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Les diagrammes suivants illustrent la mdthode. 1 2 3 1 2 3 4 5 6 r MANUAL -OF — Life Idsui^anse Eiaminations BY JAMES THORBURN, M.D. Edin., Corsulting Surgeon Toronto General Hospital ; Professor of Materia Medica and Therapeutics, Toronto School of Medicine ; Medical Dirco'or North American Life Assurance Company, &c., &c., &c TORONTO: Ellis & Moore, Prxters, J 887 jmmm ■PWH"ilWiWtMWIW«»** a ^- » 4M nl Parliament of Canada, in the year 1887, by B'/g^A I I i LIFE INSURANCE EXAMINATIONS. /TM. . 1.1>_.l»>s.-Defects of the organs of special sense should bo in.aired into such as deatnoss, » blmtoj • and the cause of such conditions should be ascertamod. If deafness, nrr HAnt IS it the result of disease, etc. ? Tetemiti s, Ih as curvature of the spine (lateral or augular). are objectionable ; exceptionable cases may be insurable. Has the person ever had any of the following ailments : ^«»ri«-Aneurism may exist without the Pf '»»'« '^^'^f.fj it may be of the heart, the aorta, or any part of the arterial sydem ?: aneurism may be so large, especially it of the '■'O'J ™-^' - io cause bulging of the parietes before its peculiar ^"^ ^ " « effects are developed ; a careful physical examination would reveal this condition. . . Thepresencs of an aneurism invahdates the risK. Apo,,le.y-A person who has ever had true apoplexy, no matter how remotely, is ineligible for life insurance. 4,ltow-Asthma embraces a variety of symptoms rather than of disease and must be valued according to the cause which produces H Those cases of asthma arising froK. idiosyncrasy such as rose or hay asthma, or that are dependent upon local atmospheric cond. lom trinot a sufficient cause to disquaUfy the applicant from some forms meurance; but the asthma which arises from oigamo les^n Ihrfrom cardiac obstruction, tuberculosis, emphysema, bronchitis, le from any peculiarity of dition of the ation, or im- ince. Any I, as the pig- coloration of Qitrate of sil- of the bones tail bones are Lgue. Asoer- the organs of or blindness, If deafness, f ftugalar), are ts : t's knowledge ; .rterial system, rajic variety, as md distressing would reveal lexy, no matter B rather than of which produces such as rose or leric conditions, rom some forms oiganio lesion, 3ema, bronchitis, V EXAMINATIONS. thorasic tumours, hepatic disease or disease of the nerve centres, is sufficient cause for the rejection of the applicant. ry ^ f .«/ mnd ^c^iM— Thls oonditiou is a symptom rather Bad, or frequent H^ad- Aches ims oiroumstanoes or than a disease. It may arise from a variety °J^ ° j ^^. causes; when from functional ^-turbance or the ^^^^ ^,. laria,itmay notbea bartoinsu^a^^^^^^ Kftnio lesion, pattionlMly of the nerves, u ib» b j La neoessitetes » most o«efal '-'^^^\Jll^^lZe» severity oi the symptom ha. » important bearmg on the examm 'tXeople suffer ^omhead-ach. -- ^»-:— ^r^ do not seem to be in impaired health ; snch P^T^' f J^^'^it „. heing sa«ao.ory, m^ be «oeptjbU ns.s ; agam, ^-"'>». t., BiU^ Co!,«-BmoasooUc when of ^^n-"-^^^-^^-^^^^^^ tended by painfaUymptoms, lessens very ^fj""? ™';;;„ *^th„^t A single attaek, with an intervening period of ^^J^k^oi the other unfavorable symptoms, would not dimmish the eligibflity applicant for insurance. Bro«KUU -The presence of bronohitU is -'"J^l^fZZ^^^^ especially iCi. a chronio form. '^^^^^^^'^^^ X paren- are usually complicated '"'^ ^""J. "Jt,,, to^eUtis is associated ehyma of the lung, or cardiac *'»'»'» 'J^ 7 "i,„„ia unhesitatingly with any of the three foregoing conditions, you snouia u further examination. for his re ection. whether it be ot ttie acqu ^^^ :^:;i:r7er;fmrr;^rs. rroperation. is very common. i. „;«.u ;« tViA female than in the Caroinoma is more frequently met with m the lemaie m Je-rd especiaUy ^^^f ^'^^ ^Ittme persistent .cfjirr (rt:XtT.l more frequently in the mal. » I I if; i:;. 'J io LIFE INSURANCE Ca; i ■ i ' I n LIFE INSURANCB recovered, the risk may be accepted. mu JThis is a general term including a ^eat variety of conditions, Bncb as apoplectic, epileptic and hysterical fits. When arising from apoplexy, reject. wnen arisi ^ ^ aV,nrf«n life but in consequence of the toe riek i. k««»°;"- j^^^ „„^, ,„.„.bie to treatment. Sometime. «P'1«.P^°^*» "^^' ^^^ ^„entrio irritations, that is B„oh as those havmg for »»«" •"«'" * jm » reflex manner nlerine, intestinal or yesioal ■^*;'^°™' ^ j!" snch acondition and oanseconvnWons of an «P>1«P^°»'.™";, b„ elapsed smce ""Epi'S'paroxysms frequently occur in dmnlcard, and may not a^ftin recur in case of reformation of habits. insurable. G^eralDeWUy.-^^^^ term is applied to a «--^|^--^^^^^^^^^^^ vXv ' if such a condition has been present and is entire y "coverea body, If sucna c^^^ ;..„,.Wa hnt of oourge much will depend on irom, tue appiiua."" » ino-.-..-- — ? — EXAMINATIONS. 18 when foreign ; in the wound, tea are usually if the result of y be insured, tally to fistula- in origin ; the ersons or those I be rejected. as the presence ent has entirely ty of conditions, asequenoe of the ase, the value of ale to treatment, •itations, that is a reflex manner ' such a condition has elapsed since le fits arise from ressed bone, intra- s, emboli, etc., we rds and may not metimes occur in e difficulty in dis- ioal fit } the latter able to treatment ; Such cases are ral weakness of the i entirely recovered uoh will depend on the cause of the debility, and the decision will be in accordance with it. Gout.— This disease is often hereditary, and is more common in the older countries of Europe than in America. ,.^ ^ x •. Although painful, the danger attending it is chiefly due to its liability to metasticis and to the degenerative condition of the heart and blood vessels which is usually found in the bon-vivant. Applicants who suffer from gout are not first-class risks. Gravel— Thia term is applied to the passage of calculi along the nreters accompanied by paroxysms of pain. A person who has experienced one attack is liable to recurrences at periods more or less remoto, and although the suffering is usually extreme, it very rarely, if ever, proves fatal, per se, the danger bemg from the serious diseases to which it may give rise, viz., destructive inflammation of the kidney, vesical calculus, etc. ITabitual Cough.