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ARMY MEDICAL LIBRARY

         WASHINGTON
             Founded 1836
Section.
Number ..£<4---?---2---!*--L---
             Form 113c, W. D., S. G. O.
■ n  3—10543    (Revised Juno 13, 1936) 
 DUE TWO WEEKS FROM LAST DATE









■r JUN »   1952
GPO  881473 
 
medical examinations
FOF
LIFE   INSURANCE.
BY
J. ADAMS ALLEN, M. D , LL. D.,
Prof. Principles and Practice of Medicine and Clinical Medicine in Rush
   Medical College ; Formerly Prof. Physiology and Pathology
         in the University of Michigan.
Jt/f'Z-U.-
.*/.-.
         CHICAGO:
HORTON St. LEONARD, BOOK AND JOB PRINTERS,
        104 & 106 Randolph Street.
           MDCCCLXVII. 
       F.-.tcifJ according to Act of Congress, in the year 1866,



                  By  J.  ADAMS  ALLEN,'



In the Clerk's Office of the District Court of the  United States, for the



                    Northern District of Illinois. 
Note  Prefatory.
  Life Insurance is rapidly growing in public favor, and it is not
extravagant to say that  the time is coming when it will be more gen-
eral  even than Fire Insurance.  All men have lives — not all  have
houses, stores, or  barns.  The system of endowments, non-forfeiting
policies, etc., has gone  far  toward making  what before was consid-
ered extra-prudential and exceptional, a  matter of ordinary business
caution and common usage.   That the Insurance Companies and the
holders of their policies should have the  highest possible advantage,
it is  clearly  necessary  that none but lives  selected with great  care
should be assured.  Hence the Medical Examiner  becomes their
indispensable  agent.   To  aid  him in the performance of  his
important work, is the object of this little Manual.
  It is not its intention to be argumentative, statistical, or rhetorical.
Neither originality in substance nor method is sought after—but only
that  more clearness, definiteness, and certainty may be achieved, by
attention to  the suggestions herein contained.
  A prime object has  been  to concentrate  to  the smallest possible
bulk.  Hence, conclusions  only are given — reasons and authorities
are  rarely alluded to.
  Justice  to myself compels me to add that, while the urgent press-
ure  of professional  duties has obliged me to write  during brief and
scanty intervals only—nevertheless, the ideas advanced  are the re-
sult  of  matured  convictions, strengthened by several  thousand
personal  examinations of applicants for life insurance.
  Chicago, 1867.                                    J.  A. A. 
t 
THE   APPLICATION.
   The Medical Examiner should first read carefully,
 point  by point, the interrogatories  proposed by the
 Company for which he is acting, and the answers of the
 applicant.   This will  save time, and indicate those
 circumstances  which  require   especial  investigation.
 The form  generally  adopted, proposes  twenty-five
 questions — twenty-three of which demand the scru-
 tiny of the Examiner.   For the purpose of brevity,
 we adopt the order of the form.

                        I.
    Name,  Residence,  and Occupation.—The name
 identifies.  The residence will suggest at once the na-
 ture of the causes  of the diseases prevalent, and the
 relative salubrity of  the  locality.   The moist atmos-
 phere  and  variable temperature prolific  of  phthisis;
 ochlesis, the products  of animal  decomposition,  and
 foul air, fertile in typhoid fevers  and cachexias; ma-
 larious districts involving endemic diseases which may
 especially prove noxious to the party, etc., etc.
   The Occupation — healthful or pernicious?  Sta-
tistics show the relative longevity of the different occu-
pations of men, but the Examiner should superadd to 
                         4
these the  inquiry:  What is  the probable effect upon
the applicant himself?—for that which is salutiferous
to one, is often  prejudicial  to  another.   Statistics
establish certain general propositions, to which, it must
be recollected, many exceptions can be taken
   Professional Men.—Teachers exhibit the greatest
longevity.   Next come Clergymen, who are subject to
few diseases save those incident to sedentary habits.
Contrary  to  the vulgar opinion, they  are not  more
liable than others  to  pulmonary affections.   Dyspep-
sia,  with  its  incidents, is  their principal affection.
Lawyers  rank next.  Then  professional  Lecturers,
and next,  Physicians.   Of the latter, it may be said,
as a class, they have not the ordinary expectation of
life,  by from one-third to one-fifth  subtraction.  Nev-
ertheless, the  variety of exposure and habits is such
that each case requires isolated investigation.
   Artists.— Painters and  Sculptors  rank among the
best risks, particularly  when  the former sketch  from
nature, and the latter merely model.   Portrait paint-
ers, and sculptors who cut marble themselves, are  not
as good risks.  Photographers and Daguerreotypists
rank second class.
   Artisans  and  Mechanics.— Painters using  lead
and oil are undesirable risks, yet need not be wholly
rejected.   Workers  in  phosphorus  and quicksilver
stand upon the same  level.  Stone cutters and millers,
and  similar  occupations, where  insoluble  or  irritant
particles find constant access to the pulmonary surface,
are less desirable, but improved methods  of ventila-
tion, now in vogue, render them less objectionable than 
                         5
formerly.   Glass blowers  are poor risks.   Compos-
itors  in printing  offices  signally demand caution in
acceptance.    Blacksmiths, Furnacemen, Carpenters,
Coopers, and  Cabinet Makers range among the  most
healthy operatives.  Shoemakers and Harness Makers,
mainly from  their sedentary habits, are second class
risks.  The same  remark may  be made of Tailors.
Butchers and  Market men, aside  from the chances of
accident, (to the former particularly,) are good risks.
Machinists, Plumbers,  Tinsmiths, Tallow Chandlers
and  Barbers,  and  similar occupations, are  generally
good risks.   Engravers, Jewelers, and the like,  are
liable to the diseases of sedentary life, but are other-
wise unobjectionable.   Brewers, Confectioners, Dyers,
Hatters, Bakers, and others whose business involves
constant exposure to warm vapors, often impregnated
with  medicinal  or poisonous  substances, are not as
desirable.  Chemists, Assayers, Gilders, Tobacconists,
etc., are liable to the same objection.   Day  Laborers,
unless exposed  to accident, are  equally as good risks
as mechanics.   Agricultural Laborers,  in  salubrious
localities, are  the highest order of desirable applicants.
   The best lives,  other things being equal, are those
of personTengaged in out-door  and yet protected em-
ployments, where the occupation  is  somewhat seden-
tary, and yet combined with a certain amount of mus-
cular exercise, with pure air, and variation enough to
secure a  stimulating  impression  upon the  system.
Inertia,  indolence,  and  absolute  uniformity  of me-
teorological influences,  are  as   prejudicial  as  over-
exertion  and  atmospheric vicissitudes. 
6
                         II.
   The Age.— Different  ages predisposeto particular
diseases.   So,  also, hereditary diseases, according to
their kind, may  be outgrown,  or not yet arrived at.
   During the period  of increase, extending to about
the  twenty-fifth  year,  (varying,  of course, in  indi-
viduals,)  the tendency to disease  and death is propor-
tionately  very great.   One-tenth of all children born
die the first month.   In large  towns, nearly one-half
die before the  fifth year.   Respiratory and strumous
diseases are especially  fatal  between  puberty and the
age  of  maturity — placed  at  twenty-five.    None
should  be  insured before  puberty,  except at  extra
rates.   Between  that  period and maturity, the  party
demands  especial  investigation  of the respiratory and
glandular systems.  Continued fevers, of the typhoid
type, are  also liable to be destructive during this pe-
riod.  The exanthems readily  implant the germs of
phthisis and other strumous disorders.
   Rheumatism, if it now occurs, in consequence, per-
haps, of  the excessive activity  of the  sanguineous
system, is exceedingly liable to beget organic disease
of the cardiac valves,  with its subsequent results.
 ^jFrom  the twenty-fifth  year  to the thirty-fifth, or
fortieth,  or age  of maturity, the best risks,  ceteris
paribus, are chosenTj  During this  period, the applicant
stands more, so  to speak, on  his own individuality.
Hereditary predispositions affect him less, and external
agencies are easiest resisted when tending to disease.
The habits and  external influences  now require  most
careful survey. 
                          7
   From the fortieth year, at latest, decline commences.
Hereditary diseases  regain their  dangerous tendency,
and acute affections are met with less power of resist-
ance.   Yet, acute diseases of various forms are less to
be dreaded than  during  the  mobile years previous to
maturity.   The  progress of changes  in the system is
slower, and the tendency is to  congestions rather than
inflammations; to urinary diseases; to fatty degenera-
tions ; to cardiac and  other  obstructions from undue
deposits; to  dropsies,  apoplexies, paralyses,  and the
like.
  The following  table  shows  the  expectations,  or
average duration of life of each  individual, calculated
from  the Carlisle table of mortality:
AGE.	EXPECT-	AGE.	EXPECT-
	ATION.		ATION.
O	38.72	18	42.87
I	44.68	!9	42.17
2	47-55	20	41.46
3	49.82	21	40.75
4	50.76	22	40.04
5	51.25	23	39-31
6	51.17	24	38.59
7	50-80	25	37.86
8	50.24	26	37-H
9	49-57	27	36.41
IO	48.82	28	35-^9
11	48.04	29	35.00
12	47-27	30	34-34
l3	46.51	3i	33 68
H	45-75	32	33°3
'5	45.00	33	32-36
16	44.27	34	31.68
17	43-57		
Other tables vary this expectation from one to two per cent.
AGE.	EXPECT-	AGE.	EXPECT-
	ATION.		ATION.
35	31.00	52	I9.68
36	3°-32	53	18.97
37	29.64	54	18.28
38	28.96	55	17.58
39	28.28	56	16.89
40	27.61	57	l6.2I
4i	26.97	5«	15-55
42	26.34	59	14.92
43	25.7I	60	H-34
44	25.O9	61	13.82
45	24.46	62	J3-31
46	23.82	63	12.81
47	23.I7	64	12.30
48	22.50	65	11.79
49	2I.8I	66	11.27
5°	21.1 I	67	10.75
5i	2O.39	68	10.23
 
8
   But it should be  recollected that, in individual
cases, the expectation of life may be increased by pass-
ing beyond  certain ages — a fact wholly ignored by the
tables.   Thus, for example, where there  is clearly an
hereditary tendency  to  phthisis—when  parents,  or
brothers  or sisters have died  of the disease before
twenty-five  or thirty,  and the party has lived, and is
now in good health, at the age of forty, half the danger
may be said to have passed;  at fifty, three-fourths or
four-fifths;  and  at sixty, but  a  mere modicum  re-
mains—certainly not over one-fifteenth or twentieth, if,
indeed, it may be said to exist beyond that of other
persons without hereditary predisposition  of  any sort.
   On the contrary, the tendency to gout,  urinary dis-
eases,  insanity,  apoplexy,   paralysis,  etc.,  increases
with the  progress of declining years.
   It is safe  to say that, when  tables  indicate a pro-
gressive  diminution of the life expectation,  this idea
should be modified and corrected by a full understand-
ing  of  the  hereditary,  constitutional,  or  acquired
tendency to, or relief from, special forms of disease.

                        III.

   The Marriage Relation suggests hygienic influences
so obvious that it is unnecessary to delay in its con-
sideration.j Married men are usually the  most desira-
ble risks.   General  statistics show  that  even  with
females,  the dangers incident  to maternity do not ma-
terially impair the risk.  A woman  who  has once
borne  a  child  with  no  extraordinary  difficulty, is  a 
                          9
 better risk than the prima para, and married women than
 those  who are  unfortunately  single.  The  circum-
 stances  of previous  labors, if any have occurred,
 should  be fully  understood, and reference  had, if
 possible, to the attending physician.
 '  In large towns and cities, applications are frequently
 made by those neither married nor single, for insurance.
 These  applications are   not infrequently made  by
 " housekeepers," who, having passed the  heyday  of
 their years without  physical impairment, save that
 which years may  bring, become solicitous of providing
 by endowment for later old age, or else for the support
 of dependants.   These cases  are not desirable, neither
 is it necessary utterly  to refuse  them.  But the most
 rigid investigation is  requisite before they are recom-
 mended.  )

                    IV.  & V.
 Sobriety and Temperance—Use of Opium, etc.—
  vThe habitual drinker of  alcoholic spirits, or the ha-
 bitual opium-eater, should, as a rule, be rejected.  The
 inquiry proposed to  the applicant will rarely  secure a
 correct answer.   Very few will voluntarily  admit  either
 intemperance, gluttony,  or other generally recognized
 vice.   The Medical  Examiner  is  expected to  guard
 the interests of the Company and  co-insurers, by ob-
 serving carefully the  signs of excessive stimulation,
 as, unfortunately, too  often furnished by votaries of
 Alcohol, Opium, Chloroform, Ether, Cannabis Indica,
and the like.  The consumption of other stimulants
and narcotics besides alcohol,  has notably — we might 
IO
 well  say  enormously — increased within  several years
 past.  The  alcoholic breath is readily  detected, but
 equally clear  to  the  educated  perception is the effect
 of other narcotics and  stimulants.  Too  often the
 applicant is induced to  apply for assurance, by self-
 consciousness  of his indulgence in some  pernicious
 method of excitement, which he knows tends to short-
 en life, but which he  vaguely believes he can abandon
 or control before it is too late.
   Intemperance, by which we mean not merely drunk-
 enness, but an inordinate, pernicious habit of stimula-
 tion  by something, is, as  likely as rheumatism, gout,
 insanity, or tuberculosis,  to be hereditary.
   The family  history here becomes noteworthv.   A
 tuberculous tendency may be, to a certain extent, con-
 trolled by hygienic influences ; among  which may be
 numbered the use of stimulants of various  kinds.
 The  rule for the Medical Examiner  is this :  If the
 stimulant taken invigorates digestion and assimilation,
 then it is  not cause for rejection:  if it merely excites
 the nervous system,  it  is an objection  to the risk.
 Observe — invigoration  of digestion and assimilation
 (real  power) is  not to be confounded with mere in-
crease of adipose  tissue,  which  is often  indicative of
depression of nutritive energy.
   Is the party an occasional  or an habitual tippler ?
There are some men who  indulge in only an infrequent
debauch, and in the interim are strictly temperate. Such
a habit, if ascertained, impairs materially the risk.
   The habitual drunkard is well described by Dr.
Brinton :   " The chief characteristics  one  can  briefly 
II
express in words, are the fiery, unctuous skin, with its
secretions reeking with volatile, fatty  acids;  the red
and ferrety  eyes, with their fitful glare, rather than
gleam ; the  furred  tongue; the  fetid breath, and the
trembling limbs, that often announce the impression
made by  the copious habitual  ingestion of alcohol on
the stomach and nervous system respectively."
   Other suggestive appearances are afforded by sunk-
en eyes surrounded  by dark  circles ; pallid, or even
waxy complexion;  moist,  sticky  skin;  emaciation;
tremulousness of the muscles, unless  rendered tem-
porarily tense by a full dose of the stimulant;  a ner-
vous restlessness of the whole person ;  often abstrac-
tion of mind, etc.,  etc.  Many times  the party will
temporarily conceal the habit, or  even persuade him-
self it does not exist to an injurious extent;  hence the
necessity  for  great  caution.   The friend's certificate
here becomes indispensable, and  the  attending physi-
cian's testimony should not be overlooked.
  Habitual  opium-eating  does not  show such easily
described and  unmistakable marks, yet can  rarely be
concealed from an observer of  ordinary sagacity, whose
attention  is directed to the point.
 . Notwithstanding the singular character of  the testi-
mony in the Earl of Mar's case, in England, in 1832,
it is safe to say that opium-eating  lessens the expecta-
tion of life, and is, therefore, a valid  reason  for de-
clining  the  risk.   Undue  nervous  irritability;  a
peculiar,  shuffling  gait;  flabby  muscles;  drooping
evebrows, with  dark lower  lids, while  the eye itself
seems to  sink  and grow dim ;  with general marks of 
12
old age ;  or  else, while the stimulant has  full effect,
excitement with brilliant eyes, but contracted  pupils ;
quick, restless  movements ;  or,  sometimes, in differ-
ent temperaments,  general  dullness, lassitude, sleepi-
ness,  and a relaxed  skin, with sticky perspiration, and
husky voice.  When the applicant says he has a diar-
rhoea  or dysenteric  difficulty which requires occasional
doses  of opium,  when the  eyes  are hazy,  and  the
tongue has a whitish coat; when  there  is a  mucous
secretion  from  the  eyes, with frequent  hawking of
mucous from  a flabby  mucous  membrane  of  the
pharynx, and  perhaps  of  the nose.   When  he  is  a
married man, and with these symptoms, has  no chil-
dren,  carefully  observe and reject him.   Much must
be left to professional discretion — but cave canem.

                       VI.

  Vaccinated ? — A person who has never been vacci-
nated or had the small pox,  should  not be accepted.
If vaccinated, the inquiry should be:  Was the vacci-
nation  successful ?   and then, how recently  was  the
operation performed ?   A successful vaccination many
years  previous, is not sufficient, but if it has been fre-
quently repeated without infection, the  case  may be
deemed clear.   In  doubtful  cases, examine the cica-
trix, or re-vaccinate  at  once.   If small pox or vario-
loid has occurred, it  requires especial caution as to the
condition of the  lungs  and intestinal mucous mem-
brane.  The  date when it occurred should be given,
and the fact of perfect or imperfect recovery noted. 
J3
                  VII. & VIII.

 (Residence in  a Foreign Climate.— Without  ex-
act reference to  isothermal  lines, natives of the zone
extending from the thirtieth  to the fiftieth parallels of
latitude, may be  considered as the best risks. > An ac-
quaintance with  the  meteorological  condition of par-
ticular  localities, is  of great importance.   Excessive
thermometrical, barometrical and hygrometrical varia-
tions, in any particular locality, usually  impair risks,
by rendering them subject to various diseases. '
  Thus, moist, warm situations usually  involve  the
malarious  diseases; cold,  or variable, and  moist re-
gions are prolific of tuberculous cachexias; dry  (yet
variable in temperature)  districts,  render  rheumatic
and inflammatory diseases more dangerous.  On equal
parallels, the temperature  of Europe is  higher than
that  of America, and  excepting the influence of the
changes produced by cultivation, present the diseases
of lower climates in  higher  latitudes.   General tem-
peraments  are varied by persistent climatic influences.
(Vid. supra.)
  Acclimation in the South.—Whilst men, almost
alone of animals,  can range from the Equator to the
" open Polar Sea," with apparent impunity, by observ-
ing certain precautions which their  reason and knowl-
edge  suggest, nevertheless,  they subject  themselves,
sooner or slower, to organic  changes which are termed
briefly "acclimation."  These changes render them less
liable to the  acute diseases  of localities, or  endemics. 
                         14
but  they are fraught with much  significance  to the
insurance examiner.
  More than two thousand years  ago, the naturalist
Pliny noticed that "those who  are  seasoned can live
amid pestilential  diseases."  The reason of  this may
be a matter  of speculation, but of its essential truth
there can be  no  doubt.   The organic changes thus
brought about express  themselves  in the larger phase
of different races of men, begotten through the opera-
tion  of ages of similar influences acting on parent and
progeny.
 \ Without descending  to  minutiae, it may be said the
Northerner going South may become, to a certain ex-
tent, acclimated by physical changes  in the skin, liver
and  spleen, especially  involving their heightened ac-
tivity of  interstitial change, and, usually,  increase in
bulk.?  Increased activity of any organ, according to a
well  known natural  law, involves greater tendency to
disease.   If,  instead of more  energetic action of the
skin, there is less, from any temporary or permanent
cause, then the mucous  membrane of the intestine will
be called into excessive  activity,  and  the  acute  or
chronic diarrhoea of tropical  climates  be produced.
Else there are the " bloated belly, distorted features,
dark yellow complexion, livid eyes and lips ;  in short,
all the symptoms of dropsy, jaundice and ague, united
in one person."
  ' Coming North, the comparatively  healthy  Southron
falls an easy  victim  to tuberculous,  nephritic,  and in-
flammatory diseases. \ The rule is to observe the rela-
tive  activity  and  development of  each  organ  or
apparatus involved — whatever the cause of variation. 
  Acclimation to the so-called malarious fevers, etc., of
the South, gives  no immunity to yellow fever, any
more than does  typhoid fever from variola at the
North, i  Yellow fever is a disease of cities and towns,
epidemic usually, and requires its especial prophylaxis
— not gained by any  mere acclimation.  As Dr. Nott
emphatically  writes:   " The citizen  of the  town  is
fully acclimated to its atmosphere, but cannot spend a
single night  in  the country without serious risk of
life; nor can the squalid,  liver-stricken countryman
come into the city during  the  prevalence of yellow
fever, without danger of dying with black vomit."
  The immunity from second attacks of yellow fever
is  nearly  complete, yet  the  constitution is liable  to
permanent impairment from its ravages, and in all cases
organic diseases are carefully to be looked for.
   The immunity from diseases  prevalent in particular
localities often exhibited, in exceptional cases, is due
principally to two causes :  First, The peculiar organi-
zation  of the individual himself; and, Second,   The
care with  which he adapts his life,  manners  and cus-
toms to his  changed surroundings.  As  Dr.  Ham-
mond remarks:  "For an  Englishman or an Ameri-
can  to  attempt a  residence in  latitude 8o° without
changing his  food, clothing or habits, by making them
conform to the climate to which he has come, would
lead to  but one  termination — death.   But  if  he
studies the conditions by which he is surrounded, and
profits by the experience of those to whom it is nat-
ural, he becomes habituated to the new order of things,
and lives in health  and comfort." 
i6
   The same law holds good with reference to a change
to hot climates.  Hence, he who has shown, by actual
experience,  that  he has  maintained good health  in
either  extreme of  latitude,  may  be more safely  in-
sured,  or, if already  insured, be  granted permission,
more readily, to take  up  a Northern  or  Southern
residence.
   Nearly the same  law holds good with regard to yel-
low fever or other  epidemic disease — the best pro-
phylaxis is for the individual so to shape his habits as
to keep well—and  he who  will attempt this, is  the
best risk.

                   IX.  & X.

   Employed in the  Army or Navy ? — The careful
examination to which the recruit is ordinarily subjected
before being mustered  into  the service, is a point in
his favor, if he was received.  Questions then arise as
to  the  influence of  the  service  upon  him.   The
diseases  to  which he has  generally been exposed  are
principally  " typho-malarial  fever,"  rubeola, camp
diarrhoea, dysentery,  rheumatism,  scorbutus,  pneu-
monia, catarrh, cardiac  changes, Bright's disease, and
not least, venereal affections.
   An individual who has escaped permanent systemic
or organic disorder,  from these various causes, may
generally be put down as a good risk, even though  his
personal or family  history is not  every way satisfac-
tory.   Nevertheless, the obscure results,  often capable
of discovery on rigid examination, require more than
usual care, before accepting the applicant. 
                         l7
  In  my own experience, I have often found cardiac
and renal diseases, and the secondary or tertiary forms
of syphilis  in  returned  soldiers,  discoverable  only
after most  careful scrutiny.   The  exposures and ex-
igencies of the service involve the most potent causes
of organic disease, even though the  elasticity of many
systems prevents immediate manifestation of striking
symptoms.
  Previous  Employments,  and  their  Effect  on
Health.— The present  occupation may be ordinarily
innoxious, but  the  previous employments  have left
lasting traces of injurious  influence.   So,  again, the
present  business  may be  such as  to endanger the
health generated by previous healthful engagements.
The peculiarities of the individual  here require cau-
tious investigation.   ( Vid. Occupation.)

