HX64074315 RA427 L62 Prolonging life as a RECAP PROLONGING LIFE AS A FUNCTION OF LIFE INSURANCE mtljfCttpflmsfork College of 3pf)j>55tctang anb burgeons Digitized by the Internet Archive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/prolonginglifeasOOIife PROLONGING LIFE AS A FUNCTION OF LIFE INSURANCE Five Years' Experience of the Life Extension Institute NEW YORK 25 WEST FORTY-FIFTH STREET 1919 u 62- Life Extension Institute, Inc. Telephone Bryant 1997 25 West 45TH Street, New York City Chicago Office 5 North Wabash Avenue OFFICERS AND DIRECTORS Hon. William H. Taft, Chairman of the Board Prof. Irving Fisher, Chairman Hygiene Reference Board Professor of Political Economy, Yale University Maj.-Gen. William C. Gorgas, Consultant Eugene Lyman Fisk, M.D., Medical Director Harold A. Ley, President James D. Lennehan, Secretary Henry H. Bowman President Springfield National Bank, Springfield, Mass. Robert W. deForest Vice-President American Red Cross Arthur W. Eaton President Eaton, Crane & Pike Company Edward L. Pierce President Solvay Process Company, Syracuse, N. Y. Charles H. Sabin President Guaranty Trust Company of New York PROLONGING LIFE AS A FUNCTION OF LIFE INSURANCE FOREWORD |UR five years' experience in this new field of social medicine has been so interesting and opens up such tremendous opportunities for service that we are impelled to lay the facts before the in- surance companies, hoping thereby to interest them in doing something along this line of con- structive effort. We see an opportunity not only for important financial returns, materially lowering the cost of insurance, but concomitantly what we consider more important, opportunities for making valuable contributions to the health of the policyholders and to the vitality of the nation. It is axiomatic, of course, that it is impossible to improve the health of policyholders and not effect a money saving represented by mortality gains. We believe that as you read this message you will be impressed by the reasonableness of our con- tention that the periodic physical examination of policyholders, together with education in right liv- ing based upon the findings in these examinations, would be a common sense conservative business measure and as justifiable as the preventive [7] methods used by fire, boiler, and liability insurance companies for the purpose of lowering the liability in these branches of insurance. In due course it will doubtless be possible to give some comprehensive actuarial expression to this saving. At present all we offer is an analysis of the conditions found and of the opportunities that exist for life saving. Individual instances are ex- hibited showing in what way such opportunities have been utilized in actual life saving. It is thus possible to bring sound business judgment to bear upon the possibilities of the work. The Institute is no longer a paper plan or theory. It is a very lively and important business and scientific entity. It merits investigation. The Insti- tute has become a national institution, is estab- lished on a sound financial basis and has examined and influenced more than a hundred thousand lives. Nevertheless we feel that it has only just be- gun to do the work for which it was organized. Now that peace has come, the progressive minds in this country are turning to reconstruction prob- lems and to the best utilization of the suggestive lessons derived from the war. There is no more im- portant duty than to act for the correction of our physical deficiencies as revealed by the war. The time is, therefore, opportune for insurance companies to consider these questions. Work of immense importance can be done by the insurance companies during this plastic period when the [8] world is struggling to higher planes of living. We offer our experience in the hope that it will have, at least, a suggestive value in broadening the scope of insurance benefits and insurance influence among the people. Harold A. Ley President March, igig 09 ] F^BtkS^WH&^-F. '^i'-*l WES^taS lllj ilfi ^^^^^mp K&JslifT^ iKf& l?' =\ ; iP^if ~'l'^;/;> v :".,'■'.£! ^^illflJife'JK ^^ k r r--i'{-'-.^0o. •■■■' }' ■-■? . . ' .a'Jo^sfl fjjtr ■'-■■ THE BIRTH AND GROWTH OF THE LIFE EXTENSION INSTITUTE THE Boston Transcript relates how a group of elderly ladies were discussing the circum- stances of their birth. One lady remarked that she weighed only three pounds at birth. This excited considerable astonishment. Another member of the group inquired solicitously: "And did you live?" "Yes," was the answer, "and they say that I did well." It is now five years since the Life Extension In- stitute was born. Notwithstanding the important scientific and financial backing that it had, many good friends thought it was a "three-pound baby" and in fact a premature birth about twenty years ahead of the times. To such who ask "did it live?" we answer "yes," and, like the lady in the story, "they say we have done well." En] After all, the proof of vitality and usefulness is actually to live and to accomplish something. The Institute was not designed as a great money- making institution; its purpose was to become self- supporting while carrying far and wide a propa- ganda for higher health ideals, for healthier and more efficient living, for disease prevention, for longer life and greater capacity for living well. These objects it has accomplished. It is well known to the life insurance world that the Institute aimed at the outset to reach the peo- ple through the life insurance companies, organiza- tions mutually interested with their policyholders in prolonging human life. Several companies had the courage to make the trial and important work has been done in this field. The