the whole attention is too often directed to establishing the presence or ab- sence of signs and symptoms in the thoracic cavity, and the ten- dency is to be so satisfied with results thus obtained as to make no further investigation. It must be emphasized that initial tubercu- lous lesions adjacent to deeply situated bronchi may be covered with normal lung tissue to such an extent as to give no sign of their presence on percussion and auscultation. It is imperative that in addition to the ordinary chest examination, a consideration of the accessory symptoms of tuberculosis shall occupy an equal place in the examiner's mind. Our excess mortality in tuberculosis must, in part, be traced to the general failure to regard seriously the sys- temic signs of this infection. These signs which raise a suspicion of tuberculosis are first a loss of weight within four months, which reduction cannot be explained otherwise. The underweight must be at least 5 per cent below the normal weight for the applicant. Unexplained fatigue is second in importance. This is shown by blueness under the eyes, a slight pallor or grayness of the skin, and an unconscious tendency to avoid exertion. Evening fever of 99.4° or more for more than a week is the third suspicious sign. An occasional temperature of 99° is not to be con- sidered fever, which must be persistent to merit this term. The morning temperature may be subnormal. Fourth, any increase in the respiratory rate normal for the age is to be carefully considered. When overexertion, nervousness, and other factors are excluded, an increased respiration is most sig- nificant. The average pulse rate for a woman falls between 70 and 80. Any rate above 90 is abnormal for a woman. Fifteen beats per minute above the normal pulse is one of the indications of tuber- culosis. An increased, pulse and subnormal morning temperature should be looked upon as doubly significant of this disease. The last and sixth sign of an early tuberculous infection is THE EXAMINATION OF WOMEN 141 found in an increased resistance in the muscles of the chest wall corresponding to the area of disturbance in the lung or pleura. It is a reflex phenomenon analogous to Hartman's sign in acute appen- dicitis. Specialists in chest diseases insist upon the uniformity and importance of its presence. Cough, sputum and hemorrhage are presumptive evidences of a well-established morbid process, not of an initial invasion and there- fore are not to be discussed under the signs and symptoms of early tuberculosis. It must be borne in mind that pulmonary tuberculosis may exist without cough or sputum, and that these signs are not necessary for a positive diagnosis. III. Cardiovascular Problems Cardiovascular problems present general considerations that un- derlie and influence many of our conclusions in regard to the cir- culation. One is that the heart is a related organ, dependent on the nervous system and the rest of the vascular system for its integrity. Inelastic vessels increase the work of the heart and in time wear out the myocardium and establish decompensation. A too relaxed condition of the vessels is equally damaging to the heart, exhausting its reserve in the effort it makes to keep the normal quantity of blood in motion. A sound heart may become abnormal by impairments outside of itself, and the conclusion that the beginning of circulatory pathology may be extracardiac forces itself more and more to the foreground. The factors involved establish a vicious circle, in which the heart, the nervous system, and the vessels act and react, but without being able to prevent a progression of the morbid processes. A satisfactory examination of the heart in women depends to an extent not usually appreciated on the manner in which it is made. The whole anterior chest should be bare and the applicant placed in a good light. Inspection will reveal any abnormal bulg- ing of the chest wall, any paleness or hyperemia of the skin, unusual fullness of the superficial vessels, abnormal pulsations in the chest or neck and a normal or a diffuse apex beat. Palpation verifies the findings noted by inspection. Much apparent thrill to the eye may give little or none to the palpating fingers, a very significant variation. 142 LIFE INSURANCE EXAMINATION By percussion, the borders of the heart are outlined, a really difficult task in a woman. The normal left cardiac diameter, the distance from the middle of the sternum to the left border of the heart, is found to be usually from 11 cm. to 12 cm. Our former teachings as to the size of the heart are liable to error in that large and interesting group of individuals belonging to the chronic con- genital asthenic type. Dr. Charles Lyman Greene demonstrated by radiographs the gross error consequent upon the peculiar confor- mation of the "drop heart" in this group, a heart which may give a total diameter of only 7.5 cm. in an apparently normal person. The way in which the stethoscope is applied, especially in women, is a matter of a good deal of importance if the elusive departures from the normal sounds are to be detected. It is best to keep away from the apex and also to make no attempt to hear through the breast while ascertaining whether or not the heart sounds are nor- mal. Place the stethoscope in the fifth interspace just beyond the margin of the breast and listen at frequent intervals while passing upward in a wide curve to the second interspace at left margin of the sternum. Cross the sternum to the right second interspace and descend slowly along the right border of the heart to the left fifth interspace at the margin of the sternum. The examiner must have clearly in mind what he wishes to find out during auscultation. The rate, the rhythm, and any abnormal sharpness or brevity should be carefully determined at this first attempt to examine the heart. If doubt remains as to these three qualities, retrace this curve till satisfied on these points. In this same manner examine again with two objects in mind, namely, to prove the presence or absence of any variation from normal heart sounds, or any accentu- ation. It is of the utmost importance to establish the character of the heart sounds. The ability to do this is the result of long and careful study of normal hearts, thus acquiring a standard by which to judge variations. To quote from Dr. Greene: "The more important variations in auscultatory signs are not necessarily con- nected with bruits of the classical type * * * but rather imper- fections of tone and accentuation alike. A murmurish first or sec- ond sound, abnormal sharpness or brevity, may be far more important than a well-developed murmur." A heart-rate in women below 60 or above 90 merits a second reading, and further investigation. THE EXAMINATION OF WOMEN 143 The arrhythmias give information as to the function of the heart. The four types are supposed to correspond to attributes of the heart, and are classified as physiologic, the type characterized by extrasystoles, auricular fibrillation and heart-block. Physiologic arrhythmia is of nervous origin, transient in charac- ter and has a wave-like rise and fall with the rate of respiration and is not of a serious nature. Extrasystoles are due to excitation of the heart in abnormal sites, but as the normal rhythm is maintained for the most part they are not an evidence of serious cardiac impairment except in applicants past 40 years of age in whom they may point to a myo- carditis. In auricular fibrillation and in heart-block there is impaired con- tractility and conductivity of the heart muscle in which no two beats and no two intervals are alike and both are dangerous forms of arrhythmia. Arrhythmias are rare in myocardial insufficiency. The accentu- ation most commonly emphasized is that of the pulmonary second sound, one of the signs of mitral stenosis. The signs and symptoms of heart murmurs are so fully dwelt upon in college and out of it, and the attitude of insurance com- panies towards them generally is so well known as to justify an omission of them in this chapter. The hearts of some women presenting organic murmurs are better prepared to endure strain than the hearts of other women that are free from murmurs. The cardiovascular problem which generally fails of solution is that of cardiovascular insufficiency. The heart shows no murmur and the heart beats are devoid of arrhythmia. A diffuse apex beat suggests this condition. The first symptoms are subjective, and for this reason our examination should include minute inquiries as to the capacity of the woman to undertake strenuous labor, climb stairs, run, etc. There are systemic signs in the more pronounced cases to assist the examiner. Paleness or grayness of the skin, a blue tint in the lips or the nails, a hyperemia of the skin, and the presence of a slight edema are suggestive. The definite proofs of cardiovascular insufficiency are found in an incompetent heart muscle and especially in the failure of the heart to respond to a standard test for cardiac reserve power. Conversely, a competent heart muscle, a proper response to effort, and a normal blood pressure exclude myocardial insufficiency. 144 LIFE INSURANCE EXAMINATION IV. Hypertension Hypertension in women is more common than has been believed. Routine examination of the blood pressure has brought many sur- prises, and shows that it is necessary carefully to consider this subject in examining women for insurance if justice is to be done to them and to the company. The so-called ''essential hypertonia" is the type of hypertension occurring most often in women. It may be defined as a form of hypertonia without gross renal or arte- rial changes. In its development, there is little in its early stages to attract attention to the heart or blood vessels. The causes of essential hypertonia as generally stated are legion. From this confusing list, three factors seem most important and most commonly present. They are abnormalities of the glands of internal secretion, an autotoxemia from an impaired digestion and constipation, and lastly and most probable, a focus of local infection. This form of hypertension begins insidiously and continues its course with transitory rises in pressure characterized by vasomotor spasm which gradually gives permanent elevation and finally ends in widespread arteriosclerosis. Essential hypertonia merits the careful attention of examiners by reason of the frequency of its occurrence and its lack of obvious symptoms, being usually monosymptomatic. The aim of the exam- iner should be the recognition of this type in the making. The prognosis in essential hypertension is regarded as benign and the increased pressure may be well borne for a number of years. Hypertension in women under thirty-five is practically always nephritic and gives a bad prognosis. The true arteriosclerotic group presents the same symptoms and follows the same course that this impairment does in men. There remain the hypertension of exophthalmic goiter and acromegaly, and a final form of great clinical interest, called non-goitrous thyrotoxic hypertension. A Suggestion for the Examination of Women The examination of the chest of a woman requires the removal of all clothing. This can be clone without the slightest objection on the part of the most sensitive woman if two towels are used to cover the chest, thus avoiding exposure while also getting free ac- cess to every part to be examined. One towel covers the front, the 145 THE EXAMINATION OF WOMEN second the back, and they overlap at the shoulder leaving a mid- dle opening for the neck. Two safety pins over each shoulder secure the towels and two more may be used below the arms at the sides if desired. Under this covering, the woman removes her waist, corset, and other upper garments, and when ready only her arms are bare. The examiner uses the lateral openings between the two towels to reach any part of the chest. The anterior towel can be raised easily to allow the doctor to reach the middle of the sternum on either side. During the entire examination, the appli- cant on looking down over her chest finds herself clothed. The same free access is to be had under the towel covering the back. At the University of Chicago, in the examination of students, a strip of sheeting wide enough for a single bed, and long enough to cover a person from the neck to the ankle, front and back, is used. This has an opening for the head in the center. It is slipped over the head, and from this opening the lengths of sheeting fall to the ankles front and back. The student undresses completely with the exception of slippers. From the sides between the two lengths of cloth any part of the body is easily exposed for inspec- tion without embarrassment to the student. Like a company of ghosts the students await their turns in the examination room. The covering recommended in making examinations of women for insurance is a modification of that in service at the University of Chicago, the only change being in the length of the material used. CHAPTER XIII THE MOUTH, NOSE. THROAT, EYE AND EAR The Mouth, Nose and Throat Often most interesting and valuable data are secured from even a casual inspection of the mouth. Recently a physician of wide ex- perience called my attention to a patient with deep unhealed seams at the corners of the mouth. Invariably such a condition results from syphilis, he stated. Primary lesions are sometimes found on the lips. Incipient epitheliomas in smokers also appear on the lips. Defective teeth, infected gums and absence of sufficient molars have never been given their proper value in the causation of disease. Fur- ther discussion will be found under the chapter on "Focal Infec- tion." There is much to see in the tongue. The sears of the epileptic may be there. Many times have I seen the unhealed ulcers of syphilis around the edges. Tuberculous ulcers are found there too. Deep fissures may be the result of syphilis. A deflection may be due to a cerebral lesion. A spasm may come from paresis; a tremor from alcoholism. The bright red glossy appearance usually shows hyper- acidity, while a dry harsh tongue may be from the exhausting fevers. A pale tongue is often seen in tuberculosis and the anemias. The gray patches of secondary syphilis are found around the edges of the tongue and the inside of the cheeks. Growths of any character on the lips, tongue or in the mouth are to be looked on with suspicion. The "Lingua Nigra," or hairy tongue, is the result of excessive smoking or stomatitis and is not disqualifying. The "Lingua Geographica" usually occurs in the young. The red plaques are often the result of defective nutrition or poor dental hygiene and can be easily cured. A coated tongue may worry an examiner, yet aside from the heavy coat of severe fevers, it may merely be caused by breathing through the mouth. Sometimes impaired digestion is the cause or it may be due to a glossitis. As a general rule, coating should not be disquali- fying. The throat should be noticed for inflammation and tonsillitis. Even diphtheria has been found by the examiner. Badly diseased tonsils have often caused a fatal endocarditis. 146 MOUTH, NOSE, THROAT, EYE AND EAR 147 The voice often tolls the examiner many things. The whispering voice of* tuberculosis, laryngitis, or a malignant growth is well known. The tuberculous voice is often high pitched. Nasal tones are produced by occlusion of the nares, often only by adenoids, polypi or enlarged tonsils. A muffled voice may be the result of inflammation of the mouth or tongue, but a mumbling voice is apt to be that of paralysis, and slow enunciation, of disseminate sclerosis. The nose may tell its own story. If it is a saddle nose, syphilis must be expected though it might be caused by fracture. Lupus is easily recognized. Polypi sometimes are seen and sometimes are a serious obstruction to respiration. Perforation of the palate usually from syphilis may be seen in looking at the mouth or detected from the voice. The Eye The examination of 1he eye is more important each year as the insured requires more and more protection and policies are being written to cover every kind of disability. It is most important that the risk is to be taken on sound eyes for if one eye is defective the chance of disability is far greater. Frequently blindness in one eye ■is accidentally discovered, even the applicant not being aware of it. It may not be necessary to use the test types, but it will take but a few seconds more to cover each eye to see if there is sight in the other. Many health examination blanks require an exact charting of the sight of each eye. Few of the application blanks for new in- surance ask specific questions as to the condition of the eye. The loss of sight in one eye may not be considered as coming from disease by the applicant. When it is found, careful questioning will usually bring out the cause. Never should the blank be sent to the home office without some comment as to the probable cause or the circum- stances accompanying it. The following case shows the necessity of careful examination of the eyes: Mr. A. applied for a large amount of insurance, and asked for all the possible benefits that could be given due to disability. The policy as applied for included a monthly income for any seri- ous disability that might occur to him. A first class examiner re- ported both eyes in splendid condition. The inspector's report showed that nothing was wrong. This company, however, adhered to an old and tried custom of having the applicant refer to several of his friends as to his general condition. One of these friends replied by 148 life Insurance Examination stating that he had successfully recovered from the loss of one of his eyes several years ago. The applicant was referred to the examiner again, who found that the applicant had worn an artificial eye for over ten years. This eye was so natural, fitted the socket so well, that it deceived both the examiner and inspector. The policy accordingly was changed to meet the new condition. Cataract is one of the most frequent causes of loss of sight after fifty years of age. It should be noted on the blank, though it should not disqualify on account of the easy operation to correct it. It should be differentiated from traumatic scars and organic disease. Exophthalmos is a very grave symptom and there is no excuse for not seeing it. It may be due to tumors behind the eyes which are most serious, to suppuration in sinuses near the orbit, to paralysis of the orbital muscles, inflammation of Tenons capsule or exophthal- mic goiter. It should always be noted and the probable cause given. Ptosis is easily seen and may be more than a mere muscle weakness. It should be investigated. Inflammatory swellings of either lid are important. Often swelling of the lower lid may show an incipient nephritis, though this is not usually inflammatory. A real inflammation may be erysipelas or a malignancy or a gonorrheal conjunctivitis. Any case of conjunctivitis should be postponed until cured. Ulcer of the lid may be due to syphilis or to a malignant growth. Iritis is usually shown by an irregular pupil. It may be due to trauma, syphilis, rheumatism or gonorrhea. The exact cause should be noted if possible. Irregularity of the pupil is always a serious symptom. It may be caused by a blind eye, disease of the teeth, traumatism, tabes, disseminate sclerosis, paretic dementia, or other organic disease of the brain. The contracted pupil of the morphine victim is well known. The arcus senilis is not so important as formerly believed. It is generally regarded as a fatty deposit in the choroid coat and not significant of approaching old age. Opacities of the cornea should be investigated as to the cause. Nystagmus may develop from tumor of the brain, diseases of the internal ear or hysteria. A squint, though simple in itself, may be associated with meningitis, locomotor ataxia, syphilis, tumors, hemorrhage or toxemia. Glaucoma, if suspected, can be readily discovered by the examiner's finger. MOUTH, NOSE, THROAT, EYE AND EAR 149 Strabismus due to muscular insufficiency is a condition that should not alter the issuance of insurance of any kind. In fact, any lesion of the eye that can be corrected by glasses should not be considered disqualifying. The Argyll-Robertson pupil which, of course, reacts to accommoda- tion, but not to light, is usually indicative of locomotor ataxia, and if it is found, means complete rejection. All applicants for large amounts of insurance should be examined with the ophthalmoscope and whenever there is any doubt aboul nephritis it should always be used. Further discussion of trachoma, glaucoma, cataract, and iritis will be found in the chapter on "Postponement in Disease." The Ear Sufficient examination should be made of the ear to give the medical director an accurate idea as to whether there is anything present that would affect the issuance of insurance. Any abnormality should be noted, as for example, the mushroom ear of the prize fighter, which might serve as a means of identification. Tumors, especially, should be carefully described as to size, consistency and history and it should be especially noted if they have shown any rapid growth. Any protuberances behind the ear should be noted as quite often the common "wen" is found in that locality, which has little insurance significance; however, malignant growths have occurred there and even a beginning mastoid disease may be shown by an increase in size in the area behind the external ear. The external auditory canal is often the seat of numerous infections, such as boils and, while these arc not disqualifying, there should be a postponement until the infec- tious process has been stopped. There is always danger of the infec- tion spreading to other structures which might make it more serious. Purulent otitis media is the most serious disease of the ear in selection for life insurance. Schwartze shows that 13 per cent of all aural diseases are of chronic purulent kind. Careful statistics in hos- pitals in London, Vienna and Copenhagen show that one out of every 187 deaths is due to aural disease. Phillips shows from the records of the Manhattan Eye and Ear Hospital, there were 7,614 cases of purulent otitis media, among the total of 29,233 eases of aural disease. There was one serious complication with every 65 of purulent cases. The fatalities were chiefly those of purulent origin. Undoubtedly the greatest danger to life in aural disease is that arising from the com- 150 LIFE INSURANCE EXAMINATION plication of a purulent infection of the middle ear, especially when it has become chronic. Osseous necrosis, with infection extending to the venous sinuses, the labyrinth, and the meninges, is the most dangerous complication and this is mostly found between six- teen and thirty years of age. Phillips believes that these individuals are more susceptible to other forms of chronic disease, such as tuber- culosis. When these complications have occurred and a successful mastoid operation has been performed, the applicant should be rated as safely insurable. Phillips suggests, "Simple catarrhal otitis, with or without deafness, aside from the possible danger of accidents, does not menace life. Chronic non-purulent disease of the labyrinth, while more seri- ous than catarrhal otitis media does not materially tend to shorten life. Acute purulent otitis media, in an otherwise healthy individual, should not debar him as a safe risk beyond the time necessary for complete recovery, a period usually of from one to six weeks. Recur- rent purulent middle-ear inflammation, especially in early life, usually results from some form of intranasal infection and is commonly asso- ciated with adenoid growths in the vault of the pharynx or hyper- trophied tonsils, and subsides promptly and permanently as soon as these have been removed, after which time such applicants should be considered safely insurable. A large proportion of the serious intra- cranial complications of middle-ear suppuration occurs in chronic purulent otitis media and the statistics above mentioned clearly prove that such complications occur with sufficient frequency to render the victims of this type of ear disease less favorable as life insurance risks. Chronic purulent otitis media, attended with continuous dis- charge with foul odor, especially when accompanied with excessive granulations, indicates necrosis and, therefore, becomes the most seri- ous type of ear disease. Such applicants should be considered bad risks under all circumstances until a cure has been effected either by local treatment or radical operative interference. Large perforations and free drainage, while militating in favor of the applicant, should not bo considered a positive guarantee against extension of the ne- crotic process to deeper structures."* From this it is seen that any examiner by using the sense of smell and sight can'readily detect whether the discharge is fetid or not, or purulent or not, and the applicant's statements will have to be taken as to its chronicity. Any discharge from the ear that is bloody, of course, must be investigated, *Diseases of the Ear, Nose and Throat, Wendell Christopher Phillips, p. 401-402. MOUTH, NOSE, THROAT, EVE AND EAR 151 but any discharge that is watery or mucoid should not be given seri- ous consideration. Menieres Disease, is treated in the chapter on Diseases of the Nerv- ous System. Total or partial deafness is of interest according to the danger the applicant may incur from accident. It should always be noted and if the hearing is absent in one car and partially present in the other, the degree should be stated, using the symbols 20/20 as normal. Change the denominator according to the number of feet from the ear that ordinary conversation can be heard. CHAPTER' XIV THE RESPIRATORY SYSTEM By William Charles White, M.D., Washington, D. C. Chairman Medical Research Committee, National Tuberculosis Association, Ex-Medical Director, Tuberculosis League of Pittsburgh Physical examinations macle by examiners for insurance com- panies are primarily to determine the fitness of the applicant to be admitted as a policy holder in the company or to exclude him as an unsafe risk. Consequently it is unnecessary to burden a text- book for the insurance examiner with details of methods which have for their additional object the treatment of existing maladies. These methods are found in the textbooks on physical diagnosis. Nor is the medical examiner for life insurance greatly concerned with acute lung diseases such as pneumonia, bronchopneumonia, and influenza, which confine a patient to bed with fever and malaise. On the other hand, he must be constantly on the outlook for a group of chronic diseases which of necessity constitute bad risks for any insurance company and which, unless carefully watched for, may escape notice in the cursory examination too often given to applicants for policies. These chronic diseases are tuberculosis, abscess of the lung, em- physema, bronchiectasis, syphilis of the lung, pleurisy with effusion, pneumothorax, empyema, tumor of the lung, sarcoma and cancer, chronic bronchitis, asthma, and occasionally rare infections such as blastomycosis, streptothricosis, actinomycosis, and some forms of pneumoconiosis. Patients suffering from many of the above named chronic diseases may be fat and apparently healthy and conse- quently escape detection. Any applicant with cough and sputum should be requested to bring a twenty-four-hour specimen of sputum to the examiner for bacterial study. It is just as important to secure a specimen of sputum for examination as it is to request a sample of urine and the results of these examinations should be demanded by every in- surance company. As Laenenc pointed out, the most common symptoms of diseases 152 THE RESPIRATORY SYSTEM 153 of the lungs arc cough, dyspnea, and expectoration, and inquiry con- cerning these should be given special place in the questionnaire preceding the physical examination. The agents of insurance companies are likely to request the ex- amination of their applicants when those applicants are feeling at their best. The physician viewing it from the company's stand- point, however, should bear in mind that in many diseases of the lungs, and especially tuberculosis, the examination should be scheduled for the afternoon. In case patients with suspicious symp- toms apply in the morning they should be requested to return again in the afternoon because of the tendency of many patients to have some fever during the afternoon hours. In laying down these laws it is not forgotten that the payment for medical examinations is not by any means liberal enough to justify physicians in devoting the time necessary for these more careful studies, but in making the suggestions in connection with examinations where lung infections are involved, it is hoped that insurance companies themselves may realize the value of the in- vestment in careful examinations and also their duty and privilege in contributing to the welfare of the public by instituting and pay- ing a fair fee for this sort of careful work. Physical Examination.-It is important that all examiners follow the classical routine of inspection-palpation, percussion, ausculta- tion, mensuration, and fluoroscope or x-ray picture. Departure from routine often means failure. General Rules for Examination.-Great care must be taken to examine each applicant thoroughly. Satisfactory examination of the chest cannot be made through the clothing. The chest should be bared to the waist. Men, women, and children all appreciate the use of an examining cape by the physician. (Fig. 18.) Posture.-The applicants should be placed in a good light and the examiner should be in a comfortable position, either standing or sitting, so that he may devote his full attention to the examination in hand. Provision should be made for examination of the applicant both sitting and in the recumbent position if necessary. Inspection.-The main abnormalities to look for in inspection are beaded ribs indicating rickets, barrel-shaped chest indicating em- physema, difference in the level of the shoulders, depressions of one side or both sides above and below the clavicle indicating old 154 LIFE INSURANCE EXAMINATION Fig. 18.-The examining cape in use. (Norris and Landis-Diseases of the Chest.) Fig. 19-Barrel-shaped chest, a case of long-standing pulmonary emphysema. (Norris and Landis1-Diseases of the Chest.) Fig. 20.-Deformity of the chest due to thoracic aneurism. (Norris and Landis-Diseases of the, Chest.) THE RESPIRATORY SYSTEM 155 tuberculosis, and local bulging indicating aneurysm or bulging of one whole side indicating pleural effusion. (Fig. 19.) The position of the heart apex is of especial importance in its relation to lung disease, especially in old pleural adhesions and pleural effusions which tend to dislocate the apex in any direction, but especially toward either side. The movements of the chest should be examined both back and front and from above the shoulders on quiet breathing and deep inspiration. Lag on either side and retraction following inspiration are indicative of tuberculous disease of either lung or pleura. Fig'. 21.-Simple clubbing'. (Norris and Landis-Diseases of the Chest.) Curvatures of the spine should also be noted during inspection. It is good practice, immediately after inspection of the chest, to examine the extended fingers, as frequently much evidence of old pulmonary disease, especially bronchiectasis, abscess of the lung and fibroid conditions following other diseases, are apparent from the clubbing of the fingers. (Fig. 21.) Palpation.--Palpation is mainly of value in routine examinations to verify conditions observed by inspection and the location of the apex beat of the heart and abnormal pulsations. Percussion.-There is no method of examination in which a physi- cian may become more expert than that of percussion. There is 156 LIFE INSURANCE EXAMINATION scarcely a time when he cannot practice it on himself, tables, chairs, and other articles of his environment. The combination of sound and resistance which this method gives, makes it of extreme im- portance in the diagnosis of disease, but especially in the limits of disease; and the more skilled the examiner becomes by practice and the wider his knowledge of the variation of sound and resistance given by all manner of articles percussed, the keener will be his judgment in the location of disease and the delimitation of disease within the chest. The middle finger of the left hand is probably the best pleximeter and the middle finger of the right hand is the best Fig. 22.-Fluid, showing massive effusion filling completely the light side of the chest. Condition readily diagnosed by physical signs even if x-ray were not available. Even such a gross condition as this is frequently passed where thorough examinations are not followed as routine. to use as a hammer. The hammer hand should be moved from the wrist with freedom. The strength of the blow, however, should usually be light. The pleximeter finger should be firmly pressed against the object to be examined. It is a good practice in the front of the chest to begin percussion from the apex to the base, and at the back of the chest to begin percussion at the base working toward the apex. The tendency is to be very careful at the apex and to release the attention as the wider base of the lung is reached. THE RESPIRATORY SYSTEM 157 Equal attention must be given to all areas. Constant comparison between exactly similar areas on the two sides should be practiced and the use of a skin pencil to delimit the areas of dullness is a constant and necessary accompaniment of percussion. Percussion is most useful in determining areas of disease of greater dullness, both in note and resistance, than the normal lung. Nothing reveals so well as percussion such gross diseases as tumor, Fig-. 23.-Empyema, showing encysted empyema. (Note: Localized empyema must be kept constantly in mind.) (Norris and Landis-Diseases of the Chest.) tuberculosis, pleural effusion, old pleural thickening, etc. Percus- sion should be applied to every portion of the chest. Percussion is one of the two methods open to the physician where neither fluoro- scope nor x-ray is available; the other is auscultation. Auscultation.-No greater confusion has been thrown around any method of examination than around auscultation. The attempt to put into words what is heard through the stethoscope has flooded our textbooks with words that mean little to any one but the 158 LIFE INSURANCE EXAMINATION examiner who used them. A very excellent attempt to reduce the interpretation of this valuable method of examination to simpler terms is lately being made. The three important things to determine are modification of breathing, modification of whispered voice, and moisture evidenced by rales. This requires going over the chest from apex to base or from base to apex, interspace by interspace, covering each interspace with the requisite number of replacements of the stethoscope in regular order as the interspaces between the ribs increase in width. It Fig. 24.-Artificial pneumothorax. Artificial pneumothorax must be watched for continuously in examination. Patients in ordinary life often have this con- dition present. requires going over the chest in this way with the stethoscope at least three times. First, with deep inspiration; second, with cough and deep inspiration; and third, with whispered voice. Absence of breath sounds noted during the first procedure will indicate either fluid or spontaneous pneumothorax or today more frequently artificial pneumothorax done for therapeutic purposes. During the first procedure, the important modifications of breath sound are harshness of inspiration and prolongation of expiration. Increase in the harshness of inspiration and prolongation of expira- THE RESPIRATORY SYSTEM 159 tion are indicative of conditions improving the carrying power of the substance of the lung and are presumptive evidences of disease to be verified by continued examination. Whispered pectoriloquy, or the transmission of whispered voice sounds through the lung so that the examiner is able to distinguish the sounds uttered, is always an indication of disease and usually of cavity accompanying chronic tuberculosis. The cavity may be present, however, in a patient far advanced in recovery with fibrosis making it not necessarily a sign of dangerous illness in the case. Certain lung signs occur normally in the chest and should not be Fig. 25.-Cavity upper right lobe showing marked fibrous capsule. Patient able to work. interpreted as evidence of pulmonary pathology. It should be re- membered that slightly harsh breathing, slightly prolonged expira- tion over the left apex above the clavicle anterior, and to the third dorsal vertebra posterior, as well as similar signs in the second interspace in the right anterior chest near the sternum, are normal. Fine crepitations under the sternum heard when the stethoscope is over the area; clicking heard during strong respiration or after cough in the vicinity of the sterno-costal articula- tion ; the so-called atelectatic rales heard at the apex during first inspiration of deep breathing or coughing and the marginal sounds 160 LIFE INSURANCE EXAMINATION resembling rales heard at the base of the lung, especially in the right axilla; sounds produced by the act of swallowing, are not evidences of disease of the lungs. X-ray Examination.-Examination by the fluoroscope may readily form a part of routine insurance examination and enables the exam- iner to verify his physical examination and to establish the presence of gross diseased conditions such as abscesses of the lungs, tumor, tuberculosis, pleural effusions, and foreign bodies in the lung which may be present without the patient's knowledge and without pro- ducing very severe symptoms. (Fig. 26.) Fig'. 26.-Foreign body in lung- without symptoms of any sort and yet offers large element of danger in insurance risks. Few opportunities will be open to the insurance examiner to make use of a most valuable feature of chest examination, i.e., stereoscopic plates, unless large sums of money are involved in the policy. If the other rules are followed, it is doubtful whether the additional expense involved is necessary, as the diagnosis of early disease of the lung is not sufficiently aided by this procedure to justify this expense. Repeated Examinations.-If any doubt exists in the mind of the examiner, second and third examinations should be asked for and THE RESPIRATORY SYSTEM 161 at different times, early morning or afternoon as the examiner may desire. If cough and sputum exists, a demand for the repeated examina- tion of a twenty-four-hour sample of sputum should be made. If there is afternoon tiredness, cough and sputum, and history of indigestion and sleeplessness form part of the history, a demand for a temperature record extending over at least a week should accompany the data upon which the examiner bases his diagnosis and prognosis. CHAPTER XV TUBERCULOSIS By William Charles White, M.D., Washington, 1). C. Chairman Medical liesearch Committee, National Tuberculosis Association, Ex-Medical Director, Tuberculosis League of Pittsburgh. A separate chapter is devoted to tuberculosis because of its great importance in the relation of policy holders to insurance companies. Its hidden character, its misunderstanding in the minds of many officers of administration and agents, and executive officers of in- surance companies, and the rapidly improving technic and knowl- edge of its care and treatment, all raise tuberculosis to a question of first importance in insurance work. It is obvious from our modern knowledge, that tuberculous per- sons wisely selected could well be accepted by life insurance com- panies either as a separate group or on regular rates under certain modified conditions. Especially is this applicable to many patients with tuberculosis who have had sanatorium care. The increasing longevity of this latter group of individuals is one of the most striking features of modern tuberculosis work. The lineal family history of tuberculosis twenty years ago was an ob- stacle to the acceptance of applicants. It is now known to be of no practical importance. Collateral history is probably of more im- portance, but even this is not a serious matter, and the exclusion of workers in tuberculosis hospitals is a serious economic mistake. The personal history of tuberculosis must be also subjected to frequent modifications as our knowledge increases; but certainly, when from 2,188 cases handled by the Trudeau Sanatorium between 1885 and 1919, or thirty-four years, 45 per cent are well in 1919 and in ten years between 1909 and 1919, 62' per cent are well, and when this is multiplied and modified for the patients from the 50,000 sanatorium beds in the United States, the argument is self-evident that it would be relatively safe for insurance companies to accept these risks. In this field, as in so many others connected with tuberculosis, a comparatively frequent readjustment of our views is necessary. In 162 TUBERCULOSIS 163 the main, if insurance companies could frankly take the position that the tuberculous portion of our population shared in a relative way the benefits open to mankind, it would materially help the movement to suppress this disease. The chief points for an insurance examiner to have in mind are first, that every applicant should be asked the question, "Have you cough and do you spit up?" If these are answered in the affirma- tive the patient should be requested to bring a twenty-four-hour sample of sputum, at the time of a second examination, for bacterio- logic study both by direct smear and antiformin if necessary to determine the presence of tubercle bacilli. A second examination should be held in the afternoon and at this time the temperature should be taken. The reason for a twenty-four-hour sample of sputum is that its measurement gives a rough estimate of the amount of the lesion in the lung, if examination does not readily reveal this, and that it provides a quantity sufficient for antiformin digestion if direct smear does not exhibit any tubercle organisms. The temperature record, if it ranges above 99.5°, would give evidence of activity of the lesion in cases of positive sputum. Active cases, those with tubercle bacilli in their sputum and after- noon fever, should naturally be excluded until more careful exam- ination demonstrates by a period of rest under physician's care what the prognosis is likely to be. The question of the extent of the tuberculous lesion, provided it is found to be present, is obtained by the methods given in the pre- vious chapter by inspection, palpation, percussion, auscultation, the fluoroscope and x-ray. The latter three are the most important methods of examination. Percussion and auscultation are open to every examiner. The fluoroscope and x-ray are often not so available. Percussion should be carried out as suggested above with great care and a light per- cussion note over the whole chest with comparison of like areas on the two sides, remembering the rule of working from below up- wards on one aspect of the chest and from the apex downwards on the other aspect. Auscultation should be carried out naturally in the routine fashion but the main method is the determination of the extent of the disease by cough and deep breathing together, which reveals the limits of the moisture in the infected parts of the lung. 164 LIFE INSURANCE EXAMINATION The fluoroscope is of comparatively little value in the diagnosis of early tuberculosis. The x-ray picture, however, single and stereo- scopic plates, is of real value when used in conjunction with the other methods of examination. X-ray plates also form the best record of a case. Each method of examination, however, is but a part of the evi- dence. All must be used and brought together as the basis of the opinion on which the examining physician recommends the accept- ance or rejection of an applicant. The afternoon temperature, the amount of sputum, the presence of bacilli, the history, afternoon tiredness, loss of appetite, loss of weight, and hemorrhage, the extent of the lesion in the lung as determined by percussion, and the moisture elicited by cough and deep respiration verified by x-ray picture, are the most important items to be borne in mind. Prognosis is of equal importance with diagnosis. This can rarely be determined save as a result of absolute rest in bed for a period of from seven to ten days which will by its influence on the tem- perature of the body, the lessening of the cough and sputum, the improvement of appetite and wellbeing, forecast the outlook for the majority of patients. The prognosis is, after all, the main point in which assurance in the acceptance or refusal of applicants for insurance is important to both company and applicant. Some plan of cooperation between insurance companies and the sanatoria of the country might very easily be arranged. The better sanatorium men in the United States could give very safe estimates on the possible length of life of many cases and this will be of increasing accuracy as the demand is made upon them to think in these terms. In this field, probably more than in any other, the cooperation between insurance companies and tuberculosis institutions and dispensaries would be productive of benefit. Tuberculosis approached from this standpoint by the insurance companies would undoubtedly have a great influence in the preven- tion and control of this disease and save great wastage not only to the companies themselves but more important still, to individuals and family groups receiving insurance. CHAPTER XVI GENERAL CONSIDERATION OF CARDIAC CONDITIONS FROM THE LIFE INSURANCE STANDPOINT By Wm. Evelyn Porter, M.D. Medical Director, The Mutual Life Insurance Company of New York Experience resulting from the examination of millions of individ- uals for life insurance during the past decade has afforded life insurance companies a fund of information in cardiac diagnosis exceeding that from any other source. Added to this, there has been acquired, during the recent war, a knowledge of the effects of unusual physical strain upon the heart, which has been of value. Views as to the significance of certain physical findings in ex- amination of the heart have thus been materially modified, particu- larly with regard to systolic murmurs over the base of the heart to the left of the sternum and, to a lesser degree, systolic murmurs at the apex. The classification of murmurs as organic and non- organic is introduced by me to eliminate the term functional, avoid confusion and convey a clear and concise knowledge of the signifi- cance of the conditions referred to. Whereas the nonorganic sounds have only a limited bearing upon the expectation of life of individuals under forty years of age, organic murmurs, the result of pathologic changes, should be re- garded as definite impairments. The shaded areas in Fig. 27, p. 170, indicate in a general way the location of maximum intensity of the systolic nonorganic sounds. They are not definitely conveyed, although the sounds are heard with diminishing intensity in various directions. In considering the sounds heard over the upper area, special care should be taken not to include systolic murmurs with maximum intensity to the right of the sternum conveyed upward. With sounds over the lower area, constant murmurs conveyed definitely to the left, increased upon exertion, should not be classed as nonorganic. Sounds in both of these areas, especially the lower, which should be regarded as nonorganic, are usually inconstant, and in a general way the feature of the constancy or inconstancy should be the determining factor 165 166 LIFE INSURANCE EXAMINATION in the decision as to the character of the sound, constant murmurs usually being considered as organic and inconstant sounds as non- organic. The heart sounds should be clearly audible at all phases of respiration where this distinction is made, as in a fat subject with thick chest walls, both the murmur and cardiac sounds may be practically inaudible at certain phases of respiration, in which case it would be unsafe to assume that the inconstant sound was not due to valvular defect. Posture has a definite bearing upon the constancy of these sounds and it is important to examine the in- dividual both in the erect and recumbent position. A sound entirely disappearing in either position may usually, although not invari- ably, be regarded as nonorganic. In determining the type of sound, the following factors should be considered in classifying all questionable cases: 1. History of streptococcus infection, or complications of any sort accompanying rheumatism, pyorrhea or dental caries, tonsillitis, nasopharyngeal sepsis, sinus involvement, otorrhea, diphtheria or scarlet fever. 2. Personal history of palpitation, breathlessness, dropsy, cya- nosis, pain, giddiness, fainting, exhaustion and headaches. 3. The presence of apparent cardiac enlargement. 4. Abnormal reaction to exertion. 5. Abnormal intensity of the second sound over the second left interspace or third left costochondral junction. 6. Lack of normal heart muscle tone. 7. Abnormal blood pressure. 8. Tachycardia or cardiac arrhythmia. Due weight should be given to any history indicating an organic change as the cause of the murmur, but it should be borne in mind that in examinations for life insurance, the personal history is not dependable, owing to frequent withholding or misrepresentation of important facts. History of infection of any sort, especially that reported as "rheumatism," or focal infection, is of the greatest importance as an indication of probable organic change in the heart. Whereas cardiac hypertrophy in conjunction with heart murmur is an extra hazard, too much importance should not be given to signs indicating apparent cardiac enlargement, for whereas the nor- mal adult male heart in the oblique position measures about five GENERAL CONSIDERATION OF CARDIAC CONDITIONS 167 inches, marked variations in position are found, and a normal-sized heart transversely placed, may appear larger than a hypertrophied one in an unusual vertical position. The position of the nipple varies considerably in different individuals but when normally placed, the apex is usually found about one inch inside the mid- clavicular or mammary line. Where it extends beyond this line, the general position of the base of the heart being normal, the heart should be considered as either dilated or hypertrophied. In a questionable case, a roentgenogram helps to eliminate any pos- sible error on this point, but this can seldom be obtained in routine life insurance work. Blood pressure readings, both systolic and diastolic, taken before and after exercise, will prove of value when uncertainty exists in examination of the heart. The auscultatory method should, of course, be used invariably and the systolic pressure will usually in- crease from 10 to 30 millimeters upon active exertion, returning to its original pressure in from one to three minutes. The change in the diastolic is very much less, usually remaining about stationary. Where the systolic pressure returns very slowly, there is an in- dication of abnormality and where it falls instead of rising, there is an organic change in the myocardium, .necessitating declination. If, in addition, the diastolic rises, there is evidence of lack of car- diac reserve power. With applicants past thirty-five to forty years of age, tachy- cardia or cardiac arrhythmia when associated with a questionable cardiac murmur, should be a cause for rejection at standard rates. Basic systolic murmurs, with maximum intensity to the right of the sternum, heard at all phases of respiration, should invariably be rejected. They indicate the existence of definite abnormality of the aortic valve and are not acceptable at standard rates. Con- stant murmurs heard over the apex and lower half of sternum conveyed to the left and increased upon exertion, would demand rejection or postponement. The presence of all murmurs other than systolic should necessi- tate rejection. The experience during the war demonstrated the importance of determining the influence of unusual exertion upon the heart action as an indication particularly of the condition of the myocardium. Few physicians are sufficiently expert to place the proper value upon the character of heart sounds, and in the absence of definite 168 LIFE INSURANCE EXAMINATION dilatation, the effort tests in conjunction with blood pressure read- ings, convey the most satisfactory information as to the condition of the heart muscle. Those whose experience has been gained chiefly from army work, are inclined to minimize the importance of heart murmurs owing to the fact that many of the younger men with normal heart walls but with valvular murmurs, particularly mitral, withstood the strain of army life without apparent ill effects. The mortality experience in life insurance, however, demonstrates that those suffering from valvular defects, as age advances show a markedly diminished ex- pectation of life, so that they cannot be accepted with safety at standard rates. Rogers and Hunter, in their admirable paper, presented at the meeting of the Actuarial Society of America in May, 1919, summa- rize the results of the experiences of their company as follows :* "Functional heart murmurs, if carefully selected, are insurable among young applicants at standard rates; among applicants over forty years of age, at rates calculated to provide for a substantial extra mortality. Mitral regurgitation, if carefully selected, may be insured on terms to provide for a mortality of from 150 to 250 per cent, ratings above 170 to depend upon the degree of hyper- trophy present in each case. Aortic is probably 25 points less favorable than mitral regurgitation. Hypertrophy of the heart, occurring in connection with heart murmur, constitutes an addi- tional impairment, and only moderate degrees of hypertrophy are insurable. Irregular or intermittent pulse increases the hazard of heart murmurs, and if more than slight, the combination results in a very high mortality. A heart murmur with a history of acute articular rheumatism, is a very serious impairment." As the results of further observations are recorded, I believe they will be found to agree quite closely with the above, and until a larger volume of statistical material has accumulated, the position taken in my suggestions, and those quoted, may be followed in the study and classification of cardiac selection in life insurance. ♦Transactions-Actuarial Society of America, Vol. XX, Part I, No. 61, p. 97. CHAPTER XVH EXAMINATION OF THE HEART AND BLOOD VESSELS By Eugene F. Russell, A.B., M.D. Associate Medical Director, The Mutual Life Insurance Company of N. Y., Lecturer on Life Insurance Medicine, University and Bellevue Medical College The examination of the heart presents to the physician concerned with life insurance, many varied and interesting features. No part of the physical examination is more important and none is more troublesome. A definite diagnosis of cardiac abnormality, based on a single examination without previous history of infection and in many cases with histories of doubtful value, is extremely difficult in the majority of cases. To be fair to the applicant for insurance, as well as to the company which lhe examiner represents, calls for the very best diagnostic skill and a thorough understanding of the normal and abnormal variations in the position of the heart, location of the apex beat, area of cardiac dullness and character of the heart sounds. Likewise the influence of rest, exercise, excitement, posture, condition of surrounding organs, especially the stomach and lungs, on the normal and abnormal heart, must be thoroughly understood before an accurate opinion can be given. As the diagnostic methods become more accurate, much of the dif- ficulty surrounding the diagnosis of cardiac conditions will be re- moved. But as a difference of opinion will always be present and as these conditions vary from time to time, there will always be the necessity that the examiner familiarize himself with the latest and most advanced methods, in order that an accurate diagnosis can be made. It will be the endeavor of the author of this chapter to present to the insurance examiner the salient points in the diagnosis of the various cardiac conditions met with in the course of an ordinary examination. Rare and uncommon conditions may be occasionally discovered but the evidence of abnormality is usually so apparent that it will hardly be necessary to touch upon them. Diagnosis of Cardiac Conditions The diagnosis of cardiac conditions calls for the use of inspection, palpation, percussion and auscultation. In addition to these, special 169 170 LIFE INSURANCE EXAMINATION consideration must be given to the following, before an accurate diag- nosis is made: 1. History, when obtainable, of infection, such as acute rheumatic fever, tonsillitis, diphtheria, scarlet fever, chronic sepsis occurring in such conditions as chronic otitis media, and chronic nasal and oral disease. A history of infection is extremely important when ac- curately obtained. Many cardiac lesions may be traced back to a trivial attack of rheumatic fever or tonsillitis, which to an applicant may have no significance. Scarlet fever and diphtheria in child- hood frequently leave their traces in a defective valve or weakened Fig. 27.-Nonorganic sounds are heard with maximum intensity over shaded areas ; organic heart murmurs over other circular areas. heart muscle or disturbance of the innervation. Chronic sepsis either oral or otherwise, may have a like effect on the heart. Given a doubt- ful heart with a murmur faintly audible and perhaps more or less constant through the phases of respiration, the determining factor in the acceptability of the risk may be the previous history of infec- tion. 2. A personal history of symptoms of cardiac embarrassment such as breathlessness, dizziness, palpitation, pain, fainting, exhaustion and headaches. Where the examiner discovers any abnormality of the heart, the applicant should be carefully questioned as to the HEART AND BLOOD VESSELS 171 presence or absence of any of these symptoms. A positive history is always important as confirming the diagnosis of organic conditions. 3. Response to the exercise test: The exercise test whether consist- ing of walking briskly up forty steps or hopping twenty times on first one foot and then the other, or bending over ten or twelve times, should always be employed in doubtful hearts. Frequently latent heart murmurs will be discovered, but more important is the fact that the examiner will be able to judge the condition of the heart musculature. In order to do this, the heart rate should be taken before and after the exercise. Normally the heart rate will increase to 110-120 beats per minute during the test and will return to normal within two minutes. Where the rate docs not approach normal within this time, myocardial changes are usually present. The manner of response to the test is especially important in judging the condition of the heart where there is a murmur present, and should always be reported. 4. Condition of the blood pressure reading, both systolic and dias- tolic: The blood pressure should be obtained in all cases as it will give valuable confirmatory data in the diagnosis of the condition of the heart and blood vessels. A low systolic reading, 110 mm. or under, in applicants forty years of age or .over, with weakened heart sounds, with or without a murmur present, is always suspicious of myocardial change. A low blood pressure, 110 mm. systolic or under, with a murmur at apex or base, may mean failing compensation. A high blood pressure, 160 mm. associated with ringing heart sounds and accentuated second basic sounds, may indicate hypertrophy or arteriosclerosis. A pulse pressure of 70 mm. or over, is suggestive of aortic insufficiency. The blood pressure reading in conjunction with the exercise test is very important. The blood pressure will increase with exercise and return to the normal for the individual in about the same time as the pulse. A slow return will indicate myo- cardial changes. 5. Condition of the pulse: The significance of the various pulse conditions will be considered in a separate paragraph and it is only necessary to emphasize that as an aid to the diagnosis of cardiac con- ditions, it is most important. 6. Associated signs in the heart itself, such as hypertrophy of the muscle, dilatation of the heart, accentuation of the basic first or second sound, when present, may give valuable aid in a correct diag- nosis of the underlying condition. 172 LIFE INSURANCE EXAMINATION Physical Examination of the Heart Before taking up in detail the physical examination of the heart, it is necessary to emphasize the following rules which must be ob- served in the examination of a heart for life insurance: 1. Removal of all clothing and examination on bare chest. This should be done in every case with the possible exception of female applicants where one thickness only should be employed. It is im- possible to arrive at a correct diagnosis if the above rule is not ob- served. 2. Privacy is important as it enables the examiner to concentrate his whole attention on the examination. Likewise excitement is avoided with the consequent nervous increase in the heart rate of the applicant. 3. Absence of noise is most essential as it is impossible to deter- mine definitely the condition of a heart when the sounds are obscured by outside influences such as the hum of machinery and street noises. 4. Use of a stethoscope is also essential, and the smaller the bell piece the more accurate will be the localization of the heart sounds. Location of Heart The location of the cardiac area on the anterior surface of chest wall is important and is approximately as follows: A point in the fifth intercostal space, 31-fj inches to left of median line, indicates the site of the apex. Left Border-Join this with a point at the upper border of the third costal cartilage one inch to the left of the sternum by a line gently curved with the convexity to the left. Base-Join this last point with a point at the upper border third costa] cartilage one-half inch to right of the edge of the sternum. Right Border-Connect this point with a point at the right seventh costal sternal articulation by straight line. Lower Border-Connect this last point with apex-See Fig. 28. Inspection Careful inspection of the face, neck and chest will give valuable data in the diagnosis of cardiac conditions. The general appearance of the applicant is to be observed first and any evidence of anemia, cyanosis or pulsation of the blood vessels noted. Cyanosis, if slight, HEART AND BLOOD VESSELS 173 is associated with mitral stenosis. Marked cyanosis may be due to a congenital heart lesion or a blocking of the return circulation to the heart. An alternating flushing and pallor of the skin coordinating with the heart beat is always pathognomonic of aortic regurgitation. Pulsations of the arteries of the neck are occasionally seen. These may be due to exercise or excitement, arteriosclerosis, aneurysm, left ventricular hypertrophy, aortic regurgitation or exophthalmic goiter. The manner of breathing is to be observed. Simple rapidity of the respiratory movements may be due to nervousness and excitement, associated with the examination. Slight dyspnea is met with in be- ginning cardiac disease. Marked dyspnea is frequently present where there is extensive hypertrophy and dilatation. Fig. 28.-Diagram showing approximate outline of heart on chest wall. The formation of the chest is important, as the position of the heart varies accordingly. Flattenings or deformities and local prominences should be noted, and their cause ascertained, especially if due to cardiac conditions. The most important point is to observe the position of the apex beat. This is normally in the fifth intercostal space, 3y2 inches to the left of the median line. This point may vary normally to a slight degree with the position of the applicant and formation of the chest. In the recumbent position the apex may be slightly higher than in the erect position; lying on the left side may displace the apex nor- mally slightly to the left; likewise lying on the right side may change the position slightly to the right. 174 LIFE INSURANCE EXAMINATION Where the chest is long and narrow, the apex beat may be normally in the sixth interspace inside the nipple line. Usually the apex beat is normally localized to an area one inch to one and one-half inches in diameter, but when the chest is flat and narrow, it may be diffuse. Likewise if the chest is deep and wide, the apex beat may be normally faint and sharply localized or entirely absent. Where there is a large amount of subcutaneous fat or where the apex strikes behind a rib, the beat may be very faint or absent. Gastric distention may cause a more forcible impulse. Emphysema or the interposition of lung tissue may also obliterate the apex beat partially or completely. The apex beat may be displaced abnormally to the left or right, or upward or downward, due either to abnormal conditions in the heart itself or to conditions outside the heart. Displacement of the apex to the left or to the left and downward, if due to changes in the heart itself, is usually an indication of hypertrophy or dilatation of the left ventricle. Conditions outside the heart which may displace the apex to the left, are pleurisy with effusion, retraction of the left lung due to adhesions, enlarged liver, aortic aneurysm or mediastinal tumor. Displacement of the heart downward may be due to aortic aneurysm; displacement upward may be caused by gas or fluid in the abdomen. Displacement of the apex beat to the right is usually due to extra- cardiac conditions, such as pleurisy with effusion, or pleural adhe- sions. Pulsations at other portions of the cardiac area are occasionally met with, especially in the second interspace, either to the right or to the left of the midsternal line. These are usually due to hypertrophy of the auricles or an aneurysm of the aorta. Epigastric pulsation should be looked for in all cases, as although it may be met with normally and due to a simple overaction of the heart, it frequently occurs with enlarged right ventricle or displaced apex beat. One should not lose sight of the fact that epigastric pul- sation may be transmitted from a throbbing aorta or an abdominal aneurysm. Palpation Palpation is important as it serves not only to corroborate the data obtained by inspection but also to give valuable additional informa- tion. Palpation is elicited by two principal methods; first by the flat of the hand over the precordial area, and second by the use of the fingers. HEART AND BLOOD VESSELS 175 By the first method we are able to tell first, whether the heart is regular, irregular or intermittent; second, the character of the beat, if heaving or diffuse, in which event hypertrophy or dilatation is suggested, and third, the presence of thrills and various pulsations. By the second method or use of the tips of the fingers, we are able to elicit all that is obtainable by the first method and, in addition, to tell definitely the position of the apex beat and the point of maximum intensity. Occasionally where the apex beat is not visible on inspec- tion, palpation will bring out the point of maximum intensity. All the data obtained by palpation may be intensified by request- ing the applicant to lean forward slightly. This is especially true where thrills are present. Thrills are always important and are pathognomonic of struc- tural abnormalities. The location, area of diffusion and the time should always be noted. A thrill felt at the apex, if systolic in time, invariably indicates mitral regurgitation, and is accompanied by the other signs of that lesion. If the thrill is presystolic or diastolic and localized over the apex, one may without hesitation diagnose mitral sten- osis. It should be remembered that thrills are the result of the same abnormal vibrations that cause murmurs, for if the vibration be of sufficient intensity it not only is audible but also palpable by transmission through the tissues. Therefore, thrills partake of the same variations in character as do murmurs and may be felt as fine, purring, rough, grating, or as long, short, localized or diffuse thrills. A thrill is never felt without a corresponding murmur being heard on auscultation. At the base of the heart, thrills systolic in time are usually due to aortic stenosis or to aneurysm. The former condition causes, in typ- ical cases, a very marked rough thrill. In aneurysm the thrill is often double, that is, systolic and diastolic. Diastolic thrills at the base are commonly the result of aortic regurgitation, but as just men- tioned they may be felt in aortic aneurysm. Over the pulmonic area, congenital heart disease produces at times very intense thrills, but these cases arc not apt to come to the attention of the life insurance examiner. Percussion Percussion is important in that it is the means of determining the size of the heart and the changes in its boundaries, as well as the 176 LIFE INSURANCE EXAMINATION relation of the heart to other organs. It is not necessary to set forth the various methods of percussion, as these may be obtained from any textbook on physical diagnosis, but to call to the attention of the reader the principal conditions which may be brought out by the careful use of this adjunct to physical diagnosis. In percussing the heart, the examiner must keep in mind that there is an area of deep cardiac dullness and an area of superficial dullness. An increase of the area of cardiac dullness usually means hyper- trophied or dilated heart in insurance work, although occasionally it may be due to conditions outside the heart, such as pleural adhesions or new growths. Pericardial effusion and solidified lungs will also cause an increase in cardiac dullness but are rarely if ever met with in insurance examinations. Occasionally a right pleural effusion may cause an increase of cardiac dullness to the left. Extension of cardiac dullness to the left or to the left and downward, means hypertrophy and dilatation. If the extension is to the left and upward, both ven- tricles and auricles are hypertrophied or dilated. An increase of cardiac dullness to the right may mean a displacement of the heart en masse or hypertrophy of one or both ventricles, or the right auricle and ventricle. It is important not to lose sight of the fact that the area of dullness is influenced to a certain extent by the age of the individual. In younger applicants it is larger than in adults. The position of the applicant, whether erect or prone, and the con- dition of the lungs, whether inflated or deflated, likewise slightly in- fluence the area of cardiac dullness. Auscultation Auscultation is the most important means employed in the physical examination of the heart. By this method we are able to determine, (1) the condition of the heart muscle; (2) the condition of the valves of the heart, and (3) the condition of the aorta. There are two rules which should be observed in the examination of the heart for life insurance: (1) that the applicant should be examined both in the erect and recumbent positions, and (2) that the heart be examined both after exercise and rest. Normally the two heart sounds, first and second, are heard over the four valve areas, which are, (1) the mitral area over the apex; (2) the tricuspid area over the lower end of the sternum; (3) the pul- monic area over the second left intercostal space near the border of HEART AND BLOOD VESSELS 177 sternum, and (4) the aortic area over the second right intercostal space adjacent to sternum. (Fig. 29.) Variations in the heart sounds may be present either normally or abnormally. Normally the sounds may be increased or diminished. If increased, it may be due to nervousness or excitement; if diminished, it may be due to abnormally thick chest walls. Abnormal accentuation of the first sound at the apex may signify hypertrophy of the ventricles associated with valvular disease, kidney disease or arteriosclerosis. Weakness of the first sound at the apex may be indicative of a heart murmur or myocardial changes. Aortlc area Pulmonic area Mitral area Tricuspid Fig'. 29. Accentuation of the second pulmonic sound may mean mitral stenosis or regurgitation or hypertrophy of the right ventricle. These conditions should always be carefully ruled out. Weakness of the second pulmonic is rarely encountered in insurance work. It is always indicative of failing heart action. Accentuation of the aortic second sound is usually due to simple vascular hypertension, or to obstruction to the peripheral circulation in such conditions as arteriosclerosis and chronic interstitial nephritis. Diminution of the second aortic sound means degenerative changes with dilatation of the heart and consequent failing compensation. It is also found in aortic stenosis. Reduplication of the heart sounds may take place normally, due to an overacting heart. Reduplication of the second sound at the apex 178 LIFE INSURANCE EXAMINATION may indicate mitral stenosis or cardiac dilatation. When occurring at the base, it may indicate beginning aortic disease. A reduplica- tion of the first sound takes place occasionally in arteriosclerosis and chronic interstitial nephritis. Heart Murmurs General Considerations.-Murmurs or adventitious sounds may replace the normal heart sounds either partially or completely. These sounds may be organic or nonorganic as to whether they originate in the heart itself or exterior to the heart. The differential diagnosis between these two groups constitutes one of the most difficult as well as one of the most important points in an insurance examination. Applicants showing organic murmurs are not acceptable for standard insurance and fall into the class of substandard risks, as they give a higher mortality rate than normal. Nonorganic murmurs show a slightly higher mortality than normal, especially over age 35, in the experience of certain of the companies, due evidently to the fact that a number of organic murmurs were mistaken for nonorganic. These nonorganic murmurs are as a rule acceptable on the ordinary rates, without any increase, but over thirty-five years of age, extreme care must be taken not to mistake an organic for a nonorganic murmur. Mitral Regurgitation.-This is the most common of the valvular lesions. Time is systolic, replacing, entirely or partially, or immedi- ately following the first sound at the apex. It is usually soft blowing but may be loud and rough. Point of maximum intensity is at the apex. May be transmitted in all directions but especially towards the axilla. May be heard just above the inferior angle of the left scapula. Area of cardiac dullness indicating enlargement is both to the left and right. The apex beat may be in the nipple line or displaced to the left, depending on the degree of hypertrophy. Pulse-nothing characteristic, except when decompensation takes place, when the pulse becomes weak and irregular. Associated signs-the pulmonic in the second left interspace is sharply accentuated. A thrill may be present over the apex in a small percentage of the eases. Blood pressure shows nothing characteristic. The response to exer- cise test may be abnormal if any decompensation is taking place. Subjective symptoms are not common in beginning regurgitation but in the latter stages may be present. Synopsis of the Common Organic Murmurs HEART AND BLOOD VESSELS 179 Differential Diagnosis.-Mitral regurgitation must be diagnosed principally from nonorganic murmurs and relative mitral insuffi- ciency. Nonorganic murmurs are inconstant, disappearing during certain phases of respiration, usually at the end of expiration or upon change of posture. They are not transmitted, there are no associated signs and response to exercise is normal. (Fig. 30.) Mitral Stenosis.-Mitral stenosis is much more frequent as ascer- tained by the various army cardiac boards, than was formerly sup- posed to be the case. The murmur is diastolic or presystolic or both depending on the stage of the lesion and the functional con- dition of the heart muscle. It is usually rough, rumbling in quality and is heard with maximum intensity over or near the apex. Accentuation 2nt pulmonic Area of transmission _ Mitral regurgitation Point of maximum intensity Fig. 30.-Mitral regurgitation. The murmur is not transmitted to any marked degree, but is usually limited to a circumscribed area. The area of cardiac dullness may not show any enlargement where tlie murmur is slight, but where the murmur is pronounced and the condition has evidently progressed, the apex beat may be displaced to the left. The cardiac dullness may increase to the right. Pulse is small and at times irregular. Associated Signs and Symptoms.-Pulmonic second sound is mark- edly accentuated where compensation is present, but as dilatation takes place, it gradually diminishes in intensity. The blood pres- sure is usually low. A characteristic of mitral stenosis is the presys- tolic thrill which is felt on palpation. Subjective symptoms such as dizziness, dyspnea, etc., are usually present. Response to exercise is usually abnormal. The murmur is likewise intensified by the slightest 180 LIFE INSURANCE EXAMINATION exercise. It is usually more pronounced in the erect position and may almost entirely disappear in the recumbent position. Likewise it is intensified by leaning forward in the erect position. Differential diagnosis must be made from nonorganic murmurs. (Fig. 31.) Aortic Regurgitation.--This murmur is frequently met with and likewise is very frequently overlooked. It is diastolic in time begin- ning when the second sound ends, tending at times to obscure the second sound entirely. It is commonly associated with a soft aortic systolic murmur, the presence of which in an elderly person should always lead to a careful search for a higher pitched and less easily audible diastolic. Pulmonic 2nd accentuated Prasi'StollL ' murtnui- Fig. 31.-Mitral stenosis. The point of maximum intensity may be in the second right inter- space-third left interspace or over the base of the sternum, although it is occasionally heard over the body of the sternum. The murmur is usually transmitted downward along the left border of the sternum, even to the apex of the heart. It may be heard over the carotid and subclavian arteries. The quality of the sound is usually soft blowing, varying in inten- sity to a rough sound. It is usually more marked in the erect posi- tion; The area of cardiac dullness is increased to the left and down- ward indicating left ventricular hypertrophy. Pulse is regular, with the characteristic water hammer quality. Visible pulsation of the arteries, especially marked in carotid, tern- HEART AND BLOOD VESSELS 181 poral or brachial, is present. Likewise a visible, alternating Hushing and paling of the skin may be present, due to capillary pulsation. A pistol shot sound is heard over the large arteries in a certain number of cases. A high pulse-pressure reading, caused by a high systolic and a low diastolic blood pressure, is characteristic. Associated signs and symptoms are usually present. A presystolic murmur (Flint) at the apex may also be heard, without a lesion of the mitral valve. Differential Diagnosis.-When the murmurs arc heard at left bor- der of the sternum it must be differentiated from mitral lesions, aortic aneurysm, and nonorganic murmurs. (Fig. 32.) Diastolic murmur ,Points of possible maximum intensity Fig. 32.-Aortic regurgitation, Aortic Stenosis.-Aortic stenosis is not so common as the pre- ceding murmurs. It is usually present in combination with aortic regurgitation. It is more frequent after the age of forty and should always be carefully looked for in applicants over that age. The murmur is systolic in time and replaces or immediately follows the first sound. It is heard with maximum intensity at the second right interspace and is transmitted upward, although it may also be heard over the base of the sternum and over the carotid and sub- clavians. On palpation a thrill is usually felt. It is rough in quality and may be very loud. It is heard best when the patient is in the recumbent position. The heart is enlarged to the left and downward. The pulse is slow, 182 LIFE INSURANCE EXAMINATION small, with slow ascent and descent. Arrhythmias may occur and are a good diagnostic sign of failing compensation. Associated signs and symptoms are usually present. The second aortic sound is usually absent or faint. Differential diagnosis should be made from- 1. Roughening or stiffening of the aortic valves, or of the aorta. This condition appears after middle life and is usually associated with arteriosclerosis. Associated with this is the accentuation of the second aortic. This accentuation is a differential point from true aortic stenosis, in which condition the aortic second is reduced, as has been Aortic atsnosls Systolic murmur Fig. 33.-Aortic stenosis mentioned. This condition, however, is extremely important and should always be noted. 2. Aneurysm of the ascending arch of the aorta or of the innomi- nate. In this condition every sign of aortic stenosis is present except characteristic pulse and diminution of aortic second. 3. Nonorganic murmurs. Pulmonary regurgitation and tricuspid regurgitation are very rarely encountered in the course of the usual insurance examination, and it will not be necessary to go into detail concerning the physical signs of these murmurs. Combinations of murmurs are occasionally met with, the most com- mon of which are, according to Cabot, mitral regurgitation with mitral stenosis; aortic regurgitation with mitral regurgitation and aortic regurgitation with aortic stenosis. (Fig. 33.) HEART AND BLOOD VESSELS 183 Hypertrophy and Dilatation of the Heart Hypertrophy of the heart, with or without the presence of a mur- mur is occasionally encountered in insurance examinations while dila- tation without some associated sign is rarely, if ever, encountered. These conditions arise from causes in the systemic or pulmonary circulation, or in the heart itself. The degree of hypertrophy and dilatation as well as the character is important in determining the prognosis of the case. Hypertrophy may involve one or both ven- tricles and auricles to a lesser degree. Hypertrophy involving the left ventricle occurs in all valvular lesions but especially in those involving the aortic valve, also in all conditions that tend to increase the systemic tension, such as arteriosclerosis and chronic interstitial nephritis. In this condition the apex may be displaced downward and to the left. It may be in the sixth or seventh interspace. The apex beat is more diffuse than normal and is powerful. The first sound at the apex is prolonged and of a booming character. Hypertrophy of the right ventricle occurs in all conditions that increase the amount of work which the right heart is compelled to do. This condition occurs especially in pulmonary and mitral disease. The apex beat is displaced downward to a certain extent but more to the left. There may be an increase in cardiac dullness to the right. The apex impulse is increased but only to a moderate degree. The pulmonic second sound is accentuated. Dilatation when marked is practically never seen in insurance work. Slight dilatation is present in valvular conditions where decompensa- tion is taking place. Dilatation follows hypertrophy. The area of cardiac dullness is increased. The apex beat is feeble and irregular. The first sound loses its muscular quality and becomes short and sharp. Where dilatation is taking place, a previously loud heart murmur may become gradually lessened and evidence of venous stasis takes place in the lungs and general circulation. Nonorganic Murmurs or Functional Murmurs A large percentage of the murmurs heard over the precordial areas are unassociated with disease of the cardiac valves and the differentia- tion between these and organic conditions is extremely important in the selection of risks for insurance. If these murmurs could be eliminated from consideration, the main difficulty in the selection of cardiac cases would be removed. Luckily the majority of nonorganic murmurs have certain definite characteristics. They are practically 184 LIFE INSURANCE EXAMINATION always systolic in time, soft blowing and arc heard best in the major- ity of cases over the pulmonic area, in the second left interspace; they are not transmitted and may disappear in various phases of respiration, as well as in certain postures of the body. Pressure on the chest-wall may modify the murmur and likewise the holding of the breath may cause an entire disappearance of the adventitious sound. Before making a diagnosis of a nonorganic murmur, special atten- tion should be given to the requirements as mentioned in the begin- ning of the chapter such as (1) history of past infection, as rheu- matism; (2) personal history of cardiac embarrassment; (3) abnormal reaction to exercise; (4) presence of tachycardia or cardiac arrhy- thymia; (5) cardiac enlargement and (6) abnormal blood pressure. If any of these conditions are present, in addition to the murmur, a diagnosis of nonorganic condition should not be made. Precordial Friction or Pericarditis Precordial friction is rarely encountered. If present, it is charac- terized by a to-and-fro friction sound synchronous with the beat of the heart. It is heard near the base of the heart, is not transmitted and is modified by pressure of the stethoscope and the position of the applicant. Chronic Myocarditis Chronic myocarditis is extremely difficult to diagnose in an appli- cant for insurance, but as the number of deaths from this cause is apparently increasing, it is important that the examiner familiarize himself with the general physical signs. Myocarditis occurs usually in applicants past forty-five years of age, who give a history of strenuous mental and physical life and of excesses of various kinds. Inspection and palpation are of negative value except perhaps that the apex beat may be found diffuse, weak and irregular. Auscultation is important. The heart sounds may be weak, irregu- lar and reduplicated. The second aortic may be accentuated if ac- companied with arterial change. There may also be various heart murmurs present and evidence of dilatation. A low blood pressure may be significant of this condition. The response of the heart to the exercise test is a very important diagnostic point in the diagnosis of myocardial changes. Likewise the manner of response of the blood pressure after exercise is very HEART AND BLOOD VESSELS 185 ORGANIC HEART MURMURS The three horizontally placed dots at the junction of the sternum and 3d left costal cartilage indicate the position of the pulmonary semilunar valve. The aortic valve forms an angle with the latter. The tricuspid valve is represented hy the vertical line marked t; the mitral valve, by the oblique line marked m lying across the third left interspace. IC-The inferior vena cava. H-The anterior hepatic level. SH-The posterior hepatic level. Sp-The spleen. M is placed in the circle which indicates where the sound of closure of the mitral valve is loudest. Mitral murmurs also have their maximum intensity here. T is in the circle which indicates the tricuspid area, where the sound of the tricuspid valve and the tricuspid murmurs are best heard. P indicates the pulmonic area, where the sound of the pulmonic valve and the pulmonic murmurs are best heard. A indicates the aortic area, where the sound of the aortic valve is best heard. Usually the murmur of aortic stenosis is also loudest here, but the murmur of aortic regurgitation is frequently best heard immediately over the aortic valve or lower down the sternum. Fig. 34.-Special instructions to examiners. Mutual Life Insurance Company. 186 LIFE INSURANCE EXAMINATION NON-ORGANIC SOUNDS The shaded areas indicate the locations in which the non-organic sounds are usually heard with maximum intensity. NON-ORGANIC Sounds similar in character to valvular murmurs, always SYSTOLIC in time, not transmitted, usually INCONSTANT, disappearing at certain phases of respira- tion or upon change of posture. LOCATION: (a) Most frequently heard at the base over the second and third LEFT inter- spaces, usually with maximum intensity upon forced expiration, disappearing during forced inspiration, (the heart sounds being normal and clearly audible). (b) Heard with maximum intensity somewhat to. the right of the apex, not clearly conveyed toward the axillary line, usually disappearing at forced expiration (the heart sounds being clearly audible). Careful inquiry should be made in each case with reference to (1) history of past infection, rheumatism, syphilis, scarlet fever, oral sepsis, diphtheria, etc. ; (2) personal history of palpitation, breathlessness, pain, giddiness, fainting, ex- haustion or headaches: about which the medical examiner should make careful inquiry; (3) abnormal reaction to exertion, by reexamining the heart and pulse after active exercise; (4) tachycardia or cardiac arrhythmia, either as a matter of personal history or if found upon examination; (5) apparent cardiac enlarge- ment or (6) abnormal blood pressure. Fig. 35.-Special instructions to examiners. Mutual Life Insurance Company. HEART AND BLOOD VESSELS 187 Name of Applicant, Date, Indicate carefully the Location of Apex by X Indicate Area over which Murmur is Heard by O Indicate Point of Greatest Intensity by Q Indicate Direction of Transmission by Is the Murmur Systolic or Diastolic? , What is your diagnosis of the case? How much hypertrophy do you find -none, little, moderate, or much? Rate and character of the pulse after exercise? (see other side) Same, two minutes later? Are there any evidences of failing- compensation such as Dyspnoea, Cyanosis or Dropsy? Is there any history of Tonsillar In- fection, of Rheumatism or of In- fectious Disease to account for the lesion? (give details) Any additional remarks necessary to a full understanding of the value of the risk? Signed Medical Examiner. Fig. 36.-Special heart blank. New York Life Insurance Company. 188 LIFE INSURANCE EXAMINATION SYNOPSIS OF HEART MURMURS Left heart involved in nearly all cases. Lesions of right heart are very rare. It is always well to examine in the recumbent as well as in the erect posture. Organic murmurs persist; functional are apt to disappear with change of posture. The murmurs described below are arranged in the order of the frequency of their occurrence. Other murmurs are very rarely found. ORGANIC Mitral Regurgitation. Systolic. Maximum intensity at apex, transmitted to axilla, heard behind at angle of scapula. Aortic Obstruction. Systolic. Maximum intensity at right second interspace close to sternum. Transmitted upwards into great vessels of the neck. Aortic Regurgitation. Diastolic. Replaces or follows the second sound. Maximum intensity at second right interspace to third left and downwards to ensiform cartilage. Mitral Obstruction. Presystolic, running into first sound. Heard in mitral area. Not transmitted. Usually accompanied by a thrill along left margin of heart area. FUNCTIONAL, Functional. Systolic. Usually heard at pulmonic area, second left interspace or at left border of sternum. Characterized by fact that it is not transmitted, is unaccompanied by hypertrophy of heart or any other evidences of ab- normality. Usually heard only in the erect posture. BLOOD PRESSURE Blood pressure observations are of great value in the study of a heart murmur. The auscultatory method should be used, and the diastolic as well as systolic pressure taken, both before and after exercise. If, after bending over and touching the floor six times, the blood pressure is immediately taken, the systolic should be found considerably above the normal, but dropping back within two or three minutes to the normal. If the systolic actually falls upon exertion, the myocardium is diseased. If at the same time the diastolic rises, the heart has no reserve power. HYPERTROPHY OF THE HEART The apex beat is normally in the fifth interspace about one inch inside the mid- clavicular or mammary line. If it is at the mammary line, the heart should be looked upon as moderately hypertrophied; if it is about one-half inch in- side the mamary line, as slightly hypertrophied; if one-half inch outside the mammary line, the hypertrophy is considerable. Great care should be ex- ercised to locate accurately the position of the apex beat. Fig. 37.-Special heart blank. New York Life Insurance Company. HEART AND BLOOD VESSELS 189 Dear Doctor: Referring- to your examination of the above named applicant, will you kindly re-examine the Heart, fill out the blank and complete the diagram on the reverse side of this letter, and return the same to the Society in the enclosed envelope. Thanking you in advance for your prompt attention to the matter, we are, Very truly yours, T. H. ROCKWELL, M.D., Medical Director. Ry IT IS VERY IMPORTANT from our standpoint to differentiate between ORGANIC and NON-ORGANIC Murmurs. It is therefore well, before reporting, to bear in mind the following general characteristics of the common murmurs: The murmurs described below are arranged in the order of the frequency of their occurrence. ORGANIC MITRAL REGURGITA- TION. Systolic. Maxi- mum intensity at apex, transmitted to axilla, heard behind at angle of scapula. MITRAL OBSTRUCTION. Presystolic, running into first sound. Heard in mitral area. Not trans- mitted. Usually accom- panied by a thrill along left margin of heart area. AORTIC REGURGITATION. Diastolic. Replaces or fol- lows the second sound. Maximum intensity at second right interspace to third left and downwards to ensiform cartilage. AORTIC OBSTRUCTION. Systolic. Maximum in- tensity at right second in- terspace close to sternum. Transmitted upwards into great vessels of the neck. NON-ORGANIC These murmurs may be divided into FUNCTIONAL OF SEVER- AL ORIGINS-U s u a 11 y heard in second left inter- space region and systolic in time. HEMIC-D u e to anemia or changed viscosity of blood. Usually heard over precordia and great vessels. Systolic in time. General condition of ap- plicant important. RESPIRATORY-D u e to variation of intrathoracic pressure due to respiration. Usually heard at apex and disappears when breathing is arrested. M. 307. 20-9 Heart Fig. 38.-Special heart letter. The Equitable Life Assurance Society. 190 LIFE INSURANCE EXAMINATION Please indicate on the diagram 1. Position of the apex impulse by (circle) 2. Area over which the murmur is heard by (clotted line) 3. Point where murmur is heard loudest by (cross) 4. If murmur is clearly transmitted from the point of maximum in- tensity indicate in what direction trans- mission is noticeable by (arrow) Please answer the following questions as fully as possible. 5. In point of time, is the murmur systolic, presystolic, or diastolic? 6. What is your diagnosis of the Lesion? 7. Are there any changes in the character of the pulse or heart sounds after exercise? 8. Is there evidence of full compensa- tion and if not what are the signs of incomplete or failing compensa- tion, if any? (such as dyspnoea, edema, or cyanosis, dilatation, etc.) ? 9. Is there true cardiac hypertrophy, and if so, to what extent? (Be careful to locate the apex impulse, as above described, accurately.) 10. Aside from the cardiac condition, do you find the applicant in first class physical condition? 11. What is the Blood Pressure? Systolic: . Diastolic: Medical Examiner. Name of Applicant Fig. 39.-Special heart letter. The Equitable Life Assurance Society. HEART AND BLOOD VESSELS 191 important. Where myocardial changes are present, the time of re- turn to normal is longer than where there are no changes in the heart muscle. In order to assist the examiner in making' a diagnosis of cardiac conditions and aid the medical director in arriving at a proper interpretation of the examiner's findings, special instructions and letters have been compiled by the various companies, of which Figs. 34 to 39 are examples. Examination of the Pulse, Arteries and Veins Examination of Pulse and Arteries.-The proper examination of the pulse furnishes important data in the acceptability of a risk for insurance, and a proper technic is very important. The points to be determined are: (a) Pulse rate or frequency. (b) Rhythm. (c) Tension. (d) Size and shape of pulse wave. (e) Synchronism and equality of right and left radial pulse. (f) Size and condition of vessel walls. (a) Pulse Rate or Frequency.-Normally the pulse rate averages 72 to the minute in the male and 80 in the female. Frequently in an insurance examination the rate will be slightly increased and it is more common to obtain a rate of 80 in the male than 72. It is im- portant that the pulse rate be taken before the physical examination is begun as during the examination of the heart and lungs the pulse is frequently accelerated by nervousness. The pulse rate should not exceed 90 normally in lhe acceptability of a risk as a persistent rate above this point indicates usually some organic trouble such as tuber- culosis, exophthalmic goiter, nephritis or excessive use of coffee, tea, tobacco or alcohol. Paroxysmal tachycardia may be occasionally en- countered but applicants showing this condition are not acceptable. Likewise a pulse rate of 30 to 50 is important to note, as a slow pulse may indicate heart-block, myocarditis, aortic stenosis, some change in the blood vessel wall or cerebral tumor. (b) Rhythm must be noted, especially whether the pulse is ir- regular in force or in rhythm. Irregularity or intermittency in rhythm means an intermission of one or more beats at regular or irregular intervals. A variation of the force in the strength of the 192 LIFE INSURANCE EXAMINATION beat may take place and is usually associated with marked cardiac disease. Irregular or intermittent pulse associated with cardiac disease is a serious condition from an insurance standpoint. Likewise irregu- larity and intermittency after the age of forty is usually associated with vascular changes. A single or irregular intermittency occurring at rare intervals in young individuals, is of slight significance, and applicants showing this condition can be accepted on standard rates. The majority of these conditions are due to extra systoles and are recognized by the fact that the premature beat is usually weak and barely or not at all perceptible at the wrist while the succeeding beat is unusually strong. Intermittency due to simple extrasystoles often disappears after exercise. Likewise on auscultation over the heart the second sound is absent and the first sound only heard. Arrhythmia or irregularity in rhythm may occur physiologically during inspiration and expiration, in which condition the heart beats slightly faster during inspiration (sinus arrhythmia). This is fre- quently found in younger people. The use of tobacco and alcohol may also cause an irregularity and it frequently happens that appli- cants showing the condition, if advised to eliminate the use of tobacco and return for examination in two to three weeks, will show the con- dition entirely cleared. Other variations in the rhythm may be met with occasionally, which render applicants uninsurable, such as auricular fibrillation, which is characterized by a total arrhythmia; auricular flutter characterized by rapid auricular contraction, which can be diagnosed only by elec- trocardiogram ; heart block or Stokes-Adams syndrome, which should be suspected in the presence of an abnormally slow pulse; paroxysmal tachycardia, characterized by attacks of extreme rapidity of pulse; pulsus alternans, showing alternation in force of heart beat, which is indicative of advancing cardiac disease. Bigeminal or trigeminal pulse may be due to heart-block or to simple extrasystoles. Embryocardia, or tic-tac heart, is significant of failing compensa- tion. Gallop rhythm may be due to reduplicated heart sounds and may or may not be of significance, according to whether it is associated with a cardiac lesion. (c) Tension.-The tension of the pulse is measured accurately by the blood pressure apparatus but it is important that the examiner HEART AND BLOOD VESSELS 193 familiarize himself with the feel of the pulse, as one will very fre- quently discover conditions which call for a more accurate reading with the blood pressure apparatus. The pulse of high tension is felt between the beats while that of the low tension is less than normal between beats. (d) Size and Shape of Pulse Wave depend on the force of the contractions of the heart and the tension of the arteries. The shape of the pulse may also vary from a sudden rising and falling to a gradual rise and fall. Likewise the pulse may be dicrotic in which ease the secondary wave is much exaggerated. The size and shape of the pulse is important from an insurance standpoint as an aid in the diagnosis of the various heart murmurs and especially mitral stenosis and aortic regurgitation. In mitral stenosis the pulse is small with a gradual ascent and descent. In aortic regurgitation the pulse is large with a rapid ascent and descent -water hammer pulse. In aortic stenosis the pulse is small and the rise and descent slow. In aortic aneurysm there is a difference in the size of the pulse wave in the radials. (e) Equality of the Right and Left Radial Pulse.-The pulse should be taken in both radials at the same time. In a certain num- ber of cases there will be a variation in the tension and size of the pulse. This is particularly important as it is very suspicious of aneurysm, especially of the arch of the aorta, and should always lead to a careful examination. (f) Condition of the arterial wall is important and should always be noted. There may be present only a slight thickening or there may be marked calcification. Where there is one or the other con- dition present, it renders the applicant uninsurable on standard rates, as arteriosclerosis is a frequent cause of death. The phrase-"No more than normal for age," in describing the condition of the arterial wall, and which is frequently used, should be discarded, as the im- portant factor in insurance is whether there is any thickening of the vessels present. Arteriosclerosis As arteriosclerosis is becoming a more commonly recorded cause of death, it may not be out of place to call attention to the importance of its consideration from an insurance standpoint. This condition usually occurs in applicants who give a history of having led a stren- uous life. Excessive use of alcohol, syphilis or chronic infections, 194 LIFE INSURANCE EXAMINATION such as lead poisoning, also are a frequent cause. Likewise it is fre- quently associated with chronic interstitial nephritis. Symptoms are rarely obtainable and it is only on careful physical examination that the condition can be determined. Inspection.-The fact that the applicant appears older than the age stated should always be suspicious. A careful inspection of the peripheral arteries should be made, especially those of the arm and forehead (temporal). Where the condition is marked, they will stand out prominently. This is especially true when the arm is held ele- vated, but a positive diagnosis should never be made on inspection alone, as prominent arteries may not mean sclerosis. Palpation is the most important diagnostic method. An artery that can be distinctly palpated where the blood supply is cut off, can be considered sclerosed from an insurance standpoint, but it is essen- tial that the blood supply be eliminated, either by the blood pressure cuff or pressure by the finger. Auscultation.-The aortic second sound is accentuated especially where the aorta is diseased. Likewise a basic systolic murmur may be present. The blood pressure, where arteriosclerosis exists, may be normal or it may be increased. Aneurysm of the Arch of the Aorta Aneurysm of the arch of the aorta is occasionally encountered and should always be looked for where a history of syphilis is present. As the mortality is very high, applicants are uninsurable. Symptoms are usually not obtainable and the examiner has to rely on physical examination. Inspection.-Bulging of the thorax and pulsating tumors are present either to right of the sternum, upper portion of sternum or to the left of the sternum, depending on the location and size of the tumor. The superficial veins of the chest may be dilated. Localized edema or cyanosis of face or arms may be present. Pressure on sym- pathetic nerve may cause either a contraction or dilatation of the pupil on the affected side, depending on whether there is an irritative or paralytic effect. Inequality of the pupils should call for a care- ful examination of the chest in all cases. Palpation.-On palpation a characteristic expansive tumor is felt over the aneurysm. This is usually firm in character. When the palm of the hand is laid lightly over the aneurysm, a characteristic diastolic shock is felt. Likewise a distinct thrill is felt in many of HEART AND BLOOD VESSELS 195 the cases. Where Ihc transverse portion of tire arch is involved, the characteristic tracheal tug is obtained. The expansive pulsation may be felt in the tracheal notch. One of the frequent signs of aneurysm is the difference in the pulse in the right and left radial arteries, but congenital differences between the two arteries should always be elim- inated. Likewise the systolic blood pressure will vary in the arms. Where there is more than 10 mm. difference in the systolic pressure between the two arms, aneurysm should always be suspected. Percussion.-Percussion may give an increase in the area of dull- ness over the site of the tumor. Auscultation may give negative results at times, or one or both of the cardiac sounds may be replaced by a bruit over the tumor. Like- wise a systolic murmur may be heard over the tumor or over the trachea (Drummond's sign) or in the mouth, when the lips are closed on the stethoscope. A low-pitched intense second sound may be heard over the aorta, corresponding to the diastolic shock. A diastolic mur- mur may also be heard when incompetency of the aortic valve is present. When there is pressure on the trachea, bronchi or lung, the respiratory murmur will be altered, depending on the site of the aneurysm. Pressure signs in aneurysm have been admirably summarized by Sanson as follows: Pressure on bony thorax causes ' Local pain Local edema (pulsation) . Absorption of tissue Pressure on nerve causes Paralysis Unequal pupils, paralysis of vocal cords, hemiplegia or paraplegia Asthmatic dyspnea Inequality of pulse Difference in blood pressure readings Pressure on blood vessel causes Local edemas Enlarged collateral veins Obstruction of veins Tracheal signs Paroxysmal dyspnea Brassy cough Bilateral stridor Pressure on air tubes causes Also paroxysmal dyspnea and cough Unilateral stridor Filling or consolidation of lung behind Bronchial signs Pressure on king causes-consolidation and displacement. Pressure on esophagus causes-dysphagia. 196 LIFE INSURANCE EXAMINATION Examination of the Veins-A general inspection of the venous system is necessary before an insurance examination is complete. Localized distention and abnormal pulsation should lead to a careful examination as to the cause. Frequently tumors are discovered by a careful application of this rule. Varicose veins of the lower extremities, when slight, are of no significance but where they are extensive and extend above the knee and into the abdomen, the condition is important and renders the applicant uninsurable. This condition should always be mentioned by the examiner. Likewise it should be stated whether a proper stock- ing or support is worn. It should always be noted whether there is any evidence of present or past ulceration, as this condition is oE serious import. Where ulceration has once been present, recurrence appears in the majority oE cases with its tendency to hemorrhage and chronic infection. CHAPTER XVIII THE ABDOMEN By John Mason Little, M.D., Boston, Mass. Assistant Medical Director, The New England Mutual Life Insurance Co. As with other areas of the body, consideration of the abdomen from the viewpoint of life insurance will comprise the collection of evidence, which represents the work of the examiner, and the weighing of this evidence, which is done by the medical director to reach his conclusions. These conclusions result in the action taken in the individual case and depend upon ordinary medical judgment and experience, as well as the experience, as collected from time to time, by actuarial and other investigations. Given enough collected statistics, analysis and study will give solid ground for the life insurance company to stand upon. The company can, comparatively speaking, place its mortality where it will. The training, common experience, and judgment of the medical direc- tor will, with proper cooperation, enable him to control it. The unknown quantity with which he has to deal is the individual case as it comes up to him from the examiner. His ability to come to right decisions will therefore ultimately depend upon the honesty, thoroughness, and skill with which the examiner is able to present the case. Where the abdomen is concerned, the examiner is handicapped because our methods of examination are ineffective and crude as compared with other parts of the body. With the exception of the spleen, the contained organs are almost wholly concerned with the digestive functions. They are subject to numerous temporary dis- turbances, due to errors of diet or living, which are difficult to differentiate from the symptoms of organic disease. Information as to their condition, past or present, will depend almost entirely on careful history-taking and analysis, plus what can be discovered by palpation, as other methods are of little use with the exception of x-ray study which is becoming more and more useful but which, except in special cases, is seldom available to the examiner. It is of great importance, therefore, that the past be carefully gone into 197 198 LIFE INSURANCE EXAMINATION to elicit symptoms, which may be difficult with an unwilling, un- observant, or stupid applicant, and that all methods of physical examination available be used. It is to be regretted that this is often not the case. It is only too common for a history of indigestion to be accepted without qualifi- cation, and for physical examination to be confined to an inspection in the standing position. The attitude of many applicants for life insurance is such that they resent a request to disrobe to the extent that an adequate examination of the abdomen can be made, and become distinctly disgruntled if asked both to uncover the abdomen and to lie down. This may be due partly to carelessness on the part of examiners in the past. It is not unusual to be told by the applicant that he has already obtained insurance, that the doctor only had him open his shirt, and the whole thing only took a minute or two. When it is considered that according to our experience 8.35 per cent of deaths are due to diseases of the digestive system, and that this does not include diseases of the kidney, pelvic organs, or spleen, typhoid fever, tuberculosis or malignant disease, diseases of the circulatory system or general diseases of which evidence may be obtained in the abdomen, it can be seen what confidence may be placed in an examiner who allows himself to be so influenced. Abdominal disease is notoriously difficult for the clinician to diagnose and he is generally confronted by a patient who comes to him because he has something the matter with him and wishes to find out what it is. The insurance examiner, on the contrary, is confronted with an individual who considers himself well, or not being so or not having been so, wishes to appear so. The clinician will have difficulty in picking out the important data from a mass of information freely imparted. The insurance examiner will have to elicit information from one whose natural tendency may be to minimize, if he does not purposely suppress or falsify. The former will be examined by his own consent, when the examination may be as thorough as possible and where every modern invention for diag- nosis may be had. The latter may very likely wish to be, or insist on being, examined between business engagements, and at a place where no facilities are to be had. In the pressure of business, and under the natural strain of competition, the agent may so influ- ence him. All this is perhaps trite and may be thought out of place and as having no especial significance in the consideration of the abdomen. But it has. Any examiner who indicates any disturbance THE ABDOMEN 199 of digestive function without going fully into detail, or who does not carefully inspect, percuss, and palpate the abdomen with the applicant recumbent in proper position and in a good light, might just as well write 11 abdomen not examined" on the application, as far as being of any use to the company is concerned. Presumptive Evidence What then is the proper procedure? And what should be in mind in the examination of the abdomen? It is not the place here, nor is there room, for a treatise on abdominal disease in general, nor on physical diagnosis in detail. These will be found in the various textbooks on medicine, surgery, and physical diagnosis, or in other chapters in this book. I shall attempt to designate the proper procedure of the medical examiner, what he should have in mind, what the medical director will wish to know, and lastly, en- deavor to give from a life insurance standpoint the application of the knowledge thus obtained, together with statistical knowledge already at his disposal, to the selection of the individual case. The examiner has not only to satisfy himself as to the existence of disease past or present, but he has to write down upon the appli- cation blank his conclusions so that they may be comprehensible and conclusive to the medical director for whose information they are obtained. These blanks ordinarily start with a questionnaire which is designed at first to allow the applicant to volunteer his history, and secondly, to bring out facts in regard to possibilities which he may not consider important, which he may have forgotten, or which have especial significance in regard to certain diseases. Besides a question specifically asking whether on careful inquiry and physical examination there is found any disease past or present of the stomach or any of the abdominal organs, there are general questions which may bring out symptoms suggestive of trouble in these organs. A question as regards past operations, in the present day is very apt to point directly to the abdomen. A common answer to the question as to what an applicant has consulted a physician for during the past five years and suggesting trouble in the ab- domen, is something indefinite such as, indigestion, dyspepsia, bilious attacks, stomach upset, gastritis, bowel trouble, constipation, diarrhea, or colic. These leads should be followed up most carefully. The full skill of the physician will be needed to differentiate be- 200 LIFE INSURANCE EXAMINATION tween the evidence of organic disease and ordinary functional dis- orders. The age of the applicant should be considered, and the diseases common to that age. Appendicitis is usually considered in a class by itself, and disease of the gall-bladder, such as stones or inflammation ; or stomach and duodenum, such as ulcer or cancer, will run a not far distant second and third. The incidence of cancer in older applicants and the ptoses and prolapses connected with general nervous symptoms must be kept in mind. Inquiry should be made as to the nuiliber and length of attacks and when they started, what the symptoms were, and the time of their coming and going in relation to meals, the bowel move- ments, or the time of day; the presence of tenderness or pain; where it was and of what kind, or of nausea or vomiting, or of chill or fever; the character of any vomited material and of the stools and urine; the occurrence of jaundice and whether associated with colic or clay-colored stools; the presence of gas in the stomach or bowels; any swelling or lumps that may have been felt; whether the applicant was in bed and how long, and whether a doctor was in attendance, and, if so, what his diagnosis was and whether it would be possible to get a statement from him. Were radiograms taken? What treatment was used and how long was the applicant away from his usual occupation? All these data should be noted down in order that it may be known that the doctor has considered them. It is not meant that in the ordinary case of acute stomach upset from error of diet or in the occasional indigestion of no moment, all these data should be given, but it is often the apparently in- significant lead that uncovers the serious defect, and enough should be given to prove that the examiner has considered the significance, understands the importance, and is willing to make and underwrite a diagnosis. This all calls for the highest skill and accuracy in history-taking, knowledge of the importance of various symptoms and ability in diagnosis. It is skilled medical work plus knowledge of diseases important from the life insurance viewpoint, plus ability to "get it across" in writing to the medical director. Positive Evidence After the questionnaire lias been filled out and the various leads as indicated have been followed as far as seems adequate or possible, the physical examination of the applicant will be in order. It is to be presumed that anything elicited by the history-taking which THE ABDOMEN 201 points towards disease of any of the abdominal organs, either past or present, will lead the examiner to make an especially careful examination of those organs. Should there be no such data in the history, the examination of the abdomen should not be slighted. Some disease of serious import may be developing or already estab- lished which has not given symptoms but which may give signs (see Fig. 47.) It is assumed that obvious abnormality will be recognized. The first information about the abdomen obtained by the exam- iner will probably be the measurement of the abdomen taken in conjunction with that of the chest. The significance of overweight in life insurance is fully recognized and when combined with a large or pendulous abdomen it is more important where future longevity is in consideration. This measurement should be made over the greatest circumference of the abdomen in the erect posture and next to the skin. The possibility of fluid or tumor as cause for enlargement should be kept in mind. At the same time inspection of the abdomen w toto should be made. Any tendency to skin rash should be observed. The presence of any scars should be noted as to solidity, and their condition determined to obtain an idea of the integrity of the abdominal wall. Any tendency towards bulg- ing, hernia, and apparent pulling which suggests adhesions, may be noted. The character of the scar will suggest whether the operative procedure was simple or complicated by drainage, and by its site an indication of the nature of the operation may be gained. The character, extent and condition of any hernia, whether epigastric, umbilical, inguinal, femoral, or other form should be made out, as well as the efficacy of any truss or support that is worn. Any en- larged vein, suggestive of portal obstruction will be best seen in this position. The strife suggestive of rapid abdominal enlargement may be seen and whether recent or not determined by their color. Any general tendency towards prolapse or ptosis of the abdominal organs or flabbiness of the abdominal walls may be indicated by the general contour. Any localized swelling will be noted, such as may be caused by tumor of the abdominal walls or of the abdominal contents. Percussion will perhaps lead to suspicion of a low edge of the liver in the erect position and may indicate a low position of the stomach. Further examination of the abdomen will be carried out with the 202 LIFE INSURANCE EXAMINATION applicant in a recumbent position. This position should be one in which the applicant is comfortable, preferably a table high enough so that the examination is made easily. The head should be on a pillow and the legs drawn up, or extended, so that the abdominal muscles will be as relaxed as possible. Inspection in this new position should again be made with the points already considered in mind. Percussion may here demonstrate some pathologic ele- ment. Dullness shifting with change of position will suggest fluid. Dullness over the pubes should be noted, as well as the area of splenic dullness and the lower edge of the liver. We now proceed to the most difficult part of the examination but the most useful in experienced hands, palpation. The applicant should breathe through the mouth, and should be told that the examination will not give him discomfort. His confidence and cooperation should be gained in every possible way. Skill in palpation is most difficult to acquire and impossible to describe. Experience is the great teacher. The main things to be looked for are rigidity (which is not due to fear or inability to relax), spasm, localized tenderness in any area, gurgling, and the presence of masses or tumors. Knowledge of the feel of a normal abdomen must be part of the examiner's already acquired equipment. It is well to place a hand on each side of the abdomen and, beginning gently, to press in on a rather broad area with the whole surface of the fingers. This should not disturb the applicant and lead him to resist. The comparative feeling of tension on the two sides may be noticed. It is my custom then, with one hand over the other, to press in deeply but gradually in the left lumbar region, it being the area least likely to be involved in any of the common inflammatory conditions in the abdomen. This again will give a sense of the tension with which to compare other and more interesting areas. I then press in the same way in the right lumbar region, and gradually palpate the whole abdomen, using as deep pressure as possible without giving discomfort, the pressure being greatest in the finger tips. The areas in which tenderness is usually felt in disease of the appendix is specially investigated, and a slight rolling motion is given to the hands when they are exerting the greatest pressure. The right hypochondriac region and the epigastric region are next examined in the same way, and gradually the whole abdomen is gone over, having in mind the organs normally situated in the different areas. (See Fig. 40.) THE ABDOMEN 203 Any unnatural pulsation will be investigated, having in mind the normal pulsation of the aorta and common iliac arteries as modified by the thickness of the abdominal walls. Any masses may be Fig-. 40.-Regions of the abdomen. (From Warbasse's Surgical Treatment-W B. Saunders Co.) mapped out and their consistency noted. The hardness of the solid tumor, the elasticity of the cyst, the doughiness of the fecal mass will he recognized. The edge of the liver and any irregularities therein may be felt. An enlarged spleen should be discovered and 204 LIFE INSURANCE EXAMINATION identified by the notch. Tumors of pelvic origin may possibly be felt in the hypogastric region. Next one hand is placed beneath the flank and with the other above it in front, bimanual palpation will help to define any masses which may then be discovered. The low kidney will be identified and its motility with respiration noted. During the whole palpation the examiner will watch the appli- cant's face for indications of discomfort. In cases where there is no pathology, the examination should be able to be made without causing pain, and any indication of discomfort would mean either that the examiner is too rough or that there is some pathologic con- dition present. It is sometimes necessary, in the case of a mass being felt, to increase the pressure suddenly in a way that has been described as "dipping" in order to catch the applicant un- awares and so feel it before he becomes tense. But this should be done at the end of the examination and only if necessary. In further examination of the hypochondriac region, one stands with the face towards the patient's feet so that with the fingers over the costal border one may feel with the tips in the gall-bladder and sphenic regions for any tenderness or tumor which may be dis- covered on full inspiration. At best, and with the greatest experience, such an examination may fail in that the abdomen may be held rigid, or the abdominal walls may be thick. What one feels must be interpreted with this in mind. In general, it may be said that points of tenderness, es- pecially in certain areas, are to be looked upon with great suspicion. Absence of tenderness does not, of course, eliminate the possibility of trouble in the past, nor even in the present. A case of a patient who was operated upon because he was going to Africa, and who having had a friend die from appendicitis, was unwilling to go where he could not obtain surgical help, lias always impressed me. In spite of the fact that there was no tenderness or spasm at the site of the appendix, and that an attempt was made to laugh him out of his supposed obsession, an appendix with a gangrenous area was removed. It should be remembered that in case of any tenderness manipulation must be gentle. I have had to remove an acute appendix within twelve hours of an examination for chronic appendicitis with in- definite symptoms of indigestion going back for fifteen years, and in which I found a definite but slight tenderness on deep pressure over McBurney's point. The description of the findings by the THE ABDOMEN 205 examiner should be definite as to location, character, outline, con- sistency, mobility, tenderness and relationship. Fig. 41.-Normal colon. Arrow points to gallstones. Confirmatory Evidence Where in the history or physical examination there is a reason- able suspicion of difficulty past or present, it may be possible to get confirmatory evidence. The examiner is handicapped in coming 206 LIFE INSURANCE EXAMINATION to his conclusions by the fact that he cannot collect these for him- self. The clinician will be able to insist upon every known method of diagnosis being used, lie will advise x-ray, he will want investiga- tion by x-ray scries after bismuth meal, and cncmata. He will have functional tests made to determine the motility of the stomach and Fig'. 42.-Facetted gallstones. the intestines. He will have the stomach contents analyzed after test meals and the acidity determined. The duodenal tube may be nsed. He will perhaps examine the patient at intervals and note any changes that take place, or he may even examine under an anesthetic. The insurance examiner has not these data at command unless they arc offered by the applicant. He can, however, ask whether any such THE ABDOMEN 207 procedure has been done in the past and can find out by whom done, what the result was as far as the applicant knows, and whether a report would be available. He may suggest that investigation of this Fig. 43.-Retrocecal chronic appendix. Symptoms all referred to right upper quadrant. kind might be made. He may suggest that the applicant have such investigation made in order to submit with his application. The examiner should be able to interpret any such data which lie may obtain. As far as the functional tests go, his clinical experience will 208 LIFE INSURANCE EXAMINATION have taught him that the results as to these tests are not to be taken as conclusive evidence, but arc to be considered as part of the whole picture and given their proper value. Fig. 44.-Chronic adherent appendix holding cecum up. In regard to x-ray examination, the technic is becoming more and more effective, the interpretation more and more exact. An x-ray may show pathology and while an examiner is not required to be an THE ABDOMEN 209 expert in interpretation, he should be able to recognize any obvious showing, in order that his own interpretation may aid him in his recommendation. It must never be forgotten that a negative x-ray pic- Fig'. 45.-Cancer of cecum. Arrows point to growth. ture does not mean that there is nothing the matter but that an x-ray may reveal a very serious state of affairs. We can learn by study of radiograms what is normal. We can learn what the x-ray may show, what it should show, and what it cannot show. For instance, in Fig. 210 LIFE INSURANCE EXAMINATION 41, a normal colon is shown but there are gall-stones easily seen. Fig. 45 shows even facetted gall-stones yet often gall-stones are present which cannot be shown by the x-ray, and there are conditions of the Fig. 46.-Cancer of cecum and ascending colon with involvement of ileocecal valve. gall-bladder and passages other than gall-stones which are not shown, such as inflammation, thickening, or tumor. Fig. 51 shows that some such condition may be indicated. Comparing the condition of this stomach with the normal type of stomach as shown in Fig. 49, Fig. THE ABDOMEN 211 51 shows the stomach in an oblique position, with the duodenum held against the liver, caused by adhesions due to cholecystitis. The x-ray Fig. 47.-Cancer of ascending colon and hepatic flexure. Inoperable. Just be- ginning to have symptoms. may help in the diagnosis of chronic appendicitis, it may show as in Fig. 43 and Fig. 44, where the appendix is plainly seen in the one ease behind the cecum and in the other distinctly holding the cecum 212 LIFE INSURANCE EXAMINATION up by adhesions. A tumor may be well defined. Figs. 45, 46 and 47 show cancers in various states of development, Fig. 47 showing a very advanced cancer involving the ascending colon and hepatic flexure which was proved to be entirely inoperable and yet the patient Fig-. 48.-Carcinoma of lower third of esophagus. Stomach normal. Duodenal cap and sphincter well shown. was just beginning to have symptoms. Diagnosis of ulcer of the stomach is at times surprisingly easy by x-ray. The normal type of stomach with the tubular shape of pyloric end, sphincter and duo- denal cap is well illustrated in Fig. 49. Compare this with Fig. 50, THE ABDOMEN 213 where there was a perforating saddle ulcer, which shows the bismuth extending into the ulcer and the spasm of the pyloric antrum so often seen in cases of ulcer. Another tumor of the stomach is shown in Fig. Fig'. 49.-Normal tubular type of stomach showing cap and sphincter. 52. This was thought to be a cancel-, but upon operation it was found to be a multiple papilloma. Fig. 5G shows an obstructing carcinoma on the greater curvature side of the antrum while Fig. 55 shows a 214 LIFE INSURANCE EXAMINATION Fig. 50.-Perforating- saddle ulcer, lesser curvature stomach. Some spasm of antrum. nonobstructing ulcer of the duodenum. Indication of ptosis may be obtained and absence of ptosis may be proved. Fig. 53 shows marked ptosis as pictured following a bismuth enema and Fig. 54 shows the long pelvic type of cecum without prolapse of the colon. THE ABDOMEN 215 The relative position of the various contents of Ihc abdomen in an erect or recumbent position may be made out by use of plates taken Fig'. 51.-Normal tubular stomajch in oblique position as seen in cholecystitis. Duodenum held against liver. in these positions or motility may be studied with the fluoroscope with change of position or by manipulation. These few examples are given to indicate what the examiner should have in mind and be able 216 LIFE INSURANCE EXAMINATION to recognize, but they are a scries of cases picked to show various conditions rather than the average which require the knowledge of an expert. Fig. 52.-Multiple papilloma of stomach, mistaken for malignancy. It will be of value to the examiner to know somewhat the attitude of life insurance companies to abdominal diseases, by what means the THE ABDOMEN 217 medical director is led in coming to his decisions and in his selection of individual cases. This is not the place to go into statistics or to give tables such as arc in the possession of our life insurance com- Fig'. 53.-Bismuth enema showing' marked ptosis. panics. In the past, selection was made according to individual ex- perience, clinical ability, and guesswork, sometimes by very good guesswork, or so-called medical insight. Gradually the medical di- rectors, through statistics collected from their own experience, began 218 LIFE INSURANCE EXAMINATION Fig'. 54.-Bismuth enema showing- long- pelvic type of cecum. to formulate more exact lines of procedure. Meetings were held in which papers were presented giving the experience of the different companies and discussions took place. There are still a great many subjects which arc not thus worked out, either because there are not enough cases on record to be of value, or because, due to advances in THE ABDOMEN 219 medical and surgical knowledge, enough time has not elapsed for sta- tistics to accumulate and be studied. The handling of the question Fig'. 55.-Ulcer of duodenum, nonobstructing, seen from behind. of appendicitis lias been pretty well worked out, but 1he surgery of the gall-bladder and ducts has been a more recent accomplishment and various questions are still sub judice. The surgery of the stomach 220 LIFE INSURANCE EXAMINATION and duodenum is becoming more standardized. Looking over the papers and discussions of the Association of Medical Directors since Fig'. 56.-Obstructing carcinoma of the greater curvature side of antrum, seen from behind. their meetings were started, 1 find that the questions which have been discussed having to do with the abdomen arc 1he question of various forms of appendicitis, with and without operation, the question of THE ABDOMEN 221 gall-stones and gall-bladder disease with and without operation, the question of renal and hepatic colic, and the question of abdominal operations such as resection of the intestines, operation for adhesions, and operation for tumor. Such papers and discussions to date are made possible by actual statistics available in tbc records of the in- surance companies, such information as can be obtained from medical articles which include tabulation of cases, such statistics as can be had from clinics, or personal opinions as obtained from leading clinicians and surgeons. The evidence is regarded as of value in about the order in which I have presented it. From the life insurance standpoint, investigation of disease is nar- rowed down by certain factors inherent in life insurance. Obviously fatal or dangerous diseases are of interest only in their discovery, so that the applicant may not be accepted. Obscure, rare, undiagnosed or inexplicable findings are also to be eliminated. For the purposes of this chapter abdominal findings, secondary to some general disease or disease of some other part of the body, need not be discussed as they will be considered in their several sections. There remain to be especially considered: 1. Appendicitis in its various forms, with and without operation. 2. Stones or inflammation of the gall-bladder and passages, with and without operation. 3. Ulcer of the stomach or duodenum, with and without operation. 4. Benign tumors. 5. Hernias. It may be said that while different individual companies vary to some extent, there is a remarkable unanimity in their acceptance of so-called standard risks. Their acceptance of substandard cases and their rating will vary. Appendicitis The operative treatment of appendicitis has been well standardized for some time, but statistics extending over long periods of time arc not as yet obtainable. There are statistics collected by actuaries as 1o the probability of longevity from a single attack of appendicitis and they are extremely favorable. However we arc in possession of general experience enough to be sure of at least a workable procedure in other cases. In general it may be said that the importance of appendicitis attacks diminishes as time elapses. When there has been 222 LIFE INSURANCE EXAMINATION one attack of appendicitis, not operated upon, the case may be ac- cepted as standard after one year free from all symptoms, where the examination is satisfactory. Where there is a history of more than one attack the outlook is less favorable: without operation it cannot be accepted as standard, and only at all after two to five years free .from all symptoms. So-called chronic appendicitis as a risk is un- acceptable, and if operated upon, can* be considered only after two years without any symptoms whatsoever and then not as a standard risk. An acute appendicitis, with one or more attacks, which has been operated upon without drainage and has shown no complications may be accepted as standard, after a satisfactory examination, in six months or less time. If the operation has been done with drainage, it will not be accepted for six months or more, depending on the con- dition found at operation, the length of time of the drainage, the general condition of convalescence, and the general health at the time of examination. In cases where the appendix has not been removed at operation, in cases where there have been any symptoms of abscess which have quieted down, possibly by draining through the bowel, the applicant can be accepted only after a five years' interval entirely without symptoms, and then only in some modified form. It will be obvious how necessary to the medical director is complete information as to the attacks and as to any operation that has been done. Stones in G-all-Bladder I cannot do better than to quote from a paper read at the last meet- ing of the Medical Directors' Association by Hunter and Rogers, Actuarial and Medical Directors of the New York Life Insurance Company, on their procedure in eases of this character. "Our treatment is the same whether the disease is described as gall- stones, biliary colic, or hepatic colic, and is as follows: Within 1 Yr. 1-2 Yrs. 3-5 Yrs. After 5 Yrs. 1 attack *R. N. A. **+ 50 + 30 + 20 2 attacks R. N. A. + 75 + 50 + 30 Repeated attacks R. N. A. +150 +100 + 50 *Risk not acceptable. **Excess mortality above normal. "Drainage of tlie gall-bladder is treated the same as one attack; but if the gall-bladder has been extirpated, one-half of the foregoing rat- ing is applied. " THE ABDOMEN 223 The examiner should note that in taking the history of operation, full details of the operation should be given, and if they arc unob- tainable from the applicant, he should ask that they be forwarded after communication with the operating surgeon. It is very necessary Io have an operation reported with the information whether there was simple drainage, or whether the gall-bladder was removed, or whether there were stones in the common duct, or whether the common duct was opened. Cases of involvement of the common duct are pretty generally considered as being uninsurable. Ulcer of Stomach or Duodenum As this is a subject which is still being worked out I include the complete report from the above named article as showing very well in what way a company will handle such a problem. "The standards employed by our company in the valuation of these risks are largely based upon the testimony furnished by the Mayo Clinic, modified by our own experience. The report of that Clinic was published in 1919 in the Proceedings of the Medical Directors' Association. We have not dared to follow the testimony of the Mayo Clinic altogether, for the reason that we have yet to learn whether the surgical treatment of these conditions is'as efficient elsewhere as it is in that institution. Besides, in dealing with cases of this kind there should always be a margin of safety. "It will be noticed in both gastric and duodenal ulcers that the extra hazard is assumed to be a temporary one which disappears altogether after a certain number of years. This may not be entirely true, but the evidence so far at hand indicates that the hazard after a limited number of years is small if not altogether negligible. We doubt, however, whether cases of gastric ulcer may safely be accepted for large amounts for several years beyond the period covered by our ratings. We believe that there is probably an extra hazard for some time thereafter. "As the element of ago docs not seem to be a factor, the extra mor- tality is expressed in terms of the number of extra deaths per 1,000 for a period of years. "It will be noted that in the case of gastric ulcer the same rating is applied whether the risk has been operated upon or not, while in the case of duodenal ulcer without operation a much higher mortality is anticipated than in cases successfully operated upon. We should like to say frankly that this distinction does not rest upon any insur- 224 LIFE INSURANCE EXAMINATION Gastric Ulcer With or Without Operation YEARS SINCE ATTACK. 1st. *R. N. A. 2nd. R. N. A. 3rd. 80 extra deaths per thousand. 4th. 45 extra deaths per thousand. 5th. 30 extra deaths per thousand. 6th. 15 extra deaths per thousand. Duodenal Ulcer YEARS SINCE ATTACK. Not operated. 1st. R. N. A. 2nd. 40 extra deaths per thousand. 3rd. 28 extra deaths per thousand. 4th. 15 extra deaths per thousand. 5th. 10 extra deaths per thousand. 6th. 5 extra deaths per thousand. YEARS SINCE OPERATION. Operated. 1st. R. N. A. 2nd. 10 extra deaths per thousand. Thereafter. 0 extra deaths per thousand. *Risk not acceptable. ance experience to which we have had access, but rather upon the observation and opinions of surgeons who have had a wide experience in these cases. "In the practical application of these ratings an extra premium is charged for a short period and as these premiums are without load- ing, neither commissions nor dividends arc paid upon them." Benign Tumors Benign tumors of the abdomen are not frequent but we arc occa- sionally called upon to consider such eases. They are only acceptable when evidence of a satisfactory nature is forthcoming that they arc benign. Such would be a report from an operating surgeon of repute, together with evidence that a specimen had been examined in a labor- atory in which one would have absolute confidence. Hernia The subject of hernias was threshed out years ago and the general practice seems to be to refuse such unless evidence is forthcoming that they are suitably controlled by an efficient apparatus which is con- stantly worn, and in the case of an applicant who is not subject to the more laborious forms of employment. There arc a few words that may be said on certain general symp- toms which have been so well stated by Dr. Greene in his "Examina-- THE ABDOMEN 225 tion for Life Insurance," and in the section written by him in Osler's "Modern Medicine" that I quote freely from them here. Colic.-"A most careful report is required as to the symptoms, dates, number of attacks, and probable cause of the condition, and the examiner should consider as possibilities renal and gall-stone colic, appendicitis, strangulated hernia, lead poisoning, Dietl's crisis, pylo- rospasm, locomotor ataxia (abdominal crises), arteriosclerotic abdom- inal colic, Pott's disease, abdominal aneurysm, spastic constipation, mucous colitis, gastric and duodenal ulcer, and ordinary acute indi- gestion." Diarrheas and Dysentery.-"An occasional attack of simple diar- rhea or acute dysentery from which the applicant has fully recovered is unimportant. "Chronic diarrhea or dysentery or attacks so frequent as to suggest special susceptibility or a chronic disturbance of the intestinal tract arc generally regarded as bars to insurance of the cheaper kinds. The word dysentery should not be used to cover a simple diarrhea, as is often done by the applicant, and, on the other hand, the examiner should remember that the victims of rectal cancer or tuberculosis often regard their troubles as merely a 'dysentery.' " It should be remembered that by our later-methods a more definite diagnosis is possible. Dyspepsia.