                       XI.
  Has the Party had any of the following Diseases?
Apoplexy,
Asthma,
Bronchitis,
Consumption,
Cholic,
Diphtheria,
Disease of the Hear
Dropsy,
  Seriatim. — A party who has had a  decided attack
of Apoplexy should  be  rejected.   Evident  tendency
thereto also should disqualify.
  Asthma is but a symptom — it may or may not be
a cause of absolute  rejection.   Each  case  requires
specific examination.
       2
Fits, Fistula,	Quinsy, Rheumatism
Gout,	Rupture,
Insanity,	Scarlet Fever,
Liver Complaint, Paralysis,	Spitting of Blood, Diseases of the Urinary
Palpitation,	Organs.
 
i8
   Observe—Asthma  may occur  merely  from  local
irritants  applied  to the respiratory surface, and the
causes of such local irritation may depend upon mere
idiosyncrasy.  Or it may depend  upon blood poison-
ing of various  kinds.  Thus particles of  hay,  soot,
excessive moisture,  atoms of certain  gases,  animal
emanations, ipecacuanha and other medicinal substances
are capable of  producing more  or  less severe  spas-
modic asthma.    Such cases,  irrespective  of organic
lesion, do  not  necessarily disqualify from  insurance.
Some persons always have asthma  in  certain locali-
ties—never in others.  Thus C.  cannot stay a single
night in Ann Arbor, Mich., without  a severe par-
oxysm of  asthma ; yet he has lived years in Detroit,
only 37 miles distant, without a  single attack.  A.,
well  known to me, lives  in  California with  perfect
health and  freedom from the disease, whereas, in the
Northern  United States,  he is  a  constant sufferer.
These individual  peculiarities, and the suffering they
generate, are the  best guarantee  that the  party will
himself protect the interests of the Company.   Nearly
the same  remark  may  be  made with reference to
asthma from blood poisoning—prominent among the
causes of  which  we  may mention  malaria, or such
other causes as  promote  portal  venous congestion.
Alcoholic stimulants, and sometimes even unexpected
articles, as  sugar,  will occasionally produce the same
result.  Here the persistence of the cause must gov-
ern the  judgment.   None  of  these  cases  wholly
preclude acceptance of the risk.
   Again,  asthma may  depend  upon  reflex causes
totally inde^ endent of permanent  orcanic disease.  It 
                         l9
may alternate with ague, or other periodical disorders.
It may depend  on  uterine, vesical, rectal, or  even
gastric disorder.  It may be dependent solely on an
excitable temperament and emotional influences.  The
gravity and  permanence of the excito-motor cause
here must be sought out, and only its due  importance
attached.   But Asthma, which  is the symptom  of
cardiac obstruction—of tuberculosis.— of emphysema—of
acute or chronic  bronchitis — of thoracic tumors — or,
perhaps,  aneurism — of hepatic venous obstruction from
thoracic  disease,  or parenchymatous  change  in the
liver itself— or from organic cerebral or spinal change,
should utterly preclude insurance.
   Bronchitis.-^-A proclivity to  attacks of bronchitis
should disqualify, not only  from the  dangers of un-
complicated  bronchitis, but because  it is  so  often
symptomatic of the tuberculous diathesis.j Again, as
indicative of nephritic, cardiac, gastric, or other  dis-
eases of remote organs, or those from septic  causes,
(typhoid, syphilis, etc.)   It may be observed, how-
ever,  that  bronchitis may,  and  often  does, leave a
condensation of a portion of the pulmonary vesicular
structure, simulating tubercular  deposit,  and  again,
that it  may leave behind  dilatations  of  the  tubes,
which simulate  very  closely excavations from  tuber-
cular softening.   Resulting emphysema  should  be
carefully searched for, and its fallacious resonance not
confounded  with  healthy  lung-vesicular structure.
Popularly, simple pharyngitis, and all slight or severe
catarrhal  inflammations, are merged  in   the  general
term bronchitis ; so that the information conveyed by 
20
  the patient's own statement is of very little practical
  value.
    Consumption. — The rule is absolute that consump-
  tive cases should be rejected.   Physical investigation
  is always to be  exact, for  the healthiest  external ap-
  pearance may but hide the  germs of the disease.
    Cholic.—This term  indicates but a symptom, the
  significance of which depends solely upon its  cause.
  Taken in  its  widest sense, we  may say  that at the
  present  time,  improved methods  of  diagnosis  and
  treatment,  have robbed the disease of  its  formerly
- dangerous  character, and  unless   proceeding  from
  peculiar causes, it need  not be considered a cause for
  rejection.   The well known  forms  are   the gastric,
  intestinal, hepatic, nephritic, and  that  from  lead, or,
  perhaps, also, copper poisoning.  The cholic of flat-
  ulency, or temporary dyspepsia, does  not particularly
  enhance the risk — neither  does  the so-called bilious
  cholic, unless the patient is peculiarly subject to it.
  If, however, the latter evidently depends upon the
  passage  of  gall-stones, and  frequently  recurs, it  is  a
  cause for rejection.   Where painter's, or other metallic
  cholic has occurred, it is not, alone, to be considered
  cause for rejection, unless it has  recurred, and partic-
  ularly, the same occupation has been continued.  The
  lead worker who has had this  cholic, and  continues in
  the business, should be rejected.  A single  attack of
  nephritic cholic  need not reject — recurrence, even at
  a distant interval of time, should  exclude.   Many so
  called cases of cholic are really enteritis,  and may in-
  dicate marasmus.  The local and  general evidences of 
21
tuberculosis of the mesenteric glands, must be inves-
tigated.
   Cardiac Disease.— Organic disease of the  heart
positively excludes.  Physical diagnosis is indispensa-
ble here,  but  it should  be recollected that, as a rule,
while the healthy heart may, from accidental causes,
give an  abnormal  sound  temporarily, the heart dis-
eased to such an  extent  as  to reject, can not, for any
continuous period, give  forth  healthy sounds.   Ab-
normality in  rhythm or impulse may depend solely
upon temporary causes,  and so, also, may abnormality
of sound —but  when  these  are  present, the  parts
should always be re-examined.  Variations in rhythm
or impulse may be individual peculiarities, and there
are evidences that varied sounds may also depend upon
idiosyncrasy,  but the safer  rule is never to accept the
party, unless the  natural sounds may be heard. When,
from any cause, cardiac disease has frequently occurred,
and  abnormalities are present, the party  should be
turned over to invalid companies.
  Dropsy.— This is another symptom which may, or
may not,  be of importance.  If present at the time
of examination, no chances  should be taken, but the
party advised to  postpone the application.  It may
have been a sequence of malarious  disease — as  often
from ague — if there  be not now malarial cachexia,  it
is no cause of rejection — but if hepatic  or splenic
parenchymatous disease  remain, the applicant should
be rejected or postponed  until that is  cured.  It may
have been left behind by scarlatina, or other zymotic
disease — if it has not  recurred, and  the evidence of 
22
 nephritic, cardiac, or  other  organic  disease do not re-
 main, it is  not  cause  for rejection.   It may  have
 resulted from  peritonitis, which has been entirely re-
 covered from — if so, the party may be received.   If
 from chronic  peritonitis, it  is  cause  for rejection.   If
 it occurs from  renal (Bright's) disease, from perma-
 nent  hepatic,  cardiac,  or pnlmonary  organic affection,
 the  party  cannot   be  assured.   The dropsy  from
 drunkard's liver,  (cirrhosis^ vitiates the  application.
   Aside from  constitutional causes,  the  effusion into
 the pericardium is more grave in insurance prognosis,
 than  that  into the pleural cavity.   The latter  than
 ascites,  and ascites  than  that  into the  areolar tissue,
 oedema, anasarca, etc.   But local  anasarca always ne-
 cessitates the greatest  care, lest albuminuria be present
 or impending,  or lest  some  permanent  organic disease
 is its origin.   Any constitutional cachexia, as syphilis,
 in connection with the dropsical effusion, even though
 organic  disease may  not   be discovered,  precludes
 insurance.
   Diphtheria, aside  from its immediate danger,  may
lay the  foundation  of tuberculosis — may be  followed
by albuminuria  or dropsical  effusions, or more or less
permanent paralysis.   It  is  not usually mentioned in
the list of diseases  about  which  the party  is ques-
tioned,  but its grave  sequelae  entitle it  to  thorough
consideration.
   Fistula.— Fistulas are of importance, as indicative
of  local or  general disease, or both.   Locally, they
may indicate  the  presence of  a foreign substance  at
the bottom, as  more particularly a bit  of dead bone, 
                         23
or cartilage.   In each of these instances the  surgical
pathology becomes the prime point of inquiry.
   The cause and  extent  of  the  necrosis whether of
bone or cartilage.    The  location  of the bullet,  or
splinter, bit  of cloth, or  whatever it may be.   The
surgical  curability of the salivary, faecal,  urinary, etc.,
false outlet,  with  the question of its cause.   So also
of the  mechanical action of muscles.   The import-
ance  of the  organ reached by the fistulous  opening
may have much to do with the decision of the case,
e. g. bone,  gland.   Some Life Companies vaguely in-
struct their examiners that Fistulas are a positive cause
of rejection.   In this case  Fistula in  ano is,  evi-
dently,  the difliculty  intended.  But whether fistula in
ano should reject depends wholly upon  its cause and
extent.
   First — If it is among the signs of tuberculosis, it
should  certainly  reject — whatever  opinion  may  be
entertained  as  to  its  hastening  or  retarding  the
tuberculous  development.
   Second—If it  has  proved  obstinate  under correct
treatment,  it should disqualify.
   Third—If it is large, burrowing,  and exhausting,
it is ample cause for rejection.
   But if it is traceable to ulceration  of the part from
merely  local  or temporary causes,  as  haemorrhoids,
acute dysentery, or direct  mechanical injury—without
evidences of the tuberculous diathesis,  or remote or-
ganic disease—if it has proved amenable to appropri-
ate treatment, and is no longer a cause of exhaustion,
it should not reject the risk.   Personally, the opinion 
                         24
 of the  writer  is  that, with  the  improved surgical
 methods  of  the present time, too much  significance
 has been attached to this usually strictly local difficulty.
   Fits.— Under this general  and  vague designation,
 the insurance forms prominently intend Epilepsy in its
 various  phases.   When Epilepsy  is clearly present,
 whatever its  degree or frequency of manifestation, it
 utterly disqualifies.   Not  that  it necessarily shortens
 life per se, but because  even without  this usual result
 it may impair the mental  faculties, or dispose to acci-
 dents, which  essentially impair the risk.   The epilepti-
 form  convulsions  of  primary  dentition,  and  the
 changes incident to that epoch, if  they have  not man-
 ifested a  disposition to return, or  injured the  mental
 faculties,  or  involved  paralyses,  in later  life  do not
 disqualify.   The irregular muscular  contractions  of
 simple Hysteria, unless connected with organic dis-
 ease,  or general  cachexia, do not prevent  acceptance.
 Males of nervous temperament sometimes  manifest
 symptoms very  like those  of Hysteria with  its queer
 symptoms—such cases should be carefully investigated,
 but  these symptoms  do  not  necessarily  disqualify.
 Youths of both sexes  about  and after the  age  of
 puberty for several years may  exhibit mild or severe
 epileptiform  symptoms, or even  decided periodical
 convulsions,  yet  if  these  either  spontaneously,  or
 under treatment subside, it may be laid down as a rule
 that  if after several years  they do  not recur, the risk
 is a good one.   The age of twenty-five  in the male,
 and  twenty-three  in  the female may  be  considered
critical in this regard. 
                         25
   Chorea,  in  all  particulars,  may  be regarded  as
identical  with the  (Cfits," of the formulary,  so far
as  its  pathology  and  influence  upon longevity  is
concerned.
   Gout,  of chronic character, and  particularly, if in
any degree  hereditary,  disqualifies.   But  it does not
follow that  all sore toes are  gouty.   Analysis of in-
dividual cases is  indispensable.   The  habits of  life,
and surroundings,  will attract  the  attention of the
examiner.    The   Dyspepsia  and   general  malaise
discoverable by examination  are of more significance
to the cautious medical  agent of the Company.
   Insanity  does  not  always  tend to  shorten life
directly, but  if present disqualifies  on account, first,
of  disease of central nervous organs  which it indi-
cates : and, second,  because of the greater liability  to
accidental  death which the withdrawal of  healthful
reason involves.   It is to be distinguished from the
delirium of temporary  disease, and  from mere eccen-
tricity.   Malarious diseases are not infrequently fol-
lowed  by an interval  of insanity,  sometimes of the
most active character,  and yet which  recovered from
tends  not  an hour to  shorten  life.    Of this the
writer's personal experience has given him abundant
evidences.     Such  cases  need  not  necessarily  be
rejected.  The  puerperal state  often,  also, involves
this condition with similar prognosis ; but  if puer-
peral insanity have occurred, it is better not to insure
unless the grand climacteric has been passed.   Hered-
itary insanity, and a single attack in  the  individual,
or marked proclivity thereto, or where it is as evident 
26
in the family  connection as other hereditary diseases
adverted to should  reject.   The well balanced mind
cannot contemplate suicide without  horror,  but the
evidences  are abundant  that oftentimes murder  and
suicide may be the only manifestations of the hered-
itary  taint of  insanity, and,  therefore, although preg-
nant  signs of mania in  any of its forms  may be
absent, and  general good  health apparent,  the  risk
should nevertheless, in  such xases, be declined.   Yet
justice to  applicants  requires, when  insanity is men-
tioned as having occurred in the connection, that the
particulars of the case be inquired into.   It may occur
that the instance  was one from  some incidental, and
not hereditary cause.   It may have arisen from local
injury, from septic poisoning  of the  blood,  or,  per-
haps,   have been  merely  senile  mental decay,   etc.,
in either instance, not invalidating  the risk.    Other
things being equal, the actual presence of insanity will
lessen the chances of longevity to one-fifth or one-sixth
the. healthy standard.
   Liver  Complaint. — Hepatic diseases are  to be
looked for in  those who are, or have been residents of
malarious  districts;  in  spirit drinkers; and  those of
the technical bilious temperament,  i. Enlargement of
the liver, if from portal  venous congestion, may not in-
validate the risk ;  if from hepatic venous congestion,  it is
a sign of disease pregnant with danger, and while pres-
ent should absolutely reject.   The hobnail or drunk-
ards'  liver (cirrhosis) should reject.  As an  isolated
symptom, the contracted or small liver  is more  sus-
picious  than  the enlarged  one.   Persistent hepatic 
                         27
disorder,  points  prominently  to  tuberculosis, fatty
degeneration,  cirrhosis,  or malignant  diseases, either
of which will disqualify.   Adjacent tumors ma)*, more
or less, permanently, obstruct the passage of bile, or
directly  interfere with  the action  of the organ.   Of
course, these should reject.  Abscesses present reject;
but, if formerly  existent,  and now  fully  recovered
from, are to be judged of  from their causes and effect
upon the system.  The abscess,  from local or acci-
dental  cause,  has less  significance than that from
pyaemia;  the latter than that from  abnormal deposit,
as of tubercle, cancer, etc.  Recurring abscesses  dis-
qualify, whatever the cause.  A tendency to the forma-
tion of gall-stones, with ileus or jaundice,  if recurrent,
should be an  obstacle to approval.
   Jaundice,  while present, postpones acceptance.   If
dependent on hepatic venous congestion, it rejects.   If
it depended simply on portal congestion, as occuring in
malarial  or other fevers,  it is comparatively  trivial.
Observe,  it  is only  a symptom,  and its  real meaning
necessitates examination and judgment.   Thus it may
appear as a consequence of a catarrhal condition of the
bile ducts ; or as the result of  impaction of gall-stone,
or the  mechanical pressure of tumors ;  faecal accumula-
tions in the  colon;  from lumbricoid worms in the
common duct, etc.  Or it may be an evidence of  ma-
lignant degeneration, or of permanent organic disease,
as  tuberculous, fibroid, fatty or amyloid  degeneration,
etc.   From the  largely more frequent causes of  this
symptom being temporary, and not permanent in ope-
ration, the isolated symptom may  be considered as 
28
suggestive of investigation, and  not as a reason, by
itself for rejection.
   Paralysis, whether  simply local,  paraplegic,  or
hemiplegic, demands the most scrupulous examination.
Hemiplegia or paraplegia, if present, totally disqualify.
But if formerly present, as clearly  the result of some
merely  temporarily acting cause, and  this cause has
been  entirely removed, e. g. infantile neurosis, acci-
dental lesion, hysteria, etc.,  it may be  passed over.
When combined with cardiac disease, or the apoplectic
diathesis, even  though there  be  apparent health,  it
should  reject.   The import of the  local cause is the
important point of inquiry.  Local paralysis may  oc-
cur from local injury,  local tumor, or similar cause,
and  not disqualify.  When present, and not clearly
explicable as the result of a removable or innoxious
local cause,  it should reject.
   Palpitation  of the heart is a symptom of little sig-
nificance.  Always noted among the list of symptoms
about which  the patient is  questioned,  it really is oT
no importance, save as directing  attention toward or-
ganic disease of the heart,  or toward dyspepsia or dis-
orders of innervation.  Taken by itself, it is a symptom
which  attracts attention  to  its  possible cause, but
neither  accepts nor rejects.
   Quinsy, or Tonsillitis.   This local affection is prin-
cipally important as one of the evidences of the tuber-
culous diathesis.   It is  capable, it  is true, of producing
death by mechanical occlusion of  the respiratory pas-
sages, but this is so rare an accident that, practically,
it  may be neglected in  calculating the chances of the 
                         29 .
risk.   The same remark  may  be made  as  with refer-
ence to the danger of lancing the swollen tonsils.   By
this little operation, branches of the carotid artery  may
be wounded, and death result, just as death may result
from choking while  eating.   But when  the party  ad-
mits being subject to this difficulty, local examination
should be made with the tongue spatula, or better still,
the laryngoscope.
   Rheumatism.—Frequent and  aggravated  attacks
of rheumatism, even though important internal organs
may not  have  been previously involved, should dis-
qualify.   Hereditary  rheumatism impairs the risk.
It is a  disease, so far as danger is concerned, character-
ized by  its tendency  to  affect particularly the white
fibrous tissues.  Thus, the  cardiac valves, the  pericar-
dium,  the  dura mater,  etc.,  become  liable  to  fatal
change.  Uric  and sulphuric acids are largely abundant
in the  secretions, and  the blood becomes abnormally
fibrinous.  The real danger of this diathesis is, in the
first place, from acute changes  which  may  involve
speedy dissolution,  or from deposits which necessitate
grave  organic disease which may, later, cause sudden
or gradual  death.   It is capable  also of so exhausting
the blood  itself, as  to  render the risk a bad  one,
irrespective of  organic change.
   In judging of the effects of the organic diathesis,
the atmospheric vicissitudes, and the habits of life of
the party must be noted ; next, the ordinary condition
of  the skin and kidneys ;   then,  most assiduously, the
irritability,  or  actual  organic  change  of the heart
structures;  then, the continuance and frequency of
return  of the symptoms. 
                         3°
   Most patients when questioned with regard to,the
presence of rheumatism, will  refer to occasional pains
in the muscles, or  stiffness in the joints, of  a quasi
rheumfttic  character, as  being true rheumatism;  the
Examiner  must observe  that  these are not  intended
by the question, else, no  person could  be considered
as exempt.  Acute rheumatism, or a decidedly rheu-
matic  diathesis, is what  is to be  looked after.   A
single  attack of even inflammatory rheumatism may
not disqualify, although it may have been severe.  But
if metastatic, it should militate against the risk.   If
recurrent, as well as metastatic, it should reject.  If the
case has been progressive, and without being metastatic,
has passed on  from point  to point, and ultimately
involved the heart,  the  insurance prognosis is more
grave than  in  case of  mere  temporary  metastasis.
Mere thickening of fasciae or  stiffening of the joints
from  long previous, but not  recurrent  rheumatism,
need not impair the  risk—neither  lumbago, nor even,
so-called, sciatica of a clearly chronic rheumatic origin ;
but when local  paralyses, or temporary or permanent
symptoms of apoplexy have resulted, the risk should be
rejected.   Coagula may be condensed on the roughened
cardiac surfaces, and their  detachment from time  to
time determine local paralysis, apoplexiae or even mor-
tification, to the extreme astonishment  of the  superfi-
cially informed.
  Chronic  Catarrhal Affections—sometimes paroxys-
mal  in character,  are often of  rheumatic or gouty
origin, so  also, sclerotitis  and even  meningitis and
maniacal delirium.   The quasi rheumatism of mala-
rious districts requires particular  examination,  and so 
                         31
 also, those varieties  resulting  from  gonorrhoea and
 syphilis — each of which may puzzle the practitioner,
 but must be isolated  to judge of its influence upon
 longevity.
   Metastatic rheumatism rejects;  syphilitic rheuma-
 tism rejects;  especially does  recurrent rheumatism of
 hereditary character reject; chronic sciatica of intense
 character rejects — so  also, does severe  lumbago, tic
 doloureux, etc.    Whenever rheumatism  is  acute or
 chronic,  long  continued,  recurrent,  hereditary or
 accompanied with cachexia,  the insurance  company
 must have the benefit  of the doubt which naturally
 arises, and the party be declined.
   Rheumatism is liable to be confounded in diagnosis
 with erysipelas, gout, trichinous disease and neuralgia ;
 especially is  it  liable to be mistaken  for phthisis,
 pleurisy,  etc., when occurring in the  intercostal  mus-
 cles.   Scorbutic pains are very  liable to  be mistaken
 for chronic rheumatism.  In  prognosis, not more than
 one or two  per cent, prove fatal, directly or remotely,
and half of these  of the latter result.  At the present
time, from improved methods of treatment, it may be
confidently asserted that the disease has been robbed of
half of its individual terror, and in its  insurance,
 direct  or  remote,  prognosis, of three-quarters of its
 significance.
   Rupture.— The frequency of Hernia in its differ-
ent forms, and its  inherently dangerous nature, renders
this  point one  never  to be  overlooked.   Accordino-
to the  mosf general statistics, hernia is to be found in
an average of one  to every fifteen of the adult popula-
tion.   It  is about fourteen   times  more  frequent in 
                          32
 males than females, although  in the  latter it  is more
 dangerous, as they are more subject to the crural form,
 and again, because from motives of  delicacy,  they do
 not as early apply  for  relief.   Hernia  progressively
 diminishes  in frequency  from  birth till  puberty, and
 then progressingly increases with advancing age.  Viz :
 First year— i in 21 ;  second  year— 1  in 29 ;  third
 year—1 in 37 ;  until at  the thirteenth year it falls to
 1 in 77.   Shortly after this, its frequency rises again ;
 thus, at the twenty-first year there is  1 case in  32 ; at
 the twenty-eighth year — 1 in 21 ;  at the thirty-fifth
 year— 1 in 17 ;  at the fortieth year— 1 in 9 ;  at the
 fiftieth year—1  in 6;  from sixty to seventy  years 1
 in 4;  from seventy to  seventy-five years—1  in 3.
 In women it occurs most frequently  during  the child
 bearing years.   Umbilical  and  direct hernia  are less
 dangerous  than the inguinal  or crural  forms;  the
 latter more so than the inguinal.  The  irreducible is
 more objectionable  than the reducible;  and  always,
where  a truss, of suitable construction fails to prevent
descent of the intestine, the risk  should  be rejected.
 Cases  of double  hernia  should always  be  rejected.
 Observe—Occasionally  parties  suppose  they  have
hernia, when there is simply an enlarged  gland, or a
fatty tumor,  retained testis, hydrocele, etc.   Accuracy
of diagnosis  is here indispensable to protect the rights
both  of the company  and the applicant.   Hernia,
whether  single or double, which  has been  operated
upon and apparently cured, it should  be  remembered,
is  liable to  recur on gradual absorption of the new
formation.  This fact will have weight  in  properly
 classifying the risk. 
                         33
  Scarlet Fever.— The larger  proportion of cases
of  scarlatina  occur before the  insurable age.   When
it  occurs in  the adult, its secondary results demand
most cautious examination.  These not rarely involve
breaking  down  of the constitution, or  serious local
organic changes, which imperil  the risk,  and this, al-
though the primary attack may have been  apparently
mild.   Taking  all the cases together, the  mortality
from scarlatina  is  scarcely exceeded  by that of any
other  single  form  of  disease.   Consumption and
typhoid fever, (including typhus,) only outrank it in
fatality.   It  is said to be even more fatal in Europe
than in this country.   Fatal as  it is in the onset,  the
medical examiner  has more to do with its subsequent
ravages  upon  the system; and  these,  it  is  found,
principally depend  on  primary  obstructions  to  the
functional action  of  the  kidneys.   Hence, uraemia,
albuminuria,  anasarca,  dropsy, etc.   Again, its local
affection of the eustachian tube, and ear may ultimate
in   destructive caries  of  the  bones, and  eventually
prove  fatal by  lesion of  the  brain.  Thus a chronic
ottorrhcea, originating from this cause, militates against
the risk,  although  it may not alone  positively reject.
Of course albuminuria, etc., reject.   If  the party has
had scarlet fever and  fully recovered from it, the risk
is  improved thereby.  Many of the  Continental Eu-
ropeans reply to  the examiner that they  have had
scarlet  fever, or  that some of their  family  have died
of  it, when on  careful questioning,  it  will  be found
that " maculated  typhus"  is  the  disease  intended.
       3 
                        34
Again, many cases of slight roseolar eruption are con-
founded with it.  Such cases  render it  necessary for
interrogation to  be minute and  exact  in all  doubtful
instances.
   Spitting of  Blood.— Unexplained  Hemoptysis  is
one  of  the  most pitilessly exclusive of  historical
symptoms.   Primarily, because it is one of the earliest
precursors of phthisis, and,  again, because it tokens its
actual  existence.  So large  is the proportion of those
exhibiting  this symptom whose  lives, sooner or later,
terminate by  consumption, that it is  unnecessary to
argue  from recorded experience, or  to  appeal to the
abundant statistics which have accumulated.   Absence
of the tubercular taint  in  the family history,  or of
concurrent signs in the individual, will not explain  it
away.  Absence of physical signs are scarcely more to
be regarded, under such  circumstances, than  those of
the rational sort.   The proof must be positive that
the spitting of blood came from other cause  than in-
cipient or present tuberculosis of the lungs.   Negative
evidences  are in no case sufficient.    It must be proved that
the blood came from the gums, the nares, the pharynx,
the oesophagus or stomach.   Or  it  must be proved that
it came from the accidentally abraded  larynx, trachea
or bronchi; or that  it depended solely on mechanical
or surgical injury of the vesicular lung structure ;  or
that  it depended solely  on vicarious  causes.   Dr.
Aitken emphatically observes :   " Cases are  recorded
of its so-called idiopathic occurrence, as from variations
(suddenly) of atmospheric  pressure, ascending high
mountains,  or descending  in  diving   bells,  violent 
                          35
 straining efforts, or from  plethora ;  but in such cases,
 according to the  experience  of Drs. Fuller, Walshe
 and others,  'there is usually some  latent mischief in
 the chest — some local  cause of pulmonary conges-
 tion— some mechanical interference with the capillary
 circulation through the lungs.''   Finally—we observe
 that it may depend upon disease of the heart, especially
 with  mitral  regurgitation;   upon  aneurism; upon
 intra-thoracic tumors, either malignant  or non-malig-
 nant;  or upon non-tubercular abscesses.  But, in either
 case, it rejects as decidedly as though dependent on
 tuberculosis.
   Hamatemesis,  a  symptom  often confounded  with
 haemoptysis, is of  vastly less significance, nevertheless
 requires, from its occasionally dangerous origin,  very
 careful inquiry as  to its real cause.   The  blood  may
 have come, from the nares, the throat or the lungs,  have
 been swallowed and vomited.  It may have come from
 aneurism above  or below the  stomach, from  ma-
 lignant or non-malignant gastric  ulcer ;  occasionally
 as  the  result of severe gastritis ;  again as  vicarious
 of  menstrual or other discharges. In the vast majority
 of cases it occurs as the result of the local congestions
 of  malarious diseases, or  from scorbutus or purpura.
 The decomposed  blood, or coffee-grounds vomit of
 yellow fever, etc., need hardly be alluded to.
   Diseases  of  the Urinary Organs.— Under,this
 euphemistic  designation are intended—nephritis, neph-
 ralgia,  cystitis, stone in  the bladder, diabetes, haema-
 turia,  albuminuria or  Bright's disease,  prostatitis,
 spermatorrhoea, gonorrhoea, stricture,  urinary fistula,
syphilis,  or  other organic or constitutional  diseases 
                          36
 involving the urinary organs, primarily or secondarily.
 The question  is  last but not  least.   The obscurities
 of diagnosis and  prognosis are more frequently hidden
 here than in any other part of the animal frame work,
 and coincidently,  here, the acuteness of the medical ex-
 aminer will be taxed  even more than  in the minutely
 studied and carefully described changes of  the thoracic
 viscera.   For the physical signs are clear to the mode-
 rately educated perceptive faculties, whilst  both physi-
 cal and rational  signs exhaust the skill  of diagnosis
 when  the  renal   and subsidiary organs come under
 view.   Chronic nephritis rejects, and  so also,  chronic
 nephralgia, whatever their causes.   Cystitis, if present,
 rejects, whether  acute or chronic.   Calculus rejects;
 but  the previous  passage of  a small  concretion  may
 not disqualify, unless the diathesis be strongly marked,
 and the evidences be strengthened by  hereditary pre-
 disposition.  Diabetes necessarily rejects, but doubtful
 cases should  be analyzed.   Albuminuria,   or  Bright's
disease  in   any  of   its  forms,  absolutely  rejects.
 Observe — that organic disease of the  kidneys  may be
present without  albuminuria,  and albuminuria  may
occur  without renal  organic  change,  but either, if
present,  reject.   Prostatitis,  or the prostatic enlarge-
ment of old age,  if sufficient to  materially interfere
with the extrusion of  urine,  must  reject.   Spermator-
rhea,  so-called, is usually  merely  a  catarrh  of the
urinary mucous membrane, analogous to the leuchor-
rhoea of females, and of trivial importance.    It is
usually an evidence either of  mere dyspeptic derange-
ment,  or of improper medication.   Notwithstanding
the stress laid upon it by many authorities, it is safe 
                         37
to say that, in at least nineteen cases out of twenty,  it
in no wise invalidates the risk.   True spermatorrhoea
will manifest itself in connection with other symptoms
involving  the  constitution  as a whole, which will re-
quire no reference  to this as  necessary  to  sustain an
opinion.   Taken as  a symptom, isolated, it is of  as
little  importance  as  a nasal catarrh.   The  previous
occurence  of Gonorrhea  is  mainly of  importance
because its old  time  treatment, by balsamic and other
highly irritant remedies, may have laid the foundations
Bright's disease ; or because  it  may have been followed
by septic poisoning of the blood, involving gonorrhceal
rheumatism, etc.   This latter is capable of producing
organic diseases, of  equal importance with  those  of
rheumatism  from the  usually  more  noted  causes.
Stricture, whether the result of gonorrhoea or acciden-
tal causes,  requires attention.   Is it spasmodic or per-
manent ?   Is it permeable or impermeable ?   Is it the
result of merely a  local  or of  a remote cause ?  It is
often  times symptomatic of renal  or vesical  organic
disease, and these disqualify.   If  trivial,  although
troublesome,  it is  of less importance.   If it  require
Syme's, or  other  severe operation  for  its relief, the
insurance should  Se postponed.   A similar  remark
may be made  of  urinary  fistula.   Let  it  be cured,
whatever  its cause, before insurance.  All  malignant
diseases of the organs of  course  reject.   In all cases
of renal or  urinary  disease, once more,  examine the
heart.
   Syphilis.—In all cases  where secondary or tertiary
syphilis is clearly present the risk should be postponed.
This  disease  is usually capable of perfect cure.   In 
                         38.
badly managed or cachectic cases it becomes dangerous
to longevity.   At the present time  it  is better man-
aged, and  the  chances of perfect recovery are better
than  heretofore.  But the rule  is  imperative—when
present, reject.   Observe, historically,  the  distinction
between the merely local sore, (however extensive its
ravages) the chancroid, and the true infecting chancre—
the latter only  of insurance  import.   The best  dis-
posed party applying for insurance will perhaps deny
its  previous  occurrence,  and there may be no signs
superficially  to be  observed.   And  yet  it  is  easy
for  the   moderately  instructed examiner,   in   the
majority of instances, to satisfy  himself of the  facts.
Nevertheless, the present writer admits the  loss of one
risk for which he was examiner, by giving credit to the
party's  own  statement  and  innocent  countenance.
Many cases of reported consumption, for whose  de-
mise the examiner is held  professionally responsible,
are in fact, syphilitic decline and ultimate decay.    But
the examiner must guard himself against  such disas-
trous result by stern disregard of appearances.   This
he can do without  violating any of the  proprieties.
Observe  whether  there  are any  traces of cutaneous
eruption—whether there is or  has  been  alopecia—
whether there is emaciation, or other signs of depraved
nutrition,  onychia, enlarged post-cervical glands, iritis,
catarrh,white patches or  tubercles, or cicatrices about
the mucous membrane of the mouth, tongue or throat;
whether there are nodes, or  have been  pains in the
bones.  If possible, (perhaps under excuse of exam-
ining for  hernia),  examine for  the  significant  indu-
ration of  the  inguinal  glands.   Indeed when  the 
                         39
attention is directed eo the matter, it does not require
much tact or  sagacity to  make up one's mind  safely.
Fortunately doubtful cases are overrated in importance.
It is  perhaps  necessary  to call the attention  of the
examiner to the general  physiognomy of urino-genital
diseases, which is almost too unmistakable for the ex-
pert ever to be deceived in— but for the inexperienced
it is proper to say that it  is  both  capable of observa-
tion and indescribable.