privilege of periodic health examination through the Institute has been extended to more than 600,000 insurance policy- holders. In addition, a number of companies have been moved to accept the principle of health con- servation among policyholders and have applied this principle in various ways, some by physical examinations or periodic urinary examinations, and others by educational measures such as health bulletins. The Institute has been deliberate in extending this life insurance work and has appreciated the importance of making good in other fields wherever possible in order that the work may not be halted by the educational effort required. to convince life Cia] insurance officers of the real need for such a ser- vice. We use the term "need" in a broad sense. No one acquainted with life insurance affairs ques- tions that present premium rates are more than adequate to cover present and future rates of mor- tality and no one in the Institute would claim that the mortality" rate in any well managed company menaces its prosperity or stability. The "need" that exists in relation to health con- servation arises from the public conviction that, following the war, all human institutions will be expected to function as broadly as possible for the public good. If a life insurance company can, with- out impairing in any way its ability to meet its death indemnity contracts or without increasing the cost of such contracts to the public, make avail- able this machinery for prolonging human life and preventing disease and disability, there will surely be a public expectation that the business of life insurance will broaden to include these functions. If there is a further prospect of effecting mortality gains from such measures, the insistent principle of conservation of man power and of all national re- sources demands action and an efficient utilization of such opportunities. The peculiar nature of the life insurance busi- ness has always given it more than a commercial significance. It has been rightly regarded as one of the great social bulwarks against poverty and its attendant evils. It comes as a message of hope and [13] relief in the darkest hours of family life. It is logical and entirely consistent that there should be blended with this business of life insurance the ele- ment of health preservation, disease prevention and death postponement, especially as the inclu- sion of these functions in the activities of the busi- ness would operate both to popularize and finan- cially strengthen the institution. Believing that such principles would ultimately be accepted in the life insurance world, the In- stitute did not press its campaign strenuously among the companies, especially in view of war conditions, but proceeded to develop its system where it could be done most readily and effectively, trusting to the persuasion of success to appeal more strongly to the life insurance companies, and also to the growth of a strong public urge for in- surance companies to broaden their usefulness and engage in such activities. In accordance with its original purpose, the In- stitute has established a specialized organization which is equipped to render a standardized service to policyholders, combining the periodic examina- tion and the necessary hygienic instruction and guidance that should accompany it. More than one hundred and fifty industrial and commercial concerns, such as the Guaranty Trust Company of New York, Solvay Process Company, and Standard Oil Company of New York, have taken this service for employees and a very large [14] individual membership has also been established. The growth of this business has been such that it now occupies two floors in its headquarters in New York, where it employs more than one hun- dred people, including twenty physicians. A large laboratory has been established with complete equipment for all forms of pathological work. This laboratory serves about two hundred physicians in New York and vicinity in addition to carrying on the regular laboratory work of the Institute. A complete X-Ray department is also included in the Head Office equipment. The Institute also has a branch office in Chicago and more than five thousand examiners in the principal towns and cities in the United States and Canada. The support of the Hygiene Reference Board has been retained and its scientific interest in- creased as the work of the Institute has grown. This board has rendered extremely important ser- vice in keeping the scientific work of the Institute in equilibrium, especially with regard to the prin- ciples of personal hygiene for which it stands. This aid has been rendered without compensa- tion and wholly as a contribution to scientific advancement and public welfare. More than one hundred and thirty thousand copies of the Institute's health bible, the book "How to Live," have been sold, and several of the leading universities and colleges have adopted it as [15] their standard book on hygiene, and the special edition of this book entitled "Health for the Sol- dier and Sailor," which includes chapters on war hygiene and sanitation has been widely distributed in the army and navy. The Surgeon-General of the Navy instructed that it be placed in all naval libraries. The royalties from the book "How to Live" have been devoted wholly to philanthropic public health work, the most notable employment of these funds being in the distribution to the draft boards through the United States Public Health Service of more than 1,000,000 pamphlets of instruction for registrants rejected in the draft. More than 100,000 individuals have been exam- ined in the individual, group and insurance service of the Institute, and in the course