-The history of habitual cough is strongly indicative of disease of the respiratory tract, and the examiner should exercise his utmost care in ascertaining the cause. Such cases are generally uninsurable. Inflammation of the Lungs or Pnmmonia.-ThiB question is suggested in consequence of the serious morbid changes which are apt to be developed by this disease, viz, : Chronic consolidation of lung sub- stance, the development of tubercle and the formation of adhesions, etc., which may seriously interfere with the due oxygenation of the blood, and with the proper performance of respiration. If any serious consequences arising from this disease are mamfest, the applicant should not be received. Insanity —If the person examined has ever been insane, the physi- sician will ascertain if the disease has been hereditary ; the form and kind of insanity ; the age of the individual at the time of the attack ; the duration, and whether the person has had more than one attack ; the nature of the real or supposed exciting cause, and whether the person at present exhibits symptoms of the disease. We must not confound mere eccentricity of manner or character or imbecility of mind with true insanity. Chronic insanity of itself does not necessarily shorten hfe. A per- son who has suffered from the acute form is apt to have a recurrence -ifff ■II ■ f, I I i !1. if- i 1 k 14 LIFE INSURANCE of it, and in oonseqnence of his inability to control his actions he is very liable to injury, accidental or self-inflicted. Insanity may arise from causes which are quite amenable to treatment, such as malaria, the delirium which accompanies acute fever, and the abuse of alcoholic liquors, etc. Some forms of puerpural mania may also be included in this division. Liver Complaint, — The liver is the alleged father of many dis- eases, and is the seat of cirrhosis, amyloid disease, fatty degen- eration, cancer and tubercular disease, all of which render the applicant unfit for life insurance. If, however, the disease has only caused a temporary derangement of the organ, such as catarrh of the bile ducts or the effect of malarial influenpe, which have yielded to treatment, the applicant may not be rejected. Lumps or SwelUnga, — This question is intended to direct attention especially to the swellings which result from scrofulous disease of the lymphatic glands, and to nodes, such as the syphilitic. Swellings of the lymphatic glands generally point to a strau- mous diathesis, which is at all events closely allied to tubercle, and the medical examiner should in these cases look carefully to the con- dition of the lungs. The mere presence of a cicatrix in the region usually aflfeoted by scrofulous inflammation of the lymphatic glands does not necessarily result from struma, as these glands frequently inflame and suppurate in diphtheria, scarlatina, etc. The presence of nodes should induce the examiner to look for a previous history of syphUis. » Neuralgia.— NevLt&]gia, is the purest type of pain, and is generally functional in its origin, that is unattended by inflammation or struc- tural change. It may occur in any part of the body, but especially in those parts most abundantly supplied with nerves of sensation. It may be caused by mechanical pressure on a nerve trunk either at its origin or in its course, as from the pressure of tumours, etc. ; it is also a common symptom in malaria and lead poisoning. Neuralgia in itself iloes not shorten life; the repeated recurrence or peraisteut presence of it, however, should excite the examiner's suspicion of some liis actions he is lite amenable to ch aocompanies Some forms of Q. er of many dis- use, fatty degen- hich render the y derangement of effect of malarial Leant may not be > direct attention }as disease of the 0. )int to a strau- to tubercle, and efully to the con- ually affected by >s not necessarily ae and suppurate nerto look for a and is generally Qmation or struo- lly in those parts lerve trunk either tumours, etc. ; it >ning. Neuralgia nee or persistent suspicion of some EXAMINATIONS. 15 morbid influence affecting the constitution, such as the individual's surroundings or personal condition. The observant physician will readily distinguish the pain of neu- ralgia from that arising from inflammation or other causes. Unless the neuralgia be obdurate and accompanied by constitu- tional vice the applicant may not be rejected. Open Sores. — Open sores point to diseased action, such as cancer, ulcers of various kinds, sinuses, fissures, fistulae, etc., and the physician should ascertain their cause and nature, and whether they are curable or not. If an open sore be due to cancer or syphilis, reject. Palpitation of the Heart or any form of Heart Disease. — Palpitation is a symptom, not a disease, and is of little practical value in itself ex- cept in calling the attention of the physician to the condition of the heart. Perhaps there is no organ of the body which requires a more care- ful study than the heart ; the skill of the physician is tested to dis- tinguish between functional disturbance and organic disease. Dr. Walsh observes that aortic regurgitation is the most common cause of sudden death. He remarks it may take place during the act of walking, eating or speaking while the person's emotions are ex- cited and, per contra, at a moment when he is perfectly calm ; and a very singular proposition is that the more pure and uncomplicated the regurgitation, the freer the heart from any other disease, the more likely is the individual to be cut off without a moment's warning ; further, that there is no direct connection between the amount of danger of disease at an orifice of the heart and the intensity of the existing murmur. The very weakness of a murmur may indeed be a fatal sign. According to Dr. Begbie, of Edinburgh, the deaths from heart disease comprise five per cent, of the deaths in adult life. The most common cause of heart disease in this country is rheuma- tism. Paralysis. — Paralysis of either motion or sensation, or of both, calls for a most careful enquiry whether it be paraplegic, hemiplegic or local. We must always endeavor to ascertain the cause in every instance. If