                       XII.

   Has the Party had Inflammatory Rheumatism?
   The repetition of this  question  by several compa-
nies in  their  forms, attests  the  great  importance
attached to  its satisfactory answer.   But sufficient has
been written upon this point upon p. 29. et seq.

                XIII.  & XIV.
   Subject to  Dyspepsia, Dysentery  or Diarrhcea ?
  A perfect state  of health of the alimentary canal
and its  subsidiary organs is, of course,  necessary in
order that there should  be  perfect nutrition  of all
parts  of  the body.  Temporary disturbances may
arise from temporarily acting causes and yet not inval-
idate the risk ;  but frequently  recurring, or persistent
disorder,  whatever the cause,  throws  doubt upon it,
and then the case must be carefully diagnosed.
   Dyspepsia is primarily noteworthy because it  is  one
of the initiatory symptoms of the tubercular diathesis. 
                         4o
 Or it may evidence organic malignant or non-malig-
 nant  disease of the stomach.   It may be sympathetic
 of cerebral or renal, of uterine or spinal affection of
 more or less serious character.  In the larger propor-
 tion of instances it indicates merely a catarrhal condi-
 tion of the gastric mucous membrane, or slight  dis-
 turbance of the hepatic functions.   But whatever its
 cause, duration or severity, whenever present, it should
 receive ample consideration.
  Dysentery, when present, rejects, and  if the party is
 subject  to  its recurrence, enquiry  must  be  made as
 to its cause and origin.   Chronic colitis or  entero-
 colitis reject.   But many cases of supposed dysentery
 depend  solely on haemorrhoids, local, curable ulcera-
 tion,  or morbid growths about the rectum. Neverthe-
 less it is safe to say that tenesmus, discharges of blood
 and  pus,  especially with occasional  febrile  heat  and
 emaciation, should reject.  The condition of the liver
 in such  cases, should be carefully observed.
  Diarrhoea  is a  term  relative  to the habits  of  the
 individual.   It does not refer so much to the frequen-
 cy as  to the  character of the discharges.   Occasional
attacks of  acute diarrhoea may occur in the  very  best
risks.   Such cases point to  an examination  into  the
habits of the party, whether of eating,  drinking or ex-
posure  to  vicissitudes of  temperature, moisture or
exercise.   Ill regulated diet,  imperfect  mastication,
improper quality of food, irregular hours, and intem-
perance  of  drink,  are among  the   most  frequent
causes,— but some form of enteritis, hepatic derange-
ment, or disease  of the glandular organs, subsidiary to 
                         4i
the  digestive  apparatus,— Bright's disease,— ochlesis
malaria, with other agencies are capable  of produc-
ing the same result.  The votary of opium or alcoholic
stimulants is scarcely ever  free from this  symptom.
In returned  soldiers, or those addicted to vegetarian
theories, it is frequently the result of scorbutus.  When
there is emaciation, a  despondent  countenance, dark
circles around  sunken eyes,  a sallow, leaden or sodden
skin, a  sunken abdomen,  a red and pointed, or a loose,
pale and flabby tongue,— an undue indifference, or an
augmented irritability of the nervous system, look out
for diarrhea and its cause.

                         XV.
   Habitual  Cough ?  The significance  of an habit-
ual cough in  life  insurance  examinations  depends
wholly  on  its cause; but if admitted, it requires criti-
cal examination.   It may depend on local causes in the
pharynx, larynx,  trachea,  bronchia,  or  pulmonary pa-
renchyma.   It may arise from cardiac, hepatic, gastric,
intestinal or  spinal disease.  It maybe a mere morbid
habit of the nerves and muscles involved in  the act.
Primarily,  it demands physical diagnosis of the condi-
tion  of the lung  tissue, especially at the apices of the
lobes,—together with a rational account of the history
and  diathesis.   Taken  as  a  mere symptom,  Dr.
Hartshorne's statement is as brief and satisfactory as
any which  can be given, viz:
   Cough is dry and hollow,  or  hacking, when  nervous  or
sympathetic.
   Dry and tight in early bronchitis ;
   Soft, deep and loose, in advanced bronchitis ;
   Hacking, in incipient phthisis pulmonalis ; 
                         42
   Deep and distressing in confirmed consumption ;
   Short and sharp in pneumonia;
   Barking and hoarse in early or spasmodic croup ;
   Whistling in advanced membranous croup ;
   Paroxysmal and whooping in pertussis [and asthma.]
   It  is  needless to  advert  to  the character  of the
expectoration, as that will at once command the  atten-
tion of the practitioner.   It may  be mucous, purulent,
rusty,  bloody and muco-purulent,  nummular and  heavy,
putrid, etc., etc.,   each case giving its distinctive infor-
mation of value to the examiner.

                       XVI.

   Mechanical or Surgical Injury ?  Any wound,
however  trivial,  makes its own demand on the  powers
of  life.   The amputation of an arm or limb, suggests
inquiry as to the  reason  for  the  operation.  Tuber-
culous deposit, malignant disease, caries and  necrosis,
requiring surgical  interference, clearly invalidate the
risk ; whereas mere mechanical injuries, as causes, may
not materially impair  it.   Caries, or  even  necrosis,
from acute periostitis  or external  injury, even though
ultimately requiring exsection  or amputation, are, by
no means, as serious objections to the risk as exostosis,
enchondroma, osteo-sarcoma, cachectic deposit and the
like.   Statistics  are wanting upon  this  point, but the
writer's general judgment, from reading and  observa-
tion, is, that the  so-called capital operations, although
recovered from,  apparently, to a certain extent  impair
the desirability of the risk.   Individual  cases,  it  is
true, may lend color  to a different  opinion, yet the
stern  proposition remains, that great injuries  to the 
                         43
system, whether accidental or surgical, tend  largely to
exhaust the original powers of life and,  pro  tanto, im-
pair the insurance expectation.  In  the case where a
limb  has  been amputated after a long continued dis-
charge, which has  become habitual, although exhaust-
ing to the system, this remark is especially  of impor-
tance.   Apoplexies, paralyses  and  various  organic
affections  are not  unlikely to  supervene.    The  old
ulcer  " cured,"  may involve new and unexpected dis-
ease.   Any  serious mechanical  or  surgical injury, un-
explained— with no positive evidences to the contrary,
lessens  the  desirability of the risk.   Long  continued
confinement in the recumbent  position,  of itself, pre-
disposes to disease; and indeed  any injury, which,
although not  severe in itself,  has necessitated sedenta-
ry  habits,  with deficient air, exercise, etc.,  will  leave
traces of its deleterious influence on  special  organs or
the general  system.

                      XVII.
  Severe Personal Injury  or Disease within the
last  Seven Years ?  This query is  based  on  the
general idea that if more than seven years have elapsed
the results of previous  disease are little liable  to  be
developed,   The  popular opinion founded, as usual,
upon an antique professional idea, is that the whole body
is changed in  its  constitution every seven years.   The
instructed examiner needs not to be  informed that all
the moving and acting parts are changed in constitution
within a space of  time scarcely exceeding, if reaching,
the third of a year.  The practical rule, however,  re-
mains,  recent diseases require more careful scrutiny 
                         44
 as to their results than those which occurred long pre-
 vious.   Some  companies  under  this  head  require
 details as to the character of the disease, and a reference
 to the attending physician.  The latter  point will be
 alluded to further along in this essay.   The former
 will  suggest, at once,  to the intelligent examiner, the
 vast differences of degree and danger, of immediate or re-
 mote disastrous consequences, which may obtain in dis-
eases which, for nosological purposes, receive the same
name.  Whatever the name, the practical fact remains
that no disease is the product of a single cause, and vary-
ing with the multiplicity of influences acting upon dif-
ferent persons—will be the result, immediate or remote,
of any single cause which may give the present affection
its scientific appellation.  Some organizations sustain
and oppose the specific causes of certain  diseases with
little derangement even of functional action — others
manifest  the evidences — the   gravest  evidences, of
organic and perhaps ultimately fatal change.

                     XVIII.
  Longevity of Ancestors ?   In the United States,
such  is the character  of the population, this  question
can,   in the majority  of instances, be answered  only
with reference to the grandparents.   Yet the traditions
of families, in the absence of registration statistics are
worth something.   The descendants of certain families
are notably long-lived, and of others short-lived.  Co-
 incident with this fact will be found certain hereditary
tendencies to disease.   The family record, if tolerably
complete and reliable,  is of the  highest insurance im-
portance.   It is well  known that hereditary  diseases 
                         45
 not infrequently  pass  over one  generation to appear
 in  the  next, or subsequent  generations.  The shape,
 capacity,  and mode  of action  of internal organs  are
 determined by the  parentage, with as much constancy
 as the external likeness.   These likenesses determine
 particular proclivities to intimate textural change, with
 the results of such change.   Nations and tribes,  clans
 and families have their marked peculiarities of external
 likeness, with almost identical tendencies toward death.
 This is especially true  in  the older countries, where
 rank, caste, and custom  keep up the usage of inter-
 marriage.   It is  of perhaps less importance in  the
 United States, where these distinctions are only tem-
 porarily recognized.     Nevertheless the observation
 of three generations, conduces much to correctness of
 judgement in any  case  under  examination.   If  the
 grandparents on both paternal and maternal sides have
 reached old age the risk is more desirable.  Longevity
 of grandparents on the maternal side is to be preferred
 to  that on the paternal  side.  In either instance, if
 possible,  the cause of the death of the grandparents
 should  be noted.    If  either of them was affected  by
 phthisis, or tuberculosis  in any of its forms; by apo-
 plexy or paralysis, by rheumatism or gout; by organic
 disease  of the heart, Bright's disease, cancer, insanity
 or epilepsy ; by syphilis, or other  transmissible disease,
 the risk must be most carefully  investigated.   Mean-
 while it should be recollected that change of location,
 intermarriage and  habits, etc., are capable, under  the
 guidance of  the  present developed  principles of hy-
giene,  of almost  entirely controlling or  obviating 
                         46
 the hereditary tendency.  All causes of disease thor-
 oughly understood may, not only  be robbed  of their
 pernicious  tendency but, be  rendered subservient to
 the increased longevity of the race.  It is to be recol-
 lected that  progressive improvements in hygiene  and
 medical science, as a whole, have largely increased the
 relative duration of human life, and that the longevity
 of our grandparents  may, ceteris paribus, be well sur-
 passed by this generation, and this still further increased
 by the next, by approximation to recognition of  the
 great laws of health as now understood.

                      XIX.

   Parents  Living or Dead—Present  Health  or
 Cause of Death, respectively.— As previously  re-
 marked, hereditary  predispositions  require at least
 three  generations  for their satisfactory elucidation.
 But as one of these, and  strongly  influencing the  re-
 sult of observation,  the peculiarities of parents should
 be studied.   " When one only of the parents is  the
 victim of constitutional  disease, the  tendency  to sim-
 ilar constitutional diseases is most obviously  expressed
 in those children  who most resemble that  parent in
 physical conformation and appearance, and it has been
 observed that, when  both parents suffer, the tendency
 will sometimes be  expressed more often in the  daugh-
 ters of the family  than in the  sons, or more often in
the sons than in the daughters." The organic peculiari-
ties, derived from the parent, will determine special and
peculiar results  from any accidental  exciting cause. 
                         47
But it should be recollected that the incidental occur-
rence of a family disease is less likely to be marked by
acute, prolonged, or  obstinate  symptoms than when
the same disease, nosologically, occurs in an individual
without such hereditary predisposition.  Nevertheless,
its  occurrence, whether severe or mild,  fully deter-
mines the hereditary  proclivity, and impairs the risk.
Family proclivities to disease are more strikingly man-
ifested in brothers and sisters than  between parents
and children.   The intermingling of  opposite tenden-
cies begets,  so to speak,  in the children,  a neutraliza-
tion  of the peculiar aptitudes to disease existing in the
parents respectively.    Physiological  likeness  of the
parents induces  imperfect  progeny, pro tanto,  just as
certainly as  intermarriage within the forbidden degrees
of consanguinity.  En passant, we remark, the offspring
of cousins,  etc., must be most  carefully examined,
prior to  any recommendation of the risk.  The ques-
tion involving any such relationship of parents should
never be omitted.
  Tuberculosis, carcinoma, and other malignant form-
ations, rheumatism, gout, insanity, paralysis, apoplexy,
syphilitic, renal and  cutaneous diseases, are especially
noteworthy  in this connection.
   In considering the influence of hereditary tendency
to disease, the remarks upon  p. 6, et seq., require  at-
tention.   // may have been outgrown, or not yet  arrived
at.   No sufficient  exciting cause may have  yet been
presented.   The individual may appear in high physi-
cal health, and yet  be on the brink of disease of the
most fatal kind. 
                         48
   It is fortunately the case that the medical science of
the present time looks largely more to individual ten-
dencies   towards   death,  and  suggests  prophylactic
hygienic measures, rather than engages in a wild pur-
suit of specifics  and mysteriously operating agents,
to do away with organic morbid changes already grown
unmanageable and incurable.
   The exact influence of hereditary tendency to dis-
ease can, probably, be never precisely estimated, be-
cause the vice of organization inherited will always
increase  the  mortality  from  other forms  of disease.
The latent predisposition  will manifest  itself in that
increased mortality.  Nearly  nine out  of ten  con-
sumptive patients will be  found,  on investigation, to
have  lost one or two  out  of the immediate  family
connexion by phthisis.
   A single instance in a  family  of a disease, usually
hereditary, need  not  invalidate the risk.  The party
is  thrown  on his own personality.   Both father and
mother   being  of consumptive  tendency,  the risk
should  be  declined.  But  either may have died  of
some accidental intercurrent disease or injury. Hence
the personal peculiarities  shonld  be ascertained.   The
mother  transmits disease more certainly than the father.
But the  likeness  of organization,  if it can be deter-
mined,  affords the best  method of general judgment.
When,  in addition to one, or both, of the parents, a
brother  or  sister has died  of an, usually, hereditary
disease, the risk should be declined.
   The  author repeats  his  carefully considered  and
matured conviction, from the evidences,  that brothers 
                        49
and sisters are more likely  to manifest hereditary pro-
clivities to disease than are  parents and children.  They
inherit respectively the  faults  and virtues,  as well
physical as mental, of each of the parents.   How far
these may counteract  each  other, and produce  a well
balanced  mental and  physical  organization, it  is  the
duty of the Medical Examiner cautiously to consider.
   In addition to general resemblance of external and
internal organization, it should be recollected,  mem-
bers of the same family  are  likely to  have acquired
similarity  of habits  of living, diet,  dress, exercise,
exposure, etc., which cannot  fail respectively to im-
press  upon  them   similar  tendencies to  health  or
disease.
   In this relation,  also, it  is  well to bear in mind the
physiological  fact  that half-brothers,  or half-sisters,
mav indicate  individual tendencies to organic change
which  may throw light  on the constitutional peculiari-
ties  of the  party  under  examination.  The second
husband may  not solely be  responsible for the organi-
zation of his  own  children.   This point, it must be
confessed,  is  one  surrounded  by obscurity, but the
indefatigable medical agent  of a life insurance society
may derive,  from  the most  unexpected   quarters,
evidences to guide him in forming an  unexceptionable
and reliable opinion.

                        xx.
   Family Physician.— The  Examiner should  never
neglect observance of this query.   First, that he may
have the testimony of  the  attendant  medical man as
       4 
                         5°
 to  any  peculiarities observed in  previous diseases.
 Clear-headed  medical men, in cases treated by them,
 gain cognizance, not only of present severe symptoms,
 but, what  is  of  more  importance, of the  tendencies
 towards a particular form of death.   Some physicians,
 and a great deal of cheap rhetoric has been expended
 upon this point, complain that insurance companies do
 not pay them for the information  conveyed in  their
 certificate.   This is simply absurd.  The family physi-
 cian is the friend of the party applying, and, it is fair
 to presume, has relations with the party not altogether
 of  the eleemosynary kind.  The trouble of filling out
 the certificate  is merely trivial, being  altogether his-
 torical in its nature.   Yet it  is of value — not solely
 to the company.   Doubtful  points may  be  thereby
 explained, and difficulties cleared up. The professional
 character of the physician, it  is needless to say, lends
 much of confidence  to  the examiner  in  making up
 his  opinion.   Aside from his  certificate, his attendance
 upon the party may lessen  (or increase)  the dangers
 of accidental disease.  One or  two companies  adver-
 tise a reduction of rates,  even  so much  as  ten per cent.,
 provided a particular species of family  "physician" is
 employed.   This would be startling to life companies,
 and examiners generally, were  it not  so  clearly an
 advertising  device — the expense  to be  defrayed by
 diminished dividends to the insured.

                      XXI.
  Intimate  Friend Referred  to. —There may  be cir-
cumstances affecting the  prospects of longevity which 
                         51
the applicant is either  ignorant  of, or wilfully with-
holds.   Thus,  habits  of intemperance are most  fre-
quently of all denied by the  party himself, and these
may be  made  known  by  his  acquaintances.   The
solicitor ought  not to neglect  inquiry upon this point,
and submit to the examiner the friend's certificate.
   Again, the applicant may have had "fits"—epileptic
or apoplectic seizure, etc., the real significance of which
may, for prudential  or  other reasons, have been with-
held from  his  knowledge.    For  these  and  similar
reasons, the corroborative evidence thus gained, should
be laid before the examiner.

                      XXII-

   Previous Rejection  or Assurance.—The fact  of
previous insurance should never be  permitted to lessen
the care of inspection.   The  previous examiner may
have been inexpert or careless, or  have inadvertently
overlooked some  important point.   Or, again, acute
or chronic, or even hereditary diseases, may have since
been developed, involving organic  changes of imme-
diate  or  remote  danger.  Previous  rejection demands
employment  of all the physician' s skill in diagnosis.
The real cause for  such  rejection should be discovered,
if possible.  It may have been in consequence of the
applicant's then habits, and some  other reason assigned
to  spare personal  feeling.  It  may  have been from
some temporary ailment  present, or  not  yet fully  re-
covered from.  It  may  have been from misapprehen-
sion of the applicant's  answers  on certain points, or
from  misinterpretation of symptoms  observed.   Or, 
                        52
again, because the company to which application was
made, excluded a particular class of cases which other
companies accept.   Or, by the baldest hypothesis, it
may have been from the human weakness of attempting
to 'gain credit for remarkable professional  skill and
acumen,  at a cheap rate.
   But when the  previous examiner and the attendant
circumstances are fully known, nothing but positive
demonstration will warrant  the medical man  in recom-
mending the  risk.  It  must be demonstrated that the
previous disease  is fully recovered  from;   that the
hereditary taint  is absent; that bad  habits  do not
exist; that the heart or lungs, or other organ blamed,
are respectively free  from  lesion.  Whilst a needless
rejection does permanent injustice to both  the appli-
cant and the company, every  medical  examiner must
avoid the imputation of making the company by whom
he is engaged, a hospital for invalid risks.

                    XXIII.

   Is the Applicant fully Aware of.the Purport of
the Questions he has Answered and Subscribed ?
He may be of limited  intelligence, or unfamiliar with
the language, the names of the diseases alluded  to,
etc.   The  solicitor  may have been careless  in  his
method,  and thus  periled  the  party's  subsequent
rights, as well as tending to mislead the examiner.
   Wherever  there is the slightest cause to  apprehend
any negligence or mistake  in this matter, the exam-
iner should  himself again propound  the  necessary
questions. 
THE  EXAMINATION.
   In  order that no point  may  be overlooked, the
Medical Examiner should adopt a regular method of
personal examination  of the  applicant —: the  form
adopted by the company for which he acts being care-
fully adhered  to, but, nevertheless, considered merely
as suggestive,  not exhaustive.   All  the considerations
noticed in the Applicant's personal  history,  must be
given full  weight in the proposition of  further ques-
tions, and  still more careful observation.  Although
not in accordance with  the usual mode of systematic
general  diagnosis, the  purposes  of this essay  will,
perhaps, be better subserved by adhering to the  more
generally adopted formulae furnished by the insurance
companies.