-"Trivial, infrequent attacks of dyspepsia are not im- portant in insurance acceptance, but chronic disease impairs the life and demands rejection under ordinary policy forms. In any event, the most careful examination is requisite to insurance even under extra rating. The question of associated disease must always be con- sidered, among the conditions being heart disease, Bright's disease, tuberculosis, and primary gastric lesions, such as dilatation, ulcer, and malignant disease. Careful inquiry as to loss of weight, pres- ence of pain, etc., should always be made." Jaundice.-"No case of existing jaundice should be accepted; the history of an attack associated with gastrointestinal disturbance and a complete and ready recovery from it are of little importance in young persons, but demand a most careful investigation in those of middle age because of its frequent relation to gall-stones or chronic disease of the gastrointestinal tract." Debility.-"The writer's personal experience would indicate that relatively few cases of pure neurasthenia occur, nearly all coming under his observation being associated with recognizable ailments 226 LIFE INSURANCE EXAMINATION often serious, although usually curable. Among the unrecognized factors in cases which had been previously pronounced 'neurasthenia' he has found gastroptosis, gastric and duodenal ulcer," as well as other general diseases mentioned. Lumbago.-"Simple myalgia is unimportant, but one must have in mind the loin weariness of Bright's disease, pyelitis, mucus colitis, sciatica, spinal caries, locomotor ataxia, gall-stone and renal colic, and even spastic constipation. Persistent backache is incompatible with a sound state of health." It is easy enough in the normal individual 1o obtain the history and make an adequate abdominal examination in a very short time, but the examiner must be wide awake to follow up any clue he may get as far as is necessary to make a diagnosis to his own satisfaction and present data as conclusive as possible to the medical director. He should learn to state on the application blank all the important facts and omit the unimportant details. The fussy examiner will try the applicant and the medical director; the careless examiner will make mistakes, will lose money for the company, and will eventually lose his appointment, but the good clinician who, with good common sense, follows out a proper procedure and can indicate that he has done so, and that the conclusions he reaches are intelligent, will please the applicant, will serve the company, will become a real help to the medical director, and will be in a position himself to have his con- clusions respected, his services desired and will find interest and per- sonal satisfaction in the work. CHAPTER XIX THE NERVOUS SYSTEM By Larue D. Carter, M.D., Indianapolis, Ind. Medical Director, Norways Sanatorium. Associate Professor Nervous and Mental Diseases, Indiana University School of Medicine, Indianapolis. Colonel, Med. 0. I\. C. It is not the object of this chapter to describe in detail the various diseases of the nervous system, or to discuss exhaustively the mani- festations of mental derangements, which have a bearing on life in- surance risks, but rather to enumerate symptoms and signs which arc indicative of some pathologic process and which should be of some significance to 1he medical examiner. This chapter will be considered under three heads: (1) history; (2) examination; (3) an enumeration of the various diseases affecting the mind and nervous system, and their most salient signs and symp- toms. It is needless to emphasize the important bearing that both organic and functional nervous diseases have on insurance risks. The slow, insidious onset, the absence of definite symptomatology, the scant physical signs, and the uncertain prognosis make of this group, one which the examiner should always have in mind, and he should always be on the alert to note the presence of any signs or symptoms, indica- tive of neuropsychopathic disturbance. 1. History The questionnaire provided by most insurance companies is ade- quate, but often certain points in the examination are brought out, which require further inquiry into both the family and personal his- tory of the applicant. The Family History is of great importance, especially in the con- sideration of mental diseases. The history ot frank insanity of the so-called functional type such as: manic-depressive, dementia pre- cox, or paranoia in either parent should be the subject for further investigation, as there is a marked tendency for these types to be transmitted downward from parent to child. The organic insanities such as: general paresis, arteriosclerotic insanity, senile dementia, 227 228 LIFE INSURANCE EXAMINATION the dementia of brain tumor, trauma, etc., in the parents could not be considered unfavorable to an insurance applicant. The presence of well-marked psychoneuroses, hysteria, psychasthenia, neurasthenia or anxious states in cither parent should call for a careful study of the habits and mental activities of the applicant. Epilepsy in one or both parents is unfavorable, and requires a searching history as to the possibility of petit mal or nocturnal attacks in the applicant; when both parents are affected with this disease, the incidence of transmis- sion is great; when present in one parent it follows fairly close to the law of dominants and recessives. Alcoholism, criminal tendencies, eccentricities, peculiarities or unusual propensities of conduct are all expressions of abnormal mental states and when present in parents should be given due consideration; not infrequently these tendencies are transmitted as such from parent to child, but more frequently, however, they are distorted and exaggerated and often show them- selves as frank insanities or profound psychoneuroses in the offspring. Idiocy, feeble-mindedness and the psychopathic state are conditions which we only too well know are dominant in many families. We have no way of knowing just how far-reaching various constitutional diseases, such as syphilis, tuberculosis, diabetes and nephritis, in the parent are, in the production of nervous disturbances in the progeny, by lowering the vital resistance of the sperm or ovum. Unquestion- ably such conditions are of great importance and are often respon- sible for otherwise unexplained mental and nervous outbursts. The Personal History of the Applicant should include a question- naire regarding birth and early development. The history of child- hood diseases; particularly diphtheria, scarlet fever, severe measles, tonsillitis, chorea, rheumatism, enuresis, convulsions, spasms, menin- gitis, otitis media, poliomyelitis or head injuries should be noted, as lhese conditions in childhood often act as factors in the later develop- ment of neuropsychopathic diseases. The habits of the applicant, particularly the use of alcohol, hypnotics and narcotics, his routine of rest and work, his temperament and moral standards, his occupa- tion, especially if exposed to metallic poisons, should all be given due importance as potential factors in the production of nervous disorders. The history of later symptoms referable to the nervous system should be carefully considered. The history of persistent headache, chronic ear disease, dizziness, vertigo, transient or persistent diplopia, tinnitus, stuttering or stammering speech, attacks of faintness, con- vulsions either local or general, anesthesias or paresthesias, muscular THE NERVOUS SYSTEM 229 spasms or rigidities, neuritic pains, tremors, difficulty in gait, exhaust- ibility, or bladder disturbances should at once suggest to the examiner the possibility of an organic nervous disease. The history of pre- vious disease or injury affecting the nervous system and from which apparent recovery is made should always be regarded seriously. Among the more important of these conditions the following may be mentioned: epidemic or other forms of meningitis, poliomyelitis, chorea, recurrent neuritis, lethargic or simple encephalitis, Bell's palsy, migraine, tetanus, syphilis, thyroid disturbance, various toxic states, brain tumor or abscess with successful operation, head in- juries with or without fracture, drug addictions, severe mental shocks or strains and acute mental disturbances. 2. Examination The importance of careful attention to neurologic signs in every insurance examination is at once apparent, and while a complete neurologic examination is intricate and time-consuming and not often required in routine examination, yet the examiner should be able to observe certain abnormal signs which will direct him to a more searching and painstaking study of the condition presented. Physical Stigmata of Degeneration.-Cranial asymmetry, micro- cephalus, macrocephalus, attached lobes or other anomalies about the ears, flecking of the iris, albinism, narrow palpebral orifice, high arched and narrow palate, irregularity of teeth, prognathism, or receding chin, with overdevelopment of the middle facial segment, excessive or scant growth of hair on face and body, anomalies of the genital organs, are all developmental abnormalities, and while the occurrence of even several of these conditions should not of themselves disqualify, yet their presence should put the examiner on the lookout for more serious signs and symptoms. Mental Stigmata of Degeneration.-During an examination the examiner has ample opportunity to observe certain characteristics of the applicant. Indifference and inattention are suggestive of dementia precox; exaltation, egotism and aggressiveness of paresis, paranoia or the manic phase of manic-depressive insanity; retarda- tion and mental cloudiness of dementia precox, the depressed state of manic-depressive insanity, epilepsy or mental enfeeblement; hy- peremotionalism of hysteria or involutional insanity; restlessness, carelessness and untidiness in personal appearance, mannerisms and 230 LIFE INSURANCE EXAMINATION surliness are all suggestive of a pathologic mental state. It is true the embarrassment and excitement of an examination may produce certain mental phases, which are by no means abnormal, but marked mental peculiarities or propensities of conduct should demand care- ful inquiry into the mental history of the applicant and final action should not be taken until sufficient time has been had for careful observation. Physical Examination.-Only the points brought out in a neuro- logic examination will be considered in this chapter. The applicant should be stripped and the examiner should provide himself with a few simple diagnostic instruments; a dynamometer to test mus- cular strength; a percussion hammer for eliciting reflexes; a tuning- fork for testing the hearing; a flash-light for examination of the eyes; pledgets of cotton or wool and a common hatpin to test tactile and pain sense; a couple of test tubes for temperature sense; a pair of calipers for localization and distance and a tapeline to determine atrophies. While there are many other elaborate instruments of precision indispensable to the neurologist, yet these few are suffi- cient to aid the insurance examiner to determine the presence of organic nervous disease. The following neurologic signs will be considered under two heads; disturbance of motion, and disturbance of sensation. 1. Disturbance of Motion.-(a) Gait.-The normal gait is straight and steady; it is tested by asking the applicant to walk a straight line, such as a crack in the floor or a seam in the carpet; first, with the eyes open and later with them closed. Irregularities in gait are described under various terms. The ataxic gait is sprawl- ing and stamping, the applicant attempting to orient himself in space and establish his equilibrium as typically seen in locomotor ataxia; the spastic gait is shuffling and mincing, with short tremu- lous steps and rigid muscles; it is indicative of disease of the upper motor neuron, and is seen in general paresis, and other inflam- matory or degenerative processes of the brain cortex or motor pathways and in paraplegia from any cause; the propulsive gait is one in which the patient appears to be constantly falling forward, the body is bowed, the steps short and trotting, the muscles rigid and the legs are flexed at the hip and knee; it is characteristic of paralysis agitans and disease of the striate body; the drunken, reeling or pitching gait is indicative of cerebellar disease and is usually unilateral; the steppage gait is associated with peripheral THE NERVOUS SYSTEM 231 paralysis of the lower extremities, there is more or less foot drop, and the high steps are taken in order to clear the ground of the dangling toes, it is seen in the various types of multiple neuritis and in advanced sciatica; in the hemiplegic gait the whole rigid extremity with its dragging toes is swung forward from the tilted and elevated pelvis. There are certain other anomalies of gait due to central or peripheral nervous diseases, and which are less well marked; frequently combinations of these different types are seen in the same individual. These disturbances in gait, of course, vary in degree, from a slight irregularity, difficult to discover, to changes so marked as to make locomotion impossible. (b) Station.-The normal station is erect and steady. In testing for abnormalities of station, the applicant is asked to stand with feet close together and eyes closed, he is then taken by the shoulders and gently swayed from side to side, forward and back- ward, he is next asked to stand first on one foot and then on the other; if there is undue swaying of the body while in these posi- tions, and if the individual loses his sense of position, it is indica- tive of disturbance in the function of equilibrium, ft is seen typically in locomotor ataxia and is known as Romberg's sign, and is also found in diseases of the cerebellum and internal ear. (c) Coordination.--To properly execute'a volitional act, all parts concerned in this act, must coordinate or operate in synergia. The unsteady gait or the swaying station, above mentioned, are examples of muscular asynergia. There are certain other tests, which are employed in determining the power of this function. The finger to nose test is executed by asking the applicant slowly to touch the tip of the nose with the extended forefinger, first with eyes open, later with them closed and changing from one hand to the other; the finger to finger test is made in the same manner by asking the applicant to extend the arms and bring the tips of the fingers slowly together, eyes closed; the heel to knee test by having the applicant, with eyes closed place one heel on the opposite knee; the heel to toe test by placing one heel on the opposite great toe; these tests are performed first on one side, then on the other. The diadokokinetic test is made by directing the applicant to execute rapidly alter- nating movements, such as: the piano-playing movements of the fingers, rapid pronation and supination of the forearms or exten- sion and flexion of the wrists. The presence of incoordination or muscular asynergia as determined by gait, station or the above 232 LIFE INSURANCE EXAMINATION described tests, is significant of grave organic nerve disease, and should call for a complete neurologic examination. (d) Tremors.-Tremors are involuntary muscular twitchings or jerkings; they may be genera] or local, involving an extremity, a group of muscles or even parts of individual muscles. A rapid tremor is one in which the impulses are from eight to twelve per second; a slow tremor is one in which the oscillations are for from four to eight per second; fine and course tremors refer to the ampli- tude of the excursion ; an intentional or volitional tremor is one which is increased by voluntary movement, and is seen typically in multiple sclerosis; a passive or nonintentional tremor is one which subsides when voluntary effort is made and is characteristic of paraly- sis agitans. In testing for tremor of the face and tongue, the applicant is asked to close the eyes, protrude the tongue, and gently draw back the corners of the mouth; in this way the tremor, otherwise un- noticed, will often be seen about the eyelids and nasolabial folds. Tremors in the hands and fingers are demonstrated by stretching out the arms, extending and spreading out the fingers, and holding the finger tips of the examiner against those of the applicant. An intentional tremor may be brought out by asking the applicant to pick up a small object, such as a pin, or perform some other delicate test with his fingers. In health, tremors are often present as the result of fatigue, overexertion or emotional disturbances, and sub- side when the cause is removed. However, a persistent tremor should be looked upon with suspicion as a sign of organic disease, especially significant of hyperthyroidism, early general paresis and multiple sclerosis. Muscular spasms, choreic movements, athetosis and local convul- sions, like tremors are the result of increased motility and are indicative of a profound organic lesion. Habit tics are psychic in origin and are usually seen about the face, as persistent winking of the eye, elevation of the brow, wrinkling of the nose or grimac- ing; in the hands, as snapping of the fingers, tapping on the desk and similar manifestations. These movements are of little impor- tance when considering an insurance risk, but should be inquired into carefully, bearing in mind that they may be the expression of a deep-seated psychic disturbance. (e) Muscular'Tone and Power.-Disturbance in the power or tone of individual muscles or muscle groups, is often indicative of some THE NERVOUS SYSTEM 233 central or peripheral nerve lesion. Muscular power is tested by having the applicant perforin various movements of the body against resistance, first on one side and then on the other, and lastly the two sides synchronously, the examiner noting any impairment or awkwardness in movement or irregularity on the two sides. Weak- ness in the facial muscles is noted by asking the applicant to elevate the brows, close the eyes tightly, retract the corners of the mouth, purse the lips and elevate the nares. Weakness in any of these movements indicates a lesion involving the facial nerve. In central lesions the upper portion of the face is either clear or only weak- ened. Ptosis of the upper eyelid is seen in third nerve paralysis. Difficulty in swallowing is seen in involvement of the glosso- pharyngeal and vagus nerves; paralysis of the tongue, with in- ability to protrude it in a straight line, difficulty in speech and de- glutition is found in lesions of the hypoglossal nerve. Disturbances of speech are frequent signs of organic nervous disease. The distorted speech due to malformations, such as cleft palate, harelip, tongue-tie, nasal obstructions, etc., of course, is not considered as being of neurologic significance, though these conditions are often seen in people of substandard mental and physical make-up. Stuttering or stammering is a condition in which there is a difficulty in enunciating words beginning with certain consonants; the persistent nasal speech is suggestive of palatal palsy due to lesion of the glosso-pharyngeal nerve, and with it the pharyn- geal reflexes are lost, it is characteristic of post-diphtheritic paraly- sis ; scanning speech in which each syllable is distinctly pronounced is seen in multiple sclerosis; stumbling speech, in which parts of words are omitted, sounds slurred and syllables repeated is noted in general paresis; thick, mumbling, indistinct speech is present in bulbar paralysis; tremulous speech is seen in diseases accompanied by general tremor, and is often in combination with slurring and stum- bling speech. Hysteria may be accompanied by partial or complete mutism; emotional disturbances often produce changes in the pitch and modulation of the voice. Aphasia is associated with organic disease of the cortical speech centers. It is of two types, motor and sensory. Tn pure motor* aphasia the power of speech is not impaired, the individual com- prehends what is spoken or written to him, can obey commands, and can enunciate or write words to copy but is unable to for- mulate written or spoken language. Paraphasia and paragraphia 234 LIFE INSURANCE EXAMINATION are conditions in which objects are misnamed or the wrong word is written; the individual is usually aware of his mistake and makes an effort to correct it. Motor aphasia is associated with lesions of the third left frontal or Broca's convolution. In sensory aphasia the power of hearing and vision is not disturbed and speech is present, but the individual does not comprehend what he sees or hears; this is a condition known as mind blindness. In certain cases only the auditory centers are involved and the patient understands written but not spoken language, on the other hand the visual centers only may be involved, and he understands spoken but not written language. The sensory speech centers are located about the angular gyrus. Weakness in the deltoid, trapezius, latissimus dorsi and pectoral muscles is tested by asking the applicant to perform movements in which these muscles are concerned. As an example: inability to raise the arms laterally to a horizontal position, is seen in deltoid paralysis; inability to elevate the shoulders in paralysis of the trapezius; difficulty in swinging the arms backward, in involvement of the latissimus dorsi, and weakness in bringing the hands to- gether in front of the body in disturbance of the pectoral muscles. Impairment of flexion and extension at the elbow is seen in in- volvement of the biceps and triceps muscles. Weakness in pro- nation and supination of the forearms and inability to flex and extend the wrists, fingers and thumbs, is indicative of impairment of the particular groups of muscles which perform these acts. The dynamometer is useful in testing the strength of the grip and in comparing the two sides. The spinal group of muscles is tested by having the applicant Hex and extend the spine and bend the body from side to side. The power of the muscles of the lower extremities is tested in a manner similar to that used in the upper extremities, the applicant being directed to perform movements against resistance, in which the various groups of muscles are con- cerned; rotation, flexion and extension of the hips, flexion and ex- tension of the knees, ankles and toes, external and internal rotation of the foot; and any abnormalities noted. Along with the tests for muscle power, other muscle changes are observed such as: spasticity, contractures, spasms, tremors, flaccidity and atrophy. Spasticity indicates a lesion of the upper motor neuron; a spastic paralysis involving one side of the body, means a lesion of the internal capsule, pons or cerebral cortex THE NERVOUS SYSTEM 235 usually hemorrhage or thrombosis; spastic weakness of one arm or leg usually indicates an old hemiplegia, in which recovery is not complete or a focal lesion in which the centers for that particular member are involved; spastic paralysis of both lower extremities is seen in spinal cord lesions, such as tumor, transverse or ascending myelitis; general muscular spasticity or hypertonus is present in extensive upper neuron disturbance, such as lateral spinal sclerosis, and chronic or acute inflammatory or degenerative diseases of the cerebral meninges or brain cortex. In cases of long standing paral- ysis, contractures, due to unopposed muscular action invariably occur. Hluscular spasms are significant of nerve irritation, and are seen in both cortical and peripheral lesions. A flaccid paralysis or weakness is associated with lesions of the lower motor neuron, either in the cells in the anterior horns of the cord or the nerve trunk somewhere in its course. In flaccid paralysis of any duration muscular atrophy appears, due to the fact that the cells in the anterior horns of the cord, which have to do with nutrition of the parts, have been destroyed or their peripheral connections broken; a flaccid paralysis is typical of anterior poliomyelitis, peripheral neuritis, or nerve injury with destruction of the nerve fibers. Gen- eral muscular hypotonus in which there /is marked fatiguability, general weakness and muscular flaceidity is seen in all debilitating diseases, chronic sepsis, myasthenia gravis, and certain endocrin dyscrasias. (f) Reflexes.-A muscular reflex is the result of sensory stimula- tion, which having reached spinal motor centers, produces mus- cular contraction. The reflex arc consists of a sensory limb, asso- ciation fibers within the cord, a spinal motor center, and a motor limb, it is in association with the higher cerebral centers, by way of the spinal tracts. A destruction or blocking of this arc produces a diminution or loss of the reflex, while interference with the pathways between the spinal centers and the cerebral cortex causes an increase in the reflex; complete division of the cord, however, produces a total loss of the reflexes below the lesion. Reflexes may be divided conveniently into deep, superficial, and organic. In testing the reflex activity, the applicant should be completely relaxed, as many of the reflexes can be inhibited or in- creased at will. The pupillary reflex, which is very important in neurologic exami- 236 LIFE INSURANCE EXAMINATION nations, will be discussed under the examination of the eyes. The pharyngeal reflex is produced by irritating the walls of the pharynx with a cotton probe, and is expressed by a spasmodic contraction of the pharynx; the jaw reflex is elicited by placing a flat object, such as a ruler on the lower teeth, the mouth being partially opened, and tapping it with a percussion hammer, when a sharp contraction of the masseter muscles is noted. The triceps reflex is tested by having the applicant, while in the prone position, fold the arms lightly across the chest, and then tapping the triceps tendon just above the olecranon when a contraction of the triceps muscle follows; the biceps reflex is determined by raising the arms to the horizontal, flexing the elbow, supporting the whole arm by holding it at the wrist and tapping the biceps tendon just above the elbow, when a contraction of the biceps muscle results; the supinator reflex is tested by placing the forearm in a relaxed posi- tion, and tapping the body of the muscle, this is followed by an extension of the wrist. The epigastric and abdominal reflexes are determined by stroking downward from the nipple and the costal margin when a contraction of the abdominal muscles results; the cremasteric reflex is produced by stroking the inner surface of the thigh, which causes a retraction of the testicles. The patellar reflex or knee jerk may be elicited in a number of different ways; prob- ably the most satisfactory method is to have the applicant sit on a table allowing the legs to hang freely over the edge, divert the attention by having him close the eyes and then strike the tendon just below the patella. A quick extension of the leg follows. It is often necessary completely to distract the attention of the applicant before his reflex is well brought out; this may be done, by asking him to clasp the hands tightly, look up at the ceiling, recite a verse, or engage him in conversation before tapping the tendon. The Achilles reflex is tested by having the applicant kneel on a table, the feet hanging over the edge; the tendon Achilles is tapped and a plantar extension of the foot results. The ankle clonus consists of a series of clonic flexions and ex- tensions of the foot; it is obtained by having complete relaxation on the part of the applicant, rotating the leg outward, partially flexing the knee, grasping the calf muscles in the hand and sharply flexing the foot on the leg. The ankle clonus is pathologic, and while it may be found in conditions of nervous and emotional ex- citability, yet it is highly suggestive of an organic lesion of the THE NERVOUS SYSTEM 237 upper motor neuron. The plantar reflex is tested by stroking the sole of the foot on either the outer or inner border; this is followed by a quick flexion of all the toes, which is the normal reaction. The Babinski reflex is a reversed toe sign, and is obtained by stroking the outer border of the foot with a fairly sharp instrument; there results a dorsal extension of the great toe, that is the toe turns up instead of down, a spreading of the other toes and a slight rotation of the hip; the applicant should be recumbent, perfectly relaxed, the leg slightly rotated outward and flexed at the knee. In noting reflexes it should be stated if they are increased, diminished or absent. Nervous excitement increases reflexes and this factor should be given due importance; muscular tension re- tards the reflexes, and this too, should be considered. In a cer- tain number of healthy individuals, the reflexes are unusually brisk and in others they are greatly retarded or even absent; however, if there is any marked variation, an accurate description of these changes should be noted on the examination forms. Disturbance of the organic reflexes especially of the bladder and sexual apparatus are not infrequently early signs of organic nerv- ous diseases. Impairment of the bladder function with partial retention, slowness in starting the urinary stream, dribbling at the end of urination or complete incontinence are often early com- plaints in tabes dorsalis, multiple sclerosis and other types of organic disease of the brain and cord. These same symptoms may be purely functional and are met with in the psychoneuroses espe- cially hysteria. Sexual disturbances, such as impotence and ex- cessive erotism are usually functional, though a diminished sexual activity accompanies organic disease of the central nervous system. 2. Disturbance of Sensation.-Disturbances of sensation are among the common manifestations of both organic and functional nervous diseases. Head has divided sensibility into three types: (a) Epicritic sensibility which recognizes light touch, fine grades of temperature (2 to 5 degrees C.), cutaneous localization and distinction between two points; (b) Protopathic sensibility responds to the extremes of heat and cold (20 to 40 degrees C.), and to painful cutaneous stimuli; (c) Deep sensibility recognizes pressure, deep pain, bone- muscle and joint sense. Tactile sense or the sense of cutaneous touch is best tested by lightly touching the skin with a wisp of cotton or a camel's hair brush, and systematically going over the whole body 238 LIFE INSURANCE EXAMINATION ill both vertical and horizontal planes. The patient should be di- rected to say "yes" whenever he feels the touch and any variation from the normal should be charted and confirmed by later exam- ination. The temperattire sense is determined by having two test tubes, one filled with hot and the other with cold water; fairly ac- curate readings are made by noting the temperature of the two tubes; epicritic sensibility recognizes differences of from 2 to 5 degrees C. while protopathic sensibility recognizes more extreme temperatures. As in testing the tactile sense the body should be systematically examined for temperature disturbances. The abil- ity to distinguish between two points is tested by using the two blunt points of calipers; this sense varies considerably in different' individuals and on different parts of the body. Two mm. is per- ceived at the tip of the tongue or fingers, while on the back and thigh the minimum distance perceived is sixty to eighty mm. Pain sense is readily determined by pinching the skin or pricking it with any sharp-pointed object; an ordinary hatpin is a con- venient instrument, touching the skin first with the point and then with the blunt head, asking the applicant to distinguish between the two. This sense, like the others, should be tested systematically. The stereognostic sense is the ability to recognize objects by the sense of touch; it is tested by placing various objects in the hands and having the applicant with eyes closed, describe them; disturb- ance of this sense is seen in brain lesions involving the sensori- motor cortex. Pressure and deep pain sense are tested by making firm, deep pressure with the thumb and forefinger over the parts to be examined. Bone sensibility is elicited by placing a vibrating tuning fork over various bony prominences. Normally the vibrations should be perceived and the absence of this sense, especially over the sacrum, is highly suggestive of tabes. Muscle and joint sense is tested by moving parts of the body, such as the fingers or toes and asking the applicant to describe the movement ; the feet or knees may be flexed under unequal pressure or unequal weights may be placed in the hands and *the applicant asked to describe the difference on the two sides. Loss of sensation is called anesthesia, this may be partial or com- plete; loss of pain sense is known as analgesia; increased sensibil- ity is referred to as hyperesthesia; paresthesias are subjective sen- sory conditions; they are expressed as tingling, itching, numbness, coldness, formications, etc. THE NERVOUS SYSTEM 239 Disturbance of special senses. There is no organ of the body which is of more vital importance to the neurologist than the eye; by the aid of the ophthalmoscope the nerve head itself can be studied and early neural changes observed. As disturbances of the extrinsic or intrinsic motor mechanism of the eye are often among the first signs of organic nervous disease, it is essential to give this organ most carefid attention. Errors of Refraction may be tested by the ordinary Snellen type. A refractive error ordinarily should not be a cause for disqualifi- cation; however, marked refractive errors with blurring of vision are suggestive of underlying nervous disturbances. The field of vision may be roughly tested by having the appli- cant close, first, his left eye and look steadily with his right eye into the left eye of the examiner, whose right eye is closed and who is seated three or four feet directly in front. The examiner holds some small object (a piece of cotton on a probe) midway between the applicant and himself and outside the field of vision; the object is then brought slowly to the midline; the applicant should see it at the same time it is seen by the examiner. The same procedure is repeated with the right eye. Each eye is tested in four planes, external, internal, superior 'and inferior. The color field may be tested in the same manner, using different colored pieces of paper fastened to a probe instead of the white cotton. Concentric contraction or irregularities of the visual field, temporal or nasal hemianopsia and limitations or inversions of the color fields are brought out in this way. Disturbance of the visual field is very suggestive of organic nervous disease, although it is fre- quently a purely psychic manifestation. Applicants presenting such disturbances should be referred to a competent oculist for a com- plete perimetric and ophthalmoscopic examination. The extrinsic muscles of the eye are under control of the motor oculi group of nerves; that is, the third, fourth and sixth cranial. Diseased condition of any one of these nerves produces impairment of the movements of the eyeball and consequent diplopia or double vision. In testing the integrity of these nerves the applicant is asked to rotate the eyes in all directions; if there is involvement of the sixth nerve the eye cannot be turned outward, in third nerve palsy the eye is turned to the outer canthus and in addition there is ptosis of the upper lid and the pupil is widely dilated; 240 LIFE INSURANCE EXAMINATION impairment of the fourth nerve which supplies the superior oblique is difficult to elicit, although it produces diplopia. In complete paralysis of any one of the motor oculi nerves, it is not difficult' to decide which one is at fault; but in case there is only muscle weakness, it is not only difficult to tell which nerve is at fault, but even which eye is diseased. In long standing cases of motor oculi paralysis the diplopia disappears as the mind learns to disregard the weaker image. A simple method for testing for diplopia is to cover one eye with a piece of cardboard, held so that the motion of the covered eye can be observed; the applicant then fixes the uncovered eye on the finger of the examiner which is held a short distance in front of the eye, the finger is then moved from side to side and the movements of the covered eye carefully noticed; if the covered eye lags in any of the movements, which are performed in the four planes, it is the one which is affected; if on the other hand the covered eye is overactive and turns farther than the uncovered eye, the latter is involved. This may be checked up by trying the same maneuvers on the opposite eye. The direction in which motion is impaired points to the diseased muscle. There are occasionally cases of monocular diplopia which are due to diseased conditions of the eyeball or to hysteria. The motor ocidi nerves may be diseased at any place throughout their course; in their supranuclear motor pathways, at their nuclei or in their peripheral course. Supranuclear lesions producing hemi- plegia, usually cause a conjugate deviation of the eyes toward the healthy side of the body except when accompanied by cortical irritation with convulsions, when the eyes are turned to the para- lyzed side. Nuclear palsies are almost always bilateral and multiple, on account of the anatomical arrangement of the nuclei on the floor of the fourth ventricle. The motor oculi nerves pass by divergent routes from their nuclei, and throughout their intra- cerebral, intracranial or orbital course may be subjected to disease or injury; in which ease the symptoms are unilateral and ordi- narily involve a single nerve. Not infrequently motor oculi dis- turbance is transient, due presumably to local effusions or swellings along the course of the nerve. A peripheral neuritis is sometimes observed which produces a partial or complete but temporary ophthalmoplegia. Whatever the cause or wherever the lesion, motor ocidi palsy is usually indicative of organic nerve disease, THE NERVOUS SYSTEM 241 either central or peripheral, and should be regarded as an un- favorable sign in grading an insurance risk. Nystagmus consists of involuntary oscillations of the eyeball, the eye moving slowly in one direction and jerking rapidly back in the opposite. This oscillation is usually in the horizontal plane, but it may be vertical or rotary. It is best elicited by asking the applicant to forcibly rotate the eyes from side to side and then vertically. Its presence is suggestive of disease of the internal ear or cerebellum. Pupils.-Pupillary activity is governed by the third cranial nerve and the sympathetic. The third nerve controls contraction of the pupil and the sympathetic dilation. The pupils normally react to both light and accommodation. The light reflex may be tested in a number of different ways, depending on a quick change from dark- ness to light. It is seen by having the applicant close the eyes and open them quickly in a bright light or by covering the eyes with the hand and quickly removing it. The most satisfactory method is the use of the electric flash; the examiner shades the eye with his hand and with his flashlight close to the eye throws a ray of light on the pupil, which should contract promptly, relax slightly and then hold the contracted position. Each .'eye is tested separately and lastly the two are tested together. Accommodation is tested by asking the applicant to look at a distant object, twenty or thirty feet away and then look quickly at a near object eight or ten inches distant. The normal pupil contracts to accommodation as it does to light. After testing the activity of the pupils several questions should be asked: Are the pupils of equal size? Is the outline regu- lar? Do they react promptly and equally to light? Do they re- spond to accommodation? Is their action prompt or sluggish? Tn certain conditions, especially locomotor ataxia and general paresis the pupils respond to accommodation but not to light; this' is the Argyll-Robertson pupil. In examination of lhe pupil the effect of drugs, especially opium and belladonna, must be borne in mind. Pupillary disturbances are almost always indicative of an organic nerve lesion and should be sufficient to reject or at least defer action on an insurance applicant. Hearing.-The eighth or auditory nerve is made up of two por- tions: the cochlear branch which conducts sound impressions to the brain and the vestibular branch which carries the sensation of 242 LIFE INSURANCE EXAMINATION equilibrium from the semicircular canals to the brain. In disease either one or both portions of the nerve may be involved. Impair- ment of hearing or deafness may be due to disease of the ear itself or to the cochlear branch of the eighth nerve somewhere throughout its course; in the latter case it is referred to as nerve deafness. Normally the air conduction of sound waves is greater than the bone conduction; this may be demonstrated by closing the external meatus and placing the handle of a vibrating tuning fork against the mastoid; when the vibration is no longer heard, the meatus is released and the fork held near the external ear, the vibration should still be heard for several seconds. If bone conduction is better than air conduction obviously the trouble is in the mechanism of the ear itself. However, if there is an impairment of hearing and air conduction is still greater than bone conduction, and bone conduction does not recognize high or low notes, there is a nerve deafness. Hyperacuity of hearing or auditory hyperesthesia is due to irritation of the cochlear branch of the eighth nerve at some place in its course from the brain cortex to the internal ear. It is seen in inflammatory conditions of the meninges and brain cortex, in brain tumor, in Bell's palsy, in maniacal disturbances, in fear and nervous excitement and under the influence of stimulating drugs. Tinnitus aurium is associated with irritation in any part of the auditory apparatus; it may be in the external or middle ear, or it may be produced by a disease or irritation of the internal ear or auditory nerve, itself. This symptom may be of little impor- tance so far as an insurance risk is concerned, but its presence should arouse the suspicion of the examiner and its exact cause should be determined before action on the applicant is taken. Aural vertigo or Menieres disease is due to disturbance of the semi- circular canals. Nystagmus is associated with aural vertigo, the quick movement being to the affected side. The subjective symp- toms of aural vertigo are those of falling or of the body's being rotated from side to side; at times it appears as if external objects instead of the body were being turned or rotated. Persistent vertigo is a common symptom in organic disease of the brain, es- pecially tumor or cerebellar disease. Tests, of which the Barany turning test and the ear douche are the most satisfactory, have been devised to determine the presence or absence of internal ear disease. Smell.-The sense of smell may be increased or decreased. It is tested by asking the applicant to distinguish well-known odors, THE NERVOUS SYSTEM 243 which are not too strong or irritating. Each side is tested sepa- rately and the inhalations should not be deep. Local conditions, such as nasal catarrh or coryza impair this sense. Perversions of smell, hyperacuteness or impairment are often the result of purely psychic conditions. Focal lesions, such as tumor, abscess, localized meningitis, etc., involving the olfactory bulb or tract will produce disturbances of this sense. The olfactory nerve probably has a bilateral cortical representation in the tempero-sphenoidal lobes. The so-called "uncinate fit" is preceded by an aura of the sense of smell and is associated with disease of the uncinate gyrus. Taste.-This sense is conveniently tested by using concentrated solutions of sugar, vinegar, quinine and salt; these solutions are applied to small areas of the protruded tongue with a cotton probe. Powders may be used instead of solutions if so desired. After the application is made it requires several seconds before the taste sen- sation is received. Sour and salt are perceived at the tip of the tongue, bitter and sweet at the base. Disturbance of taste at the tip of the tongue is found in lesions involving the chorda tympani nerve and is seen especially in Bell's palsy. Perversions of taste are frequent signs of hysteria. 3'. Diseased Conditions In this section an effort will be made to enumerate the more im- portant affections of the mind and nervous system. No attempt will be made to discuss the pathology and only the more important symp- toms and signs will be mentioned. Greater stress will be placed on the prognosis and the influence these diseased conditions should have on insurance risks. For the purposes of this chapter these affections are grouped on an anatomic rather than on an etio- logic or symptomatic basis. The following groups will be con- sidered: (a) Diseases of the cranial nerve, (b) Diseases of the cerebrospinal meninges, (e) Affections of the brain, (d) Affections of the spinal cord, (e) Diseases of the peripheral nerves, (f) Endocrin disturbances, (g) The neuroses, (h) The psychoneuroses, (i) The psychoses. 1. Diseases of the Cranial Nerves.-The cranial nerves may be dis- eased or injured at any place throughout their course from their cortical representations to their peripheral terminations. The first cranial or olfactory nerve is probably never the seat of primary or 244 LIFE INSURANCE EXAMINATION isolated involvement, but always associated with widespread disease of the central nervous system. The most common disturbances of smell are due either to local conditions in the nasal passages or to psychic manifestations. Affections of the second, or optic nerve are accompanied by dis- turbances of vision and are usually a manifestation of extensive intracranial disease or a general constitutional derangement. A general impairment and blurring of vision is seen in optic neuritis and optic atrophy. Optic neuritis is occasionally of toxic origin and may entirely disappear without serious sequela after the causa- tive agent is removed. Often, however, it is of a more serious nature and terminates in an actual atrophy of the optic nerve. The optic nerve may, itself, he diseased or injured at any point between chiasm and the globe of the eye, in which case there is partial or complete blindness and the pupil does not react to light. In lesions of the chiasm the nasal half of each retina is blinded and we have a bilateral temporal hemianopsia. If the optic tract is diseased there is a lateral homonymous hemianopsia, that is, the temporal half of the retina on the same side as the lesion and the nasal half on the opposite half are blinded. If the pupil reacts when a ray of light is thrown on the blinded retina the lesion is back of the geniculate bodies. Lesions of the optic nerve, chiasm and tract may be the result of pressure from tumors, hemorrhage, exostoses, focal soften- ing or trauma. Rarely do the signs of optic nerve involvement stand alone; they are almost always accompanied by other signs of gross brain disease or constitutional ailment. Lesions of the motor oculi group, that is, the third, fourth and sixth cranial nerves, give rise to extrinsic oculomotor paralysis. In disease or injury of the third nerve there is palsy or complete paralysis of all the extrinsic muscles of the eye, except the superior oblique and external rectus, consequently the eye turns outward on account of the unopposed action of the external rectus, the upper lid is in a position of ptosis and the pupil is widely dilated. Lesions of the fourth nerve, which supplies the superior oblique muscle, cause the eyeball to rotate slightly outward and produce the symp- tom of diplopia. Involvement of the sixth nerve which supplies the external rectus, produces a convergent deviation of the eye. Diplopia or double vision is a subjective symptom in any of the motor oculi palsies. The motor oculi nerves may be damaged in their peripheral course, at their nuclei or in their supranuclear rep- THE NERVOUS SYSTEM 245 resentation. On account of the wide dispersion of these nerves after leaving their nuclei, any one may be involved and others spared, giving rise to a single nerve palsy. In nuclear disease there is a multiple bilateral paralysis on account of the close proximity of the various nuclei on the door of the fourth ventricle. Involvement of the motor oculi group of nerves, as with the olfactory and optic, is usually a sign of extensive intracranial disease and is generally due to pressure or degenerative changes. The trifacial or fifth nerve is both sensory and motor; it supplies cutaneous sensory fibers to the entire face, taste fibers to the tongue and motor fibers to the mandibular muscles. By far the more common affection of the fifth nerve is trifacial neuralgia, which, when accompanied by facial spasm is known as tic douloureux. The cause of trifacial neuralgia is not definitely known though it is often associated with local inflammatory conditions, such as: carious teeth, infected nasal sinuses, diseased tonsils and affections of the eyes and ears. The more severe and intractable types are probably due to sclerotic changes in the Gasserian ganglion, and in cases of long standing degenerative changes take place within the nerve and a true neuritis is the result. The symptoms of trifacial neu- ralgia are classical, consisting of intense, sharp, lancinating pains along the course of the superficial branches of the nerve and with points of tenderness at the supraorbital, infraorbital or inferior dental foramina, depending upon which branch is most seriously involved. Sufferers from trifacial neuralgia should not be consid- ered good insurance risks. The disease is essentially chronic, though there may be long periods of rest between attacks. Victims of this disease sooner or later become semi-invalids, a certain number be- come drug addicts and others commit suicide. In addition to the above-mentioned common affections of the tri- facial nerve, this nerve may be diseased at its cortical motor area, at its nucleus, or its intracranial peripheral portion. Disease in- volving the motor cortex of the fifth nerve is characterized by chronic or tonic spasms of the masseter, pterygoid and temporal muscles. Nuclear and peripheral disease produce disturbance of sensation, glandular secretions and certain vasomotor changes corre- sponding to the cutaneous distribution of the nerve, and motor palsy or paralysis of the muscles supplied by its motor fibers. Such affections are usually a part of an extensive central nervous disease. The seventh or facial nerve is the motor nerve of the face, supply- 246 LIFE INSURANCE EXAMINATION ing fibers to all the facial muscles including the platysma, stylo- hyoid, posterior belly of the digastric, and in addition, taste and secretory fibers by way of the chorda tympani branch, which is given off from the facial just before it leaves the aqueductus Fallopii. Cortical disease of the seventh nerve is usually accompanied by clonic facial spasm; these spasms must be differentiated from habit or spasmodic tics which are psychic in character. Facial spasm is often a feature of Jacksonian convulsions. Supranuclear facial palsy involves principally the lower portion of the face, and is most often seen in capsular hemorrhage or thrombosis of the hemiplegic type. Nuclear palsy of the seventh nerve produces a complete motor paralysis, but there is no disturbance of taste, salivation or hearing, and other basilar nuclei are also involved. The most common type of facial paralysis is a peripheral neuritis commonly known as Bell's palsy. This condition is due to inflam- mation, swelling or injury of the nerve at its exit from the styloid foramen or within the aqueductus Fallopii. Among the more com- mon, specific causes are extension of an inflammatory process from the middle ear or mastoid, and exposure to cold directly over the side of the face. The older authorities placed much stress on the "rheumatic type" of facial paralysis. The onset is usually sudden, the sufferer often waking in the morning to find his face completely paralyzed; in other cases the onset is more gradual and complete paralysis is never reached. In a typical case the patient is unable to wrinkle the brow or close the eyes and the mouth is drawn to the unparalyzed side. It is impossible to pucker the lips, saliva drools from the paralyzed side, food collects in the cheek and the weakened buccal muscles puff out in expiration. The tongue is not disturbed and speech is not affected except by the awkward- ness of the paralyzed buccal muscles. If the lesion is fairly well up in the aqueduct it involves the chorda tympani nerve and taste is lost on the diseased side. If the lesion is still higher in the aqueduct, the nerve to the stapedius muscle is damaged and there is hyperacuity to low-pitched sounds on the paralyzed side. In the ordinary type of Bell's palsy, that due to exposure or the rheumatic type, Hie outlook is good and recovery, at least partial, is the rule. An applicant having suffered from this affection should be looked upon with suspicion, but if there are no other signs of organic nerve THE NERVOUS SYSTEM 247 disease or constitutional disability, this affection alone should not disqualify. Disease of the eighth or auditory nerve is characterized by dis- turbance in the function of hearing. This nerve is made up of two branches, the cochlear which conveys sound sensation and the vestibular which conducts sensations of space to the higher brain centers. The differentiation between nerve deafness and that due to causes within the ear itself has already been discussed. Cortical lesions, involving the first left temporal lobe, cause word deafness, or auditory aphasia; that.is the individual hears, but does not understand what is said to him. Lesions of both temporal lobes produce a complete deafness. The peripheral portion of the eighth nerve may be damaged in meningitis, syphilis, or brain tumor, or occasionally it may be the seat of a simple neuritis from exposure to cold or an extension of inflammatory processes from neighboring structures. Disease of the vestibular portion of the nerve or the internal ear is accompanied by vertigo, nystagmus and disturbance of special orientation. Nerve deafness or aural vertigo should be considered seriously as these conditions are usually associated with extensive organic disease of the central nervous system. The ninth or glossopharyngeal nerve, on account of its close asso- ciation with the tenth and eleventh nerves, is probably never the seat of isolated involvement. The tenth cranial, vagus or pnerimogastric and the bulbar portion of the eleventh or spinal accessory nerves are closely associated and together with the ninth cranial constitute the visceral nerve supply. They are both motor and sensory. The nuclei of these nerves are so intimately connected, that in nuclear disease all are affected, and the signs correspond to their widespread distribution. In destruc- tive nuclear lesions of this nerve group, there will be found pharyngeal and laryngeal palsy, tachycardia, disturbed respiration and gastric immobility. The vagal group may be subjected to injury, reflex dis- turbances or the effect of certain toxins producing either irritation or destruction. Pharyngeal and laryngeal paralysis are frequently the result of a postdiphtheritic neuritis; laryngeal spasm is the result of irritation of the recurrent laryngeal nerve; bronchial asthma and the so-called nervous cough is sometimes considered as being due to irritation of the vagus. Irritation of the vagus, as is seen in menin- gitis, brain tumor, or fracture at the base, produces a bradycardia; while paralysis of the vagus produces a rapid heart. The projectile 248 LIFE INSURANCE EXAMINATION vomiting of basilar meningitis is due to pneumogastric irritation, and many of the common cardiac and gastric neuroses are dependent on a vagal reflex. The spinal portion of the eleventh or spinal accessory nerve should not be considered a cranial nerve, as it arises from the cer- vical cord, though on account of its course it is often involved in intracranial disease or injury. This involvement may be destructive or irritative, central or peripheral. If destructive, there is paraly- sis of the sternocleidomastoid and trapezius muscles which it sup- plies; if irritative, there is a tonic contraction of these muscles, resulting in a spasmodic torticollis. This condition is often due to exposure to cold and recovery is common ; in other cases, however, it is due to organic changes within the nerve and the outlook is unfavorable. These cases should be regarded with suspicion as in- surance risks. The twelfth cranial or hypoglossal nerve is the motor nerve of the tongue. Isolated disease of this nerve is rare, as its cortical area, supranuclear course, nucleus and peripheral portion are so closely associated with other structures. In cortical and supranuclear de- structive lesions the opposite side of the tongue is paralyzed and deviates away from the lesion. Tn ordinary capsular hemorrhage with hemiplegia, the tongue is usually involved and deviates to the paralyzed side. Nuclear involvement is usually bilateral, there is complete paralysis and rapid atrophy of the whole tongue. Cortical irritation such as is seen in general paresis often produces tremor and spasmodic twitchings of the tongue. As has been stated previously, cranial nerve disease is rarely an isolated condition; considering the anatomical relationship of their cortical areas, the close approximation of their nuclei at the base and their intracranial peripheral course, it is difficult to see how one nerve can be diseased without involvement of others. On the other hand, it is easy to understand how almost any sort of an in- tracranial lesion would involve one or more of the cranial nerves. The condition known as polioencephalitis superior or ophthalmo- plegia is a nuclear paralysis of the motor oculi group of nerves, and polioencephalitis inferior or bulbar palsy is a paralysis of the lower group, that is, the seventh, ninth, tenth, eleventh and twelfth cranial nerves. To the insurance examiner, a cranial nerve disease, except per- haps a clear-cut Bell's palsy, should be regarded as a sign of THE NERVOUS SYSTEM 249 severe nerve affection until it is proved otherwise by careful exami- nation and study of the applicant. 2. Diseases of the Cerebrospinal Meninges.-The cerebrospinal meninges which invest the brain and cord consist of two membranes, an outer tough, fibrous membrane, the dura mater; and an inner, loose-meshed vascular membrane, the piaarachnoid; between the layers of the latter is the subarachnoid space, containing the cerebrospinal fluid. These membranes may become involved in acute or chronic inflammatory conditions. This involvement may be localized in areas of either the cerebral or spinal meninges, or, as is usually the case, both the cerebral and spinal meninges take part in the diseased condition. Pachymeningitis or inflammation of the dura is usually a localized process. It may involve either the cerebral or spinal meninges. It is seen in chronic alcoholism, syphilis, chronic Bright's disease, Potts' disease, severe infectious conditions and trauma. The symp- toms are those of a focal disease and depend upon the site of the lesion; if the motor cortical areas are involved, there may be Jack- sonian attacks with rigidity and later spastic paralysis; if at the base, cranial nerve palsy is usually present; if the spinal dura is involved, symptoms of cord pressure corresponding to the level of the lesion are seen. Often, especially in early cases, the signs are vague and indefinite; presistent headache, attacks of vertigo, in- somnia and mental enfeeblement are suggestive signs. Recovery from this disease is rare and depends upon the underlying causes. Leptomeningitis or inflammation of the piaarachnoid may be acute or chronic. The acute type is caused by direct invasion of the meninges by an infectious organism; this infection may be blood- borne or by continuity of structures. The most common infective organisms are the diplococcus intracellularis, the pneumococcus, the streptococcus or staphylococcus. This disease runs an acute course with more or less febrile reaction and the signs of meningeal irri- tation, such as headache, mental hebetude or active delirium, pupil- lary changes, muscular rigidity especially in the neck and back, convulsive seizures, increase in reflexes and cranial nerve palsies. Recovery from the acute attack, ('specially in the epidemic type is frequent, but in the great majority of cases the patient is more or less permanently disabled in the way of localized palsies, mental enfeeblement or psychoneurotic disturbances usually of the neuras- thenic type. It is very doubtful whether any case of recovered 250 LIFE INSURANCE EXAMINATION meningitis is a good insurance risk, certainly not for a long time after the attack. The chronic type of cerebrospinal meningitis is usually due to tuberculosis or syphilis. The symptomatology is similar to that of the acute variety, though the progress is much slower. Recovery from tuberculous meningitis probably never occurs, and while the active signs in syphilitic meningitis may subside under proper treat- ment, yet they are always uncertain. It is possible that an appli- cant in the early stage of either syphilitic or tuberculous meningitis may present himself to the insurance examiner. The history of syphilis or tuberculosis with the symptoms of headache, mental hebetude or excitement, muscular rigidities, disturbance of the cranial nerves or changes in the reflexes should at once put the examiner on his guard. 3. Affections of the Brain.-The brain, like other organs of the body, is subject to vascular changes, inflammatory conditions as the result of infectious or chemical toxins, new growths and trauma. On account of its histological and anatomical arrangement, it is more vulnerable and perhaps responds more quickly to diseased conditions than any other organ. Normally the brain is constantly undergoing minor vascular changes due to variations in systemic blood pressure; but at times, there may be an actual anemia or hyperemia of the brain substance. These conditions are secondary and are due to a general circulatory imbalance. Acute anemia of the brain is seen typically in hemorrhage; there is faintness, vertigo, tremor, nausea and vomiting and general weakness. In chronic brain anemia, such as is seen in debilitating diseases, there is physi- cal weakness, lack of mental concentration, impairment of memory, nervousness, tremor, vertigo and dizziness. Cerebral hyperemia is usually an expression of a general increase in blood pressure; it is characterized by throbbing headache, mental hebetude, blurring of vision and vertigo. The prognosis in these conditions depends on the underlying cause. Cerebral arteriosclerosis is a local expression of a general and widespread arterial degeneration; although not infrequently, the cerebral symptoms precede those of arterial changes in other parts of the body. The symptoms of brain arteriosclerosis are due to faulty nutrition and depend on the areas of the brain involved. The onset is slow and insidious; there is indefinite headache, mental changes in the way of memory defects, impaired activity, peculiar THE NERVOUS SYSTEM 251 actions and ideas of self-importance. There may be focal signs in the way of convulsive seizures, disturbance of speech, diplopia or other cranial nerve palsies, localized spasms or paralysis. In ad- dition to the cerebral symptoms, some of the signs of general arterio- sclerosis are present. Cerebral hemorrhage usually refers to the internal capsular type, in which there is rupture of the lenticulostriate artery with a re- sultant hemiplegia on the opposite side of the body. While this is the most common and usual type, hemorrhage may occur in any part of the brain and the symptoms will correspond to the site of the lesion. The onset in cerebral hemorrhage of the capsular variety is usually sudden; there is more or less loss of consciousness, slow full pulse, stertorous breathing and peripheral congestion. At first there is a general muscular relaxation and it is difficult to tell which side is involved. As consciousness returns, it is noted that one side is in a state of flaccid paralysis; generally the lower portion of the face and the tongue are also involved. After a time, the paralysis becomes of the spastic type with rigidities, contrac- tures and heightened reflexes. The individual is then in the hemi- plegic state and complete recovery from the paralysis rarely occurs. Cases in which the hemorrhage is slow and small in quantity show a slower onset and an incomplete paralysis. Not infrequently in the course of general paresis, multiple sclerosis and other general brain diseases a temporary hemiplegia is seen, due to local brain swell- ing rather than hemorrhage. Hemorrhage of the motor cortex may produce a complete hemiplegia, but the onset is more gradual and is attended by signs of cortical irritation in the way of localized convulsive seizures. Needless to say no one who has suffered from a cerebral hemorrhage should be considered as an insurance risk. The term cerebral softening is one used to cover a large number of conditions but it should apply really to those cases in which there is degeneration following arterial occlusion, embolism or thrombosis. The onset may be slow or rapid, and the symptoms vary with the location of the lesion. They may be hemiplegic or monop]egic in type, showing successive involvement as different areas of the brain become damaged. Recovery does not occur as the brain tissue is destroyed through lack of nutrition, and only moderate improvement can be expected. The venous channels as well as the arterial system of the brain may become diseased through trauma or infectious processes. These 252 LIFE INSURANCE EXAMINATION are acute conditions and would not be presented to the insurance examiner in their fulminating state. There is usually a complicat- ing fatal meningitis or brain abscess, but complete recovery occa- sionally occurs. An applicant giving a history of sinus thrombosis with complete recovery and no residual signs would not be an un- favorable risk. The brain tissue may become the seat of inflammatory processes through continuity of structures or by hematogenous infection. Practically all cases of meningitis are accompanied by a degree of cerebral inflammation. Lethargic encephalitis or as it is more properly named, epidemic encephalitis, is a disease which has come into prominence in the past few years and one which is of considerable importance to the insurance examiner. The symptoms of this disease are varied; the onset is usually gradual, following an attack of influenza or other nasopharyngeal infection ; insomnia is often an early symptom, or on the other hand there may be a marked lethargy and mental stupor; headache, general muscle and joint pains are present; al- most invariably at some time during the course of the disease there is one or more cranial nerve palsies, such as diplopia, ptosis, diffi- culty in swallowing or a seventh nerve paralysis. The facial ex- pression is immobile and the normal lines smoothed out. The disease is usually afebrile and there are no characteristic circulatory changes. Some cases are so mild that the patient is ambulatory throughout the acute stage of the disease, which lasts from two to four months. The sequelae of this disease are numerous; there may he residual palsies which never entirely clear up, mental en- feeblement or psychoneurotic symptoms of a neurasthenic or hys- terical nature. It is doubtful whether an individual having suf- fered from lethargic encephalitis is ever a good insurance risk. Bearing in mind the prevalence of this disease in recent years and the mild type it often assumes, the insurance examiner should be on the alert to detect its presence. Cerebritis or inflammation of the brain parenchyma is not often present as a generalized condition, though frequently seen as a localized inflammatory process following trauma or infective em- boli. The mental deterioration following some of the acute infec- tious diseases, such as sunstroke and chronic alcoholism is probably the result of a generalized cerebritis. A localized cerebritis is often followed by abscess formation as the inflamed and broken-down THE NERVOUS SYSTEM 253 brain tissues make an ideal lodging place for pathogenic organisms. The symptoms of brain abscess are vague and indefinite; the general symptoms consist of headache, fairly well localized, occasionally a low grade febrile state, mental stupor or active delirium. The focal symptoms depend upon the location of the abscess and the tissues invaded. Brain abscess often shows remissions during which time the patient is practically without symptoms. During this state an applicant might present himself for an examination, but a history of recent suppurative ear disease, general septic infection or trauma followed by headache, mental stupor and perhaps some focal signs would at once arouse the examiner's suspicions. Of other acute infectious diseases of the brain, may be mentioned Sydenham's chorea, hydrophobia, and tetanus. In these conditions, the cord takes part in the diseased process as well as the brain. Chorea or St. Vitus dance is essentially a disease of childhood, though not infrequently it is seen in young adults. Tt is character- ized by coarse, irregular, purposeless, involuntary movements and muscular twitchings. It is often associated with rheumatism, and damage to the endocardium is a fre'quent sequela. An applicant should not be accepted for insurance during an acute attack of this disease, and one giving a history of having had chorea should be looked upon as a potential case of organic heart disease. Both tetanus and hydrophobia, or rabies, usually end fatally in the acute attack. If, however, recovery is complete without un- favorable sequelae, there is no reason why such a case should not be a fair insurance risk. Among the chronic infections of the brain, cerebral syphilis is the most important. It is impossible to say what percentage of syphilitics develop brain symptoms. The prevalence of this disease and the variable onset of the nerve involvement is of special interest to the insurance examiner; and the reader is referred to the Chapter on "Syphilis" for a more detailed discussion. The early mental symptoms of brain syphilis are often those of mild exaltation, with expansive ideas of self-importance, changes in conduct, excesses and peculiarities, or there may be depression with vague regrets, ideas of persecution, neglect, personal inferiority, and apprehensions. Along with these emotional disturbances there is a lack of reason and judgment and impairment in the power of coordinate thought. The early physical signs may be few: a slight unsteadiness in gait, a suggestion of a positive Romberg, a fine 254 LIFE INSURANCE EXAMINATION tremor in the fingers, tongue or nasolabial fold; irregularity of the pupils, voice changes, a general increase in the tendon reflexes and possibly a reversal toe sign. Such cases should be subjected to a most careful investigation including a study of the blood and spinal fluid. While under proper treatment, many show marked remissions yet they are never suitable insurance risks. Multiple sclerosis is probably of infectious origin; though the specific agent is not known, it frequently follows the acute infec- tious diseases and is seen in connection with some of the metallic poisons. Overwork and exposure contribute as etiological factors. The pathology is that of multiple sclerotic areas scattered through- out the brain, cord and even the peripheral nerves, especially the cranial group. The symptom complex of this disease is fairly con- stant ; there is a general muscular weakness of the spastic rigid type, more marked in the lower than the upper extremities, the gait is ataxic and Romberg sign present, all deep reflexes are in- creased and the Babinski sign is positive. A characteristic sign is the coarse, intentional tremor most noticeable in the hands, the speech is slow, monotonous and scanning, the pupils are often af- fected, there may be optic nerve atrophy and often there is bulbar palsy with difficulty in swallowing; attacks of vertigo and apoplecti- form seizures are common. The mental changes are those of a pro- gressive dementia. The progress of this disease is steadily down- ward, though there are often remissions lasting quite some time. The basilar ganglia are usually more or less involved in general brain conditions and the symptoms produced by their involvement are concomitant with those of widespread brain disease. Polio- encephalitis superior or ophthalmoplegia and polioencephalitis in- ferior, have already been discussed. Wilson's disease or progressive lenticular degeneration is associated with degeneration of the len- ticular nuclei. This disease is characterized by increased emo- tionalism, progressive dementia, spastic muscular weakness and tremor with athetoid movements. Parkinson's disease or paralysis agitans is thought by some authorities to be due to changes in the striate body. Paralysis agitans is characterized by muscular rigidi- ties, a peculiar propulsive gait, a mask-like facial expression, mo- notonous speech and tremor of the nonintentional type. The re- flexes may be moderately increased and the pain which is usually present is due rather to the cramped muscles than to sensory in- volvement. The onset is slow, usually involving first one extremity THE NERVOUS SYSTEM 255 and then another. In the early stages an applicant may present himself for insurance examination; however, the muscular rigidity, tremor and facial expression should be of significance to the ex- aminer. Under the term brain tumor is included not only neoplasms of the brain itself, but new growths of the calvarium or meninges, aneurysm of the cerebral blood vessels, brain cysts and other condi- tions in which there is increased intracranial pressure with or with- out focal symptoms. The symptoms of brain tumor may be divided into two groups, general and focal. The general symptoms consist of headache, either frontal or occipital, which is dull and persistent with ex- acerbations of more acute pain; vertigo and vomiting are especially common in cerebellar tumors; mental impairment is frequent if the frontal lobes are involved; convulsive seizures either general or Jacksonian are often present and optic neuritis or choked discs arc almost pathognomonic. The focal symptoms depend upon the location of the tumor and the structures involved by it. Tumors at the base almost invariably produce some cranial nerve disturbance; if in the motor cortex, local rigidities or convulsions and paralysis of the spastic type are common; ataxia and vertigo are prominent symptoms in tumors of the cerebellum. Obviously, no case of brain tumor should be accepted as an insurance risk. The question of accepting such a case after successful operation with removal of the tumor is very doubtful. Intrauterine disease or injury of the brain at the time of birth usually results in such marked defects, both physical and mental, that such a case would hardly be presented for insurance examina- tion. In this group is placed hydrocephalus, Little's disease, the various birth palsies and certain types of idiocy. Brain injury, with or without fracture of the skull, is a condition of greatest importance to the insurance examiner. The severity of skull fracture and its prognosis depends on the damage done to the brain tissue from hemorrhage by displaced bone, by contusion and laceration of the brain tissue and by certain changes in the molecular arrangement of the brain cells and conducting fibers. These same conditions may be present in head injury without skull fracture. Applicants with a history of severe head injury are al- ways doubtful risks, especially in industrial insurance. Even though there are no physical signs of brain injury this class of 256 LIFE INSURANCE EXAMINATION patients are often semi-invalids, complaining of headache, dizziness and a wide range of psychoneurotic symptoms in the way of easy fatigue, lack of physical energy, impairment of mental activity, suggestibility and hypochondriasis. 4. Affections of the Spinal Cord.-Affections of the spinal cord may be considered as those primarily involving the gray matter, those involving the white matter and those involving the cord as a whole. Uncomplicated lesions of the spinal gray matter of whatever cause have in common certain signs: that is, flaccid paralysis of the lower motor-neuron type with loss of reflexes and muscular atrophy. Lesions of the spinal white matter, if involving the motor tracts, produce spastic paralysis with increase in reflexes and no muscular atrophy; if involving the sensory tracts there is ataxia, incoordination, and sensory disturbances. These different types may occur singly or, as is often the case, in combination, one type being primary with predominate symptoms and the other type ap- pearing as a secondary manifestation. Anterior poliomyelitis or infantile paralysis is an acute infectious disease in which the gray cells in the anterior horns of the cord are primarily involved. It is essentially a disease of childhood but may be seen in adult life. The signs are those of a flaccid mus- cular paralysis involving single muscles or muscle groups; the re- flexes of the affected muscles are lost and there is rapid atrophy. Mild or abortive cases make a complete recovery, but the more severe cases usually present some permanent muscular weakness and atrophy. There is no reason why a recovered case of polio- myelitis even with paralysis and muscular atrophy is not a good insurance risk. There is a large group of conditions in which the characteristic signs are progressive muscular weakness and atrophy. They are described under different terms, progressive muscular atrophy, amy- lotrophic lateral sclerosis, Duchenne-Aran disease, Charcot's disease, wasting palsy and chronic poliomyelitis. In certain cases the signs are purely those of a slowly developing progressive muscular weak- ness of the flaccid type with diminished or abolished reflexes and trophic changes, the so-called Duchenne-Aran type. In other cases, degeneration in the lateral tracts precedes or is coincident with the degeneration in the anterior cells, the muscles showing spas- ticity and rigidity with increased reflexes; but as the anterior cells THE NERVOUS SYSTEM 257 become involved the spasticity gives way to flaccidity with absent reflexes and atrophy. Jji the same cases there may be flaccid paraly- sis in one extremity and spasticity in another. If degeneration of lhe anterior cells, that is the lower motor neuron, is primary, the signs of degeneration in the lateral tracts are obscure. This disease usually begins in the upper extremities, in the hand or shoulder muscles and the tendency is to progress to other parts of the body; the bulbar nuclei may be involved, producing a polioencephalitis. The outlook as to recovery is bad, though at times the disease re- mains stationary for a long period. There is another group of progressive muscular atrophies, asso- ciated with muscular hypertrophy or pseudohypertrophy, which is described under the name of progressive muscular dystrophies or Erb's disease. To this group belong the pseudohypertrophies of childhood, congenital amyotonia, and perhaps Thompsen's disease. The pathology is not well known, but it is no doubt fundamentally the same as in the group previously described. Syringomyelia is caused by an enlargement of the central canal of the cord; this may be hereditary or acquired following glio- matous infiltration, central myelitis or hemorrhage. The character- istic symptoms are a thermoanesthesia and, a partial or complete analgesia but with a preservation of tactile or epicritic sensibility. These peculiar sensory changes are usually bilateral and correspond with fair accuracy to certain spinal segments; as the enlargement of the central canal becomes more extensive and encroaches on the lateral columns and anterior cells, motor symptoms appear and the clinical signs of an amyotrophic lateral sclerosis of either the upper or lower neuron type may be present. The disease is pro- gressive and is ultimately fatal, though there may be long periods of remission. The most important disease affecting the white matter of the cord is locomotor ataxia or tabes dorsalis. As general paresis is syphilis of the brain, so tabes is syphilis of the cord. The primary lesion is in the posterior root ganglia from which place the degen- erative changes extend to the posterior columns of the cord. The early symptoms therefore are sensory in character and are varied in their manifestations. They consist of sharp, shooting, lancinat- ing pains usually in the legs, often worse at night; constricting bands about the ankles and knees and especially about the waist- line; gastric crises with intense pain often mistaken for an acute 258 LIFE INSURANCE EXAMINATION intraabdominal inflammatory condition; bladder disturbance, either retention or incontinence; unsteadiness in gait, especially in the dark and incoordination in the finer movements O'f the hands. The physical signs show a positive Romberg, absent patellar reflexes, Argyll-Robertson pupil, muscular incoordination and an impair- ment of sensation, especially deep sensibility. On account of the prevalence of this disease, its insidious onset and unfavorable prog- nosis, the insurance examiner should regard any of the above symptoms and signs as suspicious and should use every means in- cluding blood and spinal fluid examination to establish a diagnosis. The condition known as posterolateral or combined cord sclerosis presents the signs and symptoms of tabes plus the signs of a lateral tract or upper motor neuron sclerosis, that is, spasticity and muscular weakness; the condition of the reflexes depends on the predominant lesion; if it is in the posterior columns they will be diminished or absent, if in the lateral columns increased. This condition is often an extension of the sclerotic changes of tabes; it is frequently associated with general paresis and there are a small number of cases which seem to follow infectious and toxic conditions, particularly pernicious anemia and pellagra. There is also occasionally seen a pure lateral tract sclerosis pre- senting the signs of upper motor neuron disease with spastic mus- cular weakness, increase in reflexes and a reversed toe sign, but without the sensory symptoms found in posterior column degen- eration. This condition is generally caused by syphilis but is some- times seen following certain infectious diseases and as an hered- itary disease is known as hereditary spastic paraplegia. Under the term family ataxia, Freidrich ataxia or hereditary cere- bellar ataxia are grouped a class of cases presenting pathologically congenital defects in the cerebellum and posterolateral tracts. The predominant symptoms are ataxia without great impairment of muscular strength, coarse jerky movements of the extremities, im- pairment of speech, mask-like facial expression, nystagmus, reflex variations, disturbances of deep sensibility and mental enfeeble- ment. Myelitis or inflammation of the cord attacks both the gray and white matter, though one may be more seriously involved than the other. The lesion may extend through a transverse area or be dis- seminated throughout the cord. Transverse myelitis is seen follow- ing hematomyelia, direct injury to the cord, pressure from fracture- THE NERVOUS SYSTEM 259 dislocation, Pott's disease, tumor or sometimes it may follow the acute infectious diseases or it may be of unknown origin. The symptoms of transverse myelitis are those of a paraplegia of vary- ing degree depending on the damage done to the cord and the spinal segments involved. Paraplegia is characterized by a spastic paralysis with heightened reflexes below the level of the lesion; there may be either incontinence or retention of urine; reflexes whose arcs are incorporated in the lesion are lost and there is muscular atrophy corresponding to the anterior horns which are damaged. Just above the segmental level of the lesion there is usually an area of hyperesthesia due to root irritation; below the lesion there is anesthesia of varying degree. The prognosis of transverse myelitis depends on the cause and the amount of de- generation which has taken place in the elements of the cord. In cases due to extraneous pressure, such as fracture-dislocation, Pott's disease or tumor, and in which there has not been great damage to the cord, fair improvement can be expected with removal of the cause. Cases due to thrombotic softening, hemorrhage, serious lac- eration and contusions or active infectious lesions in which there has been marked cord degeneration, remain in a state of permanent paraplegia. !■ Disseminate myelitis presents a variety of symptoms according to the seat of the lesions. Motor weakness of both the upper and lower neuron type may be present with the characteristic reflex change; there may be various sensory disturbances or sensation may be entirely free. Landry's ascending paralysis is characterized by a muscular pa- ralysis beginning in the feet and legs, gradually extending upwards involving the trunk, upper extremities and bulbar nuclei; the pa- ralysis may be of the flaccid or spastic type depending on the damage done to the anterior cells. Sensory symptoms may be entirely absent or there may be more or less anesthesia as the sensory tracts are involved. Recovery without sequelae occasion- ally occurs. The desirability of accepting applicants for insurance who have suffered from myelitis either of a transverse or disseminate variety is doubtful. Cases following trauma or tumor with successful operation and without marked sequelae present no particular con- traindication to acceptance; other cases, however, should not be considered as insurance risks. 260 LIFE INSURANCE EXAMINATION 5. Diseases of the Peripheral Nerves.-Neuritis or inflammation of the peripheral nerves may arise from a number of causes; direct injury with contusion and laceration, pressure from extraneous sources, such as fracture with callus formation and new growths of various kinds in the neighboring tissues; or, it may be due to systemic disturbances, the toxins of acute infectious diseases like diphtheria or beri-beri, chronic focal infection, such as diseased tonsils or teeth, or to chemical agents as alcohol, lead, arsenic and mercury; or exposure to cold. The inflammatory reaction in the nerve varies from a mild inflammation of the nerve sheath or para- neuritis, to complete destruction of the axis cylinder and myeline sheath. A neuritis may be local, involving only a single nerve trunk or group of nerves, or it may be general in which the nerve degeneration is widespread involving the major portion of the peripheral nervous system. In general the symptoms of simple neuritis from whatever cause or wherever located are the same. Sensory disturbances are usu- ally first noted; there may be numbness, tingling, or burning sensa- tions with decided pain and tenderness along the course of the nerve and in the surrounding tissues; the skin surface immedi- ately over the nerve may be reddened and hyperesthetic to pain and touch. In mild cases there are no motor disturbances; how- ever, if the nerve becomes highly inflamed and degenerative proc- esses set in there is muscular weakness and finally paralysis of the flaccid type with trophic changes. Special forms of neuritis are described and certain nerves and nerve groups seem particularly vulnerable, probably on account of their anatomical arrangement. This is seen especially in the sciatic, the musculospiral, the brachial plexus, the trifacial and the seventh cranial nerve. Neuritis of the musculospiral and an- terior tibial is common in lead poisoning; sciatica is a frequent affection on account of the liability to pressure from pelvic condi- tions and injury to the sciatic nerve from external sources. In many cases of neuritis from injury or other extraneous causes, there is no doubt an underlying toxemia. The prognosis in peripheral neu- ritis depends on the removal of the cause and the amount of damage done to the nerve fibers. Cases following injury, local conditions or acute infection even with some permanent nerve impairment are not undesirable insurance risks, provided the causative agent has been removed. Those following chronic infections or intoxications THE NERVOUS SYSTEM 261 are doubtful, not so much on account of the nerve involvement as the general underlying systemic disturbance. What has been said of individual nerve involvement in simple neuritis is true in multiple or polyneuritis, except that practically the whole peripheral nervous system is involved in a chronic low grade, progressive, inflammatory condition. The most common causes are alcohol and lead, though it is seen in other metallic poisons such as arsenic and mercury. It is occasionally a sequela of an acute infectious disease particularly diphtheria, and a feature of metabolic disturbances like diabetes, nephritis and beri-beri. The symptoms are motor, sensory and trophic; the distribution is generally bilateral. The motor symptoms usually begin in the lower extremities, the flexor group involvement preceding the ex- tensors, the muscular weakness which is progressive, gradually in- volves the upper extremities and trunk muscles, finally terminating in paralysis of the flaccid type. The reflexes are diminished or lost and trophic changes may be present as the nerve trunks become completely degenerated; sometimes contractures are seen due to the unopposed action of nonparalyzed muscle groups. The sensory symptoms consist of paresthesias, such as tingling, numbness, and subjective symptoms of heat or cold. There is often intense pain along the course of certain nerves and the nerve trunks are usually hyperesthetic and painful to pressure. As the nerve degeneration proceeds anesthesia takes the place of hyperesthesia, although the subjective sensation of pain often remains. The optic nerve may be involved, producing an optic neuritis. The Karsakoff syndrome is an alcoholic polyneuritis with the added characteristic mental symp- toms of delirium, hallucinations of sight and hearing, diminished emotional reaction, impairment of memory and extensive fabrica- tions. The prognosis in polyneuritis, like that of simple neuritis, depends upon the causative agent. Many cases make a complete recovery without nerve defect, others recover with more or less im- pairment, while others run a chronic course and show only tem- porary improvement. The desirability of recovered cases as insur- ance risks should be judged by the underlying cause and whether or not it has been entirely removed. Neuralgia is a term used to cover a multitude of conditions. It presupposes the symptom of pain throughout the distribution of a nerve which shows no pathology. Authorities differ on the sub- ject; nevertheless this term has established itself as a disease entity. 262 LIFE INSURANCE EXAMINATION The causes of neuralgia are varied and extend over a wide field. It may involve any of the peripheral nerves, but the most common and persistent type is trifacial neuralgia, which has previously been described. Chronic sufferers from neuralgia are doubtful insurance risks on account of the underlying physical or mental disturbance which is a causative factor. Herpes zoster is due to a hemorrhagic inflammation of the pos- terior root ganglia and is of infectious origin. It is characterized by a discreet herpetic eruption following the geographic course of the diseased nerve; it most frequently involves the intercostals or fifth cranial nerves. Recovery without sequela is the rule. 6. The Endocrine Disturbances.-In recent years the importance of the internal secretions on the economy of both body and mind has become more and more apparent. Oversecretion of the thyroid gland is characterized by a well marked clinical syndrome; general physical weakness, exhaustibility, restlessness, tremulousness, shortness of breath and tachycardia. The gland, itself in hyperthyroidism is not always visibly enlarged and the classical sign of exopthalmus is by no means always present; however, a careful study of the eyes generally reveals certain changes with a positive Stelwag, Von Graefe or Dalrymple sign. The diagnosis of mild hyperthyroidism is often difficult and con- fusing. These cases are not desirable insurance risks and applicants presenting the thyroid syndrome should be given a most careful examination supplemented by laboratory tests. Postoperative thy- roid cases are doubtful risks and should not be accepted until all physical and laboratory findings are negative. Under-activity of the thyroid or hypothyroidism, results in myx- edema or, if congenital, is known as cretinism. The symptoms of cretinism and myxedema are essentially the same. The cretin is a distorted, dwarfish idiot, presenting characteristic body deformities. Myxedema makes its appearance in adult life. It may be postopera- tive, following thyroidectomy in which too much of the gland has been removed; it may be associated with cystic goiter, or of unex- plained origin. The physical signs consist of dermal thickening with fat-like deposits in various parts of the body, harsh skin, scant, coarse hair, brittle nails, thickening and enlargement of the face giving it an apathetic, stupid expression, clumsiness in move- ment and mental stupor amounting even to dementia. Hypothy- roidism varies in degree and many cases improve markedly under THE NERVOUS SYSTEM 263 treatment. It is doubtful, however, whether a well-marked case of hypothyroidism even with successful treatment should be ac- cepted for life insurance. The pituitary, like the thyroid, is subject to hypo- or hypersecre- tion. Hyposecretion is characterized by infantilism, retrogressive sexual changes, adiposity and mental inactivity. Hypersecretion is accompanied by increased skeletal development, gigantism or acro- megalia, sexual precocity and alert mentality. Disease or injury of the parathyroids produces tetany, which con- sists of attacks of tonic spasmodic contractures beginning in the extremities, the fingers* or toes and gradually extending to the trunk. The frequency and severity of the attack vary; an attack may be precipitated in a given case by pressure or tapping over certain nerves (Chvostek sign). Deficiency of the adrenal secretion gives rise to general asthenia, easy fatigue, low blood pressure and mental inertia. It is doubtful whether the ductless glands are ever affected singly; but rather the whole endocrine system is involved with certain indi- vidual glands showing predominant symptoms. The insurance exam- iner should always have this group of diseased conditions in mind, as the milder types are common and easily escape notice. 7. The Neuroses.-Under this term is classified a number of syn- dromes of little known etiology or pathology. Huntington's chorea, family periodic paralysis and family tremor are hereditary conditions which progressively grow worse, though in many cases do not really shorten the life of the individual. Such cases, however, are not desirable insurance risks. Myoclonia or paramyoclonus multiplex is an acute condition char- acterized by quick clonic spasmodic contractures beginning usually in the lower extremities and later involving the upper. The spasm is bilateral though unequal and irregular. The duration of the dis- ease is variable and recovery is the rule. Recovered cases are not undesirable risks. Individuals suffering from the various occupational neuroses, of which writer's cramp, habit spasms and motor tics are types, are not as a rule good insurance risks as there is usually an underlying neuro- pathic basis and they are often substandard. Raynaud's disease and angioneurotic edema are neuroses of vas- cular origin; the former characterized by local anemia amounting to gangrene, the latter by skin or mucous membrane swellings. 264 LIFE INSURANCE EXAMINATION Raynaud's disease is a chronic condition and often results in ex- tensive deformities. Angioneurotic edema is probably dependent on some form of protein intoxication; if this can be removed, the attacks usually subside. The principal danger in this ailment is an edema of the glottis which may end fatally. Epilepsy.-The cause of epilepsy is not known and for that reason it is here classified as a neurosis. The classical symptoms of epi- lepsy consist of general convulsive seizures occurring at varying intervals and of varying severity. The seizure may be either clonic or tonic in type with biting of the tongue, frothing at the mouth, cyanosis and involuntary micturition. The attack is usually pre- ceded by an aura with some physical or mental manifestation, which the patient has learned to know indicates an on-coming convulsion. The attack is followed by a status of stupor and somnolence. Mild attacks of the petit mal type show only a momentary confusion, mental stupor or some peculiar physical disturbance. This disease is essentially chronic and the tendency is to grow worse, displaying in its later stages a terminal mental enfeeblement. Not infrequently an epileptic applies for life insurance, being ignorant of his con- dition or with ulterior motives. A history of momentary periods of unconsciousness is suspicious of petit mal; a history of bed wet- ting, muscular soreness, unexplained bruises or lacerated tongue following sleep points to nocturnal attacks; the presence of scars on the face or other parts of the body, the result of falls in attacks are often seen. In many cases the skin is thick and rough, the facial expression stupid and there is often an extensive acne due to drug administration. Migraine, hemicrania or sick headache presents characteristic symp- toms in the way of localized headache accompanied by nausea and vomiting. The attacks come on at varying intervals, often follow- ing an indiscretion in diet or some unusual mental excitement. Sufferers learn to recognize certain premonitory signs such as dizzi- ness, mental apathy or general malaise. The headache which is intense and persistent is well localized usually on one side, but it may be occipital or frontal in character. Preceding or accompany- ing the headache there is nausea and vomiting. Migraine subjects are not good insurance risks, not so much on account of the attacks of headache, but from the underlying cause. Many are semi- invalids and at frequent intervals are completely disabled. THE NERVOUS SYSTEM 265 8. The Psychoneuroses.-This group embraces a large number of borderline mental conditions of which hysteria and psychasthenia are prototypes. Neurasthenia will also be considered under this heading though it is doubtful whether it properly belongs to this group as there is usually a well-defined organic basis with chronic sepsis or intoxication as the causative agent. The less clearly defined psychoneurotic states are included with hysteria and psy- chasthenia as their fundamental cause is the same. No attempt will be made to discuss the psychic mechanism of these conditions except to say that they are probably always the expression of a congenitally substandard make up. Hysteria is characterized by both psychic and physical episodes. The psychic episodes consist of convulsive seizures, delirious states, hyperemotional outbursts, amnesias, dream states, trances, etc. The physical symptoms are extensive and may ape any organic disease. The more common manifestations are referred to the gastrointes- tinal tract, the circulatory system and the sexual apparatus. The neurological disturbances consist of various types of motor paralysis and sensory disturbances in the way of anesthesias, hyperesthesias and parasthesias which cannot be explained by the anatomical ar- rangement of the cutaneous nerves. The underlying mechanism of psychasthenia is probably much the same as hysteria though the expression is rather psychic than physical. In this disease are seen the various obsessions, doubts, compulsive acts, etc. The sufferer is in the main aware of the falsity of his ideas, but they are overwhelming and beyond his control. The advisability of accepting the hysteric or psychasthenic for life insurance is very doubtful. This is especially true in health and accident or industrial insurance, as these cases are chronic com- plainers and exaggerate any minor symptoms which may be present. Neurasthenia is characterized by the general symptoms of fatigue. There is physical weakness, tremulousness, nervousness and cardiac palpitation after exertion, mental inertia, forgetfulness, irritability, hyperemotionalism, headache and insomnia. Physical distress usu- ally directed to the gastrointestinal, circulatory or genital systems is often a complaint. The whole syndrome resolves itself into one symptom, that of fatigue. The prognosis of neurasthenia depends upon the removal of the underlying cause which may be chronic sepsis or intoxication, chronic metabolic disturbances, malignancy or excessive mental or physical effort. There are certain cases of 266 LIFE INSURANCE EXAMINATION neurasthenia which are no doubt congenital in type; they present an unstable nervous system which is unable to withstand the ordi- nary cares of life. The confirmed neurasthenic is certainly not a desirable insurance risk. Applicants having had a so-called "nerv- ous breakdown," which often means neurasthenia, should be looked upon with suspicion and accepted only after a most searching exami- nation. Of special interest to the insurance examiner is the condition known as traumatic neurosis. This condition belongs to the neur- asthenic or hysterical group and is especially common aftei1 injury to the head or spine. These cases must be separated from those in which there is actual pathology in the central nervous system and from pure malingerers. The mechanism of this disease, for it is an accepted disease entity, is difficult to explain. The mental shock and fear of injury, physical pain endured, solicitous friends, attor- neys and claim agents, repeated physical examinations, suggestive questioning and litigations certainly do much to make a serious situation of an insignificant injury. The symptomatology is exten- sive ; the most common exhibition is probably the neurasthenic syn- drome, to which is added fear; at times the condition is that of typical hysteria and often the two states are combined in varying degrees. Almost always there is some symptom pointing to the seat of the physical injury, if such has been received; for it is well known that this syndrome may arise where there has been abso- lutely no bodily injury. The prognosis is only fair, such cases are usually long and drawn out. Settlement of damages often does much to relieve the mind of constant worry and assists in an ulti- mate recovery. The term shell shock has come into popular use in the past few years. It is true that certain pathological conditions may be brought about in the brain as the result of explosions producing a vacuum or setting masses of air in violent motion; however the great majority of these cases belong to the psychoneuroses, particu- larly the hysterical group. In general it may be said that the psychoneurotic is an undesir- able insurance risk, he is unreliable and uncertain and while he may have made an apparent recovery from a given attack, yet the under- lying congenital defect is still present and other attacks may be expected whenever the proper exciting cause presents itself. THE NERVOUS SYSTEM 267 9. The Psychoses.-It is indeed difficult if not impossible to formulate a definition of insanity which will stand the tests of both the legal and medical profession. It may be said that in- sanity is a prolonged abnormal state of mind which renders the individual unfit to perform the ordinary duties of life. No attempt will be made to discuss the psychology of mental alienation and only the most simple and elementary classification will be used. The psychoses may be classified from a pathologic standpoint into two groups; the organic psychoses which are due to demonstrable structural changes within the brain, and functional psychoses or those of unknown pathology. The mental symptoms accompanying organic diseases of the brain are due to changes in the higher psychic centers. These changes may be the result of toxic agents, pressure from new growths, vascular disturbances, inflammatory changes in the interstitial tissue or degeneration of the brain par- enchyma itself. I. The organic psychoses constitute a small group of insane con- ditions. (a) The infective-exhaustive group embraces a large number of acute and usually curable conditions having as a causative basis, infection to which is added exhaustion. These cases may present an active delirium with clouding of consciousness, disorientation, hallucinations of sight and hearing, mild exaltation, flight of ideas, increased psychomotor reaction, forced attention and poorly formed delusions; at other times there is confusion, dullness, stupor and mental retardation. The prognosis in this disease is usually good; complete recovery is the rule. However, such individuals are prob- ably always substandard and liable to future attacks. (b) Toxic states. The most important psychoses in this group are those due to alcohol; the very fact that an individual is a chronic alcoholic or pathologic' drunkard is evidence of an unstable make up. Acute delirium or delirium tremens is a condition charac- terized by an active delirium to which is added a marked general tremor. Chronic alcoholism often results in certain mental impair- ment due to the continued effect of the toxic agent on the cerebral cells and to cerebral vascular changes. The mental symptoms con- sist of a blunting of intellect, judgment and reason, a dulling of the moral sense and poorly formed delusions of persecution. Tn the course of chronic alcoholism occasionally the condition of alco- holic hallucinosis develops. This is characterized by active halluci- 268 LIFE INSURANCE EXAMINATION nations of sight and hearing with delusions of persecution which harmonize with the hallucination. Karsakoff's psychosis is an alco- holic multiple neuritis to which is added the psychic syndrome with hallucinations of sight and hearing, memory defect, unemotionalism and extensive fabrication or falsification of memory. Toxic agents from other sources such as the narcotic drugs, chronic infections or metabolic diseases often give rise to marked psychoses in which delirious states are characteristic features. (c) Psychoses associated with gross brain lesions. Brain tumor, cyst, gumma or other gross brain disease is usually accompanied by mental disturbances, especially if the psychic centers are directly involved. These symptoms are usually those of a progressive men- tal enfeeblement but there may be periods of active maniacal ex- citement or of depression and lethargy. (d) Arteriosclerotic and senile psychoses. While these two con- ditions are frequently associated and the terms are loosely used as synonymous, there is often a marked difference in the general symp- tomatology; though the cardinal symptoms of progressive mental enfeeblement are always present in both conditions. Arterio- sclerotic insanity is an accompaniment of general arteriosclerosis and is directly due to cerebral malnutrition through vascular changes. The mental symptoms are characterized by memory de- fects, impairment of the moral sense, a lack of proper emotional reaction, mild exaltation and self-importance or with periods of de- pression, with ideas of neglect and persecution. There is a general deterioration of the whole intellectual fabric and the patient has no insight as to his condition. The senile psychoses are due to the cerebral changes incident to oncoming years. There is a slight clouding of consciousness and inattention, and impairment of mem- ory of recent events, emotionalism, petulance, childishness, mild egotism, irritability and desire to follow a fixed routine. (e) Traumatic Psychoses. Head injury producing extensive damage to the brain tissue is followed almost always by some per- manent mental defect usually in the way of a general intellectual enfeeblement and impairment of the higher psychic functions. Psy- choses, following injury in which there has been no damage to the brain, belong to the so-called functional class, the injury merely acting as the exciting cause which has set into activity a dormant psychosis. THE NERVOUS SYSTEM 269 (f) Cerebral Syphilis and General Paresis. Of the organic mental diseases, brain syphilis is the most important. It may be divided into three groups; syphilitic meningitis, syphilitic cerebritis or in- terstitial brain disease and general paresis or parenchymatous de- generation of the brain itself. The mental symptoms of syphilitic meningitis and cerebritis are usually characterized by apathy, for- getfulness, carelessness in personal habits, irritability and general impairment of reason and judgment. The physical signs are promi- nent and are those of meningeal or cerebral irritation. The onset of general paresis is usually slow, the first signs noted being those of dispositional changes: bad business deals, excesses, inattention to work, impairment of mental effort, fatigue, hypo- chondriasis, memory defect, carelessness in personal habits, egotism and psychomotor activity or depression with emotionalism. As the disease advances errors in judgment become more-marked; expan- sive, absurd, impossible, bizarre and unsystematized delusions de- velop. There may be high mental excitement with violence and destructiveness, untidiness and carelessness of person. In other cases the onset is abrupt, beginning as an acute maniacal or depres- sive disturbance; not infrequently the initial symptom is a general convulsive seizure. Throughout the whole cQurse of the disease lack of reason, judgment and mental coordination is the prominent feature. (g) Miscellaneous Organic Psychoses. Here may be mentioned the mental disturbances seen in connection with multiple sclerosis, chronic chorea, pellagra, Parkinson's disease, epilepsy and other conditions producing greater or less organic changes in the brain. The cardinal symptom presented in these cases is that of a progres- sive mental deterioration to which is added various phases of emo- tional, ideation, volitional and imaginative disturbances. II. The functional psychoses or those of unknown pathology con- stitute the great bulk of the insanities. (a) Manic-depressive Psychosis.-This group is characterized by remitting attacks of exaltation or depression, one form often alter- nating with the other. The manic phase presents exaltation, flight of ideas, agitation, impairment of memory, disorientation, hallucina- tions of sight and hearing, inattention due to increased activity and poorly formed unsystematized expansive delusions without insight. As this active disturbance subsides, it is often closely followed by the depressed phase with cloudy consciousness, impaired memory, 270 LIFE INSURANCE EXAMINATION mental depression, retardation, decreased flow of ideas, inattention and mild delusions of persecution or neglect. This is the typical manic-depressive syndrome, one phase passing directly to the other, the so-called circular insanity. In many cases only one phase is distinctly in evidence, the patient having repeated maniacal or de- pressive attacks, the so-called recurrent mania or recurrent melan- cholia of the older classification. Other cases pass to a state of chronic excitement or depression, which conditions were formerly known as chronic mania or chronic melancholia. A close analysis of these cases, however, shows a decided tendency to change from one emotional extreme to the other. The prognosis as to recovery from the acute attack is good but almost invariably there will be other attacks of greater or less severity. Consequently the insur- ance applicant giving a history of "nervous breakdown" or some similar indefinite ailment should be looked upon as a possible case of manic-depressive insanity. (b) Dementia Precox is a disease of the adolescent period usually making its appearance before the twenty-fifth year. Very often the precox make-up may be recognized in childhood or early adult life. These individuals are peculiar and eccentric, often precocious, they are seclusive, shut in and unsocial, they are unemotional, often cruel and careless of the feelings of others, they may assume peculiarities in dress, manner and speech; parents describe them as being differ- ent from other children, but just how they cannot explain. An individual with this make-up should always be regarded as a po- tential case of dementia precox who needs only some exciting factor, a severe physical or mental shock or an emotional disturbance to activate a process which has been present since birth. Dementia precox is divided into three types, the hebephrenic, the catatonic and the paranoid. The onset of the active expression of this disease may be slow or abrupt. Oftentimes there is noted a gradual dispositional change, the seclusive and unsocial habits be- come more marked; there is carelessness in dress and personal habits, lack of emotional reaction and inattention. Memory and orientation is surprisingly good as is also the intellect if it is pos- sible to penetrate the mind. As the disease advances consciousness becomes cloudy, the emotional reaction progressively less, the flow of ideas more retarded, negativism, impulsive acts, stereotyped movements, and attitudes are present; poorly formed delusions of persecution or grandeur develop, the patient is careless, untidy, THE NERVOUS SYSTEM 271 and destructive, with unexplained outbursts of violence. In other cases the onset is abrupt, appearing much as a phase of manic- depressive insanity, but soon the essential feature of emotional im- pairment becomes apparent. The catatonic type of dementia pre- cox is essentially the same as the hebephrenic, except there is added the feature of catatonia with stereotyped attitudes and positions. The paranoid type of dementia precox presents certain features in the way of egotism, self-importance and unsystematized delusions of persecution and grandeur. The mental deterioration is not so rapid as is seen in other types; however, there is a lack of reason and judgment, the delusional system is not well organized; and the fail- ure of emotional reaction which characterizes the other types is present. Dementia precox is a chronic disease in which the tendency is to progressive mental deterioration; however, like manic-depressive insanity, it is marked by remissions and exacerbations, but the in- dividual even at his best never reaches normal. The milder cases go through life as substandard, nonproductive, queer, peculiar, sometimes vicious individuals, never quite able to get along or co- ordinate with society. The more severe cases require constant cus- todial care. Not infrequently an individual' of the precox make-up applies for insurance examination and the examiner should always regard peculiar, eccentric, shut-in, seclusive, unsocial people as potential cases of dementia precox. (c) Paranoia and the Paranoid States.-It is doubtful whether the psychosis commonly described as true paranoia is really a disease entity, as these cases probably belong to the paranoid type of the dementia precox group. Paranoia is a chronic mental disturbance making its appearance in adult life. The onset is slow and gradual, the first signs noted being vague suspicions, doubts, and fears. The individual is reticent and does not discuss his ideas freely, his de- ductions are logical and his actions are governed by his false con- ceptions. Gradually he develops hallucinations of hearing which at first are vague and indefinite, but later become distinct and well established. The next stage is characterized by delusions of perse- cution which are the normal outgrowth of the auditory hallucina- tion; these delusions are well systematized and unchanging, the argument is logical but the premise is false. Following the perse- cutional stage come systematized and unchanging delusions of grandeur and finally a complete transformation of personality. 272 LIFE INSURANCE EXAMINATION Throughout the whole course of paranoia until the terminal stage of dementia is reached, there is no impairment of memory or orienta- tion, the emotions are under control, abnormal volition is well planned and supported by adequate argument, the intellect is clear and the faculty for reason and judgment is good except where it concerns delusional ideas. The defect is primarily in the field of the imagination and the other psychic faculties are only af- fected secondarily. This disease is chronic, lasting throughout the lifetime of the individual. In the later stages there is usually a terminal de- mentia with general impairment of all the mental faculties. Mild paranoiacs go through life unrecognized as such by their associates. Often a sudden mental shock or strain will bring to the surface paranoid symptoms which have long been concealed. In the course of paranoia there may be outbursts of active disturbance, though as a rule the disease follows a fairly even line. A case of frank paranoia should never be considered as an insurance risk. The disease itself does not necessarily shorten life, but the majority of such cases sooner or later require custodial care. The milder paranoid states are often difficult to recognize, but when once iden- tified should not be looked upon as favorable insurance risks. (d) Involutional Melancholia.-This psychosis appears about the involutional period of life and is more common in women than in men. It is characterized by emotional depression with increased psychomotor activity. The individual is dominated by imperative fears, morbid regrets, ideas of personal inferiority, self-reproach and abasement. The consciousness is clouded and attention dulled on account of the absorption by morbid thoughts. There may be mild hallucinations and a poorly organized delusional system. There is agitation, destructiveness, self-mutilation and often suicide. The outlook for recovery in the involutional group is fairly good. A certain number recover without defect or recurrence; however, on account of the age of the patient, a recovered case would not be a desirable insurance risk. (e) Defective Classes.-In this group are included the idiots, im- beciles, morons and psychopathically inferiors. Of the first three little is to be said; they are easy to recognize and are certainly never desirable insurance risks. Psychopathic inferiority embraces that large group of individuals who are substandard and who are not quite able to get along in the world or to coordinate with so- THE NERVOUS SYSTEM 273 ciety. It is a fine distinction between psychopathic inferiority and mild dementia precox. The constitutional psychopaths present a variety of symptoms; they are eccentric, peculiar, and nonresistive with moral and intellectual inferiority. Psychoneurotic symptoms are common and many later develop a well-defined psychosis. They are uncertain and unreliable and consequently poor insurance risks. In general it may be said that individuals having suffered from a psychosis with apparent recovery, or individuals presenting men- tal peculiarities suggestive of an underlying defect are not desir- able insurance risks, as it is impossible to foretell when an active outburst with its attending danger may appear. In conclusion it may be said that diseases of the mind and nerv- ous system present a serious problem to the insurance examiner. The well-known chronicity, the uncertain history, the scant physi- cal findings, the debility and invalidism attending them make this group one of the greatest importance and one which the examiner should always have in mind. CHAPTER XX THE ENDOCRTNES AND VISCERAL NERVES IN RELATION TO LIFE INSURANCE EXAMINATION By Francis M. Pottenger, A.M., M.D., LL.D., F.A.C.P., Monrovia, Calif. A life insurance examination presumes to detect applicants who show signs of being substandard risks and to pass, as suitable for insurance, applicants who are standard, risks. It is self-evident that there is a large group of applicants who are on the borderline, some of whom can be safely insured, and others who are an immediate liability to the company which accepts them. Any knowledge or any method of procedure which will aid in properly classifying the members of this group will result, on the one hand, in giving pro- tection to many who need and deserve it but who cannot with present knowledge secure it, and, on the other hand, will protect the insurance company against unjustifiable risk. It has seemed sufficient to insurance companies that an examina- tion should be largely a quickly derived opinion from a cursory examination, rather than an opinion carefully arrived at after an exhaustive study of the applicant. The opinion is based, except for large amounts of insurance, on: (1) facts elicited from the applicant as regards his family history; his history of previous or present illness; his age, and bodily form; (2\ a hasty examination of the circulatory and respiratory systems * and (3) a simple chemical examination of the urine. The final opinion reported by the head examiner, barring frank organic disease, is based largely on the law of averages. It is necessary then that the life insurance examiner be able to recognize quickly those signs which enable him to differentiate between health and disease and between organic and functional disease, so that his report will be just to both the applicant and the company. In order to do this he must know the physiologic fac- tors operating within the body, which control form and function. Aside from the inherent power to exist and function, which is found in each living body cell, there are two great correlating 274 THE END0CR1NES AND VISCERAL NERVES 275 influences which bind them together and link their action so that they operate as a whole instead of an infinite number of individual entities. These are the secretory products of the endocrine glands and the. nervous system. Every individual part of the body is so influenced by these chemical and nervous regulators that there is, under normal circumstances, a correlation and integration of action which modifies stimuli in such a manner as to preserve functional equilibrium. Normal action depends upon the stability of these two systems, which in turn may be influenced by a disturbed physical balance such as is seen in organic disease, or in a disturbed psychical balance such as we meet in the psychopathologic states which we encounter either as accompaniments of physical disease or as in- dependent entities. When these facts are sufficiently recognized and this knowledge becomes general property, the examiner will be able to more accurately judge insurance applicants. The most evident influences of disturbed function of endocrine glands are seen in departures from normal in growth and changes in metabolism. Gigantism, infantilism, cretinism, obesity, certain con- ditions of undernutrition, hyperthyroidism, exophthalmic goiter, myxedema, acromegaly, diabetes insipidus/ diabetes mellitus and Addison's disease are well known. But these frank expressions of endocrine disturbance are only a small part of the many evidences of disturbed balance which are met in the every-day clinic, did we but recognize them. It is important to recognize the slighter de- partures from normal, as well as the markedly evident. Nutritional changes, changes in energy output, the manner in which the individ- ual metabolizes the various types of food and salts, blood pressure, digestion, oxygenation, sexual function, the condition of the skin, hair, nails and bones are all influenced by the two vegetative sys- tems-the endocrines and the vegetative nerves. Just as there may be hypo- and hyperactivity in the thyroid, pituitary, and other endocrine glands, so there may be hyper- and hypoirritability of the sympathetic and parasympathetic compo- nents of the vegetative nervous system. These departures from normal in glandular secretion, and the altered irritability of the sympathetics, causing sympathicotonia; and parasympathetics, causing vagotonia (parasympathicotonia), not only cause unusual reactions to take place in the presence of organic disease and conditions of psychic imbalance, but cause dis- 276 LIFE INSURANCE EXAMINATION turbances in physiologic reaction as a result of the ordinary stimuli which occur from causes other than disease. Any observing person can recognize the disturbances in normal development which result in gross changes in form, but the exam- iner for life insurance should learn to associate these with the glands which are responsible for them. When a degree of gigan- tism, or dwarfism, is present, he should have his attention directed particularly to the thyroid, the pituitary, and the gonads. The acromegalic features should suggest hypersecretion of the pituitary. The boyish face, accompanied as a rule by a certain degree of obesity, points to a hyposecretion of this organ. Obesity itself should suggest an endocrine disturbance as a probable basis-the thyroid, the pituitary, or the gonad being most commonly at fault. It should be remembered that having the form or features in- dicative of a hyper- or hypofunction of some endocrine gland, does not mean that the function is still abnormal; only, that, at this or at some previous time it was abnormal. By assigning these changes in form to their proper cause, the examiner may note other signs or symptoms which may be more vague but which have a ready explanation upon a physiologic basis, now that a definite endocrine disturbance is evident. Such symp- toms have a much graver significance attached to them if due to other causes. There can be no great change in the product of any of the important glands of internal secretion without causing certain changes in physiologic function, because of the influence which they and the vegetative nerves exert upon the viscera, and because these separate influences are so intimately interlocked in their action. Hypoactivity of the thyroid gland is often accompanied by an obesity, which is more or less general in its distribution. The arms and legs are large, and even the fingers often show the fatty pad- ding. It also frequently causes other symptoms such as dry skin, wrinkled or senile skin, dry, brittle nails, dry hair, which turns gray early and often falls out. Hertogh has also called attention to the fact that the external third of the eyebrows is thin. Pains about the joints are frequently of hypothyroid origin, accord- ing to some authors. The diagnosis of rheumatism is usually made. These symptoms are often accompanied by an unbalanced nervous and psychical state and a lowered physical efficiency. Inasmuch as the thyroid secretion exercises the chief control over the metabolism THE ENDOCRINES AND VISCERAL NERVES 277 of the body, this process is naturally slowed when deficiency of secretion is present. As a consequence, such individuals usually bear cold poorly, and put on fat with the consumption of small amounts of food. Such symptoms should be detected by the ob- serving examiner and classified where they belong, with their bear- ing upon life properly assessed. In mild degrees of hypothyroidism there is no reason why the applicant should not be a good insurance risk, provided the cause is recognized and the appropriate gland substance administered. The acromegalic also has dryness and roughness of the skin, often accompanied by some pigmentation. The hair and nails are also brittle. This skin condition of pituitary origin may be differen- tiated from that of the thyroid origin, by the accompanying acrome- galic features, the large malar bones, the separation of the teeth, and the unusually large hands. Evidences of hyposecretion of the pituitary and thyroid frequently exist in the same individual, under which circumstances a mixed group of signs and symptoms may be found. Obesity of the hypopituitary type of pure form is accompanied by small hands and feet, with slender arms and lower limbs; how- ever, it is often accompanied by deficient thyroid secretion and the two types are fused together. Tn the male, the fat of hypopituitarism is deposited over the abdomen in the suprapubic region, about the breasts, over the hips and buttocks, and is usually accompanied by the feminine distribution of hair on the abdomen. In woman, the fat distribution is similar-often the large hips and thighs, tapering to the lower third, and the fat deposits over the shoulders are quite striking. Aplasia of the genitals and failure of the appearance of the secondary sex characteristics occur if the hyposecretion comes on early in life, while amenorrhea and lessened sexual powers ac- companies its late development. Gonad insufficiency leads to changes somewhat similar to those of pituitary origin. The two glands are so closely associated that disturbance in one is followed by disturbance in the other. The gigantism of pituitary origin is accompanied by general nerve in- stability, lessened sexual power and varying degrees of asthenia, usually progressive in character, in which it resembles gigantism of gonad origin. Many cases of mild hypothyroidism and hypopituitarism develop following infections. They may come on, following such diseases as 278 LIFE INSURANCE EXAMINATION typhoid fever, lues, scarlet fever, tuberculosis. Evidences of both hyper- and hypothyroidism and hypopituitarism are frequently met in tuberculosis. Not infrequently the hypo conditions develop fol- lowing acute symptoms of active tuberculosis, and are manifested by a rapid gain of weight, even with comparatively little food. Such alterations frequently correct themselves after a time. While Addison's disease is usually thought of when disease of the adrenals is mentioned, it is probable that there are many other conditions resulting from disturbed adrenal function which affect health, that are far more commonly met in daily practice. Follow- ing infections it is not uncommon to have hypertension and asthenia as a result of injury to the adrenals. Hypertension and hyper- glycemia may result from over stimulation of either the adrenals or the sympathetic nerves. We meet hypertension frequently in chronic toxemias; and hyperglycemia and glycosuria often result from the stimulation of these two systems by worry, fright, severe strain and toxemia. In life insurance examinations, it is especially necessary to know effects on blood pressure and blood sugar, which are produced by toxins and other conditions stimulating the sympa- thetic nerves and endocrine glands. Increased secretion of the adrenals, pituitary and thyroid may all cause hyperglycemia and glycosuria. This, however, is very different in the point of serious- ness from the glycosuria caused by deficient secretion of the islands of Langerhans, and calls for a differential diagnosis to be made in cases where small amounts of sugar are present. Inasmuch as the most prominent endocrine disturbances, those of the thyroid and pancreas, are being treated in special chapters, it seemed best for me to limit this discussion to a general statement of principles, pointing the way to more accurate observation rather than to enter exhaustively into the description of affections of each gland. At present, many of our ideas on endocrinology are sugges- tive rather than definite. I consider it much wiser to leave the more complete treatment of the subject to the future, and in this discus- sion simply point out conditions and symptoms which will be met in the everyday work of the examiner, which should call to his mind excess or deficiency in secretion of the various glands. CHAPTER XXI BLOOD PRESSURE AND HOW TO TAKE IT By G. E. Crawford, Ph.D., M.D., Cedar Rapids, Iowa Medical Director, Cedar Hapids Life Insurance Company One of the most valuable and far-reaching diagnostic measures that has been discovered during the present generation of dis- covery, is the perfected sphygmomanometer, which makes the ac- curate determination of the arterial pressure a ready and practical procedure. Throughout the past century efforts more or less suc- cessful have been made, from time to time, along this line by various investigators. Fifty or more years ago Austin Flint, Jr., demonstrated and measured the blood pressure of the dog, by placing a glass tube in the carotid artery. The old-time clinicians from Hippocrates down have appreciated the importance of arterial tension; and especially since Harvey's demonstration of the circu- lation, the study of the character of the pulse by the sense of touch,-the "tactus eruditus, " was carried to the perfection of a fine art. In our day of laboratories and mechanical appliances, this is fast becoming a lost art. As the culmination of a century of experimentation by many investigators, Riva Rocci, of the Univer- sity of Italy, invented an instrument in 1896, which became the type of all modern sphygmomanometers. It consisted essentially of a narrow rubber bag connected by rubber tubing with a reservoir of mercury, having an upright capillary tube graduated in millimeters. The bag was placed over the brachial artery and held in place with a bandage. Air was pumped into the bag until the pulse was obliterated at the wrist. The height of the column of mercury forced up in the capillary tube as indicated by the scale in milli- meters records the blood pressure. The first sphygmomanometer made in this country was designed by Dr. Henry Wireman Cook, a modification of an instrument brought to Johns Hopkins from the Riva Rocci Clinic at Pavia, Italy, by Dr. Harvey Cushing. A cut of Dr. Cook's instrument may be seen in both Dr. Janeway's and Dr. Faught's books on blood pressure. 279 280 LIFE INSURANCE EXAMINATION Dr. Cook also made the first contribution to the subject of blood pressure in its relation to life insurance, which he read at the meet- ing of the American Association of Life Insurance Examiners, at Atlantic City, in June, 1904. Among the early students of blood pressure were Drs. Janeway, Faught, Stanton, Nicholson, Erlanger and Rogers, all of whom -L3 iced jHvessuxe t« rv| (Lktecb| Uo Sou>fciJl t ivst SoKkv*>d- t&l&teVic. TvvsX - Lou.ci ckav beats Second VtWvnAvv cS it*** 4 1>V ase Louxlaleai' Leat-S Savni- Dull Sounds kDiasVAk. Ho SoiXr»A Fig. 57. designed instruments bearing their names. They also contributed some of the most valuable literature on the subject of blood pressure. AH the mercury sphygmomanometers now in use are but slight modifications of the Riva Rocci instrument; and the dial, or so- called aneroid instruments, retain the essential parts-the rubber bag for the compression of the artery, and the millimeter scale. In BLOOD PRESSURE AND HOW TO TAKE IT 281 the early Riva Rocci instrument the inflated band was too narrow, and the readings were consequently too high. Later investigations have determined that the proper width of the inflated bag is 13 cm. or about 5 inches. The sphygmomanometer is now so well known and in such gen- eral use that any extended description would be superfluous. There are many good instruments on the market, only slightly differing one from the other in some minor particulars. The Erlanger sphygmomanometer is probably the most accurate instrument yet devised; but it is too complicated and expensive for general use. Among the mercury instruments in common use, may be mentioned the Eaught, the Brown, the Baum, and the Nicholson; all good Fig. 58.-Small mercurial sphygmomanometer. and reliable instruments, ranging in price from ten to thirty dollars. There are doubtless other instruments which are just as good as these mentioned, but the writer is familiar with all of these, having used them extensively; and they are in very general use. There has been a good deal of controversy as to the relative merits and reliability of the so-called aneroid instruments as com- pared with the mercury sphygmomanometers. The term aneroid signifies without fluid. The name was doubtless suggested by the aneroid barometer in common use, which it somewhat resembles. Dr. Rogers made this suggestion which resulted in the instrument bearing his name. The essential feature of the aneroid instrument is a succession of thin metal chambers, which expand by the air pressure; and this expansion is communicated by a delicate gearing to the index needle which revolves from the center of the dial. 282 LIFE INSURANCE EXAMINATION The two instruments of this form in general use are Dr. Roger's Tycos and the Faught. There are also several other makes. It has been charged against these instruments that they soon cease to be reliable; that the metal chambers "fatigue" or lose their elasticity. The writer has used each of these instruments continuously for a period of three years without any sign of deterioration, except the occasional giving out of the rubber pump, or tube, which is as liable Fig. 59--Large mercurial sphygmomanometer. to occur with the mercury instrument. The chief merit of the aneroid instrument is its convenience and portability. In this respect it stands in much the same relation to the mercury instru- ment that a watch does to a clock. Everything will wear out in the course of time, and as delicate an instrument as a sphygmomanometer cannot be expected to last forever. Like a good chronometer watch, it needs to be sent in BLOOD PRESSURE AND HOW TO TAKE IT 283 occasionally for an overhauling and adjustment, and cleaning up, and renewal of tubes, pump, inflation cuff, etc. This applies alike to the mercury as well as the aneroid instrument. The inflation apparatus in either kind of instrument is most likely to get out of order. This is readily detected by the scale running down without opening the needle valve. Whenever the index will not stand still at any point that it is pumped up to, there is a leak, and the instrument is not fit to use. If the leak cannot be found and remedied, it should be sent to the factory for repairs. The infla- tion pump is the usual thing to get out of order. A person making any considerable use of the sphygmomanometer should have both Fig. 60.-Small mercurial sphygmomanometer. forms of instrument. They will serve somewhat as a check on each other; and when one gets out of order, the other can be used while the first is sent away for repairs. It should be borne in mind that a sphygmomanometer is a very delicate instrument, and should be handled as carefully as a good watch. I keep three instruments in use, and find it a satisfaction some- times to test all of them in one case; and have done this without finding any appreciable difference in the readings. By blood pressure is meant the arterial tension, or force of the blood stream within the arteries; it represents essentially the force of the left ventricle of the heart. The left ventricle at each 284 LIFE INSURANCE EXAMINATION systole discharges in the aorta about three ounces of blood; and the right heart sends approximately the same amount to the lungs. The force thus exerted by the left ventricle at each systole in a mature healthy man, at rest, will raise a column of mercury 125 mm. Fig. 61.-Large mercurial sphygmomanometer. in height. This force is transmitted to the column of blood, which being incompressible, is pushed onward into the capillaries and veins. But in order to make room for this sudden increment to the blood volume, the elastic walls of the arteries are made to expand by the sudden impulse of hydrostatic pressure. The re- BLOOD PRESSURE AND HOW TO TAKE IT 285 bound of the aortic wall closes the semilunar valves, and the potential energy, somewhat diminished by further oozing away into the capillaries, remains in the arteries. This is the diastolic pressure, or the pressure remaining in the arteries during the heart's diastole, or rest, and represents the resistance to be over- come by the succeeding systole before the blood column can be carried forward. The force exerted by the ventricular contraction in excess of this resistance, which is indicated by the difference between the Fig. 62.-Small anerpid sphygmomanometer. systolic or maximal pressure, and the diastolic or minimal pres- sure, is termed the pulse pressure. This in health is equal to one- half the diastolic, when at rest, and is susceptible of large increase for sudden emergencies by the rising of the systolic pressure. There are three general forces concerned in the production and maintenance of the blood pressure: the mechanical, the nervous, and the biochemical. The mechanical or physical, is represented by the muscular contraction of the heart, and elasticity of the blood vessels. 286 LIFE INSURANCE EXAMINATION The nervous force is the intricate correlation of the cerebral heart centers with the cerebrospinal and sympathetic systems, which control the heart's speed and regulate the caliber and tone of the vessels. The biochemical is represented by the secretions of the endocrine glands, and probably other products of metabolism, which as yet are but imperfectly understood. These substances probably act more directly on the heart's force, and take a prominent part in harmonizing these various activities. There are five principal factors which enter into the phenomena of blood pressure and which have a determining influence on its character and degree: (1) Cardiac strength. (2) Peripheral resistance in the vessels. (3) The elasticity of the vessel walls. (4) The volume of blood. (5) The viscosity of the blood. The important requisition of a normal blood pressure, like that of all the vital functions of the body, with which it is so intimately correlated, is equilibrium-proper balance. All these vital func- tions are normally carried on within narrow limits of variation, with ample provision for emergency demands. To illustrate: The normal pulse rate of a healthy man is 70 per minute at rest; it may rise to double this rate in a hundred-yard dash which occupies but 10 seconds of time. The balance of all these correlated func- tions of the body is probably affected by this sudden change. The promptness of the return to the normal, or with which equi- librium is restored, is an index of the health of the individual; and conversely, the delay in the return of this equilibrium may be also the measure of disease, especially of the myocardial strength or weakness. The normal relation of the blood pressure as first stated by Faught, and now generally accepted, is the ratio of 1-2-3 or rather 3-2-1 ; i.e., the systolic pressure represents the full strength of the ventricular contraction, the diastolic pressure equals two-thirds of the systolic, and the pulse pressure, which is the difference be- tween the systolic and diastolic pressure, equals one-third of the systolic, or one-half of the diastolic. It is not claimed for this rule that it is invariable, but it is ap- BLOOD PRESSURE AND HOW TO TAKE IT 287 proximately correct; and this simple and valuable working for- mula of 1-2-3, keeps constantly before the mind the normal bal- ance, or equilibrium of the blood pressure, as well as any departure therefrom. This delicate adjustment of balance results in a normal and efficient circulation, by maintaining a steady flow of blood through the capillaries at an equable pressure. The average blood pressure of a large number of insured of all ages is about 125 mm. So uniform is this result, which is further corroborated by a great accumulation of individual clinical experi- Fig. 03.