concurrent with disease of the circulatory system and lesion of Am it ; 1 • 'I f i. \ V \ u 16 LIFE INSURANCE nerve centres, the applioant must be rejected ; also in caso the con- dition be due to diseased nutrition, degenerative changes, tumours or traumatic lesion of nerve centres. Some forms of paralysis are curable, and may be entirely recovered from, especially those of a local character, as the paralysis resulting from the division of a nsrve, from pressure of a tumour, the presence of a foreign substance, as of a buUot or piece of cloth, and that form of paralysis of one side of the face caused by cold. If a considerable interval of time has elapsed since the person was afifected, and if he has now fully recovered, he may bo received. There may also be a paralysis which is usually temporary, as sequelae to such zymotic diseases as typhoid fever, diphtheria, &o., or it may arise from reflex action as in teething children ; the latter case, however, would not come under the cognizance of the examiner for life insurance. Piles. — Piles are often associated with liver disease in consequence of the communication between the veins of the rectum and the portal circulation. They are also caused by a debilitated condition of the system ; they are painful, and sometimes give rise to a hemorrhage which may endanger life. In those cases where the piles are associated with disease of the liver, or if there has been much hemorrhage, we would reject the applicant. Piles may arise from constipation, &c., or in females from the presence of a gravid uterus. These cases may sometimes be received, but in every case ascertain if possible the cause, and decide accordingly. PUurUy. — If followed by extensive adhesions, so as to interfere with the respiratory act, or if fluid be present in the pleural cavity as well as adhesions at the apex, which are usually associated with chronic inflammation and tubercle, reject. The physician must satisfy himself by a careful physical examina- tion and by analyzing the statements of persons supposed to have had this disease, as it is often confounded with intercostal neuralgia or pleuro-dynia on account of the common symptom of a stitch-like pain. Pleurodynia would not invalidate the risk. Rheumatism. — Bheumatism in its various forms, viz. : Inflam- EXAMINATIONS. 17 so in caso the con- ohanges, tumours I entirely recovered paralysis resulting uuiir, the presence }th, and that form ace the person was ly bo received, ally temporary, as liphtheria, &o.,or it n ; the latter case, f the examiner for ase in consequence tum and the portal id condition of the ) to a hemorrhage vith disease of the e would reject the 1 females from the )very case ascertain so as to interfere the pleural cavity bUy associated with l1 physical examina B supposed to have itercostal neuralgia »om of a stitch-like rms. viz. : Inflam- matory, hereditary, syphilitic, gonnorhoeal and alcoholic, is a most serious disease, not only from the danger attending its actual pre- sence, but from the sequel® which may arise from it. The rheumatic poison has a strong tendency to aflfeot fibrous tissues wherever found, as in the valves of the heart, the pericardium, the dura mater and the fibrous structure of joints, etc. These structures, although often escaping at the time of the attack, may be involved in serious lesion as a consequence of the rheumatism, even after a long period has elapsed since the last attack ; heart disease sometimes is developed in this way. The attention of the physician must be especially dureoted to the condition of the heart in those persons who have ever had rheuma- tism. If there is any disease of the heart the applicant must be rejected. Not only is there danger' from heart failure consequent on disease of the organ, but also from embolism, a sequence of diseased valves. Other objections to applicants who have suffered from rheumatism are that one attack predisposes to a recurrence, and from the degen- erative changes which ensue in the blood vessels apoplexy is not an uncommon sequence of rheumatism. We must not confound the pain in muscles (myalgia) which occurs in different parts of the body with the condition above described ; such pains are very common, and in fact there are few persons who do not experience them in some form or other now and again. Scarlatina.— ThiB is a disease of youth rather than adult life and is of importance to the examiner for life assurance because it is frequent- ly followed by serious lesion which may terminate fatally after the lapse of a long period of time. OtorrhcBa of a chronic nature often results from an attack of soar- latma and is liable to develop at any time into an acute inflammation, which, spreading to the structures of the middle ear and mastoid cells, may cause death from inflammation of the brain and its membranes. T. idneys are frequently involved in disease after scarlatina and hence we may have uraemia, albumenuria and dropsy as a result ; hence the necessity of enquirmg carefully mto the condition of these organs ia persons who have had scarlet fever ; if any of the foregoing conditions aire present at the tune of examination they disqualif;^ fViA AnniinAiif. for insurance. ^ 18 LIFE INSURANCE If a person has had scarlatina and fully recovered from it, the risk is improved thereby. ^cro>ia.— Persons of a scrofulous diathesis are less liable to stand the attack of disease than healthy people, and they are frequently carried off by tubercle of glandular structures, and hence are not good risks. The fact of former scrofulous disease of the glands of the neck does not render such persons uninsurable as clinical observation shows that those who have been thus affected in early life are not more liable than others to be carried off by tuberculous disease of the lungs in after life. Shortnets of Breath.— la often indicative of thoracic disease or func- tional disturbance, and requires the careful attention of the physician to ascertain its cause ; it is sometimes due to mental emotion or physical exertion. The gravity and permanence of the excito-motor cause must bo sought for and weighed accordingly. Small-Pox.