   Be sure  that the  person examined is the one whose
application has been read over.  Mistakes here  occa-
sionally occur, especially when parties  have the same
names,  or  several applications are received  at  once.
These  blunders  might  be deemed merely ludicrous,
were they not so important in their probable results.
                        S3 
54
                         I.
  Height and Weight. — Whilst the general propor-
tions  are, perhaps, of the most importance, yet  the
rule is, that the  medium  height is endowed with the
greatest  endurance.   Five  feet and  eight inches may
be  taken as  the medium in this  country, for  adult
males.   The  average  of adult  females  is, of course,
considerably below this — but  statistics are wanting
upon  the subject.   Probably five feet and one  and a
half inches is  the  approximately  correct  standard.
Emigrants from Continental Europe average a little
less than five feet six inches, if  we except certain  races,
as the Hungarians, Poles, and  Sclaves, who reach the
American standard.   Emigrants  from  the  British
Islands average about five feet seven  inches.
  In this country, the average height of persons bred
and living in large towns  and cities,  is something less
than that of those living in rural  districts, whilst  in
Europe,  the reverse is claimed to be the case.   This
fact is important, as to a certain extent  indicating the
general  hygienic influences which  have operated on
races, families, and,  ultimately, the individual.   The
better developed having been from a better nourished
stock, and physically superior lineage.
  Very tall men are usually of less  muscular power,
less respiratory  activity,  with  a greater tendency  to
cardiac and pulmonary diseases.  They are more liable
to  hernia, varicose veins, and  ulcers of an obstinate
kind upon the extremities.  Acute diseases attacking
them are more disposed  to  assume the  chronic  form,
with general breaking  down of  the constitution.   On 
                         \
                         55
the other hand, short persons are apt to be dispropor-
tionately developed ;  their  muscular  power, and ca-
pacity for physical endurance is small, and they become
the ready  victims  of acute, and  especially  epidemic
diseases.
   The relation of age to the  height ahould never be
overlooked, but this will  be alluded to a little further
along.
   The Weight is of moment, relatively to the height.
The simplest  statement of  the due relation is that of
Dr. Brinton :   "As a rule, it may be laid down that
an adult male, in good  health, 66 inches in stature,
ought to weigh rather more than ten stones, or 140
pounds avoirdupois.  And for every inch above and
below this height, we   may  respectively  add  and
subtract about five  pounds."
   Individuals may  present a wide range of variation
from  this; "But as a rule, twenty per cent., or one-
fifth,  is  almost the  maximum variation  within the
limits of health."
   The annexed table is introduced for convenience of
reference :
                         WEIGHT.         MEDIUM  CHEST.
                 Should weigh 120  fts      34-°6  inch.
" *	' 125 <	3513 "
ft f	' 130 *	35.70 «
tt t	135 '	' 36.26 "
t i .	' I4O '	36.83 «
tt t	H3 '	37.5O "
tt t	H5 '	38.16 »
tt t	' I48 «	38-53 "
tt t	' 155 '	39.IO "
it t	' l6o '	39.66 "
ft «	< l65 <	4O.23 "
t* *	< 170 '	' 4O.80 "
HEIGHT.
5	feet	1	inc
5	tt	2	tt
5	tt	3	tt
5	tt	4	ft
5	tt	5	tt
5	tt	6	tt
5	tt	7	tt
5	tt	8	tt
5	ft	9	tt
5	tt	10	tt
5	ft	11	tt
6	t'		
 
                         S*
   The  maximum  of  height  is usually  reached  at
twenty-five — the rate of progress  being about  ten
inches from eleven to  eighteen, and two inches only
from  that age  to maturity.   An  increment  much
surpassing this during the latter epoch is a suspicious
circumstance,  and  unless accompanied  by  apparent
coincident development of the  nutrient energy, and
correspondent increase of weight, impairs the risk.
   Excessive  obesity at any  period vitiates the risk,
and particularly where it  has come on within a com-
paratively  brief period.  After  the  age of complete
maturity, usually,  there is a  deposit of adipose tissue
which largely  increases  the relative proportion of the
weight to the  height; and if this occurs gradually and
if clearly traceable to  hereditary  peculiarity it  does
not disparage  the risk.   But the rapid occurrence of
corpulence points  almost  infallibly to deterioration of
nutrition,  the result of, it may be,  newly formed
sedentary habits, intemperance, internal organic disease,
or  that  general  cachexia  which  accompanies  fatty
degenerations.
   On the other hand emaciation slow and progressive
after middle life, if clearly a family characteristic does
not necessarily  disqualify, although  it demands close
investigation.  Rapid emaciation, even without apparent
organic cause, rejects.
   Incidentally it may be remarked, that  measurement
of the  chest will  afford an  index of the relative pro-
portions of the height and weight.  The rule suggested
by Brent  is  sufficiently  exact.   Measured over the
nipples: 
                         57
  Minimum chest: half of the stature, minus one-sixty-
first of the stature,  is equal  to  circumference of the
chest.
  Medium  chest:  half of the stature, plus one-fifteenth
of the  stature, is equal to circumference of the chest.
  Maximum chest: two-thirds of the stature is equal
to circumference of the chest.
  Irrespective of the height,  the general statement is
authorized that " the circumference of the chest  in-
creases exactly one inch for every ten pounds increase
of weight."
  If these proportions  are widely departed from, the
case requires  research as to the  cause of the unusual
deposit.
  So, also, local  emaciation suggests  similar caution.
Incipient^hthisis generally is  denoted by  wasting of
the tissues of the thorax and of the arms, long before
it is to be observed in the  face or lower extremities.
  At the  present time, when a large  proportion of
the adult males wishing to be insured  have recently
returned from the exposures of army life, it is well to
bear in mind  that  diminished weight is one  of  the
most significant  evidences of chronic,  and possibly,
painless diarhoea.

                        II.

  General Appearance. — The  proportionate  height
and weight with the  more or less  symmetrical develop-
ment of the  body, as a whole, make up a part of the
general appearance;  but beyond this the attention of
the examiner is to be directed to various details which 
                          58
 go to make up the tout  ensemble.   Among  these we
 specify :   Aspect  of the Countenance,  Complexion, Color
 of the Hair and Eyes, Size of the Bones, Contour of
 Muscles, Gait, Apparent Age, Temperament, Idiosyncrasy.
   Aspect of Countenance.—Experienced observers
 readily recognize  in diseases a physiognomy peculiar
 to each,  always  difficult and often impossible  satisfac-
 torily to describe, nevertheless so distinguishable as to
 be worthy of serious consideration in judging of a risk.
 By this observation they can ultimately decide, almost
 as quickly as an expert cashier upon the genuineness
 of a signature or bank note.   But  this acquired skill
 and  readiness never, when such  large interests are in
 issue, should be relied upon to the  exclusion of those
 rigid  tests by which the opinion may be solidified into
 an unassailable judgment.   We notice here a  few only
 of the more striking facts, as  indicating the  direction
 of observation.
   The aspect may inform  of tuberculous cachexia  by
 the delicate  skin,  tumid  upper  lip, long eyelashes,
 pearly conjunctiva, etc.  Or  it may denote  the can-
cerous diathesis by its sallow anaemic hue intermingled
with  muscular  markings,  indicating frequently recur-
 ring or continuous pain, or  of that organic pain of which
consciousness as yet takes  no note,  but which equally
calls into action the reflex sympathies of the  nervous
 apparatus.
   Hepatic disease, with its more or less yellow tinge
 and hypochondriacal look.  Or  renal affection, with-
 its  puffy eyelids, sodden or waxy skin, and  features
 either downcast or  stolid and apathetic. 
                         S9
   Hypertrophy of the heart, with its unnatural fulness
and congestion, or the same look from habitual intem-
perance.  Or the facial muscles may be permanently
contracted in forms which indicate the  continuous suf-
fering of wasting local or general disease.   Lesions
affecting  the  nervous  centres  may  find  here  their
earliest exponent.  The countenance, which  tranquil
shows no disorder, when wakened by  movement may
give  warning of  coming  paralysis.   Or the  furtive
glance from the eyes, notwithstanding immobility  of
the other features, may warn of impending insanity.
Or the rapid  transitions  in expression, flashing  or
wandering and unsteady eyes, may indicate a different
form  of the  same malady.  Or the whole face may  be
dull  and  listless, the eye  sluggish, and  the physiog-
nomy of softening  of the  brain be  almost beyond
mistake.
   Complexion, — This should be noticed as going to
make up the temperament hereafter to be considered.
But any peculiarities in hue which it may have derived
from  antecedent or present disease or exposure should
be noted, whether rendered  sallow by  residence  in
malarious districts, bronzed by exposure  or Addison's
disease, unnaturally florid  by intemperance  or cardiac
lesion, livid by imperfect aeration of the blood from
whatever cause, or "compounded of alabaster and the
rose" by incipient phthisis, or pallid and sodden from
albuminuria and anaemia.
   Color  of the Hair and  Eyes. — This point also
refers particularly to the temperament;  but attention
is called here to changes in the color of the hair from 
6o
advancing or premature age; to its nutrition, whether
dry and husky or soft and silken in texture — whether
it remains firmly rogted or  has  fallen.   These  obser-
vations may give a clue  to the diathesis  or cachexia
present.
  The movements of the eye, its expression, the con-
dition  of the pupil, contracted  or dilated, or whether
these changes  are symmetrical;  whether  there be
complete  or partial amaurosis  of either;  the arcus
senilis,  etc.
  It will be found that the eyes  can afford vastly more
information than merely as to their color.
  Size of the Bones.—- A strong bony framework is
usually connected with strength  of the nutrient system,
and is  indicative of a constitution capable of much en-
durance.  Prominence of the apophyses is an  index,
generally, of a  fully developed  muscular  system with
its concurrent advantages.   But  reference to the osse-
ous system involves more than simple observation of
the size of the bones and their normal projections.  It
suggests inquiry into the  perfection  of ossification
about  the cranium  and vertebral column, original  or
acquired deformity, rachitis, mollities ossium, curvatures
of the spine, gibbosity, &c, fragility, caries, necrosis,
morbid growths, etc.
   Contour  of Muscles.— Closely allied in prognos-
tic meaning to  the development of the bones, will  be
found the firmness and abundance  of  the muscular
fibre.  The  deposit of  adipose tissue will  often ob-
scure the  strong lines which mark the boundaries  of
the  muscles,  but their  compact  structure, contractil-
ity and tonicity can  readily be observed.  The well 
                         6i
rounded and well  developed muscular system  renders
the risk more desirable, as  the  feeble,  ill developed
fibre suggests the reverse.
   Attention is here directed to local  paralysis, which
may be present as the result of lead or  other  poison-
ing, central or excentric  affections of the nervous sys-
tem, &c.   Or again,  tonic or clonic spasms, tremors,
tremulousness, chorea, &c.
   Apparent  Age.— The applicant having  recorded
his age, it is proper to compare his apparent with his
actual age.   Some are really older at forty than others
at sixty.   Premature old age may be from hereditary
or congenital  imperfection  of structure, or it may be
the evidence of previous sickness,  long  continued ill
health, irregular or dissipated habits, overwork, expo-
sure and the like.  As a general rule, when the appli-
cant is really older than  he looks to be,  his life expec-
tation  surpasses  the  average; but  when he has  aged
beyond his years, the  risk is  thereby in so far impaired.
   Temperament.— In noting the  temperament  it is
better to adopt the simplest possible varieties, recol-
lecting that the phrase is employed simply to express
the preponderance in activity of certain  organs or ap-
paratuses in the individual.   Practically four tempera-
ments  may be recognized for purposes of description.
the Sanguine,  Bilious or Sarcous, Phlegmatic or Lymphat-
ic, and the Nervous.
   The Sanguine temperament is characterized by great
activity  of the blood  making organs,  rapid  integral
changes  and  free excretion. Activity of mental and
muscular movements, delicacy of the skin, etc., are in-
cidental to  these.  Light or sandy hair, blue eyes, florid 
6i
 complexion and the like  are  accidental, not necessary
 concomitants,  being  frequently  conjoined  with the
 other temperaments.
   The Phlegmatic temperament shows, nearly an oppo-
 site condition of  the organism.   There is  slow  and
 imperfect nutrition—the blood tardily developed  and
 assimilation comparatively feeble.  Hence languor of
 both  mind  and muscle, infrequent  and  compressible
 pulse, flabby and  soft texture, with  abundant adipose
 deposit.
   The Bilious temperament  is characterized  by great
 perfection of assimilation, but not remarkable  energy
 of digestion.  The blood making processes  are not as
active as in  the sanguine, because there is less of waste.
The quantity of excreta  is also  less.   Firmness  and
strength   of  muscle  characteristically  predominate.
The less rapidly changing skin assumes a darker  hue,
and with its appendages,  hair, nails,  &c, is drier and
harsher.   Coincidently  the liver and subsidiary organs
are largely taxed,  for the recomposition of blood  defi-
ciently renewed by food.
  The Nervous temperament, with deficient digestive
energy and muscular development, manifests a striking
activity of  the  so called nervous processes.   "The
countenance is usually pale and the  features thin  and
sharp, the pulse is quick,  small and frequent; the res-
 piration active ;  the chest not largely developed ;  the
 skin dry and rough."   These are  the incidents of the
 organic peculiarities  before noted.
   Each of these  temperaments, it is of course  under-
stood, may be modified  in its manifestations by a com-
 bination  with one of the others — a result not unlikelv 
                         6j
to occur  when  the  parents  have been  of dissimilar
temperaments.    But  almost  typical specimens  are
afforded by families, and even tribes or races,  when
intermarriage has been restricted within narrow limits.
In this country where individuals of the most diverse
nationality and parentage are " marrying and giving in
marriage," it is constantly becoming more difficult  to
assign the proper status  in this regard.  The point to
be kept in mind is,  not  the accidents of color, shape,
&c, but the preponderant activity  of special organs
and  processes.   Thus the child always  approximates
the sanguine; the adult, at maturity,  the sarcous, and
in the decline of life lapses into the  nervous or phleg-
matic, according to the peculiar organization.
   Relative to life assurance, the matter becomes of im-
portance, as evincing proclivities to particular forms
of disease.  This is  noteworthy when there exists any
hereditary or acquired predisposition thereto, or when
the occupation, habits, residence, &c, renders the party
liable to the usual exciting causes.  The sanguine tem-
perament predisposes  to miasmatic  diseases, typhoid
and remittent  fevers, the exanthems, to acute rheuma-
tism, organic and functional diseases of the heart and
arteries, to haemorhages and under conditions unfavor-
able to nutrition to tuberculosis.
   The  phlegmatic temperament on  the  contrary  pre-
disposes to chronic and often incurable inflammations,
dropsies and fluxes  of various kinds, especially from
mucous membranes, influenza and scrofulosis.
  The  bilious  temperament favors  the  occurrence of
endemic disease, febrile  affections tending  to  a low 
                         64
 grade,  hepatic  obstruction  with  dysentery,  haemor-
 rhoids, fistula in ano. &c.   When  rheumatism occurs
 in this organization the  heart rarely escapes being in-
 volved sooner or later.
   The nervous  temperament involves liability to in-
 sanity,  epilepsy, paralysis and neuroses generally.   If
 typhoid fever happens to such an one the issue is very
 dangerous.
   In taking note  of the General Appearance any
 Idiosyncrasy present  deserves careful attention and its
 possible bearing upon the life prospects of the party must
 be noted,   Idiosyncrasies vary  so  remarkably in their
 characters that it is unnecessary  to  do  more than sim-
 ply direct notice to the  fact that  they are capable  of
 largely  modifying  particular indications,  and  indeed
 the ultimate judgment.

                        II.
  The  Pulse demands  attention  to its  frequency,
 rhythm and general character.   Indications  derived
 from it require analysis to be at all satisfactory.
  The  normal  pulse  described by authors  for the
adult male ranges in frequency from sixty-eight to sev-
enty-two ;  more frequent in  infancy, childhood and
youth—again rising in  frequency  in  advanced  age,
although gradually diminishing  from maturity to per-
haps sixty or seventy.   It  is slower in the morning
than in the evening.  It is more frequent  in the erect
position than when sitting, and still less rapid when
recumbent.   It is hastened  by  nervous excitement or
muscular  exercise.   Any  tension  of the  contractile 
                          «5
 fibre will easily cause it to rise from the usual stand-
 ard to even double its  ordinary  rate.  In  fine  it is
 rather an index of the nervous system than, as formerly
 supposed, of circulatory energy.
   The pulse of Great Britain and Continental Europe
 ranges from  sixty-eight to seventy-two, but that of
 the Atlantic States of  America from seventy-two to
 seventy-six, while that of the  Northwest will  rarely be
 less than seventy-six  to eighty.   A pulse uniformly,
 or even temporarily, below sixty or above ninety must
 be explained by idiosyncrasy,  or else it rejects—at the
 best postpones judgement.
   The irregular  pulse must be likewise demonstrated
 to be  an individual characteristic, otherwise it rejects.
 Unexplained it is totally exclusive.
   The intermittent pulse calls  attention to  probable
 cerebral or cardiac  disease.  Occasionally it is the re-
 sult of temporary gastric or other local disorder;  but
 even  then it should  cause suspension  of judgment.
 The rate of the  pulse  should  be recorded when the
 applicant is sitting, or, better,  the difference in  rate
 between the two positions should  be given.
   The hammering pulse emphatically calls attention to
 the cardiac valves.
   The general  character of the pulse is  expressed by
 the terms full,  free,  hard, soft, weak, etc.
   While considering the pulse the whole arterial  sys-
 tsm should  be  taken under review.   Unnatural or ex-
traordinary  hardness  possibly  indicative of senile or
calcareous degeneration  of the arterial  parietes, to ul-
timate in aneurism, senile gangrene or  embolism.
   But the pulse is fallacissima  rerum.
             5 
66
                       III.
  The Respiratory  Organs.—A  fully developed and
powerful thorax is one of the best evidences of gene-
ral physical  capacity and  endurance, whilst a narrow,
contracted or malformed chest is a strong evidence of
a feeble constitution.  The methods of investigation
differ somewhat in details, but all coincide in essen-
tials.
  Mensuration.— Some  details  have already  been
given ( p. $6 et seq.,)as to the relation of the circumfer-
ence of the chest to the  height and weight.   It is well
to bear in mind that due proportion  requires that the
circumference  should equal twice the distance  between
the angles of  the shoulders; that it should be  four
times the antero-posterior diameter  at the lower por-
tion of  the sternum, and that this latter diameter
should exactly equal the distance between the nipples.
  Practically, measurement is best made with the sim-
ple graduated  tape line, which adapts itself readily  to
the surface  and can be always carried  in the pocket.
For physiological investigations other instruments may
be of  service,  but are unnecessary  here.  The line
should be applied under the vest,  if practicable, at the
level of the  nipples, and on  the same plane anteriorly
and  posteriorly.   If taken over the vest, or there  is
much clothing beneath  the tape, a suitable allowance
must be made therefor.
   Note now the measurement:
   ist. During the largest inspiration.
   2d.  During forced expiration. 
                        67
  3d.  During  tranquil respiration  about the middle
of inspiration.
  The first and second measurements give a clue to
the capacity of the lungs for the "complemental " air
or extreme vital capacity, whilst the  third suggests the
amount of " tidal " or ordinary breathing air, which is
perhaps of equal  importance, as exhibiting  the indi-
vidual's present  condition.   A man  five feet  eight
inches should have a breathing  capacity of 230 cubic
inches of air, while in point of fact, in tranquil  respi-
ration there is not  usually a change of over 20  or 30
cubic inches within the lungs.   Nevertheless the phys-
ical  capacity for large aeration of the  blood adds to
the desirability of  the risk.
  The extreme breathing  capacity  is  increased eight
cubic  inches for every additional inch of  stature  be-
tween five and six feet, when due proportion is  main-
tained.  If this proportion  is not maintained the risk
is, in so far, impaired.
  Observations made with  the spirometer, although
interesting in a physiological point of view, are prac-
tically of no avail  to  the  insurance examiner.   Inci-
dentally it may be observed  that the extreme breathing
capacity is diminished by  obesity ;  that  it is propor-
tionately less in females than in males, and in children
than in adults.  The volume increases with age  to the
thirtieth year, and gradually decreases from thence to
the  decline of life.  A  deficiency  from  the normal
standard of sixteen per cent, is suspicious, and if very
much below this will invalidate the risk.   Coincident
signs or symptoms under such circumstances, will  al-
most invariably confirm indications on this point. 
68
   The  average  expansion in full  respiration will  be
found to be a little over three inches, but  in tranquil
respiration it is scarcely more than an inch.   The right
side expands a little more than the left, as it is gener-
ally, in  right handed persons, a little over half an inch
largest.   Any variation  from the normal amount  of
expansion  at  any part of the chest  should be noted,
and its  cause sought out.
   Inspection.— The general form of the  chest will
suggest  particular observation.   Thus, whether there
be any flattening, especially in  the  clavicular regions,
or even across the whole anterior surface, with stoop-
ing shoulders, curved sternum and projecting inferior
angles of the  scapulae — collectively  indicative of fee-
bleness  of  constitution, slight  power of endurance,
and proneness to tubercular deposit.
   Flattening of the lateral or inferior portions, signifi-
cant of  old pleurisy with remaining adhesion, or of old
abscesses, &c.
   Again, deficient transverse diameter with projection
of  the  sternum, or "chicken-breast," suggestive  of
causes of dyspnoea in early life, or perhaps now pres-
ent, or  again, of rachitis,  tkc.   The chicken-breast is
ordinarily indicative of deficient  vital capacity, and  al-
though  not seemingly  productive of  inconvenience,
may, nevertheless, like  " hunchback," militate against
the risk.
   Respiratory Movements.—The frequency, rhythm
and type of motion in inspiration and expiration are
to be noted.
   In the  adult  male,  during tranquil breathing, the
average frequency of inspiration  may be placed at from 
                         69
fifteen  to  twenty per  minute, or about  17, but the
slightest mental influences or exercise will  vary this
widely.  Probably the point of most importance is the
ratio to the pulse, which should be very closely as one
to four  or five.  . The  movements  should be noted
while  numbering the pulse,  and  the  ratio  then ob-
served.  Nevertheless, as a rule, if the  respiratory acts
are less frequent than twelve or  more than twenty-
four,  decision should be suspended.  It is to be recol'
lected, as Walshe observes, that  the rapidity, energy
and extent of these movements " increase in the direct
ratio  of the .easy mobility of the framework of the
chest (hence greater in youth than age,) and the height
of the individual."   In  females,  generally, and  in
males  of a nervous temperament, the frequency is ex-
aggerated  easily,  and, as  a rule, slowness  of these
movements is a more objectionable feature  than  its
opposite.   But  coincident  evidence will  usually ex-
plain  satisfactorily the cause.
  The fifth expiration (on  the average,) is a little deep-
er than the others.   The ratio of inspiration, expira-
tion and quiescence should be about as five, four and
one respectively.
  If the motions are irregular, intermittent or jerking,
the case requires scrutiny.  If the ratio is widely de-
parted from, further investigation is demanded, partic-
ularly  where expiration is prolonged—the latter symp-
toms awakening  great anxiety.  The irregular, inter-
mittent or  jerking respiration is usually indicative of
derangement of the nervous system, but prolonged ex-
piration minatory of local lesion of  the lungs.  It 
                         7°
may become more than twice the  length of the inspi-
ration.
  The type  should be abdominal in the infant,  dia-
phragmatic  and  inferior  costal  in  the adult  male ;
superior costal in the adult female.   Any change of
these types is  suspicious.   Notably so pectoral breath-
ing of marked character in the man, and even  in the
woman, when  exaggerated and accompanied  by a  per-
perceptible rising of the  shoulders with each  inspi-
ration.
  Diseases.— Acute  diseases of  the  respiratory or-
gans postpone and, after apparent cure, demand search
for  lesions left  behind.   Catarrh,  Pharyngitis,  Lar-
yngitis, Tracheitis and  Bronchitis do  not necessarily
involve a tendency to Phthisis Pulmonalis, but  their
frequent recurrence gives grave doubts, which  must be
cleared  up  before  insurance.   If  they  assume  the
chronic form, it  becomes imperative  to demonstrate
the  absence of the tuberculous taint.   Or perhaps they
may be the sole exponents of Syphilis or other cachexia.
  Ulceration of  the larynx  is about infallibly an  evi-
dence of tuberculosis or syphilis.
  A slight  catarrhal condition of  the respiratory  mu-
cous membrane may have become  habitual,  and  in the
assured absence of any constitutional cachexia, or he-
reditary tendency, need not preclude the risk, although
placing it in lower grade.
  But the attention of the Examiner is with greater
earnestness  called to the more prominent affections
which, when  decided  to  be present, must  necessarily
induce him to decline the risk. 
                          7i
   As this is not intended as a  systematic treatise on
 nosology or  diagnosis, for convenience I shall consider
 these affections in alphabetical order.
   Adhesions of the pleural surfaces often occur with-
 out noticeable  morbific  results.  It  is important to
 recognize the condition  so as not to   confound such
 signs as it may afford with those of a graver  character.
 They  impair the mobility of the parietes,  and occa-
 sionally that of the arm of the affected side.   Flatten-
 ing  or  contraction, more or less discernible, usually
 of  the   lower  and  lateral  parts of the  chest; feeble
 respiration;  very slight diminution of  resonance ;  no
 bronchophony  or  augmented vocal fremitus;  inter-
 rupted   respiration,  but  not  prolonged  expiration.
 Diagnosis will be materally assisted  by  noting  his-
 torical symptoms and absence of tuberculous diathesis.
 Unless  the pleurisy  has  become chronic, or  the adhe-
 sion is so extensive  as to materially impair the breath-
 ing capacity, this condition need not necessarily reject,
 but assigns to a lower grade.    When  the results are
seen at  the superior portion of  the  lobes, its almost
certain coincidence with tuberculous deposit and result-
 ing inflammation, necessitates rejection.
  Asthma has already been noticed, (p. 17, et seq,)but
when the party has  wilfully  or negligently  concealed
 its previous occurrence, it may often  be detected by its
peculiar dry  wheezing or  sibilant whistle, even during
the interim.   The affections upon which it may de-
pend or with which it may be confounded will be con-
sidered  in another place.    See,  also, p. 18  et seq. 
                         72
of the nervous centre; or  local paralysis from local
causes only; a turgid state  of the laryngeal  surfaces ;
or ulceration, or, in old age,  ossification of the carti-
lages.  It  is an occasional  result of rheumatism, and
in some instances arises from  the pressure of a dilated
or aneurismal aorta or other tumor.
  When present it must be  demonstrated to depend
on.the trivial and transitory, and not upon the graver
causes.   Its  intimate relation with tubercular phthisis
and syphilis renders it deserving of analysis.
  Congestion.—It occasionally occurs, on percussion,
that   there  is evident  diminution of the  normal
resonance,  with deficient respiratory sound on auscul-
tation, at the same  time, the pitch is slightly elevated.
The ratio of inspiration to expiration may be unchanged
—the movements slightly augmented in frequency, and
a trifle more of muscular  effort observable, without
marked dyspnoea being present.  With the feeble res-
piration  there may sometimes be noticed a  "dryish,
rather fine, but distinctly bubbling rhonchus."
  This condition may be only temporary or be perma-
nent in its  character, as dependent on its cause.  It is
important  to diagnose it  from tuberculous  or  other
deposits.   It is the  result of congestion, and, possibly,
also  slight  pulmonary oedema.  It  demands research
for the obstruction.
  It is capable of being brought on, temporarily, by
the ordinary viscissitudes of temperature and humidity,
"functional" diseases  of  the heart,  liver, nervous
apparatus, &c.; or, by special influences—malaria, gase-
ous or atomic emanations, retained excreta and the like. 
                        13
But it is also often the  result of more or less perma-
nent obstruction  in the  pulmonary blood-vessels, or,
again, the  heart.   When present it  should postpone
decision until after a  subsequent examination.   Or
else, if the organic origin be determined, cause immedi-
ate rejection.   But it is due the applicant not to con-
found it with the result of tuberculous deposit, or other
grave disease.
   Dyspncea—depends upon such  a  variety of causes
that it is not diagnostic, alone, of any single disease.
When considerable  and permanent  it should  reject,
whatever the apparent cause.  It may, however, be but
a peculiarity  of a nervous  temperament,  or originated
only occasionally  by peculiar influences depending on
idiosyncrasy.
   If  caused  by  permanent obstruction   to  the  dia-
phragmatic movements, or by  disease of the larynx,
trachea, lung tissue, pleura or heart—it must reject, at
least  while present.  It is  well to recollect, that  it is
rarely  a  concomitant of tuberculous deposit;  hence,
the popular  notion that phthisis  and "asthma" are
incompatible.
   Deposits—may be of great variety.   Prominently
may be noticed: the Inflammatory, Tuberculous, Cancerous,
Melanoid, Typhoid, and Syphilitic.  The first two  only
claim particular notice in this place, as any peculiarities
about the latter four will  be found to depend on the dia-
thesis  or cachexia by which they are  to be determined.
   The results of Inflammatory deposit in the parenchyma
are traceable from historical and  present symptoms, and
the physical signs. 
                         74
   The consolidated exudate of acute  pneumonia may
remain unabsorbed a long time, or even permanently,
after  the individual  has regained apparent health.
Contracting, as does  all inflammatory exudate,  the
side of the chest overlying may flatten as after pleurisy.
There is less range of costal motion resulting (p.71).
It is dull on percussion, with bronchial respiration and
broncophony  over the affected  part of the lobe—not
even feeble  respiration  being heard as after  pleurisy.
Occasionally around  the part there is uneven, feeble
respiration,  but this is rather significant of oedema of
the parenchyma, as, otherwise, it will be found harsher
or puerile.   Combined with these signs it will be found,
on  cautious  inquiry,  that  there are   dyspepsia  and
irregular febrile accessions—none of which may be of
sufficient severity to attract attention unless sought for.
  This deposit temporarily postpones — but its diag-
nosis from tuberculous deposit should be made out, if
possible, to  give opportunity for subsequent examina-
tion—as well as in case of cure to  protect the Examiner's
own reputation.  All the evidences of  the  tuberculous
diathesis must  be  explored;  for, even when the phy-
sical signs presented are not about the apices,  it is well
to bear in mind that there may occur tuberculous degen-
eration of the exudate.   Where it involves the apices,
the diathesis, hereditary, or acquired, affords our only
means of judging  of the abnormal material present.
  The Life Insurance Examiner is not called upon by
Companies to investigate well marked cases of Tuber-
culous  Deposit,  accompanied with its well known
rational symptoms.  He is to watch for its incipiency 
                         IS
 with  the extremest  anxiety,  for  it is known to be
 the greatest possible source  of their financial losses.
 Obsta principiis is, most emphatically, to be his motto.
 By his  exercise  of care, skill and sagacity he will be
 enabled to reduce those losses to a minimum unexpected
 before the introduction  of Physical Diagnosis.
   It  is proper to remark, that when the physical signs
 give evidence of deposit about the superior lobes of
 the lungs it must reject, whatever the apparent diathe-
 sis.   It is equally important to remember that the dia-
 thesis may  be strongly  marked—to such  an  extent,
 indeed as to  determine  rejection, when  none of the
 usual signs of deposit  are discoverable.   In the vast
 majority  of cases,  the two  are associated long before
 manifestation of any of the  characteristic  symptoms
 produced by the process of softening.
   Perhaps the most observable early sign is Prolonged
 Expiration;  then Vesicular Murmur lessened at the part
—Puerile around; Inspiratory Sound less forcible, higher
 in pitch, and Bronchial Respiration  more distinctly
 tubular;  Vocal Fremitus exaggerated;  Dullness  more
 or less decided on Percussion ;  a little later, Flattening
with less superior costal motion and more diaphrag-
 matic—the shoulders being more perceptibly elevated
 at each inspiration, whilst the general frequency of the
 movements is accelerated to 24 or 28 in  the minute, or
 even beyond this on the slightest excitement.
   Owing, probably,  to  their usually more quiescent
 state, the apices  of the  lungs  are  most liable to the
 deposit,  but other causes enforcing similar quiescence 
                         76
of any part of the parenchyma may determine its loca-
tion in that part.  The supra scapular, supra, and infra
clavicular regions, in the absence of historical  symp-
toms pointing elsewhere, are the parts first to  come
under  investigation.
  In these regions  percussion sound elicited may  be
deficient in clearness and in duration, with lessened
elasticity, and even  when the  deposit is small and  in
scattered points,  there will  be less  increase in reson-
ance over the affected than  the sound part, when the
lung is inflated by full inspiration—the  dullness more
pronounced at the end of a  complete expiration.
  By auscultation the vesicular sounds  may be found
varied within a  limited space—suppressed, weak  or
exaggerated.   The displaced tubular sound elevated in
pitch,  harsher  and  prolonged.   Crepitant dry  rales,
or, later, of a moist character.   More or  less distinct
broncophony, and the sounds of the heart heard with
unusual distinctness through the changed conducting
medium.   The rhythm, as  previously noted, is liable
to irregularity.
  The physical signs thus briefly alluded to determine
the presence of an abnormal deposit  more or less
extensive, according to  their distinctness of manifesta-
tion, and, even in the absence of the so-called'rational
symptoms' of incipient  Phthisis, preclude  insurance—
unqualifiedly.
  Not  all of them  may be present, and  doubt may
arise, to be decided perhaps by reference to the his-
tory and  diathesis of the applicant.  If these are un-
satisfactory, the company must have the benefit of the 
                         77
 doubt and the party be declined.   (Vid: Diathesis.)
   The Typhoid Deposit is noticeable for the reason that
 whereas it will yield the same physical signs  as  the
 true  tubercular,  and  is  prone to  produce  similar
 results by its softening, nevertheless it is capable often
 of being  permanently removed, and  perfect local and
 constitutional health be  restored;  so  that  the case
 once  properly rejected  by an  experienced  examiner
 may,  ultimately, be accepted by one equally as cautious
 and expert.
   The same remark may be made  with  regard  to the
 Syphilitic Deposit.   The  " gummata' will yield the same
 physical signs as tubercle, but eventually, under appro-
 priate treatment, disappear.  But  while present they
 reject—as must the cachexia upon  which they depend.
   The Cancerous and  Melanoid Deposits likewise  ex-
 clude, because of the physical  signs afforded, as well
 as the cachexiae originating  them.
   Emphysema. — The  pathological   and prognostic
 importance  of this  lesion  depends  wholly  upon its
causation.   Unless very extensive  it may not be said
 to shorten life, yet, like a  contracted  chest and small
 lungs, it lessens vital  capacity  for aerating the blood
 under circumstances demanding an  increase  of the
 usual  energy of the process, and thus renders its sub-
 ject an easier  prey to  intercurrent diseases.  A local
 Emphysematous condition  is not infrequently associ-
ated with tubercular lesion,  but ordinarily its presence
over any  considerable  portion  of  the parenchyma  is
said to lessen the liability to tubercle, haemoptysis and
 pneumonia.   Hypertrophous Emphysema is a  nearly 
                         78
 incurable  affection—the Atrophous  or Senile form
 absolutely so.   Both varieties tend to produce enlarge-
 ment of the heart.   The hypertrophous form is  usu-
 ally associated with and probably caused by bronchitis,
 which therefore should  be looked  for.   It  may  be
 hereditary, and  in its  manifestation  is confined to  no
 age, sex, or condition.  The atrophous form  is  con-
 fined mainly to  those well advanced in years.   In the
 first form the chest is  locally or generally enlarged,  so
 as to  give a bulging  appearance, very peculiar in char-
 acter when considerable  in  extent.  The spine curves
 anteriorly, and  the  angle  of junction with  the  ribs
 becomes more obtuse.
   Percussion gives increased resonance, sometimes  of
 drum-like  intensity, but with  lesssened  resistance  of
 the thoracic parietes.  Auscultation shows feeble res-
 piration in the  affected  parts with, it may  be, puerile
 or harsh vesicular murmur in  the healthy structure.
 Associated with these are usually found the abnormal
 sounds of  bronchitis or asthma.   The rhythm of the
 inspiratory movements is  likely to  be irregular, and
 expiration prolonged.
   There is dyspnoea continually, and  this, at  times,
 deepens into the asthmatic paroxysm.   The superficial
veins are turgescent, and the hue of the skin is darkened
by the imperfectly aerated blood.  The features wear
 the characteristic marks of  habitual  laborious  breath-
 ing.   With exception of the general  expansion  and
bulging of the chest, the atrophous variety presents a
similar array of signs and  symptoms.  The existence 
 of  either form  of the lesion being  established,  the
 applicant must be rejected.
   Empy^mia is usually made out with sufficient accu-
 racy by the historic and present symptoms,  and  the
 physical signs of pleuritic effusion. It of course rejects.
 It may be  borne in mind that  occasionally a fistulous
 opening occurs,  and the contentsof the pleural cavity
 are  discharged a long distance from it.   Such cases,
 with  tolerably fair  health,  have been mistaken  for
 fistulae or  ulcers from other  causes.   The previous
 occurrence of pleurisy  and the presence of a supposed
 "fever sore"  on the back or elsewhere that pus may
 find its way, demands caution.
   Hemoptysis  has been referred to (p. 34).
   H^MATEMESIS.--(Vid. p.  ^S')
   Hydrothorax — although  the  party may appear
 otherwise in  perfect health, while present postpones,
 whatever the cause.  If connected with structural lesion
 of the heart, liver or kidneys, it positively declines.
   Pneumothorax  rejects as decidedly as Emphysema,
 and  hence its  differential diagnosis from  the  latter is
 unnecessary.
   Pleurodynia, being but a mere symptom, requires
 analysis.  The term  is carelessly applied  to cases
 which  may  prove to be rheumatism of the intercostal
 muscles;  intercostal  neuralgia, the  chest pains  of
 phthisis,  or  chronic   pleurisy, or  from  carcinoma
 within the parietes.   It is  properly restricted  to the
 first  mentioned disorder.   The pain on movement  is
likely to locally diminish the expansion of the parietes,
and hence there will be less distinct respiratory mur- 
8o
   mur, and less resonance on percussion.  The remark-
   able  aggravation  of pain by  movement,  absence of
   other physical signs of deposit, &c, and reference to
%  the diathesis, will be sufficient to diagnose the case.
     Intercostal  neuralgia is distinguishable by  the ab-
   sence of abnormal  physical signs—by its tendency to
   paroxysmal  or periodical forms, and by the diathesis
   present.   Its obstinate  continuance may  point to
   spinal lesion, or that of remote organs with which the
   part  affected  is in  relation  through reflex  nervous
   action.  Movements aggravate it very little if at all.
   Neither the  simple rheumatic  or neuralgic affection
   rejects, unless  connected with evidence  of constitu-
   tional or organic disease.
     The chest pains of phthisis, chronic  pleurisy, car-
   cinoma, &c,  need only  be  mentioned  to direct  the
   attention of the examiner to their differential diagnosis.
   Of course each rejects.
     Tumors, within the thoracic cavities, whatever their
   nature, may attain  considerable size  before producing
   noticeable symptoms.  Eventually their pressure upon
   the lungs or heart, the  nerves or blood-vessels may
   give rise to pain, dyspnoea, palpitation, dysphagia, dis-
   placement of organs, interference with the  circulation,
   haemoptysis,  inflammation with its results, bulging of
   the ribs and sternum, &c.  But where these symptoms
   are present parties rarely present themselves for exam-
   ination, or if they do, the matter is easily disposed of.
     According  to their location  they will  change  the
   normal auscultatory and percussion sounds.   Dimin-
   ished resonance and feeble vesicular murmur are  the 
8i
necessary physical signs.  Light percussion may show
resonance,  whilst a stronger blow will elicit deep-
seated  dullness.   The particular  character  of  the
tumor can only be surmised from concurrent symp-
toms, and the diathesis or cachexia present.  The most
satisfactory diagnosis is here the result of the exclusive
method—determining  the  absence  of other lesions
which might account for the signs and symptoms.
   The intra-thoracic tumor, whether  aneurismal, can-
cerous, fibrous,  fatty,  steatomatous,  or whatever it
may occur, positively forbids assurance.
   In passing from the  consideration of the respiratory
organs, it is  not out of place to remark that, the whole
thorax should be  comprehended at  a coup d* ceil,  and
yet  individual  parts be  thoroughly  scanned.   The
unassisted ear, applied to  the chest,  will often gain a
more  satisfactory  acquaintance with  its general  con-
dition and vital capacity,  than can  be gained by the
most  expert use of the stethoscope.   Whether  the
ear is  applied directly to the chest, or a stethoscope is
interposed, is  not a matter of so much  importance
as that the examiner be able to hear with the ear, and
correctly interpret the report of the organ.