-Large aneroid sphygmomanometer. ences, that we are warranted in assuming that the normal blood pressure of a mature man is about 125 mm., and that there is very little variation in health, except the transitory variation of exercise and nervous excitement. A variation of more than 15 mm. above or below this average is suggestive of disease. We do not mean by variation a transient functional elevation due to exercise or excitement, but when the individual's usual pressure is more than 15 mm. above or below this standard, it indicates, if 288 LIFE INSURANCE EXAMINATION not disease per se, that he has departed from the normal conditions which are necessary to the maintenance of good health. This varia- tion is somewhat modified by age. The blood pressure of child- hood and adolescence is considerably less than in mature life. The arteries in childhood are delicate, translucent, and collapsible. There is a relatively large amount of elastic tissue and little con- nective tissue. But it is not until mature adult age of twenty-five or thirty years that the arteries cease to be collapsible, and the lumen of the vessels remains open. As age advances there is frequently, and perhaps usually, a pro- gressive thickening of the vessel walls, with relative predominance of connective tissue. These may be regarded as the ordinary phys- iologic changes incident to age. Fig. 64.-Palpatory method. The further analysis of this great accumulation of statistics established the fact that the average systolic blood pressure of a young man of twenty is 120 mm. Also that the average blood pressure increases with age in the quite definite ratio of one milli- meter for each three years, up to fifty years of age; and one milli- meter for each two years between fifty and sixty. These figures for the five decennial periods are in round num- bers: Systolic pressure at age of twenty, 120 mm.; at thirty, 123 mm.; at forty, 126 mm.; at fifty, 130 mm.; at sixty, 135 mm. The latter may be considered as about the limit of normal blood pressure at any age. This establishes the fact that healthy old men have but slight increase of blood pressure over healthy young men. There are many men of sixty and sixty-five with healthy elastic arteries and BLOOD PRESSURE AND HOW TO TAKE IT 289 unimpaired hearts and kidneys, whose blood pressure is no higher than it was when they were thirty or thirty-five years of age, that is, 12'5 mm.; while there are many comparatively young men with sclerotic vessels of advanced senility. Other old men who have in- creased blood pressure, have it not simply because they are old, but because they have some degree of cardiovascular disease. Fig. 65.-Auscultatory method. Small instrument. Until recently little attention has been given to the diastolic pressure. The difficulty of taking it and the uncertainty of the readings by the methods in vogue, chiefly the oscillatory method, was the principal reason. Yet there have been from the first lead- ing investigators who attached great importance to the diastolic pressure, and succeeded in taking it by instruments too compli- cated and expensive for general use. 290 LIFE INSURANCE EXAMINATION In 1905, Korotkow, a Russian physician, discovered the method of taking the blood pressure by auscultation. He found by plac- ing the stethoscope over the brachial artery just below the inflated band, or at the bend of the elbow over the radial artery, that the heart pulsations could be heard with great distinctness,-much Fig. 66.-Auscultatory method. Large instrument. more distinctly and exactly than conld be determined by palpation of the radial artery at the wrist, lie also found that the diastolic pressure could be determined with much greater certainty than by former methods. This really marks the beginning of the recording of the diastolic pressure as a regular procedure. Tn spite of the value of this discovery it made its progress rather BLOOD PRESSURE AND HOW TO TAKE IT 291 slowly with the profession, and for several years was used only by a few advanced clinicians. It gradually came more and more into use and finally the insurance companies began to require this method, and to instruct their examiners in the technic. In order to do this intelligently it is necessary to get a clear understanding of the so-called points and phases, and the definite significance of these terms. When listening to the pulsations as they occur from the first clear beat, down the scale until the last sound is heard, a distance usually of 40 to 45 mm., it is noted that the sounds are not all alike, but differ markedly in character and quality, and that these changes take place abruptly, and in a quite definite order. The location on the scale where these sudden changes of tone occur are called points and the divisions of the scale between these points are called phases. These will be described later. None of the phases is of a definite length, but they may vary more or less in length and character. Occasionally a case is found where the characteristic phases are absent, the tones being of one quality all the way down the scale. The murmurs of the second phase are quite often absent. The fourth phase is the most variable in length of any of the phases. When the jblood pressure is high it is frequently only 2 or 3 mm. in length. In normal cases it is from 4 to 6 mm. and in some cases, usually of low pressure, it may be 10 or 12, or even 20 or more mm. in length. These cases of very long fourth phase are usually in young persons. Bone conduction may possibly be the cause in some instances, where the phase is pro- longed even to the zero mark. This may also be produced by too strong pressure with the stethoscope. There are rare cases where a sound can be heard after all pressure is removed. These are usu- ally cases of insufficiency of the aortic valves, but may be due to other causes. While most of the blood pressure statistics so far are based on the systolic pressure, there is now a very considerable accumula- tion of records of the diastolic pressure by the various insurance companies, which if not sufficient to make them authoritative as to the influence of the diastolic pressure on mortality, are corrobora- tive of the results of individual investigation to the degree that the relation of the diastolic to the systolic and its relative impor- tance has been definitely established. The most recent and fullest analysis of statistics covering this phase of the subject was pre- 292 LIFE INSURANCE EXAMINATION sented by Dr. L. F. MacKenzie of the Prudential Life Insurance Company, before the Medical Section of the American Life Conven- tion in 1920. The consensus of opinion gathered from many sources indicates the following as approximately the normal average relation of the blood pressure at the five decennial periods: Fig. 67.-Exercising while blood pressure is being taken. Age 20, Systolic 120, Diastolic 80, Pulse-pressure 40; mm. Age 30, " 123, " 82, 11 il 41; mm. Age 40, il 126, 11 84, 11 " 42; mm. Age 50, " 130, " 87, " " 43; mm. Age 60, " 135, " 90, " " 45; mm. BLOOD PRESSURE AND HOW TO TAKE IT 293 Both statistical analysis and individual experience confirm the essential correctness of Faught's rule of 1-2-3, as indicating nor- mal relation and balance of the systolic, diastolic and pulse pressure. To the best of our present knowledge these figures as given represent the normal average blood pressure at these various ages. Any con- siderable departure therefrom is probably to some degree patho- logic. Experience seems to justify more leniency toward a lowered pressure, than a similar degree of elevation above the standard. A very low pressure suggests a lack of vital force. The blood pressure of women is usually given as 8 or 10 mm. less than that of men. The statistics of the New York Life Insurance Company as recently analyzed by Hunter and Rogers give ''The average blood pressure of women at the earlier ages is 3 or 4 mm. lower than that of men, and with increasing age the difference between the sexes decreases, until at the age of sixty it disappears altogether. " Many elements enter into the regulation of the blood pressure and the maintenance of its equilibrium. The most important is the nervous control of the heart directly by the cerebral heart centers, and the opposing accelerator to the inhibitory action of the sympathetic; and the antagonistic action of the vasoconstrictor and vasodilator nerves, which regulate the caliber of the blood ves- sels; the opposite influences of the secretion of the endocrine glands, the adrenals and thyroids and parathyroids, and the pituit- ary, which perhaps act more directly on the arterial tension. We have some knowledge of the very intricate correlation of the cerebral vasomotor centers, with the pituitary, adrenothyroid, and cardiovascular systems, which normally maintain the equilib- rium of metabolism, and all these vital functions. We know something of the very important role played by these internal secretions in controlling or disturbing these vital func- tions, and they are liable to disturbance from various causes. It may be a hyperactivity of one or more of these internal secretions; or the diminution of the internal secretion of one gland, may per- mit overaction of the hormones of the opposing gland. High blood pressure is a very complex entity, necessarily so from the very intricate mechanism it disturbs, and its causes are various, but primarily and essentially a toxemia. It is generally believed that the intestines are the most common source of this 294 LIFE INSURANCE EXAMINATION toxemia-intestinal putrefaction. Disturbed activity of some of the endocrine glands as a cause of high blood pressure, which is as yet but imperfectly understood, probably has a more prominent part than has been supposed. This also is essentially a toxemia. The first effect of a toxic hypertension is to raise the systolic pressure, with little corresponding change in the diastolic pres- sure. With a high systolic pressure we know that the integrity of the heart muscle and vessel walls are in danger, and that it is only a matter of time when degenerative changes will take place. This high pressure, at first a result, soon in turn becomes a cause, and if persistent will produce myocardial disease, arteriosclerosis, and interstitial nephritis. As these organic changes appear, the diastolic pressure is raised, for the diastolic is the measure of the resistance; hence its importance as the real index of the condition. The pulse pressure shows the relation of the diastolic and sys- tolic pressure, and the amount of force the heart is expending over and above the resistance. It is an index of the heart's strength. A pulse pressure that responds readily to exercise, and returns promptly to the normal, indicates a strong heart. A pulse pressure that is diminished by exercise denotes a degenerated myocardium and a failing heart. There is a difference of opinion as to the exact location of the diastolic pressure. Authorities are about equally divided between the fourth or fifth point, as denoting the diastolic pressure; i.e., the beginning or the end of the fourth phase, as indicated by the "tone change" (to dull muffled beats) or the "last sound." In normal cases there is from 3 to 6 mm. between these two points, and 6 mm. is the average length of the fourth phase. It is often shorter, and sometimes much longer. Dr. MacKenzie's statistics show that while the average length of the fourth phase is 6 mm., it exceeded 6 mm. in only one-fourth of the cases; hence in a majority of cases it is less than 6 mm. For practical purposes at least it may be said in favor of the end of the fourth phase, that it is more definite. It is easier to be certain when all sound ceases, than when the tone changes, but in most cases this can be determined with certainty. It is probable that the true location of the diastolic pressure is the middle of the fourth phase. With that question unsettled, both the fourth and fifth points should be noted, and should be indicated as "tone change," and "last sound." This will give BLOOD PRESSURE AND HOW TO TAKE IT 295 all the data there is for correctly estimating the diastolic pressure. Get this clear, that what is meant by the term "tone change," as here used, is the last change, when loud clear beats suddenly become dull and obscure. This can nearly always be definitely located. How to Take the Blood Pressure The time has come when examiners, in order to do acceptable work for insurance companies, must be able to take the blood pressure, both systolic and diastolic, with absolute accuracy. This can be done only by the auscultatory method. For the benefit of those who have not fully acquired the auscultatory method I would suggest the following definite directions: Bare the left arm to the shoulder. Do not allow a tight sleeve partly to obstruct the circulation. If there is a long sleeved under- shirt, the arm will have to be slipped out of the shirt in order to take the pressure correctly. You cannot take the pressure satis- factorily with a big roll of shirt sleeve in the axilla. The blood pressure should never be taken over a sleeve of any sort. Seat the applicant comfortably in a chair facing a table or desk, and yourself facing his right side opposite his legs. Instruct him to relax all muscular effort, and lay the 'back of his left hand on the table or desk. This position applies to the aneroid type of sphygmomanometer. When the mercury instrument is used the applicant should sit diagonally with his left side close to the table, and the forearm resting upon it. The sphygmomanometer can then be placed on the table just back of the applicant's arm so that the scale will be in good view of the examiner. Place the cuff around the arm opposite the heart, about the middle of the humerus, leaving space below the cuff above the bend of the elbow to place the stethoscope over the brachial artery just inside the tendon of the biceps. Some prefer to place the stethoscope just below the bend of the elbow over the radial artery; hut the pulsations are usually heard more distinctly over the brachial artery. Instruct the applicant not to look at the instrument, as watching the index while taking the blood pressure, is apt to raise the pressure in a nervous person. Place the stethoscope over the brachial artery just above the inner condyle and to the inner side of the tendon of the biceps, and 296 LIFE INSURANCE EXAMINATION note the point in the ascending scale where the first sound is heard and also where the pulse is completely cut off, as the pressure in the inflated cuff is steadily increased. This first reading is used mainly as a guide, and shows at once whether you have a case of high or low pressure. Push the scale a few points above where the pulse ceased. Open the needle valve and allow the scale to descend very slowly one or two points at a time. At first there is nothing heard over the completely compressed artery. Suddenly a distinct thump of a pulsation is heard as the first blood is forced through the com- pressed artery. This marks the Systolic Pressure. Continue to allow the air to escape slowly, and following a succession of clear thumping pulsations, which is the first phase, a distinct loud murmur is added to the beat in most cases, much like a rough mitral murmur heard over a leaky heart; this is the second phase. Again loud clear pulsations are heard, much like those of the first phase, but usually louder; this is the third phase. These loud beats suddenly change to dull muffled tones, as the scale continues to descend; this is the fourth point and the beginning of the fourth phase; the tone change as it is designated. After a succession of these dull obscure beats, all sound suddenly ceases, as the artery resumes its normal caliber. This is the fifth point, the end of the fourth phase, and is designated last sound. Open the valve and let the air all escape; and after a moment's interval of rest, take a second reading; this should be done in the reverse order. Place the stethoscope over the artery and inflate the cuff, then note these various points and changes as the scale ascends; then again with the scale descending. When the scale descends too fast, and you are not quite certain of the point where the sound first appears or disappears, push the scale up above the point, and again let it descend very slowly, until you locate the exact point. It is frequently noticed that the systolic is higher in the first reading than in the subsequent readings taken a few moments later. This is due to nervousness. It is always necessary to take at least three readings, and in some cases more. It can all be done in the space of two or three minutes; and should never be continued long at a time. Tn some nervous cases it is necessary to have a second sitting at another date. The pressure can be taken in the right arm, in the same way; the left arm is used only as a matter of convenience. Be careful not to BLOOD PRESSURE AND HOW TO TAKE IT 297 obstruct the artery by pressure with the stethoscope. In some per- sons it is not easy to take the blood pressure; the pulse is obscure and even hard to count, and the artery may be displaced, so that it requires a little trial to find it. Tn cases of this kind a phonendo- scope which magnifies the sound is perhaps an advantage, but ordi- narily a common stethoscope leaves nothing to be desired. Each one will probably do best with the particular instrument he is in the habit of using. A little persistent practice will soon enable you to fully master this technic; and when you do you will be able to take the blood pressure, with as much certainty as you count the pulse. To recapitulate and simplify: While it is important to be familiar with all the points and phases in the taking of blood pressure, it is necessary only to look for and record three points, the first, fourth, and fifth. The first point is where the first pulsation is heard as the scale descends where the pulse has been fully compressed, and de- notes the systolic pressure; the fourth point is where the beats which are loud and clear suddenly change to dull obscure tones, and is termed tone change; the fifth point is where the last sound is heard. References Brunton, Sir Lauder: Clinical Measurement of Diastolic Blood Pressure and Cardiac Strength, British Med. Jour., 1910. Cook, H. W.: The Accurate Estimation of Pulse Tension in Life Insurance Ex- aminations, Medical Examiner and Practitioner, August, 1904. Cook, H. W.: Chronic Arterial Hypertension, Jour. Am. Med. Assn., January 28, 1905. Cook, H. W.: Blood Pressure in Prognosis, Proceedings of the Medical Sec- tion of the American Life Convention, September, 1911. Cook, H. W.: Blood Pressure-Systolic, High, Low, Etc., Proceedings of the Sixth Annual Meeting of the Medical Section of the American Life Con- vention, March, 1916. Editorial: Blood Pressure, Jour. Am. Med. Assn., July 1, July 29, August 5, August 12, September 2, September 9, and September 16, 1916. Faught, Francis Ashley: Blood Pressure, 1916, ed. 2, W. E Saunders Co. Faught, Francis Ashley: A Rational Interpretation of Blood Pressure Findings, New York Med. Jour., January 15, 1921. Fisher, J. W.: Blood Pressure Statistics, 1912. Fisher, J. W.: The Diagnostic Value of the Sphygmomanometer in Examinations for Life Insurance, 1914. Fisher. J. W.: Diagnostic Value of Systolic Blood Pressure, Wisconsin State Med. Soc., 1915. Foreheimer's Therapeusis of Internal Diseases, 1917, iii, D. Appleton & Co. Gerwood, R. L., and McKenzie, Sir James: Diseases of the Arteries, Oxford Med., 1920, ii. Goepp, Max: Blood Pressure from the Life Insurance Standpoint, Medical In- surance and Health Conservation, May, 1917, 298 LIFE INSURANCE EXAMINATION Goodman, Edward H.: Blood Pressure, 1914, Lea & Febiger. Hirshfelder: Disease of the Heart and Aorta, 1913, ed. 2, Lippincott Co. Janeway, T. C.: Clinical Study of Blood Pressure, 1907, D. Appleton & Co. MacKenzie, L. F.: Blood Pressure with Special Reference to the Diastolic, Tr. Assn, of Life Ins. Med. Directors, 1915. MacKenzie. L. F.: The Significance of the Diastolic Pressure, Proceedings of the Tenth Annual Meeting of the Med. Sec. Am. Life Con., 1920. Macleod, J. J. R.: Physiology and Biochemistry in Modern Medicine, 1922, ed. 4, C. V. Mosby Co. Nicholson, Percival: Blood Pressure in General Practice, 1913, Lippincott Co. Nicholson, Percival: Clinical Significance of Diastolic and Pulse Piessuie, Am. Jour. Med. Sc., April. 1914. Rogers, Oscar H.: Hyperpiesia or Essential High Blood Pressure-For Use of the Medical Examiners of the New York Life Ins. Co., 1921. Rogers, Oscar H., and Hunter, Arthur: Blood Pressure as Affected .by Sex, Weight, etc., Proceedings of the Eighth Annual Meeting of the Med. Sec. Am. Life Con., March, 1918. Stone, W. J.: Clinical Significance of High and Low Pressure, Jour. Am. Med. Assn., October 4, 1913. Warfield, Louis M.: Arteriosclerosis, 1920, ed. 3, C. V. Mosby Co. Warfield, Louis M.: Clinical Determination of Diastolic Piessure, Jour. Am. Med. Assn., October 4, 1913. Young, J. R.: Blood Pressure and Significance, Jour. Indiana State Med. Assn., March, 1914. CHAPTER XXII THE DIAGNOSTIC VALUE OF THE SPHYGMOMANOMETER IN LIFE INSURANCE EXAMINATIONS By J. W. Fisher, M.D., Milwaukee, Wis. Medical Director, The Northwestern Mutual Life Insurance Co. It is the purpose of this study to demonstrate the value of the sphygmomanometer in medical examinations for life insurance, as- suming that all progressive members of the medical profession realize the diagnostic value of the sphygmomanometer in all branches of medicine. Prior to the year 1907, no life insurance company made system- atic use of this valuable instrument in the examination of applicants for life insurance. In that year the Northwestern Mutual Life Insurance Company tested its diagnostic value in medical exami- nations made at its home office. We were so favorably impressed with the results that in August, 1907, we required its use by the examiners of the company who could be induced to secure an instrument, in all localities in which the company operated. Up to the latter part of the year 1911, we required the systolic pres- sure only at ages forty to sixty (the company does not insure above age sixty). Since then we have required the blood pressure at all ages and regardless of the amount of insurance applied for. Prior to the use of the sphygmomanometer we depended upon the digital determination of the arterial tension, when only a frac- tion of 1 per cent of applicants were refused insurance for this cause alone. At the present time, about 6% per cent of all cases rejected are found to have a high arterial tension and in con- siderably more than half of those with a high blood pressure, the examiner discovers no impairment which would account for the high arterial tension. This demonstrates, and the records of the company show, that many applicants who apply for insurance and who suppose they are in perfect health and normal in every respect, have a high blood pressure while presenting no symptoms or patho- logic changes discoverable by our present methods of diagnosis. While it is true, and our records show, that an apparently healthy 299 300 LIFE INSURANCE EXAMINATION person may carry a high blood pressure for a number of years with- out any discoverable pathologic changes to account for this impor- tant diagnostic symptom, there can be no question that if the cause of the impairment is not discovered and removed, premature death will result in a very large percentage of such cases. The mortality tables upon which the following statistics are based are known as the Medico-Actuarial and American Men Tables and are derived from the actual experience of forty-three leading com- panies of this country and Canada, of persons insured during the years 1885-1909, who underwent a medical examination at the time the policies were issued at the regular rates. Substandard risks were excluded. The tables were adjusted so that 300 represents the average expected death rate of insured persons covering the period 1885-1909. It should be stated that the actual death rate of the Northwestern covering the same period is slightly less than 80 per cent of both tables. In order to furnish accurate and reliable mortality statistics, the data must be based upon accurate and reliable facts. The first essential is a clean, accurate sphygmomanometer, manipulated by a careful, painstaking examiner. Frequent checking of the sphyg- momanometer with one of known accuracy is necessary. Aneroid instruments are more convenient than the mercury, but are more delicate and more liable to become inaccurate than mercury instru- ments, if not frequently checked with a clean, known, accurate mercury instrument. The use of a defective instrument not only misleads the examiner, but furnishes the insurance company with unreliable and misleading data, and, in many cases, an undesirable risk and consequent loss. The examiner is paid a fee for furnishing the company with facts upon which to base an opinion as to the insurability of each appli- cant he examines. A physician who is not fully convinced of the diagnostic value of the sphygmomanometer in his practice, as well as in an examination for life insurance, and is unwilling to keep his instrument in proper shape, to enable him to furnish accurate blood pressure readings, should resign his position as an examiner for a life insurance company. A careless examiner who fails to make a thorough, conscientious, painstaking examination and to furnish his company with complete, accurate facts in his examination of an applicant for life insurance, is receiving money under false pre- tenses. Carelessness ami dishonesty are very closely related and DIAGNOSTIC VALUE OF THE SPHYGMOMANOMETER 301 have no place in the medical profession. I have great faith in the hon- esty and integrity of the medical profession as a whole, and this has been greatly strengthened by thirty-five years' experience as med- ical director of a company which employs about twelve thousand regularly appointed examiners in the localities in the United States in which it transacts business, and I am fully convinced that the medical profession compares favorably, man to man, with that of any other profession or class of citizens. Integrity is one of the basic principles of a successful career in the medical profession. In this connection it may be of interest to state that in the early history of life insurance, many companies would not permit a family physician to .examine a patient of his for life insurance, even though the physician were a regularly appointed examiner of the company, for fear of prejudice in favor of his patient. Believing fully in the integrity of the profession as a class, the medical direc- tor was convinced that the company would secure better service from the family physician than to insist upon an examination by a physician who was not familiar with the applicant's past and pres- ent health record, and, to determine as to whether or not this was a fact, the mortality, covering a period of over twenty-eight years, on 38,550 examinations made by a regularly appointed examiner of the company who was the physician of the applicant, has been found to be twelve points better than the general average mortality of the company covering the same period. Suggestions as to Method of Taking the Blood Pressure First-Applicant's Attitude.-The subject must be relaxed, both physically and mentally. If not, the blood pressure tends to rise several millimeters. Any stimulation of the emotions produces this result. The examinee should not watch the procedure, as the in- creased muscular tension of this act, and the attendant added solicitude, are detrimental. ' If the applicant becomes faint, time should be given the arteries to regain their normal tone. If necessary, a blood pressure record should be secured the following day. Second-Applicant's Position.-Seat the applicant at a table, with his left forearm resting upon it. Place the cuff on the bare arm, preferably when he is stripped to the waist for the chest examina- tion. Avoid all constrictions or pressure from clothing between the cuff and the shoulder. 302 LIFE INSURANCE EXAMINATION Third-Methods of Securing Blood Pressure.-Record the systolic pressure by both the palpatory and auscultatory methods and the dias- tolic pressure by the auscultatory method only. Be sure the mercury column or the pointer of a dial instrument is at zero. Mercury in- struments must stand perpendicular or rest on a level table. Apply the cuff snugly over the biceps muscle. Place the stethoscope over the forearm at the point of bifurcation of the brachial artery. Grad- ually inflate the closed pneumatic system until all tones disappear, then slowly release the pressure. The first sharp tone of the re- turning pulse wave is the systolic pressure. Continuing the release of the air, the sound varies in quality through several phases, the diastolic reading being made at the point of the last loud tone which will be found at end of the so-called third phase. Also record the reading directly after the cessation of all sound. The first reading is frequently high and it is advisable to take several addi- tional readings until a uniform record is secured. All readings should be recorded on the blank. Palpatory Method.-Instead of using the stethoscope, two fingers are placed over the radial artery with just sufficient pressure to feel distinctly the pulse wave. Releasing the air in the pneumatic system at the point of the first pulsation, the systolic reading is made. Fourth-Additional Readings.-Where the systolic pressure is 10 or more millimeters above the average for the given age, addi- tional readings should be taken. At least three tests should be made, on different days and at different times of the day, to deter- mine whether or not the pressure is constantly high, and each read- ing recorded on the blank. In these cases, additional urinalyses are required. Fifth-Checking Instrument.-To check a manometer, the direct method should be used; that is, comparing two instruments on the same closed pneumatic system. This is done by rolling up a sleeve band and tucking the end strip under. Attach one instrument and inflate to about 100 mm. Withdraw the pump, bending the rubber tubing to prevent the escape of air; then to this tube attach the other instrument. By manipulating the arm band, the pressure can be increased or decreased, and it is easy to determine the comparison of the two instruments between 80 mm. and 200 mm. Our experi- ence shows that normally there may be a variation of from two to four millimeters between two fairly accurate instruments. DIAGNOSTIC VALUE OF THE SPHYGMOMANOMETER 303 The average systolic blood pressure by the palpatory method is as follows: AGE PERIODS AVERAGE 15-19 120 20-24 122 25-29 123 30-34 124 35-39 126 40-44 128 45-49 130 50-54 139 55-59 134 60-64 135 65 and over 136 By the auscultatory method, the systolic blood pressure will aver- age from 4 to 6 millimeters higher than by the palpatory method. I am fully convinced that the diastolic pressure in medical exami- nations for life insurance will prove to be of as great if not greater value, than the systolic pressure, when the medical examiner learns to be as accurate in recording the diastolic as he is in recording the systolic pressure at the present time. It is difficult to under- stand the reason why some medical examiners are unable accurately to determine the diastolic blood pressure. It should be no more difficult to determine the one than the other. Medical examiners should strive by diligent practice to improve their technic, so that lhe companies can rely upon their examinations with respect to the diastolic blood pressure with the same degree of certainty that they do with respect to the systolic pressure. It is a well-established fact that the true diastolic pressure occurs at the end of the third phase, or the beginning of the fourth phase, that is, the last loud tone. Hence the pressure should be recorded at this phase of the heart's cycle. The pressure should be recorded at the disappearance of all sound also. The one will act as a check on the other. This we have found to be of great value with the systolic pressure, by re- quiring both the palpatory and auscultatory pressure to be recorded on the blank. The 1,244 cases recorded in Table I, were examinations made at the home office, or by well-trained examiners in the field who under- stood the proper method of determining the blood pressure by the auscultatory method. There is room for improvement in some lo- calities on the part of medical examiners in ascertaining correct readings by the auscultatory method, especially the diastolic pressure. 304 LIFE INSURANCE EXAMINATION Table I Actual Mortality to August 1, 1920, as Compared With Expected (M.-A. Table). Accepted Risks With Diastolic Blood PpvEssure of 95 MM. and Above, Issues of 1915-1920 to July, Inclusive. AGES AT ENTRY ALL AGES AT ENTRY 16-39 40-60 Number Expected Actual Per Cent Number Expected Actual Per Cent Number -3 r- O g s O ft 42 p, X O Q a <1 ft 482 6.473 4 62 762 21.514 18 84 1244 27.987 22 79 Aveiage Diastolic Blood Pressure-99 mm. Average Diastolic Blood Pressure-100 mm. Average Diastolic Blood Pressure-99.5 mm. There were 4 deaths in those under age forty and 18 deaths in those over age forty. Of the former, 1 died of typhoid fever, 2 of influenza-pneumonia, 1 casualty. In the latter group there were 18 deaths. Five were due to cerebral apoplexy, 2 to influenza- pneumonia, 2 to nephritis, 2 to lobar pneumonia, 1 to angina pec- toris and 6 to miscellaneous causes. The mortality was found to be 79 per cent of the table, which is about the normal mortality of the company. The exposure is rather short to enable one to draw any definite conclusions. A longer period of exposure may show different results. Table II Low Arterial Tension The Northwestern Mutual Life Insurance Company Accepted Risks With Palpatory Systolic Blood Pressure of 100 MM. and Under to October 1, 1920 AGES AT ENTRY ALL AGES AT ENTRY 16-34 35-60 No. Deaths Y ears No. Deaths No. Deaths 1912 5 0 4 0 9 0 1913 170 2 56 1 226 3 1914 150 2 45 1 195 3 1915 133 2 41 0 174 2 1916 292 3 81 1 373 4 1917 319 6 104 2 423 8 1918' 208 1 140 1 348 2 1919 610 o 282 2 892 4 1920 521 0 228 0 749 0 Total 2408 18 981 8 3389 26 During the years 1913-192'0, both inclusive, the company issued insurance to 2,408 members with a systolic blood pressure, palpa- DIAGNOSTIC VALUE OF THE SPHYGMOMANOMETER 305 tory method, of .100 mm. and under, a pressure of practically 90-100 mm., ages sixteen to thirty-four, with 18 deaths; and 981, ages thirty-five to sixty, with 8 deaths. It is of interest to note the causes of death. In the former, 6 were due to casualties, 7 to in- fluenza-pneumonia, 1 to pleurisy, 1 to disease of stomach, 2 to pul- monary tuberculosis and 1, cause of death unknown. In the latter class, 2 were due to casualties, 3 to influenza-pneumonia, 1 to disease of liver, 1 to pericarditis and 1 sudden death. It will be noted that of the 3,389 cases, ages 16 to 60, only 26 had died. Of these 8 were casualties and 10 died of influenza-pneumonia. It was estimated, however, that including deaths from all causes, the mortality was slightly in excess of one-third of that expected by the Medico- Actuarial Table. The company has declined comparatively few cases wholly on account of low arterial tension. In those cases declined with a low blood pressure, there were other impairments which led to the rejection of the applicant. We have not found in any of our death claims of insured members, where, for instance, the death was due to tuberculosis within two years of the issuance of the policy of in- surance, that the blood pressure at the time of the approval of the application varied perceptibly from the average for the age. Table III The Northwestern Mutual Life Insurance Company. Actual Mortality by Lives to Anniversary in 1919, as Compared With Expected According to the M. A. Table Mortality of Accepted Risks with Palpatory Systolic Blood Pressure of 140-149 mm. with an Average of 142 mm.-Ages 40-60, Inclusive YEARS NO. EXPECTED ACTUAL PER CENT 1907 208 M. A. 32.263 32 M. A. 99 1908 642 91.945 89 97 1909 944 111.754 ' 108 97 1910 816 86.657 81 93 Total 2610 322.619 310 96 AGES AT ENTRY 45-53 1340 159.693 167 105 Tn Table III is a record of 2,610 persons to whom insurance was issued during the years 1907-1910, both inclusive, ages 40 to 60, with an average blood pressure slightly in excess of 142 nun. Dur- ing the time indicated, in accordance with the Medico-Actuarial Mor- tality Table 323 were expected to die; in fact the actual number of 306 LIFE INSURANCE EXAMINATION Table IV Mortality of Accepted Risks with Palpatory Systolic Blood Pressure of 150 mm. and Over with an Average of 152 mm. Issues of 1907 to 1910, Inclusive to Anniversary in 1919 AGES AT ENTRY NO. EXPECTED ACTUAL PER CENT 40-60 520 77 90 117 45-53 283 36 52 144 Causes of Death Table III Table IV 23 Cancer and Sarcoma 5 4 Diabetes 2 1 Fever-Typhoid I 2 Influenza 1 5 Rheumatism 4 6 Tuberculosis-Pulmonary 0 1 Tuberculosis-other than Pulmonary 0 11 Miscellaneous 4 53 Total General Diseases 17 35 Apoplexy and Softening of Brain 8 2 Meningitis I 6 Insanity 0 2 Miscellaneous 1 45 Total Nervous Diseases 10 23 Angina Pectoris 6 14 Pericarditis and Endocarditis 4 27 Organic Heart Disease 9 16 Arteriosclerosis (5 2 Miscellaneous 0 82 Total Circulatory Diseases 2.) 1 Pleurisy 0 19 Pneumonia 6 1 Miscellaneous 0 21 Total Respiratory Diseases 6 7 Appendicitis 2 1 Intestines-disease of 0 7 Liver-disease of o 6 Stomach-disease of 4 o Miscellaneous 0 23 Total Digestive Diseases 8 3 Bladder-disease of 0 37 Nephritis 14 3 Prostate-disease of J 43 Total Genitourinary Diseases 16 22 Casualties 4 14 Suicide 2 7 Miscellaneous 2 43 Total Violent Deaths 8 310 Grand Total 90 DIAGNOSTIC VALUE OF THE SPHYGMOMANOMETER 307 deaths was only 310, giving a percentage of 96, which is 4 per cent less than the table, and 17 per cent higher than the general average mortality of the Northwestern Mutual Life Insurance Company, covering the same period. Of these 1,340 were insured at ages forty-five to fifty-three, which shows a mortality of 105 per cent of the table. Considering the group as a whole from an insurance standpoint, the mortality is not above the normal. The average blood pressure was about 12 mm. above the average for the age. Nothing unusual was found in the causes of death, considering the age of the group. Attention is called to the fact that there were but two deaths due to influenza or its complications. It will be seen that there were 520 cases, with 77 deaths expected and 90 actual deaths, giving a percentage of 117 of the Medico- Actuarial Table. Of this number 283 were ages forty-five to fifty- three, in which thirty-six deaths were expected, fifty-two actual, giving a percentage of 144. We accepted these risks before we had learned that 15 mm. above the average for the age would give a mortality above the table. We have definitely determined that a persistent systolic blood pres- sure of 15 mm. above the average for the age, by the palpatory method, in a case presenting no other impairment, will produce a mortality of about 17 per cent in excess of the table, which would be 37 per cent higher than the general mortality of this company. Fortunately the systolic pressure has proved to be of very great value in life insurance examinations. It has enabled life insurance companies to eliminate a class of undesirable risks, as well as to en- able them to accept certain classes which otherwise would have been refused insurance. We hope in the near future to establish the value of the diastolic pressure. Much will depend upon cooperation of examiners in furnishing accurate records of diastolic pressure. It is also a fact that the work done by insurance companies in requiring the use of the sphygmomanometer as a routine in making examinations, has been of great value to the medical profession, as well as to numerous citizens who supposed they were in perfect health until they applied for life insurance and found that their blood pressure was high, and this with no other impairment dis- covered at the time of the examination to account for the increased blood pressure. This has proved to be the case in 4,165 individuals who applied to one company alone during the past fourteen years, and about an equal number have also been declined in which there 308 LIFE INSURANCE EXAMINATION Table V Actual Mortality Risks Rejected Due to High Palpatory Systolic Blood Pressure Only During the Years 1907 to 1920 Inclusive (American Men Table) To Anniversary in 1921 AGES AT ENTRY NUM- BER OF LIVES FIRST YEAR FIRST FIVE YEARS AFTER FIVE YEARS ALL YEARS RATIO % DEATHS DEATHS DEATHS DEATHS AC- TUAL EX- PECTED AC- TUAL EX- PECTED AC- TUAL EX- PECTED AC- TUAL EX- PECTED 16-29 743 5 2.0 16 7.4 2 1.8 18 9.2 195.7 30-39 731 5 2.3 28 9.8 6 3.3 34 13.1 259.5 40-49 1196 20 6.0 106 32.1 75 22.0 181 54.1 334.6 50-60 1495 24 15.3 175. 85.6 99 58'0 274 143.6 190.8 Total 4165 54 25.6 325 134.9 182 85.1 507 220.0 230.5 Ratio % 210.9 240.9 213.9 230.5 was found some other impairment at the time of the examination. Practically all of these individuals supposed they were in good health at the date of the examination. The use of the sphygmo- manometer demonstrates that a person may have an abnormally high blood pressure and present no symptoms or pathologic changes discoverable by any of our present methods of diagnosis, thereby suggesting a careful study of the case before any symptoms of dis- ease are manifest which would account for the high arterial tension. Result of Recent Investigation Covering Only Cases of High Arterial Tension With No Other Impairment at Date of Rejection Considerable difficulty is experienced in locating a class of rejected risks after the lapse of a few years. The Northwestern has just com- pleted an investigation of persons who applied to the company for in- surance and whose applications were declined on account of high arte- rial tension, covering the period from August, 1907, to August, 1920. Inquiry was conducted through our local examiners, our agency force and other sources. We endeavored to determine whether the person was living, if so, his condition of health, and if dead, the date and cause of death. As a result of such inquiry, we received information showing that fully one-half of these cases were reported to have developed impairments, a cardiovascular- renal condition or continued hypertension being the principal fac- tor of the impairments reported. It might be well to state that where an applicant was reported as having a high blood pressure with no other impairment, was DIAGNOSTIC VALUE OF THE SPHYGMOMANOMETER 309 Table VI Actual Mortality Risks Rejected Due to High Systolic Blood Pressure Only (Palpatory method) During the Years 1907 to 1920 Inclusive Mortality Computed to Anniversary in 1921 (American Men Table) Ages at Entry-16-60 Inclusive M g O h OS r-, a> > FIRST YEAR FIRST FIVE YEARS AFTER FIVE YEARS ALL YEARS > t Cl 5 to era <72 r-i 03 g £ £ § s Ga O w DEATHS DEATHS DEATHS DEATHS RATIO % ° w pq o w AC- EX- AC- EX- AC- EX- AC- EX- <s m < £ TUAL PECTED TUAL PECTED TUAL PECTED TUAL PECTED +.10-14 525 3 3.4 21 13.6 5 5.5 26 19.1 136.1 +15-24 1685 16 9.0 88 45.8 37 22.2 125 68.0 183.8 +25-34 909 7 5.8 66 32.0 45 22.3 111 54.3 204.4 +35-49 657 12 4.6 71 26.6 50 22.1 121 48.7 248.5 +50 389 16 2.8' 79 16.9 45 13.0 124 29.9 414.7 Total 4165 54 25.6 325 134.9 182 85.1 507 220.0 230.5 Ratio % 210.9 240.9 213.9 230.5 Table VII Risks Rejected High Palpatory Systolic Blood Pressure Only. Mortality to Anniversary in 1921 (American Men Table). Ages at Entry-16-60 Inclusive YEARS OF ENTRY NUMBER OF LIVES DEATHS RATIO % ACTUAL EXPECTED 1907 21 15 3.4 441.2 1908 52 32 9.4 340.4 1909 85 40 14.8 270.3 1910 108 48 18.9 254.0 1911 140 38 19.3 196.9 1912 320 72 34.7 207.5 1913 314 56 28.3 197.9 1914 239 47 17.8 264.0 1915 347 43 20.4 210.8 1916 373 43 18.0 238.9 1917 391 33 14.1 234.0 1918 326 21 8.4 250.0 1919 587 11 7.9 139.2 1920 862 8 4.6 173.9 Total 4165 507 220.0 230.5 rejected by the company, and after varied subsequent treatment (correction in diet, change in mode of living, proper exercise, etc.) the blood pressure became normal and insurance was granted in this and other companies, the hypertension having been proved to 310 LIFE INSURANCE EXAMINATION be temporary or accidental, such cases were not included in our study of risks rejected. We did, however, obtain our mortality upon this class of risks, accepted by the company as standard risks, and the mortality was found to be favorable as compared with the general mortality of the company. Table VIII Causes of Death of the 507 Cases as Shown in Table V CAUSES OF DEATH ENTRY AGES 16-39 NUMBER ENTRY AGES 40-60 NUMBER TOTAL Anemia Pernicious 0 3 3 Angina Pectoris 2 18 20 Apoplexy 5 104 109 Appendicitis 2 4 6 Arteriosclerosis 1 39 40 Bladder operation 0 1 1 Cancer 3 17 20 Casualties 4 5 9 Diabetes 0 4 4 Duodenal Ulcer 0 4 4 Gall-stones 0 3 3 Heart Disease (Organic) 5 83 88 Hernia operation 0 2 2 Influenza-Pneumonia 6 1 7 Insanity 1 3 4 Kidney operation 0 1 1 Liver Disease 0 3 3 Locomotor Ataxia 0 1 1 Lungs Oedema 1 1 2 Meningitis Cerebral 1 1 2 Nephritis 9 97 106 Paralysis 0 4 4 Pleurisy 0 1 1 Pneumonia 4 10 14 Prostatic Hypertrophy 0 1 1 Sudden Death 0 8 8 Suicide 2 n 7 Syphilis 0 2 2 Tuberculosis 2 3 5 Tumor Brain 2 2 4 Miscellaneous 2 24 26 Total 52 455 507 In Table V will be found the mortality record by ages of 4,165 eases rejected during the years 1907-1920, both inclusive. In none of these cases was there any other impairment found; the rejection was based wholly on hypertension. Table VI contains this same data, but arranged according to the number of millimeters above the average for the age. Tn both DIAGNOSTIC VALUE OF THE SPHYGMOMANOMETER 311 Summary of the Mortality Experience of The Northwestern Mutual Life Insurance Company, with respect to the Palpatory Systolic and Auscultatory Diastolic Blood Pressure. Years of Entry Range Arterial T ens tan if Entry Number of Lives Actual Deaths Ratio Actual to Expected Mortality (Amencan Men Table) Accepted Rejected )00 ?00 300 TOO % % % % % 1912 1920 l»w Blood Pressure 100 mm. and under 16-60 .3389 26 '*35. 0 1915 1920 Diastolic Bkxxl Pressure 95mm. and above 16-60 1244 oo 78. 6 1907-1910 to anniversary m 1919 Blood Pressure Av 142mm 40-60 2610 310 94 0 Blood Pressure Av 153mm. 40-60 520 -90 114 4 Risks Rejected for High Blood Pressure Only Years 1907 1920-Mortality Computed to Anniversary 1921 3 £ 5 3 Co 16-29 743 18 195 7 30-39 731 34 259. 5 40-49 1196 181 334 6 50-60 1495 274 190 8 Total 16-60 4165 507 230 5 s- s e E SA » 4 Mm. + 10-14 525 26 136 1 + 15-24 1685 125 183 8 + 25-34 909 111 204 4 +35-49 657 121 248 5 + 50 389 124 414 7 Total 16-60 4165 507 230 5 "The Northwestern Mutual Life Insurance Company's General Mortality Experience about 80% of the Table ''Estimated Mortality Table IX 312 LIFE INSURANCE EXAMINATION tables, the mortality is shown for the first year, the first five years, after five years and for all years. It will be noted that the highest mortality occurred during the first five years-241 per cent of the American Men Table. The general mortality of the Northwestern during the past twenty years is less than 80 per cent of this table; that is to say, the mortality in this class is more than three times the general mortality of the company. Note the mortality for the first year, the first five years and after five years, and for all years. Table VII shows the number rejected in each year, indicating the actual deaths, the expected deaths by the above table, and the ratio of mortality. Table VIII shows the causes of death. Table IN shows, in graphic form, the mortality on risks accepted with hypotension, high diastolic and an average blood pressure of 142 mm., ages 40-60; an average blood pressure of 153 mm., ages 40-60; also the data in Tables V and VI in graphic form. We have received notice of 45 additional deaths since the close of tabulation shown in Tables V and VI. Conclusions The conclusions to be drawn from a study of hypertension covering a period of fourteen years are : 1. That a persistently high arterial tension will result in an excessive mortality, and the higher the arterial tension, the greater the mortality. 2. That a persistent systolic blood pressure of about 12 mm. above the average for the age, would seem to indicate the limit of normal excess variation in man. 3. That a person with a persistent palpatory systolic blood pres- sure of 15 mm. above the average for the age, with no other impair- ment, will show, from an insurance standpoint, a mortality of about 2'0 per cent in excess of the Table. 4. That an apparently healthy person may have high arterial tension extending over a considerable period of time, without a discoverable impairment to account for the same. 5. That of the medical impairments found, together with high arterial tension, both below and above the age of forty, about 80 per cent are cardiovascular renal disease. DIAGNOSTIC VALUE OF THE SPHYGMOMANOMETER 313 6. That while the normal average blood pressure increases with age, a materially higher arterial tension is not necessarily to be expected at older ages. 7. That persons with a systolic pressure between 90 and 100 mm. show a much more favorable mortality than persons with a pressure of 12 mm. above the average pressure for the age. 8. That in persons whose weight is 20 per cent or more, in excess of the average for height and age, the blood pressure averages about 4 mm. higher than those of average weight, and higher among those of average weight than among persons underweight. 9. That if the cause of the persistently high arterial tension is not discovered and removed, premature death will result in a very large percentage of such cases. CHAPTER XXIII SYPHILIS FROM THE LIFE INSURANCE STANDPOINT By David N. Blakely, M.D., Boston, Mass. Assistant Medical Director, The New England Mutual Life Insurance Company. The question of insuring syphilitics may very properly be divided into two parts: (1) How shall applicants with a history of syphilis be selected? and (2) how shall applicants who have had syphilis, but give no history of having had it, be detected? In past years, many companies have insured at standard rates a certain number of carefully selected and supposedly "cured" syphilitics. The methods of selection have varied a good deal, but the results, when carefully studied, have never been wholly satis- factory. The investigation of the Actuarial Society of America, published in 1903, included the experience of thirty-four of the leading com- panies during a period of thirty years, from 1870 to 1899 inclusive. The Medico-Actuarial Mortality Investigation, compiled and pub- lished by the Association of Life Insurance Medical Directors, and the Actuarial Society of America, published in 1914, included the experience of forty-three companies during a period of twenty-four years, from 1885 to 1908, inclusive. These elaborate investigations and also studies of their own experience made by several individual companies, have shown surprisingly similar results. The mortality in the groups of those who gave a history of syphilis has been approximately double that of all lives insured during the same periods. The companies that have accepted these "cured" syphilitics as substandard risks and have charged an extra premium sufficient to allow for about a double mortality, have had results on the whole satisfactory, from a financial standpoint. It would seem to be both easy and logical, therefore, to answer our first question, "How shall applicants with a history of syphilis be selected?" by saying, "Consider them all as substandard risks and give them a sufficient rating to allow for a double mortality." This, in the light of our present knowledge, would be "safe" pro- 314 SYPHILIS FROM LIFE INSURANCE STANDPOINT 315 vided a reasonably careful method of selection was followed. Should the companies, however, be content to follow this easy and safe method, or should they try to devise a still better method of selec- tion, one sufficiently rigid to enable them to separate a relatively small group safely insurable at standard rates, leaving the larger group in the substandard class? To a discussion of this point I shall return later. The second question was, "How shall applicants who have had syphilis, but give no history of having had it, be detected?" It has been said repeatedly that at present the companies are declin- ing to insure a small group of honest syphilitics, but are accepting freely day by day a much larger group of syphilitic liars. It would be a truism indeed to say that if all unknown syphilitics could be eliminated from the standard risks, the mortality curve of every company would show a decided drop. Some may suggest that the first step toward improvement should be an effort to obtain more accurate histories from applicants. The point is well taken and without any question whatever, greater effort to obtain full and accurate histories should be made by the examiner. It has been said that "History-taking is an art in itself and, like most other arts, is practised by many tyros but by very few experts." The companies are insisting on higher standards in medical examinations and the examiners are responding in a gratifying way. A few of them-and the number is increasing year by year-already deserve a rating of 99.5 per cent on their painstaking and conscientious work, which includes both taking and recording histories and mak- ing physical examinations. It must not be forgotten that there are many cases of unrecog- nized syphilis. The symptoms are so slight in some instances that the victims do not consult their physicians. In others the symptoms are so masked or indefinite that a negative and hence a wrong diag- nosis is made. "Some of the cases are enough to deceive the very elect," said an old-time surgeon and the present day specialist an- swers, "'Tis even so." The following paragraph from a recent paper before one of the national associations illustrates this point and is worth quoting:1 "There are probably few here who have not seen patients on whom needless surgical operations had been performed-on tongue, lips or tonsils, for unrecognized primary syphilis." It would be another truism to add that syphilis as a cause of 316 LIFE INSURANCE EXAMINATION death rarely appears in insurance records, but it is equally certain that a large number of deaths of policyholders are due to diseases or conditions which are the direct result of syphilis. The two big problems of syphilis from the insurance standpoint are its manifestations in the circulatory system and in the central nervous system. It cannot be emphasized too strongly or too frequently, that tissue destroyed by syphilis cannot be replaced and when we remember that this is primarily a disease of the blood vessels, is it any wonder that approximately one-third of our policyholders die from diseases of the circulatory system? For a long time before the discovery of the Spirochaeta pallida and its demonstration as the etiologic factor in paresis and tabes, syphilis had been accepted generally as the probable cause of these serious diseases of the central nervous system. Dana wrote, in 1889: "If there were no syphilis, there would be no tabes or I might add paresis." Lang, also in 1899, wrote: "General paralysis and tabes undoubtedly owe their origin in the majority of cases to syphilis." Robinson in 1897 believed in the "Exclusive syphilitic origin of tabes." Sachs in 1894 wrote: "Of the causal relations between syphilis and tabes, there can no longer be any doubt." Bradshaw in 1902 agreed with Drummond, who said: "Tabes is always the result of syphilis." The long-accepted belief that syphilis was responsible for nearly all the deaths from apoplexy, angina pectoris, and aneurysm, in persons under forty, has been confirmed by finding the specific organism in the diseased tissues. Most writers had believed that since during the early stages of syphilitic infection, one or more of the coats of the arteries are usually affected, even though the symp- toms first present might disappear, the arteries remained in a con- dition especially liable to forms of disease which depend upon a weakening of the arterial coats, such as aneurysm, thrombosis and endarteritis. It has been estimated that syphilis causes 25,000 deaths in France every year and in his recent book, Hazen2 of Washington, basing his estimates on the census figures for 3909, concludes that in that one year there were in the United States, 26,438 deaths due directly to syphilis. He regards this as a conservative estimate and believes that the actual figures, if they could be obtained, would be larger. It is well also to remember that just now we are dealing with SYPHILIS FROM LIFE INSURANCE STANDPOINT 317 applicants who have been through, or are still in, a transition stage so far as the treatment of syphilis is concerned. Under the older methods of selection, an applicant for insurance, who gave a history of this infection, was required to show that he had been under treat- ment with mercury and iodides for a period of two or three years, and had been free from all symptoms for another period of from one to three years. Many of the facts about syphilis as we know them today are of comparatively recent origin. It was in 1904 that the Wassermann test was described. The discovery of the Spirochaeta pallida, by Schaudinn, was announced to the world in April, 1905. Nearly six years later salvarsan was produced. It was in December, 1910, that Ehrlich told the Medical Society of Magdeburg of his epoch- making discovery. It is not my purpose io discuss details of diagnosis or treatment. This, much, however, may be said in passing. Undoubtedly the Wassermann test, properly made and properly interpreted, is the best single diagnostic aid we have and the most valuable guide in determining treatment. The wise physician will employ other diag- nostic aids and certainly will observe his patient from many differ- ent angles. He will also consider effects of treatment on individual patients as well as their laboratory reports. So too, arsphenamine, or some similar preparation of arsenic, is probably the best single drug in the treatment of syphilis, but practically all clinicians continue to use some form of mercury in addition and there are many other therapeutic measures includ- ing drugs, diet, hygiene and habit of life, that have a large place in the sum total of treatment. Without doubt the next ten years will see important modifications in the present day methods of treatment. It is well to remind ourselves that the first hopes of the wonderful power of salvarsan were placed too high and certain unfortunate results followed the overestimate, unfortunate for individual pa- tients and unfortunate from the standpoint of insurance. It was believed at first that a single full dose of the drug put into the blood stream would be carried to all parts of the body and kill all the organisms wherever found. Ehrlich hoped to accomplish the cure of syphilis in man by the intravenous injection of a single dose, as he had been able to cure it in rabbits. This proved not to be possible in the great majority of patients and yet, because of the widespread publicity which had been given to this expectation 318 LIFE INSURANCE EXAMINATION (which was held for a time by many physicians), a considerable number of individuals having received the new treatment, believed themselves cured and took no further precautions. Some of them already have had a rude awakening by the development of the usual later manifestations of the disease. Others, free from symptoms up to the present time, will show in the future some of the distressing late symptoms. When salvarsan was first available, no one knew the proper dose, or how many injections were needed, or at what intervals they should be given. These were matters requiring careful study and observa- tion over a period of months and years rather than days and weeks. The idea of cure by a single treatment was very soon shown to be an error and yet during the short period that that belief prevailed, a few life insurance companies announced their readiness to accept applicants who had had syphilis, provided they had received a single dose of salvarsan, and had shown afterwards one negative Wasser- mann. Such announcements were recalled or rulings changed when it was shown that such a cure is the rare, very rare, exception to the usual rule, and also that a single negative Wassermann is not conclusive proof either of the absence of syphilis or of its cure. Treatment of Syphilis Among clinicians who are treating syphilis at present, the two most important slogans seem to be "Early diagnosis" and "In- tensive treatment," and to these a third may well be added, "Ob- servation over a long period of time." Then it must never be forgotten that, to quote one of them,3 "The one stumbling block in the treatment of syphilis is that eternal question 'When is it cured?' " From the insurance standpoint to this question must be added another, "Suppose a syphilitic is cured, what is the value as an insurance risk of the healed but scarred victim?" Whether or not a syphilitic is really ever cured is perhaps an academic question. Certainly of the hundreds of thousands of vic- tims in this country the percentage of those cured by accepted standards, up to the present time, is so small as to be almost negligible. What is "Intensive treatment"? Different clinicians give vary- ing answers to this question. Some consider biweekly or every- other-day injections of arsphenamine as intensive. Others limit SYPHILIS FROM LIFE INSURANCE STANDPOINT 319 this term to the method advocated by Pollitzer which consists of full doses of arsphenamine given intravenously on three successive days. These are followed by six weekly intramuscular injections of an insoluble mercurial. At the end of the sixth injection of mer- cury, three more daily injections of full doses of arsphenamine are given and these, in turn, are followed by six more injections of mercury. Chargin4 reported in April, 1921, the treatment of a series of 106 cases, in patients with recent infections, all of whom showed early cutaneous manifestations and strongly positive Wassermann reactions. The 106 patients, all adults, were divided into three groups numbering 37, 19, and 50, respectively. In the first group the "more intensive" method, essentially that of Pollitzer described above, was followed. The "intensive" method was followed in the second group. This consisted of three or four arsphenamine injec- tions administered on alternate days, followed by a course of six mercury injections, and this, in turn, by additional arsphenamine administrations, three, four or five in number, a week apart or on alternate days. For the third group a "less intensive" method (the chronic intermittent method of Neisser) was adopted. This in- cluded the use of arsphenamine and mercury, given alternately, from six to eight arsphenamine and from ten to twelve mercury injections constituting a course. The arsphenamine injections were administered from five days to a week apart and mercury was given in the interval. It was found that 80 per cent of the cases were Wassermann negative by the tenth week, 98 per cent by the six- teenth, and 100 per cent by the twentieth week. From a clinical standpoint, all three methods were in the end equally effective. Most observers, however, agree that the margin of safety is greater when the "less intensive" method is followed and hence this is looked upon with greater favor by conservative clinicians. Dr. C. Morton Smith,1 in a paper read at the Forty-fourth Annual Session of the American Dermatological Association, June, 1921, describes, "The minimum of treatment for a case of primary or early secondary syphilis" as follows: 1. Mercurial dressing to initial lesions. 2. Intravenous arsphenamine, 0.1 gm. to forty pounds body weight, repeated in from three to five days, and then at five day or weekly intervals until six to ten injections have been given. 320 LIFE INSURANCE EXAMINATION 3. Full doses of mercury, preferably by intramuscular injection; if an insoluble salt, fifteen injections should constitute the first course. Following the mercurial injections, an interval of five or six weeks should elapse before checking up with the Wassermann test. If it is positive, the first course should be repeated. If nega- tive, a vacation of three months is allowed, at the end of which time ten or twelve mercurial injections and from four to six of arsphenamine are given. With a second negative Wassermann re- action, during the following six months from six to eight mer- curial injections are given and during the next year the patient should receive short courses of mercury. An examination of the cerebrospinal fluid should be made early in the disease, if possible, and certainly before the patient is discharged. There should be also frequent examinations of the urine while the arsphenamine and mercury are being administered. For cases particularly severe, and for those in which the diag- nosis has been delayed, the courses of treatment must be repeated for a greater or lesser number of times, according to the conditions present. Dr. Smith added this suggestion: "There is everything to gain and nothing to lose by giving short courses of mercury through the first few years, after the Wasser- mann is negative and the patient is without signs or symptoms." Metallic Poisoning, in Industry and in the Treatment of Syphilis- a Comparison Under "Hazardous occupations" many insurance companies list, those in which workers are exposed to metallic poisonings. Some of the companies that insure "under-average" risks give a "rat- ing" for such groups of workers, the degree of rating varying according to the conditions prevailing in the individual industries. Let us suppose an impossible ease. A normal, vigorous man pre- sents himself as an applicant for insurance, and gives the following history. One year ago a series of accidents began in which he re- ceived intravenously seven injections of .3 gram each of an insoluble salt of arsenic, at intervals of five days, followed by fifteen weekly intramuscular injections of an insoluble salt of mercury, averaging one grain, or sixty-six milligrams, to a dose. These accidents covered a period of four months, followed by a SYPHILIS FROM LIFE INSURANCE STANDPOINT 321 three months' 11 vacation" and this, in turn, was followed by a repetition of another series of accidents like the first only a trifle less prolonged, and in the last three months of the year, he had received five injections of the arsenical salt and eleven of the mercurial. Would such a history improve the value of the risk? Would such an applicant be rated up? Should he be rated up? To make the analogy more complete let us suppose that, in addi- tion to the above, this apparently normal, vigorous applicant said that besides his unfortunate metallic poisonings, the treatment of which had involved weekly or more frequent visits to his physician, and constant thought about diet and hygiene necessitating certain vexatious restrictions in diet and habits of work and pleasure, he had suffered far greater mental anxiety or 11 worry" than he had ever known before-anxiety that concerned not only himself but his wife and his children, and was a burden that he had not been free from for a single day in the entire year, and that he would not be free from for many a long year to come-and again the question will come up, must come up, "Is this man a standard risk or is he to be rated up and if so, how much?" Is this an overdrawn picture? There will be differing opinions, of course. We know there are plenty of. happy-go-lucky "good fellows" who take a syphilitic infection lightly and yet who follow up treatment more or less consistently and more or less con- tinuously. We know also that there are a considerable number of business and professional men who in one way or another acquire syphilis and some of these men appear as applicants for insurance. Many of them take the matter seriously, more seriously indeed than any previous accident or incident in their lives. They follow faithfully and conscientiously the doctor's directions and hope for the best; but all the time the mental burden is far and away the biggest factor in the case. Syphilis, a General Infection Why do certain syphilitics show cardiovascular involvement while in others the chief symptoms and pathology are in the central nerv- ous system, or elsewhere? Yankee-like let us answer this question by asking another. "Why does the tubercle bacillus in some per- sons attack the lymph glands, in others the bones, in others the peritoneum, meninges and other serous membranes, in others the 322 LIFE INSURANCE EXAMINATION lungs and in still others any one or more of several different organs?" It is well known that the tubercle bacillus may attack any organ or structure in the body. It is equally well known that the Spiro- chaeta pallida may attack any organ or structure in the body, but what determines the site of chief destruction in an individual person is one of the many interesting and important problems yet to be solved. Both organisms enter the blood stream and are car- ried to every part of the body. Is there a different "strain" of the infecting organism, one having a special predilection for the heart muscle, another for the aortic valve, another for the arterial walls, another for the brain, another for the spinal cord, and so on? There are good arguments in favor of this theory. Or is the site of greatest damage determined by the number of organisms which are carried to, or which, by chance, remain in a certain part? We do not know. Or, again, is the site decided by a condition of low- ered resistance in one organ or another? This matter of lowered resistance easily might be made to include the condition of an organ due to its previous use or abuse. For example, one man may have overstrained his heart, causing a slight degree of myo- cardial degeneration of which he had recognized no symptoms but which was sufficient to cause the heart muscle to give way under the added strain of a syphilitic infection. Another may have suf- fered a chronic poisoning, a slow absorption from a focus of in- fection, in sinuses, around the teeth, in the intestinal tract or elsewhere, enough to cause a beginning of arteriosclerosis which is accentuated and accelerated by the new infection. In such a man, theoretically at least, this new infection might easily cause an aortitis which in turn might be followed by aneurysm; a cor- onary sclerosis, with or without angina; a sclerosis of the cerebral vessels or a general arterial degeneration. Another type of indi- vidual may be one with an unstable nervous system due either to heredity or to mental overstrain. Is it not logical to believe that if such an individual becomes infected, the chief symptoms may be those of disorder of the central nervous system? Syphilis of the Circulatory System As has been stated before, syphilis, from the standpoint of path- ology, is a disease of the blood vessels. From the standpoint of life SYPHILIS FROM LIFE INSURANCE STANDPOINT 323 insurance, lesions of the circulatory system include the most im- portant phases of syphilitic infection. For several years past all observers, whether health officers, clinicians, or statisticians, have called attention to the marked in- crease in circulatory diseases. Various theories have been advanced to explain this increase, but there has been little unanimity of opinion as to the relative importance of the different etiological factors which are recognized as possible, probable or certain causes of circulatory disorder. Apparently, aneurysm is the affection of the vascular system, which was first recognized as frequently associated with, if not due directly to, syphilis. According to Osler,5 Lancisi (who died in 1720) was the first to call special attention to the association of syphilis with cardiovascular disease. Morgagni, a generation later, also referred to the same close relation. The following trib- ute which Osler paid to this great physician in his lectures at Yale in 1913G is worthy of quotation: ''The great work, which has made his name immortal in the profession, appeared in his eight- ieth year, and represents the accumulated experience of a long life. From no section does one get a better idea of the character and scope of the work than from that relating to heart and arter- ies-affections of the pericardium, diseases of the valves, ulcera- tion, rupture, dilation and hypertrophy, and affections of the aorta are very fully described. The section on aneurysm of the aorta remains one of the best ever written. It is not the anatomical observations alone that make the work of unusual value, but the combination of clinical and anatomical records." Other diseases of the arteries, especially when occurring in early adult life, have long been considered as of possible, if not of prob- able, syphilitic origin. Syphilitic aortitis has perhaps received more attention than other arterial degeneration; possibly, because the gross lesions are readily recognized at autopsy; possibly, be- cause in the aorta the spirochetes were demonstrated comparatively early. Another very important reason may be that this lesion is recognized as present in many cases of great circulatory distress, when the seriousness of the situation is due really to myocardial failure. Accompanying the aortitis, there is frequently disease of the aortic valves, and many writers have called attention to the fact that syphilis is the most common cause of this form of valvu- lar disease. Various estimates are given as to the percentage of 324 LIFE INSURANCE EXAMINATION cases of aortic regurgitation which are due to syphilis. Some be- lieve that fully three-fourths are caused directly by luetic infection. More recently we have been told that syphilis of the heart is very common indeed; some writers have even gone so far as to ex- press the opinion that syphilis is the most important single etio- logical factor in the production of all cardiac disease, both myo- cardial and endocardial. It is not necessary to enter into a detailed discussion of the pathological findings in cardiac syphilis. A few points, however, should be kept clearly in mind. One of the most important is that since the discovery of the Spirochaeta pallida, numerous lesions have been transferred from the "probably syph- ilitic" to the "positively syphilitic" group. Warthin7 wrote, in 1913, of certain conditions as follows: "That these lesions are actually syphilitic could only be assumed upon the strength of circumstantial evidence, before the demonstration of the Spirochaeta pallida gave us a positive finding by which the diagnosis of syph- ilis could be made absolute. The whole pathology of syphilis then must be worked over from the standpoint of this new criterion and this is particularly true of the affections of the heart long supposed to be syphilitic and which from their nature could not positively be determined to be so." He found the spirochetes localized in the heart more often than in the liver. Brooks8 says in a very recent article: "Syphilis involves the heart with great frequency both in early and in later stages of the infection. "Syphilitic lesions of the heart may involve the pericardium, the myocardium and the conus arteriosus. "The most frequent lesions apparently originate or progress about the terminals of the coronary system, and they are located for the greater part in the myocardium. "Any form or stage of syphilitic lesion except chancre may be found in the heart." In the autopsy records of the Massachusetts General Hospital for January, 1909, appears the report of the first case of syphilitic aor- titis, proved to be such by Professor Wright's demonstration of the Spirochaeta pallida in the aortic tissue. This was the first find- ing in this country of the specific organism of syphilis in the diseased aorta. In our appreciation of the newer and more positive methods of diagnosis we sometimes forget the splendid work done by earlier SYPHILIS FROM LIFE INSURANCE STANDPOINT 325 observers. Eyes, ears and finger tips, guided by well-trained minds, have accomplished much in medical practice and in medical sci- ence without the aid of test tubes, thermostats and microscopes. We need the latter-they have become indispensable-but in our enthusiasm over their assistance let us not neglect the God-given powers of careful observation. This point is well illustrated by a paragraph from a paper on aortitis syphilitica published by Hoover9 in 1920. "The early recognition of the lesion is due to the work of Fournier and Huchard, and is based on physical examination. It is very doubtful if men who followed the work of these great Frenchmen found themselves making the diagnosis of incipient syphilitic aortitis with any greater frequency after the roentgen ray and Wassermann reaction were added to our diagnostic re- sources than was the case prior to introduction of these diagnostic aids. The Wassermann reaction, Spirochaeta pallida, and the roent- gen ray have all served to confirm and illuminate the work of these great clinicians, but bacteriology and pathology lagged many years behind the clinic in dealing cogently with syphilitic aortitis." To identify a syphilitic lesion of the heart, it is not enough to consider the gross appearance nor even tthe microscopic appear- ance of the histological changes, but certain staining methods must be applied to demonstrate the presence of the spirochetes. In this way the organisms may be found in large numbers in the heart muscle when not found elsewhere in the body. In this way, too, certain lesions in the heart are proved to be syphilitic which ac- cording to the older methods could not be so classified. As time advances this test may prove to be a large factor in reducing the size of the group of "myocardial affections of unknown origin." Many of the recent writers have believed that syphilitic myo- carditis is due to a periarteritis of the coronary vessels but Warthin7 has proved that the myocarditis may be primary and he divides the lesions into two groups, parenchymatous and interstitial. Turning now to the clinical side, there is convincing evidence that syphilis of the heart appears as one of the manifestations of the early secondary stage. There may be or there may not be phys- ical signs of the cardiac involvement at this time. Undoubtedly, the physical signs are present far more often than they are recog- nized. How many clinicians watch the heart in the early stages of this disease as they watch it in rheumatic fever, scarlet fever, 326 LIFE INSURANCE EXAMINATION diphtheria, influenza, pneumonia and other acute general infec- tions, and yet syphilis is conceded to be a 11 vascular disease par excellence"! Perhaps it is one of the misfortunes of Nature's methods that the syphilitic, under treatment, is usually an ambula- tory patient instead of being confined to bed. When present, the signs of syphilitic myocarditis are the same as those of myocardial involvement from other causes, such as arrhythmia (particularly intermittence, tachycardia and premature systoles), murmurs, cya- nosis and dyspnea. The irregular action and rapid rate are often made more marked by exercise or apprehension. Anginal pains are not uncommon. Brooks8 has reported twenty-four cases in which the cardiac involvement occurred during the secondary stage of the disease. Two of the patients died and the diagnosis was made or confirmed at autopsy. In one case death was due to "a minute perforation of the wall of the aorta just above the ring. A pronounced arteritis and periarteritis were found throughout the myocardium." In this case the secondary rash had not fully appeared and the diag- nosis had not been definitely made. In the remaining twenty-two cases, recovery was apparently complete under specific treatment. To the gi eat and lasting disadvantage of the patient the signs of early cardiac involvement usually are not recognized. It has been the rule, rather, under older methods of diagnosis and treat- ment, for the infection to remain quiescent for a long time and to manifest itself by symptoms of circulatory distress or failure when the patient is well advanced in the tertiary stage. Brooks8 reports a group of three hundred cases specially studied in regard to this point, in which he found that "two hundred and seventy- six did not come under observation until late in the third stage." Tie also says that "it appears that in so far as involvement of the heart is concerned, it begins with the general septicemic stage, pi ogresses with the development of the secondary rashes and con- tinues just as long as any phase of the disease in any of the tis- sues, that is, until cure, stabilization, or death, has taken place." It is extremely difficult, not to say impossible, to state in terms of months or years the usual time of the appearance of tertiary circulatory symptoms. They may appear very early, even in the first year, and they often appear late, say after fifteen to twenty years. Certainly they may appear at any time after the first few months from the date of infection. SYPHILIS FROM LIFE INSURANCE STANDPOINT 327 The treatment of syphilis of the circulatory system in its earlier stages is the well recognized general constitutional antisyphilitic treatment with arsenic and mercury. In its later stages, the treat- ment is still chiefly antisyphilitic but may be supplemented by such other therapeutic agents as are indicated to relieve special symp- toms, particularly rest and restricted diet, to aid in reducing high arterial tension or in reestablishing a broken compensation. In the earlier stages, the treatment of circulatory syphilis is hopeful, curative. In late stages, it is palliative-of enormous value to the patient from the standpoint of comfort and usefulness even though very rarely indeed can it be considered curative-the scar tissue remains. In circulatory disorders of unknown origin, the treatment must be, to use an old term, "symptomatic" until the diagnosis can be made. If the diagnosis can be made by exclusion or if there is a positive Wassermann test or if there are signs of syphilis in other parts of the body, then vigorous, antisyphilitic treatment should be carried out. In doubtful cases, one may be justified in applying the thera- peutic test. Let me quote from a recent writer:1 "One still sees an occasional case with .suspicious clinical signs, with negative serologic and roentgen-ray findings, in which the response or failure following two or three injections of arsphena- mine is sufficient evidence to establish the diagnosis beyond a rea- sonable doubt." That, in the opinion of most clinicians, syphilitic involvement of the heart and arteries in its later stages requires vigorous and long-continued treatment is obvious to one who reviews recent text books and special monographs. And the treatment is not a vacation trip to some hot springs or a rest cure, so-called, neither does it consist wholly of dietetic and hygienic measures. There must be in addition, and far more than in most diseases, the ad- ministration of drugs, real drugs too. No "therapeutic nihilism" prevails in these cases. On the contrary, there must be full doses of the powerful and somewhat dangerous remedies employed and they must be repeated at frequent intervals over a long period of time. Two brief quotations illustrating this opinion must suffice. Babcock,10 in 1919, wrote: "The watch word for all syphilitic patients should be eternal vigilance." "I believe that thorough mercurial medication, whether with or without salvarsan, should 328 LIFE INSURANCE EXAMINATION be resorted to from time to tim'e, practically for the rest of the patient's life." The following year Sargent3 wrote: "One needs to review but a small proportion of the mass of the present-day literature on the treatment of syphilis, to be convinced that mer- cury, not by the month, but by the year; and arsenic, not by the dose, but by the half dozens of doses, must be given before any hope of a cure of syphilis can be held." How do those who have shown a recognizable syphilitic cardio- vascular involvement stand as insurance risks? It is unlikely that any company would consider favorably any applicant in the active secondary stage while undergoing treatment, whether signs of the circulatory lesions were present or not. It is also unlikely that any company would look with favor on any applicant who showed definite tertiary lesions of the cardiovascular system, unless pos- sibly at substandard rates so high as to be practically prohibitive. It might be that a few very carefully selected cases among those who showed tertiary symptoms unusually early in the course of the disease and who had responded promptly to continued and adequate treatment and had remained free from symptoms for a reasonable time, could be accepted with a moderate rating. If any cardiovascular syphilitics are to be considered as standard risks, they must be from the group of those in whom an early diagnosis is made, prompt and adequate treatment given and who show a continually negative Wassermann for a considerable period and also who are, in other respects, especially good risks, including a favorable occupation, normal physique, an excellent family his- tory, a personal history otherwise free from objection and who pass a very rigid physical examination. Syphilis of the Nervous System Every syphilitic is a potential paretic or tabetic. Fortunately, only a comparatively small percentage of syphilitics develop either paresis or tabes; but, for those individuals who do develop one or the other, the situation becomes more than serious-it is tragic. Nearly twenty years ago, before the specific organism of the disease was known, and long before the present methods of treat- ment had been devised, the New England Mutual Life Insurance Company made an exhaustive study of the medical literature re- lating to syphilis. A search was made of all the medical journals SYPHILIS FROM LIFE INSURANCE STANDPOINT 329 on file in the Surgeon General's office in Washington (both those published in this country and in Europe), including the issues for the preceding forty years, and abstracts taken of all articles on all phases of the general subject of syphilis. Naturally, great differ- ences of opinion were found, and various conclusions had been expressed by different writers. Some of these expressions of fact or opinion are just as applicable now to our present-day conditions, as they were a generation ago. Other beliefs have been either confirmed or shown to be in error by later researches. Mention can be made of only a very few of the points studied, and these of the broader aspects rather than of details. It was generally conceded that tabes is much more common in those countries having the highest grade of civilization. Attention was called to the rarity of the disease in Bosnia and Herzegovina, where syphilis is extremely prevalent. Friedlander, in 1903, stated that "in tropical and subtropical countries, where syphilis is very widely spread, tabes is extremely rare, and in many places not a single case has been seen." Thomas, in 1899, wrote: "In negroes, tabes is relatively un- common, while syphilis is much more common than in the white population." ( Minor, in 1882, reported his observations on 1,642 neurological patients of Russian and of Jewish descent. It was found that, while syphilis was five times as common in the Russian, tabes had the same occurrence in both races. Bearwald and Daubler stated that 50 per cent of the native negroes in East Africa have syphilis, and yet they have never seen a case of tabes there. Grimmes reported 6,000 cases of syphilis in one of the Japanese Islands, and of these, only five had tabes. A collection of 24,513 cases of syphilis reported by various authors showed that only 2.9 per cent developed tabes. It is interesting to note that a great variety of opinion was ex- pressed by different writers as to the part which syphilis has, as a causative agent, in the production of tabes. A few did not consider that syphilis was in any way the cause of tabes; while others be- lieved it to be the direct cause in 100 per cent of the cases. Other opinions placed the percentage at different figures, the average of all being 73.2 per cent. It was generally believed that the intensity of the original in- 330 LIFE INSURANCE EXAMINATION fection has no relation to the development of tabes. The opinion was quite general that antisyphilitic treatment does not prevent or delay the development of the disease, and the majority of authors agreed that antisyphilitic treatment has no material effect upon tabes. A neurotic heredity adds much to the probability of a syph- ilitic's developing paresis. Nerve involvement is more common in men than in women, and among individuals who by reason of occupation are exposed to nerve tension and strain, to severe men- tal exertion, and in those given to sexual excess, or to the use of alcohol or drugs. Nerve involvement is more common also in those who contract the disease after forty years of age. It was found that of a total of 6,019 cases, studied as to the length of time between infection and the appearance of tertiary symptoms, 17.5 per cent showed the tertiary lesions during the first two years, and 26 per cent during the first three years. An- other series of 1,949 cases were considered to ascertain the length of time between infection and symptoms of involvement of the nervous system. It appeared that 16.3 per cent developed the nervous symptoms during the first year, and 27.2 per cent before the end of the second year. These expressions of opinion have more than a historical value; they are the conclusions of experienced observers and they show that while scientific facts have been added to our knowledge and we are probably better able to treat this ancient scourge now than formerly, the real essentials of the disease have long been under- stood and appreciated. The question whether or not involvement of the central nervous system depends upon a special strain of spirochete has been discussed by many, but not yet answered conclusively. Strong arguments have been advanced in support of this theory but the question is too complex for a decisive answer, in the absence of convincing experimental studies. Several recent writers have ex- pressed the opinion that many if not most of the cases of paresis and tabes occur in those in whom the infection was "mild" in the first two stages, many individuals showing no secondary eruption, and many even not being aware of the fact that they had syphilis. One writer goes so far as to say that about one-third of all tertiary syphilitics have no knowledge of having been infected. In 1914, White11 reported that of 1016 cases of syphilis in all SYPHILIS FROM LIFE INSURANCE STANDPOINT 331 stages treated in the Dermatological Clinic of the Massachusetts General Hospital, during the preceding ten years, only eight had become tabetic and one paretic, up to that time, although many of the patients dated their original infection many years back. He also reported that a study of the last five hundred cases of tabes treated at the same hospital, prior to April, 1914, showed only eighteen who "had ever exhibited any late cutaneous lesions," and of one hundred and seventy-eight cases of paresis, only two "had experienced any late cutaneous sequelae." It has been suggested that instead of explaining the incidence of nerve syphilis by assuming a special strain of spirochete, a more probable cause is inadequate treatment, or no treatment at all, either because of the mildness of the symptoms in the first two stages, or failure to make the correct diagnosis. General Considerations From the insurance standpoint the later manifestations of syph- ilis are the important ones. Whether it be cardiovascular lesions that incapacitate or kill the individual, or whether it be involve- ment of the brain or spinal cord that causes invalidism and death, the presence of the infection is of the utmost seriousness to individ- uals and groups of individuals. A knowledge of the presence or absence of this infection is therefore of the greatest importance to insurance companies. Let us assume for this discussion that examiners are careful in taking and recording histories, and that applicants are careful and honest in their statements. There will then be found a certain small percentage of syphilitics among the applicants to every com- pany. It has been demonstrated that with careful selection a cer- tain group of well-treated syphilitics can be accepted with moderate ratings. Can we go a step farther, and devise a still better method of selection, so that this group can be subdivided and a portion of the applicants be accepted at standard rates? At the present moment the answer to this question must be largely one of opinion. Attempts along this line in the past have not been successful. At a recent meeting of the Association of Life Insurance Medical Directors of America a symposium on this topic was participated in by eleven medical directors of some of the oldest and largest companies in the country. Not one was able to report results of 332 LIFE INSURANCE EXAMINATION selection such as would justify acceptance at standard rates. Some suggestions for improvement were offered and we are adding to our knowledge and experience year by year. Certainly he would be a bold man who would attempt at this time to lay down hard and fast rules, but some general principles looking toward a work- ing hypothesis may be suggested. If there is to be favorable con- sideration of a group, individual histories must show first of all, that an early diagnosis was made, and that there was nothing unusual about the attack, such as the occasional extraordinarily viru- lent type of disease, characterized by rapid progress through the different stages, also, that there was adequate treatment by a competent physician and, finally, that there has been a considerable period (two years the very minimum) of observation without treat- ment and without any symptoms whatever. It seems only reason- able to believe that there will be a better mortality among those who have been well treated, than among those in whom the treat- ment was casual or inadequate, although this point has not yet been demonstrated conclusively by thorough investigation with approved statistical methods. The family history should be given more than usual consideration. There must be no history of pare- sis, insanity or brain disease of any kind, no history of tabes, myelitis, sclerosis, or other disease of the spinal cord, no history of so-called functional nervous disease and, on the positive side, there must be evidence of longevity in the immediate family. In the personal history there must be no evidence of instability, or irrita- bility of the nervous system, nothing like periods of overwork, nervous strain, nervous exhaustion, neuritis, or of those conditions which may be due to either circulatory or nervous disorder, and, positively, the applicant must be able to demonstrate that he has a normal resistance to infections, does not have "grippe" every winter, has not had repeated attacks of pneumonia, or pleurisy, that he has recovered promptly from the minor acute infections that no one wholly escapes. Beyond this he must show that he is a man of well-balanced temperament, with good habits of living and working, accustomed to take suitable vacations and not to overwork. A good occupation will be a strong point in his favor, and by this we mean an occupation that is fairly well established and stable, not doubtful or speculative, fairly even, not one sub- ject to "rush" periods and "dull" periods, and one that does not involve working under high pressure. SYPHILIS FROM LIFE INSURANCE STANDPOINT 333 The above implies that syphilitics can be insured safely as stand- ard risks only by following a process of "super-selection." Those accepted must be well above the average in other respects. "Pre- ferred" risks, some would call them. They should be even better than "preferred" risks, as the term is commonly used. In a word they should be as nearly as possible perfect risks, aside from the history of syphilis. The subject of this chapter, Syphilis from the Life Insurance Standpoint, is broad. It easily might be made to include a discus- sion-(1) of methods of teaching syphilis in medical schools and hospitals; (2) of treatment of syphilis by individual physicians, by hospitals, by special groups, like the army and navy, or by the state; (3) of syphilis as a public health problem, with subdivisions of its industrial and economic phases, and more particularly its prevention. All in all, when we consider syphilis as a public health problem, we include the rest, even the life insurance point of view, for pub- lic health administration surely includes prevention as well as cure of disease by whatever methods, hygienic, sanitary or educational. The part which life insurance companies as such may take, or should take, in helping to educate the general public in health mat- ters is an interesting subject for discussion but it is too large and too important to be covered in this chapter. Life insurance is preeminently a practical business. Much em- phasis has been laid, and rightly, on its philanthropic or social side, and its service to policyholders and to the public, but it would collapse if the responsible officers did not keep their feet on the ground and stand financially ready to meet its every obligation. To do this, they need facts and information from many diverse sources, including medical science and medical practice, with an interpretation that shall be both reasonable and conservative. To make the application appropriate to this discussion, life insurance companies are, and must be, deeply interested in whatever adds to our knowledge of the life history of the Spirochaeta pallida in the human organism, and in the best methods of treatment of syph- ilitics, particularly as measured by the end results. These are questions which cannot be determined by theoretical considera- tions, nor in a short time. They must be decided by repeated ob- servations extended over long periods of time. Working hypoth- 334 LIFE INSURANCE EXAMINATION eses must be devised after careful thought and study, and then followed, with frequent tabulating and studying of results. When one hypothesis has been shown to be incorrect, it must be discarded and a better one tried out in its place. Thus will progress be unin- terrupted and at the same time the best interests of the companies, that is of the policyholders, will be safeguarded. References iSmith, C. M.: Arch. Dermat. and Syph., December, 1921, iv, 723. 2Hazen, H. H.: Syphilis, C. V. Mosby Co., 1919, 26. 3Sargent, J. C.: Am. Jour. Syph., April, 1920, iv, 286. aChargin, L.: Jour. Am. Med. Assn., April, 1921, Ixxvi, 1154. sOsler, Sir William: The Evolution of Modern Medicine, New Haven and London, 1921, p. 193. eibid.: p. 188. ''Warthin, A. S.: Am. Jour. Med. Sei., May, 1914, cxlvii, 667. sBrooks, Harlow: Am. Jour. Syph., April, 1921, v, 217. 9Hoover, C. F.: Jour. Am. Med. Assn., January, 1920, Ixxiv, 226. 10Babcock, R. H.: Am. Jour. Syph., January, 1920, iv, 34. nWhite, C. J.: Jour. Am. Med. Assn., August, 1914, Ixiii, 459. CHAPTER XXIV FOCAL INFECTION By John H. Warvel, M.D., Indianapolis, Indiana Pathologist, Methodist Episcopal Hospital Focal infection means the localization of pathogenic bacteria within the body with subsequent symptoms of disease due to the pathologic and chemical processes brought about by the growth of these bacteria. This localization of bacteria, or "focus" as it is most frequently spoken of, may occur in many different parts of the body. The most common foci are in the mucous membranes o>f the body cavities which have a close relationship with the outside air. In order that pathogenic bacteria may enter the body there is, in most cases, some "break" in the skin or mucous membranes. This condition occurs quite frequently following the acute infec- tious diseases such as streptococcic sore throat, influenza, scarlet fever, measles and diphtheria. When once bacteria have made their invasion through one of these surfaces, thdy may begin to grow, and, during their growth produce certain toxins, which bring about degenerative changes in the tissue involved. The individual or host who harbors these organisms may at once become aware of symptoms which denote some pathologic change. This is often seen in acute sinusitis or middle ear disease, in which the patient is aware of an acute and sudden pain with tenderness over the in- volved area. The more common type of infection is the one in which the patient exhibits some general systemic condition before he consults his physician, the primary infection having been over- looked or thought insignificant. A long and very careful search must then be instituted in order to find the long-standing or original site of this individual's infection. The discovery of this focus de- mands the united efforts of the physician, the roentgenologist and the laboratory man. Focal infections may be acute or chronic according to the length of time elapsing between the invasion of the bacteria within the body and beginning pathologic changes, with the subsequent pro- ductions of symptoms. The symptoms produced may be of an 335 336 LIFE INSURANCE EXAMINATION intermittent or constant type, they may also be of a local or sys- temic nature as mentioned in the above paragraph. Focal infection is possibly the most common subject in medical literature today, many of the profession believing that it is car- ried to extremes, but when one stops to think of the many avenues for admission of pathogenic bacteria into the human body, it does not seem that we could overestimate the number of this type of in- fections. The natural defenses of the body, of course, soon over- come the invasion of most of these bacteria. This is well demon- strated by phagocytosis and the action of the opsonins of the blood. Repeated invasions by the same type of bacteria bring about the production of bacteriolysins and antibodies which prevent the growth of these bacteria in the body. The successful establishment of pathogenic bacteria within the body of an individual depends upon the following well-known facts: (1) the virulence of the or- ganisms; (2) the number of invading bacteria; (3) the avenue or portal of infection; (4) favorable conditions for growth of the bacteria; (5) the lowered resistance of the structure upon which the bacteria are implanted; (6) a general lowered resistance on the part of the person into whose body the bacteria have gained admission. When once bacteria have passed through the surface cells of the skin or mucous membranes, great numbers of white corpuscles are rushed to the site and phagocytize the invaders. The body fluids attempt to neutralize the toxins formed by the bacteria. If these two factors are successful in this struggle, the simple inflammatory process is soon ended. At other times the bacteria are quite viru- lent and are not overcome in the conflict and then by their toxic effects produce pathologic or destructive changes in the tissues. These changes at times become quite marked before the individual calls on his 1 'reserve forces" which lay down a fibrous tissue bor- der to wall off the infection. This "walling off" process may stop the further involvement of surrounding tissues, but it ofttimes does not destroy the bacteria within the nidus. It is these foci of bacteria, which remain viable, that bring about serious local and ofttimes systemic infections. The spread of bacteria from these foci takes place through the blood and lymph streams, possibly a great deal more by way of the blood than the lymphatics. They may be carried to any or all FOCAL INFECTION 337 parts of the body, but as Rosenow has proved by animal experi- mentation, certain strains of bacteria have a predilection or "elec- tive affinity" for certain body tissues. The damage at the site of primary infection is often very slight, while the secondary lesions may show severe pathologic changes. Primary Foci of Infection The most common location of primary focal infection was stated as being from the mucous membranes which line cavities that com- municate with the outside air. This means that the tonsils, teeth, nasal and upper respiratory passages would be the most common sites. That this is the case is a fact well known by all physicians. The urethra in the male and the vagina and cervix uteri in the female are also often the points of invasion for pathogenic bacteria. The skin may be the avenue of infection as noted by secondary or systemic infections following furunculosis and erysipelas. Bacteria Found in Primary Foci of Infection The many types of streptococci, which seem to be rather closely related, are the organisms found most frequently in the primary focus of infection. The Streptococcus viridans is often found in the apical infections of teeth. This organism and the Streptococ- cus hemolyticus are found in cultures from tonsillar crypts. The Streptococcus pyogenes is often isolated from nasal or sinus cul- tures. A Gram-positive diplococcus is also found quite often in teeth cultures; this organism appears to be closely related to the pneumococcus. Staphylococci may also be found in some of these foci, but are possibly, when found with the streptococci, of second- ary importance. Sinus infections are quite often due to the staphylo- coccus alone. The pneumococcus, micrococcus catarrhalis and in- fluenza bacillus may be the organism found in nasal infections and also those of the upper respiratory tract. Secondary lesions from the last mentioned group of bacteria are not so common as from the former mentioned organisms. The gonococcus may be found in prostatic or cervical smears of a few cases which show arthritic or cardiac lesions. Bacteria in Secondary Foci of Infection (a) Endocarditis cases most frequently show the Streptococcus viridans in blood cultures. In many cases which terminate fatally 338 life'INSURANCE EXAMINATION a Gram-positive diplococcus is found; this closely resembles the pneumococcus. An occasional case shows the streptococcus mucosus. (b) Rheumatic fever cases often show a positive blood culture of Streptococcus viridans. A Gram-positive diplococcus is sometimes found in the blood stream or from the joint cavity. (c) Nephritis; cultures from the urine obtained by ureteral catheterization, following focal infections which later involve the kidney may show any of the different types of streptococci. Often- times the Gram-positive diplococcus is found. In chronic cases colon bacilli only can be found. (d) Appendicitis and cholecystitis may be due to a variety of bacteria. The most common ones found are the streptococcus py- ogenes and viridans. Staphylococci are quite commonly found, also colon bacilli. The importance of the latter organism is ques- tionable. Typhoid bacilli often cause secondary infections in the gall-bladder. Secondary Localization of Bacteria Once the bacteria have established a primary focus in any part of the body they may be carried by the blood or lymphatics to any other organ or tissue of the body. The site of secondary localiza- tion is dependent upon several things: (1) the strain of the infect- ing organism; (2) lowered resistance of certain tissues; (3) the specificity of different strains of bacteria to select certain body tissues. (1) Streptococci if introduced into the blood stream most com- monly affect the endocardium, joint cavities and kidneys. A ty- phoid bacteremia often causes gall-bladder conditions. A pneumo- coccic bacteremia usually causes the most serious changes in the respiratory tract. Each organism seems to elect its site of second- ary infection. (2) The lowered resistance of certain tissues can be brought about by chemical changes in the cells. Exposure of cer- tain parts of the body, especially to cold, allows the localization and growth to bacteria. Direct trauma of tissues changes the chemical reaction of these cells, which in turn allows the successful implan- tation of bacteria. Proximity of a primary focus, through drain- age by blood or lymphatics, to another structure may bring about an altered condition in the latter, which permits it to fall prey to any new bacterium which gains access to the body. (3) Specificity FOCAL INFECTION 339 of certain strains of bacteria to select certain body tissues lias been proved by Dr. Rosenow of the Mayo Clinic. He lias possibly done more than any other bacteriologist to prove the "specific elective tissue affinity of bacteria." He has taken certain cul- tures of bacteria from the primary and secondary lesions of focal infections in man, and by intravenous injections of the cultures produced the same lesions in animals. He obtained cultures of Streptococcus viridans from chronic septic endocarditis and pro- duced lesions of the endocardium in 84 per cent of animals in- jected. Cultures taken from cholecystitis produced a high per cent of the same lesions in animals. Dr. Rosenow has proved this "elective affinity" of certain strains of bacteria in almost every possible type of secondary infection. An example of a case which proves this point is possibly worth mentioning. A woman, age 32, consulted a nose and throat special- ist, complaining of frequent sore throat with some slight enlarge- ment and soreness of the cervical glands. The patient also com- plained of loss of weight and strength, had chronic stomach trouble and some pains in the back. An incomplete physical examination was made by this specialist. The patient was sent to hospital for removal of hypertrophied tonsils. The crypts of the tonsil con- tained free pus which could be expressed on pressure. Urine showed trace of albumin and a few hyaline casts. Tonsillectomy was done and culture from crypts showed Streptococcus hemolyticus. A rab- bit was inoculated with 2 c.c. of 48-hour growth on dextrose brain broth. The animal was autopsied on the twenty-first day. The kidneys gave evidence of a moderate degree of nephritis. The stomach showed an ulcer of the lesser curvature near the pylorus. There was some slight hemorrhage beneath the serosa. Following the findings of this latter lesion inquiry was made of the nose and throat surgeon concerning the patient's gastric symptoms. He reported that they had been entirely relieved, since the operation. Undoubtedly the primary focus of the stomach lesion of this patient was in the tonsils. The great frequency of neuritis, arthritis, nephritis, endocarditis and sometimes thyroiditis following infections in teeth and tonsils is well proved. Every examining physician now makes a careful survey of the mouth and throat as possible sources of grave second- ary infections in later years. If any evidence of disease is found 340 LIFE INSURANCE EXAMINATION the infected teeth or tonsils should be removed. Should the appli- cant present joint, kidney or heart involvement, the primary foci should be removed to prevent further tissue injury. Infections in tonsils often invite infection in the middle ear and mastoid. Infec- tion in the nasopharynx or any of the sinuses can cause arthritic or kidney lesions. Fatal cases of meningitis sometimes follow in- fections in these parts. Asthmatic conditions often follow disease of upper respiratory tract. Infections of the gastrointestinal tract often cause arthritic changes, with evidence of a general toxemia. Gall-bladder disease is often secondary to inflammations of the intestinal tract. Infections of the appendix are often preceded by an acute throat infection. The frequency of endocarditis following acute throat infections is generally known. Diagnosis of Presence of Foci of Infection (a) The Teethe-Teeth as foci of infection can frequently be de- termined by x-ray examination even when the person has experi- enced no indication of trouble there. At times the improvement obtained in systemic conditions, following the removal of infected teeth is really wonderful; at other times most disappointing. First the physician must be certain the teeth are of no value and possibly a menace to the individual; then should the patient obtain no relief nothing is lost. (b) The Tonsil.-Here the diagnosis of the etiologic factor de- pends upon the appearance of the tonsil, the history of repeated sore throat and the bacteriologic examination. The general result to the person following the removal of the tonsils is the real decid- ing factor as to whether or not they played any part in the produc- tion of the secondary or systemic conditions. People often experi- ence an acute exacerbation of symptoms following the removal of the primary focus, but this is soon followed by the period of improvement. (c) Sinus Infection.-Diagnosis of infection here is made by the history of frequent colds in head with symptoms of obstruction, pain and tenderness. Transillumination and the x-ray examination along with bacteriologic cultures help to complete the diagnosis. These sinus foci respond to treatment with difficulty. FOCAL INFECTION 341 (d) Appendix and Gall-Bladder.-These organs as primary or secondary foci of infection are quite difficult to prove. A careful history and more careful physical examination are necessary. The x-ray is often of great assistance. Blood examinations may be of a little value. Ofttimes these organs arouse suspicion as primary foci after all others have been eliminated. (e) Fallopian Tubes and Prostate.-These structures are possibly the last to be thought of as foci of infection. All other sources of trouble before mentioned are usually eliminated before searching here for the cause of the trouble. A careful history and thorough examination of the pelvis may bring forth the true pathology. When one stops to consider the many varied and serious sequelae of focal infections he realizes the importance of a careful search for these foci in all applicants for life insurance at the time of the applicant's examination. The heart function or kidney condition may be perfect, but a few bad teeth or an infected tonsil can in a very short time greatly damage both of them. A history of fre- quent sore throat and colds or a previous attack of scarlet fever or diphtheria makes the examiner look with doubt upon the sort of risk this individual might make for his insurance company. CHAPTER XXV GOITER By George W. Crile, M.D., Cleveland Clinic, Cleveland, Ohio Any discussion of goiter naturally centers about the relation of iodine to goiter since it has been shown by Marine and many others that goiter is due to a lack of iodine. There are three periods of life during which simple thyroid enlargements most commonly occur: the fetal period, the adolescent period and the child-bearing period. If the pregnant mother takes iodine in sufficient amount during pregnancy and if the offspring, from the time of weaning, takes iodine in sufficient amount until it has reached maturity, there will be no goiter. Even though goiter ap- pears in the adolescent period, the great majority of these enlarge- ments of the thyroid gland are curable if the child is given an adequate amount of iodine during the period preceding the eight- eenth year. After the age of eighteen has been reached the influ- ence of the drug decreases with each year. So, in young adult life and later life, iodine has practically no curative value. In patients with adenomata iodine may even induce hyperthyroidism or exophthalmic goiter if it is given in considerable dosage over a period of time. In addition to its curative and preventive properties during the three periods mentioned above, iodine has another use. Our ex- perience to date has proved that if iodine is given in moderate dosage for a year or more after a colloid goiter has been properly excised by lateral resection, there will be no recurrence of the disease. Goiter, therefore, may be called a preventable, controllable de- ficiency disease and the colloid goiter, relatively small yet large enough to be easily seen and palpated, carries no factor of danger that will modify the expectancy of life. There are types of goiter, however, which do alter the expec- tancy of life. These goiters are: the colloid goiter which is large 342 GOITER 343 enough to compress the trachea and to interfere with free ex- change of air; the exophthalmic goiter which usually is associated with hyperplasia; the adenoma, especially of the fetal type. The last-named type of goiter may exert three influences tending to shorten life. (1) It may deform and compress the trachea, thus interfering with free exchange of air. This is especially true of cases in which there are hemorrhages into the adenomata causing rather sudden enlargement and consequent interference with res- piration. (2) It may, especially if it is an adenoma of the fetal type, produce a weakened myocardium or, in a smaller percentage of cases, vascular hypertension. (3) It may become malignant. Ninety-five per cent of all malignant tumors of the thyroid have occurred in adenomata, particularly in fetal adenomata. For the types of goiter in which there is an interference with the expectancy of life surgical treatment offers relief. Adenomata may be safely removed, and as they do not recur, there is no in- terference with expectancy of life. In exophthalmic goiter, or hyperthyroidism associated with hyperplasia, the resection of a sufficient amount of the hyperplastic gland will result in a per- manent arrest of the disease. If the mode of life and the diet of the patient are properly controlled after operation, the expectancy of life should not deviate from normal; but, if a case of hyper- thyroidism is allowed to go on until the stage of emaciation, of heart disturbance, or nervous-system disturbance or of permanent change of life is reached, then, although the disease may be en- tirely arrested and may not recur in active form, the patient has suffered such irreparable damage that the expectancy of life must be modified. The effect of goiter upon longevity may be thus summarized: If a patient with colloid goiter is given iodine and if the operation is properly made, the expectancy of life (in my opinion) should not be impaired. If an adenoma is properly removed there should be no unfavorable change in the patient's expectancy of life. If cases of hyperthyroidism are operated upon early, before the myo- cardium, the nervous system and other tissues are markedly af- fected, the patient should have a normal expectancy of life, at the end of two years after operation. In all other cases where the patient has had a marked degenerative change, due to hyper- thyroidism, expectancy of life must be irrevocably shortened. 344 LIFE INSURANCE EXAMINATION In other words, one year after a patient has been operated upon for a colloid or fetal goiter, he should be insurable and after two or more years a patient operated upon for exophthalmic goiter should be insurable. This question of the postoperative insura- bility of goiter cases, of course, can be definitely determined only after a careful examination by a physician who is familiar with diseases of the thyroid and the end-results. CHAPTER XXVI GOITER AND LIFE INSURANCE By Robert Lee Rowley, M.D., Hartford, Conn. Medical Director, Phoenix Mutual Life Insurance Co. The thyroid gland is so situated that an enlargement of only moderate degree as a rule can be recognized easily. Its location makes it accessible for surgical treatment. These factors have been in some measure responsible for the at- tention directed to disorders of the thyroid and in the past few years an immense amount of study has given us a better under- standing. of the relation of the thyroid to systemic disturbances. The appended report (Fig. 68) from the surgeon general's office on the results of examination of the first million draft recruits shows in a fair manner the incidence of goiter and its geographic distribution. There appear to be two goiter territories; that is, the north- western states and to a lesser degree the Great Lakes region. In the Wisconsin Medical Journal for April, 1921, Blankinship reports in the examination of 13,706 entering students at the University of Wisconsin simple unclassified thyroid enlargement was found in 28 per cent and exophthalmic goiter in 6 per cent. The proportion of males to females was approximately one to two in both simple and exophthalmic goiter. Blankinship believes that this is a fair index of the incidence of goiter in Wisconsin. Iodine found by Baumann in 1895 to be a constituent of the normal thyroid, is notably deficient in the gland of exophthalmic goiter and is variable in the gland of adenoma with hyperthyroid- ism. It has been shown that iodine is a normal constituent of the tissues of the body and Kendall has recently estimated the amount to be fourteen milligrams for the average normal man. The well-known effect of administration of iodine in reducing the size of goiter has been emphasized by the work of Marine and others. This effect is noted more especially when the enlargement of thyroid is due to colloid. 345 346 LIFE INSURANCE EXAMINATION In 1914 Kendall was able to separate from the thyroid gland a pure chemical compound thyroxin and this undoubtedly marks the most important advance that has been made in biochemical studies in relation to thyroid diseases. It has been deduced by Plummer that thyroxin is present throughout the cells of the body and "is an active agent in hasten- Exophthalmic Goiter Simple Goiter Fig. 68. ing the rate of formation of a quantum of potential energy avail- able for transformation on excitation of the cells." Further, that the amount of thyroxin in the tissues, exclusive of the thyroid of the average normal man is approximately fourteen milligrams; that a variation of one milligram of thyroxin in the tissues of the body is accompanied by a corresponding rise or fall in the basal metabolism; that hyperthyroidism is the physiologic status of an individual otherwise normal when the thyroxin in the tissues is GOITER AND LIFE INSURANCE 347 sufficient to hold the basal metabolism above normal; that all the phenomena of pure hyperthyroidism are those that must attend a sustained elevation of the basal metabolism. The status of the hyperfunctionating adenomatous goiter is the result of a pure hy- perthyroidism. The average daily exhaustion of thyroxin in the tissues is between a half and one milligram. The administration of thyroxin in amounts considerably above that represented by the daily exhaustion will hold the basal metabolism as much as twenty to fifty per cent above normal, depending upon the dosage of thyroxin. To quote from a recent article by Plummer: "As thyroxin, other factors remaining constant, determines the rate of transformation of energy in the organism, it can be assumed that the rate of ex- haustion of thyroxin for a given period is determined, to a large extent at least, by the total transformation of energy. That the rate of exhaustion relative to the total metabolism is not the same in all the organs or reactions of the organism is probable. There is much to suggest that the rate of exhaustion of thyroxin in the female is higher than in the male." Plummer further says: "The highly essential function of the thyroid is the elaboration and delivery to* the body of thyroxin. The gland secretes and stores in its acini the so-called colloid. It seems highly probable that the latter function is an accessory to the production and storage of thyroxin, and that in it is stored iodine for the elaboration of this agent. There is no definite evi- dence that the thyroid has any other function." The normal thyroid gland is constituted of acini containing colloid and lined with relatively dormant appearing cuboidal or low columnar epithelium supported by connective tissue stroma. From this normal anatomical picture there may be a change to any one of three definite types: (1) hypertrophy of the alveolar epithelium; (2) an increase in the intraalveolar colloid and, (3) the development of new alveoli. On these changes goiter may be pri- marily classified as hypertrophic, colloid and adenomatous. Diffuse colloid goiter and diffuse hypertrophic goiter may be con- sidered anatomic expressions of functional disturbance in prenatally developed thyroid acini. Adenomatous goiter is new tissue develop- ing postnatally from the stimulation of embryonic cells. Adeno- matous tissue may be either encapsulated or nonencapsulated. 348 LIFE INSURANCE EXAMINATION With these three anatomic states are associated three physiologic groups: (1) Pure hyperthyroidism; (2) pure hypothyroidism and (3) exophthalmic goiter. A definite syndrome of hyperthyroidism is with rare exception associated with diffuse hypertrophic or with adenomatous goiter, or follows the administration of thyroxin. Goiters usually classified under the terms simple, endemic, adoles- cent, etc., are diffuse colloid, adenomatous, or a combination, par- ticularly at their inception, of the two types. The majority of such goiters are first noticed during the latter half of the second decade. The colloid goiter usually disappears before the twenty-fifth year. However, there is a tendency for a thyroid once overloaded with colloid, irrespective of its functional activity, to retain more than the normal amount, that is, sufficient to make the gland easily pal- pable through life. The adenomatous nodules often during the early part of their history buried in colloid goiter never disappear although they fluctuate much in size from their colloid contents, vascularity and degenerative changes. The exact mechanism by which the normal stimulation of the thyroid is brought into play is not definitely known, but there is assumed a relationship to the partial exhaustion of thyroxin in the tissues. Factors interfering with the production of this agent lower the amount delivered from the thyroid. There may be several such factors, but the one known factor is an actual or relative shortage of iodine. In the presence of a shortage of iodine the response of the thyroid to stimulation results in a deposit of an excess of colloid in its acini. This constitutes the diffuse colloid goiter of adolescence. In the presence of infections attended with fever, there appears to be an increase in the rate of exhaustion of thyroxin in the tissues. This may be due to interference with the absorption of the small amount of iodine in the available diet. The ability of the intestine to absorb iodine is variable and ap- pears to be lessened in the presence of infections involving the in- testinal tract. McCarrison's extensive work on the relationship of infected waters to the production of goiter should be borne in mind in this connection. Colloid goiter, as has already been pointed out, results from an accumulation of colloid material due to a relative decrease in the GOITER AND LIFE INSURANCE 349 available iodine. It occurs most frequently between the ages of fifteen and twenty-five, and is rarely seen after age thirty-five. It is recognized by the symmetrical enlargement of both lobes and of the isthmus of the thyroid, and while usually it feels soft to the palpating finger, it sometimes is quite firm. A colloid goiter may be large enough to cause pressure symptoms, and it may cause some subjective symptoms through the knowledge of its presence, but otherwise it can be expected to do no harm. It is the type of goiter that can be readily made to disappear under the administration of iodine or thyroxin. When it does not disappear under the adminis- tration of these agents, there is usually associated with it an adeno- matous growth of the thyroid. Colloid goiter does not call for surgical treatment, unless its size is sufficient to produce pressure symptoms. Adenomatous goiter is the most common type. Although it often develops seemingly in persons of middle age, the probabilities are that its true origin in such persons dates back to early life as by far the greater number give a history of having noticed the enlarge- ment of the thyroid at some time between the ages of fifteen and twenty-five. In other words, it has its inception in colloid goiter. The enlargement is produced by the growth within the substance of the thyroid gland of encapsulated adenomas, which probably have developed from fetal rests. In the early stages of their development they do not produce symptoms, unless through their size they cause pressure symptoms on adjacent structures. Most of the very large goiters are of this type. The rate of growth is ordinarily slow but it may be rapid. Degenerative changes are prone to occur usually through hemor- rhage within the capsule of the adenoma; which is named accord- ing to the degenerative change which predominates, such as hemor- rhagic, cystic, or calcareous. The adenomatous goiter does not always remain simple and non- toxic. Twenty-three per cent of the patients with adenomas of the thyroid who present themselves for examination at the Mayo clinic are found to be suffering from hyperthyroidism but the symptoms of hyperthyroidism had not developed until the goiter had been present from seventeen and one-half to nineteen years. Adenom- atous goiters seldom produce toxic symptoms in a person under thirty. When toxic symptoms develop, the metabolic rate is found 350 LIFE INSURANCE EXAMINATION to be increased although it is not so high as the rate in cases of exophthalmic goiter. In the adenomatous type of the disease, the long continued mild hyperthyroidism is prone to produce symptoms referable to the cardiovascular system. While with the exophthalmic type of the disease, with onset more sudden and more intense, the nervous sys- tem is more profoundly affected. Clinically adenomatous goiter may be recognized by the irregular type of growth which it produces. The thyroid is usually not sym- metrically enlarged and a single or many rounded tumors may be felt on palpation. These tumors may be hard or soft, according to the degenerative changes that have occurred. If adenomatous goiters are operated upon before the age of twenty- five or thirty, there appears to be some likelihood of recurrence, due to small nodules of adenomatous tissue being overlooked. While the normal stimulating mechanism is a factor in the incep- tion of adenomatous goiter, once this tissue has started to function, it does so erratically and without relation to the needs of the in- dividual. The adenomatous tissue furnishes an increased amount of thyroxin resulting in an elevation of the metabolic rate and intoxi- cation clinically evidenced by nervousness, tremor, tachycardia, loss of strength and weight and a tendency to hypertension and in the later stages, myocardial disintegration. With regard to symptoms, 77 per cent of the patients suffering from hyperthyroidism of thyroid adenoma on entrance to the Mayo Clinic are more than forty (the average age is forty-eight) and give a history of having had a more or less hard nodular goiter for many years (the average is nineteen years). For a long period the ade- noma causes no symptoms except that locally there may be a slight feeling of fullness and possibly a tendency to a globus hystericus. For two or three years previous to their coming under surgical treatment, a gradual change in general health takes place; the patient becomes more nervous and excitable, and in the early stages he may have even a feeling of unusual well being and of over en- thusiasm for work, which is coupled, however, with the inability to maintain for any length of time either mental or physical effort. Notwithstanding a good appetite, the patient does not gain in weight and later finds that he is actually losing in weight. His endurance is much decreased. Shortness of breath and palpitation GOITER AND LIFE INSURANCE 351 direct attention to the heart action. The blood pressure often shows a moderate hypertension. These symptoms develop so grad- ually and insidiously that the date of onset usually cannot be de- termined. Later a distinct increase in nervousness and mental in- stability, with moderate tremor, loss of weight, arrhythmia and rapid heart action. In the older and more severe cases there is evidence of cardiac insufficiency, with more or less edema of the legs and ankles, frequently accompanied by myocardial disintegra- tion, evidenced by an irregular rhythm, due either to premature contractions or auricular fibrillation. Gastrointestinal crises and exophthalmia, of so frequent occurrence in exophthalmic goiter, are characteristically absent. This history, characteristic of the systemic effects that might be expected from an increased metabolic rate with the increased load thrown upon the heart leads to cardiac hypertrophy that progresses to cardiac overstrain with dilatation and degeneration in the later stages. When, like the broken compensation of the athlete's heart, the cardiac failure may quite suddenly dominate the picture, so much so that the goiter condition may be unrecognized while the patient is under treatment for ordinary cardiac decompensation. A large number of seriously damaged hearts is found in the cases of adenoma with hyperthyroidism because of the insidious onset of the hyperthyroidism and its occurrence in patients of middle age. A patient in the twenties with an adenoma of the thyroid has a definite fixed chance of developing thyrotoxicosis from fifteen to seventeen years later. With a gradual increase in the severity of the symptoms the patient will come to operation about two years after that. Adenoma of the thyroid, both with and without symp- toms of hyperthyroidism, is frequently associated with vascular hypertension, there being an increase in both the systolic and dias- tolic pressures causing a relatively contracted periphery, while in exophthalmic goiter, although the systolic pressure is raised, there is no elevation of the diastolic pressure and, consequently no hyper- tension of the arterial tree, but rather a relatively open periphery as indicated by the increased pulse pressure. In adenoma with hyperthyroidism the curative effect of partial thyroidectomy is very strikingly shown by the drop in the basal metabolic rate within two weeks after thyroidectomy. In a group of cases studied, the average metabolic rate fell from plus 35 per 352 LIFE INSURANCE EXAMINATION cent to plus 7 per cent or well within normal limits. Plummer has frequently pointed out that thyroidectomy almost immediately cures the patient who has hyperthyroidism from adenoma and that re- currence does not follow unless a new adenoma or unless parenchym- atous hypertrophy develops in the remaining gland. Mention has already been made of the possibility of overlooking small adenomata when operation is done at the younger ages. Exophthalmic goiter occurs from five to ten years later in life than does adenomatous goiter. It is a distinct clinical entity asso- ciated with a definite pathologic process in the thyroid gland, namely, an hypertrophy and hyperplasia. If the hyperplasia is of sufficient degree or extends over a long enough period, exophthal- mos is almost sure to develop. By way of contrast, it may be mentioned that no matter how in- tense the intoxication of an adenomatous goiter not associated with hyperplasia, exophthalmos will not develop. The moderate enlargement of the thyroid gland, usually uniform in distribution, is soon followed within a few weeks or months by pronounced signs of intoxication in consequence of the increase of thyroid secretion causing a marked elevation of the basal metabolic rate. Compared with hyperthyroidism from adenomatous goiter, the symptoms of intoxication are more intense and more acute in their development. When the disease does not prove fatal, there is a gradual im- provement in the symptoms and general physical condition, but in the majority of instances, at some time within the next few years the patient passes through another similar period. During these periods, very marked damage occurs to the heart and vital organs, and patients who escape death usually become chronic invalids as the result of these degenerative changes. By means of thyroidectomy not only can the lives of most of these patients be saved, but they can be spared from years of invalidism provided the vital organs have not been damaged beyond repair. The results of operations for adenoma with hyperthyroidism and for exophthalmic goiter were reported by E. S. Judd in the collected papers of the Mayo Clinic (1920). 