— The discovery of vaccination by the immortal Jeuner towards the close of the eighteenth century has divested this disease of much of the importance which it had in the two previous centuries, when it ranked first among the acute affections destructive of human life. Whole communities and tribes have been extinguished by it and many people are still carried off by this preventible disease. The ignorant prejudice and obstinacy of man is well illustrated by the refusal of many to avail themselves of the antidote, vaccination. The proofs of its efficacy are overwhelming. It appears from the report of the Begistrar General of Eugland (1871), that of 100,000 persons who have been vaccinated, one hundred may expect in any year to have the disease, and ten of these to die. Of persons not vaccinated it is calculated that in 100,000 six hun- dred will be infected in the same time and 270 die, the probability being 26 to 1 in favor of those vaccinated. In persons having one or more clear marks the mortality was but 4 in the 100 of those attacked. With bad or indifferent marks the mortality was 25 m 100, and in patients without marks (presumably not vaccinated) the deaths were 48 in 100 of those attacked. person not vacuiiiuiuw sf^uifiM yc 5v uciujto y^*"© ivvv^^^y^% »» ?^ yiek, ' jm^t :j'.i.' 2iS\ «««>*» '«»» ""> ™"""'"' """ **"*° . accordingly. Sypm..-Bir Wm. J»ner .nd Sir J.m.. P.g.t, with many cthor enJent rargeom, consider that this disease .s a very common cause of death. , ,, , i When it iB present in any form the deoiBion bhould be post- A wLr we must not conclude too hastily. By some Se^ve y B-^n^ lals is called syphiUs. This is far from S the case; tiie true chancre is characteristic and it only is fol- towed by constitutional symptoms. The physician must look carefjUy fortra^es of eruptions on the skin, whether there is any emaciation ^ reLe of depraved nutrition, enlarged cervical glands, white ^at^^s or cicatrices on the mucus membrane of the moutii or tongue or throat, nodes, induration of lymphatic glands, onychia. &c. Such persons should not be received until aU evidences of the dis- ease have disappeared. Typhu. or Typhoid F^^.-Typhus fever is a very virulent disease wila large mortality, and like other acute fevers is apt to leave ZlL consequences which tend to weaken the constitution. For^ TiSely. however, for us it has not made its appearance m this counbry forupwards of forty years. Tvphoid or enteric fever. This f'iBease is common throughout the world. Persons in the -r « M, je woulu uot come under our Xervation in our capacity as Examiners for life assurance, but m oorsr^uence of the probabiUty of its affecting the glandu ar or nervous gystems of the body our attention must be directed towards their %he recurrence of diarrhoea in a person who has had typhoid fever would pomt to some weakness in the glandular structures of the m- ^U^'oi power or paralysis, caused by embolism, frequently follows this disease, and if present would render the applicant mimsurable. If tiiere is a tubercular diathesis, however slight, m a person who has suffered from typhoid, it is not uncommon for the latent tubercle to be developed as a result of this disease. Varicose F«r«.-The etiology of this disease is not certain ; it may . .. 1 i _„3 -•_ i.u^ «^«i, ;« fVinoA who live well and those who do not, in tiie young and in the old, and although it may EXAMINATIONS. 21 I, and decide many cthor )mmon cause lid be poBt- r. By some is is far from it only is fol- look carefully ly emaciation jlands, white uth or tongue ia, &o. ces of the dis- irnlent disease I apt to leave ution. Fortu- in this country on throughout ome under our urance, but in ular or nervous towards their d typhoid fever itures of the in- quently follows I uninsurable, a a person who latent tubercle certain ; it may live well and edthough it may interfere with the comfort of the person it does not necessarily shorten life. * u » Varicose veins may appear in any part of the venous system, but are most likely to recur in the veins of the legs. The Examiner must bear in mind that they are liable to become inflamed, or thrombosis may take place, or they may ulcerate or may rupture. n u They are common in pregnant females, but after labor usually sub- side. Unless the varicose veins are unusually large or extending above the knee the applicant may be insured. Is the person subject to dyspepsia, constipation, dysentery or diarrhoea? - . •». Dyspepsia is very common, and per se is not of grave import ; it generally indicates a catarrhal condition of the mucus membrane of the stomach or a sUght disturbance of the functions of the Hver, or it may be merely sympathetic of uterine, kidney or nervous a£fections. Such is not always the case, however, as it is frequently a premom- tory symptom of tuberculosis or it may indicate a maUgnant or non- malignant organic disease of the stomach. Whatever maybe its cause, duration or severity, it ia deserving of the serious attention of the Examiner. Conatipation.— The demands of nature allow a wide latitude in reference to the evacuation of the bowels in mdividuals, and what would be considered alarmmg in one person may be quite normal m another: for instance, some persons are never comfortable without one or more evacuations m the 24 hours ; others do not have them reUeved more than once a week, and this may be natural in both cases ; the latter is common in ansemic females or m persons who have an atonic condition of the muscular fibres of the mtestme. These and similar cases ere usually insurable, but when it arises from mechanical obstruction, such as from stricture, morbid growths, whether maUgnant or non-malignant, or if the condition be due to certain diseases of the bram or spinal cord, reject. Diarrhcea or the opposite condition of Constipation.-The character more than the frequency of the discharge is important here. Many of the causes of diarrhoea are amenable to treatment such as that arising from improper dietary ; acute attacks are very common at aU ages of life, and with every person. The frequent recurrence of this disease would lead one to enquire mto the con-oiaoa o. .fts jaEJsarawi msBssBTsmm 22 LIFII INSURANCE liver and into the habits of life of the person ; those addicted to the use of alcohol or narcotics frequently suffer from a relaxed condition of the bowelo. If the disease is persistent, and especially if the person loses flesh, the diarrhoea being attended with more or l;««^.