                        IV.
   Heart  and  Circulatory   System—The remark on
page 21 may be repeated: "Organic disease of the heart
positively excludes."   Its  acute affection or chronic
lesion with marked rational symptoms will not, mani-
festly, be  brought to the Insurance Examiner's atten-
           6 
82
 tion ;  but as its lesions, even when giving rise to no
 inconvenience of which the party himself may be  con-
 scious, nevertheless are liable suddenly  or  slowly to
 cut  short the life,  it  becomes  absolutely  essential
 to  explore  the  slightest deviation from its  normal
 condition.
   Location.—Recognized by its impulse, palpitation
 and percussion,  the heart should occupy in relation to
 the thoracic wall a space about two inches in diameter
 vertically between the fourth  and sixth ribs, and trans-
 versely a little to the left of the sternum—the impulse
 of the apex being about two inches below the nipple,
 and, varying with the size of the chest, an  inch towards
 the mesial line.
  Any change from this  location  requires inquiry as
 to its  cause.  Prominently  among causes  are to be
 mentioned;  Pleuritic Effusions, whether of serum,
 pus, or  air;  Emphysema;   Deposits  in the  Lung,
 whether tubercular, inflammatory, cancerous or other;
 Tumors;  Dilatation of  the Stomach, Enlargement
 of Liver, Ascites, &c.
  Bulging or Depression.—Protruding of the pre-
 cordial region indicative  of  Hydro-pericardium,  or
 Hypertrophy of the organ.   Depression, if consider-
 able,   indicative  of previous  Pericarditis with  its
 contracted  exudates and adhesions.
  Impulse.—This is, as might be expected, normally
 stronger in persons of a lean habit than in the corpu-
 lent.   Its location  is changed by  position,  whether
erect or supine; by distension  of the stomach; by
respiratory  movements,  &c.  It  is  augmented  in 
extent and intensity by hypertrophy.  It Is augmented
in area of vibration,  but diminished  in intensity by
dilatation  or pericardial effusion, or  fatty degenera-
tion.  A feeble  impulse, irrespective of local  lesion
of the heart itself, may indicate cerebral disease,  im-
poverished  or morbid blood, or reflex  influences of
depression from  disease of remote organs.
   A broken or irregular impulse is  suggestive of peri-
cardial adhesions.  When both a systolic and diastolic
impulse are felt, hypertrophy with  dilated ventricles
is to be  looked for.   In connection with the impulse
may be noticed the purring thrill of Laennec, suggest-
ing possible presence of valvular stiffening.   Vibration
as of friction may be felt from roughened pericardial
surfaces.
  Area of  Dullness.—The diameter indicating the
approximation  of the  heart  to  the parietes  of the
chest may be extended by strong  percussion, eliciting
deep-seated  dullness over  the  entire heart and large
blood-vessels superior.^  But if without  change  in the
strength of stroke, the area is materially  increased,
there is  room for apprehension of fluid effusions in
the pericardium or enlargement of the heart itself.  Of
course, local  pleuritic effusion may be confounded with
it, but to the examiner  this is of  little consequence,
as either must reject, or, at best, postpone.   The same
remark may  be made  as  to  the differential diagnosis
of Hydro-pericardium, and Concentric  or Eccentric
Enlargement of the Heart.
  An apparent diminution of the area of dullness is
noticeable  during a  deep  inspiration, but  if very 
                         84
 considerable,  or there is abnormal resonance,  there
 may be pulmonary emphysema, or hydroeria, either of
 which reject.  In  doubtful cases the applicant should
 be examined both in the erect and recumbent position.
 Abnormal dullness in the aortic region calls attention
 to the possibility  of dilatation, or aneurism of the
 the great arterial trunk.
   Pulsations.—In addition to the character of the
 impulse produced  by the cardiac  movements, it be-
 comes necessary to note the  rhythm, which may be
 varied in frequency, order of succession, and multiple
 character.  Coincidently,  with the pulse (p. 64 et. seq.)
 it may be increased or diminished in frequency,  or it
 may  become  irregular or intermittent.   Its  normal
 range for insurance purposes is from  sixty to  eighty-
 five, or possibly ninety in the minute.  Continuously
 above or below this  standard should reject or  post-
 pone.   But the great power  of the  nervous system
 over the contractions should be kept in mind.  Mental
 excitement under  the examination, in nervous   sub-
jects, will often  throw the beats up to a  hundred or
 more.   If without this the applicant stands erect, and
 brings the muscles of the extremities into a state of
 contraction,  voluntarily  or  involuntarily, the  beats
 will  readily pass the  hundred.  Hence the necessity
 of waiting examination until  the effects of exercise or
 mental excitement have  passed, and then,  while the
 person is in the sitting or recumbent position,  enjoin-
 ing upon him as complete relaxation of all  the muscles
 as possible.   With due  precautions, if  there  be not
 some  fixed  cause  of a  morbid character,  apparent 
                         85
abnormalities in frequency may be made to disappear.
   Extreme rapidity or  palpitation (p. 28,)  although
generally  accompanying some  lesion  of the  heart,
"bears  no positive relation  to any  special  cardiac
malady, and is therefore not diagnostic of any."  The
symptom  directs  attention  to  possible cardiac lesion,
but in  the vast majority of  instances to dyspepsia,
impaired  blood,  or nervous disorder.   Retardation
of the  pulsatjon   points to  some  affection  of the
nervous centre, or  degeneration of the cardiac paren-
chyma, or  alteration of the aortic orifice.   Irregularity
of contraction is of rather  more significance, as  indi-
cating valvular or  parenchymatous  local  change,  or
grave lesion of the nervous centres or remote organs.
Yet many cases occur  where  irregularity is the rule
even during most  perfect health.  Hence, taken alone,
it ought not  to  cause  rejection.    Palpitation  with
irregularity and deficient impulse suggests dilatation
and weakened walls, although  other physical signs
may be wanting.  In this case the rational symptoms,
age, habits, condition  of the  digestive system,  the
blood, &c, will afford sufficient concurrent evidences
to decide upon the real character of the case.
   The  intermittent pulsation  may  be an individual
peculiarity  in  health, but generally  indicates organic
cardiac  lesion,  or some cause  either temporarily  or
permanently impressing  the  nervous  system.  It is
of graver character, on the  whole,  than either changes
in frequency or regularity.
   The  relation of the systolic and diastolic sounds  to
the intervals  of rest  may  be  varied;  more usually 
86
the longest Interval is prolonged, which may depend
on  auriculo-ventricular stricture ;  or,  again, the first
sound may be prolonged over upon the second, sug-
gesting  "hypertrophy with stricture of the arterial
orifices."   In strongly marked cases of this kind the
diastolic sound is sometimes wholly suppressed.
  On  the  other hand, there may  be  heard three or
four sounds instead  of two, ascribable to  important
organic changes in the structure.   The precise nature
of these changes it is  unnecessary to point out, as this
abnormality must peremptorily exclude from assurance,
whatever its plausible explanation.
  Character of Sounds.—The "dull, booming and
prolonged" first sound of the heart, and  the " short,
abrupt  and clear"  second sound,  in  a condition of
health are sufficiently distinct to be  easily recognized,
and when  present for any even  short  period argue a
healthy organ, but variation of these sounds may arise
from  incidental causes not  implicating the structure.
The healthy sounds when heard demonstrate—abnor-
mal  sounds  throw doubt,  and  their cause  must  be
cleared up.
  Increased  intensity  of  the  sounds  may  depend
on  hypertrophy  with  dilatation,  induration  of the
muscular tissue from carditis, or merely upon nervous
excitability.   They  may derive  increased  loudness
from solid  or fluid deposits, in  which case they are
heard with  distinctness at distant parts of the chest.
  Feebleness of the  sound may indicate fatty degene-
ration,  or   softening, atrophy,  general debility,  or
accumulation of fluid  in the pericardium; or,  again, 
                        87
the interposition of the non-conducting emphysematous
lung.
   Increased  sharpness may  suggest thinness of the
walls of the heart, as dullness points to  hypertrophy
and  thickened valves.
   A dry and sharp sound—increased tensity of the
valves.   Hoarse and muffled—a tumid condition of the
same.
   Metallic  sound  is  usually  dependent  on  gastric
flatulency or nervous excitement, but sometimes due
to stiffening  of  the  muscular  structure  from old
carditis.
   The addition of a  bruit to sounds is a  circumstance
which demands all the skill of the Examiner to appreci-
ate  in its  bearings.  The blowing sound may vary
from the lightest murmur to the grating,  rasping, and
even whistling or musical sound.   It is well to  recol-
lect  that the  intensity of the abnormal sound is not
coincident  with the extent of the lesion.  The bruit
de soufflet is caused by some  obstruction  to  the free
flow of blood through the heart  and great vessels,  or
by a wrong  composition  of the  blood, or nervous
excitability.   In the  latter instances the bruit is  often
temporarily absent,  but in case of organic  lesion, the
bellows-murmur,  of  greater  or less intensity, must
always be present.
   The  differential diagnosis of the immediate causes
of the changed  character of the sounds is not so im-
portant here,  for when traced to actual organic lesion
of the heart, the case must be  rejected, whatever part 
                         88
of the structure is involved.  But for convenience of
reference Dr. Henry's diagnostic table is introduced:
  Bruit :  If systolic and loudest at
           Base ==. Aortic obstruction.
           Apex = Mitral insufficiency.
  Bruit:  If diastolic and loudest at
           Base — Aortic insufficiency.
           Apex = Mitral obstruction.
  Pulse:   If  regular,  full, or   strong, jerking  or
     resilient = Aortic disease.
  Pulse:   If  irregular,  intermittent, unequal,  soft,
     small, weak = Mitral disease.
  The systolic bruit, synchronous with the pulse and
most audible  at  the  apex, indicates  mitral  disease.
The diastolic bruit, most audible  over the centre  of
the  sternum and  along  the course of the  aorta,  is
indicative  of aortic  disease.   Blowing sounds  from
functional disorder,  impaired blood, etc., are  usually
soft — rarely harsh or musical.   Although  there is
evidence  that  the  bruit is  occasionally an  individual
congenital peculiarity,  nevertheless  the rarity of such
cases, and the difficulty of  establishing  their history,
must  preclude their acceptance.    Recurrence to  the
historical and other rational symptoms, may convince
that  the  abnormal  sound  does  not  depend  on  or-
ganic change,  but while  present  it  rejects  or  at least
postpones.
   Location of Sounds.— Effusions, tumors,  morbid
adhesions,  etc., may  displace the sounds laterally  or
antero-posteriorly.  Descent of the sounds indicates
 hypertrophy with dilated  auricles,  or tumors at  the
 base of the heart.  Abdominal distension, by raising
 the diaphragm, may cause ascent of the sounds. 
                         89
  Friction sounds are indicative of changes in the serous
lining of the  pericardium,  analogous to those  which
have been alluded to on the pleura, tendingto adhesions,
contraction and  impairment of cardiac movements.
When present they reject.
   Diseases.— Among those affections of the heart to
which the  examiner's attention  is  to  be directed may
be  noted:  Aneurism, Angina  Pectoris, Adhesions,
Atrophy, Cyanosis, Degeneration, Dilatation, Hyper-
trophy, Malformations, Myocarditis, Pericarditis, Val-
vular changes, and, lastly, disorders not involving ap-
parent structural changes, but rendering  its movements
and sounds abnormal.
   Aneurism may affect the wall of the  heart,  or the
coronary arteries.  Its symptoms and  signs are alike
obscure, but  the possibility of a  party, pronounced
free from  cardiac  disease,  dying  suddenly from this
lesion renders it  desirable for the  examiner to bear in
mind  its  occasional  occurrence — particularly  when
investigating  obscure cases.
   Angina Pectoris — that intense pain in the precor-
dial region,   with  suffocative  sensations  and  fearful
anticipations of sudden death — is generally indicative
of fatty degeneration or obstruction of the coronary
arteries.   In  all  cases it rejects.
   Adhesions, impairing the mobility of the organ, and
most usually accompanied by lingering pericarditis,
temporarily rejects.  In such cases there is possibility
of ultimate recovery.
   Atrophy — diminished  area  of  dullness,  lessened
intensity of sounds  and impulse.  This condition is 
                         9o
invariably  connected  with such  a degree  of general
cachexia,  or  debility,  that  the  latter  alone would
preclude the risk.
  Cyanosis, usually congenital, but not always—some-
times appearing late  in  life — is  both incurable and
subjects to the chances of sudden  death.
  Degeneration,  ordinarily  fatty  and coincident with
similar affection of the kidneys, liver, etc., rejects.   It
is tolerably recognizable by exclusive diagnosis. Feeble
impulse, weak sounds, slownesss of pulse, occasionally
dyspnoea  with  evidences of  pulmonary  congestion,
general debility,  giddiness, faintness, nervous exhaus-
tion,  etc.   In all  cases  of obesity,  especially where
fattening has taken place rapidly, as often  during con-
valescence  from low fevers, the heart must  be carefully
inspected for signs of this grave change.
  Dilatation may be coincident with hypertrophy, natu-
ral thickness of the wall, or with the latter attenuated.
In the last mentioned form there are increased area of
dullness, less  powerful impulse, but increased intensity
of sounds.   The pulse is weak and irregular.   Inac-
tive capillary circulation in the extremities.   Gastric
and cerebro-nervous symptoms, dyspnoea,  palpitation,
etc.   However  mild  the  rational  symptoms,  the
dilatation alone, if made out, rejects.
  Hypertrophy,  whether concentric or eccentric, declines
the  risk.  It is  usually  connected with valvular  ob-
struction, although hypertrophy of the right  ventricle
may depend on obstruction to the pulmonary circula-
tion.  Differential diagnosis is scarcely important here.
Increased  area  of dullness, augmented impulse,  less 
                         91
distinctness of systolic sound, and, usually, concurrent
changes in the valvular sounds.   Full and flushed face,
headache, vertigo, cardiac uneasiness, pain  or palpita-
tion increased by  exercise, dyspnoea,  etc.,  may  be
acknowledged  as present  to a greater  or less  extent.
The hypertrophy is rather the result of disease than a
disease itself, but it is so fraught with danger that the
applicant must be turned over to invalid companies.
   Malformations and misplacements of the heart scarcely
need more than an  allusion in this place.   Cyanosis,
dyspnoea, palpitation and morbid sounds may be pres-
ent.   The  malformed heart always  vitiates  the risk,
even though signs of its  injurious result  be not dis-
coverable.   Congenital misplacement of the heart is
so rare a phenomenon that, practically, it may be ig-
nored.  But if displaced by  effusions,  tumors,  etc.,
the cause will be warrant for rejection.
   Myocarditis is  of importance  to the examiner from
its results,  especially softening  and  induration.   The
latter  may ultimate in a dense  cartilaginous transfor-
mation of the tissue,  or even  osseous deposits.   Evi-
dences of either of these conditions utterly preclude
acceptance of the applicant.   (Vid. p. 21.)
   Pericarditis often leaves behind it  adhesions  impair-
ing the cardiac movements, or effusions impeding dila-
tation.   The methods of diagnosis  have  been pre-
viously given.   Entire absence of rational symptoms,
and physical signs of lesion, must be  insisted upon
prior   to  insurance.    Repeated  attacks disqualify,
whether any symptoms or signs of mischief are present
 or not. 
                         92
   Valvular changes, aside from their  interference with
the transit of blood through the heart,  are significant
of chronic Endocarditis,  Bright's disease,  Rheuma-
tism, Gout,  and various constitutional  derangements
of the system with impaired nutrition.   So constant
is  this association that, when there is doubt as to the
meaning of abnormal  valvular sounds, judgement can
usually be largely aided by  careful  attention to the
rational evidences of these, to the superficial observer,
apparently disconnected difficulties.
   Aside from the cachexia determining valvular change,
all forms are characterized by symptoms denoting in-
terference with  the  capillary  circulation.   Hence the
increased  frequency of respiration, and  the dyspnoea,
or rather the peculiar  breathlessness, under  all those
influences which  tend to render the pulse more rapid.
Even when there are few other noticeable  symptoms,
it will be found, on  questioning, that the  party sleeps
at  night with the  head and  shoulders  unusually ele-
vated.  There will be evidence of oppressed respiration
without actual dyspnoea, with semi-voluntary, deeper
inspirations  at short  intervals.  The movements are
languid and  the extremities, in the evening particu-
larly, are apt  to  be  puffy and swollen.  A short,  dry
cough,  palpitation,  occasional headache,  restless  and
disturbed sleep, and praecordial pains are often present,
and  usually  attributed  to  dyspepsia by  the  patient.
Hepatic venous changes and disturbed action of the
kidneys are the almost natural sequences, and without
due  consideration there is  a  liability to refer all the
unpleasant feelings of the individual to  " functional " 
                        93
disturbances  of these organs.   In all doubtful  cases,
an investigation of the condition of the renal  organs
will throw much light on the diagnosis.
  With the later symptoms and results of the valvular
lesion the Insurance Examiner, as such,  has nothing
to do, but a few words with regard to the relative  fre-
quency of the varieties, and their comparative fatality,
may not be considered out of  place.
  Aortic  Obstruction is one  of the  most  frequent  re-
sults of chronic valvular disease,  and is longer  in pro-
ducing fatal results.   It  involves  slow dilatation of
the left ventricle  and  thus renders the mitral  valves
insufficient, the consequence of which is mitral  regur-
gitation,  with symptoms  of congestion of  the  lungs.
In this obstruction there  is, when the heart is beating
forcibly,  marked  parietal  vibration over the base of
the heart and the aorta.
   Aortic  Regurgitation  is also  quite common,  and af-
fects similarly  the ventricle and mitral  valve.   The
pulse is peculiar— " short and jerking."
   Mitral Obstruction is infrequent.   It necessitates dil-
atation of the left auricle and  pulmonary artery  with
engorgment of the lungs.  The pulse  is variable in
force, but rapid.   Cough, respiratory oppression, and
general  disorder  follow,  and  death speedily  ensues,
usually from pulmonary oedema or apoplexy.
   Mitral Regurgitation is the most easily recognized of
all the valvular lesions.   The mitral valve seems to be
the  favorite point of  attack when  rheumatism  impli-
cates the heart.   The  systolic murmur is  manifested
by  the slightest  changes, even  when  symptoms are 
                         94
absent.   The blood,  escaping the imperfectly closed
orifice, is driven back upon the lungs, producing  con-
gestion, with feeble pulse and dusky complexion.  The
left side of the heart is dilated—the ventricle also be-
ing hypertrophied.   There is a chest thrill, but  it is
not transmitted along the aortic trunk.  The pulse is
irregular and deficient in fulness and force.
  Obstruction, and regurgitation, through the pulmo-
nary orifices are so rare as, practically, scarcely to de-
mand  notice.  Regurgitation  through  the  tricuspid,
however, may not infrequently occur as  a consequence
of dilatation of the right ventricle, which then be-
comes hypertrophied, the  auricle and vena cava dis-
tended, and  there is a strong tendency to congestion of
the systemic and cerebral circulation.
  So far as term  policies  are concerned,  or invalid
risks, simple  aortic obstruction  is by  far  the most
favorable for assurance.   Mitral and tricuspid regurgi-
tations are the least so.   A system otherwise in perfect
order, may gradually adapt itself to the changed cardiac
conditions, and life be prolonged indefinitely.
  Non-Organic  Diseases of the heart  are  capable
alone of producing death, and hence, on determining
the absence  of  organic lesion, they should not be  dis-
missed unnoticed.  Youths and young  adults are lia-
ble to them  to  a marked  extent.  So also women about
the  climacteric period.    They  are  the  product of
nervous  exhaustion  or oppression, of   dyspepsia,
gout and  rheumatism.   Sexual excesses, uterine  irri-
tation,  over-use  of  narcotics  and stimulants  etc.,
readily beget them. 
                         95
  Palpitation  and intermittent,  irregular and  feeble <■
pulse may be associated with valvular murmurs, closely
simulating those from organic disease.  There may be
praecordial pains, with occasional  attacks of headache,
giddiness,  or even syncope.   Violent pulsations of the
larger arteries, and a  bruit may be heard  along their
track.  There may even be subcutaneous oedema.
   Dyspnoea is rarely  present, and at times the  valvu-
lar sounds  are healthy.   All the symptoms are more
strongly marked than in real organic disease.   Careful
analysis will  detect  differences not  easily described.
The concurrence of symptoms will develop a non-in-
surable condition, at least  temporarily   existent,  in
doubtful   cases.   Diagnosis  from  fatty  degeneration
will give  the most  difficulty.   Frequent functional
disorders  increase  the  liability  to  ultimate  organic
diseases.
   Generally the blood murmurs of non-organic affection
are  heard  at  the base  of the heart,  but  occasionally,
probably rarely, the  murmur is  to be heard over the
centre of  the heart, and becomes more distinct at the
apex.   In the latter case anaemia is usually so distinct
as alone to decline the risk.
   In the  non-organic affection  the signs  of hyper-
 trophy do not accompany  the abnormal  bruit.  The
 murmur  is heard along the blood vessels.   It is fol-
 lowed by  a short and sharp second sound.  The mur-
 mur "is almost invariably,  notwithstanding the  exag-
 geration   of  other  symptoms,  of  a soft  character.
    But it must be  confessed that it often  requires the
 grestest tact to decide correctly in  these cases.   For 
                         96
the Insurance Examiner  the  best  rule is to examine
at different times and with the most rigid precautions
against error, recollecting that when the "functional"
disorder is  so  considerable as  to  give doubt of the
presence of organic change, the party is  uninsurable
on that account alone.
   Diseases of  Bloodvessels.— The occasional occur-
rence of aneurism,  without symptoms noticed by the
patient, suggests attention.   The aorta may be dilated,
or so enlarged by aneurismal tumor, as to cause bulg-
ing of the  thoracic parietes  before  its  peculiar and
ultimately  terribly distressing  effects are  developed.
Or it may cause what is supposed to be laryngitis,  by
pressure on the  recurrent laryngeal nerve;  or attacks
of dyspnoea, analogous to paroxysmal asthma.  When
its graver influences are  manifest, naturally,  the suf-
ferer  will  not  present himself for  assurance.   But
earlier examination  may detect, along the  course of the
aorta, slight  protusion and dullness over the surface.
It is more  resistant, and the systolic  impulse is com-
municated  strongly to the* finger.   There may be vi-
bration,  but this is not always present.   The persis-
tent  systolic impulse  at  the point, together with the
usually attendant dyspnoea, cough, frequent irregularity
of the circulation, swollen veins of the neck, and tho-
rax ;  sometimes diversity in the pulsations of the two
radial arteries, from pressure on the sub-clavian;  con-
traction of a single pupil on  the affected side,  with
more or Jess disturbance of remote organs, will enable
a decisive judgment against the applicant.  When evi-
dences of intra-thoracic  tumor are present, differential 
                         97
diagnosis is unnecessary, for any kind rejects, but it is
well to bear in mind that aneurismal tumors constitute
the largest majority.
   The  condition  of the  arterial system, as a  whole,
here comes under  review.   Is there an aneurismal ten-
dency, from disease affecting the arterial wall ?   Does
the rigid inelastic  artery  of advanced age suggest the
conditions of senile  gangrene ?  Is the structure such
as  to endanger rupture  and apoplectic extravasation
in the brain ?   Do the veins show  marks of tardy re-
turn of the blood  ?   Has the valvular structure  been
obliterated and  the  varicose condition  ensued ?  Ex-
tensive  varicosities of the  veins impair the risk, not
solely from the dangers of rupture  and hemorrhage,
but because indicative of either a  general tendency to
disease of  the  venous system, or some obstruction
which may be of permanent character on the  proximal
side of the enlarged vessel.
   Extraordinary pulsatory movements of the arteries,
as noticed particularly along the aorta, carotids and tem-
porals,  suggest  anaemia, structural  derangement of the
digestive organs as in the gouty diathesis, or great ex-
citability of the nervous system.   In the female it is
liable to be associated with uterine disease.
   In some instances it is  one of the concurrent evi-
dences   of abuse   of alcoholic stimulants,  tobacco,
opium,  etc.