1 'This study was based on two selected groups of a hundred cases each. One hundred consecutive cases were selected from the list of exophthalmic goiters in which operation was done in 1914, and one hundred consecutive cases of GOITER AND LIFE INSURANCE 353 adenoma with hyperthyroidism in which operation was done in 1917 and 1918. The list was chosen from 1914 for the exophthalmic goiter, because it seemed that six years was sufficient time to demon- strate the success or failure of operative procedure. The cases in 1he group of adenoma with hyperthyroidism were chosen from the years 1917 and 1918 because a study of the metabolic rate had been made in all cases. The average time elapsing since operation was two years." Inquiry was made of the patients in each group with sufficient care and detail to permit fairly definite conclusions to be reached. Information was obtained concerning all the patients with adenoma with hyperthyroidism, and concerning ninety of the one hundred patients with exophthalmic goiter. The study showed: (1) That in the exophthalmic goiter group, six years after thyroidectomy, over 64 per cent of the cases could be definitely classed as cured. (2) That in the adenoma with hyper- thyroidism group, two years after thyroidectomy, 83 per cent of the cases could be definitely classed as cured. It is reasonable to believe that a higher percentage of cures could be expected if the patients were operated upon before there was any evidence of terminal degeneration. Substernal and intrathoracic goiters are not an uncommon condi- tion and may cause all of the symptoms of hyperthyroidism without visible enlargement in the neck. Tn a series of over 4,000 thyroid- ectomies performed at the Mayo Clinic for simple colloid and ade- nomatous goiter, 13.5 per cent were found to be substernal and 6 per cent were classified as intrathoracic. Malignant tumors of the thyroid are less common than in many other organs of the body but probably exist more often than has been suspected as through errors of diagnosis they may be unrecognized. It is believed that malignancy practically always develops from a preceding adeno- matous nodule but a few instances are noted where it appears to have followed a true hyperplastic (exophthalmic) goiter. . The foregoing account of the general situation as relates to the different types of goiter may serve as a useful guide in forming a judgment as to the insurability of goiter cases. The report of examination for insurance should be made by the physician with a degree of completeness and accuracy that will 354 LIFE INSURANCE EXAMINATION permit of a correct evaluation of the merits of the case by those whose function it is to review the papers at the home office of the insurance company. It is, therefore, incumbent upon the examiner to include in his report not only a description of a present goiter but a full account of associated symptoms that might be attributable to hyperthyroidism of even mild degree. A carefully obtained his- tory is most important. Goiters referred to under such terms as simple, endemic, adoles- cent, nontoxic or colloid appear for the most part from ages fifteen to twenty-five and do not have an important bearing upon the in- surability of the possessor. Goiter of this type may be expected to disappear as a rule before age thirty. A colloid goiter that persists or that does not disappear with the administration of iodine usually turns out to be an adenomatous goiter. Adenomatous goiters are of importance from the standpoint of insurance because of two considerations: First-The likelihood of growth to such size as to cause pressure symptoms requiring surgical treatment for relief. They furnish the basis for development of malignant disease which fortunately is not common. Second-The likelihood at from forty to fifty years of age of slowly increasing thyroid secretion with resultant symptoms of hyperthyroidism vary- ing in intensity from mild to severe. The insidious development of the thyrotoxicosis over a period of two years or more with pro- gressive decrease of physical and mental endurance, appears es- pecially prone to result in the later stages in symptoms directed to the cardiovascular system and more especially to signs of myo- cardial degeneration. As regards insurance, it is of importance for the medical exam- iner to be able to recognize adenomatous goiter for it appears quite obvious that the condition may be serious and may materially shorten the life of the applicant. After a thyroidectomy for the relief of an adenomatous goiter not associated with hyperthyroidism, the examiner for insurance should have in mind the following questions: First-Was all of the adenomatous tissue removed? If not, a recurrence may be expected. Second-Had the adenoma become malignant, even though un- suspected by the surgeon? The answers to these questions may not be immediately available, therefore a conservative attitude would suggest that an interval of at least one year and preferably two GOITER AND LIFE INSURANCE 355 should pass before such a case can be safely recommended for insurance. As relates to a history of hyperthyroidism, whether from adeno- matous goiter or from exophthalmic goiter, the examiner for insur- ance must remember that serious damage to vital organs is likely to have been produced. Tn mild cases, however, such damage may not be demonstrable until the influence of physical or mental strain has been brought into the test. Until such a person has been actively engaged in his accustomed vocation for a period of a few years, perhaps four or five, the ex- aminer would have some hesitation about recommending the case for insurance. CHAPTER XXVII POSTOPERATIVE RISKS By Homer Gage, M.D., Worcester, Mass. Medical Director and Edward B. Bigelow, M.D., Assistant Medical Director, State Mutual Life Assurance Company. It is unfortunate that we have so little accurate data on the effect of traumatism and infection upon life expectancy. The lack of such data makes it quite impossible to put in statistical form the relation of even the more common surgical operations to longev- ity. Hospitals and clinics have never followed their patients to the end and insurance companies have not yet acquired a large enough experience in these cases to enable them to know exactly what has been the influence on the insurance risk. In many instances, operative procedures are so new that no ac- curate opinion as to their effect upon longevity is possible. For even after the necessity of surgical intervention has become ap- parent and has been generally accepted, it takes a long time and much experimentation to develop a safe and satisfactory technic. The operative mortality must be reduced to a minimum, so that the operative risk shall be eliminated as nearly as it is possible. The mechanical result must be so nearly perfect that no disturbance of function, no disability, not the necessary result of the original lesion, can be attributed to the surgical interference, and the relief from the distress and disability, occasioned by the condition for which the operation was undertaken, must be greater and more lasting than under any other method of treatment. Now that every small community is beginning to have its own hospital, where surgeons of limited experience undertake serious operations, the results, both immediate and remote, cannot be ex- pected to be so favorable as those which represent the highest degree of success attainable in the hands of the most expert operators with the largest experience. The insurance companies must deduce rules for action from an average of these extremes. To be able to secure relief from suffering and a prolongation of 356 POSTOPERATIVE RISKS 357 life for even a few years, as a consequence of an operation, is a great satisfaction and constitutes a genuine surgical success, but very much more than that is necessary to make a safely insurable risk. A brilliant and perfectly satisfactory surgical result will have little weight with the company, if the underlying cause of the lesion is a degenerative tendency, which is unaffected by the removal simply of its manifest and most distressing symptoms. The question of the immediate operative mortality is of little con- cern to the insurance companies, except as it affects the insurability of those whose previous history suggests the possibility that they may later require surgical assistance. Tuberculosis and Malignant Disease We can readily exclude from all consideration as standard risks applicants who present a history of visceral tuberculosis or of malig- nant disease. Surgeon's Certificate In the case of serious surgical operations it is of great impor- tance that a certificate, to accompany the report of the medical examination, should be obtained from the surgeon in charge, cover- ing the time, the tissues involved, the diagnosis, nature of the oper- ation, course of the convalescence and, if possible, a full patho- logical report of the specimen removed. Appendectomy After an uncomplicated appendectomy, an applicant is acceptable for standard insurance from three to six months after complete recovery, that is, absence of both subjective and objective symptoms. Herniotomy A herniotomy scar, which is firmly healed by first intention and is free from tenderness, makes an applicant acceptable in three months' time. Gastric and Duodenal Ulcers The treatment of gastric and duodenal ulcer by gastroenter- ostomy, though a distinct improvement over the older methods and in spite of the unquestioned brilliancy of its results, has not en- 358 LIFE INSURANCE EXAMINATION tirely removed the tendency to recurrence of symptoms and dangers in both lesions, and in the case of gastric ulcer has failed to elimi- nate the danger of a subsequent cancer. It is impossible to state just how great the danger of cancer is, but it cannot be disregarded. There is also the added liability of the formation of a gastro- jejunal ulcer. The superiority of pyloroplasty over gastroenterostomy is not certainly proved in gastric ulcers, but the mere fact that its popu- larity is increasing is of importance, because it indicates a growing dissatisfaction with the present results of gastroenterostomy. Finney and Friedenwald report in "Our experiences with gastro- enterostomy: A study of one hundred cases as compared with a similar number of cases of pyloroplasty"1 over a period of thirteen years for other than malignant conditions, that the gastroenter- ostomy cases numbering 74 followed after the first year, after eliminating untraced cases and deaths, were satisfactory in 84.2 per cent and unsatisfactory in 15.8 per cent, while of the pyloro- plasty cases numbering 78, the results were satisfactory in 93.6 per cent and unsatisfactory in 6.4 per cent. Russell,2 in a review of the literature of operative procedures for these conditions, summarizes by stating that ulcers are cured in 60 per cent of the cases. In the remaining 40 per cent, 95 per cent show symptoms within one year and the remaining 5 per cent within five years. Therefore, in these cases of peptic ulcer of the pyloric end of the stomach or duodenum, where there has been an excision of the ulcer-bearing area, closing off of the duodenum and a well- performed short-loop gastroenterostomy with the entire absence of symptoms from the date of operation after a period of say five years, they might be acceptable upon ordinary rates with fairly good results. This does not apply to ulcers of the body of the stomach or those on the greater or lesser curvature, for these are a much more serious matter. A most interesting and valuable contribution to this subject is Hunter's3 report of his mortality investigation of the Mayo Clinic, in which he determined, after eliminating the operative deaths, the duration of life after operation as compared with that of the general population. Of 521 cases of operated gastric ulcers, some followed for as long as six years, as compared with general popula- tion group of 521 persons with like distribution as to age and sex POSTOPERATIVE RISKS 359 observed during same period of time, the relative mortality was 272 per cent or nearly three times as large; while of 1651 similar cases of operated duodenal ulcer with a like comparison, the fig- ures brought out the remarkable fact that the relative mortality was only 91 per cent or actually less among the operated cases in this clinic than in the general population. Mr. Hunter qualifies these conclusions by stating that as the surgeons at the Mayo Clinic are very skillful, it would hardly be safe to assume that the operations at all hospitals would be fol- lowed by equally favorable results, and in addition, there is a selec- tion against the insurance companies, which is not shown by the statistics. On the basis of our present knowledge and the foregoing statis- tics, the conclusion is that a history of gastric or duodenal ulcer in an applicant for insurance constitutes a permanent impairment of the risk, an impairment that is less but not lost after the perfor- mance of a gastroenterostomy, and that such applicants are not to be rated as average risks insurable at standard rates. Gall-Bladder Surgery Apparently there are no untoward results from removal of the gall-bladder. According to Judd4 and at present, it is accepted as the consensus of surgical opinion, that a cholecystectomy re- duces the risk of later troubles and ordinarily is to be preferred to cholecystostomy for drainage of a diseased gall-bladder. Three-fourths of the operated cases may be expected to remain free from any impairment due to the previous existence of an infection or gall-stones, provided the operation is done early enough and discloses no other complication. When operation is not fol- lowed by permanent relief, the return of symptoms is usually ob- served early. It would seem that a two-year interval of complete freedom from abdominal or digestive disturbance was sufficient to establish the probability of a permanent immunity, whether the operation was incision, drainage or removal of the gall-bladder. However, the more severe cases and those with stones in the com- mon duct, in which permanent and progressive changes in adjacent organs are very likely to have begun, if acceptable at all, should be so only after an interval of not less than five years of perfect health. 360 LIFE INSURANCE EXAMINATION Pelvic Operations of Women Under this heading are included ovariotomies, salpingectomies and hysterectomies, complete or in part for cysts, infection or fibroids. These applicants require careful individual selection with special stress on the moral hazard. The impracticability of local pelvic examinations for insurance makes for caution and the de- mand for dependable surgical and pathologic reports. The removal of a simple cyst with a pathologic report to that effect, should make a woman insurable in a year from complete re- covery, while at least two years of good health should have been experienced before the issuance of standard insurance after an operation for an inflammatory condition or fibroids,5 because of the danger of adhesions or the possibility of malignancy. Women, whose impairment necessitated the performance of a panhysterec- tomy, showed a considerably higher mortality according to Brown,6 than after other pelvic operations. This type of case is probably not eligible for standard insurance. Nephropexy in itself adds nothing to the insurable risk of its victim, but movable kidney is not often a purely local impairment, it is usually but one manifestation of a general visceral ptosis. It is frequently associated with a long train of reflex disorders, and is seldom found in strong healthy subjects. Operation is often followed by a continued disability and many clinicians now oppose its performance, except in those cases in which the disability is very definitely due to the mobility of the kidney, as in Deitl's crises. In considering these eases for insurance, the presumption should be against regarding them as standard risks. A stone in the kidney requiring nephrolithotomy must have in- flicted more or less permanent injury and is altogether a more serious affair than the small calculi, which are capable of passing through the ureter and urethra spontaneously. Whether or not the formation of the stone is due to a diathesis, it is certainly indicative of a constitutional tendency that is not favorable to longevity. When an acute infection or an accident like a stab wound makes an operation imperative and has been followed by restoration of a perfectly normal kidney function, insurance may be safely granted after a lapse of from three to five years. Kidney Surgery POSTOPERATIVE RISKS 361 Rupture of the kidney may be followed by complete recovery and leave no trace of the damage. Even if the injury requires the removal of the kidney, the other kidney quickly accommodates it- self to the extra work and performs its function without any ten- dency to early degeneration. Such cases are probably at least average risks. Empyema Empyema, as a sequel of a frank pneumonia, drained, completely healed without deformity of the chest or evidence of lung impair- ment, other than slight pleural thickening, is insurable in two years after complete recovery. Mastoid Operation A case of this kind may be eligible for standard insurance one year after there has been an entire absence of symptoms, local tenderness and freedom from discharge from the ear. Traumatic Surgery Eakins7 sums up his memorandum concerning fracture of the skull by stating "at least a year should elapse from 1 complete re- covery'--not from date of injury-with entire freedom from symp- toms, before the individual may be considered to be free from danger" and qualified as an applicant for standard insurance. A person with an amputation of the forearm or leg is a satis- factory risk. One with an amputation below the upper third of thigh with a well-fitting artificial limb is acceptable, but above that point or at the shoulder, is a substandard risk. An applicant with a double amputation is ineligible for insurance. Sepsis The permanent effect of severe infection upon longevity lias not been satisfactorily determined, but evidence at hand indicates that there should be a very careful selection. Operations followed by, or for the relief of, severe sepsis are not unlikely to necessitate sec- ondary ones, for the infection may persist in a latent form, as has been the not uncommon experience in the late war. The appli- cant with such a history cannot be considered favorably for stand- ard insurance for at least two years after complete recovery. 362 LIFE INSURANCE EXAMINATION References iFinney, J. M. T., ahd Friedenwald, J.: Our Experiences with Gastroenteros- tomy, Am. Jour. Med. Sc., 1915, cl, 469. sRussell, Eugene F.: Discussion-Gastric Ulcer. Abstract of the Proceedings of the Association of Life Insurance Medical Directors of America, 1915 to 1916, p. 113. Arthur: Report, ibid., 1917, to 1918, p. 326. 4Judd, E. S.: The Recurrence of Symptoms following Operations on the Biliary Tracts, Ann. Surg., 1918, Ixvii, 473. 5Gage, Homer: Removal of Fibroid Tumors of the Uterus. Abstract of the Proceedings of the Association of Life Insurance Medical Directors of America, 1917 to 1918. p. 10. ''Brown, Chester T.: The Selection and Mortality Experience of Female Risks which have Undergone Intraabdominal Operation upon the Pelvic Genital Organs, ibid., 1919 to 1920, p. 31. O. M.: Memorandum re. Fracture of the Skull, ibid., 1917 to 1918, p. 57. CHAPTER XXVIII MALIGNANT EPITHELIAL NEOPLASMS By James C. Masson, M.D., Section on Surgery, and Albert C. Broders, M.D., Section on Pathology Mayo Clinic, Rochester, Minnesota There is no doubt that the statistics on cancer, even in countries of highest civilization, are far from correct. It has been estimated that if the true cause of death were known in every instance, the number of persons dying annually from this disease in the United States alone would be 100,000. The medical profession is aware that cancer in its early stages is curable, and our statistics should show a decrease in the mor- tality with each succeeding year. On the contrary, in recent years, statistics show an apparent increase. This is accounted for, prob- ably, not by the increased prevalence of the disease, but by the fact that methods of diagnosis have improved. The important work of the Society for the Control of Cancer, in the education, not only of the laity, but also of the medical profession, with regard to the necessity of early operation, is convincing evidence that more per- sons are being saved from death from cancer than during any pre- vious period. This society estimates that at least one-third of the deaths from cancer are preventable. It is hoped that in the near future some agent will be found of prophylactic or curative value in all malignant diseases, but thus far all endeavors in this direc- tion have been futile. From the life insurance standpoint it is true that a person with a history of malignant neoplasm, regardless of the type of operation or other treatment, is not accepted as a risk until at least five years have elapsed, and even then he is not accepted as a first class risk. The older the patient at the time the malignant condition develops, the better the prospect for cure. Prognosis in patients with carcinoma should always be guarded, but the type of neoplasm and the degree of malignancy are im- portant considerations. The amount of fibrosis, hyalinization, and 363 364 LIFE INSURANCE EXAMINATION lymphocytic infiltration, as pointed out by MacCarty, also has a marked bearing on the prospect for cure. At present radical sur- gical removal or destruction offers the best hope for permanent cure, regardless of the type of growth or its location, but it is possible that radium or roentgen ray in the near future may be considered quite as satisfactory in certain selected cases. If the lesion can be removed completely while it is still local, definite cure may be assured. On the other hand, if cancer cells have become detached and have passed into the lymph stream, com- plete removal of the neighboring lymph glands, besides the growth, is necessary to effect a cure. Furthermore, if metastasis has oc- curred to the regional glands, the outlook for cure is poor, even with radical removal of the involved lymph glands and the ad- joining group or groups of glands. The degree of malignancy and the tendency to metastasis can be fairly accurately estimated from a history of the case and examination of the tissues. A micro- scopic study of the growth by a competent pathologist is most im- portant from a prognostic point of view. Other factors having a marked bearing on the prognosis are the location of the growth, and the ability and willingness of the patient to continue roentgen ray or radium treatment for at least one year after operation. Malignant epithelial neoplasms start as purely local conditions in the majority of instances and growth depends in a great meas- ure on cellular activity, but is controlled more or less by the natural resistant forces of the host. These resistant forces differ widely in different patients; in some, the growth is very slow, in others very rapid. Certain patients have a tendency to malignant growths which is demonstrated by the presence of multiple malig- nant neoplasms of the same or varied structures. Often, too, the rapidity of the growth varies with the physical condition of the patient. In the majority of cases symptoms or signs on which a clinical diagnosis could be made are recognized by the patient at a time when radical surgical measures or possibly radiotherapeutic meas- ures could effect cure. The unfortunate delay that so often follows the patient's discovery of pathologic conditions before professional advice is sought may well be called the period of "fatal delay." Unfortunately further delay often occurs after the patient comes under medical care, for the family physician may delay in securing MALIGNANT EPITHELIAL NEOPLASMS 365 competent consultation or even may advise against surgical investiga- tion, until the disease is well established and the prospect for cure remote. The hope for the future lies in the education of the public to the necessity for early competent advice in all cases, and for radical treatment without unnecessary delay. Methods of treatment should be divided into three groups: pro- phylactic, operative, and radiotherapeutic. As a prophylactic meas- ure all persistent lesions should be investigated. All warts, kera- toses, moles, chronic fissures, and ulcers should receive appropriate treatment and be removed or protected against irritation. Under operative treatment is included removal by excision or cautery of the local growth with or without dissection of the regional glands. By radiotherapy the growth of the neoplasm may be controlled and metastasis averted. Pathologic Classification Iii the classification of a neoplasm it is necessary to determine either the type of cell from which it arises or the tissue into which it differentiates or attempts to differentiate. However, it some- times happens that a malignant neoplasm does not show differentia- tion and in such cases it is impossible to determine whether the condition is sarcoma or carcinoma. However, if this neoplasm could be traced directly from the skin it would be called epithelioma; if it could be traced from the regenerative cells of a breast acinus it would be called carcinoma of the adenocarcinoma group; if it could be traced from the regenerative cells of smooth muscle it would be called leiomyosarcoma. MacCarty's conception of neoplasia, from a biologic and clin- ical standpoint is briefly as follows: , "1. We should know the cells from which neoplasms develop since every living thing evolves from something living. " 2. We should know what occurs to make some of the cells of neoplasms resemble normal tissues. "3. We should know the morphology of the competent units of neoplasms. "4. We should have, if possible, a definite descriptive terminology which possesses biologic, histologic, and morphologic significance. "5. We should have a classification based on biologic, histologic, 366 LIFE INSURANCE EXAMINATION and morphologic facts and their clinical significance for economic purposes. "6. We should be able to prognosticate the clinical behavior of neoplasms or at least know definitely why we cannot accurately prognosticate, since negative knowledge is often as valuable as posi- tive knowledge. "7. We should know both the biologic and specific causes for the development of neoplasms. "In 1909, the writer undertook an investigation of pathologic conditions in the breast with the hope of proving or disproving any relationship between chronic mastitis and carcinoma. In so doing the problem of the histogenesis was uppermost. In conducting the investi- gation, one thousand breasts, including all chronic pathologic con- ditions, were studied. Many sections were made from all portions of the gland, including normal and pathologic portions. These sections were not only submitted to microscopic study but were studied photographically. Carcinoma being a growth which is in- timately associated with glandular cells, it was thought best to study such cells in the structural and functional unit (acinus) of the organ. It was found that the unit, or acinus, was lined in the resting condition and that of chronic mastitis by two layers of cells, their inner layer consisting of cuboidal or columnar cells and the outer of spheroidal or ovoidal cells, the latter lying adjacent to the mammary stroma. The embryologic origin of these two layers was studied and it was found that both were derived by means of hyper- plasia and downward growth of the cells from the stratum germi- nativum of embryonic skin. It was, therefore, supposed that the outer layer was the stratum germinativum of the secretory cells of the acinus. Photomicrographs of acini from all portions of the glands fell into three distinct histologic groups (Fig. 69). They were called primary, secondary, and tertiary cytoplasia, respectively. "The clinical significance of these histologic pictures has been of great economic importance to the clinician, the surgeon and the pathologist. The first certainly is a benign condition, the third is, without question, the condition which has been recognized as carci- noma, and the second is not so easily interpreted; it is, therefore, regarded as questionable in spite of the fact that the intraacinic cells are often identical morphologically with the cells of the third condition. ' '20 MALIGNANT EPITHELIAL NEOPLASMS 367 The foregoing principle can be applied to the histogenesis of malignant neoplasms in general. Under the term malignant epithelial neoplasm, or carcinoma, are two general groups, growths arising from the regenerative cells of the protective epithelium, epitheliomas, and growths arising from the regenerative cells of the gland or secreting epithelium, adeno- carcinomas. The neoplasms of these two groups assume various forms and differ widely in degrees of malignancy, depending on PRIMARY CYTOPLASIA Textocytes -Text o'blast s SECONDARY CYTOPLASIA Textoblasts TERTIARY CYTOPLASIA Textoblasts Fig. 69.-Diagrammatic representation of the original structural facts found in the mammary acinus. In primary cytoplasia the milk-producing cells (lac- tocytes) belong to the general group of tissue-cells (textocytes). The regenera- tive cells which constitute the stratum germinativum for the lactocytes have been called lactoblasts, and belong to the general reserve cells of the body which have been called textoblasts. In secondary cytoplasia the lactocytes (textocytes) have disappeared and there is hyperplasia of the lactoblasts (textoblasts). In tertiary /cytoplasia the lactoblasts (textoblasts) have migrated (in a biologic sense) from 'their normal acinic habitat. (After MacC'arty.) cell activity, differentiation, and the resistance exerted by the defense cells of the body. Group 1. Epitheliomas.-In this group are six types, (1) squamous-cell epithelioma, (2) basal-cell epithelioma, (3) melano- epithelioma, (4) nonmelanotic melanoepithelioma, (5) adamantine epithelioma, and (6) mixed epithelioma. As a matter of fact, all 368 LIFE INSURANCE EXAMINATION of these are basal-cell epitheliomas in their early existence because they arise from the basal or regenerative cells of the protective epithelium; they are named according to the differentiation. Some- times they show intimate structural associations; for instance, a basal-cell epithelioma may have areas of squamous cells, an adaman- tine epithelioma may closely resemble squamous-cell epithelioma, a highly malignant squamous-cell epithelioma may be difficult to dis- tinguish from a nonmelanotic melanoepithelioma, or al] six types, in some instances, may show a tendency to adenocarcinomatous forma- tion when they form alveolar structures. We have seen one epi- thelioma in which colloid formation was present. Group 2. Adenocarcinomas.-In these neoplasms that arise from the regenerative cells of gland or secreting epithelium there is also great variation, but probably not so much as there is in the epi- thelioma group. They are properly termed adenocarcinoma because, if there is differentiation, it usually tends toward gland formation. There are three other groups of malignant neoplasms, which will not be discussed in detail, teratoma, mixed tumor, and chorio- epithelioma. Some teratomas are not malignant; however, all are probably potentially malignant. This type of neoplasm may con- tain a variety of differentiated tissues and organs or parts of organs and, if malignant, the malignant element may be of the nature of epithelium or of connective tissue or of both. The mixed tumors appear to be adenocarcinoma and the cartilage so often associated with them is apparently only secondary. The chorio- epithelioma, while it resembles squamous-cell epithelioma to some extent, has an altogether different origin and for that reason should not be placed in the group with malignant neoplasms that arise from protective epithelium. Malignant Neoplasms of Group 1 Squamous-Cell Epithelioma,-This type of epithelioma is so named because the majority of its cells are of the squamous variety, or because it has a tendency to produce squamous cells. Grossly, it may be elevated, depressed, flat, papillary, cauliflower-like, ulcer- ated, smooth, soft, indurated, whitish, grayish, yellowish, or red- dish. Microscopically, it is made up of cells of different shapes and sizes. Some cells show complete differentiation with pearly body formation, while others show no differentiation; some of the MALIGNANT EPITHELIAL NEOPLASMS 369 Fig. 70.-(Case A81521.) Squa mous-cell epithelioma of the lip. Fig. 71.- (Case A75909.) Squamous-cell epithelioma of the tongue. Fig. 72.-(A89236.) Squamous-cell epithelioma of the larynx. Fig. 73.-(Case A191496.) Papillary epithelioma of the urinary bladder. Fig. 74.- (Case A62270.) Squamous-cell epithelioma of the cervix. Fig. 75.--(Case A38258.) squamous-cell epithelioma of the penis. 370 LIFE INSURANCE EXAMINATION Fig. 76.-(Case A64692.) Squamous-cell epithelioma (Grade 1) of the lip (x50). Fig-. 77.-(Case A75272.) Squamous-cell epithelioma (Grade 2) of the temple. (x50). MALIGNANT EPITHELIAL NEOPLASMS 371 cells show spines or prickles; others do not. Some of the cells re- semble those of fibrosarcoma or myosarcoma and if they could not be traced directly from the stratum germinativum they would be called sarcomas. The cells are arranged in various formations; some take on an alveolar appearance, sometimes making differentia- tion of squamous-cell epithelioma and adenocarcinoma difficult (Figs. 70 to 80). Fig. 78.-(Case A38260.) Squamous-cell epithelioma (Grade 3) of the left sub maxillary lymph node, secondary to epithelioma of the lip (xlOO). Basal-Cell Epithelioma.-This neoplasm is commonly known as rodent nicer. It is called basal-cell epithelioma because the majority of its cells tend to differentiate to a form similar to the cells of the basal or germinative layer of the epidermis. Grossly it often ap- pears in the skin as an elevated whitish nodule, which resembles an adenoma or a cyst of a sebaceous gland, such as an ulcer with in- durated borders, or a scaly lesion. Microscopically, the cells vary greatly in morphology and in arrangement. They may be long and 372 LIFE INSURANCE EXAMINATION slender, short and thick, round, oval, or spindle-shaped. In ar- rangement they may be alveolar or gland-like and resemble the structure of the thyroid; they may present a cactus-like appearance, a diffuse or circumscribed solid mass of cells, or they may present a combination of these different types. Some basal-cell epitheliomas undoubtedly change into squamous-cell epitheliomas, as the com- bination of the two is not infrequently seen (Figs. 81 to 85). Fig. 79.-(Case A61721.) Squamous-cell epithelioma (Grade 4) of the urinary bladder (x60). Melanoepithelioma.-This type of epithelioma derives its name from a tendency to produce melanin. It is variously termed melano- sarcoma, melanocarcinoma, melanoblastoma, melanoma, melano- epithelioma and chromatophoroma. Many writers name it melano- sarcoma because they believe it to be of mesoblastic origin but, as MacCallum has said, "The most striking example of the massive production of melanin is seen in the so-called melanotic tumors, which usually spring from the skin or from the pigmented tissues of the eye. Such tumors, which in their early and apparently in- MALIGNANT EPITHELIAL NEOPLASMS 373 nocent stages are known as moles or pigmented nevi, seem to be derived from the melanoblasts, inasmuch as their metastatic nodules continue to form melanin, which could not be expected of mere pigment-carrying cells, the chromatophores. The weight of evidence in the prolonged strife as to their sarcomatous or carcinomatous nature is apparently with those who hold that they are really of epithelial origin." Fig. 80.-(Case A163101.) Squamous-cell epithelioma of the gall-bladder. In its early development melanoepithelioma can practically al- ways be traced from the epithelium. It may be attached to the epi- thelium by a broad base or only by a small strand. Just because the cells of epithelioma resemble sarcoma is no reason why it should be called sarcoma. Macroscopically, it may be elevated, peduncu- lated, flat or apparently subdermal, and black, brown, black and white, or brown and white. The pigment is not always evenly dis- tributed throughout the .tumor. Tn some instances the original tumors have very little or no apparent pigment and the secondary 374 LIFE INSURANCE EXAMINATION Fig'. 81.- (Case A20310.) Epithelioma of the skin of the nose, showing squa- mous cells and gland type of basal cells intimately connected (typical metaplasia) (x50). Fig. 82.-(Case A500531.) Basal-cell epitheli- oma of the scalp. Fig-. 83.-(Case A33173.) Basal- cell epithelioma of the eyelid. or metastatic growths are jet black; the original tumor may be filled with pigment and the secondary growth or growths be free or practically free from it. Microscopically, spheroidal, spindle and MALIGNANT EPITHELIAL NEOPLASMS 375 Fig. 84.-(Case A38366.) Basal-cell epithelioma of the nose, showing solid plugs of cells (x50). Fig. 85.-(Case A71761.) Basal-cell epi- thelioma of the cheek. Fig. 80.- (Case A143701.) Melanoepithe- lioma of the skin over the left scapula. 376 LIFE INSURANCE EXAMINATION Fig. 87.- (Case A143701.) Metastatic melanoepithelioma of the left axillary glands, secondary to growth shown in Fig. 86. Fig. 88.- (Case A801193.) Melanoepithelioma of the skin of the groin. Note the alveolar arrangement (x!50). MALIGNANT EPITHELIAL NEOPLASMS 377 ovoidal cells with or without pigment may be seen. There is a marked tendency toward alveolar formation, especially in those that arise from the skin (Figs. 86 to 89). Fig-. 89.- (Case A160912.) Melanoepithelioma of the skin of the calf of the leg (xGO). Fig'. 90.- (Case A186088.) Nonmelanotic melanoepithelioma of skin over left shoulder. Nonmelanotic Melanoepithelioma.-This type of epithelioma has all the morphologic and clinical characteristics of melanoepithe- lioma, except pigment (Figs. 90 and 91). Adamantine Epithelioma or Adamantinoma.-This type of neo- plasm is considered because of its marked cellular resemblance 378 LIFE INSURANCE EXAMINATION Fig. 91.- (Case A186088.) Nonmelanotic melanoepithelioma shown in Fig. 90 (x50). Fig'. 92.- (Case A59772.) Adamantinoma showing solid areas and cysts. MALIGNANT EPITHELIAL NEOPLASMS 379 and close relationship to the squamous-cell epithelioma. There are differences of opinion with regard to its histogenesis. Falkson held that in the formation of enamel organs for the several teeth, there is a surplus of dental germs and that these additional germs are the origin of the adamantoma. Malassez ad- vanced the theory that they arose from epithelial rests or para- dental debris. Scudder says, "There is a very great likelihood that Fig'. 93.- (Case A68435.) Adamantinoma showing direct connection with the epithelium of the gum (x50). the cells of the primary epithelial cord, having served their use- fulness, are detached from the original enamel organ cells and may be the cells which, persisting, form the tumor under consideration. Buchtemann and Kolaczek believe that these tumors originate from the mucous membrane or the mucous glands of the mouth. Bland- Sutton says, "They probably arise from persistent portions of the epithelium of the enamel organs." The number of hypotheses that have been advanced relative to this tumor naturally lead one to 380 LIFE INSURANCE EXAMINATION believe that very little is known of its origin; however, in three cases we were able to trace the neoplasm directly from the basal or regenerative cells of the epithelium of the gum. Macroscopically, this neoplasm is encased in a thin bony capsule and may be 15 cm. in diameter. On section, besides the bony capsule, cystic and solid areas are to be seen. The cysts range in size from 1 mm. to 3 cm. in diameter and are filled with a thin mucoid fluid. They are sep- arated by bony or fibrous septums. The cut surface of the fresh specimen presents a reddish granular appearance. Microscopi- Fig. 94.- (Case A68435.) Section from center of tumor shown in Fig. 93, show- ing different types of cells and early cyst formation (x50). cally, the tumor has a connective tissue and bony stroma and columns of variously-shaped masses of epithelial cells. The adamantoma presents two distinct types of epithelial cells. The outer or colum- nar cells, which are undoubtedly the germinal or regenerative cells, correspond to the columnar, germinal, or regenerative cells of the enamel organ. These cells also correspond to the basal or germinal cells of the epidermis from which the enamel organ is derived. The polygonal and stellate cells which are so characteristic, are the result of differentiation. The degeneration of these differentiated cells undoubtedly accounts for the cystic formation (Figs. 92, 93 and 94). MALIGNANT EPITHELIAL NEOPLASMS 381 Fig. 95.-(Case A147265.) Mixed epithelioma of the palate showing direct con- nection of tumor cells and epithelium (x50). Fig. 96.-(Case A147265.) Different field in tumor shown in Fig. 95 showing squamous and gland epithelium intimately connected (x50). 382 LIFE INSURANCE EXAMINATION Mixed Epithelioma.-This neoplasm may be called a hybrid but it should not be confused with the familiar mixed tumor. Micro- scopically it may contain squamous epithelium directly connected with the mucous membrane. Other areas may show squamous epi- thelium separated by fibrous septums and gland or gland-like struc- Fig. 97.- (Case A89086.) Carcinoma of the thyroid. Fig'. 98--(Case A70083.) Carci- noma of the breast. tures which arc continuous with the squamous epithelium. In other words, it is a tumor arising from the regenerative cells of protective epithelium which produces both protective epithelial cells and secreting cells. The characteristic element of this neo- plasm exists to some extent in other types of epithelioma (Figs. 95 and 96). MALIGNANT EPITHELIAL NEOPLASMS 383 Fig'. 99.- (Case A26403.) Carcinoma of the breast (x470). Fig. 100.- (Case A102500). Ulcer of the stomach associated with carcinoma. 384 LIFE INSURANCE EXAMINATION Malignant Neoplasms of Group 2 Adenocarcinoma.-As previously stated, this group of neoplasms shows variation in its gross and microscopic structure. If the neo- plasm is fibrous, it is called scirrhous carcinoma; if it shows a ten- dency to the formation of glands, it is called adenocarcinoma; if it is cellular, it is called medullary carcinoma; if it is papillary, it is called papillary carcinoma; if it contains colloid material, it is called colloid carcinoma; if it is ulcerated it is called ulcerated carcinoma; Fig. 101.- (Case J575.) Carcinoma of the stomach (leather bottle type) showing glandular involvement. Note marked thickness of walls. if it contains comedones, it is called a comedocarcinoma; if it is made up of small cells, it is called small-celled carcinoma; if it con- tains melanin it is called a melanocarcinoma, and so forth. An adenocarcinoma may show different structures in different parts of the same tumor, for instance scirrhous, adeno, medullary, colloid, and papillary; most colloid carcinomas also have a gland-like struc- ture. The neoplasm may be elevated or depressed; ulcerated, an- nular, infiltrating, or circumscribed; soft or firm (Figs. 97 to 107). MALIGNANT EPITHELIAL NEOPLASMS 385 Location Epitheliomas, or malignant neoplasms, that arise from the re- generative cells of protective epithelium are found on the external surface of the body or on any part that contains skin; the mucous membrane of the mouth and its various organs such as the tongue, tonsils, and palate; the protective mucous membrane of the nose, the nasopharynx, larynx, and esophagus; the conjunctiva, the ciliary Fig. 102.- (Case S1971.) Carcinoma of the stomach. body, the retina, and probably the chorioid coat of the eye; the antrum of Highmore; the pelvis of the kidney, the ureter, the urinary bladder, and the urethra; the uterine cervix, the vagina, the glans penis, and the clitoris. They sometimes occur in dermoid cysts and in parts of the body lined with gland or secreting epi- thelium, such as the gall-bladder and the body of the uterus. Adenocarcinomas occur in sebaceous and sweat glands, in the 386 LIFE INSURANCE EXAMINATION breast, in salivary glands, in mucous glands, in the thyroid gland, in the trachea, in the lungs, in the alimentary tract from the lower part of the esophagus to the anus; in the liver, gall-bladder, bile ducts, pancreas, kidneys, adrenals, in the body of the uterus; in the cervix, ovaries, fallopian tubes, prostate, testicles, epididymis, vas deferens and seminal vesicles. Adenocarcinomas arc sometimes Fig\ 103.- (Case A145438.) Papillary carcinoma of the ileum. found in locations where one would expect to find epitheliomas, such as the urinary bladder and the skin. Teratomas are located for the most part in the ovaries and testi- cles. Mixed tumors are usually located in the salivary glands and palate; however, they are sometimes found in other locations. Chorioepitheliomas arise from the chorionic villi of the placenta, MALIGNANT EPITHELIAL NEOPLASMS 387 although neoplasms of a similar nature are reported to have arisen from the testicles and ovaries. Degree of Malignancy It is important to grade malignant conditions according to differ- entiation and mitosis, special stress being placed on the former. For Fig. 104.- (Case A336867.) Carcinoma of the cecum. convenience, they can be graded on the basis of 1 to 4. This grading is absolutely independent of the clinical history. If about three- fourths of an epithelioma is differentiated epithelium and one-fourth 388 LIFE INSURANCE EXAMINATION undifferentiated, it is graded 1. If the differentiated and undiffer- entiated epithelium are about equal, it is graded 2. If the undiffer- entiated epithelium forms about three-fourths of the growth and the differentiated about one-fourth, it is graded 3. If the cells show no tendency to differentiate, the growth is graded 4. Of course, the number of mitotic figures and cells with single large, deeply Fig'. 105.- (Case A268852.) Carcinoma of the sigmoid. staining nuclei (one-eyed cells) play an important part in the grading. Treatment and Results: Group 1 Epithelioma The treatment of epitheliomas consists in the removal of the local growth with at least 1 cm. of healthy tissue on all sides and of complete mass dissection of the gland-bearing fascia and glands MALIGNANT EPITHELIAL NEOPLASMS 389 draining the involved areas. Local recurrence can best be avoided by wide excision followed by radiotherapy, and in the infected, rapidly growing malignant lesion, by wide excision with the cautery Fig. 106.- (Case A66903.) Carcinoma of the rectum. Note the close proximity of growth to anus. followed by plastic operation. Even in cases in which involvement of the glands is slight, the prospect for cure is small, and radium and roentgen-ray treatment should be carried out after operation. 390 LIFE INSURANCE EXAMINATION The broad term "skin cancer" usually includes basal-cell epi- thelioma or rodent ulcer, and squamous-cell epithelioma. As a matter of fact, the term "skin cancer" should include four types of epithelioma: squamous-cell, basal-cell, melanotic, and nonmelanotic melanoepithelioma. These vary in degree of malignancy with their capacity to cause death in proportions approximately as follows: Fig. 107.- (Case A136043.) Carcinoma of the rectum showing involvement of circumference of bowel. thirty-five for the first type, sixty-five for the second type, and ninety-five for the last two types on the basis of 1 to 100. The recognition of the type of skin cancer under consideration is of prime importance from the standpoint of prognosis. Squamous-Cell Epitheliomas of the Skin.-Epitheliomas of the skin may be found on any part of the body, but are most likely to MALIGNANT EPITHELIAL NEOPLASMS 391 occur at the site of preexisting lesions which have been subject to irritation for a long time. They vary markedly in degrees of malignancy.1 Of 256 cases observed in the Mayo Clinic between November 1, 3904, and July 22, 1915, 236 were treated, sixteen were regarded as hopelessly inoperable, and in four, the patients refused treatment after a diagnosis had been made. Treatment of the local growth consisted of excision, cautery, radium, roentgen rays, or a combina- tion of these methods. Lymph nodes were removed in fifty-two cases. Metastasis was present in thirty-two and absent in twenty. One hundred forty-one of the 256 patients were traced. Sixty- eight were living, 73 had died. Of the 68 living, 56 (82.35 per cent) were alive without signs of recurrence an average of 7.44 years. Nine others reported slight recurrence, and three extensive recur- rence (Table I).6 Squamous-Cell Epithelioma of the Lip.-Epithelioma of the lip is one of the most satisfactory forms of squamous-cell epithelioma to treat, on account of its accessibility and the ease with which it can be diagnosed. Any ulcerated area on the lip which persists for one month or longer should be regarded with suspicion. If any doubt of its nature exists it should be removed by a wide "V" incision and examined immediately. If reported malignant, the glands and gland-bearing fascia of the submental triangle and both submaxil- lary triangles, and the submaxillary salivary glands should be re- moved at once. If the lesion is small and definitely malignant, it is advisable to remove the glands first, and after closing the neck wound, to remove the ulcer with a wide V incision or a more ex- tensive plastic operation. In some cases of large, rapidly growing lesions it is advisable to perform a plastic operation on the lip first and attend to the glands later (Fig. 70). Tn a series of 178 patients with epithelioma of the lip observed by Sistrunk, 136 answered questionnaires in 1920. Operations had been performed on these patients in the Mayo Clinic in the years 1912, 1913, and 1914, and no previous operation or treatment had been attempted. Of ninety-eight patients on whom primary com- plete operations had been performed and no glandular involvement found, fourteen had died, five from disease other than malignancy, three from cause not stated, and only six as a result of the recur- rence of cancer. Deducting the five who died of some other disease, 392 LIFE INSURANCE EXAMINATION Table I Squamous-cell Epithelioma of the Skin: Two Hundred and Fifty-six Cases (1?.8 per cent of Two Thousand Cases of General Epithelioma) from November 1, 1904, to July 22, 1915, Mayo Clinic PER CENT Patients 256 Males 205 80.078 Females 51 19.921 Age: Youngest 25 years Oldest 88 years Average age 59.34 years Occupation (males) : Farmer 102 53.96* Laborer 21 11.11 Merchant 11 5.81 Railroad employee S' 4.23 Physician 6 3.17 Agent 4 2.11 Other occupations, 22, each under 2 per cent 37 19.57 Family history of malignancy 31 12.10 Previous lesion at site of cancer: Mole, wart, pimple, scab, ulcer, leucoplakia, crack, wen, blister, lump, and so forth • 131 51.17 History of injury 61 23.82 Burns, proportion of total injuries Roentgen-ray burns, proportion of total burns 15 24.59 3 20.00 Average duration of lesion 4.8 years Longest duration of lesion 35.0 years Shortest duration of lesion 0.057 year Greatest diameter 30.0 cm. Average greatest diameter 3.854 cm. Location of the Lesion CASES PER CENT Single lesion 247 96.48 Multiple lesions 9 3.51 Cheek 69 26.95 Nose 32 12.50 Temporal region 24 9.37 Neck 16 6.25 Hand (dorsal surface) 16 6.25 Ear 13 5.07 Angle of Jaw 11 4.25 Chin 9 3.51 Eyelid 7 2.73 Leg 7 2.73 Forehead 6 2.34 Mastoid region 6 2.34 Index finger 6 2.34 Thoracicoabdominal region (ventral surface) 4 1.56 Parietal region 4 1.56 Thumb 3 1.17 Buttock 3 1.17 Perineal region 3 1.17 *A large proportion of patients coming to the Mayo Clinic are from rural com- munities. MALIGNANT EPITHELIAL NEOPLASMS 393 Table I-Continued Thoracico abdominal region (dorsal surface) 2 0.78 Arm 2 0.78 Middle finger 2 0.78 Thigh 2 0.78 Foot 2 0.78 Inner canthus 1 0.39 Occipital region 1 0.39 Upper lip (near nose) 1 0.39 Shoulder 1 0.39 Forearm 1 0.39 Hand (palmar surface) 1 0.39 Great toe 1 0.39 Cases Graded According to Cellular Activity, 256 Grade 1 31 8.20 Grade 2 178 69.53 Grade 3 44 17.18 Grade 4 13 5.07 Duration of Lesion Longest 35 years Shortest 0.05 year Operative mortality 0.42 per cent there are 90.3 per eent alive five to eight years after operation. In eleven of these, however, local recurrence was reported and in three others recurrence in the glands. Of th,e group of eleven pa- tients whose glands were involved at the time of operation, only two were alive five years afterward. Of a group of twenty-seven in whom the growth only was excised, usually because of advanced age or physical condition, nineteen are alive from five to eight years after operation (Table II).5 Squamous-Cell Epithelioma of the Cheek.-Epithelioma of the in- side of the cheek may be very malignant, and may metastasize early. Leucoplakial epithelioma, however, may be present for many years without glandular involvement. Such growths should be treated by cautery and radium, and by excision of the glands of the neck with good prospect of cure. Squamous-Cell Epithelioma of the Mucous Membrane of the Jaw. -The most common malignant tumor of the jaw is the squamous- cell epithelioma. If the growth extends into the jawbone, metas- tasis is slow, but if the soft tissues are extensively affected, early metastasis usually occurs. If there is no glandular involvement, the prospect for five-year cures is good in from 50 to 60 per cent, pro- vided the growth is thoroughly cauterized, and subsequently treated 394 LIFE INSURANCE EXAMINATION Table II Squamous-cell Epithelioma of the Lip: Five Hundred and Thirty-seven Cases (26.85 per cent of Two Thousand Cases of General Epithe- lioma) from November 1, 1904, to July 22, 1915, Mayo Clinic PER CENT Patients Men Women 537 526 11 97.95 2.05 Age: Youngest Oldest Average 21 years 97 years 57.3 years Occupation: Farmer Laborer Merchant Traveling salesman Railroad employee Carpenter Lawyer Blacksmith Clerk Other occupations 59, each below 1 per cent 56.7 9.0 3.83 2.87 2.8'7 2.68 1.34 1.15 1.15 18.4 Family history of malignancy 14.9 Previous lesion at site of cancer: Sore or ulcer (coldsore, 10.6 per cent) Crack Leucoplakia 63.3 4.1 3.7 Tobacco: Patients using tobacco Patients not using tobacco Women using tobacco (smoke) * Women not using tobacco 80.49 19.51 45.45 45.45 History of injury 8.38 Duration of lesion: Average Longest Shortest 2.58 years 28.00 years 0.08 years 12.5 cm. 2.4 cm. Size of lesion: Greatest diameter Average greatest diameter Origin of lesion: Lower lip Upper lip Left angle of mouth Right angle of mouth Left lower lip Right lower lip Middle lower lip Left upper lip Right upper lip Middle upper lip 95.69 3.55 0.56 0.18 43.60 38.64 17.75 53.33 33.33 13.33 *One patient failed to mention whether she used tobacco or not. MALIGNANT EPITHELIAL NEOPLASMS 395 Table II-Continued Grade According to Cellular Activity Cases PER CENT Grade 1 Grade 2 Grade 3 Grade 4 85 333 113 6 15.82 62.01 21.04 1.11 Results Patients traced (operable, 306; inoperable, 8) (58.47 per cent of total) 314 Patients operated on 306 Patients dead (40.52 per cent) 124 Patients alive (59.47 per cent) 182 Good result (no recurrence) (92.85 per cent of 182) 169 Fair result (slight recurrence) (6.04 per cent of 182) ' 11 Bad result (no improvement) (1.09 per cent of 182) 2 Patients Without Metastasis Operated on Patients concerning' whom no information was re- ceived 146 Patients concerning whom information was received 198 Patients living (76.26 per cent of 198) 151 Grade 1 Grade 2 Grade 3 Total Number of Good Results Patients living, good result 35 (25.00 per cent of 140) 99 (70.71 per cent of 140) 6 (4.28 per cent of* 140) 140 (92.71 per cent of 151) Patients living, fair result 1 (10.00 per cent of 10) 8 (80.00 per cent of 10) 1 (10.00 per cent of 10) Patients living, poor result 1 (100 per cent of 1) Patients dead 47 (23.73 per cent of 198) Cause unknown 10 Good result 3 (12.50 per cent of 24) 18' (75.00 per cent of 24) 3 (12.50 per- cent of 24) Fair result 1 (100 per cent of 1) Poor result 9 (75.00 per cent of 12) 3 (25.00 per- cent of 12) Total good result (patient recovered from epithelioma and is liv- ing, or recovered from epithelioma and died from other cause) 164 (87.23 per- cent of 188) Total fair result (patient living with slight recurrence, or died from other cause) 11 (5.85 per cent of 188) 13 (6.91 per cent of 188) Total poor result (patient living with no improvement, or died from epithelioma) with radium and the lymph glands and gland-bearing fascia on the affected side of the neck are removed. If even one gland is in- volved, the prospect for five-year cures is good in not more than 396 LIFE INSURANCE EXAMINATION 2'5 per cent (New). Adamantoma and mixed epithelioma are locally malignant, but they rarely metastasize, and thorough de- struction with the cautery is all that is necessary to effect cure. Only ten such cases were found in two thousand cases of general epithelioma examined in the clinic. Squamous-Cell Epithelioma of the Tongue.-Epithelioma of the tongue is one of the most malignant of any occurring in the mouth. It metastasizes early so that an involved gland is often found in the upper anterior cervical region shortly after the primary growth appears. ATost epitheliomas of the tongue infiltrate rapidly so that it is impossible in many cases to make a local excision with the cautery. The use of radium in such cases, thus far, has not im- proved the end-results, although immediate results have been much more satisfactory. The type of malignancy and the tendency to infiltrate are of great importance, as often a low grade epithelioma of the tongue will not become active for several years; this is often true in epithelioma which is secondary to leucoplakia, so that in this group of cases the prognosis is always much better than in the fulminating type of squamous-cell epithelioma. The precancerous lesions of epithelioma of the tongue are leucoplakia, broken or de- cayed teeth, benign lesions, such as ulcers, fissures, warts, and syph- ilitic gumma. Bloodgood says, ''Delay in proper treatment after the onset of the malignant lesion reduces the chances of a cure in oper- able cases from 62 to 12 per cent, and increases the chances of post- operative death from 5 to 30 per cent. Further delay means an inoperable condition for which, at present, we have no treatment that promises cure." From November 1, 1904, to July 22, 1915, 362 cases of epithelioma of the cavities and organs of the head and neck were observed in the Mayo Clinic. Statistics on these operations are not completed,* but life expectancy seems to be comparatively poor (Fig. 71). Squamous-Cell Epithelioma of the Nose, Nasopharynx, and Si- nuses.--According to New, malignant tumors of the nose, naso- pharynx, and sinuses are usually found in men of more than forty years of age. They are often secondary to chronic infections or syphilis. Because of the technical difficulties incident to a thorough removal, the prospect of a surgical cure, even after very extensive operation, is poor. The best results are obtained by radium or *These statistics will appear in an early issue of Archives of Surffery. MALIGNANT EPITHELIAL NEOPLASMS 397 cautery, or by a combination of the two. While the number of patients permanently cured is small, the number of patients who are relieved of symptoms and live several years without recurrence is quite large. This is particularly true of epithelioma of the antrum if there is little or no involvement of bone. Wherever the growth can be effectually treated by cautery and sufficient radium given postoperatively the results are better than when radium alone is used. Squamous-Cell Epithelioma of the Tonsil.-Epithelioma of the tonsil, is very malignant and if recognized early and infiltration is absent it may be excised by a cutting cautery, with subsequent radium treatment and dissection of the side of the neck affected, in order to block lymphatic involvement. Prognosis in these cases is fair if operation is performed before metastasis takes place. Prac- tically all malignant tumors of the larynx are epitheliomas. They may be either intrinsic or extrinsic. The extent of involvement usually determines the type of operation indicated. If the condi- tion is too advanced for complete removal, radium is advisable. The growth usually starts on a vocal cord and in low grade types may be present for years without becoming extensive. Recurring papilloma of the larynx in patients more thamthirty years of age should make one suspicious of papillary epithelioma. If the growth is recognized while it is still little more than a wart, removal through an endoscope with cauterization of its base, and possibly radium treatment, gives excellent prospects of permanent cure. If local involvement is more extensive, a thyrotomy or laryngectomy may be necessary. These procedures have a high operative mor- tality and the ultimate outlook is about 50 per cent of the three- year cures. In cases of extrinsic epithelioma with glandular in- volvement there is no hope of cure, and radium alone as a palliative measure is advisable. Squamous-Cell Epithelioma of the Esophagus-Epithelioma of the esophagus is considered an inoperable condition. In recent years, however, attempts have been made to remove the diseased part radically. In the reported cases all the patients except one died. Palliative measures such as gastrostomies and the use of radium often markedly extend life, but all patients die within three years. In a total of 156 cases studied in the Mayo Clinic by Vinson, the average age of patients when examined was fifty-eight and two 398 LIFE INSURANCE EXAMINATION hundredths years; 129 (82.69 per cent) were men and twenty-seven (17.30 per cent) were women. Twelve (7.69 per cent) were treated with radium or roentgen ray without gastrostomies, 14 (8.97 per cent) had gastrostomies, but no radium or roentgen ray treatment, 127 (81.41 per cent) did not have gastrostomies, or radium or roentgen ray treatment, and 3 (1.92 per cent) had gastrostomies and radium or roentgen ray. Squamous-Cell Epithelioma of the Bladder.-Malignant tumors of the bladder are usually epitheliomas (Figs. 73 and 79). As a rule they metastasize late and if their removal can be accomplished be- fore metastasis takes place the prospect for cure is good. In many cases the operation, whether simple excision or resection of the bladder, is complicated by involvement of one of the ureteral open- ings and it is often necessary to resect the orifice and a section from the lower part of the ureter. However, this adds little danger to the operation as the ureter can be transplanted to a healthy part of the bladder. It is the opinion of Judd and Sistrunk that by proper attention before operation and proper selection of cases the opera- tive mortality can be kept well below 10 per cent. Harrington has reviewed all cases of malignant papillomas of the bladder at the Mayo Clinic in which operation was performed between January, 1910, and January, 1919 (Table HI). Carcinoma of the Genital Organs.-Cancer may occur in any part of the female genital tract. In the United States in 1919, 10,550 Table III Two Hundred and Two Patients with Malignant Papilloma of the Bladder Operated on at the Mayo Clinic from January, 1910, to January, 1919 Patients 202 Died in hospital (12.8 per cent)* 26 Patients traced 158' Dead 94 Living 64 Living 10 years after operation 2 Living 9 years after operation 2 Living 8 years after operation 2 Living 7 years after operation 3 Living 6 years after operation 5 Living 5 years after operation 12 Living 4 years after- operation 3 Living 3 years after operation 10 Living 2 years after operation 13 Living 1 year after operation 12 ♦During recent years this percentage has been lowered considerably. MALIGNANT EPITHELIAL NEOPLASMS 399 deaths from involvement of these organs were reported. Except in ovarian growths, the diagnosis should be possible in time to obtain cures in a large percentage of cases. Unfortunately many women do not seek advice until metrorrhagia or a foul discharge is a marked symptom. More valuable time is often wasted by the physi- cian who neglects to make an examination when he is first con- sulted. W. J. Mayo said, in a paper on this subject, "Lack of examination, rather than lack of knowledge, is responsible for most mistakes in diagnosis."24 Examination should include a thorough bimanual examination of the pelvis, both vaginally and rectally. Visual examination of the cervix and vault of the vagina with the speculum is also important and if any doubt exists as to the cause of the irregular bleeding, examination under a general anesthetic, and microscopic examination of cervical and uterine scrapings should be made. Cancers of the vulva and vagina vary widely in degrees of malig- nancy. In many cases early metastasis to the inguinal or iliac glands occurs and if the glands are involved the prospect of cure is very poor. Treatment consists in radical removal of the local growth preferably with the cautery without regard to saving the vagina, and before or afterward, thorough ro'ent gen-ray or radium treatment. In advanced cases, radium to the local growth and roentgen ray to the inguinal and iliac glands is the best treatment. With the exception of the stomach, the uterus is the most common location of cancer in women. The latter is involved at an earlier age than the former; many deaths occur between the ages of thirty- five and forty-five. A marked distinction must be drawn between adenocarcinoma of the fundus which is the most satisfactory form of internal cancer from a surgical point of view, and squamous-cell epithelioma of the cervix (Fig. 74), which is probably the least favorable. Tn the former, glandular involvement is relatively late. On the other hand, squamous-cell epithelioma of the cervix grows rapidly, often involves important structures, and metastasizes to the regional glands in incipiency. If a cure is to be obtained, radical treatment must be instituted early. The symptoms are ir- regular bleeding and a foul, blood-stained, watery discharge. Ir- regular bleeding is such a common symptom of the menopause that its significance is often not appreciated until the discharge becomes foul. Bleeding following intercourse or examination is very sug- 400 LIFE INSURANCE EXAMINATION gestive of cancer of the cervix and should be investigated at once. Pain is a late development and should never be waited for. In a series of 277 cases of cancer of the cervix in which a micro- scopic examination was made, 249 (89.9 per cent) were found by Ross to be epithelioma, and twenty-eight (10.1 per cent) were adenocarcinoma. Only 44 were considered operable when first examined. About 70 per cent of all cancers of the fundus can be cured if operated on before involvement of other organs by local extension of the growth. Metastasis to lymph glands is relatively late. Epithelioma of the cervix is more malignant than adenocarcin- oma of the cervix, but both tend to grow rapidly. Treatment con- sists in early removal or destruction of the local growth. Percy believes that cancer cells are much more vulnerable to heat than normal cells and, in these cases, thorough destruction of the local growth with the actual cautery, followed immediately by total ab- dominal hysterectomy with the removal of both tubes and ovaries, gives the best chance for cure (Table IV). Cancer of the vagina is highly malignant, usually Grade 3 or 4, while cancers of the vulva, urethra, and penis are, as a rule, of a Table IV Results of Treatment of Cancer of the Cervix: 475 Cases between January 1, 1913, and January 1, 1919 TREATMENT PATIENTS DEAD TRACED LIVING LIVED MORE THAN FIVE YEARS LIVED MORE THAN FOUR YEARS DIED IN LESS THAN ONE YEAR AVERAGE LENGTH OF LIFE, YEARS Removal 56 30 48 18 20 24 4 3.5 and simple can- tery 23 15 20 6 0 6 2 3.08 and radium 25 14 23 10 6 2 2.83 and simple can- tery and radium 14 4 10 6 3 1 2.9 and Percy can- tery 47 31 33 7 6 10 7 2.67 and Percy cau- tery and radium 17 10 11 2 1 3 3 2.0 Radium only 133 97 91 6 2 48 1.26 Percy cautery 81 62 57 2 2 2 135 1.7 and radium 17 12 9 3 2.42 Simple cautery 26 22 20 14 0.76 and radium 36 25 25 3 2 18 0.75 Total 475 322 347 60 34 58 137 MALIGNANT EPITHELIAL NEOPLASMS 401 lower degree of malignancy. Prospect of cure is extremely bad in cancer of the vagina and fair in cancer of the vulva, urethra, and penis, if the lesions are treated early. While cancer of the vulva is little more malignant than cancer of the penis, prospect of cure in the former has not been so good because the physician was not consulted until late and because of the inaccessibility of the lesion for radical surgery. Five-year cures are obtained in only about 2'0 per cent of the cases. A patient with a history of such condi- tions should not be accepted for insurance. When recognized early the local growth should be excised, preferably with the cautery, and in eases of malignancy in the penis it is generally advisable completely to remove the organ, transplanting the urethra about 3 cm. in front of the anus. The inguinal glands on both sides should be thoroughly dissected and radium applied afterward. Table V Epithelioma of the Urogenital Tract (23.65 per cent of 2000 Cases of General Epithelioma) Treated in the Mayo Clinic from November 1, 1904 to July 22, 1915 ... PER CENT Patients 473 Women 346 ' 73.15 Men 127 26.84 Youngest patient, years 23 Oldest patient, years 86 Average age, years 50.04 Duration of lesions of all organs, years Longest, years 20 Shortest, years Average, years 0.25 1.35 LOCATION OF LESION PATIENTS OPERATIONS PER CENT Cervix 269 256 95.16 Bladder 120 109 90.83 Labium 31 27 87.09 Penis 29 28 96.55 Vagina 18 14 77.77 Urethra 4 4 100.00 Kidney 1 1 100.00 Ovary* 1 1 100.00 *The epithelioma was primary in a dermoid cyst. These 473 epitheliomas (Table V)7 of the genitourinary tract were graded on a basis of 1 to 4 according to cellular activity. Twenty- four (5.07 per cent) were in Grade 1; 116 (24.52 per cent), Grade 2; 206 (43.55 per cent), Grade 3, and 124 (26.84 per cent), Grade 4. 402 LIFE INSURANCE EXAMINATION Epithelioma of the cervix comprised 153 of the 206 epitheliomas of Grade 3, and 93 of the 127 of Grade 4. This shows the high per- centage of malignant growths in this region. Of the 337 patients (76.59 per cent) traced, seventy-two (21.36 per cent) are living and 265 (78.63 per cent) are dead; of the dead fifteen were without signs of recurrence for an average of 6.34 years. The average length of life of those who are dead is one and thirty-four hundredths years. Two hundred eight of the 265 patients are known to have died of epithelioma. Basal-Cell Epithelioma.-If a basal-cell epithelioma is confined to the soft tissues, excision, followed by skin grafting after a healthy, granulating surface has been obtained, gives excellent re- sults. Horsley advocates the use of a full thickness graft taken from a distance from the malignant ulcer as soon as possible fol- lowing excision with a cautery, believing that such tissue has a higher degree of resistance to malignant invasion than tissue in the immediate vicinity of the neoplasm. In cases in which the growth is a little more extensive and especially if bone or cartilage are involved, destruction by actual cautery followed by skin grafting or plastic operation is advisable. If the lesion is close to the eye or other important structures, radium is advisable as apparently it has selective action on the malignant cells and the deformity resulting is reduced to a minimum. All patients with rodent ulcer who have received efficient treatment should be accepted as good insurance risks if they have lived five years without signs of local recurrence. The low grade of malignancy of this type of neoplasm is evi- denced by its long duration, lack of metastasis, response to proper surgical treatment, and by the fact that 75.86 per cent of the patients heard from are alive, and of this number 75.45 per cent have been free from the disease an average of six years one and six-tenths months (Table VI).4 Melanaepithelioma and Nonmelanotic Melanoepithelioma.-The melanoepitheliomas and nonmelanotic melanoepitheliomas are all of a high grade of malignancy and unless wide removal is possible at a very early stage the outlook is hopeless. Ninety-three patients were examined in the Mayo Clinic from November 1, 1904, to July 22, 1915. Two patients were well without signs of recurrence three years after operation. In one case the condition had originated in the retina and the patient had lived for fifteen years after the re- MALIGNANT EPITHELIAL NEOPLASMS 403 Table VI - PER CENT Patients 268 Men 165 61.6 Women 103 38.4 Average age, 56.7 years Oldest 87 years Youngest 23 years Family History of Malignancy Men 17 10.3 Women 12 11.65 Total 29 10.82 Personal History History of previous mole, wart, pimple, eczema, scab, ulcer, and so forth 37.1 History of injury 9.3 Average duration of lesion 7.08 years Longest duration of lesion 45 years Shortest duration of lesion 3 mos. Average greatest diameter of lesion 2 cm. Greatest diameter of lesion 12 cm. Smallest diameter of lesion 0.5 cm. Occupation* * Men: Farmer 82 56.16 Laborer >8 5.47 Carpenter 7 4.79 Merchant 6 4.10 Real Estate dealer 6 4.10 Miscellaneous (26 occupations) 37 25.3S Women: Farm workers 39 43.33 Ultimate Result Patients heard from 145 54.10 Patients living 110 75.86 Patients dead 35 24.13 Condition of Living Patients * * * No recurrence 83 74.45 Slight recurrence 22 No improvement 5 4.54 Treatment of Patients Without Recurrence One excision with knife 38 45.77 One excision with knife followed immediately by cautery 24 28.91 One excision with cautery 8 9.62 Basal-cell Epithelioma* *The patients were treated in the Mayo Clinic between November 1, 1904, and July 22, 1915, the period antedating the active use of radium in the treatment of this type of neoplasm. ♦♦Nineteen patients did not mention their occupation. ♦♦♦Of the eighty-three living patients with good results, twenty-flve (30.12 per cent) were either operated on or treated with acid, carbon dioxid, and so forth, elsewhere. 404 EIFE INSURANCE, EXAMINATION Table VI- ( Cont'd. ) PER CENT Miscellaneous (various combinations of excisions and 8.43 cauteries') 7 Two excisions with knife 3 3.61 One excision followed immediately by cautery and later by another cautery 3 3.61 Total 83 Average greatest diameter of tumor 1.75 cm. Length of Time Since Last Operation or Only Operation Patients Patients 1 year and more 2 7 years and more 5 2 years and more 2 8 years and more 3 3 years and more 17 9 years and more 3 4 years and more 15 10 years and more 8 5 years and more 13 11 years and more 1 6 years and more 9 12 years and more 4 13 years and more 1 Total 83 Average: 6 years, 1.6 months. moval of the eye, but had had general metastasis for ten years. Microscopic examination of an axillary gland had shown metastasis. Treatment and Results: Group 2 Adenocarcinoma Life expectancy in cases of adenocarcinoma probably is not so good as a whole as it is in cases of epithelioma. This is partly owing to the fact that adenocarcinomas are not exposed to inspec- tion as are growths of the protective epithelium. Furthermore, they are more often found in young persons in whom the lymphatics are more active. In many instances complete removal of the regional glands is impossible. Malignant Tumors of the Thyroid.-Malignant tumors of the thy- roid (Fig. 97) are rarely recognized at a time when surgery gives good prospect of cure. According to statistics compiled by Wilson, there were 207 malignant tumors of the thyroid seen in the Clinic between January 1, 1905, and January 1, 1920. He found that women are affected about twice as often as men, that most such lesions occur in the fifth decade, that usually the thyroid enlarges at least one year before the probable onset of the malignancy and that in none of the cases were there symptoms suggestive of exoph- thalmic goiter (Table VII). MALIGNANT EPITHELIAL NEOPLASMS 405 Table VII Period of Recurrence after Operation for Malignant Tumors of the Thyroid PATIENT' HEARD FROM RECUR- RENCES YEARS, POSTOPERATIVE 1 OR LESS 2 3 4 5 6 7 8 9 10 11 12 13 Malignant papillomas Malignant adenomas and carcinomas 24 24 164 152 8 138 6 44 36 27 9 1 S' 7 3 1 1 1 2 1 Total 188 176 146 50 | 36 I 27 9 9 7 3 1 1 2 1 Cancer of the Stomach.-About 30,000 deaths from cancer of the stomach and liver occur in the United States each year. When it is considered that about 70 per cent of the cancers of the stomach originate in the pyloric third and that the majority arc amenable to surgical treatment at the time the diagnosis is first made, the necessity of educating the laity and the medical profession is real- ized at once. Taking into consideration all cases of cancer of the stomach, there is a high operative mortality and a short life expectancy, but this is the result of delay. Five-year cures undoubtedly would have been obtained in a fair percentage of cases, if the patients had been operated on at the time the diagnosis was first made or suspected. In reviewing the cases in our series we were impressed with the frequency of a history suggesting benign ulcer for years before the development of the malignant syndrome. In other cases the his- tory suggested ulcer, but on removal the pathologists found malig- nant change. This occurred in the Mayo Clinic in 253 cases between the years 1910 and 1921. Rosenow has shown that mouth and throat infections are responsible for a large number of benign ulcers and the fact must be accepted that destruction of cells in any part of the body always stimulates cell growth. Among the predisposing causes of gastric cancer are peptic and syphilitic ulcers. Unsanitary conditions of living, lack of personal hygiene, and disregard for the normal action of the gastrointestinal tract, no doubt exert an influence also. Heredity appears to play a part in many cases, but the prevalence of the disease throughout 406 LIFE INSURANCE EXAMINATION the entire civilized world overshadows, to some extent, the family tendency. A tumor of sufficient size to be palpated of necessity means one of some months' duration, but in some of these cases the disease is still confined to the stomach and five-year cures are made possible by operation. The examination of a patient with gastric complaint is not complete without thorough roentgenographic study and the cooperation of a skilled roentgenologist is a great aid to the diag- nostician. Modern roentgenologists can discover about 95 per cent of all gastric tumors and ulcers. As the number of reliable roent- genologists increase, the number of early operations for cancer will increase; coincident with this we hope to see much change in the mortality from this disease. If the presence of a gastric lesion has been determined the roentgen ray is a great help in deciding whether or not the lesion is operable. This information is of value oidy so far as the stomach itself is concerned. It is of no help in deciding the presence or absence of metastasis. The only rational treatment is surgical and, since most lesions- are located in the pyloric third of the stomach, operation should be undertaken in all cases in which a diagnosis is made early, even if a palpable tumor exists. In 1919, C. II. Mayo reported the results of 2,094 operations for cancer of the stomach. Seven hundred thirty-six of these were re- sections with a mortality of 13.7 per cent, and 612 were palliative operations with a mortality of 11.1 per cent. Seven hundred forty- six were explorations with a mortality of 2.9 per cent. In many cases it is advisable to perform a two-stage operation, especially if the patient is starved and dehydrated, making a gastro- enterostomy under local anesthesia at the first operation, and per- forming resection about ten days or two weeks later. As a prophylactic measure in all benign ulcers of the stomach the Balfour method of cautery excision or destruction is advisable. There is no doubt that destruction with cautery is very much safer and simpler than knife excision in cases of ulcer with very early carcinomatous involvement (Tables VIII and IX; Figs. 100, 101, and 102). Cancer of the Large Intestine and Rectum.-During 1919, in the United States 9,034 persons died of cancer of the large intestine and rectum. Under efficient management probably one-third of MALIGNANT EPITHELIAL NEOPLASMS 407 Table VIII Type of Operation and Mortality in 660 Resections for Cancer of Stomach Between 1906 and 1919 CASES MORTALITY, PER CENT Mikulicz-Hartman-Billroth No. 2 ... . . . . . 359 12.5 Billroth No. 1 . . . . 19 5.0 Sleeve resection . . . . 28 14.2 Kocher resection . . . . 7 14.2 Posterior Polya resection . . . . 115 14.7 Anterior Polya resection . . . . 120 13.3 Local resection . . . . 12 25.0 Table IX Cancer ok the Stomach, January 1, 1906 to January 1, 1917 Resections 531 Patients heard from 450 (84.74 per cent of 531) 86 Patients with five-year cures (19.11 per cent of 450) Patients living 14 years after operation 2 Patients living 13 years after operation 5 Patients living 12 years after operation 7 Patients living 11 years after operation 4 Patients living 10 years after operation 12 Patients living 9 years after operation 4 Patients living 8 years after operation 11 Patients living 7 years after operation 7 Patients living 6 years after operation 4 Patients living- 5 years after operation 30 these patients could, have been saved if the lesion had been removed during the early stages of the disease. This is particularly true of cancer of the distal half of the colon and rectum (Figs. 104 to 107). Malignant involvement of the small intestines is relatively rare (Fig. 103), most of the reported cases occurring in the duodenum or at the duodenojejunal angle. Because of the technical difficulties of complete removal and the intimate relationship with other im- portant structures, especially the common bile duct, the pancreatic ducts, and the mesenteric vessels, most malignant neoplasms of the small intestine are inoperable when a diagnosis is made. Unfor- tunately obstruction occurs relatively late, except in cases of pedun- culated adenomas. In these, intussusception often occurs before metastasis, and radical removal gives a good prospect of cure, pro- vided the patient survives operation, as the mortality in such cases is high. 408 LIFE INSURANCE EXAMINATION Judd observed thirty-one cases from January 1, 1907, to January 1, 1919, in which operation was performed at the Mayo Clinic and in which the pathologic diagnosis was cancer of the small intestine. Twelve patients (38.7 per cent) died in the hospital. This per- centage is an index of the seriousness of malignant disease in this part of the intestinal tract. Questionnaires were sent to the re- maining nineteen patients and reports were received from thirteen; two are living and eleven are dead. One had lived ten years post- operatively, two, five years, three, three years, three, two years, and five, less than one year. In two cases the length of life after oper- ation was not known. Symptoms in cancer of the large bowel vary considerably accord- ing to the location of the growth. When the malignancy occurs in the part proximal to the splenic flexure where a great deal of absorption takes place, cachexia and loss of weight and strength are early and marked symptoms; whereas growths in the descending colon, the sigmoid, and the rectum cause little constitutional dis- turbance and the first symptoms are often melena or obstruction. In these cases, operative procedures give results better than in any malignant condition of the abdomen and pelvis, except in cases of cancer of the body of the uterus. This is due to their tendency to metastasize relatively late and in the majority of cases, if operated on when the patient is in good condition, good results may be obtained. This is especially true of the napkin ring type of growth. Operative procedures in the large bowel, however, are accompanied by special danger of infection, particularly in resections below the splenic flexure, on account of the nature of the bowel content. In 1916, W. J. Mayo reported the results of 419 resections of the large bowel at the Mayo Clinic from January 1, 1898, to December 31, 1915, with an average mortality of 14.5 per cent. In 184 of these patients the lower half of the colon including the splenic flexure, but not including the rectum were resected with an average mor- tality of 17+ per cent. In resections of the upper half of the colon, the mortality was 12.5 per cent. The difference between the two mortality rates, 4.5 per cent, was due to the less septic character of the liquid contents of the upper half of the colon as compared with that of the more solid contents of the lower half and greater safety of ileocolostomy as compared with the methods of union necessary following resections of the lower half of the colon. If MALIGNANT EPITHELIAL NEOPLASMS 409 the growth is in the proximal half of the large bowel it is gener- ally advisable to cut the ileum close to the ileocecal valve, to resect to the middle of the transverse colon, and to make an end-to-end or end-to-side ileocolostomy at that point. If the growth is in the descending colon or sigmoid, it is best whenever possible to excise the local growth, removing at least 10 cm. of apparently healthy bowel both above and below the neoplasm, and finishing with an end-to-end anastomosis. In many cases it is preferable to deliver the growth outside the abdomen, if possible, as in the Mikulicz type of operation; this is safe and gives excellent results. Growths in the rectosigmoid or rectum are in the majority of cases best treated by primary colostomy followed by posterior re- section of the distal part of the bowel well above the local growth and removal of as much as possible of the gland-bearing fascia in the mesorectum. If the growth is extensive and shows involvement Table X Resections for Cancer of the Rectum and Large Intestines: 1320 Cases PER CENT Radical operations for carcinoma of the rectum and rectosigmoid 668 Patients died in the hospital r 97 14.52 Patients heard from 468 68.56 Patients dead 326 71.17 Patients living 132 28.82 Total living 3 years 195 42.57 Total living 5 years 112 24.45 Total living 10 years 24 5.25 Total living 15 years 9 1.89 • Radical operations for cancer of the upper half of the colon and cecum 96 Patients died in the hospital 15 15.62 Patients heard from 69 Patients dead 38 55.1 Patients living 31 44.9 Total living 3 years 40 52.97 Total living 5 years 27 38.13 Total living 10 years 14 20.28 Total living 14 years 12 2.89 Total living 15 years 1 1.45 Radical operations for cancer of the lower half of the colon and sigmoid 234 Patients died in hospital 35 14.95 Palliative operations for cancer of the lower half of the colon and sigmoid 69 Patients died in hospital 26 37.68 Explorations for cancer of the lower half of the colon and sigmoid 60 Patients died in hospital 4 6.66 410 LIFE INSURANCE EXAMINATION of or fixation to the neighboring organs, primary colostomy followed by radium treatment is advisable; in some apparently hopeless cases this may be followed later by resection with good hope of cure. In a series of 1,340 resections for cancer of the rectum and large intestine there were 202 deaths in the hospital (15.07 per cent). These included 668 resections for cancer of the rectum and recto- sigmoid, 234 resections for cancer of the cecum and upper half of the colon, and 342 palliative operations or explorations (Table X). Cancer of the Kidney.-During the period from January 1, 1901, to January 1, 1923, 243 patients with adenocarcinoma, including nephroma of the kidney, were treated in the Clinic, but the majority of them were too far advanced for cure. Complete statistics are not available. Cancer of the Breast.-There were 6,262 deaths from cancer of the breast in the United States in 1919. Yet, from the surgical viewpoint, cancer of the female breast is, next to cancer of the body of the uterus, the most favorable gland for cancer treatment. Because of the accessibility of the breast for examination and the frequency of the condition, most tumors are recognized by the patient at an early stage while there is little likelihood of metas- tasis to the lymph glands. If rational treatment is carried out at this time, 90 per cent of the patients should be cured. Unfortu- nately there is often a great deal of unnecessary delay before opera- tion, even after cancer is suspected. In a series of 218 cases re- ported by Sistrunk and MacCarty only 86 patients (39.5 per cent) were without glandular involvement, and 132 (60 per cent) had metastasis to the lymphatic glands at the time of operation. One hundred ten (50.5 per cent) of the patients operated on were less than fifty years; sixty-nine (62.7 per cent) had glandular in- volvement, and nine (13.0 per cent) are alive from five to eight years after operation. Forty-one (37.3 per cent) were without glandular involvement, and twenty-six (63.4 per cent) are alive from five to eight years after operation. One hundred eight (49.5 per cent) were over fifty years; sixty- three (58.3 per cent) had glandular involvement, and sixteen (25.4 per cent) are alive from five to eight years after operation. Forty- five (41.7 per cent) were without glandular involvement and twenty- nine (64.4 per cent) are alive from five to eight years after opera- tion (Table XI and Figs. 98 and 99). MALIGNANT EPITHELIAL NEOPLASMS 411 Table XI 218 Cases of Cancer of the Breast* DECADES PA- TIENTS ALIVE THREE YEARS AFTER OPERATION ALIVE FIVE YEARS AFTER OPERATION ALIVE FROM FIVE TO EIGHT YEARS AFTER OPERATION 20 to 30 with glandular involvement 0 0 0 Without glandular involvement 1 1 1 1 30 to 40 with glandular involvement 16 4 1 1 Without glandular involvement 15 11 9 9 40 to 50 with glandular involvement 50 17 10 8 Without glandular involvement 25 20 16 16 50 to 60 with glandular involvement 28 10 8 8 Without glandular involvement 31 24 22 99 60 to 70 with glandular involvement 26 12 8 6 Without glandular involvement 11 7 6 R 70 to 80 with glandular involvement 9 5 2 2 Without glandular involvement 3 2 2 2 Total 113(51.8 85(39 80(36.7 per cent) per cent) per cent) Total. . . .With glandular involvement 132 48(36.6 29(21.9 25(18.9 Without glandular involve- per cent) per cent) per cent) ment 86 65(75.6 56(65.1 55(63.9 per cent) per cent) per cent) PATIENTS PER CENT Died within 6 months after operation 6 4.3 Died within 1 year after operation 46 33.3 Died within 2 years after operation 76 55.0 Died within 3 years after operation 92 66.7 Died within 4 years after operation 107 77.5 Died within 5 years after operation 120 87.0 Died after 5 years 5 3.6 *In thirteen cases the exact date of death was unknown. Cancer of the Uterus and Ovary.-In cases of malignancy of the body of the uterus cauterization as a first step is not important since the clanger of ingrafting cells is not great. The mortality and mor- bidity of the so-called Wertheim hysterectomy does not warrant its employment in many cases. In the moderately advanced cases, or what might be termed borderline surgical cases, full doses of radium foil owed,in from three to six weeks by total hysterectomy promises in the future, better results for these cases than could be hoped for in the past. In cases of more extensive or inoperable growths, full doses of radium alone are advisable. Tn these cases ihe effect on the local growth is remarkable, in many it entirely disappears, and the bleeding and odor disappear. Unfortunately 412 LIFE INSURANCE EXAMINATION Table XII Cancer of Body of Uterus-186 Cases PATIENTS PER CENT Patients died in hospital 11 5.91 Number traced 139 Living 86 61.87 Dead 53 38.12 Died within: 10 years 23 16.54 5 years 43 30.93 3 years 30 31.58 Less than 3 years 43 30.93 Patients living 3 years 96 69.06 Patients living 5 years 66 47.48 Patients living 10 years 23 16.54 Treatment PATIENTS PER CENT Total abdominal hysterectomy with removal of ovaries and tubes 128' 68.81 Subtotal abdominal hysterectomy with the removal of ovaries and tubes 8 4.3 Vaginal abdominal hysterectomy with removal of ovaries and tubes 7 3.76 Vaginal hysterectomy 38 20.14 Curettage 4 2.14 Cautery only 1 0.53 Operative mortality 5.91 Duration of Life Postoperatively of the Living Patients Longest Shortest Average YEARS 15.63 3.48 7.23 Duration of Life Postoperatively of the Dead Patients Longest 13.56 Shortest 0.82 radium has little control of metastatic growths and in practically all these cases death occurs within five years. On account of the great expense of securing sufficient radium to be of any use in malignancies of this type and the technical knowledge necessary for its use, such treatment will remain in the hands of a few. We must not lose sight of the great benefits that can be obtained by the proper use of heat, as advised by Percy. JMiich of the adverse criticism of this method of treatment is the result of the failure to follow the technic as outlined by the originator. This treatment, or thorough cauterization followed by radical hysterectomy, can MALIGNANT EPITHELIAL NEOPLASMS 413 PATIENTS PER CENT AVERAGE DURATION OF DISEASE, MONTHS PROSTATECTOMY AVERAGE LENGTH OF LIFE AFTER OPERATION, MONTHS AVERAGE AGE, YEARS PERINEAL SUPRAPUBIC Heard from Dead Living 120 96 24 80 20 62.36 51.3 80.2 42 41 1 75 52 23 24.86 21.72 35.2 64.27 64.95 63.58 325 Patients not Treated PATIENTS PER CENT AVERAGE DURATION OF DISEASE, MONTHS WITH METASTASIS WITHOUT METASTASIS AVERAGE LENGTH OF LIFE AFTER EXAMINATION, MONTHS AVERAGE AGE, YEARS Heard from Dead Living 231 215 16 93.0 6.9 34.59 32.82 59.15 55 52 3 176 163 13 11.8 9.58 39.06 64.84 64.71 66.6 175 Patients Treated by Radium Only PATIENTS PER CENT AVERAGE DURA- TION OF DISEASE, MONTHS AVERAGE DURA- TION OF TREATMENT, MONTHS TREAT- MENT BY NEEDLES MGHR. TREAT- MENT IN URETHRA MGHR. TREAT- MENT IN RECTUM MGHR. MILLI- GRAM HOURS AVERAGE LENGTH OF LIFE AFTER RADIUM TREATMENT, MONTHS AVERAGE AGE, YEARS Heard from Dead Living 126 84 42 66.6 33.3 38.58 37.3 40.97 4.27 2.89 6.95 1526.65 1183.79 1959.73 296.76 301.73 294.43 836.65 1040.09 521.3 1866.49 1541.16 2493.9 14.17 12.83 16.66 64.8S 64.96 64.71 Table XIII Cancer of the Prostate; 146 Patients Operated On 414 LIFE INSURANCE EXAMINATION be carried out in any hospital and by any surgeon accustomed to surgery of the abdomen and pelvis. Malignant growths of the ovary vary a great deal in degree of malignancy: most papillary cystadenomas fall into Grade 1, whereas the solid cancers are, in the majority of cases, much more malignant. From November 1, 1904, to July 22, 1915, 281 patients with adeno- carcinomas and one with epithelioma of the ovary were seen at the Mayo Clinic. The epithelioma was Grade 4. Many of the patients with adenocarcinomas of the papillary cystadenoma group are alive and well five years after operation. In a series15 of cases of solid cancers of the ovary only three patients lived more than five years, and fifteen died within one year. Between January 1, 1910, and January 1, 1919, 855 cases of cancer of the uterus were examined in the Mayo Clinic,21 70.30 per cent of these being in the cervix and 29.8 per cent in the fundus. In a series of 186 cases of cancer of the body of the uterus (Table XII), the average age of the patients was 55.01 years, the youngest patient being twenty-one and the oldest seventy-three. Of these cancers, 10 (5.37 per cent) were Grade 1; 114 (61.29 per cent), Grade 2; fifty-four (29.03 per cent), Grade 3, and eight (4.30 per cent), Grade 4. The longest duration of symptoms was five years and the short- est one year; the average duration was 1.2'9 years. Cancer of the Prostate.-The outlook in cancer of the prostate is not good from an insurance point of view. Malignancy of the pros- tate is much more common than is generally thought. During the last three years 1,641 patients with prostatic enlargements were examined at the Mayo Clinic. In 260 (15.84 per cent) malignancy was present. In a series of 646 patients with cancer of the prostate treated in the Mayo Clinic 146 had prostatectomies; treatment was not employed in 325, and 197 were treated by radium (Table XIII). From these statistics it is apparent that prostatectomy gives a little better chance for cure than radium. We must not lose sight of the fact, however, that in our experience radium has been used only in the more advanced cases. Malignant growths of the testicle can be cured in a high per- centage of cases if an orchidectomy is performed before there is metastasis. MALIGNANT EPITHELIAL NEOPLASMS 415 Treatment and Results in Teratoma, Mixed Tumor and Chorioepithelioma Teratoma.-If teratomas are malignant they should be treated as malignant neoplasms in any part of the body. They should all be removed and examined by a competent pathologist in order to de- tect areas of malignancy. No doubt many patients from whom teratomas have been removed are denied insurance because of a diagnosis of malignancy when no malignancy existed. Mixed Tumors of the Salivary Glands and Palate.-As a rule mixed tumors of the salivary glands and palate are of a low grade of malignancy and in their early development are practically all encapsulated. If operated on while in this state local excision is all that is necessary for complete and permanent cure. The cases in which metastasis occurs are generally longstanding; the capsule of the gland is perforated or the growths are recurrent because of in- complete removal at a previous operation. In such cases a block dissection of the neck and wide local excision is necessary to effect a cure. Sistrunk has reported 112 cases of malignant parotid glands observed in the Mayo Clinic between 1915 and 1919. Five of these were considered inoperable at examination and treatment with radium was given. Three were explored and the growth found to he so extensive that it was not removed, and radium was used. One patient was killed in France during the war. Of the 103 remaining ninety-three were traced. Eighty-five (91.47 per cent) are known to be alive, and eight (8.6 per cent) are dead. A primary operation was performed in sixty-four (68.8 per cent). Fifty-six (60.2 per cent) of these were alive for at least three years following operation and four (4.3 per cent) had died. Forty-nine (52.6 per cent) of the fifty-six patients have no signs of recurrence, and eleven (11.8 per cent) are known to have had further operations. Thirty-seven patients were operated on for recurrence which followed one or more previous operations. Fourteen of these thirty-seven patients are known to have had recurrence within a year. Chorioepithelioma.-This neoplasm is highly malignant and, as a rule, has metastasized to a distant part, the lung for example, before a diagnosis is made. 416 LIFE INSURANCE EXAMINATION l/rban and Para/ 57ofe; Mere u7/72>a50,000 DeaMs /7om <Ssocyr7r> Me GontmentaL tMtecf efrates cfumiy Me year LOLL, gfuM/eA 3.300 tu/77 2>e gA Me Z/ucm/Saitify 34,300 of Me elfomacA anE ZfOer, 72,000 yAMe 5>er7for/eum,Zufesf/nes ancf Rectum, 73.700 gf Ole 'Eema/e GeneraSOe Oryans, 6,900 <ft6e Oreaot, 3,100 of the <5frm amt 75,200 of' OMer Oryaos an<7 'Parts. Statistician's Department, The Prudential Insurance Company c£ Aaiccka MALES RdteS Rates EEMALES Organs and Parts; /9/S-/9/9 TZrfao 97,6 &ura7 69.7 Fig. 108.-Mortality from cancer. (Courtesy Prudential Insurance Company of America.) ' 6ucca7 Gai/fty 'f'tomacll aoEZMer 'Per/fbneum thtest/oes Rectum •Fema/e Generat/Oe Oryans ■Breast <BR/n Ot/iers or _ 1/nSjOecjf/ea l.J 31.6 73.0 256 15.6 2.2 10.6 'T'e/no/es Mortality from Cancer United States Registration Area Pace; /9/S-/9/9 nates per /O0,000 of Popu/af/on 4.6 30.9 6.9 0.2 3.5 16.6 W>ife 83.9 Qo/osed 52.7 J/ge and Sex; Z9/5-/9/9 Rates JfyeS Rafes 4.7 Vmfer35 7.3 36.9 35-44 96.5 1/9.7 45-54 2494 119.4 55-64 475.1 659.7 6/1.7 64.9 47/Eyes 99.9 Genera/ Cancer S/orfa/frij /9OO-/92Q PRUDENTIAL press MALIGNANT EPITHELIAL NEOPLASMS 417 Bibliography iBalfour, D. C.: Cautery Excision of Gastric Ulcer, Ann. Surg., 1918, Ixvii, 725-731. 2Bland-Sutton, J.: Tumours, Innocent and Malignant, London, Cassell and Co., 1901, p. 48. 3Bloodgood, J. C.: Cancer of the Tongue; a Preventable Disease, Jour. Am. Med. Assn., 1921, Ixxvii, 1381-1387. A. C.: Basal-cell Epithelioma, Jour. Am. Med. Assn., 1919, Ixxii, 856-860. •r>Broders, A. C.: Squamous-cell Epithelioma of the Lip: Report of Five Hun- dred Thirty-seven Cases, Jour. Am. Med. Assn., 1920, Ixxiv, 656-664. eBroders, A. C.: Squamous-cell Epithelioma of the Skin. A Study of 256 Cases. Ann. Surg., 1921, Ixxiii, 141-160. ?Broders, A. C.: Epitheliomas of the Genito-urinary Organs, Ann. Surg., 1922, Ixxv, 574-604. sBroders, A. C., and MacCarty, W. C.: Melano-epithelioma. A report of 70 cases. Surg., Gy'nec. and Obst., 1916, xxii, 28-32. A. C., and MacCarty, W. C.: Epithelioma, Surg., Gynec. and Obst., 1918, xxvii, 141-151. loBuchtemann and Kolaczek: Quoted by Borst, M.: Lehre von den Geschwiil- sten. Wiesbaden, Bergmann, 1902, ii, p. 607. ]1Carman, R. D.: The Operability of Cancer of the Stomach as Determined by the X-ray, Jour. Am. Med. Assn., 1919, Ixxiii, 1513-1516. i2Falkson, R.: Beitrag zur Entwicklungsgeschichte der Zahn-Anlage und Kiefer-Cysten, Konigsberg, 1879, 33 pp. isHarrington, S.: Unpublished data. i4Hoffman, F. L.: The Mortality1 from Cancer throughout the World, Newark, Prudential Press, 1915, 826 pp. isHoon, M. R.: Solid Tumors of the Ovary, Unpublished thesis. i°HoTsley, J. S.: Surgical Treatment of Extensive Basal Cell Carcinoma, Jour. Am. Med. Assn., 1922, Ixxviii, 412-416. I7judd, E. S.: Carcinoma of the Small Intestine, Jour.-Lancet, 1919, xxxix, 159-169. isJudd, E. S., and Sistrunk, W. E.: The Surgical Treatment of Malignant Tumors of the Bladder. Results of Operations, Jour. Am. Med. Assn., 1920, Ixxv, 1401-1404. loMacCallum, W. G.: Text-book of Pathology. Philadelphia, Saunders, 1917, 1085 pp. 2oMacCarty, W. C.: A Biological Conception of Neoplasia, Its Terminology and Clinical Significance, Am. Jour. Med. Sc., 1919, clvii, 657-674. 2iMahle, A. E.: The Morphologic Histology of Adenocarcinoma of the Body* of the Uterus in Relation to Longevity (A Study of 186 cases). Unpub- lished Thesis. 22Malassez, L.: Sur le role des debris epitheliaux paradentaires. Arch, de physiol, norm, et path., 1885, 3.S., v, 309-340. 23Mayo, C. H.: Cancer of the Stomach and Its Surgical Treatment, Ann. Surg. 1919, Ixx, 237-240. 2<Mayo, W. J.: Carcinoma of the Gastro-intestinal Tract, Jour.-Lancet, 1912, xxxii, 35-39. 25Mayo, W. J.: Radical Operations for the Cure of Cancer of the Second Half of the Large Intestine, not Including the Rectum, Jour. Am. Med. Assn., 1916, Ixvii, 1279-1284. 26New, G. B.: The Relation of Nasopharyngeal Malignancy to Other Diagnosis, Minn. Med., 1921, iv, 419-422. 418 LIFE INSURANCE EXAMINATION 27Percy, J. F.: The Results of the Treatment of Cancer of the Uterus by the Actual Cautery, with a Practical Method for its Application, Jour. Am. Med. Assn., 1912, Iviii, 696-699. 28Ross, J. W.: Unpublished data. 29Scudder, C. L.: Tumors of the Jaws. Philadelphia, Saunders, 1912, p. 174. 30Sistrunk, W. E.: Mixed Tumors of the Parotid Gland, Minn. Med., 1921, iv, 155-160. 31Sistrunk, W. E.: The Results of Surgical Treatment of Epithelioma of the Lip, Ann. Surg., 1921, Ixxiii, 521-526. 32iSistrunk, W. E. and MacCarty, W. C.: Life Expectancy Following Radical Amputation for Carcinoma of the Breast; a Clinical and Pathologic Study of 218 Cases, Ann. Surg., 1922, Ixxv, 61-69. 33Vinson, P. P.: Unpublished data. 34Wilson, L. B.: Malignant Tumors of the Thvroid, Ann. Surg., 1921, Ixxiv, 129-184. CHAPTER XXIX URINALYSIS By Wm. G. Exton, M.D., New York City Director of Laboratories, The Prudential Insurance Company of America., Newark, N. J. When authentic specimens are properly examined and intelli- gently construed, no other feature of the insurance examination affords so exact and incontrovertible information as does the urin- alysis. When an examiner is careless in the collection or the handling of specimens or when he fails to observe a few simple and necessary precautions in sending specimens to the home office, no other fea- ture of the insurance examination gives rise to so much irritation, annoyance, error, anxiety and injustice as does the urinalysis. It is self-evident that the specimen which the examiner analyzes or which he sends to the home office must be not only adequate and fit for analysis, but unquestionably authentic. As ,a rule, no trouble is experienced in procuring authentic specimens from male applicants and the urine should invariably be voided in the presence of the examiner. Tactful persistence on the part of the examiner may be demanded by an occasional case, but under no circumstances should the examiner consent to the applicant's sending him the speci- men. By the simple explanation that he has no discretion in the matter, but must obey the company's rules, an examiner can always eliminate from an applicant's mind any feeling he may entertain that the examiner is suspicious of his good faith or is otherwise distrustful. Even though an applicant states that he has just passed water, he will usually be able to void sufficient urine for analysis, if the examiner exercises a little patience or perhaps encourages him by letting water run from a faucet or giving him a little water to drink. Any difficulty or delay in voiding urine which appears to the examiner significant or suspicious should, as a matter of course, be reported to the home office in connection with the specimen, and similarly reported should be those applicants, happily rare, who, no matter how often they may be approached, are always met just 419 420 LIFE INSURANCE EXAMINATION after they have emptied their bladders and who, therefore, can void, perhaps, only a teaspoonful of urine. The home office should always be informed when in an examiner's opinion it seems probable that the applicant is trying to evade giving a proper specimen. Female Applicants Women applicants are not expected to void the urine in the pres- ence of the examiner, but are to be permitted to retire to another room for the purpose, though in each case the examiner must be reasonably certain that the specimen was passed by the applicant. The warmth of the bottle, the presence of air-bubbles and an entire freedom from suspicious circumstances are usually taken as satis- factory evidences of the authenticity of a specimen furnished by a woman. Likewise, in collecting specimens from women, it is always perti- nent to inquire as to the possibility of contamination of the specimen by the menstrual flow or leucorrheal discharge. Sometimes it will be necessary to wait for a suitable time in order to procure a proper specimen, but it will be found generally practicable to advise an applicant to cleanse the meatus and the surrounding parts with a pledget of moistened absorbent cotton, perhaps in conjunction with a cleansing douche. If a specimen is obtained during or near men- struation or if there is much leucorrheal discharge, the home office should be so informed in connection with the specimen. Although applicants are not always able to manage it, they should be instructed to pass the first part of the urinary stream into some other receptacle and only the latter part into the bottle. In this way the urethral wash is avoided, which sometimes com- plicates matters. Also, the conditions under which insurance exami- nations are made do not always permit the collection of specimens at such times as would be preferred, but when manageable, an after- noon or an evening specimen is likely to be more informative than a morning one. In special and borderline cases, the home office will sometimes feel the necessity of calling for specimens which have been passed at different times of the day, and in this connection the examiner should always note any unusual hours of work or exercise that the applicant may be putting in. The authenticity of the specimen being established to his satis- faction, it devolves upon the examiner to make certain that the URINALYSIS 421 specimen reaches the home office without its authenticity being in any way impaired. This extremely important matter demands but a little care and a few simple precautions, which must be positively taken. The specimen should be labeled fully and properly, prefer- ably in printed letters, immediately after it is passed, and if part of it is to go to the home office, the bottle into which it is decanted should likewise be immediately and correctly labeled. It is not unusual to see on tables in examiners' offices a number of specimens in unlabeled glasses or bottles, with slips of paper or the applica- tion forms beside them. This and similar careless practices lead to mistakes and injustices, which are extremely embarrassing to all concerned and altogether unnecessary and unjustifiable. Condition of Specimen Examiners who do their analyses promptly experience no diffi- culties with regard to the condition of their specimens, and a few simple precautions carefully taken insure satisfactory condition of specimens on arrival at the home office. Whatever the bottle used for collecting specimens, be it one supplied by the company or one of the examiner's, it must be perfectly clean and sterile. To merely rinse bottles in tap water does not suffice to prepare them as con- tainers for specimens of urine, because specimens become infected with spores and bacteria, which imperfectly prepared bottles al- ways harbor. A special point should be made of not exposing specimens to the air any longer than is absolutely necessary and of adding the preservative, no matter what it may be, immediately after the specimen is passed. The part that is to go to the home office should then be transferred to a clean, sterile, properly labeled bottle. An ideal preservative for urine has not yet been found, and the insurance companies necessarily differ with regard to the preserva- tive an examiner may be requested to use. Therefore, when for any reason whatever, he sees fit to employ some other preservative than that requested by his company, the examiner should legibly print on the label of the bottle not only what preservative he has used, but also the amount that he has added. A 40 per cent formaldehyde solution in the proportion of two drops to an ounce of urine, has proved to be a satisfactory preserva- 422 LIFE INSURANCE EXAMINATION five if Benedict's test for sugar is to be employed, instead of any of the other copper tests. Under no circumstances should a specimen ever be diluted with water or anything else before analysis or when sent to the home office, and the examiner should, as a matter of routine, note the condition of the bottle, cork and container and remedy any defects before mailing the specimen. It is the examiner's responsibility to have the package always leave his hands in first-class condition and promptly. When the examiner collects a specimen for the known purpose of sending it to the home office, it is usually advantageous to have it voided directly into the bottle which is to be mailed. It is always worth an examiner's time to note carefully the color and the appearance of the fresh urine. If it be of a watery char- acter or of an abnormal color, he is then in a position to get in- formation from the applicant which may be very valuable or to tactfully pave the way for another call for specimen, if he deems it like'y that the home office will ask for it. Practically all of the companies insist upon getting a specimen which is heavy enough to indicate that the applicant's kidneys can satisfactorily concentrate urine, but if the specimen be on the borderline as regards specific gravity, the fact that an applicant has partaken freely of fluids shortly before passing the specimen may occasionally cause a relaxation of the requirements if the facts are known at the home office. If the examiner by experience or by study of the Vogel Scale is familiar with the range of color of normal urines, he is in a better position to clear up any deviations from the normal he may encounter at the time of the examination by an inquiry as to any medication that the applicant may have taken or is in the habit of taking. And if he be taking some form of treatment or something merely for carthartic purposes, this information should be submitted in detail with the specimen. Unusual indulgence in some foodstuffs or soft drinks which are not necessarily cause for rejection sometimes affect the color of the urine, and when facts of this nature are known at the home office, they act to simplify the subsequent procedure in such instances. Sometimes small aggregates of crystals, minute blood clots or other macroscopical evidences of abnormal organic elements are seen in Appearance of Specimen URINALYSIS 423 the fresh specimen, and care should always be taken to note such and to send such parts of the specimen to the home office, with whatever explanation bearing upon them it may be possible for the examiner to elicit at the time of his examination. If the urine lie cloudy or of abnormal color when fresh, such information should always be conveyed to the home office. As a rule, when the cloudiness is not significant it is due to the presence of either phosphates or urates, and the reaction of the urine to litmus will generally give a clue as to which of these is the cause of the cloudiness. Care should be taken never to use litmus paper that is faded. If the blue paper turns red when moistened with the urine, the reaction is said to be acid. If the red paper turns blue, the reaction is said to be alkaline. If neither the blue nor the red paper changes, the reaction is called neutral. If both the blue and the red paper turn color, the reaction is said to be amphoteric. It is, of course, understood that the reac- tion concentration is indicated by litmus only in a very gross way, but on account of its practicability litmus is still in universal use and is acceptable to all of the companies. Slightly warming the specimen will cause whatever cloudiness due to urates there is to clear up. The addition of acid to a cloudy alkaline specimen will usually cause the cloudiness due to phos- phates to disappear. Cloudiness of an acid urine which does not disappear on warming or cloudiness of an alkaline urine which does not disappear on the addition of acid is due either to a bacteriuria, the presence of blood, with its characteristic smoky appearance, or to some other cause, which is certain to be of interest to the home office. The urine which is to go to the home office must, of course, never be treated in any way, by heating, adding chemicals or diluting, and all the tests which an examiner may make are to be made only on that part of the urine which he analyzes for the purpose of his own report. Sometimes urine changes its color during the time it takes to get to the home office, on account of its contents of quinones or other substances, which are usually derived from medicines, cathar- tic and otherwise, though sometimes, but not commonly, from homo- gentinisic acid and similar substances. With the notation of the reaction and the appearance of the specimen, which includes both 424 LIFE INSURANCE EXAMINATION color and transparency, any unusual odor should be noted, because it may furnish a clue to some abnormality and because, as it may emanate from a volatile substance, such as alcohol, etc., which dis- appears as the specimen ages, it may, therefore, not be perceptible at the time the specimen reaches the home office. Specific Gravity of Specimen For the sake of uniformity and other reasons involved in physico- chemical changes, it is advisable not to take the specific gravity or to make the chemical tests until the body heat is dissipated from the urine and in the event of specimens becoming cooled or warmed by the temperature of the weather to make the necessary correc- tions, which will depend upon the temperature to which the exam- iner's urinometer is standardized. In insurance work it is usual to accept specific gravities from about 1.012 to 3.030 as normal. Sometimes the color of the speci- men will give a hint as to whether or not the specific gravity is above or below these limits. Any information bearing on such deviations can more easily be obtained at the time of the original examination than at any other time, and when such information is conveyed to the home office it often operates to simplify matters and, perhaps, obviate the need of calls for more specimens. It is well understood that the specific gravity of a chance speci- men of urine taken by itself is not very significant, but abnormal specific gravity always requires some explanation. High specific gravity is usually the result of sweating, insufficient ingestion of fluids, digestive disturbances, temperature, etc. Low specific grav- ity is usually due to some forms of nephritis, recent or copious drinking of fluids, nervousness, etc. It is always pertinent to add to the information furnished on the examination blank or on the label of the bottle any remarks bearing upon the quantity of fluids taken, thirst, recent colds or sore throats, overexertion, dys- pepsia, dietary fads or any other circumstances which may affect the make-up of the urine, and also to instruct individuals whose specimens tend to run low in specific gravity to abstain from drink- ing liquids previously to furnishing specimens. In taking the specific gravity the urinometer which the examiner employs should be known to be accurate. As a rule, the smaller ones are unreliable. There should be no air bubbles on the surface, URINALYSIS 425 and a perfect meniscus should be formed before tlie reading is taken, with the eye of the observer slightly below the level of the outer rim of the meniscus. By gently spinning the urinometer between the fingers and reading it immediately after it has ceased to revolve, one may make certain that the bulb of the urinometer does not ad- here to the sides of the jar. The Exton urinometer is free from the tendency to hang to the sides of the jar or to bob up and down and is extraordinarily legi- ble. If not enough urine is available to float a reliable urinometer, the specific gravity may nevertheless be accurately determined by means of the Exton Immiscible Balance, which will show the specific gravity of even a drop (see Fig. 109). Albumin Test Before testing for albumin, the urine, if cloudy, should be cleared by filtering through a hard filter-paper (Whatman No. 5 or Munk- tell Letter B), but the filtration may be advantageously dispensed with if the specimen be well centrifuged and the tests made with the supernatant urine. The specimen should, if possible, be per- fectly cleared before the albumin test is applied. The writer rec- ommends his test as being specific for the blood albumins and free from the pitfalls incident to the nitric-acid-ring test and the heat test, even when used with salt solution. For this test a special solution has been developed in the labora- tory of the Prudential. This reagent is prepared by dissolving 2'00 grams of CP. crystalline sodium sulphate in about 800 c.c. of dis- tilled water. If heat is used to hasten the solution, it should be allowed to cool down to room temperature before adding 50 grams of sulphosalicylic acid. When this has been dissolved, enough water should be added to bring the total amount of liquid up to 1000 c.c. The reagent should be absolutely clear or made so by filtering, if necessary. When properly made, it keeps indefinitely, and it is not affected by light. The test for albumin in the urine is carried out as follows: Two to three c.c. of urine and a like amount of the reagent are thor- oughly mixed by agitation or inversion of the test tube and warmed. It need not be boiled; even the heat from a match suffices. If no cloudiness is apparent in the warm test, albumin is definitely ex- cluded. If the warm test shows a cloudiness, it is due specifically to 426 LIFE INSURANCE EXAMINATION Fig'. 109.-Immiscible balance and improved urinometer. URINALYSIS 427 serum albumin and globulin and not to any other kind of protein. If the warm test is clear and an opalescence or cloudiness develops on cooling, it is due either to proteoses (albumoses) or to protamins from spermatozoa. The microscope serves to differentiate between the protamins from spermatozoa and the proteoses, which may be of primary or secondary character. This test is extremely sim- ple, rapid to carry out and perfectly reliable, as the degree of Fig. 109-A.-Standard tubes for estimating albumin quantitatively by Exton's test. Note provision for viewing against black background and by transmitted light. Dilutions of serum of known albumin content are treated with the reagent. The sealed tubes keep indefinitely. cloudiness or precipitation of albumin seen in the warm test is an exact measure of the amount of albumin which may be present in the specimen. If it has been impossible to clear the specimen, a control for comparison with the albumin test may be made by adding an equal amount of water to the untreated urine and comparing it with the 428 LIFE INSURANCE EXAMINATION urine that has been treated with the reagent. The difference in cloudiness between the test and the control will indicate the amount of albumin that the specimen contains. An accurate and rapid quantitation of the albumin in urine may be had by using the test made as above described and pouring it into the cup of the skopometer and referring the reading obtained to a table giving the percentages of albumin correspond- ing with the degree of turbidity developed by the test or less accurate by comparison with standard turbidity tubes prepared by Exton's method (see Fig. 109A). Urea While urease methods of urea quantitation may be more accu- rate, the hypobromite method has the advantage of being simpler and quicker, and it is, therefore, at the present time the most practicable method for insurance practice. Urea is decomposed by the hypobromite according to the following reaction: CO(NH2)2 - 3NaOBr = 3NaBr - N2 - CO2 - 2II..0 and this is most conveniently accomplished with Rice's solutions and the Doremus-Hinds ureometer. (Fig. 110.) Solution A is made by dissolving 400 grams of sodium hydroxide in 1000 c.c. of distilled water. Solution B consists of 35 c.c. of bromine and 100 grams of potas- sium bromide dissolved in 1000 c.c. of water. The cylindrical tube of the ureometer is filled with a mixture consisting of 5 c.c. of each of the solutions A and B, and 1 c.c. of urine is then introduced into the tube. The amount of gas formed gives a direct reading of the percentage of urea on the graduated scale, which is etched on the tube. Chlorides Studies made in recent years have shown the importance of the urinary salt, and this may be roughly tested by adding to Exton's albumin reagent or the supernatant urine of Heller's test or to urine strongly acidulated with nitric acid a drop or two of a ten per cent silver nitrate solution. If the chloride content of the urine be normal or in excess, a compact white ball of silver chloride forms, which remains intact. When the chlorides are deficient, instead of URINALYSIS 429 forming a compact white ball, the silver chloride spreads more or less throughout the urine. More accurate determinations of the chlorides are possible with the skopometer or standard tubes, men- tioned previously in connection with the quantitation of albumin in the urine, using Exton's method, as follows: Dilute 1 c.c. of the urine which is to be tested to 20 c.c. with distilled water. Make up 1 c.c. of this dilution to 25 c.c. with hundredth-normal silver nitrate solution. The turbid solution Fig. 110.-Doremus-Hinds ureometer. obtained in this manner is poured into the skopometer cup and the reading obtained is referred to a table of percentages. (Fig. 111.) Twenty-four Hour Specimen As a matter of insurance practice, it is impossible to procure twenty-four-hour specimens, and taken by itself the specific gravity or the urea or the salt which may be found in a chance specimen, such as one gets for insurance purposes, is not of great importance. With a specimen, however, which displays the power of the appli- 430 LIFE INSURANCE EXAMINATION cant's kidneys satisfactorily to concentrate urine, the relation of the specific gravity to the salt-and-urea content of the specimen affords useful information. Unless there is some reason to believe otherwise, it is fair to assume that an applicant lives on an aver- age American diet, and that his physiologic urine averages 40 pro Fig'. 111.-Skopometer for directly estimating cloudiness and color of liquids as used in Prudential Laboratory. mille solids, of which the salt accounts for 10 and the urea for about 2'0 pro mille. The specific gravity of salt is 2.15, and of urea 1.32, and on the diet of an average man about 90 per cent of the total nitrogen is excreted in terms of urea, and on any but a salt-free diet there is a surplus of salt for the purpose of this ratio. URINALYSIS 431 From these data it is plain that normal urine has a definitely normal complexion, and any deviation from this may be used as a measure of the functional ability of the kidney or an indication of some peculiarity of diet that needs explanation or of some disturbance in connection with salt metabolism. Therefore, all urines having a specific gravity of 1.015 or higher should show a compact white ball when a drop or two of silver nitrate is added to the overlying urine of the Heller's test or to Exton's test or to urine strongly acidulated with nitric acid. Any tendency to spread- ing or clouding denotes an abnormally low chloride excretion. Even urines of 1.010 specific gravity should show something of a rotundity or, at most, only a very slight spreading of the silver if the chloride excretion be normal. Lowered salt excretion is evi- dence of chloride retention or of salt-free diet. By the simple, although not exact, hypobromite method, urine of 1.020 specific gravity should show a urea content better than 0.01, and urine of 1.012 specific gravity not less than 0.006. The color of the urine is at times also suggestive, because the normal yellow-coloring urochrome is derived from the food proteins, and pale or water-white specimens of satisfactory gravity are some- times the result of low-protein or protein-free diet. 5 With these considerations any dislocation of the specific-gravity- salt-and-urea ratio may be regarded as indicative of a departure from norma] metabolism or normal diet, and the ratio proposed by 1he writer serves in some respects as an insurance substitute for a twenty-four-hour specimen. Cases are sometimes encountered with extraordinarily high specific gravities for which the salt and the urea content of the urine do not account. The high gravity shown by these specimens will be found to he due to substances such as glucose, sucrose, drugs, etc. Sugar In testing for sugar in the urine it is the usual practice and expe- dient to begin by employing one of tire copper tests. Of these Benedict's reagent has the advantage of being a single solution which keeps indefinitely and of being perfectly safe when formalin is used to preserve the urine, because even a considerable excess of formalin will not give a misleading reaction by this test if other reducing substances are absent. The test is not too delicate as 432 LIFE INSURANCE EXAMINATION regards glucose and has the advantage of reacting less intensely in the presence of uric acid, creatinin and various other interfering substances than Fehling's, Haines', Budish's, Pavy's and other solu- tions with which the writer has experimented. The solution is made up as follows, and should be perfectly clear and blue: Benedict's Qualitative Copper Solution Copper sulphate (pure crystallized) 17.3 grams Sodium or potassium citrate 173.0 " Sodium carbonate (crystallized) - (one-half the weight of the anhydrous salt may be used) 200.0 " Distilled water to make 1000.0 ' ' Dissolve the carbonate and citrate together in about 700 c.c. of water, using heat. Then pour the mixture through a filter into a glass beaker. The copper sulphate, which has been dissolved sep- arately in 100 c.c. of water, is then poured slowly into the first solution, with constant stirring. The mixture is then cooled and diluted to one liter. It wdl keep indefinitely. To perform the test 8 drops of urine are added to 3 to 5 c.c. of the Benedict's solution in a clean test tube and heated in the flame to vigorous boiling for about three minutes, it being unnecessary and inadvisable to boil any longer. If many urines are to be tested, it will be found convenient to use a calcium-chloride water- bath and leave the test tubes in it for four minutes. After boiling, the tests should be allowed to cool spontaneously down to room temperature. It is unnecessary to keep the tests any longer than this for observation. If no sugar be present, the solution remains either perfectly clear or shows a slight turbidity, which is blue in color, and due to precipitated urates. If sugar be present, the solution will be. filled from top to bottom with a precipitate, which makes the mixture opaque. The color of the precipitate may be green, yellow or red, but it is the bulk of the precipitate and not the color that forms the basis of a positive reaction, and it can, therefore, be easily read by artificial light. If more than three- tenths of one per cent of sugar be present, the precipitate forms while the test is still hot. If less than about three-tenths of sugar be present in the specimen, the precipitate forms only on cooling. Should Benedict's test show a slight or doubtful reaction, it is best to proceed to identify positively the presence or absence of glucose by more specific means than is afforded by any of the cop- URINALYSIS 433 per tests, and for this purpose the Kowarsky modification of the phenylhydrazine test, in the author's experience, has proved reli- able and more rapid than any other means. Into a test tube pour 5 drops of phenylhydrazine, 10 drops of glacial acetic acid and 1 c.c. of a twenty-five per cent sodium chloride solution. A curdy mass forms on mixing. To this add 1 to 2 c.c. of urine after shaking with Lloyd's alkaloidal reagent and filtering, and heat the whole to boiling over a flame or in a water-bath. About two minutes is usually sufficient to melt the mass, and the test is then allowed to cool down to room temperature and the sediment examined under the microscope for typical glue osazone crystals. These are of a canary-yellow color and feathery and occur in sheaves and rosettes. With experience it is possible to identify the osa- zone crystals of other sugars. For quantitating glucose the urine may be fermented by yeast, preferably in a Lohnstein tube, or the percentage of glucose may be determined directly by polarimetry. There are several polari- scopes on the market which are constructed especially for quanti- tating sugar in the urine. These are listed in the catalogues of the supply-houses as saccharometers. They are usually of the half- shadow type and will be found very satisfactory and useful for the determination of amounts of sugar greater than 0.2 per cent. For amounts of sugar less than 0.2 per cent the Benedict-Osterberg or the Folin colorimetric method may be used.* Ketones Not only in relation to sugar in the urine, but also in suspected cases of acidosis, liver trouble, digestive disturbances, etc., it is well to test for the ketones. These substances are extremely fugi- tive and will be found much oftener in fresh specimens of urine than in those which have aged during transit to the home office. No simple test for beta-oxy-butyric acid has proved satisfactory, so that only the tests for acetone and aceto-acetic acid are given as practicable for insurance work. Both of these tests are very easily and rapidly made, and it is advisable for examiners to prac- tice them and to make more frequent use of them than they have done. The presence of acetones may be discovered by dissolving 1 or 2 small crystals of sodium nitroprusside in about 5 c.c. of the *For quantitative methods referred to but not given in detail, see standard texts, such as Practical Physiological Chemistry by P. B. Hawk. 434 LIFE INSURANCE EXAMINATION urine to which 15 drops of glacial acetic acid have been added. The crystals dissolve rapidly with slight shaking, and the solution is then overlayered with ammonium hydroxide. The appearance of a violet ring at the point of contact denotes the presence of acetones. Gerhardt's test for aceto-acetic acid is unusually rapid and con- venient. To 2 or 3 c.c. of urine in a test tube a 50 per cent solu- tion of ferric chloride is added, drop by drop, until the precipitate of phosphates which usually occurs is dissolved. The possible presence of aceto-acetic acid is indicated by the appearance of a Burgundy-red coloration. Aspirin and some other drugs produce this color as well as aceto-acetic acid, and the differentiation is made by boiling the test for thirty or forty minutes and filtering. If the color disappears, the presence of aceto-acetic acid is indi- cated. If the color persists after boiling or becomes deeper, it denotes the absence of aceto-acetic acid and the presence of some other substance, usually a drug. Many instances have occurred in which coloration due to drugs has led to the discovery of impair- ments which would not otherwise have been brought to light. Bile Sometimes the complexion of an applicant or the history of an abdominal operation or of digestive disturbances or the color of the specimen will suggest the advisability of testing the urine for bile. Many tests have been proposed for the bile acids and pig- ments, and of these the Bosenbach modification of Gmelin's test has proved as simple and satisfactory as any of them. A few c.c. of urine or the sediment from the centrifuge-tube is filtered through a small piece of filter-paper, and one drop of nitroso-nitric acid is applied (nitric acid may be made to fume into nitroso-nitric acid by dropping a small piece of pine wood, i.e., a piece of a match, into the test tube holding the nitric acid). Tn the presence of bile a series of rings, green, blue and red, form around the drop of acid. Tn urines containing large amounts of coloring matters Hammer- stein's test will prove advantageous. Indican For the detection of indican Obermayer's test is in general use, because of the ease and simplicity of its performance. A few c.c. URINALYSIS 435 of urine are treated in a test tube with 5 c.c. of Obermayer's reagent (which is made by dissolving 4 grams of ferric chloride in one liter of C.P. hydrochloric acid) and adding to this about 1 c.c. of chloroform. Using two clean test-tubes, the mixture is poured back and forth a few times and the chloroform is allowed to set- tle to the bottom of one of the tubes. A blue coloration of chloro- form denotes the presence of indican in proportion to the intensity of the coloration, although pink or reddish indicans are frequently found. It is to be noted that when formaldehyde has been used as a preservative, the sensitiveness of this test is somewhat dimin- ished, and that very slight and negligible amounts of indican will not show. Blood Pigments For the blood pigments the benzidine test is exceedingly sensitive and is applied by dissolving a grain or two of powdered benzidine in 2 c.c. of glacial acetic acid, to which 4 c.c. of urine and 3' c.c. of potent hydrogen peroxide are added. After standing for five min- utes a blue color develops in the presence of blood pigments. Spectroscopic tests for the different blood pigments are very easily made with a hand spectroscope, which shows their characteristic absorption bands. The use of the spectroscope is exceedingly sim- ple and rapid and should be in much more general use than it is at the present time. In all cases in which the presence of blood is suspected a careful microscopic examination should be made. Urobilin In cases which give obscure histories it may be advisable to test the urine for urobilin, which is usually taken as an indication of blood destruction going on somewhere in the body. The test is applied by rendering some of the urine ammoniacal with ammonium hydroxide. After standing a short time the precipitate of phos- phates is filtered off and the filtrate treated with a few drops of saturated zinc chloride solution. The development of a greenish fluorescence denotes the presence of urobilin, and it is well to ver- ify this by looking for the typical absorption bands in the spectrum. The sediment which is to be examined with the microscope should be obtained by thorough centrifugalization. There is apt to be less Microscopic Examination 436 LIFE INSURANCE EXAMINATION deformity of the cells if rapid centrifugalization is used over a short period than if the specimen is centrifuged slowly for a longer time. The heavier elements will he found in the lower strata of the sediments and the lighter elements, such as casts, in the upper. It is therefore advisable to use care in preparing the slide, picking off the upper layers in a pipette and then penetrating through the lower layers, which usually contain the crystalline matters and heavier mucus. The slide should be even, and although it is possible to examine urine sediments without the aid of cover glasses, I consider such practice inadvisable for optical reasons. With an 8 or 10 eyepiece the microscope should be provided with at least 16 and 4 millimeter objectives, or much better, an 8 mm. apochromatic objective with 15 compensating eyepiece, and inasmuch as the many different structures, which are likely to be encountered in urine when examined by the microscope, will be found illustrated in standard text books, it need but be noted that the epithelium of the pros- tatic ducts is larger and cuboidal, while that from the seminal ves- icles is smaller and columnar, and usually shows pigmentary gran- ules, which the prostatic epithelium never does. The cells from the renal pelvis and ureter are sometimes caudate and distinct from these, and the epithelium from the uriniferous tubules is al- ways smaller and partly flat to cuboidal and columnar. These lat- ter cells may be studied on casts, and if present in numbers or groups, are pathognomonic of a desquamative renal process, even if no casts at all be present. When there is much routine microscopy to be done, the euscope will prove advantageous, because it permits a natural, comfortable posture of the body and head, with single binocular vision by reflected light allowing the use of more of the retina than is used in microscopy. With the large pictures afforded by the euscope and the appearance of relief, eyestrain is reduced to a minimum and with a few accessories provides a simple and direct means for photomicrography and demonstrating. (Fig. 112.) Functional Test In doing insurance work it must always be remembered that the specimens of urine which are furnished by applicants are either chance specimens, which may happen to reflect transitory condi- tions, or specimens for the passing of which the applicant has URINALYSIS 437 groomed himself. These elements of uncertainty occur in conjunc- tion with slight and presumably unimportant findings, and with features of the medical history which tend to make many cases ap- pear doubtful or obscure or borderline, also for the purpose of using better discriminations in assessing the ratings for substand- ard risks, the writer recommends a functional exercise test which he has found of great assistance in estimating the significance or gravity of findings which color many cases with doubt. Fig. 112.-Euscope set for routine microscopy as used in Prudential Laboratory. Effect of Muscular Exercise As a result of the physiologic researches of Henderson, Bar- croft, Haldane and others, and of studies made during the war in connection with problems relating to the fitness of candidates for aviation and the construction of efficient gas masks, it appears that a respiratory "X," or unknown, is developed as a result of muscu- lar exertion, and that when this respiratory "X, " or unknown hor- mone, is carried in the blood stream to the centers of the brain it pro- 438 LIFE INSURANCE EXAMINATION duces hyperpnea or overbreathing. Therefore, when the reaction of the blood is less alkaline than normal on account of metabolic or other disturbances, or when the oxygen-carrying capacity of the blood is diminished because of circulatory or other reasons, similarly when gas exchanges in the blood are interfered with because of pulmon- ary or other conditions, in fact, whenever the oxidation processes of the body are lowered, or when the blood is charged with acid or waste materials, hyperpnea and other manifestations develop sooner, and as a consequence of less muscular effort than when conditions of health obtain. As a criterion for use in judging obscure and doubtful cases, and especially cases associated with abnormal urin- ary findings, a practical insurance test may be easily performed although it is based on too many and complicated theoretical con- siderations to find place here. Experiments which have been carried out upon healthy indi- viduals and those having many different kinds of impairments show that the response to muscular exertion often gives very definite information. The subject is put to some kind of rapid muscular exertion by performing some kind of exercise, such as working a tire pump or hopping or bending or squatting up and down a number of times and the amount of exercise or degree of effort must bear some rela- tion to the age, physique and occupation of the individual. Theo- retically it is better to use a form of exercise to which the individ- ual has not become accustomed in his daily routine of work or recreation. Under the age of fifty and when the individual is not too obese, 30 to 40 bends or scpiats make a fair insurance test. Be- yond this age, or when the applicant is to be rated for overweight, the exercise may be reduced to about 20 bends. Before giving the exercise the pulse is counted and noted and the systolic and diastolic blood pressures taken. Two and one-half to 3 minutes after the exercise the pulse is again noted and counted and the systolic and diastolic blood pressure readings again taken. Any change of color or tendency to overbreathing or embarrass- ment should be especially watched for in conjunction with noting the jump of the pulse and the time it takes the pulse to return to the count observed when at rest. As a general rule the pulse has a tendency to jump higher in younger individuals and return to the original count sooner, while in the older individuals the pulse URINALYSIS 439 does not tend to jump so high, but takes longer to return to the count observed when at rest. This allowance should therefore be made in estimating the effects of the exercise. A slight rise in the systolic blood pressure or a slight fall in the diastolic blood pres- sure may be regarded as favorable responses to the test, while a lowering of the systolic or a marked rise of the diastolic pressure as a result of the exercise is to be construed as tending to be un- favorable. In all cases the amount of exercise which has been given a particular individual should depend upon his physique, occupation and other factors and these should be taken into ac- count when appraising the results developed by the exercise. In many instances the test helps to eliminate the effect of nervous fac- tors which may influence blood pressure readings and pulse ob- servations, and it also has the additional advantage of giving examiners an opportunity of getting closer to doubtful cases than they are likely to when making the routine examination. Like the test of holding the breath, suggested by Henderson, this is a test of function and useful in a large variety of borderline or doubtful cases. With a little practice examiners find it easy to apply, and with increasing experience the information developed by the test be- comes more and more definite. CHAPTER XXX THE EXAMINATION FOB ALBUMIN AND CASTS By J. Bergen Ogden, M.D., Assistant Medical Director and Chemist and John M. Connolly, M.D., Chemist, Metropolitan Life Insurance Company, New York City The determination of the presence or absence of albumin and casts in the urine is a very important part of the examination of an applicant for insurance. Some insurance companies do not re- quire the examiner to make a microscopic examination of the sedi- ment, but the examiner should nevertheless be qualified to do such microscopic work as the company for which he is working requires. The source of the albumin, whether from the kidneys, the bladder, or some other part of the urinary tract can generally be told by the microscopic examination of the sediment. In this chapter we shall discuss the methods for the detection of albumin and its significance. We shall also describe the varieties of casts and discuss their significance. Tests for Albumin From the standpoint of the Life Insurance Examiner there are two important tests for Albumin in Urine. 1. The Nitric Acid Contact Test.-Take a perfectly clear and dry wine glass (Fig. 113) and fill it half full with the filtered urine. Incline the glass as shown in Fig. 114 and allow concentrated nitric acid to flow slowly from the bottle down the side of the wine glass, underlying the urine. Use about one-third as much acid as urine. Allow the test to stand five minutes, then read. If albumin is pres- ent, it will appear as a white band or zone of coagulated albumin, just at the junction of the acid and urine. If the quantity of albu- min is small, it may be impossible to detect the white albumin zone unless a dark background is used. The background should be held 440 ALBUMIN AND CASTS 441 obliquely between the glass and the source of light-but not so placed as entirely to cut off the light. The use of a drop of silver nitrate solution-one part of silver nitrate in eight parts of water-is helpful in determining exactly where the albumin zone is to be found-as the white precipitates Fig'. 113.-Method for detecting minute quantities of albumin. (After Ogden.) Fig. 114.-Method of performing nitric acid contact test for albumin. (After Ogden.) of chlorides will lie just at the junction. The white zone which often appears above this level is due usually to the presence of acid urates. Precautions.-The urine should always be filtered through filter paper. The purpose of filtering is to render the urine clear. Tf it is not clear after filtering, use a double paper and filter again. 442 LIFE INSURANCE EXAMINATION The use of a wine glass enables a funnel to be dispensed with. Centrifuging will usually clear the urine satisfactorily. The nitric acid should be colorless. The test should not be macle or read by artificial light. Errors.-Formaldehyde used as a preservative, if in considerable quantity, often gives a white zone but it is usually above the junc- tion line and comes late, developing slowly, and growing down- ward. It has a peculiar shiny, glistening appearance. Thymol used as a preservative often gives a white band which becomes somewhat greenish later. This band is a trifle below the albumin zone and gradually fuses into it. It is apt to be fringed and uneven on its upper surface. Fig. 115.-Method for the detection of minute quantities of albumin. Lower zone, albumin; upper zone, acid urates. (From Ogden's Clinical Examination of the Urine and Urinary Diagnosis, W. B. Saunders Co.) Certain drugs when taken internally may show a band in the nitric acid test. Thus turpentine, copaiba, sandalwood od, balsam of tolu, balsam of Peru, and others, each give rise to a band, usu- ally in the case of the oils above, but with the resins usually below, the position of the albumin band. This position enables proper dif- ferentiation to be made. These are usually somewhat smoky and diffuse. The presence of sandalwood oil in the urine is detected in the course of the hypobromite test for urea or it may be demon- strated by adding 1 or 2 c.c. of the urine to a few c.c. of the "bro- mine for urea" solution. A thick, cheesy white curd is formed immediately. The presence of albumin in any quantity (trace or ALBUMIN AND CASTS 443 over) can easily be noted by the persistence of the foam in the hypobromite test. Potassium iodide, when taken internally in large doses, gives rise to a band which often simulates an albumin band, though it is usually quite sharp and glistening and there is often a slight reddish-brown coloration in the urine at the zone of contact. If Fig'. 116.-Nitric acid test for albumin, (a) Zone of acid urates; (ft) zone of albumin. a little chloroform be placed in a test tube and the contents of the wine glass from the nitric acid test added, the characteristic pur- ple color of the iodine will appear in the chloroform at the bot- tom of the tube. It may be necessary to shake first and allow the contents to settle. The nitric acid test in a test tube is performed by placing filtered 444 LIFE INSURANCE EXAMINATION urine in a test tube of about one inch caliber and allowing the nitric acid to run slowly under the urine from a pipette. The tube should be held inclined at an angle of about 45° and the tip of the pipette should rest high up on the inner surface of the tube above the surface of the urine. At the end of five minutes the test may be read. A dark background is often necessary. (An estimation of quantity of albumin present cannot be made by this method.) Do not pour the urine upon the acid-but allow the acid to flow down under the urine. 2. The Heat Test.-The heat test depends upon the coagulation of the albumin by heat. Alkaline albumin does not coagulate by heat. If alkaline or neutral, the urine should be made faintly acid by the use of a few drops of either 10 per cent nitric acid or 33 per cent acetic acid. Avoid more than a few drops of acid because acid albumin is not coagulable by heat. It is advisable always to use a saturated solution of sodium chloride in the heat test in order to prevent the coagulation of nucleo-albumin. Method.