«f d^^^^V^TlUT unhealthy hue of the courtenance, occasional chills or slight eleva- tions of temperature, the rase is serious and is probably due to ulceration of the glands of the intestine. Such persons would be ineligible for insurance. If along with the alvine evacuations aie found blood or pus, the applicant must be rejected, as serious organic disease is mdicated. Dysentery in the acute stage is sufficient cause for rejection ; if chronic, we must ascertain its cause, if possible; we will frequently find it arising from local disease, such as piles, ulcers, or morbid growth about the rectum, and may be curable ; such cases should be reported and the apphce it may or may not be rejected, according to circumstances. If the disease is persistent, and if the party has resided in hot climates or made free use of alcoholic drinks, we would have reason to suspect some obstruction to the portal circulation. As in all other cases, ascertain the cause and decide accordingly. Describe fully the person's practice in regard to the personal use of stimulants and narcotics. We need hardly expect an applicant who uses stimulants to excess to admit the fact on being questioned ; we must look for the signs of habitual over-indulgence. Those people who have occasional sprees at long intervals of time are not so apt to show the injurious impress on the constitution as those who habitually use an excessive quantity of alcoholic drmk. In the latter cases the general appearance will be a good guide to the Examiner, the complexion, the condition of the eye (arcus senUis, &o.,) any tremor of the muscles of the hands, &c., may assist us in deter- mining the habits of the applicant. Some authors have fixed a standard whereby to judge what is an excessive quantity ot alcohol for an adult. The effects on the constitution is what the Medical Examiner must investigate. The use of narcotics, which is another form of intemperance and which in some cases is even more intractable than the abuse of alcohol is detrimental to longevity. EXAMINATIONS. 23 The principal narcotics which are Ukely to be habitually used are opium, chloral hydrate, cannibis indica, tobacco, ether and chloroform. What has been the habit in this respect throughout life ? If a man has reached the age of 40 without forming the habit of over-indulgence he is unlikely to form such a habit after that age, but we must take into consideration his occupation, surroundings, &c. If a man be now a total abstainer, we must remember he may be a reformed drunkard, and besides the dangers of a relapse to his former condition we must be careful to find out if any serious morbid impress has been left on any of the important organs, as liver, kidneys and heart. Is there anything disproportionate in the weight, stature or girth measurements ? Weight. — In considering this question, the general development of the body, must be taken into aco:^unt as well as the peculiari- ties of families. Excessive weight, particularly m early life, not being hereditary, is indicative of faulty nutrition, and is often caused by in- temperance or want of exercise. Siature. — As a rule tall men are capable of less endurance than those of average height, viz., 5 ft. 8 in., and are more prone to pulmonary and cardiac diseases, and are more liable to have hernia, varicose veins, and ulcers of the extremities. Short men are apt to be disproportionally developed, and their physical endurance is small. As a limit of under and over-weight the following table will aid the examiner in forming an opinion of the safety of the risk for the Com- pany, y wenty-five per cent, xmder-weiyht is the loss of one-fourth of the man, and calls for the most searching investigation on the part of the examiner. These light weight cases may be the result of chronic dyspepsia, diarrhoea or dysentery, marasmus, scrofula, hoomorrhoids (bleeding), hypertrophy of the heart, with excessive impulse, albumin- urea, Brights disease, &c., &c. In addition to these, in the case of females, some chronic uterine disease may be suspected. The excep- tions are few in which it is safe to disregard these limits, and in every such case of under-weight tests for Bright's disease and other obscure organic mischief are imperatively mdicated. In this connection will be seen the importance of bemg accurate in stating the height and weight. Mistakes might cause the rejection by the Home Office of ^ good risk, or the acceptance of a bad oiie, M ; 24 life insurance Table of Hbioht, Weight and Measure. 25 per ot. 20 per ct. Amer'oan Standard Average Weight. 26 per ot. 40 per ot. Average Chest Height. \ "Indej* Weight. Under Weight. Over Weight. Over Weight. Measure- ment. 6 ft. 86 92 115 144 161 88 in. 6 ft 1 in. 90 96 120 150 168 84 in. 5 ft. 2 in. 94 100 126 156 175 85i in. 5 ft. S in. 97 104 130 163 182 86 in. 5 ft. 4 in. 101 108 185 169 189 36iin. 5 ft. 5 in. 105 112 140 175 196 37 in. 5 ft. Gin. 107 114 143 178 200 37i in. 6 ft. 7 in. 109 116 145 181 203 38 in. 5 ft. 8 in. 111 119 148 185 208 38iin. 5 ft. 9 in. 116 124 155 194 217 39 ip. 5 ft. 10 in. 120 128 160 200 224 89i in. 6 ft. 11 in. 124 182 165 208 281 40i in. 6 ft. 127 1S6 170 212 288 41 in. 6 ft. 1 in. 131 140 175 219 245 41iin. 6 ft. 2 in. 135 144 180 225 252 42^ in. The Respiratory System. — The importance of a thorough examination of the respiratory organs cannot be too forcibly impressed on the mind of the Examiner. In England, according to the latest authori- ties one in six ol the deaths occurring in the adult population is from diseases of the respiratory tract. Foul air is a great factor in pro- ducing respiratpry diseases. We must ascertain by inspection, per- cussion and auscultation, and ascertain whether the respiratory murmurs and percussion notes are clear and distinct and of normal character over all parts of both lungs. In general terms, in health, the act of respiration (including inspir- ation and expiration), should be quiet, easy and regular in the ratio of one to four or five of the pulse, and not exceeding 20 per minute. This may, however, be temporarily influenced by mental causes or physical exercise. Drawing a full breath and holding it for a few seconds should oanse no distress or pain. An adult should be able to count alou^ rather slowly from 20 to 80 without drawing a &esb \fXQtkth, EXAMINATIONS. 