                         V.
   Abdominal   Organs. —  The  historical  indications
may call attention to the condition of particular viscera,
      7 
                         98
but in every case the general contour of the abdomen,
its proportion,  symmetry and  movements should be
observed.  It is proportionately larger in children than
in adults,  and again  with advancing age it  becomes
more protuberant.   Obesity more speedily shows it-
self by large deposits on the omentum  and in the ab-
dominal walls.   It may be distended by ascites, by ac-
cumulated gases or by tumors.   It is more voluminous
in females who have borne children.  In the region of
the epigastrium it is always enlarged after eating, but
in many cases  of dyspepsia it may become enormously
distended by persistent flatulency.
  The liver or  spleen may be so increased in dimen-
sions as to occupy, respectively, the greater part of the
cavity.   Mesenteric disease, ovarian growths, encyst-
ed fluid  or solid tumors, accumulation  of faeces and
hernial protrusions, severally, may change  its outline
and indicate more or less grave results.
  Retraction of the walls  may call attention to general
emaciation, exhausting chronic diarrhoea or dysentery,
metallic  poisoning,  tuberculosis  of the  mesenteric
glands, or  occasionally fibroid or cancerous  deposits at
the orifices of the stomach.  The shrunken abdomen
warns  of deficient nutrition and cachexia.   It is also
liable to  be present in organic affections of the brain.
  The contour and proportion  are  best observed in
the erect position, but if circumstances require investi-
gation of the exact condition of the viscera, the person
should be  placed in the recumbent position  with the
limbs flexed on  the trunk.  With  proper precautions
to  relax the  muscular investment,  the outline and 
                         99
general condition of the contained organs can be ascer-
tained with very  great exactness,  unless the party is
very obese.
   The Stomach,  if abnormally distended,  indicates
impaired  digestion, or an  obstruction  to the passage
of the chyme from its cavity.   Deficient secretion  of
the gastric juice, or deficient  innervation with conse-
quent loss of mobility,  are  suggested—the deficient
innervation  possibly  dependent on cerebral  lesion.
Obstruction involves  either temporary spasmodic  ac-
tion, or a thickened or carcinomatous pylorus, which
latter may be detected by deep palpation.
   The small  or shrunken stomach  accompanies weak
digestive power and scanty nutrition.
   The Liver enlarged,  points to endemic influences
and portal venous congestion, or such other causes as may
produce the  same result.  Even dropsical  accumula-
tion may ensue, but as the cause is ordinarily  tempo-
rary and removable,  its  previous occurrence does not
decline, and its presence  only postpones the risk.  But
enlargement  from hepatic  venous congestion,  with or
without dropsical effusion, prevents insurance, because
 dependent on thoracic obstruction to the  circulation.
 Unless that  obstruction is proved to have been only
 temporary, the objection is a fatal one.  The diagnosis
 between these two forms is usually readily made out,
 and  the  important character of their  diversity must
 fully  impress the Examiner.  The enlargement  may
 be due to abnormal deposits in the  parenchyma — to
 determine the character  of these requires attention to
 the history, and establishment of the diathesis.   If to 
100
be referred to abnormal deposits or growths, the  case
must be rejected.
  Atrophy  of the organ is generally  connected  with
evidences of impaired digestion  and secretion, which
taken with the history,  will suffice for diagnosis.   In
vastly  the  larger proportion of cases  the small  liver
depends upon cirrhosis,  and this produced by habitual
use of alcoholic stimulants.   In all cases this  condi-
tion established, even without symptoms of its remote
results, denies the risk.  Its most obvious concurrent
symptoms  are disturbance of the stomach and obsti-
nate diarrhoea.   The  superficial veins of the abdomen
are apt to  be enlarged; the skin is sallow,  dry  and
rough.  Dr, Budd asserts  strongly :   " Slight sallow-
ness of complexion,  a  dull pain, or some degree of
tenderness  in the right hypochondrium, with occasional
feverishness, in a person above the age of thirty,  who
has  been   long  in  the habit  of drinking spirits  to
excess, are  almost conclusive evidence of  the existence
of cirrhosis, even before there is  any distinct proof
that the circulation through the liver is impeded."
   The same condition of  the  organ may be produced
by various cachexiae,  particularly malarious and syphi-
litic poisoning,  caries  and necrosis.   Whatever the
cause,  its presence rejects.
   Degeneration of  the  parenchyma of the  organ  by
fatty or amyloid deposits, begets a similar train  of
symptoms, but  is generally  associated with enlarge-
ment  of its bulk.   The  diagnosis is facilitated  by
reference  to the history of the case and concurrent
symptoms.   Both  involve   gastric  derangement, 
IOI
tumidity  of the spleen,  diarrhoea and anaemia.  The
fatty  degeneration may,  however,  be connected with
more or less general corpulence, often gained rapidly,
and in the latter case is always suspicious.  From what-
ever cause arising, and however moderate the manifest
symptoms, both varieties reject.
   Acute Atrophy  will  not,  from  the activity  of  the
symptoms, be presented  to the Insurance Examiner.
   Chronic Inflammation of the viscus, whether superficial
or parenchymatous, is the not infrequent result of resi-
dence in  tropical climates, or of intemperate habits,
or cachexias.  While present,  it rejects, whether it  has
yet produced either hypertrophy,  or atrophy, or any
of the  later symptoms of the disease.   It  is well to
recollect  that, under the influence  of  treatment,  the
person may suppose a  cure to have been effected, and
thus present himself for  insurance.  Nevertheless,  the
admitted  occasional anorexia, diarrhoea, scanty  urine
loaded with lithates, sallowness, dryness and roughness
of the skin, the physiognomy and progressive emaciation
and  debility,  will sufficiently characterize the case.
   Jaundice  has been already referred to (p. 27).   Since
while present, in all cases,  it at  least  postpones, its
differential  diagnosis is here scarcely necessary.
   The Pancreas is rarely diagnosticated as the seat
of disease.   Its enlargement can usually be determined
by palpation, and, from  whatever cause, declines  the
risk.   The increase of size is generally accompanied by
tenderness, a  sense  of fulness  or hardness, heat and
constriction, anorexia,  nausea and obstinate vomiting, 
102
 or inodorous eructations,  emaciation,  debility,  and
 mental depression.
   The Spleen is so frequently enlarged permanently,
 without any evidences of derangement of health, that
 unless the enlargement is excessive, forming abdominal
 tumor, or the signs of malarious or  other cachexia are
 present, it may scarcely be considered as impairing the
 risk.   Nevertheless, the frequent association  of en-
 larged spleen, with degenerations of the liver and other
 organs, with affections of the  lymphatic glands,  with
 leukaemia, phthisis, etc., renders it incumbent upon
 the Examiner, whenever it is  present, to make a mi-
 nute and exhaustive survey of the organs individually
 and of the system as a whole.
   The  Intestinal Tube.—There may be physical ev-
 idences  of distension of the intestines by tympanites,
 accumulated faeces, herniae or tumors.   But the atten-
 tion of  the Examiner is rather directed  to the condi-
 tion of the canal by historical or concurrent symptoms
 which indicate its condition.   Hernia is noticed upon
 p. 31, et seq.  Heterologous growths of any variety re-
 ject.  Acute affections of the tube postpone.   Chronic
 disorders and lesions may require careful investigation.
   The most frequent cause of question is the presence
 of chronic diarrhea,  meaning by the phrase abnormal
 frequency  and fluidity  of  the  alvine  evacuations.
 More important  than these will  be found the charac-
 ter of the discharge.   There may exist a chronic ca-
 tarrhal affection of the mucous  membrane, wherein,
with little or no  noticeable  disturbance of the health,
the increased frequency and fluidity of the discharges 
                         103
 is kept up  by mere habit of the  part, in accordance
 with a well understood physiological law.  Or it may
 be a normal individual peculiarity.  In such a case the
 risk may not be invalidated.   But the  fact that such a
 condition of the canal very generally denotes irregular
 habits of diet, the  abuse  of  alcoholic stimulants  or
 opium, or local disease of the adjuvant  or remote
 organs, suggests caution, (p. 40.)
   A very large proportion of those engaged in the re-
 cent war are subject to this form of diarrhoea, which,
 subsiding for a time, is readily provoked by  exciting
 causes.  In the absence of the  evidences of ulcerations,
 organic affection  of the liver or  kidneys, scorbutus,
 tuberculosis or other  cachexia, such cases  need not
 necessarily be  rejected, but very great  care should  be
 exercised.   The evidences of deficient nutrition afford-
 ed by emaciation, or its correlative, fatty degeneration,
 disqualify.   Thoracic  obstruction  to  the circulation
 may ultimate in diarrhoea, and hence inquiry is directed
 to the  heart,  lungs,  etc.   Deficient  frequency,  or
 consistence of  the  evacuations,  points to the  mere
 habit of the parts, illustrating  rather the distensibility
 of the large  intestine than disease ; or, it may remind
 of mechanical  obstruction  by bands of  consolidated
 and  contracted lymph from previous  enteritis, or her-
 nia,  or the pressure of tumors, or hypertrophied viscera,
 or to defective secretions from  the mucous membrane,
 the  liver,  and pancreas,  etc. ; or to the  benumbing
 influence of  retained excreta, or poisons received; or,
deficient innervation from  central disease of  the ner-
vous apparatus.  The varying gravity of these causes 
                        104
renders their  differential  diagnosis a matter  of great
importance, in order that justice may be done both to
the applicant and the company.
  Among  the lesions of the tube which give rise to
the least marked symptoms, and yet pregnant of grave
consequences, is to  be noticed  Atrophy of the mucous
membrane—a condition frequently found in the tardily
convalescent,  and  in those laboring under a  more  or
less manifest cachexia, tuberculous, syphilitic, amyloid,
etc.   This may be present without apparent diarrhoea,
costiveness or constipation.   When present it is likely
to invade  the entire  continuity of the membrane.
Often all the symptoms  observed are referred vaguely
to dyspepsia, but it may have originated in a true cir-
rhosis  from inflammation extending  to  the subjacent
tissue.  From whatever  cause arising, it is among the
reasons for rejection.   The labial, buccal and pharyn-
geal membrane will exhibit the  imperfect structure to
the eye, whilst anaemia and debility  are  minatory, if
not actually present—without seeming cause.   There
will be admitted anorexia, nausea on  arising from the
recumbent  position ; a sensation as though "food was
never effectually swallowed, but  stuck at  the diaphrag-
matic entrance of the stomach, causing the  peculiar
reeling of  weight  which attends indigestion  and  the
abundant generation of gaseous  fluids."
  Hemorrhoids are occasionally  of such  severity and
productive of such exhaustion,  as alone to preclude
insurance,  but ordinarily they  refer examination  to
their producing cause,  which  is usually some  obstruc-
tion to the return  of blood  from  the rectum.  Thus 
                        io5
habitual constipation, enlarged uterus, pelvic or abdo-
minal  tumors, a  cirrhosed  or congested  liver,  etc.
Or,  they  may indicate the general relaxation of the
valve structure of the veins, resulting from residence
in tropical  climates, or diseases  tending to produce
congestion of the pelvic vessels.
   Chronic  Dysentery  is noticed on page 40.  "The
prognosis is never very favorable"—but  the diagnosis
should be exact.
   In a general survey of the alimentary canal and  sub-
sidiary organs, the relative power and perfection of the
nutrient system should be comprehensively estimated.
Upon it depends the entire superstructure of organiza-
tion.    Its  condition modifies judgment  as to  the
probable  influence  of both hereditary  and acquired
predispositions.  It influences the prognosis as to the
results of both acute and chronic disease.  Even when
organic diseases of grave  character are  unmistakably
present, as developed by the expert diagnostician, its
high degree of perfection is capable of  masking and
concealing the rational symptoms usually observable in
less  fortunate  cases.   Lesions,  ordinarily confessed
beyond the control of so-called medicines,  sometimes
disappear  under the  healing influence of healthy blood
furnished  to them by a powerful  digestive apparatus.
Thus vigorous digestion  may aid the  Examiner  in
conscientiously  recommending a risk which has some
notably objectionable features.   Yet the same condi-
tion of the chylopoietic viscera, associated with organic
changes, may add weight  to  the reasons  for rejection.
Witness the  bruit  of  the heart's  valves,  while  yet 
io6
abdominal health is  undisturbed.   Witness the tu-
berculous deposit  in  the lung, which  remains  un-
heeded until  some  accidental  cause  impairs  digestive
energy, and  then the softening,  breaking down,  and
hectic speedily number the remaining days of existence.
The judgment of the Examiner is the combined result
of a multitude of perceptions, vivified by the educated
reasoning faculty—as  the body  of  man  is made  up
from  almost  innumerable parts, controlled by the
single principle of life.
  The  Kidneys.— As in the  instances  previously
cited, acute affections of the renal organs do not come
within the scope of a life insurance  examination, but
their chronic  lesions are so frequently  obscure and so
frequently misapprehended, both by applicants and phy-
sicians, and at the same time they are so dangerous in
tendency that the Examiner  should  be "armed at all
points" against mistakes in regard to them.
  Enlargement of one  or  both kidneys from hyper-
trophy, cystic or heterologous growths, etc.,  may be
discoverable  as   abdominal  tumor.   Whatever  the
differential diagnosis, such cases must be declined.
  Chronic Inflammation is one of the  forms of  Bright's
Disease to be presently discussed.   It is noticed here
as frequently confounded with simple nephralgia, spinal
irritation, chronic rheumatism (lumbago), gout  and
scorbutic  pains.   The chronic  nephritis absolutely
rejects.
  Nephralgia is  often  but the  evidence  of a tempo-
rarily, highly acrid and irritating secretion,  or  a "mis-
placed gout;" or the passage of what may prove but 
                        107
a single renal calculus; or it may be but an  alternate
of neuralgia, usually occurring in other parts,  the effect
possibly of malarious disease.   It may be the tempo-
rary result of medicines  or poisons, or, as in small-
pox, perhaps from irritation of the specific virus.  Or
the  renal  anguish  may  depend  on  enteritis.   The
diagnosis is to be exclusive — absence of the distinctive
concurrent symptoms of the other affections noticed,
must be determined.  Nephralgia readily passes into
nephritis,  and unless the fact of  its occurrence is an
isolated one, and the phenomena  definitely traced  to a
removable and   removed  cause,  it should decline.
Recurrent attacks are equally objectionable to the risk.
 (Vid.  p. 35, et seq.)
   Bright's Disease, or Albuminuria.—Desquama-
tive nephritis in the acute form, from its active symp-
 toms, does not require notice here—but the chronic
 form may exist for a long time without marked- symp-
 toms, and hence a liability for both the applicant and
 the Examiner  to  overlook  an  uninsurable case of
 disease.   Without actual sickness there  may be  gen-
 eral  feelings of malaise, with  imperfection  of health
 and general debility.   Anorexia or capricious appetite,
 with  gastric and intestinal  disorder,  vomiting  and
 diarrhoea, usually attributed  to  dyspepsia.   Progres-
 sive emaciation, which, however, is  sometimes  con-
 cealed by the puffiness of anasarca, most noticeable on
 the face and eyelids,  but gradually becoming general.
 The urine is passed more frequently than usual — the
 patient being obliged to rise in the night for the  pur-
 pose.   The urine may  be normal in its  appearance 
io8
and chemical reaction, but microscopic examination
will detect in the sediment disintegrated epithelial cells,
or even fibrinous casts of tubuli uriniferi from the kid-
neys.  The general  aspect of the party  will show the
almost  indescribable,  but  nevertheless characteristic
physiognomy of  renal  disease.   The skin  is  dry,
rough, and sallow — in time becoming anaemic, waxy,
and sodden..  There are  evidences of  oppression in
respiration from slight oedema of the lungs.   Frequent
local pains — most frequently cephalalgia, but invading
any part,  may be admitted, but are referred vaguely
to dyspepsia, rheumatism, or neuralgia.  These com-
municate  a  permanent expression  to  the  facial  lines.
Disorders of vision  are not infrequent, and the expert
ophthalmoscopist can sometimes detect on  the retina
evidences  that  the  supposed local affection depends
upon organic lesion of the distant  kidneys.   Deaf-
ness and  local  paralyses  elsewhere, may be the sole
monitions of the renal affection.  Supposed  " func-
tional," but ultimately clearly organic cardiac disease,
may mask the real difficulty.  In fine,  a marked  pro-
clivity to local  inflammation of whatever  organ  or
surface, even though  the  party,  at  the time of the
examination, be apparently in excellent health,  lends
color to suspicion of renal imperfection.
  All the symptoms here  recounted may be present in
any of the forms of  Bright's Disease, whether resolved
into atrophy,  cirrhosis,   degeneration,  or deposit.
Save in so far as the accompanying cachexia of  each
may have its own bearing on the general character of
the  risk,  their  differential diagnosis  is unnecssary. 
                        109
Their  ultimate  result is the same—uraemic poisoning
and death, which  may be hastened by the concurrent
affections of the heart, lungs, liver, general  or local
dropsy, etc.
   The prognosis is always grave, and  hence  the sub-
ject uninsurable, even though temporarily there is an
absence of symptoms.   In all doubtful cases the urine
should  be tested  in its  specific  gravity, its  chemical
reactions,  and  microscopy  of its  sediments.   The
peculiar fuliginous  appearance  sometimes  present,
probably  from some chemical change in the  haematin
accompanying the  desquamation, will readily  attract
notice.   So also the presence of albumen, but particu-
larly the low specific gravity, and the  sediment com-
posed  of the  epithelial casts  and disintegrated blood
cells.   The tests are so simple, and so easily applied,
that, while  interests  of such  magnitude are  in issue,
there should  be no  excuse permitted for neglecting
them.   It should be borne in mind that  Temporary
Albuminuria  may  have been  present, in connection
with previous diseases, and yet complete recovery have
taken place.   Thus, in connection with Scarlatina and
other exanthems,  Cholera,  Pneumonia, Rheumatism.
Or again from  confinement  to  an  albuminous diet.
Occasionally,  also,  during  pregnancy.   Probably in
these cases there has  been no considerable or  continu-
ous  exfoliation of the epitheliun of the tubuli uriniferi.
Such  cases  may  not,  from their history, impair the
risk.   But it is unsafe to  accept a case of present albu-
minuria, even though there may be strong belief that
it is the simple form. 
no
  Calculus present rejects.   Recurrent attacks also for-
bid the risk.   But it may be recollected that popularly
mere vesical pain and strangury are attributed to grav-
el, and hence, when this is spoken of,  the  case should
be further tested.
  Chronic Cystitis and Enlarged Prostate disqualify, and
so,  also,  during  its  existence,  Permanent  Stricture.
These  lesions, on occurrence of slight exciting causes,
may eventuate  fatallv.   Spasmodic  stricture  is not
infrequently  symptomatic  of  renal  lesion,  and the
chronic inflammation of the bladder may also be kept
up by  the deranged kidneys.
  Diabetes  may  be   noticed  in  this   connection,
although scarcely to be considered as a disease of the
kidneys.   From its insidious nature, and long absence
of readily cognizable symptoms, it is  liable to be over-
looked both by the party applying and the too unob-
servant Examiner.   Aside from the varying influences
which,  within the limits  of health,  may  increase  or
diminish the amount  of  urine excreted,  any  undue
quantity  habitually passed  should  direct attention.
Whether saccharine or not, the undue amount post-
pones.   If repeated tests show the presence of sugar,
or abnormal specific gravity, the risk must  be declined.
Absence  of  these,  and   increased  amount,  suggest
Bright's Disease.
  The skilled  Examiner  may often detect early the
rational symptoms  of  the affection.   The  skin is dry,
rough  and shrunken, with  a tendency to morbid nutri-
tion of its appendages, or boils and carbuncles.  Dry-
ness, also, of the buccal membrane, with shrinkage  of 
Ill
the gums.   Unusual thirst and  inordinate  appetite,
often resulting in distended stomach.   Constipation,
with dense and friable faeces.  The odor of the breath
sweetish,  or, as  has been suggested, chloroformic.
Gradual emaciation, with muscular debility, and, occa-
sionally,  local  paralyses.    Slight, mental  hebetude,
with  languid movements.   Critical  questioning may
elicit the presence  of diminished  sexual  desire  and
energy.   In  very many instances  there may be super-
added the signs of hepatic degeneration,  and, always,
disorder of the  nervous system,  manifesting itself in
all phases, from mere dullness to  irascibility, peevish-
ness, capriciousness and  monomania.   By these  ner-
vous phases  of  the disease, the  emaciation, and rough,
dry integument, there is a physiognomy impressed upon
the person which can scarcely escape the notice of the
careful  Examiner.   In such cases  the  urine should be
chemically tested  by  the  most approved   modern
methods.
   It  is unnecessary  to refer  to the causation of dia-
betes, for  its rational symptoms, when strongly marked,
would cause rejection, whatever  their cause, and the
chemical evidences of its presence are totally exclusive.
   Addison's Disease,  or  that peculiar anaemic condi-
tion, with gradual bronzing in the color of the skin
which,  within  several years  past,  has attracted the
investigation of pathologists,  need  not here  receive
more than a passing notice.  When it is possible to
achieve  an  exact diagnosis,  the concurrent  symp-
toms  will alone be  sufficient  to  establish general
disqualification. 
112
                       VI.