-To one-half test tube of filtered urine add one-sixth of its volume of saturated salt solution. Hold the tube by the lower end and boil the upper third. If a cloud forms it consists either of earthy phosphates or albumin. Add two or three drops of 10 per cent nitric or 33 per cent acetic acid and the phosphates, if present, will disappear, the albumin remaining. Care should be taken not to add too much acid or the albumin also will par- tially dissolve, especially if the urine be boiled after the addition of the acid. The heat test is a good test if properly performed- but is more difficult of proper performance by the average man than the cold nitric acid test. It is, however, very valuable as a check test. Thymol interferes with it, as does sandalwood oil. For- maldehyde does not. There are many other tests for albumin but none of them is of any present importance to the life insurance examiner-and none of them is deemed worthy of mention here. Significance of Albumin Albumin in the urine may be indicative of an abnormal condition or disturbance in any part of the urinary tract from the meatus urinarius to the remotest parts of the kidneys. Usually the very ALBUMIN AND CASTS 445 small amounts of albumin, however, come from some disturbance in the urethra, at the neck of the bladder, or in the bladder, and may represent only the remains of a urethritis years before. The microscopic examination will usually tell us where the disturbance is and something of its relative importance. We all know how unimportant such urethral disturbances generally are, provided they recover and are not accompanied by a stricture or other me- chanical interference to the natural output of the urine. Albuminuria may be divided into three classes, i.e., temporary, intermittent and persistent. It is important to distinguish be- tween these three forms in judging of the fitness of an applicant for insurance. If, for example, we find a distinct reaction for al- bumin and in the sediment some casts, or even the absence of casts, it is necessary for us to follow that case for a number of weeks or months in order to find out whether the condition is a temporary, an intermittent or a persistent form. If the examination of several specimens during a one-, two-, three- or six-month period shows that the albumin and casts have disappeared, we can safely take such a case on regular plans. It is not safe to draw a definite con- clusion as to the length of time that an albuminuria has existed from the examination of a single specimen of urine. If the abnormal condition as shown by the occasional appearance and disappearance of albumin, with or without casts, convinces us of an intermittent form, we must either decline, issue on a sub- standard plan, or possibly on a short-term regular plan. If the applicant is young, under 30 years, we must have in mind the pos- sibility of an albuminuria of adolescence. Generally in such a con- dition casts are not present, although occasionally they are. Such cases can be considered for such plans as the payment life or the endowment, provided the history and physical examination are in other respects first class. The majority of cases of adolescent al- buminuria clear up without any resulting kidney change. The only difficulty in such cases is in making an accurate diagnosis. If we are satisfied that the albuminuria is not a part of the ado- lescence, and the young person is in other respects first class, then a short term endowment or a substandard plan may be considered. Persistent albuminuria means unfavorable action, or at best a more or less severe form of rating. The only exception is where the applicant is young, under thirty years, and the history in other 446 LIFE INSURANCE EXAMINATION respects gilt-edged and no casts accompany the small trace of albu- min, then short-term endowments or substandard plans may be considered and are usually justified. Much depends on the age of an applicant. A young vigorous person without previous history or present impairment is entitled to special consideration in the issuance of insurance. Greater risks may be taken with such applicants and generally with satisfactory results. The mere presence of albumin in the urine without casts means less at the younger ages than after the age of thirty. The relative amount of albumin in the urine-that is, whether a-very slight trace, a trace, a large trace or % of 1 per cent-must be constantly kept in mind, for generally the larger the quantity of albumin the more severe the abnormal condition in the urinary tract. This statement would not, however, preclude the possibil- ity of a very important kidney disease which is generally accom- panied by a very small amount of albumin, a very slight trace or even the slightest possible trace, i.e., a chronic interstitial nephritis. A history of albuminuria, whether recent or remote, is always important in the consideration of a case. Under such a condition, intermittent or persistent albuminuria becomes vastly more im- portant and warrants substandard plans at the younger ages, or rejection. If, on the other hand, there is a history of albuminuria and in our study of the urine we find nothing abnormal in two or three specimens extending over a period of from one to three months, regular plans of insurance are usually perfectly safe, for it must be inferred that any trouble in the urinary tract which had previously existed has entirely disappeared. Casts Renal casts have been classified according to their appearance, particularly the retractility and whether or not other elements from the urinary tract are adherent or imbedded. The variety of casts found in a sediment frequently gives valuable information as to the condition of the kidneys from which they come. I. Hyaline (transparent) casts a. Pure hyaline b. Fibrinous c. Waxy ALBUMIN AND CASTS 447 II. Granular casts a. Fine b. Coarse c. Brown III. Epithelial casts IV. Blood casts V. Fatty easts VI. Pus casts VII. Crystalline casts. The pure hyaline is one of the most important of urinary casts and yet the most difficult to recognize, because it is made up of Fig. 117.-Pure hyaline casts. (Ogden.) perfectly transparent material of a refractive index very nearly the same as that of the urinary fluid itself. In order to see it, there- fore, it is usually necessary to reduce the illumination by turning the mirror or by shading with the hand. With too strong a light such casts will not be recognized. Even with proper adjustment of the light, careful focusing is essential. These casts are cylindrical and usually have parallel sides and rounded ends (Fig. 117). When the diameter of the cast is not the same throughout it varies regularly and not irregularly. A hyaline cast may be more or less pointed but when it is, the diameter changes abruptly, so that it is evident that the cast is merely a portion of a longer cast which has been torn in two by mechanical means and thus has had the end drawn out. These casts may be 448 LIFE INSURANCE EXAMINATION of small diameter originating in the smaller undenuded tubules or of large diameter from the large straight or collecting tubules of the kidney. In advanced disease the casts coming from even the smaller tubules are of rather large diameter, because the tubules are then denuded. Casts of large diameter are usually more re- fractive than those of small diameter, hence are more easily seen. The fibrinous cast is highly refractive and has a color ranging from pale yellow to deep brown. It derives its color from the blood pigment, and blood corpuscles are usually present with it in the sediment. It is called fibrinous, not because it is composed of Fig'. 118.-Fibrinous casts. (Ogden.) fibrin, but because it resembles fibrin in color (Fig. 118). It is usually of larger diameter than the average pure hyaline cast. The waxy cast also is highly refractive but it has no color. It is usually of large diameter and looks and is brittle. These casts are often marked by indentions or transverse cracks and their ends are frequently broken off sharply perpendicular to the longitudinal diam- eter. They are often coarsely granular, the granules having ap- parently the same composition as the cast itself. They are, never- theless, called "waxy" not "granular." The colorless waxy cast should be sharply distinguished from the colored fibrinous cast, for they are of entirely different import. The fibrinous cast occurs ALBUMIN AND CASTS 449 in acute conditions and does not indicate an unfavorable prognosis, but the waxy cast is found only in advanced chronic disease of the kidneys and is of bad prognostic omen, indicating death within a short time, usually within a year. When the color is so exceedingly slight that a doubt exists as to whether the cast is fibrinous or waxy, it should be called a "highly-refractive" cast until further study of the urine enables the examiner to arrive at a definite conclusion. All the casts so far described may have a few renal cells, blood corpuscles, fat drops, fatty renal cells or compound granule cells adherent-and are accordingly designated as "hyaline casts with renal cells adherent," and so on, depending on the adherent material. When a hyaline cast is completely covered with granules it is Fig'. 119.-Waxy casts. (Ogden.) called a granular cast (Fig. 1207?). Granular casts when covered with fine granules are spoken of as finely granular; when the granules are coarse, as coarsely granular; and when the granules are colored brown by blood pigment, as brown granular. Bile occasionally stains granular casts yellow or even brownish, but the true brown granular cast is always associated with blood. When a cast is practically covered with renal epithelium it is called an epithelial cast (Fig. 121-1). The renal cells may be merely adherent to, or may be deeply embedded in, either a hyaline or a granular cast. When only a few cells are adherent the cast should be called "a hyaline (or granular) cast with a renal cel] (or cells) adherent," 1he term epithelial cast being reserved to designate a cast practically covered with renal epithelium. 450 LIFE INSURANCE EXAMINATION The blood cast may be a hyaline or granular cast which is prac- tically covered with blood globules either normal or abnormal, or it may be a cylinder consisting of fibrin with blood globules embedded (Fig. 121-£). Usually the blood is abnormal (washed-out) and in- dicates slow effusion of blood or an origin high up in the kidney; but if normal blood is seen, it indicates more abundant hemorrhage or an origin in the straight tubules. Fig. 120.-a, Hyaline and finely granular cast; b, finely granular cast; c. coarsely granular cast; d, brown granular cast; e, granular cast with normal and abnormal blood adherent; /, granular cast with renal cells adherent; g, granular case with fat and a fatty renal cell adherent. (Ogden.) Fig'. 121.-1, Epithelial cast; 2, blood cast; 3, pus cast; 1, fatty; 5, cast with compound granule and fatty renal cell adherent (crystals of the fatty acids pro- truding). (Ogden.) Fatty casts are thickly covered with fat drops which may be large or small. A hyaline or granular cast with only some fat drops adherent is called not a fatty cast but a hyaline or granular cast with fat adherent. Sometimes the fine needle-like crystals of the fatty acids are seen projecting from a fatty east (Fig. 121-4). Pus casts are so called because they are covered with pus cor- puscles (Fig. 121-5). The corpuscles are frequently so granular that treatment with dilute acetic acid is necessary in order to ALBUMIN AND CASTS 451 bring out their nuclei and distinguish them from renal epithelial cells and the pus cast from an epithelial cast. Crystalline casts are ordinary hyaline or granular casts covered with crystals. Thus a urate cast is covered with crystals of am- monium urate and a calcium oxalate cast is covered with crystals of calcium oxalate, either octahedral, oval or dumb-bell forms. The importance of noting crystalline casts is that the crystals are usually deposited on the casts in the kidney and are, therefore, primary. Significance of Renal Casts True renal casts in the urinary sediment indicate that there is some disturbance or disease in one or both kidneys. The condition may be either acute or chronic; that is, we may be dealing with an active congestion, or a chronic process with its accompanying struc- tural changes in the kidneys. It is safe to say that the majority of Fig. 122.-False casts or cylindroids. (After von Jaksch). the kidney disturbances which we find in applicants for insurance are active or acute, conditions which will generally clear up in weeks or months. We, however, occasionally find a case of a marked active hyperemia of the kidneys which is persistent and evidently due to the constant elimination of toxic or irritating sub- stances which are either taken into the body from, outside sources or are formed inside of the body. Such persons are naturally unin- surable, for we are constantly mindful of the fact that long con- tinued irritation of the kidneys usually results in some chronic form of kidney disease. As a rule active disturbances of the kidneys will clear up in the course of from one to three months, at which time the applicant becomes insurable on regular plans. A definitely established chronic disease of the kidneys is, of course, not insurable on any plan. Let us consider for a moment the significance of the different 452 LIFE INSURANCE EXAMINATION forms of casts found in the urinary sediment. A hyaline cast is no more important than a granular cast or a granular cast more im- portant than a hyaline cast so far as diagnosis is concerned. These two forms of casts have equal significance, and neither form is path- ognomonic. Either form may accompany either an acute or a chronic process in the kidneys. The blood and fibrinous casts rep- resent an acute condition. The waxy casts represent a long-standing or chronic process in the kidneys. The fatty and epithelial casts may be present in either an acute or a chronic disease of the kid- neys, both, however, indicating more or less degeneration of the kidney substance. By the forms of casts found in the sediment, we may, therefore, judge something of the nature of the kidney disturbance, but we cannot depend entirely upon such a means of diagnosis. It is necessary to take into consideration also other features of the urine before approaching a conclusion. The relative number of casts which the sediment contains is al- ways important. If the number is small, one or two to the slide, it is usually less significant than if there are twenty or thirty to the slide. In other words, the larger the number of casts, the greater the importance. Such a rule is not invariable, however, be- cause we do occasionally see active kidney disturbances showing many casts where the trouble will entirely disappear in a few weeks' time. On the other hand, there may be present an important chronic kidney disease, such as a chronic interstitial nephritis with only a very few casts present in the sediment. But in general, the relative number of casts in a sediment is to be carefully noted. The diameter of casts is frequently also important. If they are small, they come from the smaller tubules high up in the kidneys, while casts of larger diameter come either from the collecting tubes or from denuded tubules, the result of a chronic nephritis. From the insurance standpoint, true renal casts are always of considerable concern. As a rule, the persistence of few or fre- quent casts in one, two, or three specimens covering several weeks or months means that the applicant must be refused insurance. If the number of casts is small in every specimen examined, only a severe form of rating or rejection is justifiable. One exception to such action is where the applicant is young, under thirty years, and the history and physical condition are in other respects first class. Then, if the number of casts is very small, one or two to the slide, ALBUMIN AND CASTS 453 and the quantity of albumin is also very small, we can consider insurance on the substandard plans. If hyaline and granular casts with only a minute trace of albumin are found at one examination and not in two or three subsequent specimens, we can look upon the case as one showing a temporary disturbance of the kidneys and not of importance from the insur- ance point of view. This statement would apply to all ages and amounts of insurance. In judging of the significance of casts, we must also take into consideration the amount of albumin accompanying them. Rarely a cast with a marked trace of albumin would be far more impor- tant than rarely a cast with the slightest possible trace of albumin. Likewise the history of casts at some earlier date is to be carefully noted. The intermittent appearance of casts in the urinary sedi- ment is never a good sign, and either a substandard plan or rejec- tion is advisable. CHAPTER XXXI ALBUMINURIA AND CYLINDRURIA By C. Naumann McCloud, M.D., St. Paul, Minn. Medical Director Minnesota Mutual Life Insurance Company. The presence of albumin and casts in the urine constitutes one of the commonest urinary impairments which we have to consider. In treating this subject from the standpoint of life insurance selection, one must admit that there still exists in the minds of many clinicians and medical directors the feeling that either albumin or casts in the urine is indicative of a grave condition and that applicants show- ing such impairments should be carefully avoided. The trend today, however, is to be somewhat more lenient in our treatment of such applicants and there is a growing tendency to give these cases the benefit of more careful and painstaking study, before pronouncing them sufferers from acute or chronic Bright's disease and thereby disqualifying them as insurance risks. Albuminuria Bright's dictum that albumin in the urine is invariably the prod- uct of inflamed kidneys was accepted apparently without question until 1878 when Von Loeb in Germany and Maxon in England simultaneously became convinced that albumin frequently occurs in persons in whom no evidence of nephritis could be found and in whom Bright's disease never developed. Since that time the term "functional" or so-called physiologic albuminuria has been accepted by most pathologists and clinicians, though it required some decades to convince medical directors of life insurance companies that they could safely insure persons whose urine showed such an abnormality even in small amounts; and all such applicants were promptly rejected. It is probable that more has been accomplished along progressive lines in this class of cases than in any we have had to consider in connection with the so-called "impaired lives." The chief factor which has brought about the reversal of opinion in the minds of 454 ALBUMINURIA AND CYLINDRURIA 455 medical directors lias been, I believe, the installation of chemical laboratories at the home offices of the companies. The large num- ber of urinalyses made in such laboratories has made possible a greater precision and uniformity in technic, and this in turn has led to a more scientific and logical understanding of the findings of the analysts. It must be apparent that examinations made in this way insure greater safety to the company than if made by the various examiners in the field (without any reflection being cast upon such examiners). Naturally the practice of allowing urin- alyses to be made by the many and varied examiners scattered throughout the country, each following his own method of examin- ing urine, and each feeling that his own particular method is the best, would tend to confusion rather than uniformity in results. Experience has also shown that many specimens reported by the examiners to contain albumin have proved otherwise on home office examination and vice versa. In a general consideration of this subject we must at once recog- nize that there are different grades of albumin and that the exact number of casts found on a slide is significant. An equally impor- tant factor is the nature of the test employed and the manner of its employment. We must assume that normal urine is free from serum albumin, i.e., that there will be no reaction for albumin by the ordinary standard tests such as Heller's (the cold nitric acid contact test) and the heat and acetic acid test. Urine showing any reaction to such reagents is, at least temporarily, abnormal. For our purpose we here make no distinction between serum albumin, nucleo-albumin or serum globulin. Their significance is the same, though their detection may require different reagents. In formulating an opinion as to the significance of albumin we must at once endeavor to separate in our minds the various grades of albumin as it is evident that a faint trace is not so significant as a large amount. At this point I quote from Sir William Osler: "The presence of albumin in the urine in any form and under any circumstances may be regarded as indicative of changes in the renal or glomerular epithelium; a change, however, which may be transient, slight and unimportant, depending upon the variation in the circulation or upon irritative substances taken with the food or temporarily present, as in the febrile states." It has been well proved to the satisfaction o,f most clinicians and 456 LIFE INSURANCE EXAMINATION chemists that such factors as exhausting exercise, excessive inges- tion of nitrogenous food or focal infections may bring about the presence of albumin in the urine and we must now recognize that there are certain types of albumin which are innocent and which are frequently found by clinical observers where no disease of the kidney can be demonstrated during life or any evidence of a patho- logic condition be found at autopsy. Ludwig Hektoen in June, 1919, said, "Repeated examinations of the urine with refined methods did not give any better indications of oncoming nephritis than did the usual standard chemical tests." Quoting Beifeld: "Although it has been generally considered normal urine contains no albumin, recent work has rendered it very probable that traces of albumin are normally present. This al- bumin is believed by Senator and Mbrner to be derived from the blood by a process of filtration through the glomeruli. Certain per- sons continually or intermittently show demonstrable quantities of albumin in their urine without feeling ill in any way. We cannot assume that the kidneys of such persons are absolutely normal in spite of the fact that the ordinary symptoms of chronic nephritis are absent and that the affected persons remain, so far as appear- ances are concerned, perfectly normal. It is certain that chronic nephritis frequently follows quite a different course from that ordi- narily described in our textbooks on medicine and it is possible that many of these cases may be exceedingly mild forms of this disease. " Grades of Albumin-Our study of albuminuria would be greatly simplified and facilitated if we could formulate some definite stand- ards and terminology that would enable the technician so to de- scribe his findings as to convey intelligently to others his meaning when he refers to the various grades of albumin as he observes them. Many forms of nomenclature have been attempted and it would seem advisable that we should reduce, as far as possible, the number of designated grades to a minimum. However, in attempting to arrive at a proper, useful, yet a simple gradation of albumin, it seems inadvisable to confine our definitions to less than four classes. Some laboratories employ the numerals 1-2-3-4; others the terms a-b-c-d; others the terms plus (+), double plus (++), triple plus (+-H-) or four plus (++++) while others desig- nate their findings as: a very faint trace, faint trace, moderate ALBUMINURIA AND CYLINDKURIA 457 quantity or large amount. The latter nomenclature is the one, I believe, used by most insurance companies. In this nomenclature the term "trace" is used to designate that amount of albumin which by the nitric acid contact test will form a band %G of an inch in thickness. This appears to me as being a rather large amount of albumin to be designated as a trace. The term "moderate amount" is used for that amount of albumin which will form a band % of an inch thick; this in turn seems to me too much albumin to be termed "a moderate amount." Doctor William G. Exton of the Prudential Life Insurance Com- pany employs the following nomenclature. A reaction by Heller's test which shows a definite white ring that can be seen without particular care as to the light in which it is viewed, is designated as "plus one" albumin. This is the starting point, and the more marked reactions than this are designated as plus two, plus three, plus four and plus five, depending upon the promptness with which the reaction appears, the color and the width of the ring. Ques- tionable rings are disregarded but specimens showing them are checked by testing them with the brine test. Because of its simplicity and reliability the Heller cold nitric acid test seems best adapted for use as the method on which'to base our standard grades of albumin. The brine test and the heat and acetic acid test are both unnecessarily delicate and often show albumin in infinitesimal amounts while Heller's test, if properly per- formed, is sufficiently delicate for our purposes. The following classification is one which has given satisfaction in daily use. It is sufficiently delicate and yet is definite enough to form a good basis for comparison of findings by different labora- tories. Class I-Faint Trace (to Heller's Test).-That amount of albumin which will produce a faintly visible ring after contact with cold nitric acid for five minutes by the underlying method or ten minutes by the overlying method; best seen on a dark background. Class II-Trace (to Heller's Test).-That amount of albumin pro- duced as above whose ring is quite distinct and wider than that of Class I, being approximately C32 °f an inch. Class III-Moderate Quantity (to Heller's Test).-That amount of albumin which will produce a distinct ring approximately of an inch in thickness, dearly cut. 458 LIFE INSURANCE EXAMINATION Class IV-Large Amount (to Heller's Test.)-That amount of albumin which will produce a distinct ring more than %G of an inch in thickness. Dr. Henry Wireman Cook, Minneapolis, has recently contributed a most valuable means of determining the amount of albumin in urine. This is known as the Visual Albuminuria Guide which we believe to be the most exact and definite standard yet devised for this purpose. (See chart.) M ith such a classification as this we should be in a position, not only to grade amounts of albumin in our own work, but also to convey to others a definite impression of our findings, thus making it possible to draw conclusions from comparable data. Cylindruria Cylindruria is the term widely used to indicate the presence of casts in the urine. As a result of the closer study and more intent analysis on the part of clinicians and laboratory workers in relation to these bodies, opinion as to their significance has apparently, in some quarters at least, undergone a decided reversal. A decade ago most medical directors looked with great suspicion upon any appli- cant whose urine showed even a few hyaline or granular cylinders. Such applicants were believed to be either suffering from acute or chronic Bright's disease or about to pass into that lamentable state. How perplexing it is, in reviewing the literature on this subject, to find a paragraph by some noted clinician wherein a fine dis- tinction is made between the significance of hyaline and of granular casts, regarding hyaline casts as possibly, though not always, inno- cent, and looking with grave suspicion and apprehension upon the applicant whose urine shows a few finely granular casts. For in- stance, Garrod writing in Osier's and McCrae's "Modern Medi- cine" says: "Granules arise from the disintegration of epithelial cells, and they are, therefore, held to indicate somewhat advanced renal lesions. They are met with in the urine in all varieties of nephritis and a few may be present in cases of granular kidneys. In cases of chronic parenchymatous nephritis a large proportion of the casts present are usually of this nature. Transitional stages between epithelial and granular casts are not infrequently met with." Another authority upon the same subject regards them Visual Albuminuria Guide Heat and Acetic Acid Heller's A .005% B 008% C .01% Heat and Acetic Acid Test-A clean test-tube is filled three-fourths full of the clear neutral or faintly acid filtered urine and heated at the top to a boil, the tube being held by its lower end. If a cloud is produced, it can be easily recognized by comparing the upper with the lower half of the tube while holding the tube against a black background. A cloud may be due to albumin, or to calcium phos- phate and carbonate. A few drops of five per cent acetic acid are then added until the urine is distinctly acid. If the cloud is albumin it will rather increase, whereas if due to phosphates or carbonates it will disappear on the addition of acid. Visual Albuminuria Guide Heat and Acetic Acid Heller's D .025% + .05% ++ .1% Heller's Test-Place in a clean test-tube about one inch of concentrated nitric acid; then incline the tube almost horizontally; from a pipette allow an equal volume of urine to flow slowly down the side of the tube, carefully overlaying the acid. Wait three minutes. If albumin is present, by the use of a black back- ground a zone will be seen just above the point of contact of the urine and the acid, the Intensity and width of the cloud depending on the amount of albumin present. -Copyright, 1922, By H. W. Cook, M.D. ALBUMINURIA AND CYLINDRURIA 459 both as of equal significance, and maintains that such bodies can be found in every urine, if we only sediment long and search dili- gently enough for them. In the light of two such contrary views it is difficult for a medical director or clinician to arrive at any definite conclusion, and one's opinion must be swayed ever and anon, depending upon his choice of literature treating upon this subject. I am inclined to follow the dictum and teaching of Dr. J. Bergen Ogden of the Metropolitan Life Insurance Company. Doctor Ogden states as follows: "My long experience has led me to believe that a hyaline cast is no more important than a granular cast, or a granular cast more important than a hyaline cast, so far as diagnosis is concerned. These two forms of casts have equal significance and neither form is pathognomonic. Either form may accompany either an acute or a chronic process in the kidney." Undoubtedly the great fault has been in not standardizing our methods of microscopic examination and in not being specific enough in our records of the findings. It would seem that we should be able to formulate some standard nomenclature that each might know what the other is talking about. What do we mean by a few casts, moderate number, many casts, et cetera? It would appear to be a simple matter to count the casts and record the results, stating whether hyaline or granular, and whether finely or coarsely granular, whether narrow or broad. Only in this way can we impart our findings intelligently to others. Perhaps some such nomenclature as this would apply: Rare: 1 to 3 casts. Occasional: 4 to 6 casts. Numerous: More than above to a slide. Origin of Casts.-The exact origin of casts is as yet not definitely known. It is probable that they arise in either one of the follow- ing ways: (a) As a result of coagulation of the blood constituents which escape into the uriniferous tubules, or (b) More directly from disintegrating renal cells or their con- stituents which have been acted upon by some noxious influence, or (c) They may be derived from both sources, i.e., from altered renal epithelium and from transuded albumin, combined. 460 LIFE INSURANCE EXAMINATION In whatever way they may originate, they appear clinically as casts or molds of the renal tubules, having to a great extent the form and caliber of the portion of the kidney whence they came. Assuming that cast formation is a result of hyaline degeneration of kidney structures undergoing pathologic changes, we can readily understand the various modifications of type, and when we use the terms hyaline, granular, fatty, or waxy in referring to casts, we speak in terms of greater or lesser degrees of pathologic degen- eration. Furthermore, we cannot consider that the causes producing these pathologic changes are always identical, nor their significance the same. Other clinical data must be considered along with the pres- ence of casts in order to understand their true significance. Such factors are the specific gravity, absence or presence of albumin (definitely stated amounts), blood pressure (diastolic and systolic), and the quantity of urine passed (24 hours). Without these other important data we are not in a position intelligently to estimate the significance of casts and must admit that their presence is a symp- tom only, and not of sufficient value to allow a diagnosis, as they may or may not indicate disease of the kidney. There are many instances of the finding of casts in persons who have no other evidence of nephritis, just as there are many instances of the finding of minimum amounts of albumin in the urine of persons who have no other evidence of the disease of the kidney and who do not develop any such disease. Morphology of Casts.-Casts may be conveniently divided into the following groups: (a) Hyaline (narrow and broad) (b) Granular (finely or coarsely) (c) Waxy (d) Fatty (e) Casts containing organized structures such as (1) Epithelial casts (2) Blood casts (3) Pus casts. True hyaline casts are pale, translucent, homogeneous cylinders with rounded ends. They may vary from small fragments to sev- eral millimeters in length. In diameter they are classed as narrow or broad. ALBUMINURIA AND CYL1NDRURIA 461 As a rule little distinction is made clinically between these various types of hyaline casts, but it would seem that the broader types would actually be more significant. True casts have the appearance of cylinders, sides usually parallel and tending to be straight; but sometimes they may be tortuous; they are never tapered at the ends, but may show an irregular outline at one or both ends. True hyaline casts are free from granules, but types are frequently ob- served containing very fine granules imbedded in the matrix and they may often have epithelial, blood or pus cells clinging to them. Significance.-Casts may occur with any condition which alters the kidney, be this condition circulatory, toxic or inflammatory; they are not pathognomonic of any one condition and may be found as a result of a simple functional disturbance. The appearance of casts usually indicates a disturbance of renal epithelium. This may be nothing more than a slight nutritional or circulatory disturbance. When, however, casts appear constantly over a given period of time and in large numbers, and particularly when other types of casts exist in addition to the hyaline or granular, then we must assume that a distinct pathologic condition of the kidney exists. If casts composed of hyaline or finely granular material (sup- posedly consisting of fibrin, although it is questionable whether this is true fibrin or not) are found alone in an occasional specimen and not associated with albumin or clinical findings indicative of diseased kidneys, their presence in moderate numbers is not signifi- cant; but when found constantly and in large numbers they may be assumed to indicate a distinct pathologic condition. As a rule, their presence should not be regarded as indicating a chronic diffuse nephritis, but only as indicating that in a small area of one or both kidneys there may be a slight change, such as might occur in any condition in which the kidney is altered by circulatory, toxic or inflammatory influences or even by a simple functional disturbance. Varieties.-(a) Hyaline and finely granular classed together have already been discussed. (b) Coarsely granular casts: These are derived from degener- ated renal epithelial cells and it must be assumed that the coarser the granules, the more severe has been the disturbance which pro- duced them. (c) Waxy: These are usually short, thick, and more refractile than the hyaline and granular, often colorless or sightly gray, never 462 LIFE INSURANCE EXAMINATION yellow or brown. They are indicative of chronic kidney disease which has resulted in a degeneration of the kidney substance. (d) Fatty: These casts composed of cells which have undergone fatty degeneration are usually found in cases of acute or chronic parenchymatous nephritis and are usually associated with coarsely granular and waxy casts. (e) Organized casts: 1 Epithelial; 2 Blood; 3 Pus. These are essentially hyaline casts to which have become attached either epi- thelial cells, erythrocytes or leucocytes in such number as to cover most of the surface of the casts, whose shape they retain. These are of such serious significance that their presence entirely disqualifies an applicant for insurance. Laboratory Technic.-It is now the established practice and cus- tom for most life insurance companies to maintain their own labora- tories for the purpose of making analyses, both chemical and micro- scopic, of the urines of certain of their applicants. Necessarily the requirements for specimens must vary with the different companies, as would also the laboratory technic. One company requires home office examination in all cases where there is a history of a urinary impairment, wherever the examiner reports the presence of albumin or sugar, where the specific gravity is found to be over 1.030 or below 1.012, where the age of the applicant is fifty years or more and where the total amount of insurance applied for, plus that al- ready carried in that company, amounts to $10,000 or more. Requirements of some other companies are more strict as to the amount and age. For instance, one company requires specimens in all cases where the amount of insurance involved is $5,000 or more, or where the age is forty-five or more. There*seems to be a tendency to stricter requirements, and since the taking of blood pressure in life insurance examinations is now routine, it is the common prac- tice of some companies to require a specimen of urine in all cases where the systolic pressure is found to be 140 mm., or more, or where the diastolic pressure is found to be 100 mm. or more. This seems to be a logical procedure and acts as a check in the clearing of these cases. (It goes without saying that all specimens sub- mitted should be duly authenticated by the examiner.) There must ever be a difference of opinion in the minds of medical men as to the relative significance of hyaline and granular casts in the urine. This subject is far from being definitely settled. ALBUMINURIA AND CYLINDRURIA 463 Each one of us, however, must formulate an opinion and act on this opinion in the treatment of applicants showing these im- pairments. I am not converted to the opinion of Osler that casts in the urine of older men are of no more significance than are grey hairs. Nor can T agree with Dr. E. W. Dwight in his opinion that albumin and casts are found in the urine of older men more often than in the urine of younger men, because the older men are nearer death. There are other factors which must be taken into account as be- fore stated, i.e., blood pressure, specific gravity, 24-hour output, etc. Perhaps a position midway between that taken by Osler and that taken by Dwight would more nearly insure safety to the company and justice to the applicant than either of the two cited. Certainly as a man grows older and approaches the time of his eventual dissolution, all of his organs may be expected to show evidence of degeneration more or less marked. This gradual change becomes apparent in various ways; in the case of the hair by change of color. It would seem reasonable to expect that the kidneys along with the other organs might show some evidence of this degenera- tion. The appearance, therefore, of a few casts in the urine .of the older applicants need not be considered evidence of abnormal changes in the kidney. In our practice we regard the appearance of a small number of casts in the urine of older applicants as rather to be expected. Careful distinction, however, must be made be- tween evidence of slight degenerative changes, such as may be ex- pected with advancing age, and evidence of a more marked change, sufficient to be considered abnormal. I am inclined to believe that in the past a gross injustice has been done in refusing insurance to many of these older men simply because a few hyaline or finely granular casts have been found on one examination of the urine. Dr. Oscar Rogers of the New York Life has shown that in a group of 650 cases with albumin and casts his company had a mortality ratio of 250 per cent, 50 per cent of the total number of deaths being due to Bright's disease. These cases were selected with special care and only the best of them were accepted. No intimation, however, is given as to the number or varieties of casts found in this study or the amount of albumin present, neither is any indication given as to the age at entry. It will, therefore, be difficult to draw any conclusion for our pur- 464 LIFE INSURANCE EXAMINATION pose from this experience. It would seem that the following would be a safe practice to follow: 1. If applicant is otherwise standard in every respect, disregard hyaline and granular casts if not more than 3 on a slide, regardless of age of applicant. 2. If more than 3 casts are found on a slide, a further study of the urine is required, action being determined by the findings in subsequent specimens. 3. If 4 to 6 casts are found on a slide in each of several specimens, the case is definitely substandard and requires a rating. 4. If casts are numerous (more than 6 to a slide) extreme caution must be exercised. 5. If there are over 15 casts to a slide the case should invariably be declined. If there is a history of kidney disease or an impairment record indicating albumin or casts within five years, repeated examinations of the urine should be made over a considerable period of time be- fore the risk is accepted on any plan. Lest we become too sanguine in estimating the significance of albuminuria and cylindruria I wish to refer to a most interesting article by Dr. Theodore Barringer Jr., (Arch. Int. Med., 1912, ix, p. 657). The investigation undertaken required a tremendous amount of work, and the results are very enlightening. A study was made of 396 men, residents of New York City who were insured in 1900 and 1901. They were all normal risks at that time except for the presence of serum albumin with or without casts, albumin being found on at least two occasions in 50 per cent of the cases. The tests used were the ordinary heat and nitric acid tests for al- bumin. Following their examinations during 1900-1901 by the in- surance company these 396 men were divided into three groups: The first group numbering 115, showed albumin without casts. Two cases of pyuria were not included in this group. The second group numbering 203 showed albumin and few hyaline casts. The third group numbering 53 showed albumin and few granular casts. The distribution by decades of these groups is of interest. Cases showing albumin alone were five times more frequent before the ALBUMINURIA AND CYLINDRURIA 465 twentieth year than after. Cases showing albuminuria and hyaline casts appeared with approximate equal frequency in the second, third, fourth and fifth decades. The group with albumin and gran- ular casts showed an increasing number in each decade until be- tween forty and fifty years they were four times as frequent as between twenty and thirty years. During the year 1911, 70 of the original 396 men were visited and examined, ten or eleven years having elapsed since first examina- tion ; 20 of these 70 men had shown albumin but no casts in 1900-1901. Tn 1911 none of these men had interstitial nephritis, as far as could be judged from examination of the heart, from the blood pressure and from examination of the urine; 12 showed no albumin, 8 showed the same condition of the urine as had been found ten years before, 4 showing in addition, tube casts. No case of interstitial nephritis had developed in any member of this group. Thirty of the men visited in 1900-1901 had shown albumin and few hyaline casts. One of the thirty in 1911 had interstitial ne- phritis and two were doubtful cases. Five showed a slight rise of blood pressure not sufficiently marked to justify any suspicion of nephritis, considering that ten years had passed since the original examination was made. Eighteen were apparently normal 'as re- gards the heart and the kidneys. Nine showed the same condition of urine they did in 1900. Twenty of the men visited had shown albumin and few granular casts in 1900-1901. Of these twenty men in 1911 two had inter- stitial nephritis and in five the diagnosis was doubtful. Eight were apparently normal as regards the heart and kidneys. Of the entire series of seventy men, thirty-eight were free in 1911 from cardiac or renal diseases, three had chronic interstitial ne- phritis and seven possibly had it. Two had diabetes. Twenty-two still showed the same urinary condition they did in 1900. Of the ten men who in 1911 had or possibly had had nephritis, but one was under thirty years of age at the time the trouble was discovered. The mortality results among the men composing the original group of 396 are very interesting. Tn 1911 twenty-five had died since examination in 1900-1901, the deaths being distributed as follows: Albumin group, four deaths; albumin and hyaline casts group, thirteen deaths; albumin and granular casts group, eight deaths. 466 LIFE INSURANCE EXAMINATION This mortality is high, as is the usual experience of insurance companies in this class of cases, the author giving 16 as the number of deaths which would have occurred had the original 396 men been normal and sound in all particulars. Upon examining some of the causes of death in this group of 396 men, we find 3 deaths from nephritis and 8 from pulmonary tuberculosis. The 3 deaths from nephritis occurred among the men of the "granular casts" group. The occurrence of 8 deaths from tuberculosis shows a high mortality, four times more than that which would be expected from this cause in 396 normal men. This experience based as it is on so small a group of lives might be regarded with some misgivings, but to support it the author quotes statistics based on an entirely different group of lives, 1700 in num- ber showing simple albuminuria. The figures for this group show that the mortality from tuberculosis in this group was 275 per cent of that expected among normal subjects; and also show that it was much higher than in either of the groups showing hyaline casts or granular casts. Whether albuminuria is a prodromal manifestation of tuberculous infection somewhere in the body is a moot question and one not easily answered. In this particular group of cases it would appear to be so. But as the author states, the high mortality in this group leads us to consider albuminuria, in the absence of other symptoms, rather as an evidence of lowered bodily resistance which appears in later years as an increased susceptibility to tuberculous infection. This paper by Dr. Barringer is instructive and his findings in many respects surprising, as we would naturally expect that more of these cases would have developed chronic nephritis in some form, or would have succumbed to this disease. It should serve as a warn- ing to us that we must ever be on the alert to determine, if pos- sible, the cause of the albuminuria and to make a very careful study of the past habits, personal history and family history of these applicants. The Medico-Actuarial Mortality investigation shows that the class consisting of applicants having on examination albumin in the urine without casts experienced a mortality of 131 per cent. The class consisting of applicants giving a history of albumin within two years of the date of examination had a mortality of 103 per cent. These results appear to be very favorable and would incline ALBUMINURIA AND CYLINDRURIA 467 us to believe that albumin and casts in the urine are of slight significance. However, Dr. Oscar Rogers has had a thorough study made of the New York Life Insurance Company cases of this class, covering a considerable number of years and a sufficient number of cases to furnish reliable data and has shown that it is dangerous to minim- ize the significance of albumin and casts. I shall not quote all of the classes studied in this group, but have selected a few which are, I think, illustrative of the whole group. The results of this study differ to a considerable extent from those of the Medico-Actuarial Mortality Investigation as the cases studied by Dr. Rogers were those of substandard lives, accepted and rated as such. He points out that in the Medico-Actuarial Investigation, cases were not included in which albumin was a constant finding, the more select cases alone being accepted and that, therefore, if fol- lowed too closely, the experience shown by that Investigation might easily encourage us to be too lenient in our treatment of these cases. In the cases included in his study, albumin was found in two or more specimens and the cases were treated as substandard. The Compound Progressive table was used in calculating the ex- pected deaths; and since this table is based on amounts rather than on number of policies, the mortality ratios are probably too low. Class I-Albumin without Examination for Casts.-Eight hun- dred cases during the years 1896 to 1899-no other impairment included. ACTUAL DEATHS EXPECTED DEATHS C. P. TABLE RATIO 78 48.5 161% ■ It was indicated that the albumin was of distinctly greater sig- nificance above age forty than below that age. Of the deaths in this group 37 per cent were due to Bright's disease-four times the normal proportion of deaths from this disease. Class II-Albumin without Casts.-Four thousand seven hun- dred persons were insured on substandard plans between the years of 1896 and 1915 inclusive and it was to be expected that the mor- tality would be better than in Class I, as the urines were subjected to microscopic examination. In this group a mortality of about 140 per cent was experienced: 25 per cent of the deaths were due to Bright's disease or about three times normal. A study of the mor- tality of this group with relation to age shows the following: 468 LIFE INSURANCE EXAMINATION EXPECTED DEATHS AGE AT ENTRY ACTUAL DEATHS BY C. P. TABLE RATIO 15-24 inclusive 52 50.1 104% 25-39 inclusive 97 65.1 149% 40 and older 41 24.6 167% Class III-Albumin with Casts.-Six hundred fifty cases in this class: ACTUAL DEATHS EXPECTED DEATHS BY C. P. TABLE RATIO AU ages 75 30 250% Deaths from Bright's disease were 50 per cent of the total; and the cases in this class were specially selected cases, only the best being accepted. It would seem from the above that we should be in a position to consider these eases intelligently and to assess a proper rating. In a general way the following might be used as a basis for such action: Cases showing a trace to Heller's test in one specimen, if appli- cant is under age thirty and if several subsequent specimens prove negative may be accepted as standard. If over thirty, the case should be rated about 150 per cent. If not more than a distinct trace to Heller's test is found in 50 per cent of the specimens examined (not less than four examina- tions) if applicant is under age thirty the case may be rated 140 per cent; if over age thirty it should be rated from 140 per cent to 200 per cent. Where there is a history that albumin has been found in the past but the urine is now free from albumin and casts, if there is no record of treatment for one year or more past and if three specimens are clear, the case may be considered standard. A history of albumin and casts whether recent or remote is a serious matter. Albumin and casts, if found intermittently or occa- sionally, are not always significant of Bright's disease; but if found constantly (and particularly so in the older ages, i.e., above forty) a diagnosis is almost certain. When so found a severe rating must be imposed on the young applicants, while the older ones will be declined. Vigorous applicants, with no other impairments and no previous history of albumin, and rarely a cast on examination, a trace to Heller's test, followed by two negative specimens, may be regarded standard. ALBUMINURIA AND CYLINDRURIA 469 In applicants forty or over the finding of albumin is cause for postponement, for further study or for rejection. If albumin is found on more than one occasion in a very young applicant who appears to be a perfect risk in every other respect, the case is to be regarded as borderline or possibly standard. Cases showing other impairments such as high blood pressure, underweight, overweight, pyorrhea, alcoholic history or tubercu- lous family history should be selected with great care, if accepted at all, as albumin in these cases is a much more serious impairment than in applicants otherwise standard. CHAPTER XXXII GLYCOSURIA By J. Allen Patton, M.D., Medical Director and George Edward Kanouse, M.D., Assistant Medical Director, The Prudential Insurance Company of Amerim, Newark, N. J. The importance of glycosuria is so thoroughly recognized that the medical departments of all life insurance organizations exer- cise great care in connection with cases giving such a history or showing signs of such a condition. They definitely determine, if possible, whether the suspicious or positive reaction for glucose in the applicant's urine is indicative of a temporary glycosuria or of a true diabetes. Diabetes should be suspected in all applicants (a) whose urine shows an abnormal reaction with the tests for glucose, (b) giving a history of or with subjective or objective symptoms of the dis- ease, or (c) with a previous insurance sugar record. Allen states that glycosuria is the chief symptom of diabetes, a disease due to a defect in metabolism, and that all clinical glycosurias should be considered as diabetes until demonstrated to be something else, and this holds equally well with all life insurance cases. Glycosuria is the broader term and means the presence of glucose in the urine for any reason whatsoever. The difficulty, in the average case of the life insurance applicant showing glycosuria, is to obtain sufficient history, observations, or other data, and enough urine specimens to enable us to decide for or against the existence of true diabetes. The training of our ex- aminers, defining the extent and method of our inquiries of the applicant, determining the character of dietetic or other tests for the applicant to take, and finally deciding upon the number of specimens and the laboratory and analytical elimination of non- diabetic conditions of the body or constituents of the urine, are features that demand our serious consideration. 470 GLYCOSURIA 471 The relationship existing between the percentage of blood sugar and urine sugar and the factor 'which the renal permeability or renal threshold plays in the sugar control in the body, is an inter- esting and very important study. Glucose excretion thresho'd means the level of glucose content of the blood above which the sur- plus is thrown off by the kidneys. A high threshold with great variability indicates diabetes controlled by diet. A moderately high but nonfluctuating threshold is of doubtful prognosis. Cases differ in the percentage of glucose excreted in the urine in the pres- ence of a given hyperglycemia, as the kidney itself plays an im- portant part in the modification of the percentage of glucose ex- creted. It has been apparently proved that while normally the kidney is not permeable to blood sugar of less than 0.07 to 0.15 per cent, yet the threshold may be raised or lowered in abnormal con- ditions. A higher threshold may result in hyperglycemia without glycosuria, or a lower threshold with normal blood sugar may show glycosuria, or a normal threshold may exist with or without gly- cosuria, or even a hypoglycemia may be present with a positive reaction for glucose in the urine. Thus we can readily see that diabetes and glycosuria are not synonymous terms or conditions and that, as many clinical cases will be difficult to diagnose correctly, the usual catch-as-catch- can" urine of the life insurance applicant with glycosuria will pre- sent many questionable features for our determination. Hyperglycemia without glycosuria may occur where the thresh- old has been raised as in associated nephritis, but this is not likely until the nephritis has advanced far enough to disturb the general metabolism of the body or in cardiovascular cases with high Wood pressure and little signs of renal trouble. The blood sugar curve after the administration of 100 gm. of glu- cose in normal persons reaches its height in a half hour and its base line in one to two hours, with the amount then always below 0.15 per cent. The highest figures, after taking 100 gm. of glucose, were found in diabetes in from one to two hours, and the fasting level, or base line, was not reached before three or four hours with the level always above 2 per cent. The best t'me to make the blood sugar determination is when the maximum concentration occurs or from one-half to two hours after the test meal or glucose admin- 472 LIFE INSURANCE EXAMINATION istration. The blood should be tested for its normal or fasting blood sugar value before the glucose is given. Failure of nitrogen metabolism often precedes, by some time, the rise in blood sugar and in this condition a serious prognosis is indicated. The threshold apparently rises with the duration of the disease, hence young diabetics usually have low or normal thresholds, mild cases are generally rather stationary, while progressive cases show rising thresholds. If this rise occurs in the face of careful dietary treatment, it is of serious omen. A high threshold in mild diabetes under proper diet is usually accompanied by arterial hyperten- sion. A high threshold may mean a physiologic attempt to con- serve food, as in severe diabetes where extremely low diets are necessary to maintain life. Maintenance as near the normal level as is possible, even with restricted diets, gives the best results, and the treatment should be controlled by blood sugar rather than by urinary tests. Hypoglycemia with glycosuria may occur and variations in the diet affect these cases very little. Since this condition is abnormal, it is not wise for the case to continue a careless diet or to refrain from occasional tests of the blood and urine sugar. Renal glyco- suria requires great care, as we are uncertain whether or not the mechanism for sugar metabolism is affected. A maintenance diet is a mixed diet as near the normal as can be tolerated by the pa- tient without glycosuria, and is selected after he has had his carbo- hydrate tolerance determined. Hyperglycemia with glycosuria points toward true diabetes. Allen believes that all diabetes is of pancreatic origin and Ruediger presupposes that diabetes depends upon a loss of balance between various ductless glands. Pituitary hypersecretion lowers the in- dividual's tolerance for sugars, as does administration of the thy- roid extract. Some observers think the sympathetic nervous sys- tem has a great part in this loss of balance by increasing the secretion of the glands which diminish carbohydrate tolerance and by inhibiting the pancreas whose normal action increases this tolerance. Thus the study of the endocrine glands and their func- tions has materially affected the glycosuria question. Administration of the pituitary substance increases the uric acid of the blood, and this is probably due to a decreased kidney per- GLYCOSURIA 473 meability. Irwin believes that the internal secretion of the pan- creas reaching the portal blood synthetizes the glucose into glyco- gen and any failure in this causes pancreatic diabetes. Thus a diabetic is one who fails to synthetize the absorbed glucose into glycogen at a sufficiently rapid rate to prevent a hyperglycemia. W. I jangdon Brown believes the sympathetics mobilize the sugar into the blood by means of the endocrine glands for the purposes of defence, while the parasympathetic stores it in the tissues as a reserve. While ordinary diabetes shows no other signs of endo- crine disease, the endocrine glycosuria does. Those of organic origin show structural changes in the glands, but those of sympa- thetic origin do not. Diabetes is not merely a disturbance of car- bohydrate metabolism, but as 70 per cent of the ordinary diet is carbohydrates, any slight disturbance of the metabolism may cause a glycosuria. Rather than permit the food to escape, the body converts it into fat, hence diabetes is closely and frequently asso- ciated with obesity. The advance of the disease interferes with fat metabolism, diacetic acid appears and all metabolism later be- comes involved. Diabetes is a sign of exaggerated metabolism, affected through the sympathetic and endocrine glands and first asserts itself in relation to the most abundant food (carbohydrates), but as it ad- vances, abnormal metabolism of all foods results. Diabetes has two essential disturbances of carbohydrate metabolism: an over- production of sugar and the abolition of the tissue ability to use it. The disease is a specific disorder of nutrition and diminishes the ability of the body cells to resist infections, repair injury or to withstand ordinary wear and tear. It is difficult to determine what constitutes a normal amount of sugar in the urine, for it is generally agreed that all urines con- tain a small percentage of sugar. Recent improved quantitative methods have shown that this amount is dependent upon the nature and quantity of the food. Cammidge, through a study of 700 cases, has shown there is no constant blood sugar level for the appearance of sugar in the urine in amounts recognizable by ordinary tests. Patients with high blood sugar may show little or no sugar in the urine, while normal or low blood sugar may show frank glycosuria. We must, therefore, check the blood and urine sugar against each other and even small amounts of urine sugar, especially in persons 474 LIFE INSURANCE EXAMINATION of middle age, should not be considered of little significance until the carbohydrate tolerance has been estimated by blood sugar tests. Hyperglycemia, with urine sugar in too small amounts to be detectable by the ordinary tests, may explain recurrent attacks of boils, carbuncles, sciatica, neuritis, etc., that do not respond to the ordinary methods of treatment. Glycosuria with normal or subnormal blood sugar may show with a starch test meal no hyperglycemia, with a subsequent de- layed return to the previous fasting level, or the blood sugar curve may follow a normal course. The dextrose test meal, causing more or less hyperglycemia, confirms the presence of a latent diabetic tendency, but the normal blood sugar curve cases are of the renal diabetes type. Many latent cases are apparently hepatic in origin and avoidance of sugar foods enables the individual to use a bal- anced starchy, protein and fat diet. An excess of sugar in the blood or an abnormal blood sugar curve, following test meals, may be due to some other disease than diabetes associated with hyperglycemia. Nephritis in its later stages usually has high blood sugar and if uremia is imminent, the blood indicates complete metabolic failure with the end-products of nitrogen metabolism correspondingly increased. Cardiovascu- lar diseases with high blood pressure may have some excess of blood sugar, as also may carcinoma cases, and this is possibly due to a faulty functioning of the endocrine glands. Cammidge also believes that heredity may have a great deal to do with this abnormal permeability of the kidneys for sugar. Hei- berg found in 100 nondiabetic family histories only 7 with dia- betic relatives, while in 100 diabetics there were 18 diabetic rela- tives. Joslin found in 500 consecutive histories of nondiabetics only 25 relatives with diabetes. Williams found that 100 cases of diabetes showed 24 without and 76 with family histories of diabetes, - arteriosclerosis, cancer or obesity. These 76 had 85 diabetic, 72 arteriosclerotic, 25 obese, 32 cancerous and 16 nervous or mental relatives. Forty-eight of these cases had 85 direct or collateral diabetic relatives and the 76 cases showed 6 fathers and paternal grandparents and 19 mothers and maternal grandparents; thus indicating a prepon- derance on the maternal side. Forty-one cases of the diabetic group had 72 arteriosclerotic relatives, and this condition occurred twice GLYCOSURIA 475 as often on the paternal as the maternal side. The family history frequently showed paternal arteriosclerosis, with maternal obesity and diabetes. Apparently a favorable soil is inherited from parents afflicted with arteriosclerosis or diabetes, or both combined. This favorable prediabetic condition may be superinduced by alcoholism, overeating, undue nerve strain, or certain chemical or metabolic intoxications. There is a prevalent belief that the number of clinical and life insurance cases showing glycosuria has proportionately increased in the last few years, hence definite methods of determining whether a true or false diabetes exists are of great importance. The number of our unfavorable actions on urinary cases for the past few years, together with the number and percentage of the glycosqric cases due to the urinary findings and the same for the male and female cases, are reproduced in the following table. This table by no means includes all the cases where we found abnormal urinary conditions, but contains only those that we were unable to clear to our satisfaction for insurance. Rejections for Urinary Findings No. TOTAL Glycosuric No. MALE Glycosuric No. FEMALE Glycosuric No. % No. % No. % 1916 6,316 705 11.16 5,769 643 11.15 547 62 11.33 1917 6,683 640 9.58 6,142 592 9.64 541 48 8.87 1918 7,318 1,139 15.56 6,569 1,057 16.09 749 82 10.95 1919 9,664 1,231 12.74 8,418 1,090 12.95 1,246 141 11.31 Judging from this table, there was a marked increase in the year 1918 and our participation in the World War might be ascribed as the most likely reason because of its disturbance of our usual meth- ods of living, especially along dietetic lines and in nervous strains, but we believe that decreased results for 1919 were in part due to improved methods in the field and in our home office laboratory technic. Williams has reported from the Rochester, N. Y., figures that per 100,000 population diabetes increased from 2.9 in 1884 to 7.4 in 1894; to 16.2 in 1904 and to 17.1 in 1914. A review of the data from the registration area of the United States shows a steady rise in the deaths from diabetes in the quin- quennial periods since 1900 for both sexes and in all age groups. 476 LIFE INSURANCE EXAMINATION All Ages No. Males 15 - 24 No. 25 - 34 No. 1900-1904 80,615,422 8,672 10.8 14,813,264 570 3.8 14,594,411 734 5.0 1905-1909 110,392,589 13,720 12.4 20,744,148 910 4.4 19,762,293 959 4.9 1910-1914 155,789,685 21,821 14.0 29,758,695 1,435 4.8 27,654,370 1,532 5.5 Total 346,797,696 44,213 12.7 65,316,107 2,915 4.5 62,011,074 3,225 5.2 35 - 44 45 - 54 55 - 64 • 1900-1904 11,661,561 856 7.3 7,717,760 1,369 17.7 4,659,751 1,906 40.9 1905-1909 15,78'4,916 1,245 1,894 7.9 3 0,918,260 2,238 20.5 6,48'5,755 3,209 49.5 1910-1914 22,082,077 8.6 15,776,516 3,507 22.2 9,263,101 5,206 56.2 Total 49,528,554 3,995 8.1 34,412,536 7,114 20.7 20,408,607 10,321 50.6 Females All Ages 15-24 55 - 64 1900-1904 79,629,838 106,362,8'56 8,788 11.0 15,729,548 454 2.9 14,103,308 577 4.1 1905-1909 15,109 14.2 21,038,797 684 3.3 18,362,378 793 4.3 1910-1914 147,045,332 24,395 16.6 29,115,270 1,125 3.9 24,894,447 1,245 5.0 Total 333,038,026 48,292 14.5 65,883,615 2,263 3.4 57,360,133 2,615 4.6 35 -44 45 - 54 55 - 65 1900-1904 10,668,777 692 6.5 7,223,329 1,360 18.8 4,668,149 2,318 49.7 1905-1909 14,316,725 1,070 7.5 9,920,850 2,348 23.7 6,213,192 4,141 66.6 1910-1914 19,861,369 1,616 8.1 13,997,217 3,733 26.7 8,566,790 6,465 75.5 Total 44,846,871 3,378 7.5 31,141,396 7,441 23.9 19,448,131 12,924 66.5 The ordinary and diabetic mortality of The Prudential by quinquennial periods from 1900 to 1914 shows a slight in- crease in the diabetic percentage of the total. Mortality from Diabetes Males and Females Registration Area Rated per 100,000 Population GLYCOSURIA 477 The Ordinary Mortality of The Prudential Since 1900 is Shown in the Pollowing Table YEARS ALL CAUSES INCLUSIVE MALES DIABETES PER CENT FEMALES ALL CAUSES DIABETES PER CENT 1900-1904 5,508 46 0.83 1,130 10 0.88 1905-1910 11,657 134 1.15 2,748 30 1.09 1911-1914 19,095 280 1.46 4,547 8'7 1.91 The Prudential 's ordinary experience and diabetic deaths by duration and by age groups from 1886 to 1914 is recorded in the two follow ing tables 1886 - 1914 MALES FEMALES NUMBER PER CENT 15 YRS. NUMBER PER CENT 15 YRS. & OVER & OVER DURATION Under 1 yr. 21 4.1 11.1 12 9.4 14.0 1-4 yrs. 193 38.0 38.9 39 30.5 43.3 5-9 yrs. 175 34.5 30.7 51 39.8' 29.5 10-14 yrs. 90 17.7 14.8 18 14.1 10.8 15 yrs. & Over 29 5.7 4.5 8 6.2 2.4 Total 508 100.0 100.0 128 100.0 100.0 1886 - 1914 AGE GROUPS MALES FEMALES AGE AT ALL CAUSES DIABETES PER ALL CAUSES DIABETES ; per DEATH YRS. CENT CENT 15-24 2,943 27 0.91 899 5 0.55 25-34 8,567 99 1.15 2,548 25 0.98 35-44 10,216 114 1.11 2,143 23 1.07 45-54 8,479 126 1.48 1,575 25 1.58 55-64 5,612 80 1.42 1,081 36 3.33 65 & Over 2,034 27 1.32 370 13 2.70 15 & Over 37,851 473 1.22 8,616 127 1.47 Therapeutics endeavors to prolong life and relieve symptoms, but therapy against causative factors is almost unknown in the treatment of chronic diseases. The majority of cases of chronic diseases die of acute superimposed infections or complications. Acquire a chronic disease and take care of yourself has been said to be a method of achieving old age. The diabetic can neither eat nor compete with his fellow man, for his narrowed vital activities and functions wall him off from many human privileges. Infections are the chief dangers in that they are responsible for 78 per cent of the deaths precipitated by coma; surgical infections, tonsillitis, tuberculosis, pneumonia, etc., 478 LIFE INSURANCE EXAMINATION are samples of these dangerous complications. Once the infection has started, effective means of combating it are difficult to put into use, as the nutrition and metabolism are so disturbed and the nor- mal vigor or resistance is materially lowered. The average dia- betic is more comfortable and has a greater sense of well-being if the urine is sugar-free, but this must not be obtained at the expense of nutrition. Sugar-free urine does not always indicate a body economy with its diabetic tendency under control. This is more definitely determined by using the percentage of the blood sugar as the criterion of the body's ability to handle sugars and a con- stant amount for this of over 0.15-0.16 per cent is grave, no matter what the urine may show. Young adults under thirty-five years of age, who have come un- der observation within one to two years after recognition of the disease, have secured sugar-free urine, although some of them have shown severe acidosis and they have secured an increased tolerance for carbohydrates by following advice. Young adults with advanced cases have not shown good results. Though the glycosuria may be easily controlled, the blood sugar has not been, and strong restricted conditions are necessary to hold the latter at or near the normal. Most of these advanced cases adhering to a diet have died from complications or infections and those not rigidly dieting have died from coma. Both groups have shown an average of two years of life after beginning treatment. Thus advanced cases in young persons, even though rigidly con- trolled, give discouraging results; but cases beginning treatment early and following it carefully show favorable results. Sugar- free urine, blood sugar as near normal as possible, and no acidosis, are necessary; and relaxation by patient or physician, no matter how normal these factors may have been maintained, is dangerous. Acidosis indicates the dangerous condition and, once the tendency is established, it is prone to return. Acidosis absent does not re- quire fast days. Fasting is best conducted in a hospital where frequent tests can be made of the blood, urine and alveolar air. Diabetic treatment aims for absence of glycosuria, and carbo- hydrate withdrawal aids in this, but may precipitate acidosis, as also may prolonged fasting. Fat excess predisposes to acidosis and its use in the diet requires careful supervision. Acidosis means a decreased alkaline reserve in the blood, rather than an increased GLYCOSURIA 479 acidity. The blood alkalinity is maintained chiefly by its con- tained bicarbonates, and this can be indirectly estimated in terms of the carbon dioxide tension of the alveolar air or directly by the carbon dioxide combination with the blood plasma. Acidosis may be produced by an overproduction of acid bodies in metabolism or by their lessened excretion. The fasting treatment in diabetes tends to free the patient from glycosuria and acidosis. Acidosis is not an actual reaction, but an accumulation of acid bodies suffi- cient to neutralize the alkaline bodies in the blood and tissues and reduce the alkaline reserve below the normal. Urinary tests for acidosis are often misleading and may merely indicate the excre- tion and not the accumulation of acid bodies. Blood bicarbonate analysis, measuring the accumulation of fixed acids, gives a true index of the degree of acidosis present. All cases may be treated safely by the fasting method if the tests for acidosis, glycosuria and blood sugar are carried out. A. P. Matthews has recently reported a rapid laboratory method of differentiating glucose and lactose and this is a very necessary procedure. The essential basis of his method is fermenting the urine with a large amount of yeast. The glucose rapidly ferments away and its reducing power is lost, while that of the lactose is unaffected and can be tested in the filtrate. This is sufficiently accurate for clinical purposes and the test can be completed in less than an hour, giving an answer as to whether lactose or glucose is present, and, if a mixture of both is present, how much of each. Yeast ferments glucose or levulose, but not lactose, and the first being of similar significance, the method assumes considerable im- portance in urinalysis. Our laboratory experience has brought about the following method that enables us to differentiate the glucose from the others. The simple and rapid Kowarsky modification of the phenylhydrazin test furnishes a sure method of differentiating the sugars most likely to be found in urine in clinical or life insurance eases, with the excep- tion of fructose, and the strong left rotation of fructose offers a rapid distinction between it and glucose. If either alone is present, the polariscope will tell which and also the percentage. If both are present in the same specimen, the relative frequency of the crystals affords a sufficiently accurate estimation for clinical purposes. 480 LIFE INSURANCE EXAMINATION Our experience indicates most of such life insurance cases are due to a temporary digestive upset and our test results are ob- tained in 15 to 20 minutes. The glucosazone crystals are feathery and the lactosazones are burr-like in appearance. Diabetes generally means persistent glycosuria throughout the patient's life, with the fatality sooner or later. Polyuria, thirst, loss of weight, failing physical powers, local lesions, such as boils, carbuncles, cataracts, gangrene, etc., are some of the usual accom- panying conditions. Many glycosuria cases apparently do recover, hence the above conception is incorrect as a universal application. Failure to dispose of the glucose normally, with resulting accumu- lation in the blood and excretion in the urine, throws all varieties of glycosuria into the diabetic group. Resumption of the ordinary diet without return of glycosuria proves that the condition was temporary. Naunyn says that any man will excrete sugar if he takes a suffi- ciently large dose of glucose on an empty stomach, but only a diabetic will show glycosuria after any dose of starch it is possi- ble to administer. Reduction of a copper test solution alone is not enough to prove the presence of glucose, as there are many bodies that will do this to a greater or less extent. Renal diabetes is glycosuria without hyperglycemia. The daily quantity of glucose is small, the blood sugar is normal or below and is not increased by glucose by the mouth, hence not by diet. There is no serious disturbance of carbohydrate metabolism and this type is thought to be due to the kidneys having lost the power to retain in the blood the normal amount of blood sugar. Hutchinson (London) has stated that 20 per cent of the cases in America that are accidentally discovered in life insurance exam- inations, develop true diabetes in five years. Turner (London) has found that many life insurance cases with a single or intermittent glycosuria finding may feel all right and be active in business. Their sugar reaction was due to a prior febrile attack, anxiety or worry, etc. The ease may have a gouty personal or family history, or may give a record of occasional diet- ary indiscretions, or finally may have a family history of diabetes. The condition is most prone to appear in the forties, and rarely GLYCOSURIA 481 after fifty. Nondiabetic glycosurias are insurable, especially if they are uncomplicated by personal habits, obesity, cardiac dis- eases, gall-stones, family history, etc., but usually not at standard rates. Cammidge states that the diet must be regulated quantita- tively as well as qualitatively and suited to the metabolic needs and capacity of the patient as soon as possible, and further that there must be a perseverance in individual treatment. The Medico-Actuarial results from the glycosuria cases reported of the applicants where examination showed sugar in the urine or where there was a recorded glycosuria within ten years, are as follows: TIME GLYCOSURIA REPORTED ACTUAL TO EXPECTED MORTALITY Found on examination 95% Once within 2 years of application 104% Once between 2 and 5 years of application 108'% Once between 5 and 10 years of application 102% There was a higher relative mortality at the older than the younger ages. Though the above results are relatively favorable, yet the occurrence of sugar in the urine on a single occasion within ten years is not unimportant. An experience that has been reported with underaverage lives shows that where glycosuria was found upon examination in more than one specimen the mortality was fuffy 200 per cent of the normal. Where sugar is found only once in a case in a series of tests extending over a considerable length of time, and the applicant is otherwise first-e'ass, it may be dis- regarded. The death rate in this series from diabetes was fully s'x times the normal and the otherwise satisfactory mortality shows the effect of rigid selection. The Medico-Actuarial experience for weight groups with glyco- suria or potential diabetes, is shown in the following table, which also indicates the age at entry in three groups. Obesity, or over- weight, shows materially higher than the standard or the under- weights. Based upon some reports of F. M. Allen, the anatomic and physio- logic results have demonstrated, on the theory of sparing the weak- ened pancreatic function, that diabetes is checked by fasting and restriction of the total diet, and the value of limiting the dietary burden has become an established fact. There is a reduction in 482 LIFE INSURANCE EXAMINATION Build and Diabetes BUILD NUMBER DIABETES PERCENTAGE RATIO PER 1000 EXPOSED Ages 15 to 29 at entry Overweight 50 lbs. or more 361 10 2.8 1.5 Standard 4,566 57 1.2 0.6 Underweight 25 lbs. or more 2,814 32 1.1 0.7 Ages 30 to 44 at entry Overweight 50 lbs. or more 2,594 139 5.4 5.9 Standard 7,886 137 1.7 1.2 Underweight 25 lbs. or more 7,138 51 0.7 0.5 Ages 45 and over at entry Overweight 50 lbs. or more 1,773 93 5.3 13,6 Standard 5,340 81 1.5 2.8 Underweight 25 lbs. pr more 2,959 11 0.4 0.6 body weight and metabolism. The true tolerance of the diabetic rises when the weight is reduced by fasting, but in mild cases the sudden administration of carbohydrates (test meals) or the protein- fat diet after fasting often causes a heavy transitory glycosuria. Latent diabetes is likely to show an appreciable excretion of glu- cose after small doses of sugar and this is markedly increased with the size of the sugar dose. So long as the diabetes is kept under control, there is evidently enough internal pancreatic secretion to use the greater part of a single dose, but a repetition of the sugar dose or the presence of any other cause of glycosuria increases the sugar loss. The overtaxing of the normal pancreatic tolerance is conceivable, as when an individual eats a whole box of candy, and this is to be considered in arranging for the sugar content of a test meal or a test depending upon sugar administration. A lowered pancreatic tolerance does not necessarily mean an established diabetes, but that there is present an abnormal tendency to hyperglycemia or glycosuria from the carbohydrates ingested. Diabetes has been identified clinically by continuous or pro- longed glycosuria and hyperglycemia. The mildest cases may re- quire a maximum intake of carbohydrate for this continuance. Experiments on dogs have shown that about .87 to .9 of the pan- creas must be removed or otherwise disabled before the test use of carbohydrates will produce continuance of the diabetic type of blood sugar or glycosuria. The results of single doses of sugar are therefore not infallible, but a continuance of a marked use of sugar GLYCOSURIA 483 even in mild diabetics shows a striking tendency to higher and longer hyperglycemia and glycosuria. There may be occasions when the full endocrine functions of the pancreas are necessary for normal assimilation, and then even a slight increased use of carbohydrates may produce glycosuria. An excess over normal ingestion may overtax the normal pancreatic function at any time. A diabetes uncontrolled by fasting is common in experimental animals, but is rare in human beings. The possible explanation in man is the existence of a functional defect which interferes with the internal secretions of the pancreas, making them susceptible to functional overstimulation. Experiments, however, do indicate that any positive means of augmenting the endocrine pancreatic function would give therapeutic results far surpassing those of the negative plan of sparing the function by diet. Benedict, hav- ing demonstrated sugar in normal urines, has suggested the term glycouresis to indicate the increase of sugar to the abnormal amounts that are detectable by the ordinary test, instead of the term glycosuria, which should be applied to the presence of sugar in the urine. Quantitative and qualitative tests made by Myers and others show that there is a gradual increase in the actual amount of sugar excreted after the ingestion of food, also that a normal individual excretes about 1 gm. of reducing sugar in 24 hours. These observations have also demonstrated that morning specimens passed before breakfast are often reported negative even in confirmed diabetics and that it is necessary to have specimens passed from one to four (preferably two) hours after a meal or during the tide of active digestion. The results of the usual qualitative tests on hourly specimens of urine show that dependence upon such tests in specimens of urine taken at random, as in life insurance, may be quite misleading as regards the carbohydrate tolerance of the case. Diabetics will do better on low calorie diets and on prevention of obesity. Careful blood estimations, the study of other kidney functions and the re- moval of al] possible foci of infection are necessary in treatment and prevention of complications. Thorough, regular routine urine examinations of single and twenty-four hour urines are essential. Carbohydrates should not be withdrawn absolutely and the muscu- lature, especially the heart, should be supported in the treatment 484 LIFE INSURANCE EXAMINATION of a diabetic. Presence of less than 2 per cent of sugar calls for less strenuous treatment. The amount of work done should regu- late the amount of the nutriments taken, as the ingestion of too much food leads to toxins in the blood. A few days' total absti- nence from food, with the drinking of water ad lib., will stop the elimination of sugar in practically every case. Drug treatment is unsatisfactory except in persons after middle life, but must be accompanied by a rigid diet. Drugs are not curative, but may alle- viate certain functional symptoms. The more severe the diabetes and the younger the patient, the more rigorously should hypergly- cemia and all other symptoms be controlled from the outset, though this often means a considerable reduction of weight and strength. Slight hyperglycemia and acetone reactions may be permissible in some elderly patients to avoid undue hardships, but diabetes after forty is by no means benign and, if neglected, frequently requires stringent measures for its control. Thorough cooperation of the patient with the physician is necessary. Glycosuria is spontaneous where it occurs on an ordinary mixed diet, but if it continues for several weeks, it is most likely diabetic. Regulation test meals can be used in clinical patients, but must be modified for life insurance cases. Assimilation tests repeated at several months' intervals are necessary after glycosuria has dis- appeared. Barniger and Roper, by assimilation tests on a series of patients five years after spontaneous glycosuria had been dis- covered, found 20 per cent had become definitely diabetic, 15 per cent were probably so, 10 per cent were more doubtful and 55 per cent were undoubtedly not diabetic. These results tend to show that all spontaneous cases are not latent diabetics. The former belief that a reduction of the Fehling or other copper test solution was a sure sign of diabetes, is thus disproved. Allen's results indi- cate that exercise aids sugar combustion and diminishes glycosuria in mild diabetes, but is ineffective or even harmful in severe dia- betes. The blood sugar of normal persons and of diabetics is in- creased, but at the same time improved assimilation may decrease glycosuria, may fail to suppress hyperglycemia and glycosuria, but properly conducted will undoubtedly aid in restraining them. The improved assimilation applies to the glucose from protein sources, as well as from carbohydrates. The effect is not lost with long usage, but becomes less as the diabetes becomes more severe, and GLYCOSURIA 485 in advanced stages it is unable to modify hyperglycemia or glyco- suria. Clinical treatment should place dependence upon diet for the control of diabetes and limit exercise to the requirements of comfort and hygiene. Exercise properly regulated and accompanied by dietary care in a forty-two year old professional man with mild diabetes, who had kept his urine practically sugar-free for four years, but whose carbohydrate tolerance decreased from 360 to 150 gm. of white bread in 24 hours and a year later to 120 gm., increased this in a year and a half to 195 gm. or to about one-half of what it had been six years earlier. The Allen starvation method of rendering a diabetic sugar-free is not only safe, but is remarkably expeditious in many cases. It has become quite generally used in hospitals and private practice. The patient should fast until glycosuria has disappeared, using al- cohol and alkalies if there is danger of coma. Feeding is then cautiously begun to ascertain the patient's carbohydrate tolerance. Regaining the lost weight is all right if the glycosuria does not return and the metabolism is not overtaxed. Joslin believes that life can be prolonged, but doubts that real cures are effected in true diabetics. Tracing 927 of 945 cases seen in private practice through a period of twenty-one years he found 425, or 45.8 per cent, had died. His tabulated results are as follows: AGE Al' ONSET FATAL CASES AVERAGE DURA- LIVING CASES AVERAGE DURA- YEARS NUMBER TION YEARS NUMBER TION YEARS 0 to 10 2.06 9 4.44 11 to 20 48 2.79 27 2.70 21 to 30 40 3.30 50 4.90 31 to 40 53 4.43 71 6.12 41 to 50 71 6.08 146 7.04 51 to 60 97 6.63 120 6.29 61 to 70 52 6.00 55 5.38 71 to 80 14 3.71 11 4.45 81 to 90 0 1 0.33 Repeated examinations of urine showing no sugar in persons who have not altered their diet, if they are otherwise satisfactory, indi- cate insurability at regular rates. Test meals or assimilation tests of some type are, however, the best protection for life insurance companies. Postprandial hyperglycemia, lasting longer than two 486 LIFE INSURANCE EXAMINATION hours, is abnormal and is probably the first sign of deranged carbo- hydrate metabolism, hence of diabetes. We should ascertain whether the applicant has ever followed any special diet, either upon the advice of a physician or layman, or of his own volition; whether he has ever fasted for 12 hours or longer because he felt that he would be the better for it; how many meals he eats daily; whether anything is eaten between meals; what time of the day the principal meal is taken, the types and amounts of solids and liquids consumed; and whether any sugar substitute has ever been used. Careful inquiry should be made about the hepatic, pancreatic and gastrointestinal history of the applicant, as well as for any symp- toms of nervous or neurotic trouble, or abnormal effects of the adrenal or pituitary glands upon metabolism. The Allen starvation treatment must receive particular attention in our investigations of dietary or other methods of treatment. We know that thorough treatment, begun in the early years of dia- betes and conscientiously continued, will usually maintain a sugar- free condition; but if this is obtained and retained at the expense of nutrition, there is a lack of resistance and the treatment injures the case. The presence of acetone and other acidosis products in the urine demands careful consideration and their significance should, if possible, be checked by examination of the blood and expired air. The best time to obtain urine specimens in glycosuria cases is one to two hours after the principal meal, and if this sample proves negative, then examine an evening and a morning specimen. The assimilation test-meal may be used, as sugar elimination is pathological with 150 to 200 grams of glucose, and the urine speci- men then obtained in one to two hours. The tests for glucose must be properly applied to obtain dependable results, and this is often difficult to have done in the field. The use of Fehling's, Haines' or Benedict's copper solutions, Nylander's reagent or the phenyl- hydrazin test should be sufficient, and the fermentation test or the polariscope are valuable in doubtful cases. We must remember that lactose, maltose, pentose and glycuronic acid also reduce copper and bismuth solutions, and therefore eliminate them. Tndicanuria may be frequently noted and it is of importance in estimating the gastro- intestinal elements of the case. Biacetic acid is satisfactorily de- GLYCOSURIA 487 termined by Gerhardt's method and the antipyretic drugs that may be present can be eliminated by boiling, which causes the rapid disappearance of the diacetic acid Bordeaux-red color. Distillation of the urine makes more delicate the Gerhardt's Test, also the Lugol's Test for acetone. Folin's method is the best for total nitrogen and ammonia. The ammonia is the measure of the body's reaction to counteract the acidosis, while total nitrogen shows the amount of acids excreted, being an index of the total proteins disintegrated. Blood sugar determinations are valuable in clinical work, but their feasibility has yet to be determined in life insurance cases. The Benedict method (based upon the fact that picric acid and glucose in the presence of an alkali on heating give a color reaction proportionate to the amount of glucose present) is standard, but requires 2 c.c. blood as a minimum. The Kowarsky and Epstein Test, which can be made with a few drops of blood, is much more readily applicable in insurance work. They use the Sahli-Gower hemoglobin colorimeter and the test can be completed in seven to ten minutes. The carbon dioxide in the blood plasma is easily determined, but requires too much blood. The hydrogen-ion concentration of the blood can be determined with 1 to 3 c.c. of blood, but its value has not yet been thoroughly demonstrated. The alveolar air carbon dioxide determination is of great impor- tance in the treatment and prognosis of diabetes, as it furnishes a ready means of estimating the severity of the acidosis'. The alveolar air carbon dioxide changes inversely as the amounts of the unusual acids in the blood. Being a measure of acidosis, it is of no value unless the urine shows acetone by the chemical tests. Normally, the carbon dioxide value is 5 to 6 per cent and cases with 2 per cent may show coma in twenty-four hours, while those with 3 to 4 per cent may go for two or three days. Sudden drop in alveolar air carbon dioxide is unfavorable and alarming. Alveolar air carbon dioxide measures the acidosis of the blood at the time of observation, whereas increased excretion of sub- stances in the urine may mean that alone and not an increased production, as production and urinary excretion do not necessarily run parallel. 488 LIFE INSURANCE EXAMINATION Acetonuria without glycosuria is not sufficient to diagnose aci- dosis as shown by many cases of acid intestinal fermentation. Addenda With the discovery of insulin by Dr. F. G. Banting, the views held on the subject of diabetes at the time this article was pre- pared have been somewhat altered. The suspicion that the pan- creas is the source of the unknown substance which figures so prominently in metabolism has been enhanced by its introduction, and while it is not known that insulin has all the properties of this substance, its effects on metabolism arc very similar. It is not the contention of the discoverer of this remedy that it is a curative for diabetes, but that if used in conjunction with the dietetic treatment of the disease it permits of the use of suf- ficient carbohydrate, protein and fat to build up and maintain the patient's weight and strength and to make of him a useful citizen. The application of the value of insulin in the selection of insur- ance risks suffering from diabetes cannot, on account of the short time that it has been in use, be considered, but undoubtedly the future will furnish information that will be the subject of investi- gation by the statistician and the deliberation of the Medical Director. Note bij Editor.-In a personal letter from Dr. F. G. Banting to the editor January 14, 1924, he states, "That since there is no doubt that insulin prolongs the lives of diabetics, and in milder cases seems to increase the tolerance to carbohydrate, that it will improve the risk and make it safe to insure, especially the milder cases of glycosuria." As new uses for insulin have recently been published notably in the vomiting of pregnancy, it may be that we have not reached the limit of its benefit. The first statistics in regard to mortality decrease after the use of insulin are shown in the bulletin of the Metropolitan Life Insur- ance Company, February, 1924. The decline in the death rate in 1923 was 6.4 per cent from the rate of 1922, but as stated, "It fol- lows a period of three years during which time deaths from dia- betes had been increasing continuously and at a considerable rate. Between 1919 and 1922 the rate rose 28 per cent. These figures are from the Company's Industrial Department. Among the ordinary policyholders 7.8 death claims were paid in 1923 per 100,000 pol- GLYCOSURIA 489 icies in force as compared with 10.5 claims in 1922, and in the Intermediate Department 9.6 claims were paid as compared with 10.2 in 1922." The figures for the year 1924 so far are most en- couraging. "The January death rate from diabetes for Industrial policyholders was 17.2 per 100,000 as compared with 2'0.3 for Jan- uary, 1923." Further information in regard to the mortality of diabetic pa- tients treated with or without insulin will be found in "The Treat- ment of Diabetes Mellitus" by Elliott B. Joslin, M.D., 3rd edition, 1923. CHAPTER XXXIII LABORATORY PROCEDURES By John H. Warvel, M.D., Indianapolis, Ind. Pathologist, Methodist Episcopal Hospital. It has only been in the last few years that laboratory methods of any kind have been used to assist in determining the health status of an individual desiring to take out life insurance. First, the routine chemical urinalysis was adopted. Second, a careful micro- scopic analysis was deemed necessary. Now it appears that several others will soon be adopted as routine measures, and a few others will be used in the borderline class of cases. 1. The Wassermann.-Syphilis in its many forms of presentation is still quite frequently overlooked by the medical examiner. It often does not produce one single physical sign. The applicant may give a negative history of a luetic infection, first for fear of refusal of his application for insurance; and still others may have syphilis and be in ignorance of the fact. Would not a routine Wassermann be of value in these examinations? It cer- tainly would at least in those applying for large amounts of insur- ance. Persons while taking active treatment for cerebrospinal syphilis have been able to obtain life insurance. A blood Wasser- mann would have revealed a four-plus reaction. The little expense of such an examination, to the company granting this insurance, would have been money well spent. A recent case in the State of Indiana proves the value of this serologic examination. A man who carried two hundred and fifty thousand dollars of life insurance, was found to have a positive spinal Wassermann. This discovery was not made until three weeks before his death. The insurance company refused to pay the claim. Their contention was that the man, at the time of his first examination, made a false statement when he denied a luetic infection. While the case was in court, great amounts of money were spent in the employment of physicians and serologists. The case ended with the insurance company's paying the claims. A Was- 490 LABORATORY PROCEDURES 491 sermann test at the time of the applicant's examination, would possibly have caused a refusal of this individual. A routine Wassermann could be made in the laboratories of the insurance companies in exactly the same manner as the urinalyses are made at the present time. The medical examiner would have no trouble in collecting the specimens and mailing them to the main laboratories, just as he does the urine specimens at present. If the test is not made a routine measure, it could be used in those cases in which the applicant is applying for large amounts of insur- ance. The added expense of making these tests would possibly be a saving in the end, for the company. 2. Blood Chemistry.-A few of the newer methods in blood chem- istry could be used to good advantage in determining the presence or absence of nephritis or diabetes in applicants. (a) Blood Sugar.-It sometimes happens that a person upon a single examination will show sugar in the urine; repeated examina- tions following this fail to reveal a glycosuria. This condition of alimentary or transient glycosuria is not infrequent. The seriousness of the condition is a debatable question. Several closely watched and carefully studied cases of this type have been found to later develop into true diabetics. During the irregular appearance of sugar in their urine they were found to have only a slightly ele- vated blood sugar content. This at other times, without any par- ticular attention to the diet, would be found to be normal. Later they developed a constant glycosuria, regardless of a careful regu- lated diet, and a marked increase in the blood sugar. Therefore a case of alimentary glycosuria may be a potential diabetic. A case of alimentary glycosuria usually has only a slightly elevated blood sugar content, while the true diabetic has a quite marked retention in the blood; the latter with the urine sugar-free has a sugar con- tent above the normal. A case of transient glycosuria, when given glucose by mouth shows an increase in the blood sugar for a few hours; a true diabetic when treated in the same manner will show a blood sugar increase lasting for eight to fourteen hours. A case with renal diabetes always has a normal blood sugar, but at the same time has sugar in the urine. The pathology of this con- dition is not understood. The true frequency of it is possibly under- estimated, as the individual has no constitutional symptoms. It is quite likely that the condition would be made evident more often 492 LIFE INSURANCE EXAMINATION in persons presenting themselves for life insurance than in the few cases met in medical practice. The unsuspected glycosuria would be discovered, and examination of the blood would show it to be of a normal sugar content. This would establish the diagnosis. Such an applicant would possibly be a safe risk for life insurance. (b) Blood Uric Acid.-Applicants for insurance sometimes show a faint trace of albumin in the urine, and on subsequent examina- tions no albumin is found. The same is true of the presence or absence of a few casts. The presence of either of these can result from overstrenuous exercise or indiscretions in the diet; without any true pathology of the kidney being present. The question then arises, "Which applicant is truly a nephritic?" A phenolsulpho- nephthalein test would be of value in these cases. An elimination of 70 per cent or better of the dye, cannot have a very serious reten- tion by the kidney. Still more sensitive than this is the determination of the uric acid content of the blood. It has been found that this end product of metabolism is often retained early in nephritis; before albumin or casts are found in the urine. The normal content is one to three milligrams of uric acid per one hundred cubic centi- meters of whole blood. Figures as high as five to seven milligrams are often encountered before albuminuria develops. This test could not be made routinely, but would be of value in questionable cases where large amounts of insurance are desired. Basal Metabolism.-Applicants for life insurance sometimes present themselves with a quite marked tachycardia. The possi- bilities of several pathologic conditions such as hyperthyroidism, myocarditis, or early tuberculosis present themselves to the exam- iner. Nervousness on the part of the applicant might be the only cause for the increased pulse rate. A history of slight loss of weight, tiring on slight exertion, etc., are all the more confusing to the examiner as to the etiologic factor in these cases. A deter- mination of the basal metabolic rate might be the only solution to this problem. A rather marked increase in the rate would mean a true hyperthyroidism. A slight increase would point towards a tuberculosis or a myocarditis. A practically normal rate would be found in the purely nervous case. The practicability of the test, except in a very few cases, for life insurance applicants is quite limited. CHAPTER XXXIV LIFE INSURANCE EXAMINATIONS IN THE SOUTH By J. II. Florence, M.D., Houston, Texas Ex-Vice President and. Medical Director, Great Southern Life Insurance Company, Ex-State Health Officer of Texas. The subject of examinations in the South is of so much importance and is of such proportions that one can expect to touch only the vital points. I shall endeavor to bring out data to impress life companies with the wisdom of writing business in the South, and to make a few suggestions to local medical examiners. I shall also dwell incidentally on the advances that are now being made for the betterment of health conditions, and I shall try not to stray far into the mystical and forbidden actuarial field. The life insurance business, especially the mortality of the extreme Southern States (i.e., Gulf and Mississippi Valley) up to probably 1910, was a serious problem. The high mortality of those early years stands more or less as a stigma on the South. The absence of highly edu- cated physicians, especially in the rural districts, for examination of applicants and treatment of the sick, the lack of health laws and preventive endeavor, and the ignorance of disease carriers enter largely into the cause. There were extenuating reasons and cir- cumstances beginning with the period during the war between the states. For some years after that time the South was recovering from the war, the people and physicians were impoverished, the lands laid waste and all institutions bankrupt. Consequently, there was but little time and money to devote to sanitation and public health, but after years of prosperity, the population and the pro- fession awakened to their needs and are now forging ahead and rapidly redeeming the fair name and removing the blot of disease and high mortality of former years. Physicians are being better educated, a four-year medical course, hospital and laboratory train- ing being requisite instead of a short two-year course affording only limited clinical experience and practically no laboratory work, such as prevailed in the eighties and early nineties. The people are realizing more than ever before that it lies with them to clean house and thus be classed with the most healthful 493 494 LIFE INSURANCE EXAMINATION and sanitary localities of the nation. The increase of deaths from cardiovascular-renal diseases is evident in the South as elsewhere. The causes are well known, likewise the remedy; but nothing short of an educational campaign for a decade or so will make any per- ceptible change. With modern ideas, education, sanitation and ample hospital facilities, never expect the mortality of the past to be repeated. There is no sane reason why the South cannot be made a veritable Utopia for living, populated by a healthy people, and a lucrative field for life insurance-in fact, the day has already arrived. Anent the foregoing I herewith present some of the Medico- Actuarial findings of the different periods. It takes only a glance to see the marked improvement in mortality. The table is taken from the Medico-Actuarial Mortality Investigation. First Five Insurance Years 1885 - 1900 1901 - 1908 Arkansas, Other Counties 160% 126% Georgia, Other Counties 140 128 Louisiana, Gulf Counties 161 105 Louisiana, Other Counties Mississippi, Other Counties 167 155 128 133 Texas, Other Counties Florida, All Counties 125 91 172 128 AH Combined (Southern States) 143 117 All Insurance Years Arkansas, Other Counties 137 119 Louisiana, Gulf Counties 157 105 Louisiana, Other Counties 171 153 Mississippi, Other Counties 141 134 Texas, Other Counties 117 95 Florida, All Counties 163 123 All Combined (Southern States) 137 120 Malaria The predisposing causes are rainfall and dampness, giving the anopheles chance to breed; the more rain, the more mosquitoes- consequently, the more malaria. The mosquito season begins in March or April and continues to November, although in the extreme borders of the South they are ever present. The soil that holds water longest is the most favorable condition for it; the higher the altitude, the less malaria. Malaria has its many peculiarities; it is far-reaching in its results, often remote in its symptoms and devastating in its effects on the human system. It is frequently confused with other troubles. (I use this opportunity to warn all LIFE INSURANCE EXAMINATIONS IN THE SOUTH 495 examiners to look well into every case of chronic malaria occurring in the past in the applicant's clinical history, for many times it may have been an acute tuberculosis giving rise to symptoms masked not unlike those of malaria.) It is slightly more prevalent among males than among females, and more so in children than in adults. The Caucasian is most liable to contract the disease. There is no doubt that it attacks more readily those addicted to alcoholics. In a few years, therefore, the mortality may be to a small degree lessened; this, however, remains to be seen. Dr. C. C. Bass makes this point, and he is eminently correct: "The decrease shown by the statistics is largely due to incorrect diagnosis. There is not so great a tendency now to carelessly put down malaria as a diagnosis or cause of death for 'most anything as formerly." In other words, in the years past, wherein the mortality was recorded high from malaria, it was not altogether due to that. Types of Malaria.-Intermittent is the most common type of malaria. Its symptoms, effects and cure are well known to every practitioner. Neurotic or Nervous variety is commonly met with in malarial countries. Instead of the chill there is a severe nervous collapse that is often described as "Nervous Breakdown." Estivo-Autumnal variety is often confusing and is sometimes des- ignated as "Remittent or Continued Fever." Irregular in its symp- toms, the paroxysm lasting twenty-four hours or longer, with an intermission very short, prostration is marked and often takes on a typhoid type. Pernicious variety; onset in this type is very severe, often causing death in twenty-four to forty-eight hours. Fortunately this variety is rapidly passing and is seldom seen now. Latent variety is often found masked and difficult to diagnose, but the parasites are present. In this form the patient will suffer from headaches, diarrhea and dysentery. Pellagra Whether pellagra is on the increase, or modern medical science has made the diagnosis more easy, is a question. Personally, I am of the opinion that the correct diagnosis has made it appear in vital statistics to be on the increase. Being noncontagious, heredity 496 LIFE INSURANCE EXAMINATION doubtful, and the etiology being helpful, it does seem that this malady should be on the wane. It appears to attack those over fifteen years of age, and females more than males. Unlike hookworm it attacks the high, the low, the rich, and the poor alike. Examiners should look well to the general aspect of each applicant, temperament and actions. Exam- iners should ask especially about indigestion and diarrhea. A close observer will probably take note of the ptyalism accompanied by excessive flow of saliva, eruption on the forearms similar to recent sunburn, and the bright red color of the tongue. He will, no doubt, notice also the scaly exfoliation about the base of the nose. Local examiners can render life companies a lasting service by looking into the living conditions and the character of food taken by pro- posed applicants. Most companies have a question as to the sani- tary surroundings, habits and manner of living. This question is very important and is often answered in a routine way without any knowledge of the applicant's real daily life. If in the family his- tory an applicant gives some member as having this disease, it certainly is very important to know whether that applicant has lived in the same surroundings and subsisted upon the same charac- ter of food as those who are suffering or have died with it. I cannot emphasize this point too strongly. Regardless of the eti- ology, contagiousness or hereditary traits, I would be loath to look favorably on the application of one so surrounded. Taking into consideration the mental and nervous symptoms of the pella- grin, I am inclined to view applicants from such families very much the same as I would those whose family history showed in- sanity. Hookworm Hookworm is not of so much importance to life companies, as those of our population who suffer from this trouble do not, as a rule, apply for insurance. I shall only say that it prevails among the poorer classes, who are overworked, underfed, having a low vitality, and living in bad sanitary surroundings, and who would not be accepted as first-class lives. Malaria and hookworm infec- tion are often associated and go hand in hand, producing anemia. It should be an easy matter for the examiner to see the symptoms, such as anemia, often profound, pale lips and gums, pasty yellow LIKE INSURANCE EXAMINATIONS IN THE SOUTH 497 skin, stunted growth both physically and mentally, relaxed tissues, protruding abdomen, lack of energy, and general weakness; and T venture the opinion that should the examiner look well into .the habits of these people, see the upground closets located near the surface drinking water, and other evidences of soil pollution, and inspect their food, noticing its lack of nutriment, he would not recommend them on general principles. The work done by the different health authorities, aided by the Rockefeller Foundation, has had a far-reaching effect, and as the work continues, the un- fortunate sufferers of this disease will be relieved and educated to avoid new infection. Tuberculosis There is an element of danger in some portions of the South from tuberculosis. This applies to those districts where the climate is conducive to cure. Tn some of these localities it is stated that 50 per cent of the population consists of those who either have had tuberculosis, or a member of whose family has had it and who have immigrated for the purpose of relief. Tn these localities the exam- iner should ask all applicants their reasons for locating there, and also whether or not any member of their family died from this dis- ease, or is suffering with it at the pr'esent time. It is commonly be- lieved by these people, and many physicians in or near these re- sorts share the belief, that a cured tuberculous patient is as good a physical risk as one who has never had it. This is hard to com- bat, but it goes without saying that such a belief is erroneous. As long as the patient remains in the locality where he has been cured, and is not overtaken by some intercurrent disease, such as typhoid fever or pneumonia, he may be as good a risk, but when he moves back to his former place of residence, a relapse or an attack of some severe acute disease will cause him to go very quickly. The examiner, therefore, should be extremely careful in examining the lungs of applicants living in these localities. Often one finds no cough, no lung lesions, only a very low blood pressure which is evi- dence of a lowered vitality which could not withstand the ravages of consumption very long, and continued residence in a tuberculosis resort necessitating daily intercourse with the sufferers, makes them especially liable to infection. Many patients who frequent these places are careless. Local regulations, however, are being generally 498 LIFE INSURANCE EXAMINATION enforced for the protection of other people as well as for the benefit of the patient himself. The young light-weight applicant with in- door employment and with not too good a family history should also receive special attention. Occupational Hazards The manufacturing business in the Southern section is in its in- fancy, except cotton, oil, lumber and their by-products. Cotton Mills.-This hazard, as far as life insurance is concerned, can be dismissed with a few words. The classes who labor in these mills are not desirable and are not often solicited, except, perhaps, for industrial business. The foremen, managers and superintend- ents are good risks, and there is practically no hazard. Oil Fields and Refineries.-The hazard in oil fields is much less than formerly. The new fields, for the first year or so, are still unsanitary, living quarters being poor, food and water inferior and unwholesome. After a field proves permanent, better living quar- ters are built, properly screened, deep water is obtained, drainage improved, and better facilities for feeding employees are secured. Outside of the "Shooters" who handle dynamite and nitroglycerin, and perhaps the "Rig Builders," "Derrick Men" and "Casing Pull- ers," the employees and workers should be looked upon favorably when not employed in the newest fields. As time goes on, the latest machinery and most modern appliances are installed to pro- tect life and limb. The old, established oil companies, as a rule, have the best medical men possible, and some have hospitals. As to those who work in the refineries, a careful survey was made recently by a representative of one of the Southern com- panies. I quote from Mr. S. E. Allison as follows: "We would not rate any of these men for life insurance, although we would not grant double indemnity provision." This seems to settle in a few words the hazard of this class. Sawmills.-Under the old regime there were many dangerous occupations around a sawmill. The old-fashioned saw filer was not written on standard rates, but at the present time saws are filed automatically; the saw filer places the saw in the filer, adjusts it, turns on the power and rarely remains near it. The sawyer's work was also considered hazardous, but with the latest machinery and safeguards he is in very little danger. All first-class mills use LIFE INSURANCE EXAMINATIONS IN THE SOUTH 499 modern methods and appliances. Some of the smaller and older mills still use the old system, so it would be well for examiners to ascertain the class of mill in which the applicant is employed. There are now only a few hazardous occupations around mills, such as the "Slab Turner," the "Dogger," the "Block Setter," and the "Edger." Health Conditions and Preventive Activities.-The foregoing has mostly to do with the extreme southern states. It is surprising, upon reading the reports of the state health departments, to note the rapid advancement and the tremendous amount of work that is being carried on in these states for the prevention and eradica- tion of disease. It has been only in the last decade that much attention has been given in these states to vital statistics, but this branch of medical science is now being perfected very rapidly as the physicians and the people are beginning to realize the impor- tance of it. The work for health betterment is being carried on not only by the states but by the Federal Government, the cities and communities. In most places their work is augmented by the International Health Board. The same modern doctors who make our life insurance examinations also teach our policyholders how to live correctly and treat them when sick by the latest methods. Modern hospitals are now in evidence everywhere. In the following paragraphs I have given attention to only five of the southern states since, in a general way, the same dis- eases exist in the other states and the sanitary and health con- ditions are the same, and the same preventive measures are in vogue. Mississippi.-For the year 1915, 1492 deaths were attributable to malaria; for the year 1916, 1426 deaths; for the year 1917, 999 deaths; for the year 1918, 792 deaths. This would seem, even to a casual observer, a remarkable record. The State Health Execu- tive reckons on a reduction of mortality from malaria to be that of approximately 20 per cent biennially. This is indeed satisfac- tory and will, no doubt, improve from year to year. Liberal ap- propriations have been made by the state. The International Health Board has set aside funds for aiding the work. While their work for the eradication and prevention of hookworm has been limited to a few counties, it has been thorough and not without lasting results. The United States Public Health Service has also co- operated in these activities. A gradual reduction in the mortality 500 LIFE INSURANCE EXAMINATION from typhoid is noticeable. A gratifying showing in the reduction of pellagra has been made in a period covering four years. Taking into consideration the large negro population and the problem of handling them, the state should be complimented and congratulated on its accomplishments. I am indebted to Dr. W. S. Leathers, Executive Officer of the State Board of Health, for valuable data in this state. Arkansas.-Dr. C. W. Garrison, State Health Officer, is authority for the information that the state has made material progress in the last five years. During the last four years 55,000 people were exam- ined for hookworm, and 10,800 treated. He intimates that this disease is almost a thing of the past. Relative to malaria, he states that a large amount of drainage is being done. The people are being educated in the schools, in their homes and by printed leaflets. The writer made a partial health survey of a few counties in Arkansas five years ago and found that a great deal was being accomplished by drainage, and by education in the matters of screening, procuring deep water and doing away with surface and shallow wells for home consumption. The small towns are especially well informed on drainage and screening, and almost all have a pure water supply. The same con- dition prevails along the Mississippi river as well. The pellagra condition is about the same as in the other states where it is found. Florida.-Dr. S. G. Thompson, Director of Bureau of Vital Statis- tics, writes that the mortality from malaria was a little higher than usual in 1939, probably due to a greater rainfall, and also to the probability that the activities for the health of the people had been somewhat lax during and immediately after the war. He reports that anti-malarial work, done by cooperation of the different health boards and bureaus, should materially lower the rate within the next twelve months. Mortality from malaria in the past ten years has been lowered at least 20 per cent; mortality from pellagra seems to be decreasing. Hookworm is moderate prevalent, but on account of its rarely being given as cause of death, the mortality shown is negligible. Four laboratories are maintained for hook- worm work, and leaflets are being distributed in infested districts. Louisiana was one of the first southern states to manifest an in- terest in public health affairs, not a little credit for which is due to Dr. Oscar Dowling. Dr. Dowling states that a large amount of LIFE INSURANCE EXAMINATIONS IN THE SOUTH 501 educational work is being done which is very effective; that an intensive campaign has been in operation several years, and that a special program is being effected for pushing a health campaign and also for a more complete report of vital statistics. It is reck- oned that the mortality from malaria has fallen at least 30 per cent in fifteen years. The records show that pellagra has steadily declined, although when crops are poor and conditions unfavorable there are a larger number of cases than at other times. Neither pellagra nor hookworm prevails to any large extent in this state, but there is probably much more of the latter. Progressive ad- vancement, however, is being made in hookworm work. Some of the unhealthy area is almost wholly inhabited by negroes. The white population in the smaller towns and communities, who live in sanitary surroundings, are alert to matters pertaining to health and are insurable. Texas.-After going into the vital statistics, and considering the effect of the large amount of educational work and the efforts of the State Health Department, supplemented by that of the Inter- national Board and the United States Marine Hospital Service, there is no doubt that deaths in Texas from malaria have decreased 20 per cent in ten years. Typhoid is rapidly on the decrease and pel- lagra is about at a standstill. The mortality from tuberculosis prob- ably remains even on account of the influx of population from other states coming to Texas for climatic advantages. Hookworm work, while in its infancy, is being carried on as fast as funds can be ob- tained and the different counties interested in it. The work is car- ried on through the schools, the press, and a house-to-house canvass by intelligent medical men and others trained in different lines of work. One or two of the large railroad systems employ physicians to superintend sanitary conditions and health work along their respective roads. Much of this work is largely educational and is by practical demonstration. Only in recent years has any attention been paid to vital statistics, but this condition is improving. The city and county health officers are convened annually for a two or three days' session, at which time everything pertaining to public health betterment is discussed. The influence of these conventions is far-reaching and is being felt over the entire state, not only by the medical profession but by the people. I am indebted to Dr. C. W. Goddard for valuable information on the health situation in Texas. CHAPTER XXXV HAZARDS OF TROPICAL RISKS By Marion Souchon, M.D., New Orleans, La. Medical Director, Pan-American Life Insurance Company Climatic Conditions.-From time immemorial it has been con- sidered an accepted fact that continued residence in a tropical cli- mate is not conducive to longevity, with the logical result that life insurance companies accepting tropical risks have felt warranted in imposing .somewhat stricter requirements than in temperate regions, together with higher rates of premium. An impartial analysis of the situation would seem to favor the conclusion that we who dwell in the temperate zone judge rather by the experience of our own people who go to live in the tropics than by evidence gathered among the natives, so many of whom live to a ripe old age. The lives of those people, pervaded by the dolce far niente spirit of race and environment, may appear dull and lethargic, but they go on living, thereby seeming to testify that climate alone does not shorten the lives of those inured to it. But in estimating conditions which favor longevity, as in every other aspect of life insurance, we have to apply the rule of general average to life as we find it in tropical and semitropical countries, where the sum total of human experience teaches that underlying conditions are less favorable to longevity among the class of people most likely to apply for life insurance than in cooler climates. This consideration presents itself as applying to climatic conditions quite independently of any added risk from diseases peculiar to the trop- ics. The latter menace is one which we have reason to hope will steadily diminish as sanitary science continues its progress. To sum up, it may be said that while a tropical climate, in the abstract, may not seem to offer any specific menace attributable to temperature, atmospheric conditions, etc., our policy must be shaped to meet the apparent requirements of the situation as we find it, with what we believe to be sufficient justification for the higher pre- miums we assess those to whom we extend the protection of life insurance. 502 HAZARDS OF TROPICAL RISKS 503 Life Habits of the People.-In speaking of the tropics, let it be understood that we refer mainly to countries of the Western Hemi- sphere near enough to interest us in the way of business. A por- tion of that territory we class as semi-tropical, and all told, it may be thought of as the domain of our Latin-American neighbors. Ac- cording to a world-wide view, the following is the present classifica- tion : TROPICAL All of Central America. West Indies, incl. Porto Rico, China, Formosa. Philippine Islands. Brazil, except as indicated as semi- tropical. Mexico, including Vera Cruz and Tamaulipas. (China north of 30° N. L. was for- merly written on semi-tropical basis, but recently the attitude of all companies has changed and all China is now written on full trop- ical basis.) SEMI-TROPICAL Cuba, Canal Zone, Jamaica. Brazil-Including only the States of, Rio Grande do Sul. Santa Catherina. Parana. Sao Paulo. F. D. Rio de Janeiro. Cities of, Nictheroy. Petropolis. Theresophilis. Nova Friburgo. Mexico, excluding Vera Cruz and Tamaulipas. In undertaking to discuss the life habits of people scattered over the wide area of Latin-America, it is, of course, possible only to generalize. For example, the mode of life among highly refined residents of a city like Havana is not to be taken into account in considering the life of the mass of the Cuban population, even in fairly large towns elsewhere on the island. Therefore, such com- ments as are here offered are to be taken as applying to life among our Latin-American neighbors at large. People from temperate climates who go to live in the tropics, while they may take with them certain ideals and material acces- sories of their home lives, must, almost inevitably, yield to the forces of environment. If they stay long enough they become more and more part of the people, conforming largely to local customs, diet and habits. From the American point of view, life in the tropics is lamentably easy-going and .slip-shod. Of course, there is a certain amount of work that has to be done, but those who are likely to become appli- cants for life insurance generally make a rule of doing as little work as possible. The relaxing climate is believed to sap much of the energy imported by those from cooler regions, so that the per- vading tone, doubtless with many notable exceptions, is one of scant 504 LIFE INSURANCE EXAMINATION energy, with more or less lowering of vitality attributable to a life of indolence with little or no physical exercise. A recent contributor to one of our leading periodicals has commented on this lowering of body-tone as observed in American women domiciled in Cuba. In the same measure as a high order of bodily fitness stands for acceptability in a life insurance risk, it may be assumed that a mode of life which produces the opposite effect is proportionally discourag- ing. Belonging to the life habits of the people and as a potent factor in its relation to preventable disease, must be mentioned a certain disinclination to take any trouble in the way of conforming to sani- tary requirements. Where some powerful and beneficient agency comes into play, like the pioneer work of the United Fruit Company in Central America, or the campaign of the U. S. Government by which the Canal Zone was redeemed from malaria, or, most recent of all, the work of the Rockefeller Institute, then and only then do we see a. prospect of arousing the dormant perceptions of our Latin- American neighbors by an object-lesson on the needs of "salvation by sanitation." Problems of Accessibility.-In order to convert a heathen the missionary must first get hold of him, and no matter how attractive any plan of life insurance may be which we have to offer the eligible dweller in the tropics, we must first manage to get at him, which it is not always easy to do. Even in parts of the world where there are plenty of railroads, wagon-roads, automobiles and buggies, it is not always an easy mat- ter to corner a prospect, or having done so, to get him before the medical examiner. How much more complicated that problem may become outside the fairly large cities of the tropics, only those en- gaged in soliciting life insurance in territory like the mountainous regions of Central America can form any adequate conception. While this particular problem may not seem to have any direct bearing on the question of hazards, it is so essentially part of the game that it cannot well be ignored, especially in its relationship to the next subdivision of the subject. Problems of Inspection.-The writing of life insurance in trop- ical countries, under strange social conditions, with applicants ami examiners speaking a foreign language, would seem to call for more than ordinary precautions in the way of inspection. Such being the case, the item of accessibility becomes one of paramount impor- HAZARDS OF TROPICAL RISKS 505 lance in our schedule of difficulties, since many desirable "pros- pects" live in relatively remote localities, not merely hard to get at, but particularly barren of opportunity to obtain disinterested in- formation about their private affairs. Even in the towns, conditions are unfavorable for pursuing the line of private inquiry upon which the value of inspection service mainly depends. The spirit of sociable inquisitiveness that pre- vails among our American people cannot be counted upon to a like extent in Latin-American communities, where incidents that would scandalize our home people pass apparently unnoticed, or are at least tacitly condoned, and where it would be considered bad form to gossip about consumption or insanity in the family of a neighbor who might be seeking life insurance. While this genteel spirit of reticence is highly commendable in some respects, it is none the less fatal to the success of private inspection methods as practiced in our home territory. To meet the demands of "Trade," commercial inspection reports are obtainable from the more important cities and districts of the Latin-American countries, but such reports cannot be expected to deal with minute personal details which are of interest to life insur- ance companies. To offset this disadvantage, our company, the Pan- American, maintains an inspection service of its own in such a man- ner as to obtain current information relative to the qualifications and changes of residence among medical examiners, the selection of analysts for making microscopical examinations of specimens, etc. The duties of these inspectors are necessarily arduous, requiring a fluent command of the Spanish language, with sterling honesty and a high order of tact. That we have been fortunate in securing men with such qualifications is sufficiently attested by the satisfactory results of their work. Without some such provision for special service, the absence of facilities for the ordinary methods of inspection must obviously put quite a handicap on placing life insurance in a large portion of Latin-American territory. No matter how capable and honest the medical examiner may be, his answers to routine questions must be based largely on what the applicant may be willing to tell him about family history, past illness, injuries and surgical operations, while it is common knowledge that much of the information on which rejections arc made is either obtained directly from inspection re- ports, or is inspired by them. 506 LIFE INSURANCE EXAMINATION Poor Mail Facilities.-On the general principle that every ob- stacle to full and prompt communication between the home office and the field is a potential hazard, it may be held that the delay incident to mail communication with agents located in the tropics is entitled to be considered at least a minor hazard. If it were not for the electric telegraph, we might even say a major hazard. Although the semi-tropical field of Cuba is "just around the corner" from us, mail communication with interior localities of that island is subject to very serious delay, while in some other por- tions of Latin-America our correspondents might as well be in Europe, so far as our being in touch with them by letter-post is concerned. From the time a medical examination report is mailed from some point accessible only by mountain roads until it reaches the home office, is passed upon and the policy issued, even when there has been no delay incident io seeking additional information, several weeks will have elapsed, during which almost any impair- ment affecting the applicant may have occurred. Under such cir- cumstances, a conscientious agent receiving the policy will, of course, hold it up and notify the home office, by telegraph if possible, but think of the opportunity thus offered an unscrupulous man to de- liver the policy and pocket his commission, taking chances on being found out. We are indebted to the demands of commerce for the fairly wide range of telegraphic communication which makes it possible to stop the delivery of a policy in seaports and in the majority of inland cities, but many small settlements arc without telegraphic connec- tions, while countless ranches and haciendas are quite isolated, even as regards accessibility by mail. Earthquakes.-While the hazard from earthquakes is not easy to estimate, it is one which at least deserves some mention as re- gards certain territory known to be subject to seismic disturbances. Under an optimistic view, it might be claimed that the danger from earthquakes is about the same as from lightning, but it is a recog- nizable hazard. Conditions Relating- to Risks Race and Family History.-Among students of biology, race- purity, as a factor contributing to longevity, is so well recognized as to require no argument. The remarkable preservation of the He- brew race in practically undiminished vigor since the time of Moses, HAZARDS OF TROPICAL RISKS 507 and despite the centuries of oppression through which that people has passed, presents a monumental object-lesson in this respect. Widely scattered among the nations of the earth, they have stead- fastly avoided intermarriage with alien races, so that the Jew of today is just as distinctly Hebrew in racial identity and race stam- ina, barring some deteriorating effects of modern civilization, as he was two thousand years ago. If we thus place a high value on race-purity as contributing to physical stamina, the conclusion is unavoidable that the selection of risks among people presenting varying degrees of consanguinity be- tween white and colored races, as in the tropics, must be attended with a special hazard, unless such selection is made with rigid ex- clusion of all but pure-blooded subjects. Companies like our own, which refuse applicants with any recognizable strain of negro blood in our home territory, find such discrimination impracticable in trop- ical and semi-tropical countries. In addition to whatever underlying hazard may be present in placing insurance on risks of mixed blood, the determination of fam- ily history, on which we properly lay so much stress, is Hable to be more than ordinarily troublesome in the tropics. Owing to laxity of marital relations, it may be quite impossible to secure information on certain points covered by questions of the medical examination blank, especially as to ages and causes of death among parents, brothers and sisters. Among our American people there is a fairly well-diffused knowl- edge of the nature of illness, such as would figure as the cause of death of an applicant's parents, but on this point the answers given by well-to-do and intelligent, people applying for life insurance in tropical countries are apt to be a repetition of words declaring en- tire ignorance. Here again, such assistance as we might otherwise hope to obtain from inspection reports is unavailable, necessitating the acceptance or rejection of a risk without depending to any extent on the meager family history given us. Insurable Interests.--In connection with this phase of life in- surance as written in Latin-American countries, those who are ham- pered with puritanical notions of morality must experience an occa- sional shock on noting the relationship of the proposed beneficiary to the applicant. A prosperous unmarried citizen, wishing to do what must be rec- 508 LIFE INSURANCE EXAMINATION ognized as "the square thing" toward a domestic helpmeet, from whom, as Mark Twain has neatly phrased it, he could separate at any time without the formality of a divorce, will apply for a liberal policy in favor of that lady, designated simply as "The mother of my children," giving their several names. Abstractly considered, it might seem like inviting untimely death by poison for a man to place such a temptation in the way of a woman bound to him by no legal ties, and whom we, from our lofty standpoint of morality, would plainly call his mistress, but whom he generously dignifies by naming her as the mother of his children. The fact that we accept such risks, and that in the long run experi- ence seems to justify the sublime faith shown by a man who thus trusts his life to the affection of his unwedded life-companion, is encouraging as far as it goes, but a distinct element of hazard is none the less present in every such instance. Other striking instances of departure from hard-and-fast ideas about insurable interests might be cited, but it must be obvious that, among people living under such peculiar social conditions as those which prevail in the tropics, it is difficult, if not impossible, to write life insurance under restrictions which are deemed legitimate and proper in our home territory. Therefore, on the assumption that our usual rules of practice as regards insurable interests are sound and safe, it logically follows that any serious departure from those rules tends toward the intro- duction of an undetermined element of hazard. The Alcoholic Equation.-In the process of adapting life insur- ance selection to a working basis suitable to the tropics, it has been found expedient to make some compromises of principle, as has been noted in connection with insurable interests. A compromise yet more noteworthy has to do with the use and sale of alcoholic bev- erages, with which we have all been particularly strict in dealing among our home people. Our attitude on this question can best be characterized as one of hopeful expediency. To avoid the need of apologizing to ourselves for the concession we seem willing to make in the interests of busi- ness, we agree that a careful study of the situation favors the belief that we can allow safely a little more latitude to our Latin-Amer- ican clients than to the unruly inhabitants of the United States, who we find cannot be trusted with liquor in any shape or form. What- ever effect nation-wide prohibition may be destined to produce in HAZARDS OF TROPICAL RISKS 509 our highly favored land, we cannot at present afford to relax our restrictions against alcoholic impairments any more than in the days when there was a legalized retail traffic in intoxicants, with an absolute ban on granting any form of life insurance to those engaged in it. But in tropical and semi-tropical countries, where the ever pres- ent Canting, with its offerings of mild beverages is accepted as a necessity, we do not arbitrarily refuse insurance to the proprietors of such establishments, many of which are merely adjuncts to some larger business. Nor do we decline prosperous commercial and pro- fessional applicants because they are described as taking aperitives before eating, or as drinking wine with their meals in accordance with the custom of Latin races the world over. The practice of life insurance companies in dealing with this feature of our business is borne out by the views expressed in the following remarks quoted from a classic paper on "Mortality in Tropical and Semi-Tropical Countries," written by Arthur Hunter in 1908.* "Instead of increasing the difficulty of the problem of dealing with the liquor trade, the general use of alcohol, usually in the form of light wines, greatly decreases it, because the Latin races, who are the principal inhabitants of the American tropics, do not drink to excess to the same extent as the Anglo-Saxon or Teuton in his na- live country. The Latin is accustomed to take wine with his meals as a matter of course, and while every one drinks more or less, there is little drinking to the point of intoxication. Those who have stud- ied the liquor problem in Italy and Spain will doubtless bear me out in the statement that drunkenness is almost unknown, and that the consumption of wine appears to have little or no effect in reduc- ing longevity." In view of this habitual and general use of intoxicants by the class of people among whom mainly our selection of risks must be made, it becomes proportionally difficult to estimate with any degree of accuracy its effect on the individual. We must also take into account the fact, due to the known tendency of the human appetite, that where so many indulge, even if only in the milder forms of intoxicants, there is always present the temptation and the oppor- tunity for greater indulgence than is likely to be brought out by the examiner, accustomed to the idea of social drinking, or by the ""Transactions, Actuarial Society of America, vol. x, p. 395. 