26 I m. in. in. in. in. in. in. in. in. ip. in. in. in. in. in. In the adult the chest should expand in all directions and the mnscles of the neck and arms (axilliary muscles) should not take any very active or visible part in the act. If the blood be well aerated the lips and ears and the tips of the fingers should not have any livid or purple tint. The respiratory murmur should be gentle like a slight breeze among the trees, not harsh or noisy. Prolonged expiration frequently points to lung disease. Irregular, intermittent or jerking respiration points to derangement of the nerve centres. If the respiratory act varies from the normal standard in frequency, a subsequent examination should be made be- fore reporting on the case. Is the character of the heart's action uniform, free and steady ? In health, the heart's action should be uniform, free and steady, its sounds and rhythm regular and normal. On inspection the impulse of the heart will be visible about one and a half inches within and the same distance below the left nipple, in the fifth intercostal space ; it should be plainly perceptible when the person is in the erect position, but should not appear jerking or widely diffused. The sounds of the heart should be quite clear and distinct, unat- tended by any murmur or friction. The rhythm of the normal heart is regular ; we must not, however, too hastily conclude when departure does take place that it is neces- sarily due to disease. Sometimes such a condition is due to idiosyn- cracy or a temporary disturbance of the nerve centres ; it may also be due to anemia. In such cases postpone decision until thoroughly satisfied as to the cause of such departure. The frequency of the pulse varies during the different periods of life and also in different climates. In the adult its rate in temperate climates is from seventy to eighty per minute, the pulse of females being slightly more frequent. In the North-west part of this continent the pulse rate is increased by about 10 beats per minute, while in the West India Islands it is reduced by about the same number. The pulse should not intermit or become irregular when the applicant is in a passive condition. Some people, without any evident cause and perfectly free from disease, have an intermittent pulse ; others have an abnormally slow one from idiosyncrasy. Note all such peculiarities. If the pulse rate is above 88 or below 54, r^-examine on another day, i 26 LIFE INSURANCE Urine. — Beference to the following tahle will be found useful when examining this fluid : — MORBID ELEMENT. PHYSICAL CHARACTERS. TESTS AND RE-ACTIONS. Albumen. Sp. gr. varies from 10.10 to 10.25 ; color, Ught ; a precipitate of a light color generally falls after a few hours. (1) If the urine is clear (and if not, filter) nearly fill a test tube and heat the upper portion ; if it becomes turbid add two or three drops of nitric acid ; the precipitate dissolves if it is phosphates, if net albumen is present. (2) To another por- tion of the filtered urine add ferrocyanide of potassium and acetic acid ; a white precipitate in the cold indicates albumen. Sugar. • Color, light ; sp. gr. high ; very pecuUar odor; rarely deposits se- diment; contains large excess of water. To a portion of the urine (if albumen is absent) add an equal volume of Fehling's solution of copper and boil; a yellow or yellowish brown precipitate in- dicates sugar ; if a slight precip- itate only is produced, add more urine, boil again and allow it to stand for a few hours ; if sugar is present, the solution becomes colorless and a red precipitate falls to the bottom of the test tube ; if doubtful, use fermentation test, which is con- clusive. Blood. Color, red, smoky or dingy ; deposits, on standing, brownish or cofifee-ground sediment ; if in large quantity, min- ute coagula may be seen at bottom of test glass. To a portion of the urine add an equal volume of tincture of guaiacum, followed by a few drops of old turpentine or solu- tion of peroxide of hydrogen ; a blue color, if produced, indicates blood. EXAMINATIONS. 27 MORBID ELEMENT. Pus. Bile. Mucus. PHYSICAL CHARAOTEBS. TESTS AND RE-ACTIONS. When urine oontains pus it deposits an opaque, creamy sedi- ment, or a gelatinous mass, is generally alka- line, and always slightly albuminous. Upon microsoopio examina tion, pus cells are readily dis- covered ; a drop of acetic acid should be added to the specimen under examination for the pur- pose of developing the nuclei. The chemical test for pus is liquor potasssB, which forms Uierewith a gelatinous precipi- tate of a light straw color. Color very dark ; sp gr. not materially changed ; generally co- incident with other symptoms of hepatic derangement. Four a small quantity of urine on a white plate or other porcelain surface ; a drop of nitric acid is then added ; a play of colors shortly takes place, commencing with green and blue, passing to violet and red, and often finally to yellow and brown. Color, light; a more or less abundant floccu- lent deposit takes place, putrefactive changes commence very early, the urine rapidly be- coming ammoniacal. Upon the addition of acetic acid, the fluid part of the mucus coagulates into a thin semi- opaque, corrugated membrane, which at once establishes the difference between mucus and pus. N.B. — In case of any suspicious color or deposit in the urine, use microscope. Nervous System.— This system of all others is most influenced by a great variety of causes. The question suggests itself, if there is any departure from the normal condition of the nervous system, is it due to organic disease or temporary functional derangement ? Digestive Organs. -The nutrition of the body depends on a healthy ^l!^ ■i II 28 LIPE INSURANCE condition of the digestive organs, and unless digestion is properly performed wholesome assimilation will not take place. Genito-Urinary Organs.— Enquury should be made as to any evidence of present or past disease of these organs. Locomotory Organs.