   Cerebro-Nervous System.—Very many of the nota-
ble disturbances of the orderly manifestations of the cer-
ebro-nervous apparatus, are directly traceable to errors
in action  of the  digestive  organs.   Hence consid-
eration  of the former, to  be  satisfactory in  result,
demands  complete survey  of the latter.   Again,  it
often occurs that the apparent disorders of a part, or
even  the  whole, of the nervous system, may depend
upon reflex influences—local derangement of a single
point begetting a train of symptoms  which may be
mistaken for those dependent on organic lesion  of the
nervous centres.  Evidently, therefore, any judgment
formed with reference to the symptoms only, is liable
to be erroneous.   Aberrations of nervous manifesta-
tions, if dependent on organic disease of the nervous
centres, while  present  utterly  disqualify — whatever
their  extent.   But, if  owing  their  origin solely to
blood imperfectly formed, or rendered  noxious  by re-
tained excreta,  or poisonous material introduced into
it, or, from reflex influences from lesions in  other or-
gans or tissues,  the judgment,  obviously,  is  to be
shaped by considerations affecting the importance, ex-
tent,  character, permanency or  removability  of the
cause.   This  will  thoroughly  tax  the skill  of the
Examiner.
   It is well, in analysis of this branch  of the subject,
so far as it falls within the scope of the present essay,
to adopt  the  simplest  possible  divisions.   Thus  we
consider:   Derangements  of Motion,  whether  of the 
                        "3
voluntary or involuntary muscles; Derangements of
Sensation, whether common or special; Derangements
of Mental Action, whether of the reason,  or of the
emotions.
   Derangement of Motion.—Tremulousness, Tre-
mors, Spasms, Convulsions, Error of Co-ordination,
Rigidity, Paralyses, severally indicate a greater or less
disorder of the nervous apparatus.   It is necessary to
inquire whether that disorder be dependent on  local
or general  causes ; whether it depend on nutrition, on
toxaemia from retained excreta, or poisons taken into
the blood  from without, or upon  organic  changes at
the nervous centre.
   Tremor, or tremulousness, may be due merely to the
changes of advanced age.   If this sign of age comes
prematurely, the premature age marks a condition of
the system, as a whole, which lessens the desirability
of the risk.   Very frequently it is dependent on the
use of tea, coffee, opiates or alcoholic stimulants; being
the result  of their  action, although temporarily re-
lieved by them.  Concurrent symptoms here must be
carefully scanned.   The tremors of the opium eater,
or spirit drinker,  whilst deprived  of the accustomed
stimulus, should determine  rejection.  Metallic pois-
oning, as from lead, mercury, etc.,  may give the same
result.   Concurrent symptoms may determine  morbid
nutrition,  or  exclusive diagnosis  may refer the feeble
muscular agitation  to central disease of the brain or
spinal cord.  But  meanwhile it  may  be  a  nervous
idiosyncrasy,  or  temporarily  the   result  of reflex
influences, from removable  disease of remote  organs.
      8 
                        n4
   Convulsions, or Spasms, sometimes readily occur  in
persons of  a highly  mobile  nervous  temperament.
Hysterical females are especially liable to them, but
males  are not exempt.   Like the  milder symptom
just noted,  they majy be of centric or eccentric origin.
But ordinarily, when occurring without other evidences
of cerebro-spinal lesion, they  may be adjudged of ec-
centric origin.  Among the causes of the latter variety,
may be mentioned  dental and  intestinal irritation,
more frequent in children, but not  confined to them.
Uterine,  vesical  and  rectal  irritation in  the  adult.
Contaminated blood, from retained excreta or poisons,
and powerful  emotional influences.   Among the cen-
tric causes, we advert  to mal-nutrition of the  brain,
or its inflammation,  deposits,  morbid growths,  sudden
interference  with the cerebral circulation, as by emboli,
the shock  of injury, haemorrhage, effusions, etc.
  Epilepsy, one of the forms  of  convulsive action,  is
distinguished  prominently by its tendency  to recur  at
intervals, which may  be more or less distinctly periodic.
The period  between  the paroxysms  may show no
marked derangement  of  health, although, unfortu-
nately, there is likely to be mental hebetude and tardy
development of all normal  bodily action.  Its pecu-
liar  suspension  of consciousness serves to assist  in
diagnosing it from hysterical,  and, indeed, most forms
of convulsions.  True epilepsy always excludes, what-
ever its  supposed cause.   Convulsions from  other
causes, must be  measured by  them,  their permanence
or removability, and by concurrent  evidences regard-
ing their centric or eccentric origin,  and the respective 
                        us
bearings of these,  rather than the accidental symptom.
Generally speaking, recurrent  convulsions, even from
clearly  mild and  removable causes,  should postpone
until the  tendency to  them  has entirely  subsided.
Local  convulsive action of  greater or less  intensity
and duration, accompanied with numbness and inability
to move the part—or cramp, as popularly designated,
is sufficiently common to  persons in good health, and
need not  necessarily  disqualify.   But its  occasional
occurrence among the initiatory  symptoms of central
nervous lesions, or of  metallic poisoning, or, as reflex
from important remote organic  disease, suggests in-
quiry into the real meaning.
   Defective Co-ordination of the movements as exem-
plified  in Chorea, but present in  other cases without
the intensity of contraction observable in that disease,
points  to  a similar train of inquiries  as  to its causa-
tion.   It is often one of the most insidious of diseases,
occupying months  or years in its  full  development.
Thus in Duchenne's " Progressive Locomotor  Ataxia,"
characterized by long antecedent impairment of vision,
with inequality of the pupils, with wandering, brief
but piercing  pains,— " like  electric flashes"—then
vertigo and difficulty  in maintaining  the equilibrium,
and in  co-ordinating the movements, with local  anaes-
thesia or paralyses.  Functional  concurrent disorders
of the  bladder and rectum.   The necessity of a strong
effort of the will, in  connection  with the usually im-
paired  eyesight,  impresses an unmistakable  physiog-
nomy on the case.  Owing its causation, as it probably
docs, to atrophy  or degeneration of the great  nervous 
u6
centres,  and  its  prognosis always  being grave,  its
incipient signs should be carefully explored.
  Rigidity of the  muscles is closely  akin to paralysis.
It may involve but few muscles, or as many as in half
the  body.  It is  so  generally associated with  organic
disease of the brain, especially ramollissement that, un-
less  traceable  positively  to some  local cause,  it must
exclude.
  Paralysis, if involving any considerable portion of
the  body, as hemiplegia  or paraplegia, inexorably must
meet with refusal.  But  many  cases  of local palsy,
from definite  local causes  only,  are not  debarred  in-
surance.   Thus  where a nerve has  been divided  by
accident  or  surgical operation;  the  pressure of a  re-
movable tumor or growth; the presence  of some for-
eign substance, as a bullet or splinter, etc.; or, wherever
clearly referrible  to  the local  lesion  alone.   Again,
paralysis, as  well as  convulsions, may be reflex, and
the  lesion at the excitor  point  be  capable of relief.
Local vicissitudes may beget a local paralysis of mo-
tion, as when, e. g.,  the facial muscles  of one  side are
temporarily paralyzed  by  exposure  to a draft of  air.
In  like  manner  the  muscles of  articulation  may, by
paralysis, beget  aphonia.  Pressure on a nerve from
mere position,  local shock from a blow, or common
inflammation  may ensue in palsy of the parts  to which
that nerve is distributed.   Such cases  need  not neces-
sarily be rejected, but the large  proportion of cases,
wherein  this symptom is a concurrent  one of  diseases
of the brain or spinal cord, requires the  most minute
and exhaustive  research.  Occasionally it may happen 
                        ii7
that the loss of mobile power will be found dependent
on  the influence of some pervading poison, e. g. lead,
toxaemia,  etc.
  Deranged Sensation may be observed as affecting
nerves of common or special  sense.   Of the former,
pain is  the prominent exponent;  but  sensations of
heat or cold,  itching, tingling,  formication,  pressure,
etc., may co-exist, or be the sole manifestation.  Mu-
tatis mutandis, the same considerations enter into exam-
ination of the case, as in instances of deranged motion.
There is, however, this important diversity, that  the
intensity  of deranged sensation has no such  constant
relation  to the severity of the cause as  exists in dis-
ordered  movements.   The commingling of  mental
emotions may magnify or diminish the  real importance
of  the  symptom.  It is well remarked: "That acute
sensibility is not of necessity  inflammatory, is one of
the triumphs of modern pathology."
    Diminished sensation is  more analogous in its indi-
cations to paralysis  of motion,  than is  hyperesthesia
to  tremor or convulsion.   It is more liable to be con-
 nected with  central organic  disease,  or some over-
 powering general poison.   Extended anaesthesia, over
 a considerable surface,  is  exceedingly  apt to  be con-
 nected with  central ganglionic nervous lesion.   But
 sometimes  even the small and  circumscribed  part,
 which has become thus  affected, is among the premon-
 itory evidences  of brain or spinal disease.   In such
 cases the method of exclusive diagnosis  will clear up
 the difficulty.  It may depend on local influences, upon
 noisons  in the blood, or other abnormal conditions of 
n8
that fluid,  [e. g. rheumatism),  or be  the characteristic
symptom of certain cutaneous  eruptions.
  The Special Senses may present a similar variety of
perversions from merely local causes, reflex influences,
impaired or poisoned blood, or central disease of the
brain.
  Deranged Intellection acknowledges  the  same
variety of causation, and  while present positively de-
clines the risk, whichever may  have been the imme-
diate source of disturbance.
  Diseases.— Among  the  forms of disease of the
brain, against which the Insurance Examiner must put
himself on  guard,  as liable to be masked by general
indications of fair  health, are  to  be  noted:  Chronic
Meningitis, Apoplexy,  Deposits or Growths, Ramol-
lissement,  Insanity, Atrophy,  and,  not  the least  in
frequency, Chronic Poisoning.  As  affections  of the
Spinal Cord: Chronic Inflammation, Softening, De-
generation, or other evidences of its deranged  nutrition.
  Encephalitis of the  acute form  possesses  suffi-
ciently  distinctive  symptoms.    But it  may,  from
the beginning, be  sub-acute, and readily lapses into
the chronic  character.  In  the latter case,  the  brain
substance  is likely to become implicated, with  more
or less modification of  phenomena presented.  There
may be very slight vascular or general disturbance, but
careful  investigation may detect  more or less distinct
evidences of lesion.  If the pulse is perceptibly affect-
ed, it is  likely to be slower, or irregular and  intermit-
tent.   A little  impairment of the special  senses; it
may be hesitation or stammering in articulation,  which 
                         IIQ
 afterward, perhaps, will deepen into complete aphasia;
 constant, deep-seated  headache, nausea and vomiting,
 general malaise; some stiffening of particular muscles;
 limited paralysis, either of motion or  sensation,  or
 both ;  sluggish action of the secretory  organs,  with
 constipation and unusual  retention of urine.   Some
 peculiarity  of  mental  manifestation,  "eccentricity,"
 hypochondria, or preternatural elevation of spirits, or
 unusual proclivity to  entertain false or absurd notions.
 Restless vigilance may  alternate with profound sleep,
 with,  ordinarily,  stertorous  respiration.   The occur-
 rence  of previous traumatic injury of  the  head, or of
 some  disease  tending to  affect the brain,  will throw
 light  on the  diagnosis.   Location of  the cause of
 these  symptoms  in the brain, will frequently require
 the exclusive method of diagnosis.
    Apoplexy.—Undoubted apoplexy previously occur-
  ring,  although the party be now in apparently perfect
*health,  peremptorily rejects.   The  Life  Insurance
  Examiner is called upon rather to study premonitions
  — the forerunners of  the lesion before  it makes  its
  appearance.   The apoplectic habit is  popularly sup-
  posed to be one  where there is corpulency with a short
  neck, a florid face, and injected conjunctiva ; the latter
  appearances more marked in cases of excitement,  and
  accompanied  with a sensation of fullness  of the head,
  or vertigo and throbbing of the carotid and temporal
  arteries    If apoplexy occurs  in individuals of this
   Physique, it is rather because of fatty degeneration of
  the organs, than the condition of rude health supposed
  present   Or, as in  very  many cases reported, there 
120
was uraemia or other toxaemic causes of congestion of
the brain, mistaken for real apoplexy.   The tendency
to the so-called congestive or serous apoplexies, is  to
be elucidated by studying the mal-action of the nutrient,
secretory and excretory organs.
   True apoplexy involves haemorrhage into  the tissue
or cavities  of the  encephalon, and this presupposes
degeneration of  the  tissue involving  the coats of the
supplying arteries,  or,  the  originating lesion  may  be
confined to the  arterial wall.   The symptoms of real
apoplexy are closely simulated by  the detachment of
embolon,  and  its  projection  into,   and  consequent
closure  of,  some important artery of supply.  The
existence  of aneurism, save from simply  traumatic
causes,  always should suggest examination, so far  as
possible, of all  the arterial trunks.   Whatever inter-
feres with the activity of the  circulation,  when  the
arterial  parietes  are weakened  by calcareous or other
abnormal deposits,  by  fatty degeneration or arteritis,
etc., may  at once  involve apoplectic seizure in  the
midst of apparent high health.  Thus muscular efforts,
mental  influences,  especially of the  emotional kind,
disordered digestion, stimulants or narcotics, febrile
accessions, retained excreta, etc.  Not only persons of
"full habit," but those of  spare  frame,  long necks
and scant blood, may die  of it from  similar  exciting
causes.   There  may  be none of the  commonly  sup-
posed prodromata present, and yet the  party  be on  the
verge of an attack.   Something more than head symp-
toms are to be looked for.   When "shadows are cast
before," they are manifested " by great depression of 
f2I
spirits, by attacks of loss of memory, by illusions, by
vitiated perceptions, by vertigo, by odd sensations in
the head ;"  but these are rather the indications of the
degeneration than of the coming apoplectic seizure.
   Deposits  or Growths of an  abnormal  character
will vary in the symptoms presented, according to the
part of  the  encephalon invaded, and the degree of
mischief or size of growth.  The symptoms are often
obscure, and their character opined from the diathesis
or cachexia present.   Exclusive diagnosis is  the most
satisfactory;  the most  common  symptoms   being
" headache,  sickness, mental depression with  confu-
sion,  partial paralysis, and epileptiform convulsions."
   Atrophy of the encephalon is usually the condition
of senility;  but it may occur in the child or adult, as
the result of those lesions which cut off the supply of
blood — e. g. pressure of tumors or growths, embolon,
ligature of arteries, etc.   Advancing insidiously, it may
ultimate in utter dementia.
   Hypertrophy is  very rare,  but  sometimes  is  no-
ticed  in adults between  twenty and thirty.   It  seems
more probable that  what is denominated hypertrophy
of the brain, is rather a  disease of its bony case,  in-
volving  replacement of the cartilaginous substance, by
abnormal calcareous deposit.   Hence,  the unchanging
cranial  wall  develops the effects of gradual and pro-
longed  pressure upon  the contents.   This increased
density and  hardness of  the bone is gained at the ex-
pense of its elasticity, and hence, in such cases, there
is unusual fragility of the bones everywhere.  Repeated
fractures of bones from  slight causes, with any of the 
122
ordinary evidences of cerebral disorder,  direct atten-
tion to the  condition described.  It is fatal to  the
risk.
   Softening {Ramollissemeni) of the encephalon is one
of the most covert and insidious and, at the same time,
one of the most frequent and dangerous lesions of the
brain which the Examiner is called upon to discover.
Noticeable enough  in the acute form, it may advance
from  utter obscurity with  steps so treacherous and
and stealthy, that only the wariest observer can gain a
clue to its  presence, or avoid sometimes  confounding
it  with trivial affections.   Softening may  occur as one
of the results of acute  inflammation, or, as a conse-
quence of  senility.    But without any such history it
may come  on gradually,  at any  age, as the result of
those causes which beget local or general degeneration.
Thus mal-nutrition, diseased arteries, emboli, typhoid
or other  deposits, fatty degeneration, etc.   The func-
tional disorder of the brain, taken with the concurrent
symptoms, will clear up the diagnosis.  The evidences
of chronic  (white) softening are similar  to those of
the acute inflammatory  (red)  form, differing  mainly
in their intensity and duration.   The great difficulty
is  in assigning due weight to those diseases of other
organs, to  which  the brain  symptoms  may be only
secondary,  and  here, again,  the exclusive  method of
diagnosis becomes  indispensable.  Unless clearly at-
tributable to remote lesions of a removable character,
a case which has presented suspicious brain symptoms
should be  declined.  Among these suspicious symp-
toms,  we  note paroxysmal headache, aggravated  by 
12^
noise, light, exercise, etc.;  nausea and vomiting with,
generally,  constipation,  which  are not  traceable to
deranged digestion;  lessened  sensibility  of the blad-
der;  vertigo, nervousness,  hypochondria, diminution
of  mental  powers, with obtuseness of special  sensa-
tion.   Sensations of "prickings  and  twitchings in the
limbs,  sometimes pain, and  sometimes numbness."
Local cramps, and more or less permanent rigidity of
particular muscles.   General feebleness of the muscu-
lar sjystem, and hebetude of all the faculties.  A feeble,
irregular and  intermittent pulse.  The party may con-
fess difficulty in  "collecting  his ideas" — there is  a
little hesitancy of speech, a little  delay  in answering
questions — a little appearance of abstraction, and the
articulation not quite perfect.
   If historically  there  has been some disease or ca-
chexia present, which notably affects the encephalon—
some local  injury  from a fall,  or blow,  or  surgical
operation,  and especially  if the age  is  above  fifty—
the diagnosis is strengthened, that softening, or some
equally  important lesion  of  the brain,  is present.
The  physiognomy  of the affection is very impressive;
in  fact,  scarcely to be mistaken.
    In passing  it  may be  remarked,   that a condition
very analogous to chronic softening, with its attend-
ant symptoms, is very  frequently  observable after se-
vere Coup  de Soleil.   In  cases of  the latter the
 prognosis is  not  as grave, nevertheless, as it is capable
 of passing into actual  ramollissement, with paralysis,
 insanity, etc., wherever  the party has been so affected,
 the examination  should be cautious in the extreme. 
                        124
   Chronic Poisoning of the  brain may occur  from
the  habitual use  of Alcoholic Stimulants,  Opium,
Tobacco,  "Hasheesh," even Tea and  Coffee, and, in-
deed, a great variety of agents taken for the  purpose
of exhilaration or soothing.   During  the  use of the
narcotic, the individual may, so far as  external indica-
tions are concerned, .be on the level of perfect health ;
but, let any accidental  physical cause interfere with its
usual impression, or let its use be suspended, and the
condition  of  Nervous Asthenia  immediately super-
venes.  A  similar condition is  often observable in
those whese mental  faculties have been  overwrought,
and it engenders  an  almost uncontrollable  desire for
stimulants or anodynes—which latter  then  get the
discredit of its production.
   "Physicians,"  says Dr.  Flint, "are often consulted
by patients who, although far from being  well, have
no well-defined malady.   They complain of languor,
lassitude,  want of buoyancy, aching of the limbs, and
mental  depression.  They are wakeful during the
night, and enter upon their daily pursuits with a sense
of fatigue.   Under the pressure of mental excitement,
they may  be able  to  exert  themselves,  but, when the
excitement  subsides, they are  jaded  and  worn out.
They become  apprehensive that their  powers are giv-
ing way,  and are apt to fancy the  existence of some
serious malady.   An investigation of the different or-
gans of the body reveals no  evidence  of disease; the
lungs, heart, kidneys,  etc., are sound.  None of the
affections  embraced  in the nosological catalogue may
be discovered, yet the  morbid condition  is  real." 
                        I25
  A person in this condition is, clearly, laboring un-
der the result of undue changes in the minute structure
of the brain, precisely analogous to those which occur
from chronic poisoning.   The expert Examiner will
recognize the symptoms  when  present, or, if tempo-
rarily held in abeyance by the accustomed  excitation,
will scan closely the history, as given by the applicant
and sustained by the friend and physician.  Although
the prognosis, under correct therapeutic and hygienic
treatment, may be pronounced  by the physician  not
grave, the uncertainty of this being  carried  out,  and
its dangerous tendency if neglected, precludes, utterly,
acceptance of the risk.
   Delirium Tremens, Dipsomania, etc.,  previously exist-
ent, imperil  the risk.  It is only after the lapse of a
long period of time and  great  weight of  collateral
moral  evidences  of  reform,  that a  party  who  has
suffered from them can be accepted.
   Insanity.—Some general observations on this sub-
 ject have  been  made  on page 25, et seq.   In  this
place, we refer rather to the detection of incipient or
of masked  insanity.   The  importance of this topic
demands that it shall receive the most careful attention
 of the Examiner.   Distinct cases, or those connected
 with obvious disease of the nervous centre,  of course
 will not be presented for insurance.   But the cunning
 maniac, with proverbial ingenuity, has been  known to
 outwit examiners, and secure large policies upon his
 dangerous life.  Hence, clear ideas upon its diagnosis
 become as indispensable to the Insurance Examiner as
 to the Medical Jurist. 
126
   "The  Family  History  first calls  attention  to  the
 point, as it is well recognized as one of the most com-
 monly  transmissible of affections.   It is  safe  to  say
 that in  from one-third to one-half of all cases of obvious
 insanity, its presence in the family within three genera-
 tions can  be  traced.   If those slight  aberrations  of
 mind or eccentricities, which, from absence of existing
 causes,  do not deepen into such  mania  as requires
 treatment,  were  taken into  account,  the  proportion
 would certainly be largely increased.
   Atavism is  here frequently witnessed.   Baillarger's
 propositions appear to be generally confirmed :
   " The insanity of the  mother, as regards transmis-
 sion, is more  serious than that of the father; not only
 because the mother's  disorder  is more frequently he-
 reditary, but also because she transmits it  to a greater
 number of children.
   " The transmission of the mother's insanity is more
 to be feared with respect to the girls  than the boys ;
 that of the father, on the other hand, is  more dan-
 gerous  as regards the  boys than the girls.
   " The  transmission of the  mother's  insanity  is
 scarcely more to  be feared, as regards  the  boys, than
 that of the  father;  the mother's  insanity, on  the
 contrary, is twice as dangerous  to the daughters."
   To  these it may  be  added  that  the  insanity of
 brothers and sisters respectively, is  a matter of even
 more import, as establishing  the  family proclivity,
 than that of parents.
   The  hereditary  tendency  follows  the same  law as
 other inherited  tendencies,  as  to  its  occurrence  at
 certain  ages.   (Vid. pp. 8 and 47.)
   A similar rule obtains as  to  resemblances between
parents  and particular  children,  (p. 46.)   Owing to 
                        127
the absence of exciting causes, the hereditary  predis-
position may never have been manifested in any strik-
ing derangement, and yet the observant Examiner may
notice in  the temperament, in the habits of life, in
the occupation, the peculiar features of intercurrent
diseases, domestic or civil  troubles,  etc., additional
reasons for declining the risk.  Pursuits which subject
to great mental "wear and  tear," and  intemperance,
are among the most potent of predisposing influences.
Many cases are  vaguely attributed to religious excite-
ment, grief, joy, fear or other emotions, but it is safe
to assume  that when insanity ensues upon them, it is
because the nervous centre is already  on the brink of
disease.
   There are  unusual difficulties  attendant  upon the
decision in suspicious cases.  But the  Examiner  at
least  escapes  the  necessity  of determining the differ-
ence  between feigned and real  insanity.   The trouble
will be in baffling the  great ingenuity with which the
party  will  often  conceal  the mental  disorder.   As
Bucknill and  Tuke remark:
   " The dread  of insanity  in many  families of this
kind  is so great as to constitute, in  itself,  a morbid
feeling sufficiently strong to mislead the observation,
to warp the judgment,  and to occasion sins of con-
cealment  and untruthfulness towards  those who have
a right to  expect,  and to demand  the fullest and most
explicit confidence."
   Next to the hereditary predisposition, may be men-
tioned that arising from the temperament, either orig-
inal or acquired.  Although examples of insanity may
be found  in  any described temperament, yet in the 
128
Sanguine or Phlegmatic they are about invariably con-
nected with notable organic lesion.   In the pure Ner-
vous temperament, or particularly in the Bilio-Nervous
or Melancholic variety, it is apt to occur with very little
or no evidence of internal lesion aside from the mental
disorder.   The  form of insanity which  occurs to  the
melancholiac is  that  which is most  likely to  come
before the Examiner.  There is  usually  deficient  en-
ergy of digestion, with costiveness  and constipation ;
pale and abundant, or scanty urine loaded with lithates;
pulse,  soft and compressible;  skin, sallow,  hard and
dry, or sometimes cool  and  clammy.    " The  com-
plexion of the insane person is never clear and healthy."
Fixed  dull pain may be complained of in the head, or,
at least, a sense of oppression.   There are impassive,
immobile features, with a moody or saddened expres-
sion.   " The eyes are  motionless, or directed towards
the earth or some distant point;  and  the  look is
askance, uneasy and  suspicious."   In the more dis-
tinctly nervous temperament there is,  as would be ex-
pected, a  more changeful  countenance, and a greater
activity of movement.  There is loquacity, and varied
emotions lend vivacity to the features;  the eye is  quick
and flashing; the skin dry, and more florid in parts,
with unnatural pallor in others ; the pulse is rapid,  but
feeble  and jerking.   There are  derangements  of the
secretions, irregular and capricious  appetite, and ten-
dency  to  emaciation.  Indeed, defective  nutrition is
so large an element in the etiology of  insanity, that
some high authorities  attribute to it the whole disease.
All diseases which notably impair the  constitution of 
                         129
the blood may awaken, or exaggerate, the hereditary
or acquired predisposition.   Unfortunately  the  con-
verse is not always true :  insanity  once existent,  with
evident poor bodily health, is not always removed when
health seems  thoroughly  restored.  The worst cases,
notoriously, are those which manifest mental derange-
ment with high health.   Briefly:  In making up an
opinion in a suspected case,  in addition to the family
history,  the habits of eating,  drinking, sleeping, and
occupation; the diseases previously existent; the  exact
present condition of  the digestive and cerebral organs;
the peculiarities  in surroundings,  dress, bearing, and
expression, as contrasted  with the antecedent usage;
and, finally, the  general physiognomy of the case are
each to be fully investigated.   In the absence of  glar-
ing evidences  of eccentricities, or peculiarities, as  com-
pared with those which sane people may exhibit, the
individual must be compared, or contrasted with his
previous  self, and then the change, if any, be traced to
its real cause.
   Spinal  Diseases.—Spinal Inflammation of the chronic
form, whether  of the meninges or substance,  is an
insuperable obstacle  to insurance.  The comparatively
light local symptoms frequently  cause it to be con-
founded  with rheumatism or neuralgia,  but careful
examination  will ordinarily  elicit the presence of a
much greater general disorder  than would occur in such
cases.
   There is generally a fixed pain,  usually high up on
the vertebra,  slight tenderness on percussion or  deep
pressure ; the pain aggravated  by movement, especially
      9 
                         130
if quick.  The passage of a hot sponge over the  part
is also likely to give increased pain.   There is a liabil-
ity to spasms or paralysis, particularly of the muscles
of the neck and back, upon the occurrence of exciting
causes.
   The occurrence of curvature with these evidences of
local lesion, adds to the certainty of diagnosis.
   Spinal Irritation,  or  that ill-defined  assemblage of
hyperaesthesia,  nervous  excitability,  with  disturb-
ances of remote organs, whatever its real pathology, is
usually  accompanied by such evidences of digestive,
thoracic, or cerebral disorder,  that they alone suffice
for rejection without differential diagnosis.
   Paralysis, of whatever degree, whether dependent
on  Morbid   Nutrition,   Degeneration,   Tumors,
Apoplexy, Traumatic  Lesion, or Softening,  always
disqualifies.
   The trouble in diagnosis here, is mainly due to  the
imagination of the patient.  Without actual paralysis,
either of motion or sensation, there is often  Deficient
Innervation. There is a sense of weakness of the knees,
with slight numbness or prickling sensation ;  a loss of
perfection of the muscular sense; disturbance of  the
function of the organs of the trunk  on the level  of
the lesion—thus disturbed respiration and circulation,
disturbed digestion, slow  and imperfect extrusion  of
the faeces and urine.  The genital  system is depressed
in activity; the muscular  tissue wastes,  and  nutrition
generally is imperfect.   The brain  sympathizes more
or less,  and spasmodic  contraction may alternate with
the paralysis or deficient power of motion. 
                        l3l
  The history of the case  will here throw light upon
the symptoms present.  A blow, a wrench,  a  concus-
sion ; exposure to cold and  moisture;  excessive fa-
tigue,  long continued  cramped  positions incident  to
various occupations, certain morbid habits and indul-
gences,  mineral  poisons,   hereditary predispositions,
and cachexia,  severally, may be identified as originating
the difficulty.   On the other  hand,  hypochondria and
hysteria may imitate the  symptoms  very  closely.
There is a large amount of vulgar literature afloat
which serves to torture young adults, especially,  with
the  idea that the dreaded tabes dorsalis has  already
seized upon  them.   Half of the symptoms  in these
cases depend  upon  dyspepsia, and  two-thirds of the
balance upon the imagination of the victims.