510 LIFE INSURANCE EXAMINATION inspector, mainly impressed with the respectability and solvency of the applicant. It is all very well to talk about the consumption of intoxicants being usually in the form of light wines, but we know that with the American domiciled in the tropics, his aperitive is almost sure to be a cocktail, with its vicious compound of strong liquor and doubt- ful "bitters" taken on an empty stomach, and as we are more inter- ested in the individual than in the national custom of drinking, it behooves us to take notice. Therefore, on the doctrine that no chain is stronger than its weak- est link, we cannot well afford to dismiss as entirely negligible the hazard presented by the undetermined alcoholic equation in trop- ical insurance. Diseases.-No discussion of hazards peculiar to tropical risks can be considered complete that does not mention malaria and yellow fever. There is also a formidable list of "Tropical Diseases," the very names of some of which are probably unknown to the lay reader, but it is a fact, sufficiently borne out by statistics, that any special hazard offered by most of those diseases is rather theoretical than actual. In certain localities, untouched as yet by the redeeming hand of science, malaria is still rife, while, from the same cause, yellow fever still claims a few victims in tropical seaports, but, on the whole, the hazard presented by those mosquito-borne diseases may be con- sidered almost negligible in comparison with such ordinary causes of death as pneumonia, heart disease, Bright's disease, tuberculosis and typhoid fever with which we are only too familiar. In support of this statement the accompanying table is submitted, showing our percentage of total mortality from the several diseases therein named: Percentage of Total Mortality, Domestic, Semi-Tropical and Tropicat from the Diseases Specified, 1912 to 1919 incl. DOMESTIC SEMI-TROP. TROPICAI Influenza and Pneumonia ... . .... 38.30 28.57 16.08 Organic Heart Disease .... 1.38 6.34 8.92 Bright's Disease .... 4.15 3.17 7.14 Tuberculosis .... 3.80 1.59 8.92 Typhoid Fever .... 2.76 4.76 3.57 Malaria .... 1.73 1.59 3.57 Yellow Fever 34 (None) (None) The .special menace of lhe so-called social diseases is real and terrible. Syphilis, it will be remembered, was unknown in Europe until brought back, as it is claimed, by adventurers who had con- tracted it from the natives of the West Indies. That original strain, HAZARDS OF TROPICAL RISKS 511 doubtless augmented in virulence by proliferation in new body-cul- tures, as observed with certain organisms in laboratory work, con- stitutes a powerful undercurrent of contamination, both through heredity and acquisition. When we consider the vast extent to which luetic infection per- vades the structure of our own social life, where it has been gather- ing force through generations during which no systematic attempt has been made to control it by educational propaganda, it is not difficult to imagine the corresponding condition in tropical coun- tries, where it has had full swing for centuries. Only in comparatively recent years have we learned to recognize the remote effects of supposedly cured syphilis, especially as mani- fested in lesions of the brain and spinal cord, so that in dealing with applicants who admit having had the disease, but believe them- selves cured, we usually accept them with reluctance and only on modified plans of insurance. Applying this lesson to tropical risks, there would seem to be ample justification for requiring a Wassermann test before grant- ing any form of policy to a "cured" luetic applicant. In thus .singling out syphilis as presenting fearful hazards, the other social disease is by no means to be underestimated as regards its special impairments, which are all the more to be watched for because the disease itself is so often made light of or disregarded. Revolutionary Hazards.-For the same reason that we hesitate about accepting as risks men who are in any way connected with a feud, we cannot consistently ignore the danger that lurks in the atmosphere of revolution which seems ever present in certain Latin- American republics. Mr. Sinclair E. Allison, the actuary of our company, has aptly summed up the situation as follows: "Another great factor to be considered is the changing political conditions. In many of the Central American countries there is al- most constantly a revolutionary movement on foot. "People in the past have been inclined to consider these revolu- tions as opera bouffe affairs, such as described on some of our stages, yet the danger from this source must not be discounted or over- looked. "While this is true, I believe, that the inhabitants of the sea- coast cities are largely free from this danger, but in all cases the underwriter should endeavor to have brought out whether or not the applicant is engaged in one or the other of the factional cabals which are virtually always existing there." 512 LIFE INSURANCE EXAMINATION Conditions Relating to Examiners Selection.-In the principal seaports, and in nearly all interior cities of any size, it is usually possible to find physicians familiar with the language of the country who also enjoy the advantage of holding diplomas from American or European medical schools. Obviously, if such men otherwise eligible, they are to be pre- ferred, but in the absence of that ideal combination of qualities, as in countless small communities, we have to make the best choice practicable among native physicians educated in their home uni- versities. While this prospect might at first glance appear discour- aging, the truth is that some of the best insurance examiners in tropical and semi-tropical countries are men graduated from those modest, but painstaking medical schools. They go through years of study, and with a high average of honesty, are certainly more to be depended upon than a large class of time-serving "doctors" of our own country who are being continually disrated for careless work. In this connection, what has already been remarked about 1he difficulty of securing disinterested inspection will probably be found specially applicable in the selection of a native medical examiner, a consideration which leads naturally to the next subdivision of the subject: Qualifications and Equipment.-Regardless of whether we are to choose a native examiner, or one from some other country, we are interested in finding out, not only where our candidate studied his profession, making sure that he actually has a diploma from a rep- utable medical school, but also whether he seems really to know his business. In the better regulated governments of tropical coun- tries the existence of some statute equivalent to our Medical Practice Acts may be of service as showing whether any given "Doctor" is a duly registered practitioner. Such official evidence of registration should ordinarily suffice to attest a man's professional status, but before appointing him no effort should be spared to determine, first, whether he is reputable, and second, whether he is apparently up-to-date according to modern requirements. On this latter point we may reasonably expect to get a suggestive hint from a doctor's office equipment. No matter how much knowledge and skill a workman may possess, he is prac- tically helpless without tools of his trade, and if he is expected to HAZARDS OF TROPICAL RISKS 513 undertake fine work, it is indispensable that he must be suitably equipped with high-grade implements and accessories. Applying this line of argument to what is expected of a medical examiner, we can hardly count on getting entirely satisfactory serv- ice from a man possessed of only the most meager outfit of instru- ments and chemicals, as is not infrequently the case with physicians located in the smaller settlements of the tropics, where clients are not apt to be exacting and where the atmosphere of environment is not conducive to scientific accuracy. Considering their remoteness from observation, precluding to a great extent the possibility of checking their work, it must be evi- dent that the clement of hazard from this source is by no means inconsiderable. The single item of requiring blood pressure to be taken under specified conditions, has resulted in the discovery that quite a number of physicians occupying positions of prominence where they reside, have never thought it worth while to provide themselves with a sphygmomanometer until forced to do so by life insurance regulations. Our company makes a point of supplying its general agents with such instruments, so as to anticipate any possible embarrassment from want of them in their territory. A.s has been remarked under the heading of Selection, it is usually possible to secure the services of well-educated physicians in the principal cities of tropical countries, and as such men commonly set up a good laboratory for their own use, lhe delicate work of making microscopic examination of specimens can be delegated ad- vantageously to one conveniently located, thereby obviating the loss of time otherwise requisite for sending specimens to the home office. Fortunately, this plan also leaves only the simplest tests to the skill of the examiner who takes the specimen, thus materially reducing the margin of possible error. Political Entanglements.-The profession of medicine, with its life-and-death responsibilities, is the one calling among all human avocations which demands the most single-minded devotion from those who adopt it as their life work. For this, and for other cogent reasons, we cannot too seriously deprecate instances in which physicians are tempted to engage in politics to the detriment of their legitimate interests, as so fre- quently occurs in Latin America. The objection to having to depend for examinations on a 11 polit- ical doctor" is founded not only on such misgivings as we may 514 LIFE INSURANCE EXAMINATION have about his giving proper attention to the details of the work in the intervals of outside distractions, but also on a well grounded fear lest he may be tempted to favor some doubtful applicant from ulterior motives. To the lay reader this may seem like an unkind aspersion of an honorable profession, but we know what opportunities there are in an insurance examination for not finding things unfavorable to the applicant, and that on certain points the unfair examiner need only keep silent. If he has no weighing scales at hand he can easily "estimate" fifteen or twenty pounds off an overweight subject, or he can draw his tape-measure tight enough to eliminate several un- desirable inches in the girth of an abdomen, or he can manage not to hear a slight heart murmur, etc. An agent will occasionally recommend the appointment of some physician who holds a public office, with the idea that the doctor's official influence may be made a paying asset, and if the man is one who still devotes his attention mainly to his profession, the re- sult may prove satisfactory all around, but to appoint a full-fledged politician as a medical examiner merely because he happens also to be a "doctor" would be to deliberately invite a needless hazard, whether at home or abroad. Comparison of Premium Rates As a matter of interest in connection with the subject of Hazards of Tropical Risks, the following tables are submitted, showing by comparison the current scale of premiums, Domestic, Semi-Tropical and Tropical, for standard policies at the ages'specified: Domestic AGE ORDINARY LIFE 20 PAY LIFE 20 year endowment 25 $16.90 $24.95 $43.20 35 22.68 31.03 44.81 45 32.98 40.50 49.52 55 51.41 57.36 61.22 Semi-Tropical 25 $22.37 $31.19 $46.98 OK 28.98 37.67 49.32 45 40.57 48.04 54.90 55 61.95 66.59 69.21 Tropical 25 $27.37 $36.97 $52.68 35 35.10 44.33 55.30 45 48.53 56.08 61.92 55 72.95 77.18 78.(74 CHAPTER XXXVI ARMY SERVICE AS AN INSURANCE PROBLEM By George S. Strathy, M.D., Toronto Assistant Medical Director, Canada Life Assurance Company, Toronto, Lieut. Colonel, Canadian Army Medical Corps The ex-soldier is a member of a large class of the community which after passing a searching physical examination lived for months or a few years under unusual conditions of housing, occupation, and exercise, and which were subject to unusual injuries, diseases, and privations. As a result the class is found to contain a high per- centage of strong muscular men, a considerable percentage of un- usual deformities and disabilities, and a higher percentage of men who have shown the effects of nervous exhaustion. The time elapsed since the war impairments began is too short to permit reliable statistics of mortalities, therefore, in discussing the ex-soldier as an insurance risk one has to rely on what is to be gathered from the experience of various observers up to the present time. Further experience may materially alter these opinions. The ex-soldier must be considered in three ways. First, the con- ditions under which he lived, the privations, hardships, physical strain and nervous strain, which he endured; secondly, the diseases and injuries from which he suffered; and thirdly, his condition as he is found today. In many ways the War of 1914-1918 was different from all pre- vious wars. It is generally regarded that the nerve strain was greater, the volume of shell fire vastly greater, asphyxiating gases were used for the first time, aerial combat was introduced, and at least one new fever was epidemic. To gain a proper perspective it must be realized that the war of 1914-1918 was a series of wars or campaigns with the struggle in the western European front monopolizing most of the attention of the North American Continent. This was the crucial struggle and it was the only campaign in which troops from this continent par- ticipated in any great numbers. For this reason it is the campaign of most importance to the insurance companies of North America. 515 516 LIFE INSURANCE EXAMINATION A war of movement entails as a rule great physical strain due to long marches and rapid fortification building, trying living con- ditions, long periods of exposure to climatic conditions such as ex- tremes of temperature and moisture, and lack of equipped hos- pitals. In compensation there are less artillery fire, less nerve strain, less asphyxiating gas, and longer periods of rest. The short campaign of Gallipoli was a failure more due to dis- ease than to battle casualties. Dysentery and enteric were treated with insufficient supplies and unsuitable food. The mortality was high. The nervous strain was great. Fig'. 123.-Advanced dressing- station in a trench. Tropical diseases caused a heavy death loss and wastage in the Macedonian campaign. Monotony, homesickness, and war weari- ness became marked as time went on and led to considerable inva- liding for "nerves." The terrific heat of the summer entailed heavy losses from sick- ness, in the Mesopotamian campaign. There was lack of suitable food and accommodation for sick men. Many hundreds died of dysentery or fever on the river boats used for transportation to the base. The losses from heatstroke, dysentery, and tropical fevers were very heavy and the sufferings of the sick and wounded ARMY SERVICE AS AN INSURANCE PROBLEM 517 intolerable. The temperature in the shade, of which there was little, was frequently 110°. One of the scourges of this campaign was the septic sores. Slight injuries such as insect bites, or rubbed heels frequently led to severe sepsis or perforating ulcers, an indication of the low resist- ance of Europeans living under such unnatural conditions. These sores became less frequent as the supply of vegetables and fruit juices increased. The Egyptian and Palestine Campaign was one of movement, consequently nervous breakdown was rare. There was much Fig. 124.-Field ambulance stretcher bearers at Passchendaele, November, 1917. malaria and dysentery bnt not of a severe type. Casualties were heavy, but owing to the dry climate severe sepsis was rare and anaerobic infections almost unknown. Sand-fly fever, a fever usu- ally lasting five days and followed by no serious sequelae, and oriental sores were common affections but without danger to life. The campaign in German South West Africa was a healthy one. This was a sharp contrast to that for the Cameroons where the com- batants were exposed to all the dangers of an equatorial climate. The wastage in the German East Africa campaign amongst un- acclimatized Europeans from malaria, blackwater fever, bacillary dysentery and heatstroke was high. The campaign might be de- 518 LIFE INSURANCE EXAMINATION scribed as one, three quarters against jungle and jungle diseases and one quarter against the enemy. The Western European Front was the front of few privations, epidemics, and diarrheal diseases, but it was the front of greatest casualties, nerve strain, and gas poisoning. It also shared with the Eastern European Front the distinction of being the most vermin- ous area and consequently had the greatest wastage from trench fever and trench nephritis. The campaign of 1914 had not been many weeks under way on the richly manured wet soil of Belgium and Eastern France before Fig. 125.-Light railway for evacuating wounded from forward area. the inadequacy of accepted methods of war surgery was very ap- parent. Nearly every wound was infected; most compound frac- tures led to amputation or death. The mortality from compound fractures of the femur in the British Expeditionary Force for the first six months of the war was 85 per cent. Gangrene in its most virulent form ravaged the wounded. Many were wounded by large pieces of shell which carried in pieces of uniforms previously soaked in a mixture of mud and feces. This led to a change in the rules of army surgeons. At first, instructions were not to open wounds but merely dress them with antiseptics frequently and send them to the bases 70 to 150 miles away where the operating surgeons were collected. In 1915 orders were issued to drain ARMY SERVICE AS AN INSURANCE PROBLEM 519 wounds more freely and operating teams were sent forward to casualty clearing stations which henceforward were the main op- erating centers. In 1916 free incision and removal of foreign bod- ies, especially pieces of clothing, if accessible, were advocated. Aifter the experience of the Battle of the Somme in 1916 early operation with the excision and thorough cleansing of wounds and the continuous application of antiseptic solution by Carrel's method were introduced. This was modified further in 3917 and 1918 by the introduction of the method of closing small wounds after ex- cision and cleansing and the introduction of Bismuth Iodoform Fig. 126.-German prisoners stretcher-bearing on their way out. Passchendaele, 1917. Tape for a track. Fatigue parties carrying mats for a track. Paraffin Paste in suitable cases. Today it is striking to see the difference between the wounds of the different years of the war. The later years show clean scars with a history of a much shorter stay in hospital. The mortality in all classes of wounds fell stead- ily and the necessity for amputation was correspondingly infre- quent. Relapses of sepsis except in compound fractures are com- paratively infrequent in the scars of 1918 as compared with those of 1915-1916. 1 'Leave the chest and abdomen alone. Keep the patients quiet. Dress the wounds with mild antiseptics." These were the instructions of 1914-1915. Hemothorax was not aspirated until definite signs of sepsis appeared. Abdomens were unopened 520 LIFE INSURANCE EXAMINATION unless peritonitis was very evident. Gradually the wisdom of early careful aspiration for hemothorax and early laparotomy became apparent. Patients left with a large sterile hemothorax, although usually out of danger, were found to be permanently disabled by deficient expansion of the affected lung. The lung was unable to expand owing to the thick deposit of fibrin in the pleura. Cases of peritonitis that recovered were more disabled than cases of pene- trating gunshot wounds where early laparotomy had been per- formed. In the final stages of the war active, not passive surgery was the rule. From an insurance standpoint an understanding of this out- line of war surgery is useful, for the risks who recovered from wounds received early in the war had more severe and long con- tinued sepsis, had more retained foreign bodies and more damaged lungs and abdominal viscera. It is not an uncommon experience to have sepsis recur in old wounds even four and five years after the date of injury. The im- portance of this fact varies with the location of the wound. If the wound is in muscle or subcutaneous tissues the importance is tri- fling as the sepsis is seldom virulent. If, however, the sepsis is in an old fracture or a body cavity, the importance is considerably greater on account of the dangers of complications and the greater danger of the operation which is usually necessary. Danger of gas gangrene and tetanus is negligible at this late date. Recurrent sepsis, apart from that occurring in the cranial, thoracic or abdom- inal cavities, owing to its low virulence or the increased resistance of the patient, cannot be regarded as a great danger but there is at least the danger attendant on a general anesthetic. Compound Fractures of Long Bones.-Amputations.-In the first few weeks following injury, compound fractures of the femur, tibia, and fibula, tarsus and metatarsus, radius and ulna, and humerus, follow each other in the above order of mortality. The mortality of 85 per cent for compound fractured femurs in 1914 and 1915 was lowered to about 15 per cent in 1918. For two years after the wound is healed there is considerable danger of recurring sepsis and osteomyelitis, which dangers decrease as time passes. Where a foreign body, especially a piece of shell, is still embedded in the bone the chances of sepsis are greater. The insurance im- pairment where amputation did not follow may at this late date ARMY SERVICE AS AN INSURANCE PROBLEM 521 be considered as confined almost to the extent of the resulting dis- ability in reducing the amount of exercise of the applicant during the remainder of his life. Where amputation follows fracture the dangers of sepsis are usually less but the mortality associated with body mutilation and interference with exercise must be considered. The Canadian Medical Directors' Association, considering the mortality due to amputation, drew up the following schedule which is a useful one in considering the effects of amputation: Fig. 127.-Working in a main dressing station. Amputations at the hip-joint or through the upper third of thigh, expected mortality at least 135%. Amputations above the knee below the upper third of the thigh, expected mortality at least 125%. Amputations below the knee, expected mortality at least 115%. Amputations of the arm at or near the shoulder-joint, expected mortality at least 125%. Amputations of the arm above the wrist and below the upper third of the arm, expected mortality at least 115%. The total disability clause is not allowed in any of these cases. 522 LIFE INSURANCE EXAMINATION Head Wounds and Fractures of the Skull.-Head wounds may be divided into six classes. The first class are those where a for- eign body is still retained within the cranium. The second class includes those where a foreign body pierced the dura and either passed through the skull or was removed at operation. The third class comprises those in which the skull was fractured and the dura torn or there was intradural hemorrhage but no foreign body passed through the dura. The fourth class are those cases where there was intracranial hemorrhage without fracture of the skull. In the fifth class are cases with depressed fracture of the skull Fig'. 128.-German prisoners carrying a wounded Britisher. without signs of intradural hemorrhage. In the sixth class are those where there was a wound of the scalp without depressed fracture or intracranial hemorrhage. Roughly it may be said that the expectancy of life is worst in the first class and improves with each class up to the sixth. Of the first class there are very few alive and none of these is likely to apply for insurance. They are quite uninsurable: complications such as brain abscess and cerebral degeneration are too frequent and too fatal. In the second class there are these same two dangers. Only the ARMY SERVICE AS AN INSURANCE PROBLEM 523 most carefully selected are insurable and then only after at least three years have passed without symptoms, where an x-ray shows no depression of the skull and no foreign bodies within the skull, and where the applicant is free from any but the slightest subjec- tive or objective symptoms. Even the most rigidly selected must be considered somewhat substandard. Complication of epilepsy and mental deterioration are frequent in this class. In the third class the danger lies in the possibility of Jacksonian epilepsy. Where subjective symptoms are almost entirely absent and there is little or no paralysis these cases are probably insur- able after a probation of three to five years. Even then they are slightly substandard. Fig. 129.-Stretcher-bearing down a trench mat track. November, 1917. Pas- schendaele front. Where symptoms at the time of injury were slight, where there has been freedom from dizziness or epilepsy for three years, and where there is little paralysis, applicants of the fourth class are usually insurable at standard rates. The fifth class are insurable where the depression of the skull is no longer present and there is freedom from symptoms for three years. Epilepsy is the main danger. The sixth class are freely insurable but care must be taken that a gutter depressed fracture has not been overlooked. Chest Wounds.-Wounds penetrating the thoracic cavity were of three main varieties. (1) Those passing through, having a wound 524 LIFE INSURANCE EXAMINATION of entrance and exit. (2) Those where the missile penetrated the chest and was removed at operation. (3) Those where the missile is still retained in the chest. There is also a difference in impor- tance of wounds caused by rifle or machine bullets and those caused by pieces of shell or bombs or by shrapnel bullets. Where a wound was caused by an intact bullet the wound was usually clean and no piece of dirt or clothing was carried into the thoracic cavity. The extra danger of wounds caused by rough missiles lay in the like- lihood of sepsis following. A considerable percentage of penetrating chest wounds were fol- lowed by death on the field. Nearly 20 per cent of those reach- ing the clearing stations were fatal in the first twenty-four hours frohi hemorrhage. These percentages were somewhat decreased where the chest wounds had been immediately sutured in the field. Deaths from loss of blood were rare after the third day, but at that time the danger of sepsis began. It was hoped that the method of opening and cleaning out the chest soon after arrival at the clearing station would reduce the percentage of septic cases. It is doubtful whether this result was attained, but the healing' proc- esses in both the lung tissue of the intrathoracic wounds and the thoracic wall were more rapid, and where sepsis did not follow, the functional results were better than when the thoracic cavity was not explored and cleaned. Viewing a thoracic wound from an insurance viewpoint one must consider three questions: (1) Is the missile retained? (2) Did sepsis occur and if so how severe was it? Was drainage for em- pyema necessary? (3) What is the present functional damage of the lungs? Where a bullet or foreign body passed through the chest and no sepsis followed and there is little or no apparent decrease in lung- expansion at the time of examination, the risk may be regarded as standard. Where a foreign body is retained within the chest and sepsis has not followed and there is no recent history of purulent bronchitis or hemoptysis, experience has shown that there is a slight danger of trouble following from the retained missile. The danger is greater the larger the missile and the closer it lies to vital organs such as the aorta, vagus nerves, or the heart. The rarity of trouble following in such cases, when three years have passed since the ARMY SERVICE AS AN INSURANCE PROBLEM 525 wound was received and no complications have supervened, makes the extra hazard slight. Where a foreign body has been retained and is still within the thorax and sepsis occurred but there is freedom from sepsis for over three years, recurring sepsis is not common and when it occurs is seldom virulent. The difficulty of treatment where the foreign body is dangerously or deeply placed adds further to the risk. These cases will show a slightly higher mortality. Cases of septic chest wounds should not be accepted within two or three years of Fig. 130.- Dressing wounds at an advanced dressing station. any signs of sepsis. Where purulent bronchitis or hemoptysis have been present within two years there is a further increase in the hazard. Where there are present signs of considerable restriction of the lung with much thickening of the pleura or displacement of the heart there is a considerable risk which will increase as the years pass. Some of these cases already show slight cyanosis or clubbing of the fingers. If added to this condition there is a history of sepsis, the risk would in mosl cases be considered uninsurable. As'in the early years of the war it was common practice to leave a large sterile hemothorax to absorb, many of these cases show much 526 LIFE INSURANCE EXAMINATION thickening of the pleura and restriction of expansion, with no history of sepsis. These cases may easily be mistaken for cases of old empyema. The mortality to date of old septic chest wounds is unexpectedly good, but it is to be expected that an increasing mortality will be experienced in later years. Wounds Penetrating the Abdomen.-Wounds penetrating the ab- domen are less of a novelty because peritonitis which accompanied them is a frequent occurrence in civilian life. Most missiles pene- trating the abdomen were removed at operation if they had not passed through. Foreign bodies in the liver if not easily removed, were usually left, but these were rare. Where operations were per- formed early, peritonitis was often very slight. Freedom from symptoms for two years after the injury usually suggests perma- nent cure but old abdominal injuries have led to obstructions total or partial in many cases. To judge such a case as to suitability for insurance one must depend largely on the history. How severe was the injury? What was done at operation? Has the applicant been free from symp- toms since? The estimation of the risk will largely depend on the history since the injury. Here the medical director is dependent on the history obtained by the examiner. Nervous Disorders and "Shell Shock.''-The nervous effects of service have been widespread and varied in their manifestations. The milder degrees at least were manifested in nearly all who served overseas for many months. Frequently the men affected realized their condition only after demobilization when they found themselves irritable, hypersensitive to criticism, inclined to depres- sion, and lacking in self-confidence. The more severe degrees were found in those who had undergone the great nervous strain of severe fighting or heavy responsibility, or in those who had always been nervously unstable, or who had suffered from severe illness such as malaria, dysentery, influenza, or enteric fever. Many of the most severe cases of nervous depression occurred in Macedonia and Mesopotamia where an attack of malaria following on the mod- erate strain of some months of trench holding led to complete "nervous breakdown." Commotio cerebri or actual macroscopic damage to the brain was much rarer than was thought to be the case early in the war. Most of such cases showed physical signs such as paralysis or pare- ARMY SERVICE AS AN INSURANCE PROBLEM 527 sis of ocular muscles or ruptured ear drums. However cases did occur where no objective signs were found but their rarity makes them of academic interest rather than of practical importance. To estimate the importance of nervous disorders of warfare, the various types of individuals who were affected, and the various ways in which they were affected, and circumstances leading to the nervous symptoms, must be considered. Each individual risk must be judged by his normal nervous balance, how severely that bal- ance was upset, and the weight of nervous strain which was re- quired to cause that degree of upset. Roughly, the individuals may be divided into four types: (1) Those of average or above average nervous stability. (2) Those with a tendency to imbalance of the sympathetic nervous system. (3) Those of low nervous stability, that is, of so-called neurasthenic or hysterical temperament. (4) Potential insane, epileptic and mentally defective individuals. Those in Type 1 broke down nervously only after long continued strain of flying, infantry fighting, or steady artillery fire, or after experiences of the most trying kind. This class nearly all returned to normal after a few months' rest. One boy of nineteen years fell 32,000 feet in a burning aeroplane and miraculously escaped death. It is not to be wondered that his nerves were upset for some months. He afterwards returned to normal. Those in Type 2 form a large class and some observers would not class them as nervous cases. In any large general hospital were found wards of soldiers who were troubled by persistent vomiting occurring just after meals, in other wards cases of "disordered action of the heart" (D. A. H. in the British nomenclature, or neurocirculatory asthenia in the American nomenclature), in other wards men with nervous tremors, and again wards with men who had frequent enuresis, either nocturnal or diurnal or both. On examination these men from different wards were found to be suffering with similar symptoms although in some cases the gas- tric, in others the circulatory, nervous or bladder symptoms were most prominent. In all there was marked vasomotor instability: Flushing, sweating and dizziness, occurred with the least excite- ment: the extremities were blue: tachycardia was easily produced, but usually disappeared rapidly after short exercise; cardiac and pyloric spasm were frequently present; the fine tremor of the ex- tended hands, characteristic of autonomic nervous system upset, was 528 LIFE INSURANCE EXAMINATION invariably present, and frequency of micturition without polyuria was the rule. This syndrome was found usually in men who had had months of hard fighting, but, in those with a history suggestive of autonomic nervous system (endocrin?) imbalance, a short period of fighting or one great fight would produce the symptoms. These eases early in the war were frequently diagnosed as hyperthyroid- ism. In one instance many such cases were seen among the per- sonnel of a base hospital after it was severely bombed. Many of these men had been sent to hospital duty on account of nervousness or had purposely enlisted in hospital units knowing their inability Fig. 131.-Getting wounded prisoners out. to sustain the nervous strain of combatant service. It was to this autonomic nervous system type that the name "shell shock" was first applied. They had a somewhat characteristic appearance. When removed from danger and especially when assured that they would not be returned to the front, and more especially after the Armistice, most of the men of this type recovered fairly rapidly, but even three and four years after the onset of their symptoms many of them showed marked vasomotor instability, a tendency to faint, and general nervousness. Alost of them are apprehensive and many still suffer from having been diagnosed as " shell shock," "gastritis," "heart disease," "exophthalmic goiter," or "cystitis." ARMY SERVICE AS AN INSURANCE PROBLEM 529 The ex-soldier does not like to admit that he suffered from nervous- ness in the army; that was regarded as too close to cowardice, there- fore, he describes his trouble as having been "indigestion," "strained heart" or "shell shock." This has led to many being rejected for insurance. Those of type 3 include most of the "shell shocks" of long stand- ing. After very little exposure, during which they frequently per- formed deeds of marked bravery, they suffered from nervous col- lapse. In their case the nervous exhaustion showed as marked Fig. 132.-The ground over which wounded had to be evacuated at Passchendaele. depression, hysterical fits, hysterical paralysis and inability to do anything but the simplest work. There was frequently a history of nervous instability in the family. Recovery in these cases has been slow. They show inability to work and constitute most' of the "unemployable old soldier" class. Those of Type 4, the potential insane, mental defectives and epi- leptics, were found in all armies, but owing to the methods of re- cruiting early in the war many were enlisted in the British and Canadian forces. Even the American army, which, benefiting by the experience of the Allies, was carefully recruited and selected, contained a percentage of such cases. This type broke down easily 530 LIFE INSURANCE EXAMINATION under the strain of service. Colin of Paris believes that the strain of service caused rapid development of general paresis. Schroder with his large experience of the German Army concludes that war strain was not a cause of epilepsy but that hysterical soldiers were very subject to epileptoid attacks. Most of his cases of malinger- ing were in individuals of Types 3' and 4. In describing a nervous breakdown it is well that the examiner should obtain particulars as to the usual nervous state of the ap- plicant, the experience which he has undergone, his exposure to Fig. 133.-German prisoners carrying out their wounded. danger and privation, the symptoms which resulted, the duration of symptoms, and the present state of the applicant's "nerves." Applicants of Types 1 and 2 may be accepted at standard rates if they now appear normal. Applicants of type 3 must be judged as neurasthenics and hysterics who have had a nervous breakdown. They will break down more easily again. They are probably more prone to suicide and insanity than the average, and are as a rule below standard. Applicants of Type 4 are not safely insurable. Effects of Gas Poisoning.-Just before the Armistice was signed in November, 3918, there were 40,000 patients in hospitals in Eng- land who had been evacuated from France for gas poisoning. So ARMY SERVICE AS AN INSURANCE PROBLEM 531 severe was the wastage from gas that one of the experienced army consultants was appointed as consultant for gassed patients and he reported that 30,000 of the gassed patients had entirely recov- ered from any toxic effects of enemy gas but were suffering from various degrees of nervous exhaustion resulting from service. His opinion was shared by nearly all medical officers of large war ex- perience. Arrangements were made to transfer these cases to con- valescent depots, where it was expected that rest, remedial gym- nastics and military discipline would soon make them into troops fit for service. The Armistice was signed before the scheme was put into practice. The official viewpoint was expressed in a pam- phlet published in April, 1918, by the Chemical Warfare Medical Committee (British). As this pamphlet summarizes, very thor- oughly, clinical knowledge of gas poisoning it is here freely quoted: "The Symptoms and Treatment of the Late Effect of Gas Poisoning "The gases used most commonly by the enemy are of three main varieties: (1) Suffocative: for example, Chlorine, Phosgene (COCI2), Di- phosgene, Chloropicrin (CCI3NO2). (2) Vesicants: Dichlorethyl sulphide (C2H4CI)2S. (Mustard Gas or Yperite). (3) Pure Lachrymatory: for example, Xylyl-bromide. Gas may be liberated from cylinders (cloud gas) or from shells. "Cloud Gas Attacks.-The gas is liberated from cylinders, and drifts forward on the wind. Chlorine alone was used in the first attacks of April and May, 1915. Tn December, 1915, phosgene was used together with chlorine, and this mixure was repeated in the attacks from April up to August, 1916. Since that date no cloud gas attacks have been made by the enemy against the British front. "Gas Shells.-At first these only contained lachrymators, which affected vision for a short time, but produced no other serious, and no lasting, effects. In the autumn of 1916 lethal gas shells were used; these contained phosgene, chloropicrin, and other allied lung irritants in varying proportions. In July, 1917, the enemy intro- duced another shell, 'Yellow Cross,' containing the new substance, 'Mustard Gas.' Shortly after this, shells containing organic ar- 532 LIFE INSURANCE EXAMINATION senic compounds such as diphenylchlorarsine, were also brought into use, the shell being marked as 'Blue Cross' or 'Red Cross.' "The general aim of the enemy in the present use of gas shells is to fire simultaneously shells of different types, some of which will cause so much sensory irritation that the man will discard his respirator, and then become vulnerable to lethal shells containing phosgene and similar substances. Owing to this mixture of shells the symptoms reported by patients are often very confusing. "Action of Gases.-1. Suffocative.-These gases act mainly on the alveolar epithelium of the lungs, causing acute edema of the lungs, of very rapid onset, and thrombosis of the pulmonary capillaries. Fig'. 134.-German prisoners carrying out British wounded. They have less effect on the air passages, but may have an irritant action on the pharynx, larynx, and bronchi. Chloropicrin is a powerful lachryniator, but chlorine and phosgene do not affect the eyes to any great extent. "Early Symptoms.-The immediate effects of irritation of the eyes may be prominent at first, but as a rule quickly pass off; within three to twelve hours after exposure to the gas the main symptoms, asphyxia and prostration, due to affection of the lung alveoli and accumulation of fluid in them, appear. In this stage the patient's respiration is rapid and usually accompanied by pain (often in- ARMY SERVICE AS AN INSURANCE PROBLEM 533 tense) in the chest; there may be violent fits of coughing, but the amount of expectoration is variable, being profuse in some cases, and very scanty in others; in the more severe cases the patient is restless and anxious, or may be semi-comatose with muttering delirium, therefore many patients will be unable to give a definite account of their symptoms, as loss of memory of immediate events may last for several days. Patients with severe pulmonary edema fall into two groups: "(a) Those with definite venous engorgement. In these the face is congested, the lips blue, and the superficial veins of the face may be visibly distended. There is true hyperpnea, i.e., the breathing is not only increased in frequency but the actual amount of air reaching the lungs is greater than normal. The pulse is full and of good tension, and the rate is not often much above 100. "(b) Those with collapse. In these the face is pale and the lips of a leaden colour. The breathing is shallow, so that there is but little true hyperpnea. The pulse is rapid (130 to 140) and weak. "In patients who recover, the edema fluid is absorbed within a few days; in some cases signs of bronchitis or bronchopneumonia, due to a secondary infection, persist for some time, but in most cases the lung returns to a condition which is normal except for the presence of some disruptive emphysema. In consequence, how- ever, of the edema of the lungs during the early stage, deficient oxygenation of the blood occurs, unless prevented by the admin- istration of oxygen. The deficient oxygenation gives rise to wide- spread temporary injury in the various systems, leading to the gen- eral symptoms to be described later. "2. Vesicants.-The only one hitherto employed is dichlorethyl sulphide, an oily liquid used in shells, and scattered from them on the ground, where it slowly evaporates. This not only attacks those in the immediate vicinity of file shell-burst, but may also affect those who may walk over the contaminated ground later. The fluid may be spattered also on clothing, shell-casings, rifles, etc., and may thus become effective through direct contamination of the skin. "The main action of this group is an irritant one on tire skin, eyes, and respiratory passages. 534 LIFE INSURANCE EXAMINATION " Special Symptoms. (a) Early.-These are insignificant, nothing being noticed imme- diately except a smell reminiscent of mustard, from which the gas derives its name (Mustard Gas). A soldier may not realize for many hours that he has been exposed to gas, until the more important delayed symptoms develop. (b) Delayed.-These are the principal symptoms of this group and appear three to twenty-four hours after being gassed. They occur usually in the following order, and approximately after the intervals stated. (1) Conjunctivitis, (three hours). This rapidly becomes very acute, and is accompanied by intense photophobia, and swelling of the lids, which may cause closure of the eyes for days. (2) Vomiting and epigastric pain, (four to eight hours). These symptoms appear together as a rule, and are apt to be persistent and intractable. (3) Burns, (twelve hours). Widespread erythema with local vesication occurs, going on to definite burns. The com- monest sites are the axillae, genitals, and back, but no area may be exempt. The affected surfaces frequently develop very marked pigmentation. Deep burns some- times occur when the liquid itself comes into contact with the clothes or skin. (4) Laryngitis, pharyngitis, tracheitis and bronchitis, (twenty-four to forty-eight hours). These are the most dangerous symptoms. The degree and extent of the lesion may vary from a simple irritation of the surface to an ulceration of the mucous membrane of the whole passages, followed by infection of the raw surfaces. These conditions may be so extensive and severe as to cause death by themselves or in consequence of the de- velopment of bronchopneumonia. "In a certain number of cases with severe involvement of the re- spiratory organs, which recover, there has evidently been some inter- ference with the proper oxygenation of the blood, which may give rise eventually to symptoms resembling the after-effects of the suffoca- tive gases as described below. ARMY SERVICE AS AN INSURANCE PROBLEM 535 "When a soldier is protected by the respirator the respiratory and eye symptoms are absent or slight. "Late Signs and Symptoms of Irritant Gas Poisoning.-These are the symptoms most commonly observed in the United Kingdom. The acnte stage has subsided, and the patients are received on the average, about fourteen days after being gassed. Depending on the action of the gas, these late symptoms will vary. "(1) General Symptoms.-There is one group of symptoms which is more or less common to all forms of gas poisoning. These closely resemble those characteristic of 'Disordered Action of the Heart,' or the 'Effort Syndrome,' and commonly include dyspnea, pain in chest, palpitation, dizziness, and easy fatigue on exertion. The patient complains frequently of disturbed sleep, varying in degree. This may be characterized by dreams, paroxysms of coughing, starting awake with pressure on the chest, and even acute attacks of dyspnea. Polycythemia frequently occurs in association with these symptoms. There are also various nervous symptoms of a functional character, closely associated with this symptom-complex. In any given case, these symptoms may occur in varying degree. "The gas which is most productive of these symptoms is Phos- gene. They occur very frequently after this form of gassing and constitute by far the most important cause of discharge from the army or reduction in category in those who have been gassed. These symptoms also follow 'Mustard Gas,' but are not as common nor as severe. "Treatment.-Tn patients exhibiting these general symptoms, pro- longed' rest in bed is contraindicated. These patients should be en- couraged early to undertake increasing amounts of exercise. When practicable they should be placed on graduated physical exercises- mild ones at first, and gradually increasing in severity and dura- tion. If this be not possible, the patients should be required to undertake definite amounts of walking, which should be increased in length and speed every few days until several miles at a fair marching pace are accomplished each day. Care should be taken that the exertion is not increased too rapidly. This may be deter- mined by the condition of the patient at the end of the exercise. If there is obvious respiratory distress, which persists for more than a few minutes after the exercise is finished, or if the pulse rate re- mains appreciably above the resting rate for more than five min- 536 LIFE INSURANCE EXAMINATION utes, it may be judged that the exercise has been too severe. Also, the patient's subjective complaints must not be ignored, as they form a most valuable index to his condition. Precordial pain, se- vere dyspnea, giddiness or fatigue in an obvious degree, should be carefully avoided. Patients who are making good progress should be returned as soon as possible to army discipline; the milder cases to their regimental depots, and the moderate ones to a command depot. Prolonged stay in hospitals, either primary or auxiliary, is particularly apt, in these cases, to exaggerate the neurotic conditions, which are difficidt to overcome. Recent experience of casualties from mustard gas in France has shown that the best results are obtained by vigorous measures at the outset for all except the very serious cases. Eye-shades are removed as soon as possible, and the men are not allowed to stay in bed for more than two or three days. They are sent out of doors early, and encouraged by disci- pline and exercises to forget that they have been gassed." Remote Effects of Gas Poisoning.-Longer experience has con- firmed the opinions quoted above. Several years after the cessa- tion of hostilities many men are found complaining of symptoms "the result of being gassed." Commonly one hears men say, "I have never been right since I was gassed." JXFost of these cases are examples of war neurosis: in most cases the symptoms com- plained of are very slight. On the other hand there are also many men (but a very, very small percentage of those who were gassed) who have permanent damage to their lungs following inhalation of gas. Where the burns of the bronchi were severe most of the cases terminated fatally in a few hours or a few days. Where death did not follow within three days, but where the soldier continued with lung symptoms of many days or many months the cause lay in the infection of the bronchi and lungs which followed. These patients now show a chronic bronchiolitis or bronchitis or a tendency to frequent attacks of bronchitis. Of all the gases chlorine gave the highest percentage of permanent lung damage. Fortunately a very small percentage of the army received a severe dose of this gas. Owing to the danger of its blowing back on the troops dis- charging it from cylinders, its use was discontinued by the Ger- mans in the summer of 1916. Tn applicants for insurance who give a history of being gassed the importance of this history may be judged by the severity and ARMY SERVICE AS AN INSURANCE PROBLEM 537 duration of the illness which followed, a history of bronchitis or freedom from bronchitis since and the presence or absence of physical signs of bronchitis. Where the gassing was not severe and there has been no tendency to bronchitis since, and the chest on examination is free from moisture or other signs of chronic bron- chitis, the history of gas poisoning may be disregarded. When the history indicates a more or less severe attack of bronchitis or pneu- monia immediately following the gassing and there has been com- plete freedom from symptoms since, the risk may be compared to one where there is a history of bronchopneumonia or severe bron- chitis without gassing. Briefly there are no remote toxic effects of gassing; the danger lies in the damage which the lungs suffered following the gassing.* Pneumonia and Bronchitis.-The years of war coincided with two epidemics of lung diseases. In 1916 and 1917 there was a rising wave of streptococcal lung infections and in 1918 the influenza epi- demic burst on the world and combined with the streptococcal wave to overwhelm many millions of people. Consequently the civilian in- cidence of chest infections for the years 1914 to 1918 was probably much above the average of most five-year periods. It is not sur- prising therefore that the army experienced a high incidence for those same five years. In addition to these causes the army had to contend with the lowered resistance of lungs irritated by poisonous gases, the smoky atmospheres of the dugouts, and the somewhat doubtful danger of exposure to all kinds of weather in the open. Many of the re- sults of influenza] and streptococcal infections have been put down to gas poisoning even where the patients had not inhaled gas for several weeks previously. It must always be kept in mind that a very large proportion of the army were never in the front line and were not exposed to great hardships. Nearly 50 per cent of the army were on the lines of communication and a further percentage were in the "back areas" so that at any given time but a small proportion of an army *Dr. A. H. W. Caulfeild, who has had a very extensive experience of the late results of gassing agrees with these opinions. In a letter to the writer he states: -"As regards the late results, of gas poisoning, I feel in the first place that con- sidering the numbers severely exposed, complete recoveries must have been made in a very high percentage of the cases. I am also left with the impression that those now suffering from chronic bronchitis or bronchiectasis with marked changes and symptoms, either had before the gassing considerable tendency to chronic bronchitis, or developed the condition during the hospitalization (for the gassing) or soon after their exposure." 538 LIFE INSURANCE EXAMINATION was fighting. This is somewhat counterbalanced by the fact that most of the casualties occur in the forward areas and therefore in the course of a campaign large numbers take their place in the front line. A high percentage of the army therefore spent their time in the healthy life of the camps and billets of the lines of communication and "back areas." On the other hand in the line everybody had a cough--"that cigarette and dugout cough" as it was explained. In spite of this, severe bronchitis and pneumonia were not unusually prevalent except for small epidemics of severe purulent bronchitis, such as occurred in the winter of 1916-1917. In the rest camps in England these respiratory infections were quite as common as in France. Of the 400,000 Canadians who went over- seas, 776 died of influenza and 1,194 of pneumonia, a total of 1970, which is not a high figure when compared with the death rate from the same diseases in the civilian population. This it must be re- membered is from an average exposure of about 200,000 for four and a half years. From the streptococcal and influenzal epidemics mentioned some cases of chronic bronchitis, chronic bronchiolitis and bronchiectasis resulted. Many of them are now regarded as the results of gassing. It must be remembered that gassing, when not fatal in the first forty-eight hours, was dangerous only from the infection of the lungs which followed. It is therefore impossible to distinguish between chronic bronchitis which is the result of gassing and that which is not. A correct history of the onset is the only guide. The general impression of those who had the greatest opportu- nities of observing is that life in the army in the field during the years 1914 to 1918 did not of itself predispose to chronic nontuber- culosis lung epidemics. Tuberculosis.-During the second and third years of war it was generally thought that tuberculosis was very prevalent among all the allied armies, but especially the French. This was due to the combination of chronic coughs and war debility which was diag- nosed clinically as tuberculosis. Later it was found that a high proportion of soldiers diagnosed as consumptive were not tuber- culous. The statistics of all the armies are not now available. Von Schjerning in the official medical report of the German army states there was a proportionate decrease of tuberculosis in the German ARMY SERVICE AS AN INSURANCE PROBLEM 539 army during the war. In the German navy there was a slight pro- portionate increase in tuberculosis with a slightly higher mortality rate. This may be accounted for by the fact that the navy did not get its accustomed amount of fresh air, as it was unable to cruise. The report of the Board of Tuberculosis Consultants for Canada states that the incidence of pulmonary tuberculosis in the Canadian army was nearly double that of the civilian population of the same ages, but from this must be deducted the fact that the army has been most thoroughly examined both during the war and since and the civilian population has not, and in the army statistics are in- cluded many cases which would not have been diagnosed in civil- ian life. While 8,571 so-called tuberculous ex-service me*n have been treated by the Department of Soldiers' Civil Reestablishment out of a total of 590,572 enrolled, only 3,117 were diagnosed as tuberculous while overseas out of 396,000 who reached England. Parfitt esti- mates the incidence as 4.3 per 1000. The incidence in the British Expeditionary Force is given as about half this figure, but this in- cludes only cases in which tubercle bacilli were found. The Brit- ish incidence was approximately the same as the Canadian. The figures for the American Expeditionary Forces were very slightly higher, being 2.9 per 1000. The problem of the incidence of tuberculosis is well summed up in the report quoted. "A comparison between the incidence of tuberculosis in the army and in civil life, while of interest and importance may only be approximated. Too short a time has elapsed for the death-rate from tuberculosis in the army to become reliable for comparison with the civilian death-rate. The civilian death-rate is the only index of the amount of tuberculous disease in the community at large; and, by multiplying this by various factors, estimates have been made of the morbidity, or tuberculous status, of the commu- nity, existing at any one time. It is fallacious, however, to com- pare this momentary status with the annual incidence, or crop of tuberculosis, yielded by the army, removed from it, and placed in sanatoria. The civilian incidence is that amount of new tubercu- losis which yearly enters the tuberculous group to replace losses by death and recovery, absolute or relative. The civilian inci- dence with some variation, has long been operating to evolve the tuberculous group. 540 LIFE INSURANCE EXAMINATION "In Canada, the death rate from tuberculosis in 1915, was 1.08 per 1,000 for the whole population. For men of military age, the rate has been estimated at 1.36 per 1,000 for the whole country, from incomplete vital statistics. This group had a rate of 1.06 per 1,000 in the provinces of Alberta, Saskatchewan, Manitoba and Ontario. The civilian rate for these four provinces was .84. This relatively more vigorous population provided 66 per cent of the enlistments. The development of tuberculosis will continue, somewhat mod- ified, because of selection, in the army group, apart from all consid- erations of army life. The army has had the advantage of the selection of'an average higher physical manhood than the average of civilian life, while the men composing it have had the advantage of regularity of life, much time spent in the open and a higher standard of food. On the other hand, the men have undergone varied hardships of service, and have been exposed to intercurrent disease through close association in barracks, etc., to a greater extent than have civilians. Any difference between the natural civilian incidence for men of military age, and the actual incidence in the army group, will be due to army life. An incidence rate somewhere between one and one-third times and twice the death rate (1.36 for males of military age) may reasonably be assumed to be operating in any case, as among civilians. This will be from 1.8 to 2.7 per 1,000. An additional incidence rate somewhere be- tween 2.5 and 1.6 per 1,000 may, therefore, fairly be considered due to army life. This is an increase over the estimated rate of inci- dence for civilians of 140 per cent in the first instance, and 60 per cent in the second. Broadly speaking, there is, then, twice as much tuberculosis among the ex-service men of the Canadian Expedi- tionary Force, as among civilians of the same age period (20-44 years)." The Effects of Service on the Heart.-If the large number of sol- diers admitted to "heart hospitals" or "heart centers" were taken as a criterion of the effects of service on the heart, the expectation would be that a large percentage of ex-soldiers would show symp- toms of damaged hearts. Fortunately a very high percentage of patients admitted to "heart centers" were suffering from nervous instability, temporary weakness after fevers, such as trench fever, malaria, pneumonia and influenza. Valvular disease of the heart ARMY SERVICE AS AN INSURANCE PROBLEM 541 was not unusually common in soldiers but since discharge from the army a proportion, slightly higher than usual in the civilian population, are suffering from subacute bacterial endocarditis. Dr. G. W. Lougheed and Dr. Leonard Murray of Toronto reported twenty-eight fatal cases occurring in two hospitals in eighteen months. They draw attention to the fact that nearly all of them had had long service, an average of over two years, and that they were nearly all infantrymen or artillerymen. Apart from bacterial endocarditis and syphilitic endocarditis and aortitis which are un- usually common, discharged soldiers are not showing a marked tendency to cardiac disease. When the heart of the soldier is normal on examination and there is no history of syphilis, endocarditis or pericarditis, there is little reason to fear a damaged heart. Most of the cardiac cases of the army were temporary derangements. It must be remem- bered that the nervous ex-soldier shows a tendency to tachycardia on excitement, but this soon disappears when his nervousness is allayed. Trench Fever.-This louse-borne disease which the Germans called "Five Day Fever or Gaiter Fever" was the greatest cause of wastage, apart from wounds, on the Western European Front. It was first recognized as an entity in the winter of 1914-1915 but became more widespread in 1916 and 1917. It varied greatly in its severity and manifestations, and no deaths from it have been re- ported. The usual onset was sudden with high fever and consid- erable prostration, pain in the back, and headache. The initial fever lasted but three or four days, but relapses occurred usually at four- or five-day intervals and sometimes the intermittent fever pecurred for months. In a large proportion of cases the symptoms of onset were mild and the soldier never reported sick, but had slight malaise for a few days with debility following and lasting several months. After the first few days nocturnal pains in the shins, ribs or forehead became troublesome in about half of the cases. Convalescence was slow in most cases; lack of energy, irri- tability and low blood pressure sometimes continuing for several months. In some cases intermittent fever and debility lasted for three years. The pains in the shins and back led to a diagnosis of rheuma- tism or myalgia. Most of the cases of "rheumatism" occurring in 542 LIFE INSURANCE EXAMINATION the army were of this nature. Rheumatic fever was uncommon. Another sequel of trench fever was a disordered heart action which was easily confused with, and often added to, the vasomotor insta- bility of the nervous soldier. Following up the work of McNee, the American and British Trench Fever Committees were able to establish the louse as the carrier of the disease, but it is only since the war that the rickettsia which are the causative organisms have been discovered. They are very minute and have never been seen in human blood or tissues but are found in the gut of the louse after he has been fed on the trench fever patient for twenty-four hours. This interesting new method of diagnosis has been called "Ceno-Diagnosis." Trench fever as before mentioned has no mortality and it ap- pears that all who suffered from the disease during the war are now fully recovered but its importance from an insurance stand- point rests in its sequebe being confused with rheumatic fever and heart disease. It constitutes the large majority of cases in the British Forces diagnosed as P.U.O. or pyrexia of uncertain origin. The general opinion of the harmlessness of trench fever must be modified if one accepts the theory, which towards the end of the war was gaining ground, that trench nephritis was a complication of trench fever and caused by the same organism. The pros and cons for the acceptance of this theory cannot be discussed here but there is much ground for thinking that the two diseases are closely related.* Perhaps one is on more certain ground in saying that trench nephritis is probably a louse-borne disease. Certainly the symptoms of trench fever were common in patients suffering from trench nephritis. Trench Nephritis and Albuminuria.-In the British Services ex- amination of the urine was not made at the time of recruitment. Macleanf examined the urine of 10,000 accepted recruits at Aider- shot Camp in England and of 50,000 apparently healthy men at Etaples in France, most of whom had served in the line. He ob- *This opinion is sub judice until it is determined whether trench nephritis is a complication of trench fever. Several deaths occurred where the patient had no clinical symptoms ordinarily associated with nephritis ; death followed inside twenty-four hours and at autopsy the kidneys showed obliterative endarteritis of the capillaries of the glomeruli as is seen in trench nephritis. There was usually no edema. If later experience proves that trench nephritis is a complication of trench fever these must be looked upon as fulminating cases of trench fever. Albuminuria, was very common in trench fever. tReport of Medical Research Committee, February 14, 1918. ARMY SERVICE AS AN INSURANCE PROBLEM 543 tained almost identical figures in the two camps. The summary of his valuable investigations are here quoted: "(1) In 50,000 men who had practically completed their training, the incidence of total albuminuria of all kinds was found to be 6.48 per cent. After allowing for cases with pus, spermatozoa, etc., the general incidence came out at 5.62 per cent. "For well-marked albuminuria the numbers were 2.55 per cent for all kinds of albuminuria; and 2.19 per cent after allowing for pus, etc. "Roughly speaking, the total incidence of albuminuria unac- counted for by the presence of spermatozoa, pus, and other sub- stances was about 5 per cent, while the corresponding figure for well-marked albuminuria was only about 2 per cent. "(2) Well-marked epithelial and various kinds of hyaline casts were present in certain urines. Very few blood casts were met with. "Out of the 50,000 men, the average number of urines found to contain casts was 1.87 per cent; of these, 0.84 per cent had definite epithelial casts, while in 1.03 per cent hyaline casts were found. "(3) The total number of men who had albuminuria together with moderate or often large numbers of epithelial or hyaline casts was 550. Of these, 271 had epithelial casts, while in 278 the casts were of the hyaline variety. "It appears that the minimum number of men suffering from more or less definite kidney disease was 550. It is therefore prob- able that the 'active service' part of the army contains, during training, at least, 1.1 per cent of men whose kidneys are inefficient and who are suffering from some degree of disease. "As far as can be determined by examination of the urine it can be stated with some confidence that not more than 2 per cent of- men give any definite indication of kidney disease as indicated by the presence of albuminuria and fairly large numbers of casts. Definite signs of disease are found in about 1 per cent of men. "(4) The albuminuria which is produced by sudden severe exer- tion passes off on resting, and does not appear to become any more marked with prolonged training than it was at the beginning. There is no evidence that it tends to become chronic. "(5) No relationship between incidence of albuminuria and oc- cupation was found in this inquiry. The number of men investi- 544 LIFE INSURANCE EXAMINATION gated from this point of view was only 10,000, and the number of different occupations was so great that no figures of statistical importance were available. "(6) Neither the incidence of albuminuria nor of casts has any tendency to increase as the result of long service. This observa- tion appears to be of great importance in its possible bearing on war nephritis. "(7) As a general rule, the incidence of albuminuria is greater in young soldiers (from eighteen to twenty-two years or so) than it is in older men; after twenty-five years it decreases somewhat, and then remains more or less constant. Indeed, in soldiers over forty there is a distinct tendency for it to decrease to an appre- ciable extent. "(8) The investigation at Aidershot gave similar results to those obtained at the base in France. "(9) The general results of this investigation strongly support the view that no injurious effects are produced on the kidney by any of the conditions associated with training for active service; the soldier during training does not appear to be more liable to deleterious kidney effects than is the civilian in ordinary life. From this it would appear that war nephritis is probably not the result of any condition present during training, but is due to some factor which is operative, chiefly, in the fighting area." In a later publication (Medical Research Committee, June 7, 1918), Maclean described the later history of the 50,000 men examined. One hundred and sixty developed nephritis or albuminuria in the next ten months. Of these 132' were definite nephritis. Only 28 of the 160 had had albuminuria when previously examined. From these results he concludes that "it is now proved that the great majority of the cases that return from the front area as war neph- ritis did not show albuminuria a few months before contracting the disease. It would seem therefore that previous albuminuria plays little or no part in the etiology of war nephritis." There were about 25,000 cases of trench or war nephritis in the British Expeditionary Force in France in four years and although much patient research was carried out by all the countries engaged the cause of the outbreak, which was common to all the armies, has not been discovered. In 1918 and since the end of the war there has been an increasing weight of opinion that it was a louse-borne ARMY SERVICE AS AN INSURANCE PROBLEM 545 disease. On the other hand, many workers, but more especially those working at the base and in home hospitals and who did not see the cases in the early stages, were of the opinion that it was the same disease as the nephritis of civil life. It is hard to explain the widespread epidemic on this hypothesis. It is quite true that in its later stages it is impossible to distinguish between civil and war nephritis, as the anatomical lesions are then similar. Nearly every one who has seen the early stages of war nephritis is con- vinced that it is a different disease. Of course mixed in with the epidemic cases, if it was a distinct type of nephritis, there must have been cases of ordinary nephritis. It is also worthy of note that in campaigns where there was little or no trench fever, neph- ritis was very rare. At the onset the disease in a large proportion of cases was bron- chial and pulmonary rather than nephritic. Bronchiolitis and dyspnea were usually marked. Many cases died without any signs of edema after being ill less than forty-eight hours. Oliguria and blood casts were seldom prominent and many cases showed marked hematuria but not the smoky urine of ordinary acute nephritis. The difference between war or epidemic and ordinary nephritis is stressed because it is important from an insurance standpoint. War nephritis, on the average, is not nearly so serious a disease as ordinary nephritis. The mortality for the first six months of the disease in the cases in the British Expeditionary Force was under 2 per cent. Recovery from acute symptoms was usually rapid, the disease appearing to terminate by crisis. McCordick and Robins analyzed* 87 cases of nephritis returned to Canada. In 3' cases the nephritis occurred as a complication of other diseases. In 7 cases there was a history of a previous at- tack before enlistment, 9 cases had never been in France so that only 68 of the 87 (78 per cent) were true cases of war nephritis. The problems of war nephritis from an insurance standpoint are three: 1. Did the applicant suffer from true war nephritis, ordinary nephritis or albuminuria without nephritis? 2. Is the nephritis cured? 3. If the lesion is healed, to what extent is the normal function of the kidney impaired? *Medical Science, Abstracts and Reviews, i, No. 1, p. 97. 546 LIFE INSURANCE EXAMINATION 1. To decide this question it should be understood that a history of a previous attack of nephritis, or a history of nephritis follow- ing another disease, trench fever excepted, would lead one to be- lieve that the attack was probably not one of war nephritis. If the attack was of short duration or accompanied by marked hema- turia, it was probably war nephritis. Albuminuria apart from nephritis was usually discovered on routine examination while in hospital and was unaccompanied by subjective symptoms. Dixon while in charge of the medical ward of a corps rest station found that 22 per cent of all his patients showed albuminuria on admis- sion. Nearly all had had trench fever or were very verminous and had furunculosis as a result, and in nearly all cases the albumin- uria cleared up in a few days. If a medical officer was not cog- nizant of the frequency of albuminuria in front-line troops, he was very apt to diagnose many cases showing albuminuria as nephritis and to send them to hospital so diagnosed. This could partly ac- count for the large number of cases diagnosed nephritis and also for the very favorable mortality rate. 2. If the applicant was discharged from hospital with urine nor- mal, and this would only be done after repeated analyses showed no albumin or casts, and the urine was normal on every examina- tion for the next two years it would appear reasonable to suppose that the kidney lesions were healed. 3. If the kidney is damaged to such an extent as to interfere with functional efficiency, and yet the urine is free from albumin and casts, increased blood pressure and cardiac hypertrophy will fol- low after an interval varying with the severity of the functional impairment. There are many functional tests of the kidney which might aid in deciding this question, but it is very seldom possible in life insurance examinations to make these tests. Taking into consideration the findings and opinions of various observers it is suggested: 1. That where the attack was short and the urine was free from albumin in less than six months, an applicant with a history of war nephritis is acceptable at standard rates after a probation of two years when the urine, blood pressure and heart are normal. 2. When albuminuria persisted for over six months after an at- tack of war nephritis, it is probable that the risk is substandard. ARMY SERVICE AS AN INSURANCE PROBLEM 547 The extra mortality must be judged by the features of Hie con- valescence and the condition present at the time of examination. 3. Applicants with a history of war nephritis who show cardiac enlargement, increased blood pressure, albuminuria, casts in the urine or low urinary specific gravity are only insurable with a heavy loading of the risk in the best class, and must usually be considered as uninsurable. 4. Functional tests of the kidney made two years after the attack are of great value but seldom obtainable. 5. Attacks of nephritis which occurred before the applicant reached the war area, that is, before he became verminous, are very likely not to have been attacks of war nephritis and should be regarded more seriously. Tropical Diseases.-Malaria, blackwater fever, bacillary and ame- bic dysentery, and heatstroke played havoc with unseasoned troops in all the tropical campaigns. Malaria was especially severe in Macedonia, Palestine, and Cen- tral and East Africa. The importance of a malaria] history in insurance lies in the possibility of recurrence and the danger of some of its complications. Tn England, which is practically free of anophelines, 14,000 cases of malaria were reported in discharged soldiers between March and December, 1919. The mortality in England before the war averaged 50 to 60 per year. These were all in people returned from malarial countries. In 1919 the mor- tality was nearly 300. The majority of these were from chronic cachexia. Blackwater fever was the cause of death in others. To safeguard against the risk of malaria in insurance applicants, a year of freedom from all attacks should be demanded before acceptance. Malaria cachexia is characterized by marked anemia and a hard enlarged spleen. Applicants should not be accepted while showing these impairments. Cerebral manifestations of malaria were very common, leading to mania, insanity, or neurasthenia. Applicants with such a history must be regarded as having a nervous system which has been dam- aged to some extent. The severity of the damage may be estimated from the history of the nervous disturbance and convalescence. Many of these cerebral malarial eases have been confused with sunstroke. 548 LIFE INSURANCE EXAMINATION Iii discussing the effects of malaria Dr. Phear states: ' ' The after-effects of malaria were numerous, and examples were commonly to be seen not only in the wards of general hospitals but also in the various special departments of the medical service. In the cardiological department a large proportion of the cases of D. A. H. with unduly sensitive exercise-response were traceable to malaria. In the neurological departments, in addition to cases of peripheral or central lesions of the nervous system directly due to malaria, the influence of the disease as a contributory factor in various functional condi- tions was clearly manifested. In the mental department a majority of the cases under treatment was attributable to the same cause. In an analysis pub- lished in The Lancet of January 3 by Major A. T. W. Forrester, R. A. M. C., who was latterly in charge of the department, it appears that the commonest type of psychosis following malaria was either some form of mental confusion or depression. The outlook in these, as in other post-malarial psychoses, is favor- able, and after a course of treatment it was generally found possible to transfer cases to the general wards, whence they could be sent home by hospital ship as ordinary patients. "No one passing through the malaria wards of any general hospital could fail to be impressed by the large proportion of cachectic cases, with profound anemia, enlarged spleen, marked wasting, more or less pyrexia, and persistent tachycardia increased on any slight exertion. "Owing to increased submarine activity in the first half of 1917, facilities for invaliding by sea became greatly restricted, and there ensued a gradual accumulation in the Salonika command of men whose usefulness for military purposes was practically nil, since by reason of repeated attacks of malaria they spent the greater part of their time at hospitals and convalescent depots, in many cases being readmitted from convalescent depots to hospital for a malaria relapse before their period of convalescence was completed. These men were not only unfitted for active service and an unnecessary burden on the military machine, but as possible carriers they constituted an actual danger to the com- munity. On the other hand, there was a fair prospect that under less trying climatic conditions a proportion of them would recover to a sufficient extent to be of use in the home command or in France. These circumstances led to the inception and organization of the Y scheme, and by the latter part of Decem- ber, 1917, the necessary arrangements had been completed and the first drafts were evacuated from Salonika under the scheme. The men were chosen with the greatest care, every case being inspected either by the D. M. S.* or the con- sulting physician before being passed as suitable for evacuation. The scheme worked well, and by Oct. 31, 1918, a total number of 26,001 officers and other ranks had been evacuated, to the great advantage both of the command as a whole and of the men themselves. I am told that these officers and men, not only useless but a danger to their companions in the East, have in a large pro- portion of cases regained their health and strength, and have been responsible for much good work at home and on the Western front. "Next in numerical frequency to malaria, and hardly less important in its consequences, was dysentery. The total number of admissions for the three ♦Director Medical Services. ARMY SERVICE AS AN INSURANCE PROBLEM 549 years was 21,147, representing a ratio per 1000 troops of 64 in 1916, 29 in 1917, and 58 in 1918. The total number of deaths was 414, equivalent to 1.9 per cent of admissions; or calculated as a ratio per 1000 troops, 1.4 in 1916, 0.6 in 1917, and 0.98 in 1918. The above figures are probably in excess of the actual numbers, especially for the year 1918, as, owing to the importance of early treatment and the impossibility of bacteriological examination in all cases, it was agreed to accept as the basis of diagnosis clinical criteria irrespective of bacteriological proof. This policy was deliberately adopted as affording the maximum of protection to the community, though it doubtless involved a diagnosis of dysentery in a certain number of cases of acute enteritis which were really due to some other cause. ' ' Blackwater Fever.-This serious complication of malaria may lead to considerable damage of the kidneys. If the hemoglobinuria lasted more than a day or two the damage is usually serious. A close study of the urine is necessary in such cases. Bacillary Dysentery.-Most men who have had dysentery know the name of the type from which they suffered. While Mesopo- tamia was by far the worst field for dysentery, it was common in all the tropical fronts and was not very uncommon in the bacillary form in France and Belgium. Bacillary dysentery was everywhere much more common than amebic dysentery. The mortality was severe but when the attack did not last longer than a few weeks or a few months and there has been freedom from recurrence for two years a history of bacillary dysentery is not a bar to standard insurance. Amebic Dysentery.-This variety of dysentery is a greater dan- ger than the previous form, owing to its tendency to lie latent for months or years only to reappear in chronic ulcers or liver ab- scess. Freedom from symptoms for two years reduces the proba- bility of such recurrence. The recent improvement of treatment by means of emetin has reduced the frequency of complications. Sunstroke.-A history of sunstroke or heat exhaustion may be of importance both on account of the nervous instability which fre- quently follows a severe sunstroke and also because "sunstroke" or "a touch of the sun" or "a tap" (the soldier's term) may be used to describe a nervous breakdown or attack of insanity occur- ring in hot countries. If the attack was severe the sufferer must be regarded as a distinctly substandard risk. Suicide not infre- quently follows. 550 LIFE INSURANCE EXAMINATION The Ex-Soldier's Opinion of His Diseases and Injuries.-It is difficult for those who are not well versed in their ways to understand the mental viewpoint of ex-soldiers. It was recognized by those who came in contact with the veterans of the Civil War, the Crimean War, or the Indian Mutiny. They had taken an active part in some of the great events of history and were proud of it. Those events were of all the events of their lives most indelibly impressed on their mem- ories. In most cases considerable sacrifices of various kinds were involved. Nearly every weakness, physical or mental, which devel- oped during or after their service was laid at the door of their service. If they committed a disgraceful act, it was because their nerves had never been the same. If they developed rheumatism or bronchitis thirty years later, they believed it was the results of their hardships. The same outlook is discernible in the veterans of the recent war. They attribute then- disabilities to their service, often honestly for- getting that they were present before enlistment. As ex-soldiers, and justly proud of it, they have a tendency to have military diseases. Chronic bronchitis is interpreted as the result of gas poisoning, even if they were never sufficiently gassed to be off duty. If tuberculosis developed, it was the result of gassing. Indigestion is given as the result of gassing, and to "shell shock" is attributed all nervous manifestations. Nervousness to the soldier was considered too close to cowardice to talk about but "shell shock" was a good soldier's disease. As years pass, the memory for events before the war and pre-war diseases gradually fade and the war memories become more fixed but less reliable. A good illustration of this occurred in the Toronto General Hos- pital a few months ago. A discharged soldier was admitted for bronchitis which he described as having followed gassing. His his- tory stated that he was quite healthy on enlistment. He died and his lungs were shown at the weekly pathological conference of the staff as typical specimens of the late effects of gassing. They showed chronic bronchiolitis and marked emphysema. A.few days later his official military medical history sheet arrived from Ottawa. It showed that he had been "boarded" to Category B. 2.,* for chronic bron- chitis of seven years' standing, before he ever went to France. He had managed to be sent to France a few months later, but went to ♦Men in this category were considered fit only for service in England or at the Base. ARMY SERVICE AS AN INSURANCE PROBLEM 551 hospital immediately after arrival there and a week later was re- turned to England. He had never even smelt German gas. Realizing these peculiarities of the soldier, it is necessary to ques- tion him closely as to the onset of his war impairments and to check up his war service accordingly. It is an interesting fact that in Turkey, where there are no pensions, war neuroses are almost un- known. "Post hoc" must be distinguished from "propter hoc." In the examination of applicants with a history of nervous affec- tions, it is especially necessary to know how far their war experiences justify a nervous breakdown. Therefore the applicant should be questioned as to what area of the service he was in, to what nerve strain he was exposed, and for bow long. Only in this way can an estimate be made of his normal nervous stability. Service without History of Illness.-Finally the ex-soldier with- out any history of wound or disease must be considered. He has several factors in his favor. It may be presumed that at the time of his enlistment he was in good health with no serious physical impair- ments. For some months he underwent a careful physical training so that he was brought to a high degree of physical fitness before being sent overseas. On the whole, his life there was a healthy one. He lived a great deal in the open air and was well but plainly fed. The result was that, on demobilization, he appeared to be in a state of health distinctly above the average. On demobilization he was again examined and his state of health carefully scrutinized. There- fore, if found "fit" he could be considered as selected before he underwent an examination for insurance. It must be admitted that venereal disease was distinctly more com- mon among soldiers than in the general population of the same sex and age. This is true in spite of all the pains that were taken to reduce the incidence of venereal infection. The soldiers' physical vigor, absence from influences of home surroundings, recklessness of danger, and the disturbing influences of war on morals, account for this. Counter-balancing to some extent is the fact that efficient and early diagnosis and treatment was carried on in the army. It is hard to estimate the effect of the physical strain of service on the circulatory organs. For generations soldiers' hearts have been under suspicion. Dr. Leonard Murray, who is in charge of heart cases in the Toronto area of the department of soldiers' civil reestab- lishment, believes that the heart and blood vessels of the soldier who 552 LIFE INSURANCE EXAMINATION has experienced long service show signs of early degenerative changes. Time alone will determine to what exent this is true. The following statistics of the Canadian Expeditionary Force ob- tained from the Director General Medical Services, Ottawa, in the autumn of 1920, show that, apart from wounds and influenza, the Canadian soldier showed a low rate of mortality and disease. Casualties Total killed or died from wounds 55,951 Total died from disease 3,871 Total wounded 144,606 Total sick admitted to Hospital 395,084 The chief causes for admission to Hospital are as follows: * Diseases Admission to Hospital Deaths Cerebrospinal Meningitis 39!) 219 Diphtheria 1,700 18 Enteric Fever 422 16 Paratyphoid, A. and B. 358 7 Scarlet Fever 271 4 Measles 2,816 30 Measles, German 2,641 Influenza 45,954 776 Mumps 9,643 --•-- Dysentery 1,500 13 Malaria 550 6 P. U. 0. (Pyrexia Uncertain Origin) 15,353 4 Erysipelas 252 66 Inflammation of Connective tissue 16,823 4 Tetanus 31 7 Endocarditis 133 30 Pneumonia 4,771 1,194 Rheumatic Fever 1,258 2 Tonsillitis- 10,461 9 Tuberculosis, lungs 3,117 174 Tuberculosis, other organs V. D. G. (Gonorrhea) 298 37 47,471 1 V. D. S. (Syphilis) 18,612 - Trench Feet 1,330 9 Trench Fever 2.997 - Insanity 1,683 - *This list is not quite accurate but very nearly correct. Disease ratio was probably fairly even in all the Allied Armies on the Western European Front and these statistics may, there- fore, give a general idea of the prevalence of the most important diseases. CHARTER XXXVII NUMERICAL METHOD OF VALUING LIVES FOR INSURANCE For about twenty years there has been in use among a steadily in- creasing number of Life Insurance Companies in this country, a numerical method of determining the value of risks for insurance. This method originated in the office of the New York Life Insurance Company, as a result of statistical studies made by Dr. Oscar II. Rogers, now Chief Medical Director of that Company, and by Mr- Arthur Hunter, now its Chief Actuary. It has for its object to meas- ure in advance the insurance value of each risk that applies for mem- bership, so as to determine whether it may properly be admitted and upon what terms. The principle underlying the method is that if we wish to know the influence upon longevity of any one of the factors which go to make up a risk, we have simply to make a statistical study of lives which possess that factor. For example, to determine the effect of various degrees of overweight upon longevity, we should study a large number of insured lives of various degrees of over- weight. In the same way, the effect of heart disease or of albuminuria or of a history of renal colic or of hepatic colic and the like, or of the various occupations, may be determined by studying the mortalities which occur in large numbers of insured lives, good average risks in all other respects except the factor in question. If an applicant for insurance is, for example, a locomotive engineer and in all other respects a normal average risk, his insurance value is the same as that of locomotive engineers generally of the same age. This method assumes that every risk for insurance is made up of, 1. Build 2. Family record 3. Occupation 4. Personal history 5. Habits 6. Physical condition 7. Residence 8. Moral hazard 9. Plan of insurance applied for 553 554 LIFE INSURANCE EXAMINATION and that the value of the risk as a whole may be determined by the summation of the value of each of these several factors ascertained by statistical studies. It is understood that whenever, as sometimes occurs, two or more factors are correlated, the numerical equivalent of the correlation is used instead of that of each factor taken sepa- rately. In the course of a presentation of the method, one of its originators stated:-"Everyone who passes judgment upon a risk carries out this process in his mind. He begins with the applicant's build. If the risk is distinctly over- or under-weight the impression upon his mind is unfavorable more or less in proportion to the degree of its depart- ure from the normal with respect to that factor. He turns then to the family history and, if this is an excellent one, his judgment is favorably influenced; if it is bad he makes a more or less definite addition to his first mental valuation, and his judgment up to that time is the sum of the two previous impressions. Taking up the next factor, occupation, his judgment of the risk is influenced favorably or unfavorably according to the nature of that factor, and so on through the entire case. Thus the reviewer carries on in his mind a process of addition and subtraction, or a modification of this proc- ess, according as each factor is favorable or unfavorble or negative, and his final judgment of the risk is the total of these various favor- able and unfavorable impressions. The numerical method expresses each step in this mental process in terms of a definite standard and the final valuation of the risk, with comparatively few exceptions of material importance, is the sum of these various items. If the med- ical reviewer knows the insurance significance of the applicant's build, as determined by past experience of similar cases, he uses this value as a foundation to which he adds or from which he subtracts the effect, as determined by statistical studies, of the other factors in the case, family history, occupation, and so on. "Wherever there is clear evidence that two factors arc interdependent so that their addition is not sufficient or is distinctly too large, allowance is made for that interdependence." Elsewhere the authors of this method have said: "During the last twenty years there has been accumulated a great deal of information regarding most of the factors that enter into the composition of a risk. It is not unlikely that we know more about the element of build than any other of them, but we have a great deal of informa- tion regarding occupations, habits, various types of personal his- NUMERICAL METHOD OF VALUING LIVES FOR INSURANCE 555 tory, or physical condition, and the like. Indeed, the information available in one form or another bearing upon all of these factors is so considerable, that no medical director who takes the pains to study it need feel that he is entirely in the dark with reference to any of them. " Making use of a vast amount of statistical material, this plan of numerical valuation takes as its foundation the insurance value of the build of the individual expressed in terms of a standard mortality table. The influence of build upon longevity has already been quite thoroughly studied and the value of each risk so far as build is con- cerned may be very easily determined by reference to tables which have been prepared as a result of these studies. Thus, a person twenty-five years of age, 5 ft., 8 in. in height and of average weight, has a build value of 95, meaning thereby that the mortality which may be expected to occur in a large group of lives of that sort is 95 per cent of the normal. If, however, this person were 20 per cent underweight, the mortality of his class would be 120 per cent and his basic value would be described as 120. If he were 50 per cent overweight, the basic value or build rating would be 160, and so on. Having thus determined the value of the risk from the standpoint of build alone, the next factor, family history, is taken into account. If the family history is an average one, no addition to or subtraction from the basic rating is made. If it is an unusually favorable family history, a credit of as many as 15 points is made, so that the basic ratings referred to would be decreased by that amount and would read 80 instead of 95, or 105 instead of 120, or 145 instead of 160. If, on the other hand, the family history is quite unfavorable, these 15 points or even more would be added to the ratings and they would read 110, or 135 or 175, as the case may be. Passing to occupation, the insurance value of the factor occupation is taken into account and the addition to or subtraction from the previous rating is made. This process is continued through each one of the factors enumerated and the value of the risk is the algebraic summation of all of these factors. The value of the numerical method is still in question. Those who employ it claim that it produces greater uniformity of medical selec- tion, that it diminishes the number of errors incident to the handling of a large amount of business, that a great deal of the work can be done by lay persons, and that when the advice of a medical officer is needed, his .judgment is steadied and greatly assisted by the standards employed, which express with regard to each factor what has in the 556 LIFE INSURANCE EXAMINATION past happened to large numbers of risks possessing that factor, and what, therefore, may be assumed to probably occur in the future in other similar risks. It is not claimed for these values that they apply exactly to the given case, but the plan leaves the medical director to decide whether the case under consideration is better or worse than the average of its class and to what extent. It may be said also, that the authors of the numerical method say that they expect to make changes in the ratings in the future as new facts are brought out, and that the ratios of extra mortality which they publish should not be looked upon as absolute, but rather as reasonable guides in the selec- tion of risks for insurance.* *The following examples will suffice to illustrate the method: 1. A carpenter aged 30. Height 6 ft. 2 in. Weight 138 lbs. (25 per cent underweight). Father died of consumption, aged 30, family history' otherwise of average quality. Basic Rating (25 per cent underweight) 115 Addition for height +5 Addition for one consumptive in family history +30 Occupation +10 Total value 160 2. A journeyman butcher, aged 40. Height 5 ft. 2 in. Weight 162 lbs. (20 per cent overweight) with excess abdominal girth of three inches. Family History average. Applies for $2,000, 15-year Endowment. Basic Rating (20 per cent overweight) 115 Allowance for Height -5 3 In. excess abdominal girth -...., +10 Occupation +15 Flan of Insurance -5 Total value 130 3. A farmer, aged 30. Height 5 ft. 8 in. Weight 137 lbs. (10 per cent underweight) Of very long-lived family. Applies for 10 year Term. Basic Rating (10 per cent underweight) 100 Excellent Family History -15 Occupation -15 Plan of Insurance +15 Total value +85 NUMERICAL METHOD OF VALUING LIVES FOR INSURANCE 557 Those who are opposed to the numerical method claim that the judgment of a well-trained medical selector is more to be depended upon than any sort of numerical method, and that by its system of debits and credits it may in unusual cases produce results so far at variance with the truth as to be of problematical value, and all the more so because there is no hard and fast method of determining which cases are "unusual." It is probably sufficient to say that this method is the nearest ap- proach that has so far been made to a truly "scientific" medical selection; that it operates in practice with surprising accuracy and that until a better plan has been devised, it will be used by a steadily increasing number of life companies. Those who are especially inter- ested in the subject and wish to pursue it further will find a great many papers bearing upon it in the Proceedings of the Association of Life Insurance Medical Directors and in the Transactions of the Actuarial Society of America, between the year 1906 and the present time. CHAPTER XXXVIII INSURANCE OF SUBSTANDARD LIVES By Robertson Gf. Hunter, Des Moines, Iowa. Second Vice-President and Actuary, Equitable Life Insurance Company of Iowa, The insurance of substandard lives may be said to have had its beginning in the United States in 1896. It was practiced to a lim- ited extent before that time but without much success. In England the practice of rating up underaverage lives had been in existence a great many years, but little attempt had been made by life insur- ance companies to tabulate any statistical data by means of which an underaverage life might be assessed accurately. The medical director, or medical officer as he is called in England, determined 1he advance in age according to the impressions gained by him from personal observations and experiences, supplemented by a few sta- tistics. In 1896 the New York Life Insurance Company began the issu- ance of substandard insurance upon an extensive scale. The basis of the rating for substandard lives had been derived from an investi- gation of the mortality among applicants declined by the New York Life by reason of various impairments for many years prior to its entrance into the field of substandard insurance. For some years after its initial step the New York Life held undisputed sway, but gradually one or two companies undertook the issue of substandard insurance. It was not, however, until recent years that the pub- lication of more and more statistical information regarding the in- fluence on mortality of family history, physical impairment, personal history, etc., caused a decided movement among life insurance com- panies in general to enter the field of substandard insurance. The problem of insuring an underaverage life is not alone that of discovering the extra mortality to which the life will be subject, but also to determine its nature or incidence, and to cover such mor- tality by a policy that will protect the insurance company and will appeal to the public. We may know, for instance, that the extra mortality over a period of years due to a certain impairment can be expressed as a percentage or an addition to the normal mortality, 558 INSURANCE OF SUBSTANDARD LIVES 559 KEUFFEL &, ESSER CO.. NEW YORK. NO. 334 0 /'(j 30 40 50 bO 70 80 AGES Fig. 135. Mortality rate-American Men Mortality Table. ----- Mortality rate-Large Eastern Company. Mortality rate-Moderate sized Middle West company. 560 LIFE INSURANCE EXAMINATION but we may be ignorant whether such extra mortality accrues at the younger ages and diminishes or disappears at the older ages, or is very slight at the younger ages and increases to a considerable extent at the older ages. It will be well, therefore, at the outset to consider the nature, or incidence, of the extra mortality upon substandard lives. It is well known that the mortality rate of a group of lives accord- ing to age can be represented graphically by a curve. Not al] mor- tality curves take the same form, but it will be found that the mor- tality curves of a group of lives accepted by life insurance compan- ies in the United States as standard risks will have the same general form. In other words, the incidence of mortality of one company is much the same as that of another company.' This is shown in Fig. 135. The mortality curves here represented show: (1) The combined mortality rate of a large number of companies from which has been derived the American Men Mortality Table. (2) The mortality rate of a large eastern company. (3) The mortality of a moderate sized middle-west company. If the mortality experienced among all substandard lives could be represented by a single curve in the same manner as the mortal- ity among standard lives, the insuring of substandard lives would be a simple matter. All that would be necessary would be to base the premium rates upon the substandard mortality table in the same manner as the premium rates for standard insurance are based upon the standard mortality tables. In England a mortality table was constructed from the combined experience on damaged lives insured by a number of English companies, but this table was never used for determining the extra premiums for underaverage lives. To have done so would have caused a marked selection against the insurance company, since the lives that were slightly impaired would naturally refuse to pay the extra premium required, while those that ivere decidedly impaired would pay the extra premium with alacrity. This selection would result in throwing entirely out of joint the mor- tality table upon which premiums had been based. It is, therefore, necessary to classify substandard lives in groups that experience a mortality within comparatively narrow limits and treat each group according to the rate and incidence of its mortality. It is generally believed that the mortality of impaired risks with respect to the mortality of standard risks can be classified according to four principal types: INSURANCE OF SUBSTANDARD LIVES 561 (1) Where the extra mortality is slight at the younger ages but increases with the increase in age. (2) Where the extra mortality is considerable at the younger ages but diminishes with the increase in age. (3) Where the extra mortality is a constant addition throughout life to the normal mortality. (4) Where the extra mortality is a constant percentage of the normal mortality. Within recent years writers on this subject have maintained that there are no classes of medically impaired lives which conform to Types 1 and 4; that the extra mortality may increase with age for a period of years, but that it reaches a maximum later on in life and then begins to diminish and eventually disappears. Be that as it may, there is no doubt that during a considerable period of the his- tory of the impaired risks, the mortality does, in the main, partake of the nature of these two types. It is, therefore, important for a proper understanding of substandard insurance to be able to visual- ize the form or shape of the mortality curve that is representative of an impaired life. Figs. 136, 137, 138, and 139 illustrate the four types of mortality curves. As representing the increasing, the de- creasing, the constant addition, and the constant percentage types of extra mortality, the mortality of overweights, of lightweights com- bined with tuberculous family history, of locomotive engineers, and of free users of alcohol respectively has been chosen. These mor- tality curves are not imaginary, but are derived from medico-actuarial experience with slight modifications. In the actual practice of rating impaired risks little or no attempt is made to indicate the form of the mortality curve. The medical director is content, as a general rule, to indicate the extent of the extra mortality that is expected over the whole of life, or at least over a long period of years, and to express it as a percentage of the normal mortality. If, for instance, the medical director is of the opinion that the mortality rate among risks with a certain impair- ment is 50 per cent in excess of that among standard lives, he ex- presses his opinion by stating that the mortality is 150 per cent of 1he standard. It is then the part of the actuary, bearing in mind the incidence of the extra mortality, to advise the kind of policy that should be issued. While this procedure seemingly makes a dis- tinct cleavage between the part played by the medical director and that played by the actuary, in reality the two parts blend together 562 LIFE INSURANCE EXAMINATION KEUFFEL & ESSER CO.. NEW YORK. NO.334D. 25 50 35 4-0 4-5 50 55 60 65 70 56L Fig. 136. Ultimate rate of mortality-American Men Mortality Table. ----- Ultimate rate of mortality-50 to 60 pounds overweight. INSURANCE OF SUBSTANDARD EIVES 563 KEUFFEL & ESSER CO.. NEW YORK. NO. 334D. ZO Z5 30 35 40 45 50 5-5 60 65 10 ME Fig-. 137.- Ultimate rate of mortality-American Men Mortality Table. ----- Ultimate rate of mortality-25 to 45 pounds underweight and tuberculous family history. 564 LIFE INSURANCE EXAMINATION KEUFFEL 4 E88ER CO.. NEW YORK NO. 334 D Z5 30 35 4-0 45 50 55 GO (,5 10 AGO Fig. 138. Ultimate rate of mortality-American Men Mortality Table. ----- Ultimate rate of mortality-Locomotive engineers. INSURANCE OF SUBSTANDARD LIVES 565 in such a way that it is difficult to say where one begins and the other ends. The best results arc obtained by the medical director and the actuary combining their knowledge and passing judgment upon individual risks at one and the same time. There are a number of plans of insurance in use whereby the extra mortality indicated by the medical director can be covered. The most common of these are: (1) Extra premiums added to the premiums for standard lives. (2) Charging a lien against the face of the policy for a fixed period of years or diminishing the lien each year by a certain stated amount until it vanishes. (3) Rating up the age so that the premium charged will be that for a higher age than the true age. (4) Placing the risks in four or five special classes, for each of which an increasingly larger premium is charged. Each one of the above methods is an attempt not only to cover the extra mortality, but also to cover the incidence of the mortality. No one is entirely equitable in itself, and accordingly some com- panies use two or more. Other companies, believing that our knowl- edge of the incidence of the mortality on substandard lives is in- adequate to determine whether even a combination of the methods is equitable, are content to follow one method as the simplest and most practical way to meet the problem. Extra Premium Method.-This is the first known method of in- suring hazardous lives. It consists of adding to the regular premium a flat extra premium that is, so far as hazardous occupations are con- cerned, the same for all ages, but is less on endowment than on life policies. It is seldom applied to medically impaired lives, but when it is so applied, the extra premium may be constant or it may vary with the age and the plan of insurance. The extra premium is, as a rule, non-participating and does not increase the surrender values. The extra premium method was used by the English companies in the first place for covering the extra mortality due to travel, mili- tary or naval service or occupation. As far back as 1821 we read of the Scottish Widow's Fund char ging an extra premium of one- eighth of 1 per cent of the sum insured for the sea risk from Great Britain to France and back by way of Dover and Calais. In 1823 a policyholder was permitted at an extra premium of one-twentieth of 1 per cent to sail in his pleasure boat. 566 LIFE INSURANCE EXAMINATION Extra premiums are very well adapted to those hazardous risks whose mortality can, be represented by a constant addition to the normal mortality. Since there are a number of occupations that in- volve an accident hazard alone, which hazard may be well repre- sented by a constant addition to the normal mortality, the extra premium method has been used very largely in this and other coun- tries for the insuring of persons following hazardous occupations. It is customary to assume that the extra premium is used each year to pay for the extra mortality experienced and accordingly no part of it is accumulated to add to the regular reserve of the policy. Lien Method.-The lien method consists of imposing a lien against the face of the policy so that in case of death the amount payable is the face of the policy less the lien. This lien may be constant for a period of years, after which it vanishes and the full amount of insurance is payable, or the lien may be diminished by a certain stated amount each year, usually the tabular annual premium. The amount of the lien varies with the expected extra mortality. The premium is the same as that for a policy issued for a standard life. The decreasing lien system is well adapted to the type of under- average risks whose extra mortality decreases with increase in age or with duration of the insurance, as, for instance, lightweight risks with a tuberculous family history, but it is unsatisfactory when applied to the type of risks whose extra mortality increases with age or duration of insurance or remains constant. Nevertheless, it had an extensive vogue in the early days of substandard insurance in this country. In England it was harshly criticized for its unscientific character when it was first suggested, but in recent years it has gained some popularity in that country. In the United States, on the other hand, it has largely fallen into disuse due to the fact that it requires a large lien to cover a comparatively small mortality. In the Transactions of the Actuarial Society, Volume XVI, page 69, there appears a table showing that on an Ordinary Life policy a lien of $300 per $1000 of policy, reducible each year by the annual premium, covers a mortality of only 6 per cent of the American Table at age 40, a lien of $500 covers a mortality of only 22 per cent, and a lien of $700, a mortality of 65 per cent. In the type of risk, however, where the lien is most applicable, namely the early extra mortality decreasing with age, the mortality covered by these liens would be considerably greater than that shown in the table. Tn the early days of substandard insurance, when the Hen system INSURANCE OF SUBSTANDARD LIVES 567 was extensively used in the United States, it was the practice to place such policies in a special class as to dividends and distribute the dividends at the end of the deferred dividend period in accord- ance with the mortality experienced in that class. This made it pos- sible to impose a much smaller lien than would otherwise have been necessary. With the prohibition, generally, of deferred dividend policies, the practice of placing impaired lives in special classes as to dividends has almost entirely disappeared. Rated-Up Method.-Coincident with the decline in favor of the lien system, the rated-up system increased in favor. It consists in adding a number of years to the true age of the insured and issuing a policy at the advanced age. Thus, an impaired life thirty-five years of age which is rated up ten years is considered for all purposes the same as a standard life forty-five years of age. The premium, sur- render values, and in the case of participating insurance, the divi- dends are the same as in the case of a policy issued to an insured whose true age is forty-five. This, generally speaking, is the practice of American companies at the present time. In England, on the other hand, where the rated-up system had its birth, less than one- half of the companies that use the rated-up system grant surrender values and dividends at the rated-up age. When the rated-up method is used to cover occupational hazards, a uniform addition to the age is made regardless of the age of the insured or the plan of insurance. As a result, the extra premium charged is too low at the younger ages and too high at the older ages. On the whole, however, the uniform age addition gives satisfactory premiums and has the merit of simplicity. Some companies modify the uniform age addition at the older ages by reducing the age addi- tion so as to make the extra premium approximately the same for all ages above 40 or 45, but as the large majority of hazardous occupa- tions are found at the younger ages, this is not a matter of much practical moment. When the extra mortality to be covered is due to a medical im- pairment, a different procedure is adopted. The advance in age varies with the age of the insured and the plan of insurance. It is the equivalent of the mortality rating expressed as a percentage of the normal mortality. For example, a mortality rating of 150 per cent requires a rating up of ten years on an ordinary life policy at age twenty-five, a rating of eight years at age thirty-five, and a rating up of six years at age forty-five. On the 20 year endowment 568 LIFE INSURANCE EXAMINATION 25 30 35 40 45 SO ' 55 60 65 10 AGE Fig. 139.-■ Ultimate rate of mortality-American Men Mortality Table. ----- Ultimate rate of mortality-Free users of alcohol. INSURANCE OF SUBSTANDARD LIVES 569 30 35 4-0 4-5 true 50 age 55 bO b5 38 4-3 4-8 53 rateo-up 58 age 63 68 73 Fig. 140. Rate of mortality-American Experience Table at True Age. - - - Rate of mortality-150 per cent of American Experience Table. . . . Rate of mortality-American Experience Table at rated- up age. 570 LIFE INSURANCE EXAMINATION the same mortality rating would require a rating up of sixteen years at age twenty-five, ten years at age thirty-five, and seven years at age forty-five. (These are not exact ratings but are approximately correct). To those who have not given much thought to the matter, the larger rating-up on the endowment plan than upon the life plan seems at first glance to be incorrect, but a little consideration will enable them to see that the extra premium obtained by the larger rating-up on the endowment plan is less than that obtained by the smaller rating-up on the life plan. In determining the rating-up required to cover the extra mortality, the assumption has been made that the extra mortality is a percent- age of the normal mortality. The net premium is then calculated upon this basis and compared with the net premiums for standard lives. The age at which the latter net premium approaches nearest to the net premium based upon the multiple of the standard table i the required rated-up age. For example, the net premium at age thirty, based upon 150 per cent of the American Table with 3 per cent interest, is $23.21. The net premium based upon 100 per cent of the American Table with 3 per cent interest at age thirty-eight, is $23.16. Therefore, the required rating-up for a risk thirty years of age rated 150 per cent, is 8 years. This method first of all assumes that the mortality curve conforms to Type 4 (see Fig. 139), namely, where the extra mortality is a percentage addition to the normal mortality and then substitutes a mortality curve conforming to Type 1 (see Fig. 136) ; that is, where the extra mortality is slight at the younger ages but in- creases with the increase in age. For the sake of clearness, a dia- gram (see Fig. 140) is appended showing (a), the normal mortal- ity curve, (b), the multiple mortality curve upon which the net premium for the substandard life is based, and (c), the rated-up mortality curve upon which the actual premium is based. From the foregoing diagram it is evident that the rated-up method is well adapted to that typo of substandard risks whose extra mor- tality increases with age or with the duration of insurance. It is not satisfactory, however, for the type of risk whose mortality decreases with age or duration of insurance. There is always the danger that the insured, if he belongs to the latter type, may become dissatisfied at paying an extra premium when he realizes that through the proc ess of time he has become a standard risk. Those companies that adopt the rated-up system for this class of risks either reduce the Fig-. 141.-Basic ratings for build. The basic rating for men of average height, viz., 5 feet 8 inches, is shown in heavy type in the middle of the square. The ad- ditions to, or deductions from, the basic rating for men under the average height is shown to the left of the basic rating and for men over the average height is shown to the right of the basic rating. For example a man 35 years of age 6 feet in height and 50 per cent overweight has a basic rating of 180 plus 15 or 195. 572 LIFE INSURANCE EXAMINATION Fig. 142.-Additions to basic ratings for tuberculosis in family record. advance in age or remove it after a certain period of years has ex- pired. To make it possible for companies to do this, it is necessary that an additional rating be imposed at the time the policy is issued. Special Classes.-This method consists of placing risks in a num- ber of classes in accordance with the mortality expected in such INSURANCE OF SUBSTANDARD LIVES 573 classes. For example, there may be three classes designated as A, B, and C. In Class A, would be placed all risks whose mortality ranged from 126 per. cent to 150 per cent; in Class B, all risks from 151 per cent to 175 per cent, and in Class C, all risks from 176 per cent to 200 per cent. If it were desired, further classes could be added to cover a mortality up to 300 per cent or 400 per cent. The premium for such classes is based upon a mortality equal to the mean of the minimum and maximum rating of the classes. Thus, the pre- mium charged for Class A would be based upon a mortality of 138 per cent, Class B, 163 per cent, and Class C, 188 per cent. The sur- render values as a general rule arc based upon the same multiples of the normal mortality table as the premiums. This results on the whole in larger surrender values on life policies but lower values on endowment policies than those for standard lives. One or two companies using this method grant the same surrender values as on standard lives. The method of special classes is open to the same objections as the other methods described, in that it assumes that the substandard risks conform to one type, being in this case, the type where the ex- tra mortality is a constant percentage of the normal mortality. It meets, however, one of the greatest objections to the rated-up method, by granting surrender values more in conformity with the mortality likely to be experienced on substandard lives. It lacks the sim- plicity of the rated-up method in that its use requires elaborate tables of reserves and surrender values and the multiplication of the routine actuarial work of an office. Besides the four methods described, some companies accept slightly substandard risks on the endowment plan maturing in twenty years or less. This practice is less common today than it was ten or twenty years ago. Then it was very generally believed that the extra mor- tality among many types of impaired lives, such as overweights, syphilitics, free users of alcohol, was deferred until the risk was fifty or sixty years of age. The many mortality investigations of such lives, that have taken place in recent years, have proved that this impression was erroneous, and as a consequence, a number of com- panies have abandoned the practice. There are, however, occasional risks that may be accepted with negligible loss on the endowment plan. For instance, the extra mortality on a slightly substandard overweight is less over a short period of time than over the whole of life and since the net risk on an endowment policy, by reason of 574 LIFE INSURANCE EXAMINATION Additions to basic ratings for abdominal girth greater than chest expanded. Deductions from basic ratings for abdominal girth less than chest expanded. Deduction from basic ratings for endowments maturing under age of 55. Fig 143 the reserve, decreases rapidly, the extra premium required to cover the extra mortality on an endowment policy is so small that most companies are willing to accept such cases on the endowment plan without any imposition and restriction except possibly the elimina- tion of the term extended option of the non-forfeiture values. During the last ten years, much valuable information has been published concerning the mortality experienced on substandard lives. Much of the information is scattered through the writings of Dr. INSURANCE OF SUBSTANDARD LIVES 575 Rogers and Arthur Hunter. With the permission of the authors, the mortality ratings on impaired lives that arc most frequently met with in practice are given. The original papers and the dis- cussions thereon dealing with each impairment should be read in their entirety before making use of the ratings in actual practice. Additions to Basic Ratings by Reason of Medical Impairment ALBUMINURIA ; Standards used are those recommended by the Association of Life Insurance Medical Directors. Accidental-if found but once in several tests. Intermittent-if found in 2 out of 3 or 4 tests. Constant-if found in 2 out of 2, or 3 out of 3 or 4 tests. Accidental 0 Intermittent ages under 30 30-45 Over 45 Faint trace 0 10 Trace 0 10 20 Moderate 10 20 30 Large Amount 50 up 75 up 100 up Constant Faint trace 10 20 25 Trace 25 35 50 Moderate 40 50 75 Large Amount 100 up 125 up 150 up Ilistory of Within 1 year 10 20 30 Between 1 and 2 years 0 10 20 After 2 years 0 0 0 GASTRIC AND DUODENAL ULCERS: Gastric, with or without operation Within 2 years Decline After 3rd'year SO Deaths per M " 4th " 45 " " " " 5th " 30 " " " " 6th " 15 " Duodenal Ulcer Deaths Per M Year since attack or operation Non-Operated Operated Within 1 year Decline Decline " 2 years 40 10 " 3 " 28 0 " 4 " 15 0 " 5 " 10 0 " 6 " 5 0 GLYCOSURIA: Intermittent-If clearly without diet or treatment 50 to 100 With diet or treatment Decline Persistent-If clearly without diet or treatment but less than 1% sugar in urine ....100 to 150 With diet, treatment, or more than 1% sugar in urine Decline History of-Given by applicant or physician, repeated findings, without diet 20 to 100 576 LIFE INSURANCE EXAMINATION GOITER With tremor, tachycardia or exophthalmos Decline Without any of above: Small 10 to 50 Medium 50 to 75 Large 100 up Operation for: Within 1 year Decline 1 to 5 years, With History of Symptoms 50 up for 5 yns. 1 to 5 years, Without History of Symptoms 0 After 5 years Disregard HABITS IN THE USE OF ALCOHOL-: Occasional excess for day or evening (a) Not more than once every 2 months 50 to 100 (b) Not more than once a month 75 to 150 (c) Once a week Decline Occasional excesses lasting 2 or 3 days (d) Not more than three times per year 150 up (e) More frequently than above Decline (f) Steady, free user, but never intoxicated 50 to 100 History of ' Within 2 yrs. 3 to 5 yrs. 5 to 10 yrs. Over 10 yrs. (a) 40 to 80 30 to 60 20 to 40 10 to 20 (b) 60 " 120 45 " 90 30 " 60 15 " 30 (c) 100 "200 75 " 150 50 " 100 25 " 50 (d) 100 " 200 75 " 150 50 " 100 25 " 50 (e) Decline 100 " 200 75 " 150 50 " 100 (f) 40 " 80 30 " 60 20 " 40 10 " 30 HEART MURMURS: Very best Average With With With con- No Hyper- No Slight Moderate siderable trophy Hyper- Hyper- Hyper- Hyper- trophy trophy trophy trophy Mitral Regurgitation... 60 75 100 125 Decline Mitral Obstruction 200 275 300 350 Decline Aortic Regurgitation.... 200 275 300 350 Decline Aortic Obstruction 75 100 125 150 Decline Pulmonic Regurgitation Like Aortic ' ' Obstruction " " Tricuspid Regurgitation Like Mitral ' ' Obstruction " " (Where pulse is rapid, irregular or intermittent, additional rating is necessary) Functional Ages up to 35 10 Ages 36-45 30 Ages 46 up 50 PULSE: Rapid 90-100 50 to 75 100-110 75 to 125 110 up 125 up Slow 55-65 -10 Below 55 Danger of fatty heart. INSURANCE OF SUBSTANDARD LIVES 577 Irregular and Intermittent 15-30 31-45 40-55 56 up 5 or less per minute 20 40 60 80 Over 5 per minute 30 55 80 100 Irregular and Intermittent 40 75 100 125 RHEUMATISM : Acute articular Single 2 or more attack attacks Within one year 30 40 One to five years 20 25 More than five years 10 15 Chronic deformity 25 up Severe Lumbago 25 up RENAL COLIC: One Two Repeated Attack Attacks Attacks Within one year 50 75 100 up One to two years 30 50 75 up Two to five years 20 30 50 Over five years 10 15 30 TUBERCULOSIS OF LUNGS: A. Without physical signs Age Weight- -20% -10% 0 10% 20% 25 Within 2 years Decline Decline Decline Decline Decline 2 to 5 years 260 175 125 80 60 5 to 10 years 170 115 80 55 40 10 plus years 80 55 40 25 20 35 Within 2 years Decline Decline Decline Decline Decline 2 to 5 years 190 130 90 65 40 5 to 10 years 125 80 60 40 30 10 plus years 60 40 30 20 15 45 Within 2 years Decline Decline Decline Decline Decline 2 to 5 years 95 65 45 30 20 5 to 10 years (.0 40 30 20 10 10 plus years 30 20 15 10 5 B. With physical signs of old trouble 25 Within 2 years Decline Decline Decline Decline Decline 2 to 5 years 370 260 175 125 80 5 to 10 years 235 170 115 80 55 10 plus years 130 85 60 40 30 35 Within 2 years Decline Decline Decline Decline Decline 2 to 5 years 280 190 130 90 60 5 to 10 years 170 125 80 60 40 10 plus years 100 65 45 30 20 45 Within 2 years Decline Decline Decline Decline Decline 2 to 5 years 145 100 65 40 30 5 to 10 years 85 60 40 30 20 10 plus years 50 35 25 20 10 578 LIFE INSURANCE EXAMINATION SYPHILIS : Cured Thoroughly treated Not thoroughly treated Initial Lesion only 30 50 Slight secondaries 40 75 Marked Saturations 50 100 Tertiary Symptoms Decline Decline Note: By thorough treatment is meant adequate supervision for at least two years including mixed treatment, and freedom from symptoms for at least one year before discontinuance of treatment. Bibliography Journal of Institute of Actuaries of England:' xxiv, 385; xxv, 408; xxix, 419; and xli, 461. Transactions of the Actuarial Society of America: xv, 315; xvi, 64; xvii, 17; xviii, 311; xx, 273, 333 and 353, xxi, 16, 151; xxii, 343; xxiii, 347. Proceedings of the Medical Directors Association of America: 1913-1915, 4, 90, 246; 1915-1916, 33, 132; 1916-1918, 29, 34, 326, 365; 1919-1920, 173. Fifth International Congress of Actuaries, i, 207. Specialized Mortality Investigation. Medico-Actuarial Investigation, ii-v. Report of Joint Committee of Actuaries & Medical Directors on Functional Heart Murmurs and Intermittent Albuminuria. Macauley, T. B.: Methods of Dealing with Underaverage Lives: 1901. CHAPTER XXXIX THE RELATION OF BUILD TO MORTALITY By Henry Anthony Baker, M.D., Kansas City, Mo. Medical Director Kansas City Life Insurance Company In the selection of risks for life insurance, the element of build is perhaps the most important single factor we have to consider, and al] methods of rating a risk, either by tire numerical plan or by one of the older plans, start with the consideration of the appli- cant's build as a basis. Early in the history of life insurance, it was found that persons who showed a marked deviation from the average build were sub- ject to a higher mortality, and height and weight tables for the selection of risks were accordingly adopted by most of the com- panies. These tables gave the average weight for the different heights and ages together with figures showing the maximum over- weight and the minimum underweight accepted by the company, 25 per cent overweight and 20 per cent underweight being the usual variations allowed. The first extensive investigation, which was undertaken with a view to securing accurate information upon this subject, was the "Specialized Mortality Investigation," the results of which were published in 1903. This investigation, which included the mortal- ity experience of practically all the old-line companies of America, showed clearly the hazardous nature of risks having at the time of their acceptance a considerable degree of overweight. As a result, insurance practice in regard to the underwriting of overweight risks, particularly those over forty years of age, was considerably modified; and many cases were declined or given substandard pol- icies, which previously had been accepted at standard rates. How- ever, the Specialized Mortality Investigation was not regarded as being entirely satisfactory, on account of the very general charac- ter of the results obtained, and the lack of specific information regarding build groups from which all impairments had been excluded, except those resulting from overweight or underweight. Accordingly, in 1909 the Medico-Actuarial Mortality Investiga- 579 580 LIFE INSURANCE EXAMINATION tion was undertaken, and carried out upon a much larger scale than any previous investigation of this character. The results of this investigation, particularly as regards the mortality of the dif- ferent build groups, included the experience of classes so large, as to be practically conclusive; and some form of table, based on these results, is now used by all life insurance companies in their selection of risks. The original medico-actuarial table was open to some objections, due to the fact that it did not distinguish between applicants of different height, and no adjustment had been made for the undue preponderance of experience in the early policy years. Both of these factors would tend to reflect a more favorable mortality than would actually be experienced in the classes given, and a careful revision of the tables was, therefore, macle by the Joint Committee of the Actuarial Society and the Association of Life Insurance Med- ical Directors, the results of which were published in 1918. Soon after this, a very valuable paper entitled "The Numerical Method of Determining the Value of Risks for Insurance" by Dr. Oscar H. Rogers and Mr. Arthur Hunter was read before the above mentioned Societies, and this paper contained a modification of the table recommended by the Joint Committee which may, at the present writing, be considered the latest and best information upon this subject. With the permission of the authors, this table is reproduced (Table I). The table of mortality, used as a standard of comparison in making these percentages, represents the actual experience of the best American companies on risks, which were accepted at regular rates, and shows a considerably lower mortality than the American table upon which life insurance rates are based. A company, there- fore, experiencing a mortality equal to 100 per cent of this table will make the average mortality saving of the best life companies, which is essential in order to insure its prosperity and endurance. Most companies do not consider it good underwriting to accept any case, at standard rates, where the final mortality rating according to this table is over 120 per cent; for each case accepted with a rating of 120 must be balanced by one for an equal amount with a rating of 80, in order to secure a standard of 100. In calculating the degree of under- or overweight, the Standard Build Table of the Medico-Actuarial Investigation was used, and a THE RELATION OF BUILD TO MORTALITY 581 AGE 30% 25% 20% 15% 10% 5% 0 + 5% + 10% 15% + 20% + 25% + 30% + 35% 40% %■ 45% + 50% + 55% + 60% 65% + 70% *15 *155 *145 *135 125 115 no 105 100 95 95 95 100 105 no 115 125 135 140 150 165 175 *20 *140 *130 *125 115 no 105 100 95 95 95 100 105 no 120 130 140 150 160 170 180 195 25 130 120 115 110 105 100 95 95 95 100 105 no 120 130 140 150 160 170 180 195 205 30 120 115 110 105 100 100 95 95 95 100 no 120 125 135 145 160 170 180 195 205 220 35 115 110 105 100 100 95 95 95 100 105 115 125 135 145 155 165 ISO 190 205 215 230 40 110 105 100 100 100 95 95 95 100 105 115 125 135 145 160 170 185 195 210 220 235 45 105 100 100 100 95 95 95 100 105 no 120 130 145 155 165 175 190 200 215 225 240 50 105 100 100 100 95 95 95 100 105 no 120 130 145 155 165 180 195 205 220 230 245 55 100 100 100 100 95 95 95 100 105 no 120 130 145 155 165 ISO 195 205 220 230 245 60 100 100 100 100 95 95 95 100 105 no 120 130 145 155 165 180 195 205 220 230 245 5-0 -10 -10 -10 -10 -10 -5 -5 -5 -5 -5 -10 -10 -15 -15 -15 -15 5-2 -5 -5 -5 -5 -5 -5 -5 -5 -5 -5 -5 -10 -10 -10 -10 5-4 -0 -0 -0 -0 -0 -0 -0 -0 -0 -0 -0 -0 -5 -5 -3 5-6 +0 -0 -0 -0 -0 -0 -0 -0 -0 -0 -0 -0 -0 -0 -0 -0 5-10 +0 +0 +0 +0 +0 +5 +5 +5 +5 +5 +10 +10 +10 +10 +15 +15 6-0 -0 +0 +0 +0 +0 +5 +10 +10 +10 +10 +15 +15 -15 +15 +20 +20 6-2 +5 +5 +5 +5 +5 +10 +15 +15 +15 +15 +20 +20 +25 +25 +30 +30 6-4 +10 +10 +10 +10 +10 +10 +15 +15 +20 +20 +25 +25 +30 +30 +35 +35 Table I BASIC RATINGS FOR BUILD. (AVERAGE FAMILY HISTORY). Percentage Departure from Average Weight MODIFICATION FOB HEIGHT 582 LIFE INSURANCE EXAMINATION Table II This table of modifications to be used only at age 15 with 30%, 25%, 20% and 15% underweight, and age 20 with 30%, 25% and 20% underweight as indicated by *. DEGREE OF UNDERWEIGHT * -30% -25% -20% -15% AGE 15 AGE 20 AGE 15 AGE 20 AGE 15 AGE 20 AGE 15 5-0 -20 -15 -20 -15 -15 -10 -15 5-2 -15 -10 -15 -10 -10 -5 -10 5-4 -10 -5 -10 -5 -5 -0 -5 5-6 -5 -0 -5 -0 -0 -0 -0 5-10 +5 +0 +5 +0 +0 40 +0 6-0 +10 +5 + 10 +5 +5 +0 +5 6-2 +15 +10 +15 +10 +10 +5 +10 6-4 +20 4-15 +20 +15 +15 +10 +15 Table III Debits for Abdominal Girth Greater than Chest Expanded 30% OR LESS 31% to 40% 40% OR MORE ABDOMINAL OVERWEIGHT OVERWEIGHT OVERWEIGHT GIRTH AGE AGE AGE AGE AGE AGE AGE AGE AGE UNDER 40 TO OVER UNDER 40 TO OVER UNDER 40 TO OVER 40 50 50 40 50 50 40 50 50 0 inch excess- 0 0 0 0 0 0 0 5 10 1 ( ( c c 0 0 5 0 5 10 5 10 20 2 c c c c 0 5 10 5 10 15 10 20 35 3 (( (( 5 10 15 10 20 25 15 35 55 4 ( c < c 10 15 25 20 30 40 25 50 75 Credits for Abdominal Girth Less than Chest Expanded Table IV ABDOMINAL GIRTH LESS THAN CHEST EXPANDED INCHES 20% to 30% OVERWEIGHT 31% to 40% OVERWEIGHT 40% OR MORE OVERWEIGHT ■AGE UNDER 40 AGE 40 TO 50 AGE OVER 50 AGE UNDER 40 AGE 40 TO 50 AGE OVER 50 AGE UNDER 40 AGE 40 to 50 AGE OVER 50 -1 inch 0 0 0 0 0 0 0 0 0 -2 " 0 0 0 0 0 -5 0 -5 -10 -3 " 0 0 -5 0 -5 -10 -5 -10 -15 -4 " 0 -5 -10 -5 -10 -15 -10 -15 -20 copy of this table is also given (Table VIII). In using this table in the case of female applicants, it must be remembered that the av- erage female is about five pounds lighter than the average male, at a given height and age, and a simple rule of sufficient accuracy will be to deduct five pounds from the weight given in the table, in order to determine the standard weight of a female. THE RELATION OF BUILD TO MORTALITY 583 Table V Men Table of Average Height and Weight at Varying Ages 20% Under and Over HEIGHT AGES 15 20 25 30 35 40 45 50 to to to to to to to and Ft. In. 19 24 29 34 39 44 49 over 90 95 99 102 103 106 107 108 5 0 113 119 124 127 129 132 134 135 136 143 149 152 155 158 161 162 92 97 101 103 105 107 109 110 5 1 115 121 126 129 131 134 136 137 138 145 151 155 157 161 163 164 94 99 102 105 106 109 110 111 5 2 118 124 128 131 133 136 138 139 142 149 154 157 160 163 166 167 97 102 105 107 109 111 113 114 5 3 121 127 131 134 136 139 141 142 145 152 157 161 163 167 169 170 99 105 107 110 112 114 115 116 5 4 124 131 134 137 140 142 144 145 149 157 161 164 168 170 173 174 102 108 110 113 115 117 118 119 5 5 128 135 138 141 144 146 148 149 154 162 166 169 173 175 178 179 106 111 114 116 118 120 122 122 5 6 132 139 142 145 148 150 152 153 158 167 170 174 178 180 182 184 109 114 117 119 1.22 123 125 126 5 7 136 142 146 149 152 154 156 158 163 170 175 179 182 185 187 190 112 117 120 123 126 127 129 130 5 8 140 146 150 154 157 159 161 163 168 175 180 185 188 191 193 190 115 120 123 126 130 131 133 134 5 9 144 150 154 158 162 164 166 168 173 180 185 190 194 197 199 202 118 123 126 130 134 135 137 138 5 10 148 154 158 163 167 169 171 173 178 185 190 196 200 203 205 208 122 126 130 134 138 140 142 142 5 11 153 158 163 168 172 175 177 178 184 190 196 202 206 210 212 214 126 130 135 139 142 145 146 147 (5 0 158 163 169 174 178 181 183 184 190 196 203 209 214 217 220 221 130 134 140 144 147 150 152 153 6 1 163 168 175 180 184 187 190 191 196 202 210 216 221 224 228 229 134 138 145 149 153 155 158 158 6 2 168 173 181 186 191 194 197 198 202 208 217 223 229 233 236 238 138 142 150 154 158 161 163 164 6 3 173 178 187 192 197 201 204 205 208 214 224 230 236 241 245 246 584 LIFE INSURANCE EXAMINATION Table VI Women Table of Average Height and Weight at Varying Ages 20% Under and Over HEIGHT AGES 15 20 25 30 35 40 45 50 to to to to to to to to Ft. In. 19 24 29 34 39 44 49 54 83 86 88 90 93 96 98 100 4 8 104 107 110 113 116 120 123 125 125 128 132 136 139 144 148 150 85 87 90 92 94 98 100 102 4 9 106 109 112 115 142 122 125 127 127 131 134 138 118 146 150 152 86 89 91 94 96 99 102 103 4 10 108 111 114 117 120 124 127 129 130 133 137 140 144 149 152 155 88 90 93 95 98 101 103 105 4 11 110 113 116 119 122 126 129 131 132 136 139 143 146 151 155 157 90 92 94 97 99 102 105 106 5 0 112 115 118 121 124 128 131 133 134 138 142 145 149 154 157 160 91 94 96 98 101 104 106 108 5 1 114 117 120 123 126 130 133 135 137 140 144 148 151 156 160 162 94 96 98 100 103 106 109 110 5 2 117 120 122 125 129 133 136 138 140 144 146 150 155 160 163 166 96 98 100 102 106 109 111 113 5 3 120 123 125 128 132 136 139 141 144 148 150 154 158 163 167 169 98 101 103 106 109 111 114 115 5 4 123 126 129 132 136 139 142 144 148 151 155 158 163 167 170 173 101 103 106 109 112 114 117 118 5 5 126 129 132 136 140 143 140 148 151 155 158 163 168 172 175 178 104 106 109 112 115 118 121 122 5 (i 130 133 136 140 144 147 151 152 156 160 163 168 173 176 181 182 107 110 11,2 115 118 121 124 126 5 7 134 137 140 144 148 151 155 157 161 164 168 173 178 181 186 188 110 113 115 118 122 124 127 130 5 8 138 141 144 148 152 155 159 162 166 169 173 178 182 186 191 194 113 116 118 122 125 127 130 133 5 9 141 145 148 152 156 159 163 166 169 174 178 182 187 191 196 199 116 119 122 124 127 130 133 136 5 10 145 149 152 155 159 162 166 170 174 179 182 186 191 194 199 204 120 122 124 126 130 133 136 139 5 11 150 153 155 158 162 166 170 174 180 184 186 190 194 199 204 209 THE RELATION OF BUILD TO MORTALITY 585 Table VII Expectations of Life YEARS OLD EXPECTATION YEARS EXPECTATION EXPECTATION YEARS YEARS OLD YEARS YEARS OLD 10 48.7 40 28.2 70 8.5 11 48.1 41 27.5 71 8.0 12 47.4 42 26.7 72 7.6 13 46.8 43 26.0 73 7.1 14 46.2 44 25.3 74 6.7 15 45.5 45 24.5 75 6.3 1G 44.9 46 23.8 76 5.9 17 44.2 47 23.1 77 5.5 18 43.5 48 22.4 78 5.1 19 42.9 49 21.6 79 4.8 20 42.2 50 20.9 80 4.4 21 41.5 51 20.2 81 4.1 22 40.9 52 19.5 82 3.7 23 40.2 53 18.8 83 3.4 24 39.5 54 18.1 84 3.1 25 38.8 55 17.4 85 2.8 26 38.1 56 16.7 86 2.5 27 37.4 57 16.1 87 2.2 28 36.7 58 15.4 88 1.9 29 36.0 59 14.7 89 1.7 30 35.3 60 14.1 90 1.4 31 34.6 61 13.5 91 1.2 32 33.9 62 12.9 92 1.0 33 33.2 63 12.3 93 .8 34 32.5 64 11.7 94 .6 35 31.8 65 11.1 95 .5 36 31.1 66 10.5 37 30.4 67 10.0 38 29.6 68 9.5 39 28.9 69 9.0 Iii using the Rogers and Hunter table, the percentage degree of overweight or underweight should first be determined, and by fol- lowing this column down to the nearest age line, the mortality rat- ing will be found. The correction for height will be found by following the same column down to the table of modifications. This correction should be added or subtracted as shown in the table. (The corrections given do not apply at ages fifteen and twenty among the extreme light weights marked with a star*, and the small table, No. II, should be used in these cases.) Excessive abdominal girth in overweights has also been found 586 LIFE INSURANCE EXAMINATION Age 5ft. 5ft. 1 in. 5ft. 2 in. 5ft. 3 in. 5ft. 4 in. 5ft. 5 in. 5ft. 6 in. 5ft. 7 in. 5ft. 8 in. 5ft. 9 in. 5ft. 10 in. 5ft. 11 in. 6ft. Oft. 1 in. 6ft. 2 in. 6ft. 3 in. 6ft. 4 in. 6ft. 5 in. 15 107 109 112 115 118 122 126 130 134 138 142 147 152 157 162 167 172 177 16 109 111 114 117 120 124 128 132 136 - 140 144 149 154 159 164 169 174 179 17 111 113 116 119 122 126 130 134 138 142 146 151 156 161 166 171 176 181 18 113 115 118 121 124 128 132 136 140 144 148 153 158 163 168 173 178 183 19 115 117 120 123 126 130 134 138 142 146 150 155 160 165 170 175 180 185 20 117 119 122 125 128 132 136 140 144 148 152 156 161 166 171 176 181 186 21 118 120 123 126 130 134 138 141 145 149 153 157 162 167 172 177 182 187 22 119 121 124 127 131 135 139 142 146 150 154 158 163 168 173 178 183 188 23 120 122 125 128 132 136 140 143 147 151 155 159 164 169 175 180 185 190 24 121 123 126 129 133 137 141 144 148 152 156 160 165 171- 177 182 187 192 25 122 124 126 129 133 137 141 145 149 153 157 162 167 173 179 184 189 194 26 123 125 127 130 134 138 142 146 150 154 158 163 168 174 180 186 191 196 27 124 126 128 131 134 138 .142 146 150 154 158 163 169 175 181 187 192 197 28 125 127 129 132 135 139 143 147 151 155 159 164 170 176 182 188 193 198 29 126 128 130 133 136 140 144 148 152 156 160 165 171 177 183 189 194 199 30 126 128 130 133 136 140 144 148 152 156 161 166 172 178 184 190 196 201 31 127 129 131 134 137 141 145 149 153 157 162 167 173 179 185 191 197 202 32 127 129 131 134 137 141 145 149 154 158 163 168 174 180 186 192 198 203 33 127 129 131 134 137 141 145 149 154 159 164 169 175 181 187 193 199 204 34 128 130 132 135 138 142 146 150 155 160 165 170 176 182 188 194 200 206 Table VIII Build-Men Graded Average Weight THE RELATION OF BUILD TO MORTALITY 587 35 128 130 132 135 138 142 146 150 155 160 165 170 176 182 189 195 201 207 36 129 131 133 136 139 143 147 151 156 161 166 171 177 183 190 196 202 208 37 129 131 133 136 140 144 148 152 157 162 167 172 178 184 191 197 203 209 38 130 132 134 137 140 144 148 152 157 162 167 173 179 185 192 198 204 210 39 130 132 134 137 140 144 148 152 157 162 167 173 179 185 192 199 205 211 40 131 133 135 138 141 145 149 153 158 163 168 174 180 186 193 200 206 212 41 131 133 135 138 141 145 149 153 158 163 168 174 180 186 193 200 207 213 42 132 134 136 139 142 146 150 154 159 164 169 175 181 187 194 201 208 214 43 132 134 136 139 142 146 150 154 159 164 169 175 181 187 194 201 208 214 44 133 135 137 140 143 147 151 155 160 165 170 176 182 188 195 202 209 215 45 133 135 137 140 143 147 151 155 160 165 170 176 182 188 195 202 209 215 46 134 136 138 141 144 148 152 156 161 166 171 177 183 189 196 203 210 216 47 134 136 138 141 144 148 152 156 161 166 171 177 183 190 197 204 211 217 48 134 136 138 141 144 148 152 156 161 166 171 177 183 190 197 204 211 217 49 134 136 138 141 144 148 152 156 161 166 171 177 183 190 197 204 211 217 50 134 136 138 141 144 148 152 156 161 166 171 177 183 190 197 204 211 217 51 135 137 139 142 145 149 153 157 162 167 172 178 184 191 198 205 212 218 52 135 137 139 142 145 149 153 157 162 167 172 178 184 191 198 205 212 218 53 135 137 139 142 145 149 153 157 162 168 172 178 184 191 198 205 212 218 54 135 137 139 142 145 149 153 158 163 168 173 178 184 .191 198 205 212 219 55 135 137 139 142 145 149 153 158 163 168 173 178 184 191 198 205 212 219 & up 588 LIFE INSURANCE EXAMINATION to result in an increased mortality, and a further correction for this factor is necessary. The extra mortality for excessive abdom- inal girth shown in Table III should, of course, be added to the mortality for overweight, which has received the proper correction for height, while the credits for abdominal girth less than chest expanded shown in Table IV should lie subtracted. A few examples will suffice to show the ease with which these tables may be used in determining the basic mortality for build. (1) Applicant age thirty, height 5 feet 8 inches, 30 per cent overweight- abdomen one inch less than chest expanded. Mortality rating for overweight 125 Correction for height 0 Correction for abdominal measurement 0 Build rating 125 (2) Applicant age forty-five, height 6 feet, 35 per cent overweight-abdomen one inch greater than chest expanded. Mortality rating for overweight 155 Correction for height +10 Correction for abdominal measurement + 5 Build rating 170 (3) Applicant age forty, height 5 feet 2 inches, 45 per cent overweight- abdomen two inches greater than cheist expanded. Mortality rating for overweight 170 Correction for height - 5 Correction for abdominal measurement +20 Build rating 185 (4) Applicant age twenty-five, height 5 feet, 2 inches, 20 per cent under- weight. Mortality rating for underweight 115 Correction for height - 5 Build rating no (5) Applicant age twenty, height 6 feet, 25 per cent underweight. Mortality rating for underweight 130 Correction for height + 5 (See Table II) Build rating 135 The rating for build having been determined, the final rating for the risk can be calculated by subtracting from or adding to the build figures, according as the other factors are more or less favorable than the average risk. THE RELATION OF BUILD TO MORTALITY 589 Among the underweights, the favorable factors would be longev- ity in the family history, outdoor occupation and residence in a place having a fine climate; whereas, unfavorable factors would be a family history of tuberculosis, personal history of tuberculous infection or indoor occupation. Among overweights, favorable factors would be longevity in the family history, an occupation involving considerable muscular exercise, and abstinence from alcohol; while unfavorable factors would be sedentary occupation, personal history of cardiovascular or renal disease, and indulgence in alcoholic beverages. In select- ing overweight risks, it is essential to determine accurately the blood pressure, both systolic and diastolic, and to make a careful microscopic examination of the urine. Any abnormality so discov- ered should weigh heavily against the risk. It may be accepted without question, that these tables repre- sent with great accuracy the present value of life insurance risks with reference to build, and it is probable that no great change in rating will occur in the immediate future. What eventual change may occur as the result of habits of living, better or worse than present standards, remains to be seen; but it is within reason to believe that with the advancement of knowledge, the general mor- tality at all ages will improve. Bibliography The Specialized Mortality Investigation, Actuarial Society of America, New York, 1903. The Medico-Actuarial Mortality Investigation, The Association of Life Insur- ance Medical Directors, and The Actuarial Society of America, New York, 1912. Standard Mortality Ratios Incident to Variations in Height and Weight Among Men. Report of the Joint Committee of the Actuarial Society of America and the Association of Life Insurance Medical Directors, New York, 1918. The Numerical Method of Determining the Value of Risks for Insurance. Dr. Oscar II. Rogers and Mr. Arthur Hunter, Transactions Actuarial Society of America, New York, 1919. CHAPTER XL EXAMINATIONS FOB HEALTH AND ACCIDENT INSURANCE By M. C. Wilson, M.D., Hartford, Conn. Assistant Medical Director, The Travelers Insurance Co. Examinations for accident and health insurance require not only a good medical and surgical knowledge, but also the fundamentals of accident insurance, the principles upon which it is based, the main points of policy coverage and the requirements of the company. Accident insurance is issued on an application setting forth cer- tain facts descriptive of the risk; namely, age, height and weight, nationality, residence, occupation, insurance history, beneficiary, medical or surgical history and the present physical condition. The consideration also takes into account the financial and moral status. The premium rates are based on the occupational hazard. A medical examination is not required unless the information obtained in regard to the case renders the risk a questionable one. Under such circumstances, an examination may be requested in order that a more accurate knowledge of the physical condition be obtained and thus enable the underwriter to give due consideration to the points in question. From a physical standpoint, the policy coverage presupposes a normal individual. Deviations from normal complicate coverage in that death, disability or other loss may not be caused entirely by an injury independent of other factors. Tn underwriting this form of contract, the facts as set forth in the application are carefully weighed to determine whether or not there is any condition in the history or a physical impairment that would render the applicant more prone to accidents or that his reaction to injury would be impaired. To describe the application somewhat more in detail, it may be divided into three parts; namely, identification, exposure and phys- ical condition. Under identification is included the name, residence and physical description of the applicant, and name, address and relationship of the beneficiary. 