— The connection between the diseases of nervous system and the locomotory system is very close, and reference has already been made to the more promment ones. Cutaneous System.— ItB abnormal condition often points to constitu- tional disease, hence the importance of careful observation when examining this system. The Organs of Seme.— Disease of the organs of special sense is sometimes fraught with danger, as in the case of disease of the ear ; although not urgent at the time of examining, still may at some future time prove fatal by an extension of the inflammatory process to the structures of the middle ear and mastoid cells and thus light up an inflammation of the brain and its membranes. The loss of sight, although not in itself lessening the " expectation of life," exposes the aflicted one to greater dangers of accident than he otherwise would have. Do you find any tendency past or present to cough, expectoration, difficulty of breathing, or palpitation ? Or of predisposition, heredi- tary or acquired, to any particular disease ? This question is intended to direct the Examiner's attention par- ticularly to the condition of the thoracic viscera, past or present, and to ascertain, if possible, whether, when there has been any departure from the healthy condition, if it has been due to hereditary or acquir- ed causes. Do you find that there have been any cases of consumption or other hereditary disease among the parents, brothers or sisters of the applicant ? On the evidence or non-evidence of such, the fate of the applicant fcr insurance frequently depends. At the present day the hereditary nature of some diseases is un- questioned, and of all the diseases wb'ch exercise an hereditary influence, consumption is the most prominent. The proportion of hereditary and acquired cases vary at the different ages of life. According to Dr. Fleming those cases which occur be- EXAMINATIONS. 29 fore the age of forty or forty- five are usually hereditary ; after that period they are usually acquired oases. The same authority states that there are fewer deaths from con- sumption in Insurance institutions in the period of life embraced be- tween 15 and 80 years than is experienced in the general population, but a considerably higher proportion above this period, that is after 80 years of age. That consumption is capable of being transmitted from parent to offspring, we presume is admitted. The offspring of consumptive parents may or may not be attacked by the disease, or the seeds may lie dormant in one generation and become developed in another ; thus we find phthisical parents bearing apparently healthy children, or the children of such parents who seem themselves to be healthy having phthisical offsprmg. In such cases individual modifying circumstances must be carefully examined and weighed. The age, personal health, configuration, habits, residence and occupation of the person examined, and the health and longevity of relations generally must be considered before deciding on a case; also ascertain if more than one relative has died of the disease and the degree of propinquity, the age or ages at which death occurred, the number of deaths and the ages and state of health of the members of the family now alive. Drs. Begbie and Ohristison state :— When two members of a family have died of consumption the risk must be declined. This rule is not, however, always acted upon. The following general rules have the approval of medical experts in reference to accepting applicants who have the history of consump- tion in their family : — In the following cases reject : 1. When three cases have occurred in a family. 2. When the appUcant is under twenty-one years of age and one case has occurred. 8. When under thirty and a parent has died of the disease. 4. When under thirty-five and two members have shown the 5. V/hen under forty and both parents have died of the disease. These are the general rules for applicants on the whole life plans of insurance, but some of the foregoing cases may be taken on en- iii I V ^ do LIFE INSURANCE dowment plans for a suitable term of years, when the personal history of the applicant is good. The communicability of consumption is patent to all physicians of any considerable experience ; how this communication occurs is still an open question. Among the other hereditary diseases we may mention insanity, gout, cancer and epilepsy. Has the applicant ever had any serious illness or injury ? The Examiner will here enquire carefully ; bojae illnesses are £re> qnently followed by organic lesion, such as malarial fever, typhoid or diphtheria, &o. As to injuries : Injury to the head or spinal cord may, after the lapse of months or years, give rise to fatal results, hence the importance of finding out the fact and history of any such occurrence and its probable effect on the constitution or on any important organ. As an instance, a man may receive injury of the brain or spinal cord, and although he recovers from the immediate effect, it may be followed by ulterior consequences which may terminate unfavorably. If the applicant be a woman, state number of children, if now when last pregnant, whether there have been any miscarriages or difi&cult labors, are the uterine functions now regular, has she ever suffered from uterine or menstrual disease or disorder ? Most Companies do not insure a pregnant woman, nor a married woman until she has had one child, unless she is over forty years of age ; nor an unmarried woman, except on short endowments. With the whole population the duration of life amongst females exceeds that amongst males ; but in the experience of life insurance companies the reverse is true. If this curious fact is to be explained on the assumption that medical examinations of females are not usually so thorough and disingenuous as that of males, it is a reflec- tion upon our profession which we hope the future will remove. There are certain conditions incident to females which render their lives somewhat hazardous, such as menstrual functions, child-bearing, miscarriage or dif&culty in labor, &c. A woman who has once borne a child without any considerable difi&culty, is a much better risk