                       VII.
   Miscellaneous Affections.—Psoas and lumbar abscesses
while present reject;  and even  when  recovery seems
perfect,  from their great   tendency  to return, throw
doubt  on  the propriety   of accepting the applicant.
All abscesses of any considerable  extent postpone.  Re-
current abscesses involve  suspicion of some cachexia.
Even furunculi should  not lightly be passed over, and
carbuncles reject.
    Open ulcers and obstinate  cutaneous  affections  are so
generally connected with  constitutional taint,  or per-
manent lesion of nutrition,  that the case is  rendered
doubtful by their presence.
    Large or extensive varicose veins, chronic and numer-
ous enlargements  or induration of the lymphatic glands, 
                        132
fistula (p. 22, et seq.),  morbus c&xarius, or acute or
chronic inflammation within, or about any of the larger
joints.
  Irreducible hernia,  double hernia.
  Excessive loss of structure, as amputations above  the
middle third of the  thigh, or at the shoulder joint.
  Tumors of a non-malignant character, but involving
danger by their anatomical position,  or as requiring  a
severe surgical  operation.
  All tumors or growths of a malignant or scrofulous
nature; Exostoses,  Enchondroma, etc.
  Loss of sight or hearing from  accident or  causes
not involving  disease of the cerebral  centres,  never-
theless impair  the risk,  as  subjecting the  unfortunate
subject unduly to injuries which the deprivation of the
special sense does not permit him to avoid.
  Finally, diseases which may have been present,  but
from  which there seems  to have been perfect recovery,
not infrequently leave discoverable  effects and influ-
ences to the educated eye, which materially lessen the
life expectation.

                      VIII.
  Female  Applicants.— Although  some companies
decline all female risks, it  is safe to say  that, taken
together,  they are equally  eligible as  those of males.
As before  remarked, even the child-bearing period
does  not bring to them a mortality, materially prepon-
derant over  that of males of similar age.   Indeed, if
anything,  the exposures  and  vicissitudes  to which
males are ordinarily subjected, during the active years 
                         133
of adult life, more than  balance, in fatal results,  the
incidents of the female life during  this period.
  Certain  anatomical difference, with  regard  to  the
height, weight, chest measurement,  and capacity, have
previously been noted, (p. 54.)
  There is, numerically,  a greater proportion of ner-
vous temperaments, and the modes of life more  fre-
quently expose to the evils of deficient ventilation and
sedentary habits.   But to these their systems become
accustomed, by well known  physiological law, so that
not  as deleterious results are produced as would be  in
the male.
  The regularity and perfection of the menstrual func-
tion  is to be ascertained; it being remembered  that
individual peculiarities in this respect are to be weighed
rather in their relation to the general health than with
references to exact rules.   If there is good health oth-
erwise, irregularities in the menstrual function scarcely
impair the  risk.  But at the climacteric period,  the
difficulties  incident to the  cessation  of the  function
must be  carefully  inquired after.   This is  an objec-
tionable time to insure ;  but in the absence of notable
disturbance of the  general health, or evidences of local
disease, the party  need not  be  declined.  An anaemic
or chlorotic condition, or signs of the cancerous cachexia
will exclude.
   Primary  gestafion  impairs the  risk, but, if this
 proceed without difficulty or danger to its termination,
 subsequent pregnancy need not be  considered as  add-
 ing  to the risk.   Statistics are said to  show that  the
 mortality from first  labors, and   ensuing  puerperal 
                        l34
fever, is about twice that of all ensuing  labors up  to
the ninth;  after the  ninth, the  danger  is increased
with  each  succeeding  pregnancy  and  parturition.
Whether  this proportion  is closely  approximated  or
not, there is  no doubt of the  general  truth of the
proposition.
   Labors requiring instrumental  assistance,  miscar-
riages, or repeated mal-presentations, or haemorrhage,
impair or exclude the risk. The occurrence of Puerperal
Fever, or Mania, also declines.  Remarkable varicosity
of the veins, phlegmasia dolens, dropsical effusions, etc.,
are equally  objectionable.   Vesico-vaginal, or  rectal
fistulae, or  lacerations,  also,  while  present,  exclude.
Emaciation  and exhaustion,  during lactation,  also
militate against  assurance.  Chronic Metritis  or Sub-
involution, deep ulcerations and  profuse lencorrhoeal
or purulent  discharges, at least, postpone.
   But it  should be recollected that mere dyspeptic
derangements, or the habit of the parts, may keep  up
apparent symptoms when important organic disease
has passed away.  The real condition of the general
health is here  the point to  be investigated.
   It is unnecessary to  remark, to the experienced prac-
titioner, that organic uterine  disease is vastly  less fre-
quent and important than is claimed  by the specialists.
The symptoms paraded as proving its  existence, in
the large majority of  instances,  being due to totally
different causes.  Even if it would be permitted, it is
doubtful whether,  so  far  as  insurance is concerned,
specular or digital examination would give any valua-
ble information aside from that which can be gathered 
                        l3S
from the history and the general symptoms presented.
Cases which suggest such  examination to the family
physician, so frequently have concurrent evidences  of
disease, that differential diagnosis becomes unnecessary,
for these alone decline.
(■?■. The  facts  with regard  to  the  transmissibility  of
hereditary diseases, insanity, etc.,  in certain instances,
rather to the females than  to the males of the  family,
and vice versa, may  have weight in deciding upon  the
risk.  (p. 126.)

                        IX.
   General Character of  the Risk.—The systematic
survey  which  has been  taken of the  history of  the
applicant, and the present  condition of the individual
organs  and functions of the body, is  merely prepara-
tory  to answering  the  all important question pro-
pounded  by  the Insurance  Company:   "Do  you
recommend  the  risk?"   This  question should be
answered definitely and distinctly — Yes, or No.
   But, before answering it, there are certain general
considerations which  it is necessary  to  have  fully in
mind.  These are derived from the general'physiognomy
of the  case as indicating  the Constitution.   Under
this somewhat indefinite  designation  we refer to  the
Temperament, the  Diathesis, or the  Cachexia of the
party.
   The Temperament has already been referred to, (p. 61
et seq.)  Here the  question arises :   Is  the  party so
situated that  his peculiar temperament modifies  the
character of  the risk ?  And  in  answering this,  the 
                         136
 same principles of prognosis are involved as in weighing
 its relation to present acute disease.
   The Diathesis bears the same relation to disease that
 the temperament does to health.   Original or acquired
 abnormalities in the organs determine, on the occur-
 rence of any  special disease, a modification in  its course
 or tendencies, which assimilates its changes and symp-
 toms  to  those  which  are especially peculiar  to the
 diathetic infirmity.  In  the  absence of exciting cause
 the diathesis  may be apparently latent.  In the absence
 of direct manifestation it may  sometimes  be cogently
 inferred from the family  or personal history, or  from
 the  obvious  results  of  previous disease.   Each im-
 presses its own physiognomy.  Among those diatheses
 prominently  demanding study,  may be mentioned the
 Strumous,  ultimating in scrofulosis, or tuberculosis, and
 characterized by defective  nutrition,  imperfect assimi-
 lation with consequent impaired function of the organs,
 with slow and deficient reparative power.
   The Gouty or Rheumatic diathesis, characterized by
 " a predisposition to the undue formation of uric  acid,
and  to congestion, irritation or inflammation of the
muscular and sero-fibrous tissues, of the vascular sys-
tem, of  the  serous  membranes, and  of the perito-
neum."  The development of,  on the one hand, gouty
affections, and on the other, rheumatic disorders, seems
to be due to the relative conditions of the skin,  and
digestive mucous membrane.
  The Adipose  diathesis  is marked by  its  results.
Ordinarily there is deficient digestive energy and mus-
cular weakness.   The viscera  are large,  but notably
inactive. 
                         '37
   The Phlogistic, usually engrafted upon the Sanguine
Temperament,  where acute inflammation, with active
symptoms,  readily  supervenes upon  slight  causes.
Here  there  is  generally great activity  of the blood
making processes,  with some imperfection of structure
of the excreting organs.
   The Typhoid, when with rapidity of textural changes,
easily  exaggerated  by  disturbing  influences,  there  is
feebleness  of nutrition and  repair with  inactivity of
the excretories.
   In fine,  the acute  physician may recognize  a  great
number  of these  general proclivities  to  disease, yet
each consistent  with present  health,  which,  being
known, must enter into  his well  compacted decision
as to the real character of the risk.
   The Cachexia, unlike  the  Temperament or Diathe-
sis, determines the presence  of disease,— not, perhaps,
involving any  particular organ, but pervading, in its
malign influence, each and all.   It may be the diathesis
developed  into an  existent  disease.   The diathesis,
being  known,  may never find development into ca-
chexia  or local  disease, being prevented by appropriate
hygienic influences.   But the -cachexia may  originate
without the previous existence  of the diathesis,  and,
in this case, is usually more  amenable  to therapeutics.
When  both co-exist, the prognosis is thereby rendered
vastly  more  grave  than it  would be even with  greater
severity of local symptoms.
   The noticeable cachexiae are those connected with the
developed  diathesis, as above suggested, and to these
may be added,  as  requiring attention, the Syphilitic, 
 Erysipelatous,  Anaemic  or Chlorotic,  Albuminoid,
 Haemic,  Haemorrhagic, Rachitic, Cancerous, etc.
   The sum total, so to speak, of  the power of carry-
 ing on the processes of life, ministering to  repair, and
 resisting morbific influences, derived by  the system as
 a whole,  is expressed by the term  the  Constitution.
 This word is significant of the Vital Force,  or indi-
 vidual capacity for living.   It measures,  for the Exam-
 iner,   the  Life-Expectation.    Deviations  from  the
 typical standard of formation and action, as arbitrarily
 established for purposes of  scientific comparison,  may
 be found present to an  indefinite extent, and  yet  the
 capacity for living be fully equal to, or even above the
 Insurance Average.
  Poetical descriptions, or  ideas, of the mens sana in
corpore sano, may differ as widely  as men themselves,
and it is idle to set up either Apollo or Vulcan as types
of  Methuselah.    Nay,  the educated  intellect,  by
adapting the frail body appropriately to  its  surround-
ings,  may cause  its years to  surpass those of the most
symmetrical and well developed athlete.
  Mode of  Filling up  the  Blanks in the Insurance Forms.—
The answers should be clear, definite and precise.  Use no general
phrases or terms, but put down particulars.  Do not say the Respi-
ration, or the Pulse is " Normal,"" but state concisely  what its char-
acteristics are.   Do not  say, " / think so," or  " In my opinion," or
" / believe so," but distinctly Yes or No, as the case demands.  In
answering the last question, "Do you recommend the Risk?"  write
Yes, or No.  If the former, it is perhaps well  to qualify the  state-
ment by classifying it in some form agreed  upon with  the company, 
                               139
expressing your opinion whether the party will barely come up to,
or largely  surpass  the usual life expectation.   The  writer's  own
method is to divide the acceptable risks into four classes, thus :
   Yes.
   Yes. — A good risk.
   Yes.— A first class risk.
   Yes.— A splendid risk.
   The first formula  calls  attention to something  in the answers  of
the Applicant, or his personal  condition, which may  be objectiona-
ble ;  the second points to  the same, or some peculiar diathesis, or not
insuperable objection;  the  third  suggests a clear record; the last,
remarkable vital capacity.
   The history may afford reasons which, unexplained, would  cause
rejection  of  the Applicant by the Central Examiner.   Hence  there
should be appended  a clear exposition of all doubtful points, so as to
render addition to  the  voluminous  correspondence  of the Home
 Company unnecessary.
   As rejection, by one  of the  Examiners, always renders the  party
 peculiarly anxious for insurance, the reasons for  rejection, and such
 information as  is necessary to  identify  the  Applicant,  should be
' forwarded to the Examiner-in-chief.
   It is recommended that the Examiner keep a duplicate of his cer-
 tificate for subsequent reference.  Aside from  its  value in this regard,
 there will thus eventually be accumulated  a mass  of reliable data  for
 general scientific  uses.    A  small printed blank, with  appropriate
 abbreviation, would suffice for the purpose.   It need not be larger
 than an ordinary prescription paper.   It is unnecessary to specify to
 the educated physician  the  great advantages which might be gained
 by a general preservation of the statistics thus  easily procured. 
 
INDEX.
                 A.
                                 Page.
Artists....................................  4
Artisans...................................  4
Age......................................6, 61
Acclimation............................. 13
Army Employment..................... 16
Asthma...............................  17, 71
Apoplexy.........;...................17, 119
Ancestors Longevity.................... 44
Answers of Applicant.................. 52
Appearance, General.................... 57
Aspect of Countenance................. 58
Age, Apparent.......................... 61
Aphonia................................... 71
Aneurism of  Heart.................... 89
Aneurisms................................ 96
Angina Pectoris ......................... 89
Adhesions, Heart........................ 89
Atrophy, Heart.......................... 89
Aortic  Obstruction..................... 93
Aortic  Regurgitation.................... 93
Abdominal Organs...................... 97
Atrophy of Liver.......................100
Atrophy of Mucous Membrane.......104
Albuminuria.............................i°7
Addison's Disease........................m
Atrophy of Brain........................I21
Asthenia, Nervous....................i24
Abscesses.................................J3'
Amputations.......................42» J32

                  B.
Bronchitis................................. x9
Bones, Size of............................ 69
Bilious Temperament.................. 62
Blood Murmurs........................•• 95
Blood Vessels, Disease of............... 96
Bright's Disease..........................io7
Brain,  Disease of........................Il8
Brain Chron. Poisoning................124
Blanks, Filling up of...................'38
                                     I
                 c.
                                 Page.
Climate............... ....................  13
Consumption.............................  20
Cholic.....................................  20
Cardiac Diseases.........................  21
Chorea....................................  25
Catarrh....................................  30
Cough, Habitual........................  41
Chest Measurement....................  55
Complexion...............................  59
Color of Hair and Eyes................  59
Congestion of Lungs....................  72
Cyanosis...................................  9°
Congestion, Liver........................  99
Cirrhosis of Liver........................100
Calculus...................................no
Cystitis, Chronic........................no
Cerebro-Nervous System...............112
Convulsions..............................114
Co-ordination, Defective...............115
Coup de Soleil...........................123
Cutaneous Affections...................131
Climacteric, Female.....................133
Constitution..............................135
Cachexia..................................137
Certificates, Duplicates..................139
                 D.
Diseases, Previous....................... 17
Dropsy................................... ZI
Diphtheria...............,................ 22
Dyspepsia................................. 39
Dysentery................................. 4°
Diarrhtca.............................40, 102
Disease within Seven Years............ 43
Dyspnoea................................. 73
Deposits, Pulmonary.................... 73
Deposits, Signs of Pulmonary......74"76
Degenerations, Heart................... 9°
Dilatation,  Heart........................ 9°
41 
142
INDEX.
                                 Page-
Degenerations, Liver....................100
Digestion, Importance of...............104
Diabetes...................................no
Duchenne's Disease.....................114
Deposits, Brain...........................121
Delirium Tremens..................10, 125
Diathesis..................................136

                 E.
Employment, Previous.................. 17
Eyes....................................... 60
Emphysema.............................. 77
Empyaemia.......................,..... 79
Epilepsy .............................24, 114
Encephalitis..............................118

                 F.
Fistula.................................... 22
Fits...................................24, 114
Friend,  Reference to.................... 50
Furunculi.................................131
Female  Applicants.......................132

                 G.
Gout...............................  ...... 25
Gonorrhoea............................... 37
Growths, Intracranial..................121

                 H.
Heart Disease....................21, 81, 89
Hernia...............................31, 132
Haemoptysis.............................. 34
Haematemesis............................ 35
Hereditary Disease..............6, 47, 126
Height.................................... 54
Hair.....................................  59
Hydrothorax.............................. 79
Heart—Signs of Disease:
  Location..............................  82
  Bulging or Depression.............. 82
  Impulse................................ 82
  Area  of Dullness................... 83
  Pulsation.....................,........ 84
  Sounds................................. 86
  Location of Sounds................... 88
  Non-organic  Disease of.............. 94
Hypertrophy, Heart...................... 99
Hepatitis, Chronic.......................101
Haemorrhoids...........................104
Hysteria.............................24, 114
Hypertrophy of Brain..................121
Hip Disease..............................132

                  I.
Intemperance........................10, 124
Insanity........................25,  118, 125
Injury, Traumatic'....................... 42
                                 Page.
Insurance, Previous..................... 51
Identity of Applicant.................. 53
Idiosyncrasy.............................. 64
Inspection................................ 68
Intestinal Tube..........................102
Intellection, Derangement.............118

                  J-
Jaundice................................. 27
Joints......................................132

                  K.
Kidneys,  Disease of.....................106
   "   Enlargement of.................106

                  L.
Life Expectation.........................  7
Liver, Disease  of.......................26, 99
Longevity of Ancestors................ 44

                 M.
Mechanics...............................  4
Marriage..................................  8
Muscles, Contour of, etc............... 60
Mensuration.............................. 66
Movements, Respiratory............... 68
Malformations, Heart.................. 91
Myocarditis............................... 91
Mitral Regurgitation.................... 93
  "   Obstruction...................... 93
Motion, Derangement of...............113
Menstrual Functions....................133
Metritis, etc..............................1 34

                 N.
Name......................................  3
Nervous Temperament................. 62
Neuralgia, Intercostal.................. 80
Nutrition.................................105
Nephritis, Chronic.......................106
Nephralgia................................106
Nervous Asthenia.......................124

                 o.
Occupation...............................  3
Opium Eating........................... 11

                  P.
Professional Men........................  4
Paralysis.......................28, 116, 130
Palpitation................................ 28
Parents, Living or Dead,  etc.......... 46
Physician,  Family....................... 49
Phlegmatic Temperament............. 62
Pulse....................................... 6^
Pneumothorax........................... yg
Pleurodynia.............................. 70 
INDEX.
J43
                                 Page.
Pericarditis................................  91
Pancreas..................................101
Prostate, Enlarged......................no
Poisoning of Brain......................124
Pregnancy and Parturition.............132
Phlegmasia Dolens......................134


Quinsy....................................  28

                 R.
Residence.................................    3
Residence, Foreign......................  13
Rheumatism..........................29, 39
Rupture...................................  31
Rejection, Previous....................  S1
Respiratory Organs.....................  66
Respiratory Organs, Diseases of.......  70
Rigidity of Muscles.....................116
Ramollissement, Brain..................122
Ramollissement, Spinal Cord.........130
Risk, General Character...............135

                  s.
Sobriety...................................    9
Scarlatina.................................  33
Spitting of Blood........................  34
Syphilis.................................... 37
Stricture.......................  ......37, no
Skin.......................................  59
                                 Page.
Sanguine Temperament................  61
Stomach...................................  99
Spleen.....................................102
Sensation Derang. of-..................117
Spasms....................................114
Softening of Brain......................122
Softening of Spinal Cord...............130
Sunstroke.................................123
Spinal Diseases...........................129
Senses Special, Loss.....................132

                 T.
Temperance..............................   9
Temperament.......................61, 135
Tumors, Intrathoracic..................  80
Tremor....................................113
Tumors, External .......................132

                 u.
Urinary Organs, Disease of............  35
Ulcers....................................131

                 V.
Vaccination..............................  12
Valvular Changes, Heart...............  92
Varicose Veins...........................131

                 W.
Weight.................................... 54 
 
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