590 HEALTH AND ACCIDENT INSURANCE 591 Under exposure may be grouped the statements describing the occupation and business duties of the insured, any specific under- takings in which he may be temporarily engaged, his financial condition and an enumeration of such other insurance as he may carry. The description of the occupation controls, not only the premium rate at the time the policy is issued but, by the terms of the policy, also directly controls the payments of benefits pro- vided by it. Under physical condition is the description of the risk; namely, age, height, weight, bodily and mental condition, impairments or infirmities, if any, medical or surgical treatment and previous claim experience with other companies. Height and weight are impair- ments when the extremes are reached. Deformities such as club foot, infantile paralysis, ankylosed joints, etc., manifestly render one so afflicted less able to protect himself against injury. Impairments or infirmities refer to those diseases or deformities which by their nature may complicate, simulate, prolong disability or other loss or in themselves be a cause of injury. Defects of sight or hearing are of importance when the degree is such that the condition becomes an impairment. A history of illness or injury must be carefully considered, for if by its character the resistance of the individual is lowered or the condition be one that may be excited into activity by trauma, the insurability is necessarily affected. Any existing anatomical defects or abnormal conditions produced by injury or disease, such as hernia, varicose veins, loose joint bodies or fibrocartilages must be eliminated from the contract cov- erage by means of a waiver, providing the risk is otherwise an acceptable one. The application for health insurance does not materially differ from that for accident insurance. The chief points in the selection are the determination by the history and the investigation of same, as to the possibility of disease already being existent or whether diseases suffered may be recurrent in nature. Owing to the fact that most individuals suffer some disability during a year period and in view of the broad coverage of the health policy, it is essen- tial that the risk be carefully scrutinized, as it is impossible for any company to grant coverage to one in whom disease has already 592 LIFE INSURANCE EXAMINATION had its inception or has had an illness or condition, the very nature of which makes recurrence probable. The application for accident or health insurance is incorporated in, and when issued becomes a part of, the contract. The Accident Policy.-The accident contract provides indemnity for loss of life, limb, sight and time, caused by bodily injuries af- fected through external violence. The following description quotes and in part describes some of the provisions and benefits set forth in an accident policy with which the examiner should be familiar. This knowledge will be of aid in answering the questions found on the examination blank and will also make clear the requirements of the company. The accident contract has an insuring clause which is the key- note of policy coverage and reads as follows: "Insures against loss resulting from bodily injuries af- fected directly and independently of all other causes through external and accidental means." This requires that disease or infirmity be not a contributing fac- tor to either the accident, the injury, or the disability. Interpre- tation is as follows: If, at the time of an injury, the insured was suffering from some disease, but the disease had no causal connection with the injury or death resulting from the accident, the accident is to be consid- ered the sole cause. If, at the time of the accident, there was an existing disease, which, cooperating with the accident, resulted in the injury or death, the accident cannot be considered as the sole cause or as the cause independently of all other causes. It is, of course, easy to conceive of an accidental injury so mani- festly destructive that the diseased condition of the individual would contribute in no way to the catastrophe. "Accidental Means" refers to the event which immediately pre- ceded the injury in which something unforeseen, unusual or unex- pected occurred. An unexpected result may be the unforeseen or unlooked-for consequence of an intentional act, or it may be the consequence of unintentional acts or of causes not within control. The latter group of cases falls within the scope of accident insurance. Specific Losses.-Life. Both hands or both feet or sight of both eyes, one hand and one foot. Either hand or foot and sight of one HEALTH AND ACCIDENT INSURANCE 593 eye. Either hand or foot. Sight of one eye. Thumb and index finger of either hand. by severance at or above wrist or ankle joints; with regard to Loss shall mean, with regard to hands and feet, dismemberment eyes, entire and irrecoverable loss of sight; with regard to thumb and index finger, severance at or above the metacarpophalangeal joints. The principal sum is paid for loss of life, both hands, both feet, a hand and a foot, or a hand or foot and an eye. The sum payable under the other specified losses differs somewhat according to the form of contract carried. These losses must result from the bodily injuries alone, without complication from any preexisting disease or infirmity, or any sub- sequently acquired disease that may become a contributing factor. The time limit in which a specific loss shall occur is designated by the following clause which appears in most accident contracts: If such injuries shall wholly and continuously disable the insured from date of accident from performing any and every kind of duty pertaining to his occupation, and during the period of such contin- uous disability, but within two hundred weeks from date of acci- dent, shall result, independently and exclusively of all other causes in one of the losses enumerated, or within ninety days from the date of the accident, irrespective of total disability, result in like manner in any one of such losses, the company will pay the sum specified for such loss. Total and Partial Disability Total loss of time.-If such injuries, independently and exclusively of all other causes, shall wholly and continuously disable the insured from the date of the accident from performing any and every kind of duty pertaining to his occupa- tion, the company will pay, (period differs with the form of contract) a weekly indemnity of $ Partial loss of time.-If such injuries, independently and exclusively of all other causes, shall wholly and continuously disable the insured from date of acci- dent from performing one or more important daily duties pertaining to his occu- pation, or for like continuous disability following total loss of time, the company will pay, during the period of such disability, but not exceeding (duration differs with policy form) a weekly indemnity of $ Surgical Hospital Benefits and Doctor's Fees.-The policy con- tains a "Schedule of Operations." Should the injury necessitate one of these operations, the insured is entitled to the amount pro- 594 LIFE INSURANCE EXAMINATION vided for the same in addition to such other indemnities as are provided in the policy. Should the injuries necessitate hospital treatment within ninety days from the date of the accident, the insured has the option, pro- vided no claim is made for an operation fee, of being reimbursed for the amount actually expended for hospital treatment in a sum not exceeding one-half of the total weekly indemnity over a period not exceeding (period as given in form of contract). Should the injuries not result in any loss for which indemnity is payable under the policy, but require surgical treatment, the com- pany will pay the amount expended for that treatment, but not exceeding the amount of one week's total indemnity. Optional Indemnity.-The policy also contains "Schedule of Elec- tive Benefits." The insured, if he so elect, within twenty days from the date of accident may take, in lieu of the weekly indemnity provided for total and partial disability, indemnity in one sum, ac- cording to the schedule, if the injury is one set forth in such sched- ule, but not more than one elective benefit shall be paid for injuries resulting from one accident. The policy contains a provision in regard to examinations which reads that-"The company shall have the right and opportunity to examine the person of the insured when and so often as it may reasonably require during the pendency of a claim, and also the right and opportunity to make an autopsy in case of death where it is not forbidden by law. The Health Policy.-The health contract provides indemnity for disability caused by disease. The Schedule of Indemnities often found in such contracts are as follows: Temporary Disability.-For a period of continuous disability dur- ing which the insured shall independently of all other causes, be wholly disabled and prevented by bodily disease, not excepted by the policy, from performing any and every kind of duty pertaining to his occupation, the company will pay a weekly indemnity of $ . Some policy forms divide the period of total disability into two parts, namely, house confining and non-house confining, the latter period calling for a lesser amount of indemnity than the former. Another form provides for partial loss of time during which the HEALTH AND ACCIDENT INSURANCE 595 insured shall be continuously disabled and prevented by disease from performing at least half the work essential to the duties of his occupation. The period of time during which indemnity shall be paid varies with the contract. Permanent Disability.-In certain specific losses, namely, entire and irrecoverable loss of use of both hands or both feet, or of one hand and one foot, or the sight of both eyes as the result of disease, the company pays an additional weekly indemnity as set forth under that provision. Hospital Indemnity.-If on account of illness for which weekly indemnity is payable, the insured shall be removed to a hospital within a given period (usually ninety days) from the date of com- mencement of disability, the company pays per cent addi- tional weekly indemnity for the period during which he shall be a patient in the hospital, but not exceeding consecutive weeks. Surgical Benefits.-A schedule of operations is provided which if performed by a surgeon on account of a disease covered by the policy, and within a given period from the date of the commencement of such disease, the company pays the benefit specified in the sched- ule in addition to any other indemnity to which the insured may be entitled. Only one operation fee is payable for one illness; if the illness necessitates more than one operation, the largest fee as provided in the schedule is paid. The policy does not cover disability, temporary or permanent, un- less the disease is contracted and the disability begins while the policy is in force. The policy also requires that the insured be treated by a physician for the disease for which claim is being made. The usual health policy dates its coverage fifteen days from the date of issue. The right to examine is the same as set forth under the accident policy. The Examination of Claimant.-When a notice of injury or ill- ness is given the company, an examination is usually requested. The purpose of such an examination is to determine the nature of the injury or illness, the disability suffered and the probable dura- tion, the character of operations, if any have been performed, and the existence of complications. An examination blank is furnished. The questions as set forth 596 LIFE INSURANCE EXAMINATION vary somewhat in different companies, but in general have the one aim and are designed to bring out information essential to the handling of the claim. Name of Claimant. Give full name. Do not use initials. Date of Examination, (a) Place of Examination, (b) The date of examination shows when examination was made in relation to the disability claimed, and makes apparent differences in visible evidence of injury and those alleged to have occurred. The place of examination aids in the determination of disability and whether it is total or partial. Describe occupation, nature of business engaged in and duties performed. Accident risks are classified and the premium rates based on occupation. The answer should be descriptive, as it serves as a check and aids the claim department in their investigation. It is also essential to the exam- iner in his estimation of total or partial disability. Date of accident (a) Date of Commencement of disability (b) The date of accident must be accurate and should be known to claimant unless he is mentally confused as a result of the accident or by disease. In such an event, the date should be determined from witnesses or one whose knowledge of the occurrence can be relied upon. It is not infre- quent that those-who are suffering from some condition believe that their troubles are the result of some accident which they must have had, al- though they cannot place or describe the incident. Therefore, it can readily be seen that the accuracy or inaccuracy of a date may be the determining factor in differentiating accident from disease. The date of commencement of disability must not be confused with the date of the accident. It is designed to show whether disability was immediate fol- lowing the accident or was delayed. If disability does not immediately follow an injury, the examiner should explain, describing what took place in the interval and whether any other factor, such as disease, entered and was the real determining cause in producing disability. Describe the Accidental Occurrence. This question calls for a description of "Accidental Means." It is the act which preceded the injury in which something unforeseen, unexpected, or unusual took place. Describe and locate accurately character and extent of injury and visible evidence of same at time of examination. It is not always possible to describe the appearance of an injury when the part is protected by dressings, casts, etc., but the examiner can usually conclude more or less accurately from the history and the character of dressings as to the nature of the injury. When in doubt, an appointment HEALTH AND ACCIDENT INSURANCE 597 should be made to inspect the part when the attending physician is present. It is important that the site of injury be anatomically located. Wounds should be described as to extent and character; i. e., whether incised, con- tused, or lacerated, whether clean or infected. Fractures-give the name of bone, the line of fracture and through what portion. Was it simple or compound? If a joint is involved or there has been unusual injury to the soft parts, so state. Joints-give the name of joint and the nature of the injury, stating whether the soft parts, liga- ments, or intra-articular structures are involved and what, if any, inflam- matory reaction took place. Dislocations-do not describe as dislocations other than those in which a true displacement of the bone occurred and required some external force or manipulation for its reduction. So-called "partial dislocations" or those in which the joint is carried beyond its physiological limit but return to their normal position without outside in- terference, constitute sprains and must not be confused with or classified as true dislocations. If fracture or dislocation, state whether complete or partial. Policy coverage differs with the form of contract and in order to know what fee is properly payable, it is necessary to know, if a fracture, the part of the bone involved and whether the line of fracture completely in- terrupted the continuity of the part or was merely a crack or " green stick" fracture. Impacted fractures are considered as complete fractures. Dislocations should be stated whether complete or partial. The descrip- tion in the preceding question will describe. If injury required surgical operation, describe operation performed. In fractures and dislocations state by what means reduction was per- formed. All other operations should be described as to their character and purpose; e. g., incision of an abscess or infected area for drainage. Cutting into abdominal cavity for repair of injured viscera, etc. The use of sutures should be stated when they constitute the surgical procedure, but not when they are merely a part incident to an operation. Estimation of Disability. Total Disability-Weeks-days. Partial Disability-Weeks-Days. The probable duration that the disability should continue as total or par- tial is to be your opinion, based on information obtained by examination and history of the case. The claimant's opinion as to how long he expects to be disabled or what the attending physician has led him to believe must not be taken into account. Those cases in which disability has terminated, it is permissible for claimant to give the duration, but the nature of the injury should be such that inability to perform any or part of the duties of his occupation would appear reasonable, if not, explain. In estimating disability, the nature of the occupation must be taken into account with the character of the injury for loss of time based on the inability to per- 598 LIFE INSURANCE EXAMINATION form, because of this injury, all or one or more important daily duties pertaining to the occupation. It is not expected that the final claim will necessarily conform to the estimate as many unforeseen factors may inter- vene, but the periods given serve as a basis on which the Adjuster may reasonably expect to make settlement. If disease or infirmity is a contributing factor to either the accident, the injury, or the disability, state how and to what extent. The answer to this question can be brought out in the history-taking or observations while making examination. It is not necessary to always make a complete physical examination, but when in doubt, an examination of the chest, abdomen, blood pressure, etc., should be made and a specimen of urine obtained. If any laboratory tests have been made by the attend- ing physician he should be consulted as to the findings. Disease may con- tribute to either the accident, the injury, or the disability, and thus not conform to the insuring clause of the accident policy. For example, an individual with arteriosclerosis or a high blood pressure may be found suffering from a cerebral hemorrhage and with some slight evidence of injury to the head. The question always arises, was the hemorrhage spon- taneous and the cause of the fall or did the fall cause the hemorrhage? No matter which occurred first, the result was not independent of all other causes. Disease may complicate injury and prolong disability. Diabetes is a condition in which the resistance of the individual is greatly lowered. The susceptibility to septic infections in this type of case is especially prominent. Tuberculosis, although apparently arrested, may be excited into activity by a trauma either at its original site or localized by trauma at some other point. State Insured's history as to previous injury or illness. This question is of great importance as it should show whether or not the warranties at the time of application were properly and correctly answered. It will also show any possible etiological relationship between prior illness or injury and the condition for which claim is being made. Histories must show not only the nature of the condition but the date, (month and year), duration, and name of physician in attendance. The nature of treatment when important should be stated. Name and address of attending surgeon: This should include any other physician who may have been in attendance for the injury, or consultation, if any. General instructions: The Examiner is expected to personally examine the Insured. The Ex- aminer should not discuss with the claimant the merits of the claim or the coverage of the policy unless requested to do so by the Company. It is important that examinations be made during the disability period. Examination should be made promptly and report returned to office re- questing it without delay, whether claim is to be made or not. HEALTH AND ACCIDENT INSURANCE 599 Examination of Health Claimant.-The questions as set forth on the Health blank differ from the Accident only with reference to the nature of the disease suffered, the history as to the inception of the disease, and a description of the disability period, including an estimate as to its probable duration. The first question calling for description is that of the inception of disease and the date of first confinement to the house. When did first symptoms of disease causing the disability appear, (a) Date first confined to house, (b) Part (a)-Other than conditions having an acute onset or a short period of incubation as in infectious diseases. The question is designed to bring out the first known history in those diseases which by their nature are slow in development and do not produce disability until the disease process has advanced to a considerable degree, or there has been an acute exacerbation of the condition. The individual, of course, may be wholly unaware of the existence of disease until symptoms arise calling attention to the fact that there is a departure from good health or else the knowledge was accidentally brought to light incident to a physicial examination. The knowledge as to the presence of disease and the commencement of dis- ability rarely coincide in this class of cases. The Examiner should ascer- tain-when the first symptoms were noted or when the presence of dis- ease was known. When a physician was first consulted, giving name and dates. What diagnosis was given. When treatment was advised or in- stituted. Part (b)-Date first confined to the house. This should not be confused ■with the date of commencement of disability as there may be a period preceding house confinement in which, although totally disabled as to occupational duties, house confinement had not taken place. Therefore, dates should be given indicating the various periods. This information is essential owing to the difference of coverage under health policies. State diagnosis and symptoms. The symptoms should be sufficiently descriptive so that those reviewing the file may have a comprehensive picture of the case. The diagnosis is to be based on your examination and observation inde- pendent of the diagnosis given the patient by his physician. When in doubt as to the nature of the disease, an inquiry should be made of the attending physician. If any laboratory tests have been made, the findings should be included in the report. If disease required a surgical operation, describe. The answer to this question should describe what was done. For example -operations on the gall-bladder should show whether the gall-bladder was merely drained or removed. An accurate statement regarding the nature 600 LIFE INSURANCE EXAMINATION of operations is essential in order that the proper fee set forth in the schedule may be paid. Estimation of disability. How long, in your opinion, based on examination and diagnosis, will claimant be w'holly disabled and prevented from performing any of the duties of his occupation? The estimate is to include disability already suffered. The description of the disability period should show for what period during total disability there will be house confinement and for what period he will not necessarily be confined to the house but still totally disabled from performing any of the duties pertaining to his occupation. CHAPTER XLI THE SELECTION OF RISKS FOR DISABILITY AND DOUBLE INDEMNITY BENEFITS By W. W. Beckett, M.D., Vice-President and Medical Director AND D. C. MacEwen, Junior Vice-President, The Pacific Mutual Life Insurance Company, Los Angeles, Cal. The clause in the Pacific Mutual policy covering the permanent total disability benefits and on which the bulk of this business has been written, is as follows: Should the insured, before attaining the age of sixty years and while this policy is in full force and no premium thereon in de- fault, become so disabled as to be totally and permanently unable to perform any work or engage in any occupation or profession for wages, compensation or profit, or suffer the irrecoverable loss of the entire sight of both eyes, or the use of both hands or feet, or of one hand and one foot, the company will waive the payment of future premiums and pay the insured 1 per cent of the face of the policy each month as long as the insured lives, and at death will pay the beneficiary the full amount of the policy. Most standard risks for fife insurance can be given permanent total disability benefits. There are exceptions, however, and a cer- tain amount of care should be exercised in the selection of these risks. The factors that enter into the composition of a fife risk for fife insurance, as a rule also enter into the composition of the risk for permanent total disability benefits. In the selection of risks for this plan of insurance the family and personal history should be carefully considered. The experience of various companies has shown that tubercu- losis stands at the top of the claim list, and insanity is next. We should therefore be very cautious in the selection of risks for dis- ability benefits that have a family history of tuberculosis or in- 601 602 LIFE INSURANCE EXAMINATION sanity. Many cases with a tuberculous family history that can be accepted for life insurance are not safe risks for disability benefits. A personal history of tuberculosis of the lungs or any other part of the body places the risk in the substandard class. Only those cases with a tuberculous family history that are well past the family tuberculous age and of good weight, should be considered for disability benefits and then only with a most careful selection. There should be a very rigid selection when there is a family history of insanity. It has been our rule to decline all risks where there is more than one case of insanity in the family. This is especially important on account of the possible duration of the disability. Applicants with a personal history of nervous breakdowns should not be given disability benefits. An applicant who has had syphilis can never be looked upon as a safe risk for disability benefits. This company does not issue insurance to any applicant who has ever had this disease. Certain physical impairments as the loss of one eye or an arm or a leg, should prevent the applicant from receiving disability benefits, unless a clause is placed in the policy that would invalidate the disability provision should the insured lose the other eye or a limb. Disability benefits should be refused those engaged in hazard- ous occupations unless an extra premium be charged sufficient to cover the increased hazard. The Pacific Mutual Insurance Company's experience is shown in the following table of approved claims 1907-1923 (October) inclu- sive: Tuberculosis 30.7 Insanity 16.1 Paralysis 12.6 Accidents 8.2 Circulatory System 4.7 Loss of Sight 3.9 Genitourinary System 2.7 Paresis 2.2 Digestive System 1.6 Rheumatism 1.6 Cancer 1.5 Sundry 14.2 100.0% DISABILITY AND DOUBLE INDEMNITY BENEFITS 603 Broadly speaking, the "double for accidental death" feature may be issued to any risk eligible for life insurance. This state- ment, however, can be. given its widest application only in the event that the premium or extra charge for the double indemnity feature is based on the occupational exposure to accidents. It is only fair to assume that a locomotive engineer is exposed to accidental death to a greater extent than is a bank cashier. It holds, therefore, that to issue successfully the "double for accidental death" feature, a company must charge a premium commensurate with the exposure. A bank cashier and a locomotive engineer may both be eligible for life insurance, and they are both eligible for the "double for acci- dental death" feature only if the proper premium rate is collected. The experience of several companies shows that the cost of this doubling accident feature is materially affected by the occupational hazard, and that it is absolutely necessary to recognize this feature and to classify and charge accordingly. There is fully as much reason for following occupational classifications in connection with the doubling accident feature in the case of life insurance as there is in the case of regular accident insurance policies. It cannot be said that the issuance of the doubling feature tends to increase fraud and unusual hazard. This is to say, the doubling feature does not, in itself, prove an incentive for the securing of insurance for fraudulent purposes. To secure the amount of the doubling accident feature it is necessary to take a corresponding amount of life insurance, so that if the insurance is taken for fraud- ulent purposes the fraud applies to the life insurance and the in- centive is not the doubling accident feature. If the incentive were the accident feature, it would be cheaper for the applicant to secure the coverage under a regular accident policy where he could secure a larger amount for a much smaller premium and also avoid the necessity of a medical examination. It is, however, no doubt true that an element of fraud is injected after death by reason of the beneficiary or representative of an estate endeavoring to establish a case of accidental death out of a death from purely natural causes. Instances of this kind have oc- curred. A policy for $5,000 doubling to $10,000 in the event of death from accidental means, was issued to a man who died of tuberculosis of the throat. The beneficiary endeavored to establish 604 LIFE INSURANCE EXAMINATION that the policyholder died as the result of accidental means, but this attempt was not successful. Another policyholder, insured for $2,000 Jife insurance, doubling to $4,000 in the event of death from accidental means, was found in his garage shot through the head, with every indication of suicide. Claim was made for the amount of $4,000, accidental death being alleged. Claim was finally adjusted on a mutually acceptable basis, but there was no doubt in the minds of the company's officials that the case was one of suicide for which no amount whatever should have been paid under the doubling accident feature. A policyholder carrying $1,000 doubling to $2,000 in the event of death from acci- dental means, died as the result of heart failure. Beneficiary en- deavored to establish death as the result of accidental means, but was unsuccessful. The following tabulation, covering 169 claims paid by this com- pany under the doubling accident feature, as to the cause of death, may prove interesting: Cause of Death No. Per Cent of Total No. Automobile 51 30.2 Firearms 33 19.5 Drowning 21 12.4 Falling 14 8.3 Burns 12 7.1 Railroad 9 5.3 Struck by falling objects 7 4.1 Machinery-Farm 5 3.0 Machinery-Shop 4 2.4 Animals 3 1.8 Miscellaneous 10 5.9 ■ * 169 100.0 CHAPTER XLII HEALTH CONSERVATION By Wm. Muhlberg, M.D., Cincinnati, Ohio Medical Director, Union Central Life Insurance Company The truth of the axiom, "An ounce of prevention is worth a pound of cure," is clearly demonstrated in the brilliant results achieved through prophylactic methods in the prevention of in- fectious disease in army and navy life. Prophylaxis, however, ap- plied to the community at large, is always more successful where it can be enforced without the active participation of those it hopes to benefit. I may illustrate this best by citing our experience in Cincinnati with reference to typhoid fever. For years the Health Department, the newspapers, civic organizations and the physicians waged an active campaign, advising the citizens to boil the drinking water, etc., but the response was lukewarm and the results meagre. Where- upon, the city adopted the only sensible plan and installed a new waterworks with a splendid filtration plant. Typhoid fever, except for imported cases, is now rarely encountered. Another excellent illustration is the wonderful record established by the Federal health authorities in the Panama Zone. It is not always possible to enforce health laws by control, such as the army or navy service brings to bear, nor can all diseases be stamped out by the simple expedient of building new waterworks, or draining swamps, or by quarantine regulations. The active propaganda and the education of the public have their field of usefulness, but the results are less brilliant and the methods usually more expensive and more painstaking. The United States Government, the various medical journals and such societies as the American Public Health Association, the Anti- Tuberculosis Leagues and numerous other organizations are doing most laudable work; and while the benefits may not be immediately discernible, there is no question but that patience, persistence and devotion to the work will reap rich rewards in the future. 605 606 LIFE INSURANCE EXAMINATION It seems rather strange that only recently insurance companies have awakened to their potential powers, not only of improving the public health, but of lowering their own expenses by an active health campaign among the policyholders. It is estimated that the insurance carried by policyholders in the United States in 1916, on the ordinary plans, amounted to about $22,000,000,000, distributed among some 5,000,000 risks. Most of this, of course, is carried on persons aged twenty or over and on men. So that, granting that there are about 30,000,000 males in the United States past the age of twenty, and that these for the most part are heads of families, consisting of four members each, it is quite possible for insurance companies to reach about one home out of every five or six in the community, and thereby in- struct in proper health measures, directly or indirectly, about 20,000,000 persons-or about 20 per cent of the population. Further, bearing in mind that policyholders, as a class, repre- sent the more thrifty, intelligent and successful members of the community, even a larger percentage than 20 per cent can be reached, on account of the tendency of people at large to be in- fluenced and guided more or less by the actions and practices of the more successful element. In addition, some 35,000,000 industrial policies are carried, but much of this is on women and children. The industrial companies have, however, been very active in distributing literature on such subjects as tuberculosis, whooping cough, drinking cups, dangers of flies, etc. From the financial standpoint, the insurance companies have much to gain. It is estimated that the average amount carried by a policyholder in most old-line companies doing an ordinary standard business, is about $3,000. Let us assume that through some good advice to the policyholder, the company succeeds in prolonging his life only one year; the saving to the company will be approximately $240. This figure is arrived at as follows: By deferring payment on a $3,000 claim for one year the company earns five per cent or over on the money and collects one more premium, which averages about three per cent. The total, eight per cent of $3,000, is $240. Furthermore, the insurance company has very little difficulty in approaching its policyholder. Most companies issue bulletins HEALTH CONSERVATION 607 that are mailed annually or semi-annually to their members. The policyholder must be written to every year in connection with his premium notice, and, most important of all, the company, if it is perfectly frank and ingenuous in its statements, can convince the policyholder that it is to the mutual selfish interest of both himself and the company to heed any advice given-thereby break- ing down one of the barriers that generally obstruct a clear under- standing ; namely, the suspicion on the part of the recipient that the donor may have some ulterior motive. I may state that all of the old-line insurance companies have not as yet embarked on the venture of free health examinations- and I think properly so. The whole matter is still in its experi- mental stage; the methods that can be employed are numerous and varied and no doubt, as is usually the case, some fairly recog- nized standard plan will some day be employed by all, after ex- perience has taught which is the best to follow. There is con- siderable expense involved, and executives in charge of the insurance finances do not lose sight of the fact that the proper function of insurance companies is to insure people, and that the expenses incurred through health-test examinations must not exceed the financial benefits that the companies hope to derive therefrom. Let us assume that a company has about 150,000 policyholders with $500,000,000 in force; the average net death losses will be about $3,000,000. If the company offers to every policyholder annually the privilege of being examined thoroughly without ex- pense by some high-class physician, and if all responded, and if the examinations cost $5.00 each (and a thorough examination, including a careful chemical and microscopical examination of the urine, cannot be made for much less), the outlay would amount to $750,000 annually. Since the death losses, without this life- prolonging service are only $3,000,000, it is very questionable whether the health examinations would return to the company a saving of $750,000, or 25 per cent, through reduced mortality, especially since about 33 per cent of insurance losses are due to accidents and accidental diseases. The methods employed by insurance companies offering this service vary in detail. In a general way, however, they may be described as: 608 LIFE INSURANCE EXAMINATION 1. Circularization of the policyholder, advising him especially with reference to the prophylaxis of typhoid, malaria, tuberculosis. Other matters-like overweight, underweight, rheumatism, diph- theria, pneumonia, etc., are also discussed. 2. Health examinations at certain intervals-preferably annually. The policyholder is permitted, without expense to himself, either to undergo a full examination by a physician selected by the com- pany, or to submit for free examination annually a sample of urine, with a statement of illnesses and condition of health during the past year. These reports and examinations form the basis for advice from the medical director, which usually takes the form of some simple hygienic control for the minor complaints, or the sug- gestion that he consult some good internist or specialist for the major ones. Of course, the medical director does not presume to treat him; he merely offers, gratis, such advice or suggestion as he deems necessary, always leaning to the side of conservatism by referring him to a physician, whenever any doubt exists in his own mind. 3. Advice to rejected applicants for insurance. This is usually some circular form of pamphlet, expressing the regret of the com- pany that insurance cannot be issued, and offering suggestions under various headings of the booklet, as to what course would be the proper one to follow for any particular ailment. 4. Advice to persons to whom policies have just been issued. In the conduct of the business of medical selection, it is expedient to issue insurance to risks who are slightly impaired. Companies doing a substandard business issue to decidedly impaired risks. Some companies send with their policy a little booklet calling the policyholder's attention to the fact that he has some little flaw in his medical or family history, and suggesting measures intended either to correct or minimize the clangers. This has particular reference to overweight, underweight, previous history of otorrhea, rheuma- tism, pneumonia, gall-stones, traces of albumen and sugar, etc. 5. Finally, it has been proposed that insurance companies take a direct financial interest in supporting health departments, where the community is too small or too poor to maintain one, or in estab- lishing in various sections of the country, bureaus whose function shall be the education of the people with reference to the preven- tion of diseases prevalent in the immediate locality-such as the HEALTH CONSERVATION 609 control of malaria and hookworm in the Southern States, etc. This, however, is still in embryo. It is further proposed that insurance companies establish sanatoria for the treatment of their policy- holders, as is done by certain fraternal organizations. I may, perhaps, make clearer one or two of these methods by a more detailed statement. The company with which I am connected offers the privilege of a free urinalysis annually to its policyholders. There is sent to every one yearly with his premium notice, a postal card, which reads as follows: FLEE HEALTH TEST Your Health is the most precious of your possessions. You must keep well if you expect to achieve the success you have planned. Prudent Men have the urine tested once a year. This requires, at some expense, the service of a competent analyst or physician. Your Company will give you this service free of charge. Many Diseases do not "hurt" in the beginning. You may not know that you are ill until the disease has reached a serious stage. This is especially true of kidney troubles. Watch Your Condition. It Pays. Our perfectly equipped labora- tory and corps of expert analysts are ready to serve you. T7ie Standing of Your Policy can in no way be affected by the health test. If we find something wrong we tell you frankly and suggest what to do to regain your health, and both you and the Company will be helped. A Test May Prolong Your Life. Medical Director. Gentlemen:-I am a policyholder in your Company and I under- stand that as a part of your regular service to policyholders you will make a urinalysis for me free of charge, and advise me as to the result, so that I may seek further medical advice if I need it. ' With the understanding that the result of the test will be entirely confidential between myself and the Company, send full instructions and a mailing tube to my address as shown on the reverse of this card. Insured The query naturally occurs to you, why the policyholder should be encouraged to send a sample to the company, rather than to offer him an opportunity of a full examination by a regular physi- cian. Both methods were considered for quite a while before it 610 LIFE INSURANCE EXAMINATION was finally decided to have only a sample submitted, for the reason that the policyholders must first of all be educated into the idea of submitting to any sort of examination, while they are, so far as they know, in good health. It was decided that the average person has no serious objection to answering a few questions and mailing a specimen of urine-but to go to a doctor's office, undergo a thor- ough examination, etc., means considerable time, additional anxiety and trouble for the policyholder and a great deal more expense to the company. We figured that this method would bring more re- sponses and pave the way in the future for more complete exami- nations. The responses have far exceeded our expectations. Almost 12 per cent of the policyholders are taking advantage of the service and the percentage is increasing every year. Companies that offer complete examinations by physicians are receiving, I am told, re- plies from a much smaller percentage of their members. On receipt of the postal card from the policyholder, a mailing tube, containing a two-ounce bottle, with four grains of boric acid in it, is mailed to the policyholder, together with the following form: DIRECTIONS FOR FREE HEALTH TEST To the Policyholder:- Void your urine directly into the bottle, preferably after your noon meal. Do not remove the preservative tablets from the bottle. Press the cork firmly into place. The standing of your policy can, in no way, be affected by the Health Test. I will notify you of the result of the test, which will be entirely confidential between you and the Company. If I find something wrong, I will advise you what course to pursue. Answer each question given below; then fold the sheet around the bottle and place it in the container. Remove the wrapper addressed to you and you will find the container properly addressed to the Home Office. Mail it immediately. Medical Director. The following questions are asked: What is your age? What is your height in shoes? What is your weight in ordinary clothes? Has your weight changed recently? If so give full particulars under remarks. Have you had any severe coughs or colds in the past year? If so, state number of months' duration. HEALTH CONSERVATION 611 Have you hafl any of the following symptoms in the past two years?-Blood spitting, chronic hoarseness, pleurisy, evening fevers, night sweats, slight chronic cough? Have you had any illness or have you consulted any physician in the last year? If so, explain, giving: Illness, symptoms, duration, result, physician's name and address. Full name My address is On receipt of the sample and statement of health, a report is made directly to the policyholder. He is given suggestions regarding overweight, underweight and minor ailments. But where the state- ments or the urinalysis indicate that he may be developing more serious trouble, he is advised to consult his physician at once. The officers of the medical department try to place themselves in the position of a physician who is referring a case to another physician for expert treatment. All statements made by the policyholder are strictly confidential. In no case is either the agent or any other company advised of their nature, nor do any statements of the policyholder or any findings in the sample influence the company in the consideration of any subsequent application that the policyholder may submit to the company. But, of course, on request from the attending physician, a copy of our urinalysis or other findings is cheerfully sent. It is absolutely essential that all these precautions be taken, in order to instill confidence in the policyholder, that this work is done in absolutely good faith. Some companies notify the policyholder's physical!, instead of notifying the policyholder himself. This plan has the merits of not unduly alarming the patient and at the same time of securing a better cooperation of the attending physician. Whatever method for improving the public health is used, some benefit will be derived; but the practical handling of the situation demands considerable tact, patience and time, and a most whole- hearted cooperation between the practitioner in the field and the insurance companies. It is on this phase of the work that I should wish particularly to lay stress. Prophylaxis for the convenience of this discussion, may be divided into two groups: (1) The prophylaxis with reference to the prevention of such diseases as tuberculosis, typhoid, malaria, 612 LIFE INSURANCE EXAMINATION etc. (2) The prophylaxis that aims to diagnose and cure a disease in its earliest incipiency or to prevent it in persons especially pre- disposed. The prophylaxis governing typhoid fever, etc., can be handled best by the method of the propagandist-and that phase of activity on the part of the insurance company does not require, except in a general way, the active cooperation of the medical practitioner-but the arrest of such processes as incipient diabetes, Bright's disease, tuberculosis or the handling of mild obesity cases, anemia, etc., does. Unfortunately, it is just here that some friction arises. The con- flict is partly the fault of the medical directors and partly the outcome of a lack of clear understanding on the part of the prac- ticing physician in handling these cases. The insurance companies are constantly studying the effects of certain impairments of health or of family history on the expectancy of life of their policyholders. The ■ statistics have assumed very respectable proportions. We know quite accurately that a certain degree of overweight, or underweight, or a previous history of gall-stones, or blood spitting, or rheumatism has a tendency to shorten life. These statistics are of great value in the selection of insurance risks and are of great value to medical science; but un- fortunately, except for an occasional article published by insurance medical directors or actuaries, they have not been properly brought to the attention of the profession at large. There is in the medico- actuarial statistics a wealth of material for any medical investi- gator, who approaches the subject from the purely medical side and who has the necessary talent for interpreting mathematical and statistical data. As a consequence, the average doctor does not know that over- weight, of even minor degrees, at certain ages, is a menace, and that this is also true for lightweight, and for persons giving past his- tories of pleurisy, spitting of blood, rheumatism, etc. Furthermore, even where the general practitioner has knowledge of these facts, his medical education and literature and textbooks impart very little practical knowledge that can be used in giving his patient the needed advice. I have some little personal experience with reference to this mat- ter. Some years ago, I prepared a booklet for distribution among our policyholders, advising them what precautions to take to avoid HEALTH CONSERVATION 613 recurrences of attacks of pneumonia, rheumatism, etc., and what dietetic, hygienic rules to observe to prevent the development of diabetes or Bright's disease, or what means to employ for the re- duction of moderate overweight; and I was just a little annoyed to discover that my own knowledge and that gleaned from standard textbooks and available literature, while abundant in generalities, was peculiarly deficient in the precise instructions that the patient expects when he receives advice from his doctor. In fact, when preparing the article on reduction of weight for persons slightly above the safe margin of overweight, I had to reconstruct all the dietetic tables ordinarily given in textbooks, so that they might apply to the mild case, rather than to the gross impairment. It is most important that this phase of medical science be de- veloped more extensively. Heart and kidney diseases cause more deaths after the age of fifteen than does tuberculosis, and while the warfare against tuberculosis seems to be making considerable headway, the deaths, especially from cardiorenal disease, continue to increase in percentage-particularly the degenerative form of heart disease, dependent not on valve lesions, but on arteriosclerotic changes and myocarditis. Nor should cardiorenal disease be looked upon merely as an evidence of senility. The average age of death from cardiorenal disease is only fifty-five years; from tuberculosis it is thirty-seven years. From our present knowledge of the etiology and pathologic physi- ology of cardiorenal diseases, it is most difficult to formulate any satisfactory regimen, designed to counteract their development. We know, of course, in a general way, that alcoholism, hereditary syphilis, overweight, hard physical work, overeating, acidosis, nerve strain, constipation, chronic intoxication from foci of bacterial growth, lead poisoning and gout have something to do with causing the disease; but many of the etiologic factors are controversial and some not strongly supported by the actual facts. It is, for instance, difficult to assign any good reason why these diseases should be so very prevalent among farmers, while railroad engineers and trainmen are least affected. Wherever the etiology of an affection is vague or comprehends such a variety of causes, it is not easy to give advice that will be of real service. The sub- ject is one that merits as much study and effort as does the pro- phylaxis of tuberculosis. 614 LIFE INSURANCE EXAMINATION All too frequently, when an insurance company suggests to a, policyholder that he consult his physician for reduction of his weight, the policyholder is told by the doctor that his overweight is of no moment, or is given such instructions that are either too drastic or not sufficiently explicit, and the policyholder, ever sus- picions, scents some sharp practice on the part of the medical director, or discouraged, discontinues his efforts. Nevertheless, the medical director knows from statistical knowledge that the over- weight is a menace and that the correction of it might add several years to the expectancy of the policyholder's life. The most discouraging experience is met with in connection with urinalysis. A policyholder, let us say, submits a sample to his insur- ance company for analysis; this discloses the fact that there is a trace of albumin or sugar, or a few casts. He is referred to his doctor, who fails to confirm the laboratory's findings. It is, of course, not unusual, as attested by the experience of handling applications for insurance, that albumin temporarily appears, as a result of very minor disturbances-such as overexertion, ordinary rhinitis, etc.; nor, on the other hand, is it unusual for albumin, and especially sugar, to appear intermittently in the incipient stages of Bright's disease or diabetes. The physician, however, without regard for these facts, or without any attempt at explanation, states his find- ings and thereby promptly arouses the suspicion of his patient as to the honesty of the motives of the company. Again, (and I say this with considerable hesitation) many a physician fails to detect traces of albumin or sugar when they actually exist. The technic of chemical urinalysis is so simple that the average physician frequently neglects to observe the neces- sary precautions in his technic. It is not an unusual experience in the course of our business, to encounter cases where the examiner reports no albumin, or no sugar, but, nevertheless, where a portion of the same sample, examined with care at our laboratory, demon- strates the presence of a decided amount of albumin, and as much as 1 per cent of sugar. A little cooperation, a modicum of regard for the really honest motives of the insurance companies in offering this service to their policyholders, and a bit of tact, would do much in the way of helping all concerned in overcoming this difficulty. It is the endeavor of the medical departments of the insurance HEALTH CONSERVATION 615 companies to help in every legitimate way, the efforts of the physi- cian in getting their patients to seek advice early in the course of the disease; to discourage the taking of patent medicines; to have them consult their physicians, not only in disease, but in health; to encourage annual examination, if possible, for the purpose of discovering ailments in their incipiency; to overcome the popular fear of surgical operations; to aid in the exposure of medical frauds, practices and isms. The insurance company is in a strong position to help in these matters. The policyholder knows that the com- pany is interested financially in his living out his expectancy; he knows, since the medical director receives no fee for his suggestions, that his advice is probably disinterested, but all of these efforts will prove worthless, if there is instilled in his mind, at the outset, that our suggestions are either bad or unduly of the alarmist nature, or tinged with sharp practice. Cooperation, therefore, is absolutely necessary, if any results are hoped for. The medical director must keep in closer touch with the profession at large; must make more readily accessible the results of medico-actuarial investigations; must cooperate more fully with the general practitioners and health officers in their many excellent endeavors and ideals. The physician, on the other hand, must be- come better acquainted with the endeavors of insurance companies along these lines; must be prepared to handle with greater skill, the incipient diseases referred to him by medical directors. Just as it would be eminently unjust and unethical for a medical director to criticize the skill of physicians when they fail to agree either in treatment or diagnosis, so it is equally unethical for the practitioner to impugn the motives of the medical directors of insurance companies in their efforts for the public good. We can be a great deal of help to each other if we both remember that, though engaged in different fields of medical science and prac- tice, our ideals, motives and ethics remain identical. CHAPTER XLHI INSURANCE WELFARE WORK Many insurance companies are increasing their departments for the promotion of health conservation. This may be confined to their policyholders and employees, or it may even go further in the realm of public welfare. A broad view of this subject shows that anything, that promotes public health redounds eventually to the financial or the moral credit of the company. On this account, I take pleasure in giving a short resume of how this has been put into practice by one large institution which has probably done more extended work of this character than any other. I refer to the Metropolitan Life Insurance Company of New York City. In 1909 Mr. Haley Fiske, at that time vice-president, instituted a broad program of welfare work for policyholders under the direction of Dr. Lee K. Frankel. The first efforts were the preparation and issuance of single health pamphlets, the first being entitled "A War Upon Consumption," published in 1909. Since then hundreds of millions of pamphlets have been dis- tributed to the general public, a few of them being shown in the accompanying illustrations. These textbooks for good health are entitled as follows: Whooping Cough, Smallpox, Malaria, Measles, Typhoid Fever, Hookworm, Diphtheria, Pneumonia, Scarlet Fever, The Child, First Aid in the Home, Health of the Worker, Milk, Cook Book, Care of the Teeth, How to Live Long, Mother Goose, Child Health Alphabet, Clean Up, Teeth, Tonsils and Adenoids, Information for Expectant Mothers, Food Facts, Directions for Living and Sleeping in the Open Air, Swat the Fly, and others. Shortly after the beginning of the educational campaign a system of visiting nursing was established. This now covers more than 4000 towns. Following this, health surveys have been instituted and hundreds of towns have had "Clean-up Week." Booths ad- vocating health have been put in operation at county and state fairs. Outings and picnics have been arranged with athletic con- tests. Propaganda has been used in campaigns for hospitals, sana- 616 INSURANCE WELFARE WORK 617 Fig. 144.-Health conservation methods used by the Metropolitan Life Insur- ance Company. 618 LIFE INSURANCE EXAMINATION toriums for tuberculosis and the insane, and for procuring new water supplies. A sanatorium for tuberculosis for its own employees has been put in operation. A campaign against smallpox has been in force in several states and special literature showing the need for vaccina- tion has been distributed. Millions of sanitary drinking cups have been given away. Prizes have been offered for the best essays on "Sex Hygiene for Adolescents." death Rate per 100,000 180' 160 140 120 100 I I ol M.L.I.Co. U.S. Reg. Area 1911 1912 1913 1914 1915 1916 1917 1918 1919 1920 Fig. 145.-Mortality organic heart disease. Courtesy Metropolitan Life Insurance Company. Unemployment statistics have been collected and in several cities housing facilities have been increased by the financing of projects of that character. Contributions have been made for scientific research. Special attention has been given to epidemics more espe- cially those of influenza, typhoid fever and infantile paralysis. An Immigrant and Citizenship Bureau has been established. Among its own employees, it has encouraged the formation of literary societies, musical clubs, athletic teams and the formation of libraries. Twice a day in their own office all the windows arc opened and every employee stands up and exercises for five minutes. INSURANCE WELFARE WORK 619 Fig'. 147.-All causes of death compared with mortality of Metropolitan Life Insurance Company. Courtesy Metropoli- tan Life Insurance Company. 1911 1912 1913 1914 1915 1916 1917 1918 1919 1920 M.Ll.Co. U.S. Reg. Area Daath Rate per 1,000 20 18 16 14 12 10 8 I i Ol Fig. 146.--Mortality of tuberculosis of the lungs. Courtesy Metropolitan Life Insurance Company. 1911 1912 1913 1914 1915 1916 1917 1918 1919 1£?r M.Ll.Co. U.S. Reg. Area Death Rate per 100,000 220 200 180 160 140 120 100 I l ol 620 LIFE INSURANCE EXAMINATION Fig. 149.-Total mortality puerperal state. Courtesy Metro- politan Life Insurance Company. 1911 1912 1913 1914 1915 1916 1917 1918 1919 1920 Puerperal State- ~Total M.L.I.Co. U.S. Reg. Area - Death Rati per 100,000 30 25 20 15 i 0 1911 1912 1913 1914 1915 1916 1917 1918 1919 1920 Fig. 148.-Mortality from cancer. Courtesy Metropolitan Life Insurance Company. M.L. I. Co. U.S. Reg. Area Death Rate per 100.000 90' BO 70 60 I I ol INSURANCE WELFARE WORK 621 Fig. 151..-Mortality of children's diseases, (measles, scarlet fever, whooping cough and diphtheria). Courtesy Metropolitan Life Insurance Company. 1911 1912 1913 1914 1915 1916 1917 1918 1919 1920 M.Ll.Go. U.S. Reg. Area Death Rate per 100.000 70' 60- \ 50; 40 30 i I Ol Fig. 150.-Mortality of Bright's disease. Courtesy of Metro- politan Life Insurance Company. 1911 1912 1913 1914 1915 1916 1917 1918 1919 1920 M.Ll.Go. U.S. Reg. Area Death Rate per 100,000 110 100 90 80 70 60 0 622 LIFE INSURANCE EXAMINATION Death Rate per 100,000 25" 20S 15 10- 5 0 M.L.I.Co. U.S. Reg. Area • 1911 1912 1913 1914 1915 1916 1917 1918 1919 1920 Fig. 152.-Typhoid fever mortality. Courtesy Metropolitan Life Insurance Com- pany. Death Rate per 100,000 15" 10 5 0 M.L.I.Co. U.S. Reg. Area 1911 1912 1913 1914 1915 1916 1917 1918 1919 1920 Fig. 153.-Puerperal septicemia mortality. Courtesy Metropolitan Life Insurance Company. INSURANCE WELFARE WORK 623 Death Rata par 100.000 500 ' 450 400 350 300 250 200 150- 100 50- 0. M.L. I.CO. U.S. Rag. Area 1911 1912 1913 1914 1915 1916 1917 1918 1919 1920 Fig. 154.-Influenza and pneumonia mortality. Courtesy Metropolitan Life In- surance Company. 624 LIFE INSURANCE EXAMINATION Many of the publications are printed in foreign languages. The registration of births has been increased by the distribution of cards for that purpose. The organization of Health Leagues has been encouraged. Saving funds are promoted for the use of its own employees and carefully planned luncheons are provided without expense, for the employees of the home office. Medical and hospital care is also furnished them. Death Rate per 100,000 100 ' 90 88- 70 60 50- i I oL M.Ll.Co.- U.S. Reg. Area - 1911 1912 1913 1914 1915 1916 1917 1918 1919 1920 Fig-. 155.-Accident mortality. Courtesy Metropolitan Life Insurance Company The Industrial Service Bureau is utilized to give advice to em- ployers in their personal problems arising from their relations with their employees, insured under the group insurance plan. The above information is given to show how life insurance com- panies can aid in welfare work, and that the writing of insurance is only part of the service a modern life insurance company gives to the public. CHAPTER XLIV INSPECTION REPORTS • By Walter C. Hill, Atlanta, Ga. Vice-President, Retail Credit Company When an insurance company is asked to create an immediate personal estate, in consideration of an annual policy premium, it lias every right to inform itself fully about the person applying for the contract. The great difference between the amount of the policy and the amount of the premium, places the obligation of in- quiry upon the insurance company to inform itself on all points that might affect the insurability of the person who proposes the contract of insurance. If the applicant is personally known to the underwriting officer of a company, the application form and the medical examination supply about all the information ordinarily needed for accurate underwriting of the risk. The application and medical examina- tion, alone, however, leave a broad field not covered, on appli- cants whose personality or daily life is entirely unknown to the underwriting officer. The inspection report supplies this informa- tion and gives the underwriter the advantages he would have if each applicant were known to him personally. It is a means of extending his personal acquaintance, as it were, to people here- tofore unknown to him, regardless of where they may live. The inspection report discloses the applicant as he is known to those who see him in his daily pursuits. Its primary service is to report any moral hazard that might impair the risk. The chief consideration of all underwriting is to avoid assuming risks that are not insurable, or risks that do not qualify on the standard of the contract proposed. The information available through the in- spection report has this protective quality. The inspection report deals largely in the abnormalities of peo- ple. Habits in the use of liquor or drugs make up the largest field of its protective service. It is always important, yet very diffi- cult, to learn how much an applicant drinks. The inspection report 625 626 LIFE INSURANCE EXAMINATION has been found the most satisfactory method of getting this infor- mation. Following habits, the next most frequent service rendered through the inspection, is information regarding the health of the appli- cant. This is often supplementary to, or in confirmation of, infor- mation developed by the examination. It is, however, a matter of surprise how often the lay sources through which inspections are macle, are able to contribute valuable information regarding past illnesses, or physical conditions that were not disclosed to the exam- ining physician. A very painstaking examination by the company's examiner might fail to detect impairments that are known to the applicant's acquaintances,-epilepsy, fainting spells, rheumatic, nervous, or digestive attacks. If concealed by the applicant from the examiner, it will likely reach the company only through the inspection report. The ratio of each of the principal points criticized out of 100 unfavorable reports is shown in the following table: For habits 32.5 For health 25.5 For reputation 17.3 For family history 13.7 For finances 6.1 For occupation 4.4 For miscellaneous .5 100.00 (Ratios macle from a review of 4,508 unfavorable reports distrib- uted over entire United States in approximate proportion to the amount of new business written in each state in October, 1919.) In addition to its protective features, the inspection report is capable of rendering other valuable service to an insurance com- pany. It often supplies the information on which a risk may be safely assumed; yet, without the inspection report, might have to be declined. If the question of one's insurability is once raised, then this must be fully satisfied before the company can afford to take the risk. These questions come up principally on account of the records of some previous postponement, declination, the applicant's occupation, home life or previous illness, etc. The inspection report provides INSPECTION REPORTS 627 an avenue for securing the supplementary information and often questions once raised can be satisfied, and the risk safely assumed. In situations of this kind, the disinterested or impartial sources, from which the inspection report is secured, bring an additional element of protection and of service. The report also contributes valuable side lights on the work of the agent, and provides the medical director a means of measuring the accuracy and careful- ness of his examiners without waiting on the slow process of the mortality records. Probably the largest service rendered by inspections does not come through the number of cases declined or from the number of applications accepted in the light of the fuller information given in the report. It comes from the large amount of undesirable busi- ness that is never submitted to a company which is known to use the inspection reports as a system on all new business. The greatest restraining influence is probably on the producing agents. If the agent finds that his home office informs itself on the questions of moral hazard, he will anticipate its action by not writing undesirable business. It is only human that the agent would not wish to show up at a disadvantage to his home office, and in view of the inspection, is more considerate of the insurability of the risk he proposes. Being informed and being in position to discuss with the agent doubtful points about a risk when it is advisable to do so has worked out as effective in avoiding undesirable business. It is a better plan than keeping the inspection system a secret. In the first place it is practically impossible to inspect business and the agency force not find it out. In the second place, it is very diffi- cult to manipulate or handle the information when a lot of secrecy is thrown around it. Though the inspection is not for the purposes of checking the examiner, yet it does have a toning-up effect on the work of the examining physician. It relieves him of no responsibility, yet puts upon him the necessity of being careful in his work. It prompts him to make inquiries of the applicant, to bring out in- formation about his past health, habits, etc. If the examiner knows that some reliable person is to make a confidential report on the risk to the home office, he is going to be a little more careful in his work. He would certainly not wish a layman to be able to report 628 LIFE INSURANCE EXAMINATION well-known facts affecting the insurability of the applicant that should have been apparent to his trained eye and scientific knowl- edge. It is also true that examiners sometimes suspect intemperance, immoral relations or unhealthful or dangerous occupation. It would hardly be expected of the examiner to make personal inquiries other than through the applicant himself about these matters, yet, when he knows that inspections are being secured, he is more likely to suggest to the home office that careful inquiry be made along the lines which have aroused his suspicions. Cooperation of this nature between the examiner and the inspection department produces very beneficial results. The inspection system does not in any manner relieve the obliga- tion of the agent to select good business, or the responsibility of the examiner to do careful work. It has not been the experience of companies using inspections as a system, that either the agency organization or the corps of examiners claimed any release from their respective obligations. On the other hand, there have been many instances reported where the work of both the agency forces and examiners showed marked improvement after the system of inspection had been installed. The inspection report is not so much to furnish an opinion from a layman of the insurability of the applicant, as it is to furnish information on which this conclusion can be formed at the home office. The report is based on current information about the per- son being reported on. The report is the net resultant of the things the applicant may have said about himself, the opinion others have formed about him, and the beliefs entertained by those who come in contact with him. This information, when impartially assembled, gives sufficient information for most careful and accu- rate classification of risks. There is necessarily a considerable range of inaccuracy to be looked for in the inspection report. This inaccuracy, however, is principally in the emphasis or prominence given by the inspector to the unfavorable feature. This comes of the wide difference in attitude among men on questions of morals, habits, social relations, etc. Two men reporting the same fact or circumstance, might give it quite a different aspect and reach even contrary conclusions. The main service here is that the fact or fundamental has been INSPECTION REPORTS 629 brought to light and the underwriter in the home office must read the report with the idea that it is not the conclusion of the inspector which counts most, but the essentials regarding his health, habits, reputation or finances that might affect his insurability. The tips brought out in reports should not be ignored, even though they may be expressed in very unscientific terms, or only slightly indicated or touched upon by the inspector. The inspector is not an underwriter, and often does not appreciate the value in underwriting terms of the information he gives. He is not able to use scientific terms that indicate exact physical condition and is often unaccustomed to expressing himself in writing. He may not be able to set out his information in clear, consecutive or convincing style. The reports, however, imperfect as they are, often render great service by bringing to light some item of in- formation which, if confirmed and worked out through the regular channels, shows that the applicant is not a desirable risk or not acceptable on the policy applied for. Such expressions as sickly, poorly, off-color, etc., with reference to appearance, fair or aver- age, as to health are tips that should not be passed without careful inquiry into what is in the inspector's mind that prompted him to sound this note of warning. A case in point is that of an inspection report referring to the applicant as "muscle bound." Subsequent correspondence failed to develop little beyond the statement that he did not seem to have free use of himself. The examining physician did not find anything fundamentally wrong with the applicant, and the medical director was not disposed to accept the inspector's unscientific expression "muscle bound" as being very important. The policy was issued, but within six months' time the applicant was a para- lytic and within a year the widow was presenting the claim. The inspection report, as we know it today, is the outgrowth of the system of "Friends Reports" which have been used from the very beginning of the life insurance business. For years these "Friends Reports" were the only underwriting information secured by the insurance company. Even the "Proposal" for the insurance gave only the applicant's name, address and age, and it was upon his friends that the company depended for information regarding his health, habits, morals, etc. On this information the proposal was accepted or declined. 630 LIFE INSURANCE EXAMINATION The inspection report was first developed by the Equitable Life Assurance Society, of New York. This was a recognition of the value of securing confidential information from a source selected by the company, and not from a friend or reference selected by the applicant. The idea of paying the reporter for the information, thereby making it a strictly business transaction, was begun about the same time. The difference between the original system of liFriends Report" and the present inspection report, is not so much a difference in the range of information as in the source from which the information is secured. The principles introduced by the Equitable were rapidly followed by other companies by the organization of inspection departments. Confidential inspectors were appointed, and practically all new business passed through the inspection department in order that the confidential reports might be secured. A great deal of secrecy was observed in most companies with reference to its inspection system. The department was kept under cover as much as possible, and in many instances the agency force did not know that inspections were secured. As a result of this policy of secrecy, a great deal of mystery seems to "have grown around the inspection practices, and this is probably responsible for some of the opposition found among agency forces today to the idea of having a confidential report made on all applicants. All this has been changed in recent years, and though no inspection system presumes to disclose its source of information, yet, the fact that inspections are secured and the general plans of operation are usually common knowledge. This has resulted in a much better atti- tude towards the inspection idea, particularly on the part of agents. It is a matter of considerable interest to note how little change there has been in the questions originally used in the old "Friends Report" and the questions that appear on the modern inspection blank of the companies or agencies. The report blank as used by the Eagle Assurance Company of London, England, is reproduced below. This company commenced business in 1807, and it is one of the oldest companies in existence granting life assurances. The following is one of their early "Friends Report" blanks. Eagle Life Assurance Office. Sir: Having been referred to you for an account of the health and habits of I request the favor of a reply to the following questions. INSPECTION REPORTS 631 On your answer, which shall be considered as strictly confidential, the validity of the proposed Assurance must, in a great degree, rest: you will therefore, pardon me for reminding you of the importance of a full and deliberate state- ment. I have the honor to be, Sir, Your most obedient humble servant, Actuary. How long have you been acquainted with ? How often are you in the habit of seeing him? When did you see him last? In what state of health was he when you saw him last? What is his general state of health? Have you attended him in a medical capacity and to what extent? Are you acquainted with his ever having been affected with a rupture, gout, dropsy, asthma, consumption, vertigo, fits, hemorrhage of any kind, cancer, insanity, or other disease, or of his having any symptoms of any disease? Do you believe he is now quite free from any disease or symptoms of disease and in perfect health? Is he active or sedentary? Are his habits perfectly sober and temperate? Has his life to your knowledge been refused at any insurance office? Did any member of his family die of pulmonary or hereditary disease of any kind? Are you acquainted with any circumstances having a tendency to the shortening of his life, or which can make an insurance upon his life more than usually hazardous? Are there any circumstances within your knowledge which the Directors ought to be acquainted with? Signed Dated This company is now the Eagle Star and British Dominion Assur- ance Co., Ltd., of London. References, at one time extensively used, have been discarded by most companies, and when used at all are employed not so much as sources of information on the applicants, but as leads for new business. They are secured as a part of the sales expansion plan of the company, and are very rarely used as sources of informa- tion as to the insurability of the applicant. An applicant would naturally not name as a reference one whom he thought would make an unfavorable report on him. As a consequence, the per- centage of reports from references which throw any light of underwriting value on the case, is so small that it does not pay for the expense and delay involved in getting the report. 632 LIFE INSURANCE EXAMINATION The vital difference between the inspection report and the "Friends Report" is that the inspection comes from sources selected by the company, and the "Friends Report" comes from sources selected by the insured. The first is a paid service, and the second complimentary. The experience of most companies which have used both systems, is that the paid inspection service gets satisfactory results, and the free report from the friends of the applicant does not pay for itself. The established agencies report for a great many companies. The large volume of business handled offers several advantages to the individual companies using their service. The record of previous reports that an agency might have made on an applicant, often serves as a direct means of protection against undesirable risks. If the agency has reported to some other company on the applicant, on a certain date, and the applicant does not report having a policy granted at that approximate date, then it may be readily inferred that he was declined, postponed, or limited in some manner by the company to which the report was first made. Correspondence with such a company, which can be reached through the agency, will develop the facts which prompted their action if he was declined. It is also a custom, when an agency has reported on an applicant, to supplement the report with any information which might develop at a later date that could affect the desirability of the risk. This information will enable a company to protect itself, if an oppor- tunity is presented, from a risk that has become impaired. Cases of overinsurance, where applications are simultaneously placed with several companies, are often brought to light through the service of the inspection agency. Serving many customers, the agency would be in receipt of many duplicate inquiries on the same applicant, and be able to notify all subscribers of the number of other companies interested, and of the amount applied for in each. The agencies, through the larger volume, are able to meet the difficulties of selection and instruction of inspectors. An agency, handling the business of a number of companies, has a sustained contact with their inspectors even in the small towns. This enables them to keep up the interest of the inspectors, and eliminate quickly anyone whose replies are not prompt, or whose reports are unsatis- factory. In the large towns it gives a volume of business sufficient to retain the services of the most capable inspectors, and in the INSPECTION REPORTS 633 cities provides enough revenue to maintain salaried investigators who give their entire time to the work. Any arrangement made for inspections should be capable of producing reports in the home office within the shortest possible time after receipt of the application and examination from the field. Keen competition for business makes it necessary for the home office to issue its policies promptly, and no inspection service will be satisfactory that defeats the prompt issue of business. No company should make arrangements for inspections unless it can have fast service, but at the same time, it should guard carefully against the disposition to take too quick or hurried action in individual cases. This is especially true when the necessity for prompt action is being urged by the agents to save the business. There have been many cases of regret over hurried action when a little more deliberation would have saved the company an early loss. It is a fact that unfavorable reports do not come through as fast as favorable reports. The inspector is naturally more cautious in making such a report and holds the matter over to see additional people and to confirm his information. Quite often inspectors, par- ticularly in small towns, prefer not to make an unfavorable report and make no response to the first inquiry, and render a report only when crowded by the company or agency. There is an element of liability on the part of the insurance com- pany in handling information secured through the inspection re- port. The chance for libel arises when information is "published." The company is in no danger as long as the information is not passed to others. Information from the inspection reports should never be repeated in correspondence with either agent, manager or examiner. Due caution must be used even when the general con- clusion of the information is given. The law does not recognize clearly the right of a company to transmit damaging information to its agents and in some instances have held that to give it out in this way is "publishing." The best practice when corresponding with either the agent or the examiner on issues raised by information developed in the in- spection, is to ask questions of the agent or examiner. These ques- tions can be so worded, as to suggest the nature of the information. In getting information for the answers to the questions they will, in all probability, get the same information the inspector has. If 634 LIFE INSURANCE EXAMINATION they do not get it, their replies will probably be complete enough in detail and carry sufficient evidence that the inspector's informa- tion is wrong. The system of developing further data through questions compared with quoting from the report is not only the safe practice but usually the speediest method of getting at the facts in the case. The applicant should never be written anything that refers to, or is based on, information contained in the inspection report. Notice of postponement or rejection should make no reference to, or make mention of, reasons based on the inspection information. Substitution arises when an insurable person applies for insur- ance, and is examined giving the name, address, etc., of an uninsur- able person. Such persons are usually strangers to both agent and examiner. Substitution is nearly always uncovered by the in- spection. A man may successfully pose as the applicant in the pres- ence of both the agent and the doctor, but the inspector will get his information about the man whose name and address is given in the application. The imposter cannot substitute his personal record for that of the insured. The imposter must give the name, address, occupation, etc., of the supposed applicant, and cannot inject into the transaction anything of himself except his own person for physical examination. It is not a matter of everyday occurrence, yet, it is continually coming to light that some friend or neighbor, or relative, con- spires to defraud the insurance companies by submitting himself for examination in the name of some one who is not insurable. The inspection report does not always indicate who it was that appeared for examination. It shows only that the applicant whose name is used is an undesirable risk. Sometimes the facts regarding his physical condition are so at variance with what was found by the examiner in the person examined by him, that there is no pos- sible conclusion other than that substitution had been practiced on the company. The inspection service which a company is able to get depends largely on the data of identification it is able to provide the inspector on the applicant to be inspected. The kind of data of identification needed varies with different classes of business. What might take care of the needs of a com- pany writing largely in rural sections would not answer for a INSPECTION REPORTS 635 company writing among employees of large industrial plants. It is important, therefore, that a company have in its application, questions which meet the particular needs. The inspection ques- tions should be incorporated along with the other questions that are needed in an application. This does not make the application too long, nor is there any information requested which would not be known to, or easily secured by the agent. There should be no possible question as to the identity of the person on whom the inspector is to make the report. This requires very full and complete information regarding the applicant's resi- dence, how long he lias resided there, and his previous address, if any. Also, the exact business address, the name of the firm or employer, and previous occupation, if any. If the applicant lives outside the town given as his address, the distance and direction he lives from the town given as his post office and, also the trading point at which he is known in a business way should be included. If the applicant is a woman the husband's name should be given as a means of identifying her; if a minor or child, the name of the parent or guardian; if a newcomer in the community, then the pre- vious address. All this information can be developed by a few care- fully worded questions, and when placed in Part I of the applica- tion form, will be systematically answered by the field agent, and can in turn be given to the inspector when the report is requested. Applicants for accident insurance are inspected to cover the same moral hazards to which we are accustomed in life insurance inspec- tions. The underwriting problems are fundamentally the same, with special attention given to the occupational hazard, and the exact earning capacity, in addition to the health, habits, and reputation, as ordinarily covered in the life insurance inspection. The blanks used for the Accident Report are drawn up to give occupation and finances the special emphasis they require. Accident insurance is not usually written with the same care or regard to insurability as is customary in life insurance. The ab- sence of a medical examination is largely responsible for this, and it is also true that a great deal of this business comes through brokers and . agents whose principal business is in other lines of insurance. The policy contract, by its terms, is subject to being cancelled by the insurance company on any anniversary, or at any time under some conditions. This has had its effect in making 636 LIFE INSURANCE EXAMINATION companies less painstaking in their method of selecting accident business. On account of the small premium loading in accident business, companies as a rule, inspect only those applications where the premium is sufficient to provide for the inspection cost. This is customarily premiums of $25 and up. Also, all applicants regard- less of the amount of premium, where the occupation is indefinite, such as broker, agent, promoter, etc., or where there is some indica- tion through previous history, or statement in the application that would suggest to the underwriter the need of more complete infor- mation. Occupation.-Since the rate for accident insurance is determined by the hazard involved in the applicant's occupation, it is essential that full details of his daily employment be given. The under- writer should be continually on the outlook for cases where the applicant is engaged in more than one occupation, and states the least hazardous one in his application. Also, where he is given to sports, pastimes, or recreation, such as aviation, that involve an unusual exposure to accident or death. Finances.-Next in importance, from an underwriting standpoint, comes the moral hazard produced when an applicant is insured for an indemnity greater than the amount of his earning capacity. It is very difficult to learn the exact amount of weekly or monthly income of an applicant, and when this is raised as an underwriting question, the inspection report is the best means of securing the best information available. Even though it may not be practicable to secure the exact amount of one's income, the report will disclose the best general information, or opinion of what the amount is. This is particularly true of incomes that are dependent on com- missions or fees. The character of the applicant is also an item for consideration in connection with the finances, particularly in the absence of definite information as to the amount of income. Though the income may not be subject to accurate determination, the appli- cant's reputation for fair dealing may be sufficiently established to indicate whether the prospect is favorable or unfavorable. The applicant's physical condition is a matter of major impor- tance in accident underwriting. This is particularly true when applicant is subject to any chronic kidney, heart, or nervous dis- INSPECTION REPORTS 637 ease. In the absence of a medical examination, the inspection re- port is the best avenue available for information covering these points. Some diseases not only increase the exposure to accident, but are likely to prolong the period of disability, or contribute to the applicant's death during the period through which this is covered by the policy. Hearing, sight, habits, should also be covered in this report. They are not only items to be considered with the writing of the first policy, but on subsequent renewals after periods of three or five years. Reinspections.-By the occasional reinspection of risks, a com- pany is able to protect itself against a high loss ratio, incident to the changes in the activity, physical condition, or habits of their accident policy holders. Reinspections are especially important on business that is renewed through brokers, also on policy- holders who pay by mail or over the counter, and are not on the renewal lists of agents directly responsible to the company. CHAPTER XLV FRAUD By Albert Seaton, M.D., Indianapolis, Ind. Vice-President and Medical Director, The Century Life Insurance Company Insurance is a business, involving, as all other business, the use of money. The lack of money is responsible for much deception. As Benjamin Franklin once said, "It is hard for an empty sack to stand upright." Many agents approach the borderland of dishon- esty because of financial distress and a few members of the medical profession have loved money not wisely, but too well. Modern life consists of many complexities. More and more the mind of man becomes the dominant factor of his existence. Man not only thinks to exist, but his thoughts determine the manner of his existence. The complexities of life and the uncertainty of existence have stimulated the ingenuity of man and among the many things pro- duced has been the great business of life insurance. This has grown in magnitude in less than a century from a few small com- panies into a business controlling more money than any other busi- ness in the world and represents a business in which the mind of man has not only modified his own manner of existence, but has extended to that time beyond his own existence to determine in a greater or less degree the manner in which others will exist. Since the days before record, through all the ages, the mind of man has possessed the faculty of deception. Wars, kingdoms, for- tunes and religions have been made, lost or changed by its influ- ence. Deception may become dishonesty, and deceptive dishon- esty when it results in loss is fraud. It is a far cry from the days of personal contact without exam- inations to this day when a company depends not only upon the knowledge of its examiner many miles away, but upon that ex- aminer's honesty and ability to discern honesty in others whom in many cases he has seen but once. The examiner's skill as a diag- nostician is often of secondary importance to his honesty of char- 638 FRAUD 639 acter and his ability to observe honesty of intention in others. If he is endowed with those qualities of mind, which make him a good insurance examiner, he has qualities found in diplomats, bank- ers and successful business men. If he sees only the dial of the blood pressure instrument or the chemical reaction in his labora- tory, he lacks finesse and has lost much in his work that is really worth while. Deception often occurs when least expected and I have often thought it strange that an individual endowed with those qualities of character that result in his making sacrifices to buy insurance to benefit others, would also be capable of any great degree of deception. Yet many times it has occurred. In the files of life insurance companies are many instances of attempts at fraud. Each year the court records show new cases of fraud contested. As long as man exists he will practice decep- tion. Some will be dishonest and a few will attempt fraud. Some time ago the insurance companies compared their experi- ences relating to fraud and arrived at plans to protect themselves against the consequences of fraudulent applications. Case histo- ries were made and the companies sent in letters outlining the cases selected. Many of these letters show very similar experiences. A few replies are given. "A year or so ago we received a telegram from one of our rep- resentatives asking permission to use a doctor other than our reg- ular medical examiner, explaining that our regular examiner was out of town and not available. Having but one examiner in that locality we wired a favorable response, but filed the telegram so that it would come up when the medical report was received. We also wrote our regular examiner explaining the circumstances. In a few days the application and medical report were received and a day or two later a letter from our regular examiner, stating that he had not been out of town, that he was aware that this risk had been examined by our company and suggested that it be investi- gated closely, as he did not think the risk an acceptable one. The confidential report was requested by our representative. We, how- ever, put the case in the hands of a second reporting company, re- questing that they give it special attention. Both confidential Fraud by the Examiner 640 LIFE INSURANCE EXAMINATION reports were unfavorable to the applicant, confirming the opinion of our regular examiner. The medical report submitted by the new examiner, however, was without a single flaw. The application called for a $10,000 five-year-term policy. It was declined. Two months later we received notice from one of the reporting com- panies that the applicant had died of pulmonary tuberculosis. This report also stated that at the time he was examined for this com- pany he was being treated for this trouble by the doctor who made the examination. It might be advisable for me to add parenthet- ically that the doctor who made this examination was accidentally killed when duck hunting a few weeks later." Fraud by Applicant and Examiner "Mr. E. applied for $2,000 whole life total disability contract. Accompanying the examination by the alternate examiner, is the following letter of explanation by the agent: 'I have your letter of the 27th inst., asking me to advise you why Mr. E. was exam- ined by Dr. G., your alternate examiner, instead of Dr. AV., your chief examiner. In reply will say that Mr. E. absolutely refused to be examined by Dr. AV. On account of some personal differ- ences, they are not the best of friends. Some years ago Mr. E. called Dr. AV., so he says, to attend his wife during an illness. Mr. E. states that Dr. AV. held her head back and poured chloroform into her nose in a sufficient amount that it entered her brain and caused her to be insane for several months; for this reason Mr. E. absolutely refused to be examined by Dr. AV., and I referred him to your alternate examiner, Dr. G. ' Further investigation of the case revealed good evidence that the man had serious heart disease, was an inveterate smoker, and, as reported by the lay inspector, his home life, associates, surroundings and tendencies rendered him a doubtful risk. This appears to be a case where an applicant pre- fers to go to an examiner who he has reason to believe will pass him, or who is ignorant of his impairment and alleges that the chief examiner is personally distasteful to him, is a political antag- onist or has unfriendly religious or banking connections." Fraud by the Beneficiary ''About three years ago, one of our agents called in a little town to solicit insurance, and the cashier of the bank told him he had a FRAUD 641 friend who wanted some insurance, but that he was off on a hunt- ing trip at the time, but that if he would leave the papers with him, and pay him a commission of $5.00 per thousand that he would see to taking his application and having the examination made. It developed later that the banker who interested himself in the matter was a brother-in-law of the applicant. About a week after the agent's return the application and examination came into the office in regular form, the applicant being, apparently, a first-class risk. The inspection was clean-we have reason to believe, how- ever, that the inspector was an attache of the bank of which the applicant's brother-in-law was cashier. Our policy was issued in due time, settlement made for same, and three days after the policy was mailed out the applicant died from consumption, having been bed-ridden for six months. We allowed them to bring suit, and the .judge, at the conclusion of the trial very promptly asked the jury to bring in a verdict in favor of the company, which they did without leaving the jury box. I was nonplussed during the inves- tigation of this case, regarding the local examiner at that point. He seemed to be a fair, honest country doctor. He assured me that he had never before met the man he examined (purporting to l)e the applicant). The man was strong and healthy and claimed he lived eighteen miles in the country. The doctor stated that the man came to his office and asked him whether he was the examiner for this company; replying in the affirmative, he examined the man and recommended him as a first-class risk. The doctor looked like a good, plodding, honest fellow, and I have never been able to make up my mind whether he was in on the deal or not. The case was never appealed and I believe our fighting the suit and winning on the grounds of fraud, helped not only this company in Texas, but others as well." Fraud by the Applicant "Doctor T. applied to us for a $5,000 term policy, his age being fifty-seven. This applicant was one of the leading physicians in his town, had been our examiner for more than six years and had made a large number of examinations for us. He was examined by Dr. W. who recommended him as a first-class risk. Dr. W. was not our regular examiner, but had made three examinations for us two years before, when a regular examiner was not available- 642 LIFE INSURANCE EXAMINATION was a graduate of a good school, and our information about him was entirely favorable except that he was then seventy-seven years old, though still engaged in practice. The inspection report was entirely favorable, the correspondent stating that he had known the applicant for twenty years, had seen him the day before and rated him 'good' instead of 'first-class,' merely on account of his age. There was absolutely nothing to arouse suspicion and the policy was issued. A month later, the applicant died suddenly and investigation disclosed the fact that shortly before he applied for this policy, he had gone to a sanitarium in another town for a diag- nosis of his condition, and had been informed that he had a hope- less case of lymphatic leukemia. It was also ascertained that at the time he was examined he had plainly visible on his neck en- larged glands the size of a hen's egg, with a larger bunch of glands in his groin. I wrote the examiner and asked him why he did not mention the enlarged cervical glands in his report, and he replied that he noticed them, but the applicant told him they did not amount to anything. We paid $2,500 to compromise this fraudu- lent claim, rather than take chances with a jury of paying the full amount. ' ' Fraud by Suicide "Application was for $10,000 insurance on a cheap plan, man, aged forty-three. This examination was made by the medical di- rector. It was admitted that the applicant had been declined by another company nine months before for reasons unknown. AH illness of every kind was denied. Family history good. The exam- ination was entirely satisfactory throughout, except absence of knee reflexes. Correspondence with the rejecting company brought out the fact that applicant had suffered a severe attack of renal colic twice within the year of his examination. Applicant was declined. The next day he died by fire in his own house. Infor- mation afterwards was to the effect that he had been at home sev- eral days on account of an accident in alighting from a train. His older children had gone to school, his wife was away at a neigh- bor's house. The house caught fire in his own room. The servant girl noticed the flames and knocked at his door and called to him, telling him the house was afire, and he replied, 'all right.' The girl made her escape and before the fire company could inter- FRAUD 643 vene the house was entirely consumed and the charred body found. One life insurance company paid $10,000 to my knowledge and several others were involved, lie had very recently taken out $100,000 accident insurance in several different companies on the double indemnity plan in case of fire. These companies contested the claim in the courts, but afterwards compromised with the pay- ment of. a very considerable sum. The applicant possessed some property but was very deeply in debt and upon the brink of fail- ure, and had been very despondent for several months. There was no question in the minds of those familiar with the facts that it was a case of premeditated suicide, and that the late application for life insurance and the accident insurance were incidental to the coming suicide." Fraud by Substitution "Mr. C., aged fifty years, height five feet eight and one-half inches, weight two hundred and fifty pounds, made application to this company for a $1,000 policy. The examination and applica- tion came into the office absolutely all right, with the exception of weight. The applicant made a statement to the examiner that he had never been declined; that he had never been refused a policy as applied for; that no unfavorable action had ever been taken by another company; that he had not been ill, or that any unfavorable condition had been found in his physical condition by any physi- cian or examiner. Upon subsequent investigation this man was found to have made application to another company a few days prior to the application made to this company and was refused a policy because of weight and unfavorable conditions found in the urinalysis, which were the presence of sugar, albumin, and hyaline casts. He was informed by the other company that it could not issue a policy to him. We took the matter up with our examiner who, in company with the examiner for the other company, visited the applicant, who admitted having been informed of the unfavor- able action of the other company. Our examiner stated in a let- ter to this company that the applicant had voided the urine (as he supposed) in the room where the examination was made and the substitution had been made in such a clever way that the examiner was not aware that it had been made." 644 LIFE INSURANCE EXAMINATION Fraud by Beneficiary, Agent and Examiner "Two years ago this company received an application for insur- ance upon the life of a woman whose age was given as fifty-six, occupation as that of a housekeeper, unmarried, and whose brother was named as beneficiary. The medical report was fay orable, made by our regular examiner in that locality-the inspection reports were favorable and the policy was issued as applied for. hen the second premium became due the company's inspector and re- newal man called upon the applicant for the purpose of securing the second annual premium. The applicant informed him that she did not have a policy in this company, and that she knew nothing in regard to the matter. The inspector reported that her age was apparently more than the age given and suggested an investiga- tion. The local examiner was taken to the home of the applicant and he stated that he had examined the applicant and would rec- ommend her for insurance. After some difficulty the facts were ascertained that the applicant had desired a small industrial policy and that the brother of the applicant desired her to take a larger amount of insurance. The examiner, who also examined for the industrial insurance company, secured the applicant s signature under the pretense that he was examining her for an industrial policy. The premium for the policy was paid by the brother named as beneficiary. Further investigation seemed to indicate that the applicant's mental condition was not entirely normal. The first premium was refunded and the policy cancelled. A review of the records in the files of insurance companies will show that a large percentage of the cases of attempted fraud con- sists in the failure of the applicant to give information material to the risk. A sort of negative deception exists where the exam- iner fails to obtain valuable and material information because of the applicant's attitude. In a general way classification of attempted fraud may be made based upon the individual being a party thereto. Usually for one application there are five individuals and the company concerned: the applicant, the agent, the examiner, the inspector, and the bene- ficiary. In practically all instances of fraud the applicant is dis- honest and in practically all cases the examiner is either dishonest or careless to a degree approaching dishonesty. Tn a few cases the applicant, the examiner and the inspector are dishonest and very FRAUD 645 rarely a conspiracy occurs involving every one except the com- pany. The company protects itself under all circumstances, usually by the introduction of an individual of known honesty into the transaction. It is solved usually like a problem in geometry where the unknown angle of a triangle may be found if the other two angles are known. The sooner education in insurance matters is acquired by the local examiner, the sooner will he become proficient in his work and in many instances evade circumstances that may seriously embarrass him and often reflect either on his skill or honesty in an unfortunate manner. I know of many physicians who have disqualified themselves as insurance examiners because of carelessness, haste or failure to grasp the requirements of their position. Attempts at fraud in nearly every instance can be dis- covered by a wise examiner. The examiner cannot witness the signature of an applicant unless the applicant actually signs it in the examiner's presence. Nearly every case of substitution has occurred by failure on the part of lhe examiner to follow instructions. Family and personal history can be obtained accurately or otherwise in a great degree by the manner in which the questions are asked. This part of the required examination will be the greatest test of the examiner's ability. The company wants valuable information and has arranged de- tailed questions to obtain detailed answers. The questions and answers have a legal significance, which is frequently forgotten by the examiners. The physical examination proper is signed only by the examiner and consists in his report based upon examination as to the applicant's present physical condition. The questions are grouped for the convenience of the examiner and cover first, identity. If the applicant is a stranger the examiner should obli- gate himself to determine the identity. A stranger may sign "John Doe" in the examiner's presence and still not be "John Doe." John may be home too ill to come down town and Joe Doe, his brother, may be the one examined. Beware of strangers and ap- plicants brought from the next town or examinations requested under other unusual circumstances. Det the company know. It will save embarrassment; for a company will not accept strangers without assuring itself of their identity. The medical report is usually a matter of professional skill and the examiner's ability to determine abnormal physical condi- 646 LIFE INSURANCE EXAMINATION tions often under adverse circumstances. It offers a field interest- ing and profitable. If it is not interesting to the examiner, he should refuse to make examinations because sooner or later he will be professionally embarrassed. His work is under constant sur- veillance and his value as an examiner is very quickly determined. Mistakes are often made by the examiner in departing from the order in which the questions are answered. Blanks have received a great deal of study on the part of the companies and often the things considered trivial develop important results. If the applicant is known, his circumstances in life and his habits and reputation familiar to the examiner, the company ob- tains much valuable information, if the examiner is sufficiently interested to write the company and advise it of any unusual cir- cumstances of any character pertaining to the applicant. I remember a case where a banker in the South applied for $20,000 insurance. All factors were favorable but the company was ad- vised confidentially that the applicant's life had been threatened by a fellow townsman. His application was declined. Sixty days later he was shot and killed. Before closing this chapter I wish to relate an actual occurrence to prove that circumstances occasionally happen so closely related to each other that true facts are concealed and deception is suc- cessful. Fraud by Applicant and County Clerk A few years ago a Kentucky mountaineer, T. W., living twelve miles from a county seat, was sold a small insurance policy by an agent of a large insurance company. He was examined by the village doctor and his policy was delivered and paid for. In less than a year the company received a poorly written, misspelled let- ter advising them that T. W. was dead, and that the writer was the son of T. W., and was the beneficiary under the policy. Blank proofs of death were mailed and in time were returned. No funeral had been held, no undertaker and no doctor had been employed. A letter accompanied the returned papers stating that T. W. had died suddenly and that the body had been buried in a small burying ground by members of the family. The papers were returned to the writer with the request that the statements be sworn to before a notary public and the seal of the clerk of the FRAUD 647 county be affixed thereto. In due course of time the proofs and affidavit were returned and the clerk of the county advised that the seal of the county had been lost since the Civil War. A check for the amount was mailed to the general agent with instructions to pay the claim. The general agent thought of the long mountain journey, the small size of the claim, and decided to mail the check and request the return of the policy by mail. He called the exam- iner over the long distance telephone a short time later and told him that the company intended to pay a claim upon the life of T. W. The examiner replied that T. W. had been in town that day and was alive and well. The agent made the long trip and came to the home of T. W. and was met at the door by T. W. himself. The simple-minded mountaineer had written the letters himself, advising the company of his death purely as a matter of curiosity to ascertain what would happen, and the seal of the county had actually been lost since the Civil War. The clerk of the county was an habitual drunkard, who would make an affidavit to anything as long as the party requesting it was a personal friend. If the reading of this brief chapter results in directing the exam- iner's attention to the occasional existence of fraud and deception in the insurance business, it has accomplished the purpose intended. CHAPTER XLVI LEGAL ASPECTS OF LIFE INSURANCE EXAMINATIONS By T. W. Blackburn, Secretary and Counsel, American Life Convention and William Ross King, Editor, The Legal Bulletin Omaha, Nebr. The Relation of the Medical Examiner to Insurer and Insured.- The first question which occurs to a lawyer dealing with medical examinations for life insurance is whether the medical examiner is the agent of the insurer or the insured. General Rule.-The general rule is that a physician employed to make a medical examination is the agent of the insurer, which is bound by his act in the absence of fraud on the part of the insured. This means that if the medical examiner makes any mistake in reporting the answers as given or improperly reporting the an- swers, the company is bound by his acts. Where the applicant intentionally either deceives the medical examiner or connives with him, the company may show mistakes or misconduct of the exam- iner by way of defense to any action brought upon a policy. The Exception.-The most frequent example of the application of the exception to the general rule is where the medical examiner is informed or has knowledge of the falsity of the insured's answers concerning his health and puts the answers down in the report under the mistaken impression that his sole duty is to report cor- rectly the answers of the applicant. Under these circumstances it is generally held that the medical examiner is the agent of the insurer, at least a special agent so far as such matters in the med- ical report are concerned. It has also been held that a physician who has made an examination with personal knowledge of facts material to the risk but fails to report them, by this conduct makes the insurer liable when the question of agency arises.1 False answers in an application for life insurance have likewise been held not to defeat liability on the theory that they misled the med- ical examiner where he testified that he made his report on his own examination and paid no attention to the answers of the applicant.2 648 LEGAL ASPECTS 649 Again, an insurer cannot rely upon a warranty by the applicant that the answers to the questions in the medical examination are properly recorded if it appears that the medical examiner knew at the time that they were not true.3 Incompetency of Examiner.-It is not open to an insurance com- pany to claim that the medical examiner has disclosed incompe- tency in making the examination since he is its agent and not the agent of the insured.4 Stipulations in the application that the examiner is the agent of the applicant do not make him so or affect the agency of the medical examiner for the insurer.5 Connivance with Applicant.-Where, however,, the fact appears that the insured was a party to a deception practiced in making the medical report, it is immaterial that the medical examiner was likewise guilty of fraud. The genera] rule in such cases is that the fraud on the part of the applicant vitiates the contract and the insurer is not estopped by the knowledge of its agent who took the application or the physician who made the medical examination, from setting up the falsity of the answers in the medical examina- tion.6 Reason for Relieving the Company of Liability.-In a federal case it was held that the fact that the medical examiner was in- formed or had knowledge of the falsity of the insured's answers concerning his health did not affect the insurer's right to avoid the policy on the ground of material misrepresentations, since while the medical examiner was a special agent of the company, his authority did not cover that of making a waiver or entering into a contract other than that specified in the written contract. The court said: "And defendant well knew that his application and the accompanying answers to 1he questions of the medical ex- aminer were addressed to the insurance company and were to be submitted to its officers * * * * He is not to be heard to assert the contrary under the circumstances of this case."7 Interpretation of Questions by the Medical Examiner.-As the medical examiner is frequently called upon to decide whether cer- tain ailments reported to him by an applicant are of sufficient importance to be mentioned or to interpret technical language in the application or medical report, the legal question arises whether the insurer can be estopped by the medical examiner's interpreta- tion or opinion to set up as a defense to the policy fraudulent or 650 LIFE INSURANCE EXAMINATION untrue statements in the report. As a general rule it is open to the insured to prove, if he can do so, that he answered the questions in good faith, relying on the interpretation of the medical exam- iner as to their meaning. It therefore becomes the duty of the ex- aminer, acting as agent for the insurer, not only to ask but to explain fully all questions.8 This is peculiarly true when the ques- tions propounded are of a technical character so that the matter comes within the knowledge of the physician as to whether the applicant ever had any serious illness, constitutional disease or injury because the applicant, while stating the facts, may be en- tirely innocent in making negative answers. In such cases the insurer will be bound by the act of the medical examiner, who must ascertain the facts and see that such questions are correctly an- swered.9 The medical examiner cannot assume that he is a mere amanuensis for the applicant. Examples.-The words lispitting of blood" used in filling out an application for a policy were thought by the examiner to mean the spitting of blood from the lungs or bronchial tubes only. The applicant reported that he had expectorated blood, although not sufficient to become a hemorrhage, apparently coming from the stomach. The court held that the company was bound by the in- correct answer as it was a matter peculiarly within the knowledge of the medical examiner, who was bound to interpret properly this technical term.10 In another case the attention of the examining physician was called to the fact that he had been previously consulted by the insured for a certain trouble of the same character as that for which another physician had previously been consulted. The ex- aminer indicated to the applicant that it was not necessary to dis- close the previous consultation in the answer to the question about the attendance of a physician. The court held that the applicant was thereby released from any imputation of falsity in the answer made to the physician since he was justified in relying upon the advice of the medical examiner.11 Of course if the opinion of the physician is accompanied by a correct statement of facts upon which the opinion is based, the examiner is fully protected. This puts the matter up to the home office medical director.12 Company Bound Where Examiner Incorrectly Reports Answers.- Where the examiner writes false or incorrect answers which were LEGAL ASPECTS 651 not given by the applicant, the courts have almost universally held that the insurer is estopped from asserting forfeiture of the policy for such false answers.13 Especially is this true where the appli- cant has not read the report as made or been asked to read it be- fore signing. If the medical examiner will take the precaution to have the applicant read or ask him to read it he will go far to pre- vent the applicant from avoiding the consequence of his own fraud by the claim that he correctly answered the questions, but that they were not properly entered by the examiner. It may be con- tended that this rule opens a wide door for prejudice on the part of the person seeking to recover on a policy fraudulently obtained. The obtaining of a satisfactory medical report probably requires that the medical examiner shall write down the answers to the questions, but if the insured is required to read the report before signing, he cannot then claim that the examiner has written false answers. Personal Knowledge of the Medical Examiner.-Where the med- ical examiner, as is frequently the case, is the family physician of the applicant, the question often arises whether the company is chargeable with knowledge of the facts within the knowledge of its agent, the examining physician. This presents a case often difficult to determine as a matter of law. It would appear from reading the decisions on this point that where the facts are not peculiarly medical in their nature, the examining physician may be content with entering the answers given, but if from any pro- fessional relations with the applicant or otherwise the examiner is aware of any ailment not disclosed, the company will be bound. Thus the insurer is not chargeable with facts within the knowl- edge of the physician where they were not disclosed to him by the examination, but were acquired previously and while material to the risk were not matters upon which the medical examiner was any better informed than the applicant.14 So, as to medical at- tendance, it has been held that although the examiner knows that the applicant has had medical attendance other than that given by himself, the company is not thereby notified of the result of such other examinations and treatment.15 Where the examining physician was also the insured's doctor and had personal knowledge concerning his ailments, the company is held to be estopped from taking advantage of false answers.16 652 LIFE INSURANCE EXAMINATION And where the medical examiner assumes to write in the applica- tion answers to the questions upon his own knowledge rather than upon the answers given by the applicant, the insurer is not in a position to claim that the answers were untrue.17 Medical Examiner's Knowledge of Facts in Application.-A few cases have arisen where the medical examiner has also taken the application and although facts correctly stated in the medical report were improperly answered in the application, the medical examiner was not the agent of the company so far as the applica- tion was concerned.18 The scope of his agency includes only the medical examination and report. Under these cases the company is not estopped to plead the fraudulent answers. Examiners not Regularly Employed.-Where a physician is called upon in a particular instance to make an examination, although not accustomed to making examinations for the insurer and not in the regular employ of the company, so far as the particular med- ical report is concerned, the company is estopped by his actions.19 Ratification by Applicant of Examiner's Acts.-Some courts have indicated that while the medical examiner is the agent of the in- surer, there is a certain duty on the part of the applicant to see that his answers are correctly written down. If it appears that the insured discovers incorrect and false answers relative to his phys- ical condition and family and persona] history written by the med- ical examiner he may repudiate the contract,20 and while an appli- cant for life insurance is not bound to exercise complete supervision, yet if he knows that his answers have been incorrectly reported, it is his duty to see that corrections are made.21 One would nat- urally think that since a copy of the application and medical re- port are attached to the policy, the retention by the insured of the policy would charge him with knowledge of any false answers which he did not intend should go into the report, but only in a few instances have the courts recognized this as sufficient notice to the insured.22 Rule as to Agents Under Iowa Statute.-In Iowa there is a pe- culiar statute on the subject of the agency of a medical examiner. It provides in substance that where the examiner has declared an applicant "a fit subject for insurance" the insurer "is estopped from setting up in defense to an action on the policy or certificate that the assured was not in the condition of health required by the LEGAL ASPECTS 653 policy at the time of the issuance or delivery thereof unless the same was procured by the fraud or deceit of the assured." Thus with respect to all matters inquired about, so far as they bear on the health and physical condition of the applicant as affecting the risk the responsibility rests with the medical examiner. Under this statute it is the procuring of the certificates of the medical exam- iner by fraud and not the procuring of the policy by fraud which may be shown to defeat the policy.23 It will be observed that the statute does not preclude an insurer from setting up fraud since fraud in procuring the certificate may result in fraud in procuring the policy.24 Under the Iowa statute unless the examining physi- cian is misled or deceived, the company is bound, and it therefore behooves him not to report an applicant favorably without thor- ough investigation in every respect with reference to insurability. The Iowa statute is principally important as showing the variation from the general rule, which does not place the responsibility for a full disclosure as to all matters commonly covered by medical examinations on the examiner, but only makes him responsible with respect to matters peculiarly medical in their nature or arising out of his previous relation to the applicant. The Medical Examinations.-In preparing answers to medical inquiries, it is highly important that they shall not be left open to interpretation but shall be definite and certain in every respect. The law resolves ambiguity against the company, which usually in- cludes the application and answers in the medical report, generally referred to as Part II of the application. When the policy stipu- lates that statements of the applicant, in the absence of fraud or deceit, are to be considered as representations and not warranties, and a case of doubt as to the meaning of an answer gets into court, the burden is upon the company to prove not only that the state- ments claimed to be false are untrue, but that they were made with the intent to conceal the true condition and that the company would not have issued the policy except for the fraud practiced upon it. The inquiry is first as to the truth of the representations and second, if untrue, whether they were intended to mislead. These inquiries are to be answered by a jury. Matters of Opinion.-The distinction is more observable in case of answers to matters on which the reply of the applicant must 654 LIFE INSURANCE EXAMINATION necessarily be a matter of opinion. Where this sort of question is to be answered, it is likewise incumbent upon the medical examiner to make a searching interrogation and accurate and complete state- ments. Otherwise, the insured or his beneficiary may escape an apparent misrepresentation on the ground that it was his honest opinion, made in ignorance of the true conditions.25 Name and Age of Insured.-The first question on the medical blank usually relates to the name and age of the insured and as this and similar matters, not strictly medical in their nature, are included in the medical examination, it would be well for the medical examiner to keep on the right side of the law in respect to them as well as to inquiries relating strictly to the condition of health. An answer as to the question of applicant's name which gives the name by which he is commonly known, being a name adopted by him without judicial proceedings, is not improper.26 A false and fraudulent statement as to the applicant's age, however, is very material. If the misstatement is not made with fraudulent intent to deceive, the amount payable is the sum which would be due for the correct age. Formerly a misstatement would void the policy.27 Where the applicant has correctly stated his age, but it has either inadvertently or intentionally been misstated by the examiner, the policy is not void.28 Statements as to General Health-Temporary Ailments.-Tn de- termining whether statements as to general health and physical condition should include certain ailments, the rule of reason must control. "Ailment" has been held to mean a disease of such char- acter as to affect the general soundness and healthfulness of the system seriously and not a mere temporary indisposition which does not tend to undermine and weaken the constitution and there- fore the insurability of the applicant.29 But "ailment" in the home office of the company does not have so narrow a definition. Good Health.-The term "good health" does not mean absolute perfection but is a comparative term. The insured need not be entirely free from infirmity if he enjoys such health and strength as to justify the reasonable belief that he is free from derangement of organic functions, and free from symptoms calculated to cause a reasonable apprehension of such derangement and to ordinary observation and outward appearance is reasonably in such health that he may be insured with ordinary safety, the requirement of LEGAL aspects 655 good health is satisfied.30 In other words, the term "good health" when used in an application or medical examination for life insur- ance means that the applicant has no grave, important or serious disease, and a temporary indisposition which does not weaken or undermine the system at the time of making application does not render a policy void.31 Similarly a question calling for "sound health" does not refer to slight troubles or temporary and infre- quent attacks of sickness.32 The same is true of questions refer- ring to "sound body" and "perfect health." Nevertheless the examiner should not rely upon these court-made definitions, but should give the home office the facts and let the medical director assume responsibility for the interpretation of the words. Moreover, where diseases have well-marked symptoms which all well-informed persons regard as affecting the general health and threaten the continuance of life from the danger of their recur- rence, the applicant is bound to state the exact truth.33 If the insured, when he makes application, knows or has reason to believe that he has a disease, even though it may be latent and undeveloped, he is in duty bound to make it known whether questioned specif- ically or not.34 The medical examiner may be doing insurer and insured an injustice by minimizing symptoms such as "colds," "dyspepsia," "headaches" and the like. Specific Disorders-tfpjYhnp of blood is one of the most common disorders inquired about and has reference, generally speaking, to expectoration from either the lungs or the stomach and while the courts hold it does not refer to the spitting of blood from any tem- porary disorder,35 the examiner cannot omit mentioning the fact. The question is intended to elicit information in regard to the health of the applicant as affecting his desirabilty as a risk, and, like other inquiries relating to his health, is not meant to include mere trivial ailments. The fact that some years prior to the appli- cation the insured had had lung trouble and had then spat blood should be reported and a proved false statement of this character is a good defense on the policy.36 There is no doubt about the company's rights if the spitting of blood was in such form as to be called a disease or constitutional vice. It is immaterial whether the spitting is sufficient to be called a hemorrhage or not37 or when it took place even though the applicant thinks he is well again. 656 LIFE INSURANCE EXAMINATION Colds.-Very slight colds do not ordinarily need to be mentioned even though they may afterwards develop into a serious illness resulting in death.38 Similarly, tonsillitis and even influenza have been held as not sufficient to disable an applicant so that it is nec- essary for him to report such ailment in answer to a question as to "serious personal illness"39 but the efficient and honest examiner will carefully report such disorders. Bronchitis.-In the case of bronchitis, like any other illness, it depends on whether the trouble is acute or chronic. Tn a Wisconsin ease the assured's physician had examined the applicant and rec- ommended postponement of a prior application which was referred to in the application on which the policy was issued. Bronchitis was defined as an "inflammation acute or chronic of the bronchial tubes or any part of them." A rule of construction in favor of the assured, as is ordinarily adopted, was followed in this case and the statement in the application was construed not to mean an acute attack from which the applicant had fully recovered, but covered only a chronic disease not readily yielding to treatment and tend- ing to impair his strength and vigor.40 Catarrh.-Where there is a specific question referring to catarrh, it must, of course, be truthfully answered, but a catarrhal condi- tion of the throat sufficient eventually to result in consumption need not be detected and reported by the medical examiner when applicant is not aware of a serious condition requiring treatment.41 Here again the examiner must be governed by home office instruc- tions and may not excuse inefficiency by reference to this court sentiment. Dyspepsia.