than a primipara, and married women are belter risks than those who are single. Previous labors, if any, should be carefully enquired hato. Is the tierson matured ? EXAMINATIONS- SI Rupture is much more common than is generally suppoaed and is met with oftener in the male than in the fema' ., the proportion heing 5 to 1. According to Malgaine one man in every thirteen m France is ruptured. The word Hernia in insurance papers refers especially to the various forms of abdominal hernia ; the dangers attending this condition are well known, but at the same time it is a remarkable fact that the mortality due to hernia is only four per cent, of those so affected. Hence, if a properly adjusted truss be worn, the risk may be received, and in most policies a clause is inserted to the effect that the insured must wear a suitable and well fitting truss. Are the muscles hard and strong ? Is the gait firm and elastic ? These questions have a bearing on the general condition and physique of the person examined. Is the spleen or liver enlarged ? If the party is residing at present or has resided in a malarious dis- trict, we may find some enlargement of the spleen or liver as a result of the influence of malarial poison acting on these organs. If the enlargement be chronic it is due to organic change in the structure of the organs themselves, and would be a cause for rejection. If the person has been a bonvivant, or used alcoholic drinks to excess, or if he has resided in tropical climates, we may have an en- larged liver as the result. Such cases must be postponed or rqected, as the circumstances point out. Does the state of the teeth, mouth and throat indicate health ? Persons who have sound teeth masticate their food properly and are not liable to dyspepsia. Sound teeth are usually associated with a strong constitution, and decayed teeth with the reverse. Inherited syphilis may sometimes be recognized by the conforma- tion of the teeth, particularly that of the incisors, and also by the state of the mouth and throat ; look for any evidence of syphilis, see if chronic pharyngitis be present or if the tonsils are enlarged. If any evidence of ill health be found from the condition of these parts, weigh carefully its importance. Do you find by examination or enquiry any indications that the applicant's habits of life are or ever have been other than co^^^ a^^ .Zr..r.^.? Make a searching investigation here. The observant li 11 88 LIFE INSURANCE Examiner can usually judge of this from the general appearance of the applicant. Excess of anylcind, if continued for a period of time, will lessen the chance of longevity, but there is a great difference between indi- viduals as to toleration of the system. Inroads upon the constitution will be recognized if looked for, and should be weighed carefully. Do you find any unfavorable features whatever in the applicant's physique, family or personal history, residence {e.g., if malarious), occupation {e.g., if involving any special exposure or danger), habits or circumstances of life ? This question is a summary ot the circumstances affecting the pro- posed risk, and the answers to it should be well weighed and studied. Physique refers to conformation or build ; any departure from the normal standard would be of importance only when it affects the probable duration of life. Family and personal history. Special care must be exercised to ascertain if there have been any cases of hereditary disease in the immediate family or near blood relations. Personal history refers not only to his present physical condition, but also to his present and past habits of life, &c. Residence, whether healthy or otherwise. If malarious, the person is exposed to the dangers of the various forms of malarious disease, both of an acute and chronic nature. Who is the applicant's medical adviser ? Do you need any inform- ation from him ? This question may sometimes be of importance, as applicants for insurance have denied having had any medical man attending them, and it became subsequently known that they had undergone a serious illness, and had been under professional treatment. A false answer to this question might invalidate the pohcy. Sometimes much valuable information may be obtained as to the habits and former health of the applicant from his usual medical adviser which might not be brought to light by the Company's Medi- cal Examiner. Do yon think the appUoant will reach the full expectation of life ? By "expectation of life" for a given age, is meant simply the probable average duration to which life, among men who have attain- ed that a"e. will be further extended^ Thus takin" IjOOO heftltby men who have attained the age of 85, the aggregate durt^tion of life < 0) QU 1 EXAMINATIONS. 88 beyond that age for the v/hole number, will be 81.020 years, or an average of 31.02 years for each man. . , i i Tables of " life expectation " are a deduction, by a simple calcula- tion, from the -mortality tables," which are made up from observations of the rate of mortality at each separate age. Several such tables are in use, but the one named in the Dominion Insurance Act of 1880 is the Hm Table, and is made up from the experience of 20 leading English offices. The following is the expectation of life, for each age! from 20 to 70. on the basis of the Hm. Mortality Table :- Table of Life Expectation. (a ^ 42.06 41.83 40.60 39.88 89.15 88 41 37.66 36.91 36.16 85.42 84.08 33.95 33.21 o > .2 --^ PM CD O > O (p iga 32.48 31.75 31.02 30.29 29.56 28.84 28 12 27 40 26 68 25 96 25.23 24.51 23.70 23.08 22.38 21.68 20.99 20.81 19.63 18.95 18.28 17.62 ■^6.96 16.32 15.68 15.05 -TlT^uTco^derations involved in the foregomg questions lead „„1o this most important one. The skilful examiner having investi- V.dtherbits the personal and family history, and the present fhtslcaSt^ n become acquainted wih the LnTi ions and influences which surround him in his daily he is /r^pared to give a reliable opinion as to the probable duration of the "'JnTntafof reasonable doubt he should give the Company the Inan> cas application, or by recommendmg an benefit of it by rejecung ui pf ^^^ probable endowment policy ^fhase term suall .8 w^.i witi- duration of the applicant's life. ^ ^-