-Ordinary stomach trouble is not a disease within the contemplation of the law but chronic dyspepsia extending over a number of years must be reported and an answer that applicant has had dyspepsia only in a slight form may void the policy.42 The examiner should assume that any stomach trouble may be a serious impairment and should not lightly pass over even "slight stomach trouble. " Nephritis.-Tn an Oklahoma case the testimony was undisputed that the insured had suffered from nephritis immediately prior to the issuance of the policy. There was a sharp conflict on the point whether the disease was chronic or acute but he responded readily to treatment and fully recovered. He afterwards died from gun- LEGATj ASPECTS 657 shot wounds. It was held that if the jury should find he was suf- fering from nephritis the insured had failed to answer properly a question relating to "defects in body" and the nephritis therefore should have been reported in the application. The fact, however, that applicant a few months later may develop the disease from which he dies within a year, does not indicate that the medical ex- amination has been improper.43 Fainting Spells.-A fainting spell produced by indigestion or lack of proper food which is a mere temporary disturbance or en- feeblement, is not " a disease or bodily infirmity" within the mean- ing of the law44 but cannot be ignored by the conservative examiner. Hernia.-Hernia frequently arises as a possible breach of con- dition or warranty as to health or bodily condition. Questions most frequently arising with respect to this trouble relate to predispo- sition to rupture and cases of corrected hernia. Where the appli- cant states affirmatively that he is in sound health and bodily condition but it develops that he has had premonitory symptoms or a predisposition to hernia, it matters not that the symptom itself develops after the policy is issued. The case will call for a jury to decide whether this increased the risk of loss by accident or other- wise.45 As a matter of law one who has once had hernia is not thenceforward called 11 ruptured" providing the condition be cor- rected.40 Where the truthfulness of all statements in the applica- tion is made a condition to the validity of the policy, a false statement as to whether the applicant has ever had rupture voids the policy.47 Hence it is important to notice whether the question refers to the present only or to past conditions. Pregnancy.-Where a married woman is the holder of a life in- surance policy it is not a false representation for her to state that she is sound in bodily health although she be pregnant.48 Preg- nancy is not a personal illness or continuance of bad or unsound health so as to violate a provision that a member of a benefit soci- ety should not be reinstated unless in good health.49 Where, how- ever, the application specifically inquires whether the applicant is pregnant, a false answer will void the risk.50 Miscellaneous Ailments.-Among diseases which courts have con- sidered serious are aneurism, tuberculosis, gall-stones necessitating operation, renal colic, and typhoid fever.51 Other infirmities not so regarded are pleurisy, quinsy, liver trouble, where not affecting 658 LIFE INSURANCE EXAMINATION the functions of the organ, biliousness, sunstroke and appendicitis where there has been a complete recovery.52 Here, again, the courts are more lenient than the home office medical director who regards all the infirmities mentioned in the preceding sentence as highly important in the examination. Contact with Transmissible Diseases.-Denial in an application for life insurance of intimate association with any one suffering from any transmissible disease within a year voids the policy if the applicant has within a year nursed members of his family ill with typhoid fever. It has also been held that questions in the application as to how recently the applicant has been associated with a person having tuberculosis or has occupied apartments for- merly occupied with one having this disease are material and if the applicant has recently or at all been associated with a person who has had tuberculosis or occupied apartments knowing that the previous tenant had tuberculosis, his negative answer would preclude a recovery on the policy.53 In the case last cited a report stating the complete facts might not have prevented issuance of the policy but would have enabled the company to obtain a showing of what precaution or disinfection had been taken by the applicant. Medical Attendance.-Here, as in the case of statements as to general health, false statements material to the risk must neces- sarily be guarded against, but consultations with a physician for mere trivial ailments do not need to be enumerated or set forth in the report. Policies usually contain warranties on the subject of medical attendance. Whether the ailment for which attendance has been sought would affect insurability is the important question, though the failure of the applicant to mention some trivial or tem- porary ailment which in no wise affects his general health would not void the policy.54 Courts, however, are not entirely in harmony on this subject, some courts holding that a negative answer to the question, "Have you consulted any other physician?" is not rendered a correct answer merely because the interview concerned some temporary indisposition.55 Attendance for Serious Diseases.-Where the policy stipulates that it shall be void if the insured has been attended by any physi- cian for a serious disease, there is little danger in making a negative LEGAL ASPECTS 659 answer where the only consultation had referred to temporary disorders.56 Eczema.-Reference may be made to a few illustrative cases re- lating to particular diseases near the borderline. It has been held that the fact that insured had consulted doctors for eczema which had disappeared was not fraudulently concealed by failure to dis- close it in the medical report.57 Inflammation of the Throat.-Where an applicant for reinstate- ment of a life insurance policy had been treated by a physician for what was regarded as a common temporary inflammation of the throat, it did not constitute a consultation within a statement of the applicant that he had not consulted a physician since a certain time although it subsequently appeared that applicant had tuber- culous laryngitis.58 This court certainly went the limit to defeat the company. It has also been held that a consultation for influenza and tonsillitis need not be disclosed.59 Headache.-The fact that insured consulted a doctor and pro- cured glasses or that a friend who was a physician prescribed for him some years before for headache occasioned by temporary worry over business, but that the applicant had not mentioned them when asked what doctors he had consulted, did not invalidate the pol- icy.60 It must be clear from the foregoing illustrations that exam- iners are charged with a grave responsibility and should come as near getting all the facts the blanks are intended to disclose as possible. The fact that in a contested case some court has indicated that failure to report a particular ailment or medical attendance for some borderline trouble does not void the policy is proof of the necessity of reporting such ailment. On the other hand, the fact that a certain physical impairment of doubtful importance has been held to be material emphasizes the importance of not relying upon the applicant's interpretation of the questions to be answered but of discovering the true answer in the light of legal and medical authority. Thus, for example, in one case61 it was held that while "the aspiration of the chest" was as a matter of law "a surgical opera- tion" the good faith of the applicant in stating that he had never undergone a surgical operation was for the jury to determine and the jury found that the statement was made innocently. It ap- 660 LIFE INSURANCE EXAMINATION peared that the applicant's physician knew his patient was suffering from a serious condition of the lungs and the patient later died of tuberculosis. A more careful inquiry on the part of the examining physician might have uncovered the existence of the first stages of the disease of which the patient was kept in ignorance by his physician. But the finding of the jury carried with it the same effect as though the aspiration of the chest were not a surgical operation which needed to be reported provided such was the understanding of the applicant. The case is cited to emphasize the fact that the examiner must not lose sight of the applicant's good faith and innocence in answering technical questions. Statements as to Occupation.-The question has frequently arisen in litigation as to what time is covered by a provision or representation with respect to the occupation or habits of insured. Thus, for example, a statement by the insured in his application, "I am temperate in habits" and a negative answer to the question, "Do you use alcoholic stimulants?" has been held to refer to the present and such statements were not necessarily shown to be false by proof that the insured had drunk intoxicating liquor to excess at intervals from his youth.62 Even where in reply to the double question in an application for life insurance, "What are your habits with respect to the use of intoxicating liquor?" "Have you ever used intoxicating liquor to excess?" the answer referred only to the habits of the applicant at the time the application was made.63 Doubtless the medical examiner frequently is called upon to ad- vise the applicant as to the proper answers in such cases. As a special agent of the company with duties confined strictly to the medical examination, he is probably not responsible if the answers to a specific question relating to occupation or habits fail to reflect the facts, but if it appear that he is cognizant of the true state of affairs, it behooves the medical examiner not only to advise but insist upon true and correct statements in these as well as strictly medical matters. In fact, these questions in the medical blank are frequently duplicates of inquiries in Part I of the application and are important-often quite as much so as inquiries relating to physical health. Questions as to Temporary Employment.-Suppose, for example, a question in the application required the applicant to state his LEGAL ASPECTS 661 occupation or employment, the medical examiner knowing it to be the fact or upon information from the applicant learns that at the time of the application the applicant is employed as a waiter although his trade or calling is that of calker, it would be improper merely to insert as an answer the word "waiter."64 In a Pennsyl- vania case it was held that a statement of the applicant, "My occu- pation is a laborer in a rolling mill and I have no other occupa- tion," was not falsified by the fact that six months prior to the application he had quit working in a rolling mill but had not been engaged in any other or different work between that time and the time of the application.65 On the other hand, the answer "laborer" in reply to the question, "What is your occupation?" was held misleading so as to void the policy, it appearing that as a matter of fact the applicant had suspended labor for several years prior to making the application, either on account of age or other con- tinuous disability.66 From these and numerous other cases that have arisen in the courts it may safely be said that while a mere temporary suspension of one's ordinary occupation does not bring about a change, the ride would not embrace a suspension extending through several years. Divided Employment.-Many difficult questions arise where an applicant is engaged in doing certain work but has various other business connections. Probably the safest rule to follow is to make careful inquiry and a full statement of all of the facts, as a failure to mention a hazardous employment to which the applicant may devote only a small part of his time, may work against both the interests of the insurer and the insured by causing the issuance of a policy which might otherwise be declined. Examples.-Following are examples arising from misstatements as to the real nature of applicant's occupation. Insured stated that he was the proprietor of a grocery store hav- ing a bar in connection but that he had a clerk to tend the bar exclusively. It appeared that insured occasionally tended the bar. Policy was held void.67 Insured stated his occupation to be "importer and wholesale dealer in wines and liquors," and also stated that he was not en- gaged in any way in the retail of alcoholic liquors, kept no bar and sold only at wholesale. It was proved that he kept no bar but kept a wholesale liquor store where he occasionally sold in quanti- 662 LIFE INSURANCE EXAMINATION ties under five gallons. The medical examiner testified that he fully understood the nature of applicant's business and had at- tempted to describe it exactly. Yet the question was submitted to the jury as to whether there had been a full disclosure.08 "Ice dealer and proprietor of transportation company, office work only" was the answer made by another applicant where it appeared that he was also engaged in buying and selling cattle to the extent of 1500 head annually. It was there held that this constituted a business or occupation which should have been given in the an- swer.09 On the other hand, it has been held in the following illustrative cases that the provision as to warranties in the policy had not been violated: Insured had stated that he was "agent and collector and at- tended to the real estate" where it appeared that he was connected with the real estate department of a brewery.70 Another answer, "manufacturing" was held not to be fraudulent where it appeared that the applicant kept a billiard hall, but had been for several years engaged in the manufacture of soda water and at the time of making application for insurance was under a contract to begin again such manufacture.71 Applicant stated that he was a "livery stable proprietor (not working)." The evidence showed that he had superintended the business and occasionally he hitched up teams and drove people about.72 Insured in his application gave his occupation as that of "in- spector," but the proof showed that he was a boss in charge of a gang working on pipes in a certain water works.73 In still another case it was held that the occupation of a "store- keeper" was not affected by the fact that the applicant occasionally was employed as a bevel smoother of plate glass.74 In a Wisconsin case on an accident insurance policy it appeared that the applicant had represented himself to be a "miller" and that at or shortly after making application he attached to his flour mill a circular saw which cut logs into lumber. It was held that although operating a circular saw was a prohibited occupation with the insurance company, the applicant made no false representation in merely giving the answer that he was a miller.75 LEGAL ASPECTS 663 Conclusions as to Occupational Answers.-These cases may be sufficient to indicate the general rule by which the medical examiner must in the exercise of sound discretion be governed. Legally a man's occupation is the calling or employment to which he devotes the principal portion of his time and a change of occupation is not accomplished by the fact that the person temporarily engages in work of a different character or even ceases to perform the duties incident to his usual or regular occupation. But the company is entitled to the facts. Conclusion.-The foregoing illustrative cases are comparatively few of the decisions by American courts in which the subject of medical examinations has been considered in its legal phases. This is not a brief for beneficiaries, although the very large number of cases decided unfavorably to the companies and the medical exam- iners might so indicate. But the general tendency of the courts has always been to construe all matters relating to insurance contracts favorably to the insured on the theory that the insurance company or its agents and representatives are dealing with persons under a disadvantage. The rule as commonly stated is that the contract wherever ambiguous is construed against the party dictating its terms. Whether we like the application of this principle or not, the fact remains that the medical examiner along with the other representatives of the insurer-for he must consider himself as such -must guard against all uncertainties. The question goes beyond the mere one of honestly stating the facts. It goes further than mere diligence or persistency of inquiry. On the other hand it is not necessary where the matter is not mate- rial to the risk that the report be cluttered up with detailed state- ments of trivial ailments. It is, of course, highly desirable that all reasonably safe risks be accepted and that the applicant be not unnecessarily subjected to a gruelling examination which will cause him to drop the insurance before the policy ever issues. However much the medical examiner may be interested in the acceptance of the risk, whether properly or improperly, he cannot forget that legally he is the agent of the company. The only safe way to make a medical report is to make it on the theory that all cases of doubt as to the materiality of the facts should be resolved in favor of dis- closure. It is better for the company, safer for the applicant and more satisfactory to the examiner's conscience to err on the side 664 LIFE INSURANCE EXAMINATION of safety, than to guess at the extent of an impairment or pass lightly a possible hazard for the purpose of saving time in filling out the blank. A good rule for the examiner in making his recommendation, hav- ing secured as complete a disclosure from the applicant as con- science and efficiency require, is to ask himself whether or not he would be willing to assume the risk if he were personally liable to the insured. Another equally good rule is to endeavor to obtain from the applicant as much information as the examiner would feel to be necessary if he were diagnosing the case for a clinical report upon applicant's state of health, environment, habits and occupation. Bibliography iMystic Workers vs Troutman, 113, Ill. Apps. 84. 2Roe vs National Life Insurance Association, 137, la. 696, 115 N. W. 500. sSternaman vs Metropolitan, 170, N. Y. 13, 62. N. E. 763. vs. Life Insurance Co., 1 Woods 674, Federal Case No. 6625. sRoyal Neighbors vs Bowman, 177 Ill., 27, 52 N. E. 264. flMudge vs I. O. O. F., 149, Mich. 467, 112 N. W. 1130; Globe Mutual Life vs Meyer, 118, Ill. App. 155. ''John Hancock Mutual vs Houpt, 113 Fed. 572. General vs McMurdy, 89 Pa., 363. Life vs Blodgett, 8 Tex. Civ. Apps., 45, 273 S. W. 2S6. loMutual Benefit Life vs Robinson, 58 Fed. 723. vs Modern Brotherhood, 148 la., 600, 127 N. W., 52. Trust Co. vs Tarpey, 182, Ill., 52, 54 N. E., 104. 1341 L. R. A. Page 507 and note. Fraternity vs Karnes 24, Tex. Civ. Apps. 607; 60 S. W. 576. isMutual Life vs Nichols, 24 8. W. 910. isFranklin Life vs Galligan, 71, Ark., 295, 73 8. W. 102. 1'Pudritzky vs Supreme Lodge 76, Mich., 428, 43 N. W. 373. isFlynn vs Equitable 67, N. Y., 500; Leonard vs State Mutual 24, N. E., 7, 51 Atl. 1049. Workers vs Troutman 113, Ill. App. 84. soBonnett vs Massachusetts Mutual, 107, Tenn., 371, 65 S. W., 758. 2iEquitablc Life vs Hazlewood, 75, Tenn., 338. 22McGreevy vs National Union, 152, Ill. App. 62; Hook vs Michigan Mutual 44 Misc '1 478, 80 N. Y. S. 56. 23Steward vs Equitable Mutual, 110, la., 528, 81 N. W. 782; Peterson vs Des Moines Life Assn., 115, la. 668, 87, N. E. 397. 24 Welch vs Union Central, 108, la., 224, 78 N. E. 853. 25Collins vs Catholic Order of Foresters, 43, Ind., App. 49. 2fiSmith vs United States Cas. Co., 197, N. Y., 420, 99 N. E. 947. 2rAetna Life vs France, 91, U. S., 510, 23 U. S. Law Ed. 40. 28Fidelity and Casualty Co. vs. Meyer, 106, Ark., 91, 152 S. W., 995. 29Schafield vs Metropolitan, 79, Vt., 161, 64 Atl. 1107. soCaruthers vs Kansas Mutual, 108 Fed., 487, U. S. Sup. Ct. siJoyce on Insurance Law, 2nd Ed. Vol. 3, Sec. 2004. 32Metropolitan vs Howie, 62, O., St. 204, 56 N. E., 908; Brown vs. Metropolitan, 65, Mich., 306-314. LEGAL ASPECTS 665 ssBarteau vs Phoenix Mutual, 67, Barber 354, 67 N. Y. 595. 34Knights of Pythias vs Rosenfeld, 92, Tenn., 508, 22 S. W. 204. 3523 L. R. A. N. 8. 918. 3«Smith vs Aetna Life, 49, N. Y., 215. 3?March vs Metropolitan, 186, Pae., 629, 40 Atl. 1100. 38Joyce on Insurance Sec. 2004. ssSmith vs Travelers, 135, N. Y. S. 18, 76 Misc'l 441. 4oFrench vs Fidelity and Casualty, 135, Wis., 259, 115 N. W. 869. 4iLippincott vs Supreme Council R. A., 64, N. J. L. 309, 45 Atl. 774. 42Jcffry vs United Order of Golden Cross, 97, Me., 176, 53 Atl. 1102. 43Columbian Life vs Tousey, 152, Ky., 447, 153 S. W. 767. 44Mfgs. Acc. Ind., Co., vs Dorgan, 58 Fed. 945. 45Hines vs New England Cas., 90, S. E., 131, LRA 1917 B 744. 4<5Lieb vs Metropolitan, 163, Mass., 117, 39 N. E., 792. 4?Aetna Life vs France, 91 U. S. 510, 23 U. S. Law Ed. 401. 48National Council K. L. S., vs Glenn, 80 So. 516 (Fla.), 2 L. R. A. 1503. Lodge K. L. II. vs Payne 101 Tex. 449, 108 S. IV. 1160. 5014 R. C. L. Sec. 250. srJoyce on Insurance Sec. 2004. 52Gardner vs Northern States, 163, N. C., 367, 79 S. EE. 806. ssNational Protective Legion vs Allphine, 141. Ky., 777, 133 S. W. 788. 54Franklin Life vs Galligan, 71, Ark., 295, 73 S. W. 102. 55Metropolitan Life vs Brubaker, 70, Kans,, 146, 96 Pac. 62; Cobb vs Covenant Mutual Benefit Assn., 153, Mass. 176, 26 N. E. 230. vs Little, 149, S. W., 998. STDelvaux vs Metropolitan, 172, Ill. App. 537. 58Cole vs Mutual Life of N. Y. 129, La. 704, 56 So. 645. 59Smith vs Travelers, 135, N. Y. S. 18, 76 Misc'l 441. eoHoeland vs Western Union, 58 Wash. 100, 107 Pac. 866. oiPelican vs Mutual Life, 119 Pac. 778. 62Bacon vs N. E. Order of Protection, 123, Fed. 152. c>3John Hancock Mutual vs Daly, 65, Ind. 6. G4Wright vs Vermont Life, 164 Mass., 304, 41 N. E. 303. vs Metropolitan, 20, Pa. Sup. Ct., 567. reunited Brethren Mutual Aid Soc., vs White, 100, Pa. 12. 67Malicki vs Chicago Guaranty Fund, 119, Mich. 151, 77, N. W. 690. esKcnyon vs Knights Templar Assn. 122, N. Y., 247, 25, N. E., 299. soStandard Life and Acc. vs Ward, 65, Aik., 295., 45 S. W. 1065. vs Life Assn., 152, Ill. Apps. 173. TiMowry vs World Mutual Life, 7 Daly, N. Y. 321. 72Brink vs Guaranty Mutual, 55 Hunn 606. 73Smith vs Prudential, 10 App. Div. 148, 41 N. Y. S. 925. 74Perrin vs Prudential, 29, Misc'l 597, 61 N. Y. S. 249. TsDenoyer vs First National Acc. Co., 145, Wis. 450, 130 N. W. 475. CHAPTER XLVII THE INFLUENCE OF OCCUPATION ON LIFE UNDERWRITING By Charles II. Beckett, Indianapolis, Indiana Actuary, The State Life Insurance Company It is of supreme importance that the attitude of underwriters toward occupations be clearly understood, since otherwise, our point of view will not include the important observation that insurance companies are seeking constantly to enlarge and multiply the classes to which insurance may be safely granted. A correct concept of the fundamental spirit of the life insurance business will be formed when we review the endeavor to extend its beneficence even to groups beyond the limits of standard lives, so that life insurance may serve in the largest possible way as a universal provident in- stitution. Briefly stated, underwriters now approach the question of insurability from the positive rather than the negative viewpoint. Among the numerous investigations which have been conducted by life insurance companies, not the least interesting have been those based upon the experience of the various companies with in- sured lives whose applications showed that they were engaged in occupations which might adversely affect mortality. The impor- tance of this phase of the development is apparent when we consider that, of the various types of impairments which occur in practice among companies doing a substandard business, occupations involv- ing extra hazard constitute one-third of the cases. As a result of these studies, a very great number of risks engaged in occupations which, ten or fifteen'years ago, were quite universally found in the prohibited list, have either gradually come to be accepted for in- surance at standard rates, or placed in the lists of those accepted with slightly higher premiums than are charged for insuring stand- ard lives. Another notable and far-reaching change in this same direction is the elimination from policy contracts of restrictive provisions relating to change in occupations. Tn this latter course, the com- panies have taken the initiative and their action has been followed 666 INFLUENCE OF OCCUPATION ON LIFE UNDERWRITING 667 by legislative enactments which prohibit the inclusion of such restrictions in policy contracts. The laws of most states now pro- vide that policies of life insurance are incontestable after not more than two years from the date of the policy, except for violation of the conditions of the policy relating to naval or military service in time of war. Notwithstanding this privilege, it is now an almost universal practice among companies to issue policy contracts which are entirely free from restrictions governing change of occupations even during the two-year contestable period, so that the question of occupational hazard must be decided before the contract is issued. The Accident Hazard.-The extra liability to death from accident in many occupations must be considered aside from its bearing upon risks for double indemnity and disability benefits which will be sub- sequently discussed. This will be best illustrated by examining a few types: electric light, heat and power company employees. It has been found that among insured lives in these occupations lhe death from accidents has been as follows: Stationary Engineers and Firemen-Three times the standard. Timers and arc light trimmers-Five times the standard. Mining Industry: Engineers, Superintendents and Managers who occasionally go under ground-Four times the standard. Foremen, Bosses and Working Miners, other than coal mines- Seven times the standard. Working Coal Miners-Five to six times the standard. One hundred and ninety-nine cases were studied and reported in Vol. II of the Medico-Actuarial Investigations. The results in many of these cases illustrate the force that must be given to this phase of selection. There are a few occupations which are conducive to good health, but in which the accidental hazard is above the normal. Great care should be exercised so as to be certain that the extra deaths from accident are fully considered, with the result that the total ex- perience will be such as is anticipated, and that the underwriter will not be unduly influenced by the otherwise favorable mortality. Applicants from occupations in which the death rate from acci- dent is several times the normal are rarely acceptable risks for life insurance at standard rates. 668 LIFE INSURANCE EXAMINATION Living Conditions.-It is very difficult to separate deaths due primarily to occupation, unless they be accidental, from those due to living conditions of those employed in the given occupation under investigation. The group of wage earners who are usually classed as industrial are not so well prepared to protect themselves against the effects of sickness and disease as are the more prosperous strata of the population. These facts determine important health conditions such as diet, housing, clothing and standards of medical service. Such groups are largely urban and are subjected to the unfavorable influences of city life. Therefore, the mortality experi- ence will show characteristics very different from the experience among groups which have distinctly better living conditions. The effect upon classification due to working and living conditions is well illustrated by the occupation "laborer." If the applicant lives in a city, the company must have definite information concern- ing the accident hazard, but other additional facts are likely to be of equal importance. If he is a man of some education, reads well and writes legibly, has a fair and steady income and is of an age such that he is likely to improve his condition, he is in an entirely different class from one, say of foreign birth, who is a floater, who is ignorant of the simple laws of good living and not likely to have proper medical attention, if ill. Two laborers who are engaged in the same kind of work and of the same condition in respect to age, wage and intelligence, might very properly fall into widely separated groups as insurance risks merely on the ground of habitat. A laborer in the pine woods of northern Michigan is not in the same class as he would be placed if he were working in the pine woods in a southern Louisiana swamp. The factor of education should be given less importance in rural districts than in cities, since many farmers and farm laborers are of a steady type and are better risks for insurance than the average laborer, even though they have but meagre education. It is, there- fore, impossible to make broad and inclusive rulings in such occu- pations as require that all facts such as are numerated herein shall be taken into consideration. Degenerative Influences.-Apart from the accident hazard, and also from the living conditions, we must consider the effect of engage- INFLUENCE OF OCCUPATION ON LIFE UNDERWRITING 669 ment in certain occupations upon the wear and tear of the human machine as contributing to degenerative diseases which shorten life. Among workers with poisonous metals and those whose occupations involve much strain of the circulative system, arteriosclerosis with re- sulting cardiac hyperthropy is one of the most common diseases. This is likewise true of those whose work involves the constant strain of lifting heavy weights or other forms of strenuous muscular exertion. In the group of those in which the nature of their work is such as to cause liability to tuberculosis are found workers in mineral or metallic dusts, toxic gases, vapors and fumes, and any strong respiratory irritant; also those exposed to sudden temperature changes, as stokers, heaters, bakers, and those exposed to cold and wet, as sawyers in stone mills. Any statistical study will disclose numerous occupational diseases of the nervous system. However, all authorities agree that in most cases it is exceedingly difficult to determine whether the disease is due primarily to the occupation, or is merely contributed to thereby. It is not unlikely that living and domestic conditions cause the greater part of mental and nervous diseases. The predis- position to such diseases is especially noticeable among workers where the practice of "speeding-up" is in vogue. Such seasonable work, as fruit and vegetable canning, clothing manufacture, brick making and outside painting, involving rush periods with seasons of idleness, contributes to nervous troubles. Classes of workmen who must endure excessive dry heat such as puddlers, foundrymen, pottery-bakers, glass-blowers, bakers, work- ers with electric furnace and workers in asphalt paving are subject to rheumatism, bronchitis, and chronic nephritis. It is not easy to estimate the insidious and progressive effects of these occupational diseases. Conditions of employment have such an important bearing upon most of them, that few general rules can be laid down and in all such cases, careful inquiry should be made so as to ascertain to what degree the workers are protected in any specific industry, and if the nature of the work necessarily involves risks of degenerative diseases, then suitable allowance should be made in offering insurance contracts so as to place such risks in a class under which they contribute their proper share to the com- pany's mortality fund. 670 LIFE INSURANCE EXAMINATION Moral Environment.-It very frequently occurs that because of moral features associated with certain occupations, applicants are rated heavily or declined. Taxicab drivers in large cities, in addi- tion to being under-average because of accident liability, are sub- ject to moral conditions which make them not acceptable as life insurance risks at standard rates. Bookmakers, theatrical em- ployees, actors and actresses are not considered to be in a sub- standard class on account of accident, unhealthful conditions of employment or unsanitary surroundings, but rather on account of what might be termed moral environment. The same observation would apply to any class whose occupation is such as would mark them generally as poor types of risks be- cause of low standards of morality and as lacking in responsibility. Liquor Business.--The enactment of the Volstead Act has quite materially affected a large class of occupations. Applicants for- merly connected with the liquor business, but now engaged in occu- pations which indicate complete severance from former connections may be accepted at standard rates, if physically first-class, but of course, the medical examination should be studied with the facts in mind of the former occupation. Occupations closely allied with former liquor connections, such as soft-drink dispensers and employees of billiard parlors, should be scrutinized very carefully and the fact which should be looked into very cautiously in connection with all such applicants is as to whether or not there be any suspicion of their illegal connections with liquor business. Also a careful inquiry as to their personal habits should be made. The results shown in the Medico-Actuarial Investigation should be considered in connection with these classes, and for a guide in standards to be followed, reference should be made to a paper entitled, "Ratings for the Principal Impairments," by Arthur Hunter and Doctor 0. IT. Rogers, read before the Medical Directors Asso- ciation in 1921. Methods of Rating.-Most authorities divide hazardous occupa- tions into two different classes for rating purposes. In one are placed those in which the hazard is chiefly due to accident and does not vary with age until after ages 60 or 65. Example-Mail clerks, Telephone repairmen, Bridge carpenters. In the other are placed those in which the extra hazard increases INFLUENCE OF OCCUPATION ON LIFE UNDERWRITING 671 with age, and is chiefly caused by following an occupation which is likely to impair health; also those who, from exposures of various kinds, are subject to abnormal morbidity. Example-Pottery in- dustry, Hat Factory employees, Stone Mill workers. Therefore, in the first class the mortality fund is provided for by charging an extra premium which does not vary with age or kind of policy, but is calculated simply to cover the extra mortality due to accident, and there would be no change in policy values on ac- count of such rating. Applicants following occupations belonging to the second class are charged extra premiums, which are computed on the basis of percentage of extra mortality and such premiums vary, therefore, with age, and kind of-policy. As an alternative method for calculating the proper mortality in groups of the second class, recourse is frequently made to the plan of advancing the age a sufficient number of years to include in the premium the extra mortality to be provided for. From practical considerations, it is almost necessary to give surrender values based upon the age as advanced whenever this plan of rating is used. An objection to the latter method arises from the fact that if a policy is issued at a rated-up age with the same policy values as would be given a standard life at the advanced age, it will fre- quently occur that the values allowed for surrender or loan are in excess of the values that would be granted if the premium and reserves are based upon a proper mortality table. It has been fairly well established that the extra mortality in a group of lives, substandard on account of unhealthfulness of occu- pation, increases for a few policy years, then reaches a maximum, and afterwards diminishes. Such incidence of mortality results in reserves on whole life and endowment policies which are less than standard reserves. If therefore, surrender values are based upon standard reserves at a rated-up age, the supposedly extra premium is likely to be refunded to the insured either in whole or in part. The accompanying table will illustrate the comparative reserves according to tlie American Experience Table with 3% per cent inter- est on the twenty payment life plan (preliminary term basis of valuation) for actual age thirty-five, for 150 per cent mortality at age thirty-five and for rated-up age forty-three, which is the cor- responding rated-up age to provide a premium equal to that accord- ing to the 150 per cent table at age thirty-five: 672 LIFE INSURANCE EXAMINATION 700 500 SOO 4Oo 300 ZOO loo 3 2 t 56 7 8910II12, 13 IS 16 77 Z<5 19 Years. 1 Actual Age. 35. 2 /50 7o Table,. 3 Rq ted- Up Age 4- 3. Fig. 156. influence of occupation on life underwriting 673 Terminal Reserves American Experience with 3% Per Cent Interest. Twenty Payment Life Plan, Preliminary Term Basis. DURATION 5th yr. 10th YR. 15th yr. 20th yr. Actual age 35 . . 88.88 219.96 377.22 566.15 Rated-up age 43 . . 108.35 264.26 446.06 663.83 Age 35 (150 per cent table).. . . 95.72 238.60 412.25 625.11 If the risk is properly rated at 150 per cent, the correct reserve at the end of the tenth year is $238.60. Should the insured be granted a policy at an equivalent premium rate, but with cash values based upon age forty-three, and at the end of the tenth policy year withdraw and be paid the reserve of $264.2'6 as a cash surrender, he has been paid $25.66 from presumably earned mor- t ality. Another practical objection to issuing standard policies at a premium rate based upon an advance in age arises from the fact that while accidental death rates in a general population doubt- lessly increase from age sixty-five, accidental deaths due to occu- pation have a tendency to decrease with advance in age. It there- fore follows that the advance in age method of providing for extra mortality would result in premiums higher than necessary for the more advanced ages. The very considerable difference in the extra premium on ordi- nary life and twenty payment policies, especially at the younger ages, and the difficulty of rating up ages on endowment policies sufficiently to cover any substantial extra premium furnishes an additional excellent reason for employing a different method. If a suitable extra premium is charged for a limited number of years, only the difficulties above enumerated would be overcome to a considerable extent. The extra premium would be based upon the assumed extra mortality and reserves calculated on said as- sumption. The policy values including extended insurance, paid-up insurance, cash and loan values, would all be based upon the re- serves for assumed extra mortality with limited premium payments. It would, of course, be necessary to calculate extra premiums and reserves for intervals only-as, for example, for 125 per cent, 150 per cent, 175 per cent and 200 per cent with assumptions that the extra mortality would be incurred for a limited number of years only, and not throughout the table. 674 LIFE INSURANCE EXAMINATION Removal of Rating.-The question of the removal of a rating on account of hazardous occupation frequently presents itself. Of course, the company must have reasonable assurance that the in- sured will not again be engaged in the occupation for which he was rated, and also that his health has not been impaired thereby. If there be any question concerning the elimination of the extra hazard, a period from one to two years in a non-hazardous classifica- tion is usually considered to be satisfactory evidence of permanency. After having been satisfied as to the above, many companies fur- ther require satisfactory evidence of insurability. This should al- ways be done if the company, by removing the rating, should incur any additional liability on account of total and permanent dis- ability benefits. If evidence of standard insurability is required, there will be a few members of such groups who will be forced to continue pay- ment of extra premiums, and it is most likely that such payments will be a real hardship for the insured in his impaired condition. Unless the impairment is clearly due to his engagement in the occu- pation for which he was rated, there would appear to be little justification for the company's changing an occupational extra premium to a medical extra, and it would be very much more desirable to charge such sufficient extra premiums as would enable the company to discontinue them without raising the question of insurability. From practical considerations of keeping satisfied policyholders, such a course would find justification. In this connection we again encounter a problem which was dis- cussed in connection with the question of "Methods of Rating." If the policy is issued on a substandard life with premium rates and policy values based upon an advance in age, and subsequently the company desired to remove the rating and exchange the policy issued for one with standard premiums and values based upon the true age, the question of the difference in cash values of the two policies will be involved. Naturally the insured will feel that he should be credited with the difference in the cash values in the exchange, but such a course would result in the company's returning to the insured a substantial part of the extra premium which was earned on account of the extra hazard covered. If, however, the policy had been issued on a basis by which the proper values for a substandard life had been given, such practical difficulties would INFLUENCE OF OCCUPATION ON LIFE UNDERWRITING 675 be largely eliminated. If extra premiums are charged for a limited number of years only, as previously suggested, the difference in reserves on account of removal of ratings would be overcome to some extent. Disability Benefits.-It is very important to keep in mind that the selection of risks as among different occupations when disability benefits are to be granted, is not identical with selection for life insurance. In some occupations there is an extra hazard of disability from accident, and in others from disease, and frequently from both. The following are examples of extra disability risks from accident: Railroad Freight Brakemen-from loss of hands or feet. Hand Blowers-from blindness. From diseases caused by, or associated with occupations, are employees in dusty trades and stone cutters. A large percentage of disability claims results from tuberculosis; therefore, applicants engaged in occupations which render them more likely to contract this disease would be unsatisfactory risks for disability benefits. The character of the benefit provided in the proposed policy is also important, since the more valuable the benefit is, the harder will the applicant try to secure it, and after the policy is issued, disability claims are more likely to be presented if the benefit is a valuable one. Therefore, the waiver of premium during disability could be granted in some groups which would not be acceptable for this benefit, combined with the annuity during disability. Particular care should be exercised in limiting the amount of the last named benefit, so that in no case could an applicant secure from all of his insurance an annuity disability benefit in an amount dispropor- tionate to the income from his occupation.* Double Indemnity.-Occupation is the most important factor en- tering into the determination of the double indemnity risk. In this we are concerned with the increase in the death rate caused by accident, and the statistical information is fairly satisfactory. If a company charges a uniform premium rate for the double indemnity benefit, then the freedom of selection would depend upon the amount of the premium charged. If the standard premium is based upon $1.50 per thousand, risks could be accepted somewhat ♦Total and Permanent Disability Benefit in Relation to Life Insurance, Ac- tuarial Studies, No. 5. 676 LIFE INSURANCE EXAMINATION more liberally than when the standard rate is based upon $1.00 per thousand. A few companies grant the double indemnity benefit to applicants from groups in which the accidental death rate is somewhat higher than the average, by charging an additional premium for this benefit. Of course, such a practice necessitates a refinement in selection and classification which, in most cases, is exceedingly difficult to justify. It is strikingly apparent that the rules and classifications of such companies differ widely, and this fact is evi- dence of a considerable difference of opinion among those who have given the subject special investigation. If the application for insurance shows that the applicant has frequently changed his occupation, it would fall into a group which is most likely to result in a selection against the company. There- fore, applicants whose history shows frequent changes of occupa- tion should be selected with great care. An accident manual furnishes no practical assistance as a guide in passing upon applicants for double indemnity benefits because the accident classifications are based upon disabling as well as fatal injuries. The paper of Hunter and Rogers, "Influence of Occupa- tion upon Mortality," Vol. 21 of the Transactions of the Actuarial Society, will be found to be very helpful. Another very valuable paper will be found in the Proceedings of the 16th Annual Meeting of the American Life Convention entitled "The Additional Acci- dental Death Benefit," by W. N. Bagley. Occupational Blank.-A practical difficulty in passing upon, or rating risks for occupational hazards is caused by the very fre- quent omission of exact information concerning the occupation. In later years, most companies have found it to be desirable to have a special occupation form executed at the time the application for insurance is made. Such a form usually requires that general ques- tions shall be answered by all applicants whose occupation is such as would require full information, and then specific questions are arranged in groups so that the applicant would usually answer all the general questions and then the questions from the group to which he belongs. A type of general questions would be as follows: 1. What is the name of the company, mill, plant, factory, shop or railroad in which you are employed? 2. In what department are you employed? INFLUENCE OF OCCUPATION ON LIFE UNDERWRITING 677 3. What is the name of your occupation? 4. Describe your duties in detail. 5. (A) Do you work about machinery in motion? (B) Give details. 6. (A) Do you attend engines or dynamos in motion? (B) Do you attend switchboards or handle live wires? (C) If so, state voltage generated or carried in wires. 7. (A) Do you do any grinding or polishing? (B) Wet or dry? (C) Is exhaust blower provided for dust? 8. (A) Are there any mechanical blowers, ventilating, or dust collecting systems in use? Describe them. 9. (A) Do you do any welding? (B) Electric or acetylene? (C) Inside or outside? (D) Large or small pieces? 10. Do you work in yards where cars are in motion? 11. Are you required to cross and recross railroad tracks in pursuit of your duties ? 12. Do your duties expose you to extreme heat? 13. (A) Does your work require that you climb upon high structures or go under- ground ? (B) Describe fully. 14. Do you handle explosives? 15. (A) Do you operate a motor-driven or horse-drawn vehicle? (B) If so, describe fully, stating kind of vehicle, and nature of loads hauled. (Additional facts regarding any occupation, or continuation to any of the questions contained herein may be written below or on the back hereof.) Occupations which are exceptionally healthful and which do not subject persons engaged therein to unusual hazards from acci- dental death, present no difficulties. However, due credit is given to these facts in any scientific system of passing upon applications for insurance with the result that applicants such as clergymen, authors, judges, nurserymen and school teachers receive such favor- able ratings from occupation as tend to offset the deficiencies from personal history, weight or other detracting factors, and these classes thus receive the benefit in selection from their occupations. Our chief concern is for those groups that are likely to be classed as of questionable hazard. These present unusual difficulties, and they elicit our sympathy for the reason that we are apprehensive lest we shall treat them unjustly. It is, therefore, necessary that we have a well-defined notion as to what constitutes a questionable Remarks. 678 LIFE INSURANCE EXAMINATION hazard, so as to be able to determine in any case, or in any given class, whether the risk is speculative on account of insufficient in- formation relative to the hazard; whether it belongs to a group for which the mortality can be predetermined with a sufficient de- gree of accuracy to permit the company to issue a suitable contract; whether the risk be too great to justify the issuance of any con- tract whatever. Questionable Hazards.-A questionable hazard from the life underwriting standpoint is a risk which belongs to a class of which the mortality cannot be predetermined with a sufficient degree of accuracy to permit of the calculation of the death strain, or the degree of departure from a standard table of measurement. Classes which are known to be subject to mortality above the normal are not, therefore, questionable or speculative, provided: First, that the mortality can be accurately calculated from statistical data. Second, that the conditions which cause the extra mortality are unchanging and have remained practically constant over the period included in the statistical study. If conditions are changing, it is necessary that the effect of change may be ascertained in such a manner as will enable the actuary to make suitable modification in the mortality which is to be expected. The risk of loss or gain is that fraction of the sum to be lost or acquired which expresses the chance of losing or gaining it. When the doctrine is applied to the question of the selection of life insurance risks, it is necessary to know the probability of death during each year, and not merely the prospect of longevity. In other words, it is important that the incidence of mortality be definitely ascertained. It is, therefore, of little value to know merely the expectation of life of an applicant from any class or even the average excess mortality if it is not shown year by year. It should also be kept in mind that in questionable hazards which occur on account of occupation, the problem of determining the degree of extra hazard is usually dependent for its solution upon conditions which are themselves constantly changing. Conditions in the industries which subject those employed therein to extra hazard on account of accident or occupational diseases have changed materially within the last decade, so that a calculation of the costs of such hazards, based merely upon statistical data, would in many cases be incorrect and misleading. INFLUENCE OF OCCUPATION ON LIFE UNDERWRITING 679 For many years the great industrial systems in this country seemed to devote all their energies toward improving the efficiency of the corporation. Then followed a period of combination for greater profit and efficiency. Today we appear to be entering upon an era in which the industrial and commercial worlds are begin- ning to realize that efficiency, in its truest sense, must begin with the conservation of the health and strength of the individual, and they are placing a higher estimate upon the value of the human machine. The next decade will doubtless show great changes affecting both the morbidity and mortality as influenced by indus- trial occupation, but the extent to which the improvement.now being made will be offset by the effect of high specialization remains to be seen. Many organizations are seeking to improve conditions affecting occupational mortality and disease. Among these are: American Association for Labor Legislation, American Museum of Safety, Bureaus of Factory Inspection, State Commissions on Occupational Diseases, Boards of Health, Bureau of Labor Statistics, United States Commerce Commission, Safety First Crusades, Joint Board of Sanitary Control in the Cloak, Suit and Skirt, Dress and Waist In- dustries, Public Safety Commissions of the larger cities, Interna- tional Association for Labor Legislation, Bureau of Labor Safety, Welfare and Statistical Bureau Departments of Life Insurance Com- panies. There is no question but that the information being gath- ered by these, and other sources, is becoming authoritative. The excessive death rate in many occupations has undoubtedly been caused by conditions which should change, and which we have reason to believe are showing improvement, but at the present time the nature and degree of improvement cannot be ascertained in all instances. Therefore, it is not practical at this time to attempt to give an extensive rating schedule for occupations chiefly met in connection with uncertain risks. There is a marked difference of opinion among actuaries and medical directors, both in respect to the assumed extra mortality, and in the practice of granting disability and double indemnity benefits to applicants from large and important classes of occu- pations. Several companies have published more or less comprehensive 680 LIFE. INSURANCE EXAMINATION rules and ratings relating to occupations. A very notable publica- tion is that of Dr. 0. H. Rogers and Arthur Hunter referred to above. If a comparison is made of all the recent published rules and ratings, it will be found that such differences exist in most cases as to convince one that these various students of the question have been greatly influenced by their own experience and observation, so that the subject is not sufficiently standardized to justify the inclusion of any set of rules or schedules in a book of this character. There is a movement partially under way which has for its pur- pose a comprehensive and progressive study of the problem of selecting and insuring under-average lives, and, of course, the prob- lem of occupational hazard will receive its due consideration. Until such time as the question is worked out more satisfactorily, com- panies must be content as best they may, with the somewhat chaotic state and be guided by general principles and such statistical in- formation as is now available. CHAPTER XLVIII POSTPONEMENT IN DISEASE The Duration of Postponement in This List of Diseases Dates from the Time of Complete Recovery This time may vary according to the judgment of the Medical Director, as the statements made show the opinion of the majority of authorities consulted. Revision of decisions will have to be made from time to time, as science pro- gresses, and Insurance Companies accept substandard business more and more. This compilation was made many years ago by the editor, and revised from year to year with the assistance of many of the leading specialists and insurance experts of this country. His gratitude to them cannot be expressed in words, and as they number several score, it is impossible to enumerate them by name. A ABDOMINAL S E C- TION FOR LESIONS OF UTERUS AND APPENDAGES Malignant Growths Other than Malignant (if no tumor) See chapter on Post- operative Risks. Decline One to three years After complete recovery and get full statement from operating sur- geon as to exact char- acter of operation and result. When premature meno- pause results. Two years at least ABORTIONS Two to four years After one abortion if otherwise very favor- able ; or until normal pregnancy. Get location and size of abscess. Any glands involved ? Treatment 1 (If operative give date and details, condition of scar, and glands at present.) ABSCESS (External) Acute Chronic Psoas Until well Ten years Ten years ABSCESS OF LIVER ABSCESS OF LUNG (See Hepatic Abscess) (See Pulmonary Abscess) 681 682 LIFE INSURANCE EXAMINATION ACTINOMYCOSIS Five years ACUTE INFLAMMA- TION OF UTERUS (See Inflammation of AND OVARIES Tubes and Ovaries) ADDISON'S DISEASE Decline ALBUMINURIA See chapter on Albumi- nuria. See chapter on Insurance of Substand- ard Lives. Send speci- mens to home office for microscopic examina- tion. ALCOHOLISM Occasional Decline Especially bad within two years. Reformed by Cure Five years Then 20-year Endow- ment if otherwise first- class. See chapter on Insurance of Substand- Reformed without ard Lives. Treatment Five years Investigate carefully. AMPUTATIONS Each case to be classified as to cause and result of amputation. See chapter on Army Serv- ice as an Insurance Problem and on Post- operative Risks. ANAL FISSURE Accept if cured Get certificate from at- tending physician. ANCHYLOSTOMUM DUODENALE (Hook Worm) Two to five years ANEMIA Simple Three months After complete recovery. Chlorotic Five years Get statement from at- tending physician that it was real chlorosis. Pernicious Decline ANEURISM Decline ANGINA PECTORIS Decline POSTPONEMENT IN DISEASE 683 ANGIONEUROTIC EDEMA Decline ANTERIOR AND FRONTAL SINUS INFECTION Six months to two years After operation and com- plete recovery. ANTERIOR POLIO- MYELITIS Two to five years If deformity is not too - great. ANTHRAX Two years AORTIC INSUFFI- CIENCY OR STEN- OSIS Decline APHASIA Decline APPENDICITIS Period of postponement may be reduced to one year in carefully selected cases. Get number and dates of attacks, treatment, (operative or medicinal) exact date of operation. Was appendix removed? Any symptoms since operation? APPENDECTOMY Three to six months One year at least Decline If uncomplicated and without drainage. If complicated and if drainage was used. If abscess cavity was opened and drained without removal of ap- pendix. See chapter on Postoperative Risks. ARTERIOSCLEROSIS See chapter on Blood Pressure. Get if the arteries are palpably thickened. Are the temporal vessels tor- tuous? Cause, if dis- coverable? Treatment, if any? Blood pres- sure-two o b s er v a- tions. ARTHRITIS ARTHRITIS DEFORM- ANS (See Rheumatism) Decline 684 LIFE INSURANCE EXAMINATION ASCARIS LUMBRI- COIDES Ignore ASCITES Get cause and classify. ASTHMA Watch cases occurring Recurrent Rated or decline during previous two years. Get frequency and severity of attacks. B BILHARZIA HEMA- TURIA Five years BILIOUSNESS (See Indigestion) BLACKWATER (See chapter on Army Service as an Insurance Prob- FEVER lent) BLINDNESS (Total) Decline or annual extra premium with no bene- fits. BRADYCARDIA See chapter on Heart. BRIGHT'S DISEASE Acute Two to five years Urine should be sent to home office for micro- scopic examination. Chronic Decline BRONCHITIS Acute Until entirely well Six months to a year Five years If it has lasted one to three weeks. If it has lasted four weeks or over. Be careful about appli- cants whose weight is below standard. Membranous Chronic Decline, accept over- weights only, rated. BURNS On recovery Six months If of first and second de- gree. If of third degree, un- less there is a marked deformity. C CESAREAN SECTION Decline Until subsequent normal pregnancy. Occupation must be sat- isfactory. CAISSON DISEASE Five years POSTPONEMENT IN DISEASE 685 CANCER Decline (See Epithelioma Even if operated on. of Lip) CARBUNCLE Three months If uncomplicated. Speci- men to be sent to home office. CARCINOMA (See Cancer) CATARACT Unilateral Acceptable If of long standing with no increase of size, no operation c o n t e m- plated, and other eye is normal. Double Six months After complete recovery from operation for ex- traction, if sight is good. CELLULITIS External One month If mild and without gen- eral septic infection. CEREBRAL HEMOR- RHAGE Decline CEREBRAL TUMOR Decline CEREBROSPINAL MENINGITIS Two years CHANCROID Four to six months After complete recovery without internal medi- cation. Get statement from attending physi- cian. CHOLECYSTECTOMY Two years and more or Provided the operation rated after one year was uncomplicated and there have been no symptoms since. Cases in which the operation upon the gall bladder was extended into the common duct should be postponed live years or longer. See chap- ter on Postoperative Risks. 686 LIFE INSURANCE EXAMINATION CHOLECYSTOTOMY Two years and more or Provided ease was un- rated after one year complicated at time of operation and there have been no symp- toms since. Cases which were complicated either at or after operation will require a longer period of postponement, but each case will be judged on its own merits. See chapter on Postopera- tive Risks. CHOLECYSTITIS (See Gall-stones) CHOLERA, EPIDEMIC One year Have urine sent to home office for microscopic examination. CHOREA Two years Must be exceptionally good otherwise. CHYLURIA Decline CIRRHOSIS OF LIVER Decline COCAINE HABIT Decline COLIC Get cause, then classify. COLITIS Membranous Two years Ulcerative Five years Tuberculous Decline CONCUSSION OF BRAIN One year If without depression. CONDYLOMA When well If nonsyphilitic. Get statement from attend- ing physician. CONSTIPATION (See Indigestion) Inquire about obstruc- tion. POSTPONEMENT IN DISEASE 687 CONSUMPTION (See Tuberculosis) Get if apices have dull- ness on percussion, diminished or altered breathing, rales, etc. Has the applicant re- cently lost weight ? Give figures. Has the sputum or blood ever shown the presence of tubercle bacilli? If so, when? Has the ap- plicant ever changed his occupation or resi- dence or been treated at a Sanitarium for tuberculosis ? Are the applicant's domestic or business surroundings conducive to develop- ment of tuberculosis? Prognosis as to life and recurrence? Treat- ment? Result of any X-ray findings? CONVULSIONS Get history, cause, and character, then clas- sify. COUGH (Persistent) Get cause and classify. CURVATURE OF SPINE (See Spinal Curvature) CYSTITIS Acute Three months Urine must be micro- scopically normal in at least two specimens. Chronic Two years If not due to some other disease. D DEAFNESS Date of onset? Sudden? Gradual ? Degree of deafness in each ear? Is the defect sufficient to considerably in- crease the hazard as to accident or life? Partial Get cause and classify. Total Decline or heavy rating with no benefits. 688 LIFE INSURANCE EXAMINATION DEFORMITIES Get history, cause, and degree. Treat each case individually. DENGUE Three months DIABETES INSIP- Accept only after care- IDUS ful history has been taken and urine speci- men sent to home office is negative. DIABETES MELLITUS Decline See chapter on Glycosu- ria and Insurance of Substandard Lives. DIARRHEA Acute Until well and weight See that weight is up to back to normal. standaid. Chronic Two to five years If nontuberculous. DILATATION OF HEART Decline DILATATION OF STOMACH Decline DIPHTHERIA Three months If mild and uncompli- cated. Have urine sent to home office for microscopic examina- tion. DIZZINESS (See Vertigo) DOG BITE (See Rabies) DROPSY Get cause, then classify. DRUG ADDICTION Decline DUODENAL ULCER (See Gastric Ulcer) DYSENTERY Mild Two months Chronic One to two years Tuberculous Decline DYSPEPSIA (Nervous) Two months to one year Exclude organic trouble and see that weight is up to standard. Get underlying cause if possible, number and dates of attacks, dura- tion, treatment, prog- nosis. POSTPONEMENT IN DISEASE 689 E ECTOPIC PREGNANCY Only acceptable when both fallopian tubes have been removed and two years have elapsed since operation. ECZEMA Ignore Unless extensive; then accept upon recovery. ELEPHANTIASIS Three years After thorough operation and complete recovery. Take care that it was not due to syphilis. EMPHYSEMA Ten years EMPYEMA One to two years If normal weight is re- gained. See chapter on Postoperative Risks. ENDOCARDITIS Acute Five years Heart must be normal. Chronic Decline ENDOMETRITIS Six months On statement that the tubes were not in- volved. ENLARGED GLAND Nontuberculous One year After removal. Must have positive state- ment that microscopic examination showed no evidence of being tu- berculous. Tuberculous Ten years After removal. ENLARGEMENT OF HEART Decline See chapter on the Heart. ENTERIC FEVER (See Typhoid) ENTERITIS (See Gastroenteritis and Colitis; ENTEROPTOSIS (See Gastroptosis) EPILEPSY Decline or five years with rating EPITHELIOMA (See Cancer) 690 LIFE INSURANCE EXAMINATION EPITHELIOMA OF Ten years (See Cancer) After complete removal EIP without glandular in- volvement on satisfac- tory statement from surgeon. ERYSIPELAS Mild Severe Recurrent One month Six months These apply to first at- tacks only. Should be postponed much longer. ESOPHAGEAL (See Oesophageal) ETHMOIDITIS Two years F FACIAL PARALYSIS Get cause, then classify. FAINTING SPELLS Get cause, then classify. FILARIA MEDINEN- SIS One year FILARIA SANGUINIS HOMINES Five years F1STULA-IN-ANO Six months (if over- weight) Two years (if under- weight) Ten years (if tubercu- lous) After complete recovery, if nontuberculous. Get statement from operat- ing surgeon. FLOATING KIDNEY (See Movable Kidney) FOCAL INFECTION (See chapter on Focal Infection) FRACTURES (See chapter on Army Service as an Insurance Prob- lem) FRACTURE OF SKULL One year Decline if there is de- pression or removal of bone, but may be ac- cepted after five years if trephine opening has been closed by bone. See chapter on Postoperative Risks, POSTPONEMENT IN DISEASE 691 FURUNCULOSIS Three months Without recurrence. Specimen sent to home office. G GALL-STONES Recline If there have been two or more attacks. Get number and dates of attacks. Was jaundice present ? Treatment (Medical or operative). If operation give exact date of operation. Was operation for drainage or removal of gall bladder? Any subsequent symptoms of any character? See Cholecystotomy. See chapter on Abdomen. GANGRENE Six months If due to heat, cold, or pressure, and not to any constitutional dis- ease. Five years If due to Raynaud's Disease. GAS POISONING (See chapter on Army Service as Insurance Problem) When did the gassing oc- cur? Duration of isymptoms ? Character of gas? What was the principal lesion? (Re- spiratory or Local B u r n-internally o r both?) Examine care- fully for any after ef- fects and describe if any are found. GASTRALGIA (See Gastritis) Look out for other neu- rotic symptoms. 692 LIFE INSURANCE EXAMINATION GASTRIC ULCER Five to ten years- If operated on, postpone for at least six years. Sec chapter on Postop- erative Risks. Get date and duration of attack, pain? If present give exact location. Vomit- i n g ? Hemorrhage ? Any hunger pain two or three hours after eating? Was x-ray picture taken? If so, result? Treatment? Medicinal or operative? Give name of attend- ing physician or sur- geon. Operative, what was done? Present condition? * Is appli- cant still on a 'diet? Any abdominal discom- forts or digestive dis- turbances of any char- acter? See chapter on the Abdomen. GASTRITIS Acute Six months to a year Exclude poisoning, ulcer, gall bladder disease, and appendicitis. See that weight is up to standard and he is not on diet. Chronic One to two years GASTROENTERITIS GASTROENTEROS- TOMY GASTROP'TOSIS Two months to a year Depending upon severity. See chapter on Postopera- tive Risks. Decline Accept With proper support. Handle each case in- dividually. GLANDERS GLAUCOMA Acute Two years One to two years After successful iridec- tomy for acute unilat- eral glaucoma, pro- vided other eye is nor- mal. Chronic Decline POSTPONEMENT IN DISEASE 693 GLYCOSURIA (See Diabetes) See chapter on Glyco- suria and Insurance of Substandard Lives. GOITER Simple Women can be granted 20 Year Endowment in simple, uncompli- cated cases. The age limit in carefully se- lected cases should be reduced to twenty yeans. See chapters on Goiter. Exophthalmic or Toxic Decline GONORRHEA Acute When well Six months After complete recovery, provided there is no stricture. Send speci- men to home office. Chronic GOUT Mortality is so high, even when only one at- tack is recorded, that these risks are almost uninsurable. If ap- proved the case should be superexcellent in all respects. GUNSHOT WOUNDS (See chapter on Army Service as an Insurance Prob- lem) II HEMATURIA One to five years Urine should be sent to home office for micro- scopic examination. HEMOGLOBINURIA Five years Urine should be sent to home office for micro- scopic examination. HAY FEVER Accept Eliminate Asthma. HEADACHES Get cause, then classify. HEART MURMURS (See Valvular Heart Le- sions) 694 LIFE INSURANCE EXAMINATION HEMATEMESIS (See Gastric Ulcer) Get number and dates of attacks, cause, treat- ment. If operative give full details and name of operating sur- geon. HEMOPHILIA Decline HEMOPTYSIS (Sec Tuberculosis) Get date. Was it tuber- cular and if so, were tubercle bacilli ever found? Symptoms? (Collateral or subse- q u c n t) Treatment? Any evidence of past or present tuberculosis. Result of any x-ray findings? HEMORRHAGE Get cause and where, then classify. HEMORRHAGE INTO RETINA At least five years Then blood pressure must be satisfactory before acceptable. HEMORRHOIDS Is applicant subject to attacks? If so, give frequency and dura- tion. Are attacks severe or accompanied by hemorrhage? Treat- ment ? Any suspicion of chronic hepatic de- rangement? After operation and com- plete cure, and upon statement from attend- ing physician that there was no suspicion of malignancy. If not too extensive. Get statement from attend- ing physician. Operation or Injection Two months HEPATIC ABSCESS Five years HEPATIC CIRRHOSIS Decline HEPATIC CONGES- TION One year POSTPONEMENT IN DISEASE 695 HERNIA Accept, if properly supported. If unsupported, study each case separately as to occupation, etc. HERNIOTOMY Three months After simple operation for radical cure with good results. See chapter on Postopera- tive Risks. One year If for strangulated her- nia. Get statement from operating sur- geon. HIP JOINT DISEASE (See Tuberculosis of Bone) HODGKIN'S DISEASE Decline HOOKWORM Two to five years Some companies postpone until cured, shown by normal color and sev- eral negative stool examinations a week apart. See chapter on Life Insurance Ex- aminations in the South. HYDROCELE Three months Six months With no recurrence after first tapping. If small and no operation. Without recurrence after tapping when previous operation has been per- formed. HYDROCELE OF SPERMATIC CORD Accept If small, no enlargement within past year, and without operation. HYDRONEPHROSIS Decline HYDROPHOBIA (See Rabies) HYPERTROPHY- CARDIAC Decline See chapter on the Heart. HYPERTROPHY OF TONSILS Accept If no pus present. 696 LIFE INSURANCE EXAMINATION HYSTERECTOMY (See Abdominal and See chapter on Postopera- Vaginal Section) five Risks. HYSTERIA Five years Must be exceptionally good otherwise. I INDIGESTION Get complete history of symptoms, previous at- tacks, treatment and diet. Eliminate Ap- pendicitis, Carcinoma, Colic, Gall Bladder Disease, Pyloric Stric- ture, Gastric or Duo- denal Ulcer. See chap- INFANTILE PARAL- ter on Abdomen. YSIS (See Deformities) INFECTIONS (Sec Pyemia) INFLAMMATION IN- VOLVING TUBES AND OVARIES Acute, non-septic One year Get satisfactory state- ment from specialist. Septic cases Decline Unless operated on. Get full statement. INFLUENZA Mild Severe One to two months Six months to year Look out for pulmonary, renal and myocardial complications, and see that weight is back to normal. See chapter on Respiratory Dis- eases. INSANITY Decline INTERMITTENT PULSE (See chapter on Heart) INTESTINAL OB- STRUCTION Acute One to two years If operation was per- formed, postpone two to three years after complete cure and upon satisfactory statement from attending physi- cian. Chronic Decline POSTPONEMENT IN DISEASE 697 IRITIS Unless due to Focal In- Severe One year fection which has been removed. Exclude Syphilis and Cancer. Get cause, dates, re- sults and treatment. IRREGULAR PULSE (See chapter on Heart) J JAUNDICE Acute Catarrhal Four months Malarial One year L LABOR, ABNORMAL Was it the first? Instru- mental ? Why ? Com- plications? LARYNGITIS Acute Until entirely well Chronic One year If nontuberculous; get Tuberculous Decline cause if possible, dates LEAD POISONING (See Plumbism) and treatment- LEUKEMIA Decline LITHOTOMY See chapter on Post- operative Risks. LOCOMOTOR ATAXIA Decline LUMBAGO (See Rheumatism) LUPUS VULGARIS Ten years See Tuberculosis of Skin. M MALARIA Intermittent Three months Six months One to two years If sick one week or less. If sick two weeks to four weeks. If sick over four weeks. Get full details of pre- vious attacks and get condition of spleen. Remittent One year Pernicious Five years Includes Malarial Hema- turia or Swamp Fever. Note: Repeated attacks of Malaria showing marked sus- ceptibility but without cachexia, postpone two years. Removal to nonmalarial locality would favor risk. See chapter on Life Insurance Exami- nations in the South. Malarial Cachexia Five years * Inquire for Hematuria 698 LIFE INSURANCE EXAMINATION MALTA FEVER One year MASTOIDITIS One year Decline After complete recovery from operation. See chapter on Postopera- tive Risks. If no operation. MEASLES Mild Severe One to two months Six months to a year Look out for pulmonary complications and see that weight is back to normal. MENIeRE 'S DISEASE Decline MENINGITIS Two years Only when it is of the acute simple type. METRITIS (See Endometritis) MIGRAINE Get cause and classify. MILIARY FEVER Mild Four months Severe One year MITRAL INSUFFI- CIENCY OR STEN- (See Valvular Heart Le- OSIS sions) MOVABLE KIDNEYS Two to five years rated After fixation. Urine must be sent to home office for microscopic examination. MUMPS When entirely well MYOCARDITIS Decline N NASAL POLYPI Six months After first operation without recurrence. Get statement from at- tending physician. One year After subsequent opera- tions without recur- rence. Get statement from attending physi- cian. POSTPONEMENT IN DISEASE 699 NEPHRECTOMY Three years or Endowment only. If Decline there have been no subsequent symptoms. Urine should be sent to home office for micro - s c o p i c examination. See chapter on Postop- erative Risks. NEPHRITIS (See Bright's Disease) NEPHROPEXY (See Nephrectomy) NERVOUS PROSTRA- TION (See Neurasthenia) NEURALGIA Varies with cause, sever- ity, and location. NEURASTHENIA One to two years After complete recovery. Get full statement from attending physi- cian, especially as to possibility of insanity. If in hospital, learn whether sent by legal procedure; also get condition of reflexes. NEURITIS Localized Three months to year Depending on location and severity. Multiple Two to five years Have urine sent to home office for microscopic examination. O OBSTRUCTION (See Intestinal Obstruc- (Intestinal) tion) OEDEMA Get cause and classify. OESOPHAGEAL DILA- TATION Decline OESOPHAGEAL DI- VERTICULUM Decline 700 LIFE INSURANCE EXAMINATION OESOPHAGEAL SPASM Several years Look out for neurotic symptoms. OESOPHAGEAL STRICTURE Decline OOPHORECTOMY (See Abdominal and Vaginal Section) OPIUM HABIT Decline OSTEOMYELITIS Two years If not due to Tubercu- losis or Syphilis. OTITIS MEDIA Acute Three months After cessation of dis- charge and complete cure. Get date of first and last attacks. One or both ears affected? Is or was the discharge offensive? Any dis- charge from mastoid at present? Any ten- derness of mastoid or bone involvement? Any impairment of hearing in either ear? If so to what degree as shown by the tick of a watch? Treatment? Prognosis as to recurrence? Is the defect sufficient to considerably increase the hazard as to acci- dent or life? Chronic Decline If present and persistent. Note: If there is a record of only one attack of Acute Otitis Media, a certificate from a competent aurist should not be required, unless the attack occurred within six months of examination. A certificate should not be required if there has been no discharge within one year, unless the case is one of relapsing, recurrent, or intermittent otorrhea, in which case a certificate should be required if there has been a discharge within two years. See chapter on the Ear. POSTPONEMENT IN DISEASE 701 OVARIOTOMY (Sec Abdominal and Vaginal Section) OVERWEIGHT See chapters on Influ- ence of Build and In- surance of Substand- ard Lives. OXYURIS VERMICU- LARIS Ignore P PALPITATION Three months to year Get certificate from at- tending physician. Decline In an elderly applicant. PANCREATITIS Decline PAPILLOMA OF BLADDER Five years After successful removal and microscopic exam- ination of urine. PARALYSIS Get cause, then classify. PARALYSIS AGITANS Decline PARATYPHOID (See Typhoid) PARESIS Decline PARONYCHIA On recovery. PELLAGRA Decline See chapter on Life In- surance Examinations in the South. PERICARDITIS Five years Heart must be normal. PERINEPHRITIC AB- SCESS Two years Get full statement from operating surgeon. PERITONITIS Acute General Two years Acute Localized One year Get certificate from at- tending physician. Chronic Decline PERTUSSIS (See Whooping Cough) 702 LIFE INSURANCE EXAMINATION PHARYNGITIS Acute Until well Chronic Significance varies Get a statement from greatly attending physician. PHLEBITIS Three years Mild cases may be ac- cepted in less time. PHTHISIS (See Tuberculosis) PILES (See Hemorrhoids) PLEURISY Dry Purulent PLUMBLSM Both show a very heavy mortality when the attack occurred within five years of application, and some excess for the next five years. These risks should not be approved within five years, with rare ex- ceptions. Even after five years they should be scanned carefully with regard to other conditions which tend toward tuberculosis. Aspiration of clear fluid is often a forerunner of tuberculosis. Chronic Three years Provided that present oc- cupation is safe. PNEUMONIA One year or until after a This applies to all vari- winter eties, but may be re- duced to three months in favorable cases. PNEUMOTHORAX Ten years POLIOMYELITIS (See Deformities) POLYPI (Ear) One year After complete recovery from removal. POTT'S DISEASE (See Spinal Curvature) PREGNANCY (Normal) Three months After delivery. PROSTATECTOMY Decline PROSTATITIS Acute Three months If there has been no suppuration. Two years If there has been sup- puration. Chronic Two years Only when applicant is under 40 years. There must be no present en- largement and a full statement must be given by attending physician. POSTPONEMENT IN DISEASE 703 PROSTATORRHEA Six months PROTELD POISONING Decline PSEUDOLEUKEMIA Decline PSORIASIS Ignore Unless marked. PULMONARY AB- SCESS Five years If nontuberculous. PULSE OVER 100 (See Chapter on Heart) PURPURA HEMOR- RHAGICA Five years PURPURA RHEUMA- TICA One year PYELITIS Two years If it originates as a com- plication of Typhoid, Pneumonia, Diphthe- ria, and other fevers. PYREXIA Above 99 degrees to be regarded with suspi- cion. PYEMIA One year (at least) See chapter on Postop- erative Risks. R RABIES Accept Four months One year If Pasteur treatment is successful. If it has not been known if dog had Rabies. If dog had Rabies. RAILWAY SPINE Two to five years If uncomplicated. RAYNAUD'S DISEASE Decline RECTAL PROLAPSE One year After complete and sat- isfactory statement from operating sur- geon. RELAPSING FEVER Six months 704 LIFE INSURANCE EXAMINATION RENAL CALCULUS Six months (for ages be- Urine must be examined low 40 years) microscopically in each case and blood pres- One year (for ages above sure taken if possible. 40 years) Weight must not be over company's maxi- mum. Recurrent Attacks Five years to decline Careful history should be taken. RETROPHARYNGEAL ABSCESS One year If nontuberculous. Get statement from attend- ing physician. RHEUMATISM Articular Cases should be approved of Substandard Lives, with care, as it is a Careful examination of distinct impairment un- the heart should be til after live years made. have elapsed. See chapter on Insurance Muscular Until entirely well Six months If mild. If severe. These rules apply only to uncom- plicated cases. In most cases get certificate from attending physi- cian. Gonorrheal One year RUBELLA When entirely well If weight is back to nor- mal. S SALPINGITIS See chapter on Postop- erative Risks. SARCOMA (See Cancer) SCARLET FEVER Six months to one year Send sample of urine to home office for micro- scopic examination SCIATICA Mild Four months Severe One year SCROFULA (See Enlarged Gland) (See Tuberculosis of Glands) POSTPONEMENT IN DISEASE 705 SCURVY Five years SEPTIC INFLAMMA- TION (See Inflammation of Tubes and Ovaries) SEPTICEMIA (See Pyemia) SHELL SHOCK (See chapter on Army Service as Insurance Problem) SINUS Nontuberculous Three months If of short duration. Tuberculous Ten years At least. Ten years or decline If due to tuberculosis of spinal column or hip joint. SINUSITIS Until cured SKIN DISEASES Eliminate Syphilis, Lu- pus, Fevers, Rashes, Tuberculosis and Can- cers. Get history and treat each case indi- vidually. SMALLPOX Mild Three months Severe Six months to a year Look out for complica- tions. SPINAL CURVATURE Lateral Decline Unless history of case shows continued good health for ten years and superexcellent in all other respects. Anterior and Posterior Decline STAPHYLOCOCCUS INFECTION (See Pyemia) STREPTOCOCCUS IN- FECTION (See Erysipelas) SUNSTROKE Mild Until the next summer if without symptoms Severe Two to five years Must be able to with- stand hot weather with- out symptoms. 706 LIFE INSURANCE EXAMINATION SYNOVITIS Acute Three months Chronic One year Get* statement from at- tending physician that there was no suspicion of Syphilis or Tuber- culosis. SYPHILIS The time elapsed since the completion of treatment may be disregarded. The best authorities con- sulted advise that no attention be paid to Wasser- mann tests, either blood or spinal, or any form of salvarsan treatment. If more than one year has elapsed since the cessation of all symptoms and treatment, one provocative test (Wassermann) may suffice. Should have two years of mercurial treat- ment; at least five years should have elapsed since the initial lesion. The blood pressure must be taken in all cases. See chapters on Syphilis and Insurance of Substandard Lives. Cases acceptable under the above conditions will re- ceive 20 Year Endowments up to age of 35 and 15 Year Endowments thereafter. T TACHYCARDIA (Paroxysmal) Five years See chapter on Heart TAENIA ECHINOCOC- CUS Five years TAPEWORM Two months After head is discharged. Six months If head was not found, but there are no signs of recurrence. TESTICLE Castration Six months If for injury, benign growths, or inflamma- tion, and then only when satisfactory mi- croscopic examination has been made. Elimi- nate Cancer and Tu- berculosis. Cancer Decline Tuberculosis Decline With rare exceptions ac- cept after ten years and after x-ray exam- ination. POSTPONEMENT IN DISEASE 707 THYROIDECTOMY Two to five years If the goiter was simple, parenchymatous with- out complications. Get statement from attend- ing surgeon. Decline If exophthalmic or toxic. TONSILLITIS Follicular Until well Suppurative Two to six months TRACHOMA Decline If chronic. TRAUMATIC LESIONS OF VULVA, VAGINA AND CERVIX Accept Upon complete recovery from operation and satisfactory statement from attending physi- cian. TREMORS Decline TRICHOCEPHALUS DISPAR Ignore TRICHINA SPIRALIS One to two years TUBERCULOSIS O F LUNGS Decline See chapters on Respira- tory System and on Life Insurance Exam- inations in the South. Does the applicant now or has he in the past lived in the same house with any one suffering from tuberculosis? If in the past give date when exposure ceased. What measures have been adopted to com- bat t h i is tendency ? (Medicinal, nutritive, change of occupation, climate.) 708 LIFE INSURANCE EXAMINATION TUBERCULOSIS O F BONE Ten years If entire absence of symptoms during that period and is above standard in all other points. Get what bone or joint was affected? Give date. Was the condition clearly tuber- culous necrosis or a pyogenic osteomyelitis? Treatment? If opera- tive give date and ex- t e n t of operation. Character of scar, and adjacent glands at present? TUBERCULOSIS O F GLANDS (See Enlarged Gland) TUBERCULOSIS 0 F Was the condition that of true Lupus Vulgaris or SKIN that of nontuberculous Lupus Erythematosus? Treatment? If by radium or radiotherapy, where and when? Prognosis as to recurrence? Has there been any recurrence in the past? Any scar tissue present ? TUMORS Benign Have usually been accepted upon satisfactory state- ment from operating surgeon or attending physi- cian if important structures are not involved and they have not enlarged in past two years. Two to three years If of breast, after oper- ation without recur- rence. Malignant Keloid Decline As a rule. If small. After complete recovery without recurrence. Accept Three years TUMORS OF BRAIN Decline POSTPONEMENT IN DISEASE 709 TYPHOID FEVER One year Note: This can be reduced to six months in selected cases. Have the normal weight regained before applying for life insurance. Usually this takes about six months, although sometimes longer. Each case has to be judged on its own merits, as we know that in some cases chronic inflammation of the intestines results and some even acquire tuberculosis. In case of doubt a certificate from the family physi- cian stating that the applicant has entirely recov- ered his health is necessary. Find how much the heart may be damaged; a number are left with a myocarditis, sometimes of low grade. TYPHUS FEVER Six months If weight is back to nor- mal. U ULCERS Acute or Simple One month Be sure that they are not due to specific or ma- lignant disease. Six months to a year Chronic If due to varicose veins, depending on duration, size, and degree of support. Two months to a year UNCONSCIOUSNESS Get cause, then classify. UNDERWEIGHT See chapter on Influence of Build. UREMIA Decline URETHRAL CARUN- CLE Accept Upon complete recovery. . Get statement from at- tending physician un- less date of disease was remote. URETHRAL RUPTURE Two years After injury. Be sure no stricture exists of a severe degree. URETHRAL STRIC- TURE Accept When dilatation is suc- cessfully completed. 710 LIFE INSURANCE EXAMINATION URETHROTOMY Internal Six months After recovery and pas- sage of 26 French Sound. External One year URINATION (Frequent) UTERINE DISPLACE- MENTS Get cause and classify. Six months After complete cure. Not acceptable while wear- ing pessaries or any form of support. V VAGINAL SECTION (See Abdominal Section for Lesions, etc.) VAGINITIS Simple Accept Upon complete recovery with statement from attending physician. Gonorrheal Six months On statement that there was no involvement of uterus or tubes. VALVULAR HEART LESIONS Decline See chapter on Heart. Mitral regurgitation, under age of 40, is sometimes taken at 20 Year Endowment, with loading. Have heart blank completed. See chapter on Insurance of Substandard Lives. VARICELLA When entirely well VARICOCELE Ignore Unless very large. VARICOSE VEINS Ignore Accept Reject When only moderately enlarged. If not enlarged to ex- treme degree and meas- ures for support are effective. If marked. VARIOLA (See Smallpox) 711 VERTIGO * Get cause and classify. VESICAL CALCULUS One to two years After operation. Get statement from attend- ing physician if opera- tion is within five years. Send specimen to home office for mi- croscopic examination. VULVAR ABSCESS (See Urethral Caruncle) VULVITIS (" " " ) VULVOVAGINAL CYST ( " " " ) W POSTPONEMENT IN DISEASE WHOOPING COUGH Mild Two to four months Look for pulmonary com- plications and see that weight is back to nor- mal. Severe One year WOUNDS On recovery If uncomplicated and not involving deep or im- portant structures. See chapter on Army Sendee as an Insur- ance Problem. Y YELLOW FEVER Six months to a year Have urine sent to home office for microscopic examination. INDEX OF AUTHORITIES A Allen, 40, 470, 472, 481, 484, 485, 486 Allison, 498, 511 B Babcock, 327 Bagley, 676 Baker, 579 Balfour, 417 Banting, 488 Barcroft, 437 Barniger, 484 Barringer, 464, 466 Bass, 495 Baumann, 345 Bearwild, 329 Beckett, C. H., 666 Beckett, W. W., 601 Biefeld, 456 Bigelow, 356 Blackburn, 43, 648 Blakely, 314 Bland-Sutton, 379 Blankinship, 345 Bloodgood, 396 Bradshaw, 316 Bright, 454 Broders, 363, 417 Brooks, 324, 326 Brown, 360 Brown, W. Langdon, 473 Brunton, 297 Buchtemann, 379 C Cabot, 182 Cammidge, 473, 474, 481 Carman, 417 Carr, 137 Carter, 227 Caultield, 537 Chargin, 319 Colin, 530 Connolly, 440 Cook, 75, 279, 458 Crawford, 279 Crile, 342 Cushing, 279 ]) Dana, 316 Daubler, 329 Dowling, 500 Drummond, 316 Dryden, 45 Dublin, 138 Dwight, 44, 463 E Eakins, 361 Ehrlich, 317 Erlanger, 280 Evans, 137 Exton, 419, 457 F Falkson, 379, 417 Faught, 279, 282, 286, 293 Finney, 358 FitzGerald, 45 Fisher, 85, 297, 299 Fiske, 616 Flint, 181, 279 Florence, 493 Forcheimer, 297 Forrester, 548 Fournier, 325 Frankel, 616 Franklin, 638 Friedenwald, 358 Friedlander, 329 G Gage, 356, 362 Garrison, 500 Garrod, 458 Gerwood and McKenzie, 297 Goddard, 501 Goepp, 297 Goodman, 298 Greene, 47, 142, 224 Grimmes, 329 Grosvenor, 92 II Haldane, 437 Halpine, 66 Halstead, 85 713 714 INDEX OE AUTHORITIES Masson, 363 Matthews, 479 Maxon, 454 May, 25, 29 Mayo, 223 Mayo, C. IL, 406 Mayo, W. J., 399, 408 McCarrison, 348 McCloud, 454 McConnell, 54 McCordick, 545 McNee, 542 Minor, 329 Morgan, 27 Morgagni, 323 Morner, 456 Muhlberg, 605 Murray, 541, 551 Naunyn, 480 Neisser, 319 New, 396 Nicoll, 27 Nicholson, 28G O Ogden, 440, 459 Osler, 225, 323, 455, 463 P Parfitt, 539 Patton, 470 Percy, 400, 412 Phear, 548 Phillips, 150 Plummer, 346, 347 Pollitzer, 319 Price, 27, 98 Porter, 165 Pottenger, 274 R Riva-Rocci, 40, 279 Robins, 546 Robinson, 316 Rogers, 40, 280, 281, 282, 463, 467, 553, 575, 580, 585, 670, 676, 680 Rogers and Hunter, 85, 168 Roper, 484 Rosenow, 337, 405 Ross, 400 Rowley, 345 Ruediger, 472 Ruskin, 108 Russell, 36, 169, 358 Hamilton, 108 Harrington, 398 Harvey, 279 Hazen, 316 Heiberg, 474 Hektoen, 456 Henderson, 437 Hill, 40, 625 Hirshfelder, 298 Hoffman, 417 Hoon, 417 Hoover, 325 Horsley, 402 Huchard, 325 Hunter, 358, 509, 553, 575, 580, 585, 670, 676, 680 Hunter, Robertson G., 558 Hunter and Rogers, 222, 293 Hutchinson, 480 I Irwin, 473 J Janeway, 279 Jenney, 113 Joslin, 474, 484, 485, 489 Joyce, 664 Judd, 352, 359, 398, 4C~ K Kanouse, 470 Kendall, 345 King, 648 Kolaczek, 379 Korotkow, 290 L Laennec, 36, 152 Lancisi, 323 Lang, 316 Larkin, 67 Leathers, 500 Little, 197 Lougheed, 541 M Macauley, 84, 578 MacCallum, 372 MacCarty, 364, 365, 410 MacEwen, 601 MacKenzie, 292, 294 Macleod, 298 Mahle, 417 Malassez, 379 Marine, 342 INDEX OF AUTHORITIES 715 s Sachs, 316 Sanson, 195 Sargent, 328 Scliaudinn, 317 Scholz, 97 Schroder, 530 Schwartze, 149 Scudder, 379 Seaton, 638 Senator, 456 Sieveking, 43 Sistrunk, 391, 398, 410, 415 Smith, C. Morton, 319, 320 Souchon, 502 Stanton, 130, 280 Stone, 298 Strathy, 515 Symonds, 101 T Talmage, 54 Thomas, 329 Thompson, 500 Toulmin, 25 Trudeau, 85 Turner, 480 u Upchurch, 58 V Vinson, 397 Von Loeb, 454 Von Schjerning, 538 W Walford, 25, 107 Warfield, 298 Warthin, 324 Warvel, 335, 490 Wassermann, 317 Weisse, 44 Wells, 51 White, 152, 162, 330 Williams, 474, 475 Wilson, 404 Wilson, M. C., 590 Wright, 324 Y Young, 298 Z Zartman, 29 INDEX A Abdomen, 48, 197 Abdominal disease, 198 girth less than chest-ratings, 574 section, 681 for malignant growths, 681 for other than malignant growths, 681 wounds, 526 Abriormal health conditions, 105 intensity of second heart sound, 166 Abortions, 681 Abscess, 681 of liver, 681 of the lung, 152, 681 Absence of breath sounds, 158 Accentuation of aortic second sound, 177 of basic first or second heart sound, 171 of heart sounds, 177 first sound, 177 second pulmonic sound, 177 Accessibility, 504 Accident examination blank, 595 hazard, 667 insurance, 590, 635 mortality, 624 policy, 592 Accidental means, 592 Accidents in women, 137 Accomplishments of life insurance, 67 Acetone, 486 Achilles reflex, 236 Acidosis, 478, 486 Acinus, 366 of mammary gland, 367 Acquaintance, mutual, 131 Acromegaly, 275 Actinomycocis, 152, 682 Active surgery in war, 520 Actors, 670 Actuarial science, 85 Actuary, 95 Acute appendix, 204 Adamantoma, 396 Adamantinoma, 378, 379, 380 Adamantine ephthelioma, 367, 377 Addison's disease, 275, 682 Additional blood pressure readings, 302 Address, 117 Adenocarcinoma, 365, 368, 384 location, 385 Adenoma, 343 of the fundus, 399 with hyperthyroidism, 353 Adenomatous goiter, 347, 348, 349, 354 Adhesions of left lung displacing apex beat, 174 Adolescent albuminuria, 445 Adrenal secretion, 263 Advice to policyholders, 608 to the rejected, 608 Affections of the brain, 250 Afternoon examinations, 153 temperature, 164 tiredness, 164 Age, 118 Ages at which family died first asked, 36 Agency and medical departments, 77 force, 627 Agent as a civic factor, 68 Agents in 1851, 36 work, 67 Aids to examiner, 69 Ailment, definition, 654 Albumin, classification as to amount, 446 in urine, significance, 444 mortality, 466 test, 425 with casts, mortality, 468 without casts, mortality, 467 Albuminuria, 122, 445, 456, 682 and cylindruria, 454 history, 446 intermittent, 445 persistent, 445 ratings!, 575 temporary, 445 Alcoholic equation in the tropics, 508 habits, ratings, 576 hallucinosis, 267 Alcoholism, 682 American Association for Labor Legis- lation, 679 Experience Table, 671 Men Mortality Table, 560 Museum of Safety, 679 Public Health Association, 605 Amicable Society, 97 Amount of sputum, 164 Amphoteric reaction in urine, 423 Amputation of arm or leg, 361 mortality, 520 ratings, 521 717 718 INDEX Amputations, 682 Amylotrophic lateral sclerosis, 256 Anal fissure, 682 Analgesia, 238 Analysis of urine, 113 first required, 40 introduction, 98 Anchylostomum duodenala, 682 Ancient Order of United Workmen, 58 Anemia, 682 in hookworm, 496 of the brain, 250 Aneurysm, 323, 657, 682 causing pulsation in the neck, 173 of aorta, 194 auscultation, 195 inspection, 194 of ascending arch, 182 palpation, 194 percussion, 195 Angina pectoris, 682 Angioneurotic edema, 263, 683 Anglo-Saxon guild agreement, 56 laws, 56 Ankle, clonus, 236 Ankylosed joints, 591 Answers incorrectly reported, 650 Anterior poliomyelitis, 256 Anthrax, 683 Antibodies, 336 Anti-Tuberculosis League, 605 Aortic aneurysm displacing apex beat, 174 regurgitation, 180 area of cardiac dullness, 180 associated signs and symptoms, 181 blood pressure, 181 causing pulsations in the neck, 173 differential diagnosis, 173 insufficiency, 180 intensity, 180 pulsation, 180 time, 180 transmission, 180 stenosis, 181, 683 differential diagnosis, 182 heart enlarged, 181 second aortic sound absent, 182 time, 181 valves roughened, 182 Apex beat, displaced, 174 obliterated, 174 of heart, 167 when recumbent, 173 Aphasia, 233, 683 Apoplexy in women, 138 Appearance of examiners, 129 of specimen, 422 Appendectomy, 222, 357, 683 Appendicitis, 123, 221, 338, 658, 683 Appendix, 341 Applicant to walk, 49 Applicant's attitude in blood pressure taking, 301 insurance history, 37 position for blood pressure taking, 301 Appointment of examiners, 78 Arcus senilis, 148 Argyll-Robertson pupil, 241 Arkansas health conditions, 500 Army service, 515 Arrhythmia, 192 Arrhythmias in women, 143 Arsphenamine, 317 Arterial disease in women, 137 Arterial wall condition, 193 Arteriosclerosis, 193, 294, 683 auscultation, 194 causing pulsations in neck, 173 inspection, 194 palpation, 194 Arteriosclerotic psychoses, 268 Artery examination, 191 Arthritis, 339 Arthritis, 683 deformans, 683 Ascaris lumbricoides, 684 Ascites, 684 Asphalt paving workers, 669 Aspiration of the chest, 659 Associated signs in heart cases, 171 Association of Life Insurance Agents, 68 Asthma, 121, 152, 340, 684 Asylum inmate, 120 Ataxic gait, 230 Attendance for serious diseases, 658 Auditory aphasia, 247 hyperesthesia, 242 nerve lesions, 247 Aural vertigo, 242, 247 Auricular fibrillation, 143, 192 Auscultation, 157, 163 in blood pressure, 290 of the heart, 176 Authentic specimens, 419 Autotoxemia in women, 143 Average age at death from cardiorenal disease, 613 age at death from tuberculosis, 613 amount of policy, 606 blood pressure at different periods, 292 mortality, 580 systolic pressure, palpatory, 303 INDEX 719 B Babinski reflex, 237 Bacteria in primary foci of infection, 337 in secondary foci of infection, 337 Bacteriolysins, 336 Bakers, 669 Balsam of Peru, 442 of tolu, 442 Barany test, 242 Barringer's investigation of albumin- uria, 464 Basal-cell epithelioma, 367, 371, 402, 403 statistics, 403 Basal metabolism, 492 and hyperthyroidism, 492 and myocarditis, 492 and tuberculosis, 492 in goiter, 351 Basic rating additions in tuberculosis, 572 ratings for build, 571, 581 systolic murmurs, 167 Bell's palsy, 246 Benedict's test, 432 Benign tumors, 224 ulcers of stomach, 406 Benzidine test, 435 Biceps reflex, 236 Bigeminal pulse, 192 Bile in urine, 434 Bilharzia hematuria, 684 Biliary colic, 222 " Bilious attacks," 199 '' Biliousness, " 657, 684 Bimanual palpation, 204 Binding receipt, 72 Birth palsies, 255 Bismuth iodoform paraffin paste, 519 Blackwater fever, 517, 684 in war, 549 Blanks of Association of Life Insur- ance Medical Directors, 43 Blastomycosis, 152 Blindness, 147, 684 Blood casts, 447, 450, 460, 462 pressure, 127 chart, 280 condition in heart cases, 171 definition, 283 factors, 286 cardiac strength, 286 elasticity of the vessel walls, 286 peripheral resistance in the ves- sels, 286 viscosity of the blood, 286 volume of blood, 286 Blood casts-Cont'd first required, 40 in heart disease, 166, 167 in women, 293 instruments illustrated, 281, 282, 283, 284, 285, 287 of the aged, 288 taking, 279 taking, illustrated, 288, 289, 290, 292 pigments in urine, 435 spitting, 122 sugar, 471, 491 curve, 471 tests, 487 uric acid, 492 Boards of health, 679 Body tone lower in tropics, 503 Bone sensibility, 238 Bookmakers, 670 " Bowel trouble," 199 Bradycardia, 684 Brain, abscess, 253 injury, 255 tumor, 255 Bridge carpenters, 670 Bright's disease, 454, 684 in the tropics, 510 in women, 137 mortality, 621 Bronchial asthma, 247 Bronchiectasis, 152 Bronchitis, 534, 656, 684 acute, 684 chronic, 684 from age, 537 in war, 537 membranous, 684 Build, 46, 553 and diabetes, 482 as basis of all ratings, 579 basic rating table, 571 table examples, 588 value, 555 Bulbar palsy, 248 Bureau of Labor Safety, 679 statistics, 679 Bureau of Factory Inspection, 679 Burns, 534, 684 Business training, 86 C Caisson disease, 684 Cancer, 123, 685 carcinoma, 685 epithelioma, 689 in the old, 200 in women, 138 frequency in stomach and uterus, 399 720 INDEX Cancer-Cont'd increase, 363 mortality, 620 of ascending colon, 211 of breast, 410 statistics, 411 of body of the uterus, statistics, 412 of cecum, 209 of cervix, 399 results of treatment, 400 statistics, 400 of kidney, 410 of large intestine and rectum, 406 of ovary, 411 of parotid glands, 415 of prostate, 413 of respiratory system, 152 of rectum and colon, 210 of small intestines, 407 of stomach, 405 statistics, 407 of testicle, 414 of uterus, 411 of vagina, 400 of vulva and vagina, 399 of vulva, urethra and penis, 400 prognosis, 363 risks, 363 sarcoma, 704 Carbohydrate metabolism, 473 tolerance, 483 Carbon dioxide determination, 487 Carbuncle, 685 Carcinoma, 365, 685 of breast, 382, 383 of cecum, 387 of esophagus, 212 of genital organs, 398 of rectum, 389, 390 of sigmoid, 388 of stomach, 220, 385 leather bottle, 384 of thyroid, 382 Cardiac arrhythmia, 167 conditions, 165 diagnosis, 165 dullness, 176 deep, 176 superficial, 176 enlargement, 166 hypertrophy, 166 insufficiency in goiter, 351 Cardiorenal disease, 613 in farmers, 613 Cardiovascular insufficiency, 143 problems in women, 141 syphilitics as risks, 328 Care of teeth, 616 Carnegie Institute, 68 Carrel's antiseptic method, 519 Casts, 446 in the aged, 463 relative number, 452 Casualties of war, 552 Cataract, 148, 685 double, 685 unilateral, 685 Catarrh, 656 Causes in high tension rejections, 310 of death in high systolics, 306 Cavity in lung, 159 Cecum, pelvic type, 218 Cellular activity in cancer, 364 Cellulitis, 685 ' ' Ceno-diagnosis, ' ' 542 Cerebral arteriosclerosis, 250 hemorrhage, 251, 685 softening, 251 syphilis, 253, 269 tumor, 685 Cerebritis, 252 Cerebrospinal meningitis, 685 Certificate from attending physicians, 25, 36 Cesarean section, 684 Chancroid, 685 Character of applicant, 636 of injury, 596 Charcots disease, 256 Checking blood pressure instruments, 302 Chest and abdomen in war, 519 examination in women, 144 wounds, 523 Child health alphabet, 616 Children's diseases, mortality, 621 Chlorine gas, 531 Chlorides in urine, 428 Chloropicrin gas, 531 Cholecystectomy, 359, 685 Cholecystitis, 338, 686 Cholecystotomy, 359, 686 Cholera, 686 Chorea, 686 Chorioepithelioma, 368, 415 location, 386 Chromatophoroma, 372. Chronic appendicitis, 208, 211, 222 bronchitis, 162 diseases, 152 Chyluria, 686 Cigarette cough, 538 Circularization in health work, 608 Cirrhosis of liver, 686 of liver in women, 137 Claim department, 93 INDEX 721 Classification of applicants, 128 of risks, 628 ' ' Clean up, ' ' 616 Clean up weeks, 616 Clerical organization, 92 Climacteric, 125 Climatic conditions, 502 Cloud gas attacks, 531 Cloudiness in urine, 423 Club foot, 591 Clubbing of fingers, 155 Coarsely granular casts, 461 Coated tongue, 146 Cocaine habit, 686 "Colds," 655, 656 Colic, 199, 225, 686 Colitis, 686 membranous, 686 tubercular, 686 ulcerative, 686 Color of urine, 422 Colloid carcinoma, 384 goiter, 342, 347, 348, 349 Color field, 239 Comedocarcinoma, 384 Commencement of disability, 596 Complexion, 47 Commercial inspections, 505 insurance: first, 57 Common symptoms respiratory diseases, 152 Commotio cerebri, 526 Community efficiency, 52 Competition, 110 Complaints from agents, 95 Compound fracture of femur mortality, 520 of long bones, 520 Conclusions in examination blank, 128 Concussion of brain, 686 Condition of the aorta by auscultation, 176 of heart muscle by auscultation, 176 of specimens, 421 of valves of heart by auscultation, 176 Condyloma, 686 Confidential information, 630 Confinement questions first asked, 37 Confirmatory evidence, 205 Congenital amyotonia, 257 Conjunctivitis, 534 Connivance with applicant, 649 Constant murmurs, 165 Constipation, 199, 686 Consumption, 687 in women, 137 Consumptive association, 124 Contamination of specimens, 420 Contracted pupil, 148 Contractures, 235 Coordination, 231 Copaiba, 442 Configuration, 46 Convulsions, 687 '' Cook book, ' ' 616 Corrections, 116 Correspondence, 82 Cotton mill worker, 498 Cough, 153, 687 and sputum in tuberculosis, 163 chronic, 122 in tuberculosis, 163 Country applicants, 70 Courts construe contract favorable to the insured, 663 Credits for abdominal girth less than chest expanded, 582 Cremasteric reflex, 236 Cretinism, 262, 275 Criticisms of decisions, 73 Crystalline casts, 447, 451 Cuboidal or columnar cells, 366 ' ' Cured ' ' risks, 85 syphilitics, 314 Curvature of spine, 687 Cyanosis, 173 Cylindruria, 458 Cystitis, 687 Cysts, 380 Cytoplasia, 366 D Date of birth, 118 Deafness, 151, 242, 247, 687 Deaths from syphilis under 40 years, 316 rates, 137 Debility, 225 Debits for abdominal girth, 582 Deception, 638 Declination, 626 Deep sensibility, 237 Defectives, 272 Deformities, 688 Degenerative influences, 668 Degree of malignancy, 363, 387 of underweight, 582 Deitl's crisis, 360 Delay, 116 Delirium tremens, 267 Dementia precox, 227 catatonic, 270 hebephrenic, 270 paranoid, 270 Dengue, 688 722 INDEX Dental caries, 166 germs, 379 Description of accident, 596 Detailed answers necessary, 62 Detection of syphilitics, 315 Development of examinations, 43 Diabetes, 61, 470, 473, 688 and arteriosclerosis, 474 and cancer, 474 and obesity, 474 insipidus, 275, 688 in youth, 478 mellitus, 275, 688 mortality of Prudential Insurance Company, 477 Diabetic treatment, 478 Diagnosis, 600 of cardiac conditions, 169 Diadokokinetic test, 231 Diagnostic value of the sphygmoman- ometer, 299 Diameter of casts, 452 Diarrhea, 199, 225, 688 in pellagra, 496 Diastolic blood pressure, 291, 303 Dichlorethyl sulphide gas, 531 Diet in diabetes, 486 Differential diagnosis in murmurs, 182 Difficulty in voiding urine, 419 Dilatation of the heart, 171, 183, 688 of stomach, 688 Diphtheria, 166, 335, 616, 688 Diphosgene gas, 531 Diplopia, 240 Directions for health test, 610 for living and sleeping in the open air, 616 Disability and double indemnity, 601 benefits, 675 claims, 602 Disease as a factor in disability, 598 of cranial nerves, 243 of peripheral nerves, 260 Discretion of medical referee, 103 Disordered action of the heart, 527 Displacement of heart, 174 Disrobing, 126 Disseminate myelitis, 259 Disturbances of motion, 230 of sensation, 237 Divided employment, 661 Dizziness, 688 Doctor's fees in accident cases, 593 Dog bite, 688 ' ' Don't know ' ' not accepted, 49 Dormemus-Hinds ureometer, 428, 429 "Double for accidental death," 603 Double indemnity, 675 claims, 603 Doubtful reports, 49 syphilitics, 327 Dressing of wounded, 518 Drop heart in women, 142 Dropsy, 688 Drug addiction, 688 habits, 119 in albumin tests, 442 Drummond's sign, 195 Duchenne-Aran disease, 256 Duodenal ulcer, 223, 357, 688 ratings, 575 Duration of life in diabetes, 485 Dysentery, 225, 516, 517, 548, 549 amebic, 549 bacillary, 549 chronic, 688 mild, 688 tubercular, 688 Dyspepsia, 199, 225, 656, 688 Dyspnea, 153 E Eagle Assurances Company of London, 630 Ear, 149 infections, 149 Early examination reports, 98 Earthquakes, 506 Ectopic pregnancy, 689 Eczema, 659, 689 Edema, 690 Educational work of the referee, 104 Effect of muscular exercise on urine, 437 Effort syndrome, 535 Effusion in chest, 156 Egyptian war, 517 Elective affinity of bacteria, 337, 339 Elephantiasis, 689 Embryocardia, 192 Emphysema, 152, 689 Employer-Employee Mutual Benefit proposition, 51 Empyema, 152, 157, 361, 689 Encyclopedia Brittannica on life insur- ance, 67 Endocarditis, 337, 339, 689 Endocrine disturbances, 262 Endocrine glands, 473 Endocrines, 274 Endometritis, 689 Endowments maturing under age 55- ratings, 574 English social guilds, 55 Enlarged gland, 689 liver displacing apex beat, 174 nontuberculous, 689 tuberculous, 689 INDEX 723 Enlargement of heart, 689 Entente cordiale, 131 Enteric fever, 689 Enteritis, 689 Enteroptosis, 689 Epicritic sensibility, 237 Epigastric pulsations, 174 reflex, 236 Epilepsy, 122, 264, 689 in parents, 228 Epithelial casts, 447, 449, 450, 460, 462 Epithelioma, 365, 689 of antrum, 397 of bladder, squamous-cell, 372 of cervix, squamous-cell, 369 of cheek, basal-cell, 375 of eyelid, basal-cell, 374 of gall bladder, squamous-cell, 373 of larynx, squamous-cell, 369 of lip, squamous-cell, 369, 370, 690 of lymph node, squamous-cell, 371 of nose, basal-cell, 375 of palate, mixed, 381 of penis, squamous-cell, 369 of scalp, basal-cell, 374 of skin of nose, squamous-cell, 374 of temple, squamous-cell, 370 of tongue, squamous-cell, 369 of the urogenital tract, 401 locations, 385 treatment, 388 Epithelium in cancer, 373 Equipment, 110 for examination of nervous system, 229 of examiners in the tropics, 512 Equitable Society in England, 25 of England, 98 Erb's disease, 257 Erysipelas, 337, 690 mild, 690 recurrent, 690 severe, 690 Estimation of disability, 600 of disability time, 597 Ethmoiditis, 690 Etiquette of medical examinations, 130 Euscope, 436, 437 Examining cape, 154 Examination, destroyed, 133 for albumin and casts, 440 for health and accident insurance, 590 of health claimant, 599 of heart and blood vessels, 169 of nervous system, 229 of women, 137 suppressed, 133 Examiner, 627 card, 83 not regularly employed, 652 selection, 100 Excess of blood sugar, 474 Excessive abdominal girth, 585 Excitement causing pulsations in the neck, 173 Exercise causing pulsations in the neck, 173 in diabetes, 484 test in cardiac cases, 171 Existence of disease, 199 Exophthalmic goiter, 275, 343, 348, 352 causing pulsations in the neck, 173 Exophthalmos, 148 Expectancy in head injuries, 522 of postoperative goiters, 344 Expectoration, 153 Expense of medical referee, 102 Experience with disability claims, 602 Exposure in accident insurance, 591 Ex-soldier's opinion of his disease, 550 Extent of tuberculosis, 163 Exton immiscible balance, 425, 426 test for chlorides in urine, 428 urinometer, 425 Extra hazard, 678 mortality from medical impairment, 567 premium in occupations, 673 premiums, 565 Extrasystoles, 143, 192. Eyes, 147 ulcer of, 147 F Face, 48 Facial nerve lesions, 246 paralysis, 246, 690 Factors causing casts, 460 Faint trace of albumin, 457 Fainting spells, 657, 690 Fallopian tubes, 341 Falsity of statements, 648 Family ataxia, 258 history, 29, 100, 125, 134, 626 in the tropics, 507 of nervous diseases, 227 physician as an examiner, 301 record, 553 periodic paralysis, 263 tremor, 263 11 Fatal delay" in cancer, 364 Fatty casts, 447, 450, 460, 462 Female diseases, 125 Fibrinous casts, 446, 448 Field of vision, 239 724 INDEX Filaria, 690 medinensis, 690 sanguinis hominis, 690 Finances, 626 Financial ability, 636 Fine tremor, 232 Finger examination, 155 to nose test, 231 to finger test, 231 First aid in the home, 616 confinement to house, 599 physical examinations, 29 suggestion of physical examination, 36 symptoms of disease, 599 use of blood pressure instrument, 299 Fistula, 123 in-ano, 690 Five-year cure, in cancer, 393 of stomach, 405 Five-day fever, 541 Flaccid paralysis, 235 Floating kidney, 690 Florida health conditions, 500 Flushing of face, 173 Focal infection, 335, 690 acute or chronic, 335 in heart disease, 166 in women, 144 Food facts, 616 Forces producing blood pressure, 285 biochemical, 286 mechanical, 285 nervous, 286 Foreign body in chest, 524 in cranium, 522 Foremen bosses and working miners, 667 Formaldehyde, 442 as preservative, 421 Formation of chest, 173 Foundrymen, 669 Fracture, complete or partial, 597, 690 of skull, 361, 522, 690 Fraternal examination, 60 insurance, 54 growth, 58 in force, 59 origin, 54 society; first, 58 policy holders, 59 Fraud, 638 by applicant and county clerk, 646 by applicant and examiner, 640 by beneficiary, 640 by beneficiary, agent and examiner, 644 by substitution, 643 by suicide, 642 Fraud-Cont 'd by the applicant, 641 by the examiner, 639 Free health examinations, 607 Friendly societies, 98 Friends' Provident Institution, 27 Friends' report, 629 Freidrich ataxia, 258 Functional albuminuria, 454 heart murmurs, 168 murmurs, see nonorganic murmurs, 183 test of kidney, 431 tests of urine, 436 Fundamental object of insurance, 58 Furunculosis, 337, 691 G Gait, 48 Gaiter fever, 541 Gain in weight, 124 Gall bladder, 341 surgery, 359 Gallop rhythm, 192 Gallstones, 206, 210, 222, 657, 691 Gangrene, 518, 691 Gas poisoning, 691 effects, 530 shells, 531 symptoms, 532 Gastralgia, 691 Gastric ulcer, 224, 357 . perforating, 214 ratings, 575 Gastritis, 199, 692 acute, 692 chronic, 692 Gastroenteritis, 692 Gastroenterostomy, 357, 692 Gastrointestinal crises in goiter, 351 Gastrojejunal ulcer, 358 Gastroptosis, 692 General considerations of syphilis, 331 General paresis, 269 Gerhardt's test. 434 German East Africa campaign, 517 Southwest Africa campaign, 517 Germanic sacrificial banquets, 55 Gigantism, 275 Glanders, 692 Glandular involvement in cancer, 399 secretion in women, 144 Glass blowers, 669 Glaucoma, 148, 692 Glucose and lactose test, 479 Glycosuria, 122, 470, 693 and blood sugar, 491 ratings, 575 INDEX 725 Glycouresis, 483 Goiter, 342 adolescent, 354 and life insurance, 345 colloid, 354 endemic, 354 exophthalmic, 693 geographic distribution, 345 in Wisconsin, 345 in women, 138 middle age, 139 toxic, 139 tremor, 139 physiologic, 139 under 25 yrs, 139 nontoxic, 354 ratings, 576 simple, 354, 693 territories, 345 toxic, 693 Gonad insufficiency, 277 Gonococcus, 337 Gonorrhea, 693 Good health definition, 654 Gout, 693 Gradation of albumin, 456 Gram-positive diplococcus, 337 Granular casts, 447, 449, 450, 458, 460 brown, 447, 449 coarse, 447, 449 fine, 47, 449, 450 Gross brain lesion psychoses, 268 Group examination in fraternal soci- eties, 60 insurance, 51 amount, 52 cost, 52 defined, 51 general hazard, 53 Guilds, 55, 97 Gunshot wounds, 693 Gurgling, 202 II Habit spasms, 263 Habits, 118, 553, 625 Hand blowers, 675 Hands, 48 Hat factory employees, 671 Hay fever, 693 Hazard due to accident, 670 of gastric ulcer, 224 of tropical risks, 502 Hazardous occupations, 320 and disability, 602 Headaches, 122, 659, 693 Head wounds, 528 Health, 626 conditions in the south, 499 conservation, 605 departments maintained by com- panies, 608 examinations yearly, 608 history, 134 insurance, 591 leagues, 624 of the worker, 616 pamphlets, 616 policy, 594 record, 120 test, 609 Hearing, 241 Heart, and lungs, 127 blank, New York Life, 187, 188 block, 143, 192 disease in the tropics, 510 disease in women, 138 disease mortality, 618 effects from war service, 540 examination, 135 after exercise and rest, 176 auscultation, 142 erect and recumbent, 176 in women, 142 percussion, 142 failure not an accident, 604 history, 166 in adenomatous thyroid, 351 in syphilis, 323 letters,-Equitable Life, 189, 190 murmurs, 143, 178, 693 ratings, 576 sound accentuation, 177 aortic second sound, 177 first sound, 177 reduplication, 177 second pulmonic sounds, 177 Heat in cancer treatment, 400 test for albumin, 444 Heaters, 669 Heatstroke, 516 Heel to toe test, 231 Height, 127 weight and chest measures first re- quired, 36 Heller's test, 455 Hematamesis, 694 Hematuria, 693 Hemicrania, 264 Hemiplegic gait, 231 state, 251 Hemianopsia, 244 Hemoglobinuria, 693 Hemophilia, 694 Hemoptysis, 694 726 INDEX Hemorrhage, cerebral, 685 from lungs, 164, 694 into retina, 694 stomach, 694 Hemorrhoids, 694 Hemothorax, 519 Henderson's test, 439 Hepatic abscess, 694 cirrhosis, 694 colic, 222 congestion, 694 Hereditary cerebellar ataxia, 258 Heredity in cancer, 405 in diabetes, 474 Hernia, 224, 657, 695 Herniotomy, 357, 695 Herpes zoster, 262 High blood pressure, 293, 299 alone, declined cases, 308 in heart disease, 171 High specific gravity of urine, 424 systolics, temporary, 310 tension and mortality, 312 Highly refractive cast, 449 Hip joint disease, 695 History of cancer cases, 364 of illness, 591 of infection in heart cases, 170 of life insurance examinations, 25 of syphilis, 314 taking, 315 Hodgkin's disease, 695 Honesty, 111 Hookworm, 496, 616, 695 Hospital indemnity, 595 service a good thing for examiners, 109' Hours for examination, 70 Huntington's chorea, 263 Hyaline casts, 446, 447, 458, 460 Hydrocele, 695 of spermatic cord, 695 Hydrocephalus, 255 Hydronephrosis, 695 Hydrophobia, 253, 695 Hyperacidity, 146 Hyperemia of brain, 250 of kidney, 451 Hyperesthesia, 238 Hyperglycemia, 278, 471 with glycosuria, 472 Hypertension, 287 in women, 143 Hyperthyroidism, 275, 343, 348 Hypertonus, 235 Hypertrophic goiter, 347 Hypertrophy, cardiac, 695 of heart, 168, 182 muscle, 171 Hypertrophy, of heart-Cont'd right ventricle, 182 tonsils, 695 Hypobromite method, 431 test for urea, 428 Hypoglossal lesions, 248 Hypopituitary type of obesity, 277 Hypothyroid, 262, 276, 348 Hysterectomy, 360, 696 Hysteria, 265, 696 I Identification, 590 data, 634 Identity, 46 of applicant, 635 Idiocy in parents, 228 Idiots, 272 Imbeciles, 272 Immigrant and citizenship bureau, 618 Impairments, 591, 626 from occupation, 666 Incidence of tuberculosis, 539 Income, 115 Incompetency of examiner, 649 Incorrect answers, 50 Increasing occupational hazards, 670 Indefinite terms. 116 Indican in urine, 434 Indicanuria, 486 Indigestion, 121, 198, 696 in pellagra, 496 Industrial insurance, 45 examiners, 45 needs of agent or applicant, 46 policy holders, 606 service bureau, 624 Infantile paralysis, 256, 591, 696 Infantilism, 275 Infection (see pyemia) frontal sinus, 705 in diabetes, 477 in large bowel operations, 408 Infective-exhaustive psychoses, 267 Inflammation of throat, 659 of uterus and ovaries, 696 tubes and ovaries, 696 Influence of exertion on heart, 167 of occupation on life underwriting, 666 Influencing examiners, 71 Influenza, 335, 696 bacillus, 337 in the tropics, 510 mortality, 623 Information for expectant mothers, 616 Injuries, 120 Injury to nervous system, 229 INDEX 727 Ink', 133 ' Insanity, 122, 227, 696 as a health risk, 601, 602 Inspection, 126 blank, 630 in group insurance, 53 in heart examination, 172 in tropics, 504 of applicant, 46 of chest, 153 practices, 630 reports, 625 Instructions to examiners, 113 Insulin, 488 mortality statistics, 488 Insurability, 625, 627 Insurable interest, 124, 508 Insurance in force in the United States, 606 history, 119 of substandard lives, 558 welfare work, 616 Intensive treatment of syphilis, 318 Intentional tremor, 232 Intentions as to travel, 37 Intermittent glycosuria, 480 pulse, 192, 696 International Association for Labor Legislation, 679 Interpretation of questions, 649 Interstitial nephritis, 294, 465 Intestinal obstruction, 696 Intrathoracic goiters, 353 Intussusception, 407 Investigation of deaths, 106 of examiners, 107 Involutional melancholia, 272 Iodine after goiter operations, 342 in goiter, 342, 345 Iowa statute as to agents, 652 Iritis, 148, 697 Irregular pulse, 192, 697 J Jacksonian epilepsy in head injuries, 523 Jaundice, 225, 697 catarrhal, 697 malarial, 697 Jaw reflex, 236 Joint Board of Sanitary Control in the Cloak, Suit and Skirt, Dress and Waist Industries, 697 Judgment of examiner, 62 Karsakoff syndrome, 261 psychosis, 268 Ketones, 433 Kidney operations, 360 Kowarsky test, 433 Knights of Pythias blank, 64, 65 L Labelling specimens, 421 Labor, abnormal, 697 Laboratories at home office, 455 Laboratory, 92 procedures, 490 technic, 462 technician, 76 Laborer, 668 Lachrymatory gas, 531 Lack of muscle tone in heart disease, 166 Landry's ascending paralysis, 259 Large amount of albumin, 458 Laryngeal palsy, 247 spasm, 247 Laryngitis, 534, 697 acute, 697 chronic, 697 tuberculous, 697 Last sound in blood pressure, 295 Lateral tract sclerosis, 258 Lay checkers, 89 Lead poisoning, 697 Legal aspects of life insurance examin- ations, 648 Legibility, 109 Leiomyosarcoma, 365 Leptomeningitis, 249 Lethargic encephalitis, 252 Leucoplakial epithelioma, 393 Leucemia, 697 Liability of the company, 633, 649 Libel, 633 Liens, 566 Life expectancy in adenocarcinoma, 404 in epitheliomas of cavities and organs of head and neck, 396 Life habits in the tropics, 503 Life insurance examinations in the South, 493 Limit of normal blood pressure varia- tion, 312 Lingua, geographica, 146 nigra, 146 Lips, 146 Liquor business, 670 Lithotomy, 697 Little's disease, 255 ' ' Liver trouble, ' ' 657 Living conditions, 668 Localized tenderness of abdomen, 202 Location of cancer, 364 of diastolic pressure, 294 of heart, 172 728 INDEX Locomotor ataxia, 257, 697 London Assurance Corporation, 27 Longevity of goiter cases, 343 Loss in weight, 124, 164 of appetite, 164 of eye and disability, 602 Louisiana health conditions, 500 Low specific gravity, 424 Low systolic in heart disease, 171 Low tension and mortality, 313 Loyalty, 111 Lumbago, 226, 697 Lupus vulgaris, 697 M Mail clerks, 670 facilities in the tropics, 506 Malaria, 494, 616 cachexia, 697 in the tropics, 510 in war, 517, 547 intermittent, 697 pernicious, 697 remittent, 697 types, 495 intermittent, 495 latent, 495 neurotic, 495 pernicious, 495 remittent, 495 Malignant disease, 357 epithelial neoplasms, 363 papilloma of the bladder, 398 tumors of the thyroid, 343, 353, 404 Malta fever, 698 Manic-depressive insanity, 227 psychoses, 269 Manner of breathing, 173 Manner of making examinations, 49 Married or single, 118 Massachusetts Mutual Blank in 1851, 99 Masses in abdomen, 202 Mastitis and cancer, 366 Mastoid operation, 361 Mastoiditis, 698 Matters of opinion, 653 Mayo Clinic mortality of gastric ulcers, 358 records on peptic ulcers, 223 results in goiters, 352 Measles, 335, 616, 698 Measurement of abdomen, 201 Mediastinal tumor displacing apex beat, 174 Medical assistants, 76 attendance, 658 attendant, 28 Medical-Cont'd blank, 134 blanks too long, 63 department, the credit, 63 director, 92 a scientist, 76 director's position, 76 examinations, 653 examiner, 78, 108 as family physician, 651 selection, origin, 100 examinations instituted first, 25 fee in fraternal insurance, 63 insight, 217 personnel, 75 referee, first, 101 referees, 97 report, 645 selection, 90 in fraternal insurance, 59 Medico-Actuarial mortality investiga- tion, 579 results in diabetes, 481 Medullary carcinoma, 384 Melanin, 372 Melanoblastoma, 372 Melanocarcinoma, 372, 384 Melanoepithelioma, 367, 372 of axillary glands, metastatic, 376 of skin, 375 of groin, 376 of leg, 377 Melanoepithelioma and nonmelanotic melanoepitheliomas, 402 Melanoma, 372 Melanosarcoma, 372 Meniere's disease, 151, 242, 698 Meningitis, 340, 698 Meniscus in examining urine, 425 Menopause, 135, 399 Mental attitude, 131 honesty, 96 Mercers' Annuity Company, 97 Mercury and arsenic in syphilis, 328 Metallic poisoning, 320 Metastasis in cancer, 364 of the breast, 410 Method of taking blood pressure, 301 Methods of examination, 197 of health examinations, 607 of rating, 670 Metritis, 698 Metrorrhagia, 399 Micrococcus catarrhalis, 337 Microscopic examination of urine, 435 first required, 40 Migraine, 264, 698 Miliary fever, 698 Milk, 616 INDEX 729 Mining, engineers, superintendents, and managers, 667 Minimum treatment of syphilis, 319 full doses of mercury, 320 intravenous arsphenamine, 319 mercurial dressings, 319 Miscarriages, 125 Misleading statements, 132 Mississippi health conditions, 499 Misstatements as to occupation, 661, 662 Mitosis, 387 Mitral insufficiency, 698 regurgitation, 168, 178 area of cardiac dullness, 178 associated signs, 178 blood pressure, 178 differential diagnosis, 179 pulse, 178 time, 178 stenosis, 179, 698 area of cardiac dullness, 179 associated signs and symptoms, 179 presystolic thrill, 179 time, 179 Mixed epithelioma, 367, 382, 396 tumors, 368 location, 386 of the salivary glands and palate, 415 Moderate amount of albumin, 457 Modification of breathing, 158 of whispered voice, 159 Moisture in the lung, 164 Moles, 373 Monocular diplopia, 240 Moral environment, 670 hazard, 553, 625 Morphology of casts, 460 Morons, 272 Mortality curves, 559, 560 experience of the Northwestern Mutual Life Insurance Com- pany, 311 from cancer, 416, 620 from diabetes, 476 in albuminuria, 465 in the South, 493 in the tropics, 509 in women, 138 of accidents, 624 of Bright's disease, 621 of children's diseases, 621 of gastric cancer operations, 406 of high diastolics, 304 of influenza and pneumonia, 623 of low arterial tension, 304 of Metropolitan Life Insurance Com- pany, 619 Mortality-Gout 'd of operations on large bowel, 408 of organic heart disease, 618 of Prudential Insurance Company, 477 of puerperal septicemia, 622 of pulmonary tuberculosis, 619 of septic chest wounds, 526 of systolics of 142 mm., 305 of systolics of 152 mm., 306 of the puerperal state, 620 of typhoid fever, 622 of wounds, 519 Mortality rate, 559 in alcoholics, 568 locomotive engineers, 564 of rated-up ages, 569 25-45 pounds overweight and tuber- culous family history, 563 50-60 pounds overweight, 562 tables, 300 American Men, 300 in England, 560 Medico-Actuarial, 300 with casts, 463 "Mother Goose," 616 Motor aphasia, 234 oeuli disease, 240 lesions, 244 tics, 263 Mouth, 146 Movable kidney, 360, 698 Multiple neuritis, 261 Mumps, 698 Muscle and joint sense, 238 ' ' Muscle bound, ' ' 629 Muscular atrophy, 235 exercise test, 438 spasms, 232, 235 tone, 232 Multiple sclerosis, 254 Mustard gas, 531 Mutual Life, Blank in 1857, 31, 32 Insurance Company, 32 Myocardial disease, 294 Myocarditis, 698 chronic, 184 auscultation, 184 exercise test, 184 Myoclonia, 263 Myxedema, 262, 275 N Nails, 48 Name, 117 and age of insured, 654 "Napkin ring" type of cancer, 408 Nasal polypi, 698 speech, 233 730 INDEX Nasopharyngeal sepsis, 166 National Provident Institution, 28 Nationality, 46, 134 Nature of incidence of extra mortality, 560 Neck, 48 Neoplasia conception, 365 Nephrectomy, 699 Nephritis, 61, 338, 339, 456, 466, 474, 656, 699 acute, 699 chrdnic, 699 in ex-service men, 543 Nephrolithotomy, 360 Nephropexy, 360, 699 Nerve strain in war, 515 Nervous breakdown, 530 breakdown as a health risk, 602 disorder's in war, 526 exhaustion, 529 prostration, 699 system, 227 Net premium calculation, 570 Neuralgia, 123, 261, 699 Neurasthenia, 265, 699 Neuritis, 260, 339 localized, 699 multiple, 699 Neuroses, 263 Neurotic heredity, 330 New England Mutual Life Insurance Company, 29 New York University, 68 Nitric acid contact test, 440 Nitrogen metabolism, 472 Nominators for medical examiners, 100 Nonmelanotic melanoepithelioma, 367, 377 of skin, 377, 378 Nonorganic heart murmur, 178, 183 chart, Mutual Life, 186 sounds, 165 Normal balance of blood pressure, 287 blood pressure, 286 colon, 205 lung sounds, 159 specific gravity, 424 sugar in urine, 473 tubular type of stomach, 213, 215 Northwestern Mutual blank, 41, 42 Nose, 147 Number of policy holders, 606 Numerical method, 90, 580 examples, 556 of valuing lives, 553 value, 555 Nutrition, 46 Nystagmus, 148, 241, 247 o Obermayer's test, 434 Obesity, 275 Obligation of agent, 628 Obstruction, intestinal, 699 Occupation, 47, 553, 626, 636, 660, 666 change, 117 of husband first asked, 40 Occupational answers, 661, 662 blank, 676 hazards, 498, 567 new, 106 Odor of urine, 424 Oedema, 690 Oesophageal dilatation, 699 diverticulum, 699 spasm, 700 stricture, 700 Office of examiner, 71 system, 84 Oil refiner, 498 Olfactory nerve disturbance, 243 One examiner best, 70 One eye lost, 147 Oophorectomy, 700 Opacities of cornea, 148 Open office, 89 Operable lesions of stomach, 405 Operative cure of cancer, 365 mortality, 356 in cancers of bladder, 398 Ophthalmoplegia, 248 Opinion of family physician, 75 Opium habit, 700 Optic atrophy, 244 Optic neuritis, 244 Optic nerve disturbance, 244 Optional indemnity, 594 Orchidectomy, 414 Organic heart murmur chart, Mutual Life, 185 psychoses, 267 reflexes, 237 Organization of medical department, 75 Organizations improving living condi- tions, 679 Organized casts, 462 Oriental sores, 517 Origin, of casts, 459 of life insurance in America, 29 Osteomyelitis, 700 Otitis media, 149, 700 acute, 700 catarrhal, 149, 150 chronic, 700 purulent, 149, 150 Otorrhea, 166 Ovariotomy, 360, 701 INDEX 731 Oversecretion of the thyroid gland, 262 Over insurance, 632 Overweight, 62, 701 of a minor degree, 612 Overweights, 589 and blood pressure, 313 Oxyuris vermicularis, 701 P Pachymeningitis, 249 Pain sense, 238 Palestine campaign, 517 Palpation by flat of hand, 174 of abdomen, 202 of chest, 155 of heart, 174 of heart by fingers, 175 Palpatory method in blood pressure taking, 302 Palpitation, 123, 701 Pancreatic tolerance, 482 Pancreatitis, 701 Papillary carcinoma, 384 of ileum, 386 Papillary cystadenoma, 414 Papillary epithelioma of bladder, 369 Papilloma bladder, 701 of the stomach, 216 Paragraphia, 233 Paralysis, 123 agitans, 254, 701 Paramyoclonus multiplex, 263 Paranoia, 227, 271 Paraphasia, 233 Paraplegia, 259 Parathyroids, 263 Paratyphoid, 701 Paresis, 701 Paresthesia, 238 Parkinson's disease, 254 Paronychia, 701 Partial disability, 593, 597 Passive tremor, 232 Patellar reflex, 236 Patent medicines and health, 615 Pathologic classification of cancer, 365 Pectoriloquy, 159 Pellagra, 495, 701 Pelvic operations, 360 Penn Mutual Life Insurance Company, 35 blank, 38, 39 Pennsylvania Company for the Insur- ance of Lives, 29 Peptic and syphilitic ulcers as cancer causes, 405 Peptic ulcers and cancer, 405 Percussion, 163 of abdomen, 202 of chest, 155 of heart, 175 Pericardial effusion, 176 Pericarditis, 184, 700 Perinephritic abscess, 701 Peritonitis, 701 Permanent disability, 595 Persistent albuminuria, 445 Personal contact between the examiners and the medical department, 95 examination, 27 history, 553 in nervous diseases, 228 interviews with medical director, 63 Pertussis, 701 Pharyngeal palsy, 247 reflex, 236 Pharyngitis, 534, 702 Phases in blood pressure, 291 Phenolsulphonephthalein test, 492 Phlebitis, 702 Phosgene gas, 531 Phthisis, 702 (See Tuberculosis) Physical condition, 553, 591 defects, 135 Physical examination, 126 of the heart, 172 absence of noise, 172 privacy, 172 removal of clothing, 172 stethoscope, 172 of the lungs, 153 Physician as agent of insurer, 648 Pigmented nevi, 373 Piles, 702 Pituitary gland, 263, 276 substance, 472 Places of examination, 596 Plan of insurance applied for, 553 Plantar reflex, 237 Pleurisy, 123, 657, 702 dry, 702 displacing the apex beat, 174 purulent, 702 with effusion, 152 Pleximeter, 156 Plumbism, 702 ' ' Plus ' ' method of rating albumin, 456 Pneumococcus, 337 Pneumoconiosis, 152 Pneumogastric lesions, 247 Pneumonia, 123, 616, 702 in the tropics, 510 in war, 537 in women, 137 mortality, 623 732 INDEX Pneumothorax, 152, 702 artificial, 158 Points in blood pressure, 291 of tenderness, 204 Policies without examination, 108 Policy contract, 635 first life insurance, 57 Polioencephalitis, 248 Poliomyelitis, 256, 702 Political entanglements, 513 Polycythemia, 535 Polyneuritis, 261 Polypi, 702 ear, 702 nasal, 698 Position of apex beat, 173 Positive evidence, 200 Postdiphtheritic neuritis, 247 Postero-lateral cord sclerosis, 258 Postoperative risks, 356 Posture in chest examinations, 153 in heart sounds, 166 Potassium iodide, 443 Pottery bakers, 669 workers, 671 Pott's disease, 702 Precancerous lesions, 396 Precedent, 94 Precordial friction, 184 Pregnancy, 657, 702 Premium loading, 636 rates in the tropics, 514 Presbyterian Ministers' Corporation, 29 Present health, 124 Preservative for urine, 421 President of first life insurance com- pany, 55 Pressure sense, 238 signs in aneurysm, 195 symptoms in goiter, 354 Presumptive evidence, 199 Prevention of disease in army and navy, 605 Previous history of injury or disease, 598 Primary foci of infection, 337 Prognosis in tuberculosis, 164 Progressive lenticular degeneration, 254 muscular atrophy, 256 muscular dystrophies, 257 Prolapses, 200 Prompt examination aid to agent, 71 Promptness, 110 Prophylactic cure of cancer, 365 Prophylaxis, 611 Propulsive gait, 230 Prostate, 341 Prostatectomy, 702 Prostatitis, 123, 702 acute, 702 chronic, 702 Prostatorrhea, 703 Protamins in albumin test, 427 Proteid poisoning, 703 Protopathic sensibility, 237 Prudential Assurance Company of Eng- land, 25, 30, 33, 34 Prudential Friendly Society, 45 Prudential (of England) application of 1857, 26 Pseudohypertrophies, 257 Pseudoleukemia, 703 Psoriasis, 703 Psychasthenia, 265 Psychoneuroses, 265 in parents, 228 Psychopathic inferiority, 272 Psychoses, 267 Ptosis, 200, 217 of eyelid, 148, 233, 239 Ptyalism in pellagra, 496 Public Safety Commissions, 679 Published reports are a libel, 633 Publishing confidential reports, 633 Puddlers, 669 Puerperal septicemia mortality, 622 Pulmonary abscess, 703 edema from gas, 533 emphysema, 154 regurgitation, 182 tuberculosis (see Tuberculosis) Pulsations in second interspace, 174 in the neck, 173 Pulse, examination, 191 in heart cases, 171 over 100, 703 pressure, 294 rate, 127, 191 ratings, 576 rhythm, 191 tension, 192 wave, 193 Pulsus alternans, 192 Pupil, Argyll Robertson, 149 Pupillary reflex, 235 Pupils, 241 Purpose of medical department, 93 Purpura, 703 hemorrhagica, 703 rheumatica, 703 Purulent bronchitis, 525 Pus casts, 447, 450, 460, 462 Pyelitis, 703 Pyemia, 703 Pyloroplasty, 358 Pyorrhea, 166 Pyrexia, 703 INDEX 733 Q Qualifications and equipment of ex- aminers in the tropics, 512 of examiners, 130 Quality of service, 78 Quantitation of albumin, 428 Quantitative glucose test, 433 Question concerning female applicants, 37 Questionable hazards, 677, 678 Questions by applicant's physician, 35 Quinones, 423 Quinsy, 657 R Rabies, 703 Race, 134 Races in the tropics, 506 Radial pulse equality, 193 Radiotherapeutic cure of cancer, 365 Radium and x-ray as cure for cancer, 364 Railroad freight brakemen,... 675 Railway spine, 703 Rales, 160 Rapid tremor, 232 Rates, 68 Ratification by applicant, 652 Rating of applicant with casts, 452 of impaired risks, 561 of nervous disorders, 530 Ratings, Abdominal girth larger than chest, 574 for albuminuria and casts, 468 in war nephritis, 546 with casts, 464 Rating-up the age, 567 Ratio of blood pressure, 286 Raynaud's disease, 263, 703 Reaction to exertion in heart disease, 166 Readings in blood pressure, 296 ''Real examiner," 1.15 Record of examiner's work, 104 Rectal growths, 409 prolapse, 703 Recurrence in cancer of the nose and pharynx, 397 Recurrent sepsis, 520 Reeling gait, 230 Reexaminations, 105 References, 631 Reflexes, 235 Regions of the abdomen, 203 Registration area, mortality, 137 Reinspections, 637 Rejection of applicant, 29 Rejections for hypertension, 309 for urinary findings, 475 Relapsing fever, 703 Relation, of build to mortality, 579 of medical referee to the examiner, 103 of the agent to the medical examiner, 67 Relationships with other departments, 77 Relatives, 133 Remote effects of gas poisoning, 536 Removal of rating, 674 Renal calculus, 704 Renal casts, significance, 451 Renal colic, 657 ratings, 577 Renal diabetes, 480, 491 threshold, 471 Repeated chest examinations, 160 Repeated observations in syphilis, 333 Repetition, 129 Report to home office, 128 Reputation, 626 Requirements as to urinalysis, 462 of medical examination, 27 Resections of rectum, statistics, 409 Residence, 553 Respiratory system, 152 Responsibilities of medical director, 92 Responsibility, 113 of examiner, 628 Restrictions from occupation, 667 Results of investigation of high systolics, 308 Retropharyngeal abscess, 704 Review of applicant's answers, 128 of examination blanks, 103 Revolutionary hazards, 511 Rheumatic fever, 338 Rheumatism, 121, 704 as cause of heart murmurs, 166 articular, 704 gonorrheal, 704 history, 50 in army, 541 muscular, 704 ratings, 577 Rickettsia, 542 Rigidity of abdomen, 202 Rodent ulcer, 371 risks, 402 Roman guilds, 55 Rosenbach modification of Gmelin's test, 434 Rubella, 704 Rupture, 127 of kidney, 361 734 INDEX S Saddle nose, 48 Safe risks, 108 Safety First Crusades, 679 Salaried examiners, 101 Salesmanship, 67 Salpingectomy, 360 Salpingitis, 704 Salvarsan, 317 Sandalwood oil, 442 Sand fly fever, 517 Sanitary drinking cups, 618 Sanitoria for policy holders, 609 Sanitorium for tuberculosis, 618 Sarcoma, 152, 365, 704 Sawmill worker, 498 Sawyers in stone mills, 669 Scanning speech, 233 Scarlet fever, 166, 335, 616, 704 Scars, 201 Sciatica, 260, 704 Scientific medical selection, 557 progress, 85 Scirrhus carcinoma, 384 Scottish Widows' Fund and Life As- surance Society, 25 Scrofula, 704 Scurvy, 705 Sebaceous cyst, 371 Secondary localization of bacteria, 338 Secrecy, 630 Secretory products of endocrine glands, 275 Sediment in urine, 422 Selection and instruction of inspectors, 632 in syphilitics, 314 of examiners in the tropics, 512 of risks for disability and double indemnity benefits, 601 Self-reliance in examiners, 111 Selling force, 68 Semitropical countries, 503 Senile psychoses, 268 Sensory aphasia, 234 Sepsis, 361 in old wounds, 320 Septic chest wound mortality, 524 chest wounds, 525 inflammation, 705 sores, 517 Septicemia, 705 Serious diseases, decided by the courts, 657 aneurysm, 657 gallstones, 657 renal colic, 657 Serious diseases-Cont'd tuberculosis, 657 * typhoid fever, 657 Service without disease, 551 "Sex Hygiene for Adolescents," 618 Shell shock, 266, 526, 528, 529, 705 Sick headache, 264 Signature, 128 Significance of casts, 461 Sinus, 705 infection, 340 involvement, 166 nontuberculous, 705 thrombosis, 252 tuberculous, 705 Sinusitis, 335 Situation of medical department, 87 "Skin cancer," 390 Skin disease, 705 Skopometer. 428, 430 Slow tremor, 232 Small-celled carcinoma, 384 Smallpox, 616, 705 Smell, 242 Society for the Control of Cancer, 363 Source of albumin, 440 Spasm of abdomen, 202 Spastic gait, 230 paraplegia, 258 Spasticity, 234 Specific gravity of urine, 424 not a guide, 61 losses, 592 Specimens from female applicants, 420 Spectroscopic test, 435 Special higher premium classes, 572 Specialized mortality investigation, 579 Speech disturbances, 233 Spheroidal or ovoidal cells, 366 Sphygmomanometer, aneroid, 280, 281 first, 279 mercury, 280 Sphygmomanometers, illustrated, 281, 282, 283, 284, 285, 287, 299 Spinal accessory lesions, 247 cord affections, 256 curvature, 705 anterior, 705 lateral, 705 posterior, 705 Spinal Wassermann test, 492 Spirochete pallida, 316 Spirochete, special strain, 330 "Spitting of blood," 650, 655 Sputum examination, 163 Sputum importance, 152 Squamous-cell epithelioma, 367, 368 of the bladder, 398 of the check, 393 Index 735 Squamous-cell epithelioma-Cont'd of the esophagus, 397 of the lip, 391 results of operation, 391 statistics, 391, 394 of mucous membrane of the jaw, 393 of nose, nasopharynx and sinuses, 396 of tonsil, 397 Squamous epithelioma of the skin, 390 statistics, 391, 392 Squamous epithelioma of the tongue, 396 Squint, 148 Stammering, 233 Standard, blank, 43 build table, men, 586, 587 risks good for disability benefits, 601 Staphylococcus, 337 infection, 705 Starvation in diabetes, 485 State Commissions on Occupational Dis- eases, 679 Statements as to general health, 654 Station, or position of applicant, 231 Stationary engineers and fireman, 667 Statistics, 94 on cancer, 363 Steppage gait, 230 Stereognostic sense, 238 Stethoscope first used, 36 Stigmata of degeneration, 229 Stokes-Adams syndrome, 192 Stokers, 669 Stomach upset, 199 Stone in kidney, 360 Stone mill workers, 671 Stones in gall bladder, 222 Stiabismus, 149 Strain of army work on heart, 167 Streptococcus hemolyticus, 337, 339 infection, 705 pyogenes, 337 viridans, 337 Streptococcic infection, 166 sore throat, 335 Streptothricosis, 152 Study of mortality statistics, 44 Stumbling speech, 233 Stuttering, 233 Substandard insurance first used, 558 risks on endowment plan, 573 Substernal goiters, 353 Substitution, 634 Suffocative gases, 532 Sugar in urine, 431 Suicide not an accident, 604 Sunstroke, 658, 705 in war, 549 Superselection in syphilitics, 333 Supinator reflex, 236 Surgeon's certificate, 357 Surgery as cure for cancer, 364 Surgical benefits, 595 hospital benefits, 593 Surrender values, 671 ' ' Swat the fly, ' ' 616 Sydenham's chorea, 253 Sympathicotonia, 275 Symptoms of cardiac embarrassment, 170 Symptoms of thyroid adenoma, 350 Synovitis, 706 acute, 706 chronic, 706 Syphilis, 121, 706 a general infection, 321 among Russians, 329 and tabes compared, 329 as a health risk, 602 from life insurance standpoint, 314 in Bosnia and Herzegovina, 329 in East Africa, 329 in Japan, 329 in tropics, 329, 510 mortality in France, 316 mortality in the United States, 316 of circulatory system, 316, 322 of the heart, 324 of the lung, 152 of the nervous system, 316, 328 ratings, 578 Syphilitic aortitis, 323 lesions in the heart, 324 meningitis, 250 Syphilitics not at standard rates, 331 Syphilitic ratings, 331 Syringomyelia, 257 System, in medical department, 86, 88 of inspection, 628 Systolic blood pressure, 296 average, 288 murmurs, 165 nonorganic heart sounds, 165 T Tabes dorsalis, 257 over the world, 329 Table, expectations of life, 585 of average weight and height, men, 583 of average weight and height m women, 584 of build in men, 586, 587 Tachycardia, 166, 167, 706 736 INDEX Tact, 50, 110 Tactile sense, 237 Tactus eruditus, 46 Taenia echinococcus, 706 Tapeworm, 706 Taste, 243 Taxicab drivers, 670 Technic in blood pressure, 303 Teeth, 47, 340, 616 • Telephone repairmen, 670 Temperature sense, 238 Temporary ailments, 654 disability, 594 employment, 660 glycosuria, 479 ill health, 132 Teratoma, 368 location, 386 treatment, 415 Terminal reserves, 671, 672 Territory of examiners, 69 Testicle, 706 castration, 706 cancer, 706 tuberculosis, 706 Tests for albumin, 440 for glucose, 486 for sugar, 432 Tertiary circulatory symptoms, 326 syphilitics not aware of infection, 330 Tetanus, 253 Texas health conditions, 501 "The Child," 616 Theatrical employees, 670 Thick speech, 233 Thomsen's disease, 257 Thoracic aneurysm, 154 wound insurability, 524 Threats, 646 Thrills felt in heart examination, 175 of heart due to aortic stenosis or aneurysm, 175 Throat, 48, 146 Thymol, 442 Thyroid gland, normal, 346 recurrence of malignant tumors of, 404 Thyroidectomy, 351, 352, 354, 707 Thyroiditis, 339 Thyrotoxicosis, 351, 354 Thyrotoxin, 346 Tic douloureux, 245 Timers and arc light trimmers, 667 Tinnitus auriuin, 242 Tips from inspections, 629 Tone change in blood pressure, 295 Tongue, 47, 146 Tonsils, 340 Tonsils and adenoids, 616 Tonsillitis, 166, 707 Total and partial disability, 593 Total disability, 601 Toxic psychoses, 267 Trace of albumin, 456, 457 Tracheitis, 534 Trachoma, 707 Transverse myelitis, 259 Transmissible diseases, 658 Traumatic lesions of cervix, vagina and vulva, 707 neurosis, 266 psychoses, 268 surgery, 361 Treatment of gas poisoning, 535 of syphilis, 318 Tremors, 232, 707 Tremulous speech, 233 Trench albuminuria, 542 fever, 518, 541 nephritis, 518, 542 Triceps reflex, 236 Trichina spiralis, 707 Trichocephalus dispar, 707 Tricuspid regurgitation, 182 Trifacial nerve lesions, 245 neuralgia, 245 Trivial ailments, 663 Tropical climate, 502 countries, 503 diseases, 510 in war, 516, 547 hazards, 502 residence first asked, 40 Tubercle bacilli, 164 Tuberculosis, 152, 162, 357, 657, 707 as a health risk, 601 bone, 708 death rate in Canada, 540 glands, 708 in ex-service men, 540 in the south, 497 in the tropics, 510 in war, 538 in women, 140 accessory symptoms, 140 fatigue, 140 fever, 140 increased pulse, 140 increased respiration, 140 loss in weight, 140 muscle resistance, 141 mortality, 619 of throat not an accident, 603 with sanitarium care, 162 INDEX 737 Tuberculous infection and albuminuria, 466 longevity, 162 meningitis, 250 statistics of Trudeau sanitarium, 162 Tumor, 123 of larynx, 397 of lung, 152 of stomach, 213 Tumors, 708 benign, 706 brain, 708 keloid, 70S malignant, 708 Turbidity tubes, 427 Turpentine, 442 Twenty-four hour specimens, 429 Types of extra mortality, 560 of heart sounds, 166 of nervous balance, 527 Typhoid bacillus, 338 fever, 605, 616, 657, 709 in the tropics, 510 mortality, 622 Typhus fever, 709 U Ulcer, 123 acute, 709 chronic, 709 of duodenum, 219 of stomach, 212, 223 of stomach with carcinoma, 383 Ulcerated carcinoma, 384 Unconsciousness, 709 Undesirable business, 627 Underinsurance, 73 Undernutrition, 275 Underweight, 589, 709 Underwriter, 629 Uniform blank, 80, 81, 82 Uniformity of action, 90 United States Commerce Commission, 679 University of Chicago examination of women, 145 Unrecognized syphilis, 315 Urea, 428 Uremia, 709 Urethral earuncle, 709 rupture, 709 stricture, 709 Urethrotomy, 710 Urinalysis, 127, 136, 419 in health examinations, 614 Urinary requirements, 462 Urination frequent, 710 Urine, 127, 1.36 sediment examination, 436 to home office, 129 Urinometer, 424 Urobilin in urine, 435 test, 435 Uterine displacements, 710 V Vaccination first required, 40 Vaginal section, 710 Vaginitis, 710 Vagotonia, 275 Valvular heart lesions, 710 Variation in blood pressure, 287 in weight, 579 Varicella, 710 Varicocele, 710 Varicose veins, 196, 710 Varieties of casts, 461 Variola, 710 Vein examination, 196 Ventricular hypertrophy, left, causing pulsations in neck, 173 Vermin in war, 518 Vertigo, 247, 711 Vesical calculus, 711 Vesicant action of gases, 533 gas symptoms, 534 Visual Albuminuria Guide, 458 Vogel scale, 422 Void urine at night, 122 Voice, 147 Vomiting, 534 Vulvar abscess, 711 Vulvitis, 711 Vulvovaginal cyst, 711 W Waiver for defects, 591 "Walling off" process in focal infec- tion, 336 War impairments, 515 nephritis problems, 545 neurosis, 536 upon consumption, 616 Wart, 397 Wassermann test, 317, 490 as routine measure, 491 Wasting palsy, 256 Water hammer pulse, 193 Waxy casts, 446, 448, 449, 460, 461 Weakness of heart sounds, 177 first sound, 177 second aortic, 177 second pulmonic, 177 738 INDEX Weakness of muscles, 234 Weight, 47, 127 Welfare and Statistical Bureau De- partments of Life Insurance Companies, 679 Welfare work, 616 Wen, 149 Wholesale insurance, 51 Whooping cough, 616, 711 Wilson's disease, 254 Wine in the tropics, 509 Witness to signature, 645 Writer's cramp, 263 Women applicants, 124 examination of, 137 Workers with electric furnaces, 669 Working coal miners, 667 Wounds, 711 X X-ray examination, 206 of chest, 160 in tuberculosis, 163 Xylyl bromide gas, 531 Y Yellow fever, 510, 711 Yperite gas, 531