of this work standardized methods of examination and of in- struction in personal hygiene have been developed. It is evident, therefore, that the equipment of the Institute enables it to render this service to policy- holders in a more complete and satisfying way than would be possible for a single life insurance com- pany. There is no effort to separate "good risks" from "bad risks." The purpose of these examina- tions is to make a spot map of the individual as regards his physical defects, family and personal history and his life tendencies, and convey counsel not only as to the prevention of disease and dis- ability but as to possible increase in vitality. Apart from the actuarial study presented by [16] Mr. C. W. Jackson to the Actuarial Society of America, October 16, 19 13, on a special group of lives that came under a similar system of periodic examination, there has been no complete actuarial study made of the insurance policyholders that have had these periodic examinations. The diffi- culties of such an analysis are well understood, especially with regard to an agreement upon stan- dard factors for comparison. It is hoped, however, that such a study will soon be available. In the interval, we have abundant evidence in the form of collected individual cases, showing the successful operation of this principle, and we have the results of these examinations showing the de- gree of impairment that is found and the obvious opportunity for relief developed by this examining system. The following is a typical case illustrative of the way in which this system works: A policyholder, 25 years of age, when first examined by the Institute was not aware of impairment except tendency to catarrh. He weighed 213 pounds, height, 5 ft. 10% in.; albumin present, diastolic blood pressure increased to 108. On second yearly examination diastolic blood pressure reduced below 100, no albumin, weight reduced to 200 pounds. On third yearly examination blood pressure normal, 115 systolic, 75 diastolic, weight reduced to normal for age, 170 pounds, a total reduction of 43 pounds; no albumin in urine. These changes were brought about by simple regulation in diet, and exercise. That this man is in a much more favorable mor- [17] tality class on his physical showing alone cannot be denied. That allowance must also be made for his recognition of the need for guarding against overweight and organic strain is also true. There are hundreds of such cases on record showing the margin of possible improvement that exists among standard policyholders. There are numerous instances of co-operation of this type and it must be evident that any individ- ual who takes the trouble to be examined would be at least to some degree co-operative and en- deavor to profit by the counsel he receives. Prob- ably no one who has not been engaged in this type of work can appreciate how much can be done by personal hygiene alone to change the physical condition or life trend of individuals with common types of impairments or departures from the ideal of health which we too often accept as a matter of course. As we have pointed out, the policyholding body of any company is made up of a mixture of types. Under a critical and careful examination none will be found absolutely free from impairment, as the intensive work done by the Head Office staff of the Institute among large groups of supposedly healthy people has shown. On the opposite page is an analysis of typical industrial, commercial and insurance groups (figures derived from more than 10,000 cases): [18] INDUSTRIAL COMMERCIAL LIFE INS MEN AVER. AGE 34 WOMEN AVER. AGE 2 5 MEN AVER. AGE 26 WOMEN AVER. AGE 26 AVER. AGE 37 No physical impairment re- ported — no modification of living habits required % % o O % Slight physical impairment or defect requiring observa- tion or hygienic guidance. . 10 n 10 12 6 Moderate physical impair- ment or defect requiring some form of hygienic guid- ance or minor medical, den- tal or surgical treatment. . . 42 54 5 2 58 63 Moderate physical impair- ment or defect, medical su- pervision or treatment ad- vised in addition to hy- gienic guidance 35 9 19 4 27 9 21 21 Advanced physical impair- ment or defect requiring systematic medical super- 9 7 Serious physical impairment or defect urgently demand- ing immediate attention. . . 4 2 3 [19} Among life insurance policyholders more than 30 per cent, of those examined required important medical attention and of this number 90 per cent, were unaware of any important impairment. The periodic examinations of life insurance policy- holders scattered throughout the country and dis- tributed through a staff of 5,000 physicians has, of course, been less directly supervised and less in- tensively critical; hence the results are not abso- lutely comparable with those of the Head Office staff, yet they reflect similar conditions of impair- ment. It is evident from such figures that there is abundant opportunity for corrective work among insured risks. When figures of this nature were first produced by the Institute there was considerable astonishment expressed in some quarters. There was doubt as to whether the work had not been done in a hypercritical way. The fact that only 10 to 15 per cent, of applicants for insurance are declined obscured the problem. Too many people have been accustomed to jump to the conclusion that those accepted for life insurance are practi- cally free from defect. No experienced life insur- ance reviewer would upon reflection endorse such a view. There is a vast range of defects, disabilities and impairments which are not recorded in a life in- surance examination, yet they are not without their effect on mortality. They are disregarded [20] simply because life insurance premiums cover the risk assumed. It is probable that many life insur- ance men of experience do not often stop to re- flect on the reasons why it is necessary so rapidly to increase the premium rate with advancing age. It is obvious, of course, that this increase is almost entirely necessitated by the increasing death rate and also shorter duration of premium payments, but why the death rate increases is seldom in- quired into; it is accepted as the expression of a natural law. Also, many do not reflect that the so- called American Experience Table is really an arti- ficial table constructed many years ago and that it could not, except by chance, reflect present mor- tality conditions. The possibility of searching out the causes that produce the death rate and modi- fying them in a way to effect mortality gains must be apparent to anyone who critically examines the evidence with an open mind. [-1] The following chart, derived from the U. S. Life Tables of the Census of 1910, abruptly "hits us in the face," as it were, and shows how rapid is the loss in vitality after age 12: Death Rate per iooo Living Among White Males Cities in Original Registration States United States Life Tables, Census of 1910 36. 69. 137. 245. 386. 585. D.R. 18, 12. 4-5 6.8 70 80 90 100 106 ages D.R. 2.4 AGES 12 20 30 4O 50 60 Those who wish to believe that the death rate at 40 is nearly treble what it is at 20 because of a natural law are welcome to such a belief, but we claim that the more scientific attitude of mind is to assume that there must be many causes at work producing this increase in the death rate which are [22] to some degree controllable by science. As a mat- ter of fact, many of these causes have been ascer- tained and neutralized as in the case of communi- cable and epidemic disease. The death rates at the early periods of life have been profoundly altered by scientific work; indeed, the statistics of a num- ber of countries, Sweden, England and Wales show a substantial decrease in the death rate at every age period of life. Evidence is lacking that there has been any improvement at the elderly ages in this country; in fact, the reverse would seem to be the case. However that may be, it is now a matter of almost common knowledge which insurance officers cannot afford to disregard, that a vast amount of chronic disease and prema- ture death is caused by infection, by faulty living habits, by such conditions as mouth infection, constipation, dietetic excess, overweight and like conditions which a thorough physical examination can reveal and which hygienic government, medi- cal, dental or surgical treatment can mitigate, control or cure. It is also true that these are the very types of impairment that are disregarded in a life insur- ance examination unless they are present in a most extreme and menacing degree; hence it is quite clear that in every policyholding body these factors are constantly at work keeping the death rate much above what it need be if reasonable attention is given to detecting and correcting [23] these impairments and improving faulty living habits. It may come as a shock to some insurance offi- cers to be told that the influence of the present in- surance system is rather to encourage physical neglect and increase mortality than to the contrary. A man who has been accepted for life insurance is inclined to slap himself on the chest and be con- firmed in any physical neglect of which he may be guilty. It is not uncommon for the examining phy- sician to tell him, as contribution to the amenities of the occasion, that he is "the finest specimen of physical manhood that he has ever examined." Learning that his various sins against his body have apparently been without any ill effect, he continues to commit them. He regards his exami- nation as giving him what is known as a "clean bill of health." That the average accepted risk is actually far from being entitled to a clean bill of health is shown by any regular system of examin- ing that takes into account the factors hereinbe- fore mentioned which have been scientifically demonstrated materially to influence health and longevity, even though in the mass they do not call for sub-standard premium rates. At certain ages mortality rates have altered very materially for the better in the past thirty years and they are, at all ages, as we have frequently contended, subject to very considerable control by scientific methods. t> 4 ] It is true that insurance examinations have also saved many lives in that they have made known to impaired individuals who have been rejected the fact that they require some change in their method of living or some form of medical treat- ment. We have known of many such instances and all such instances tend strongly to confirm the value of periodic examinations. We believe that the idea that risks accepted for life insurance are on the average of such a high quality that there is little opportunity for improvement and that the expense of periodic examinations would not be justified has had a very profound influence on the views of some life insur- ance experts; in fact, at the time of the organiza- tion of the Institute this criticism was made by a very able life insurance officer who now views with favor the general development of the Institute. He contended that a very small proportion of in- dividuals would be found in the average insurance company whose mortality could be materially in- fluenced. Since then a wealth of information has become available with regard to the causation of disease, especially as to the role of focal infection in causing chronic disease and those gradually ageing pro- cesses which are not dignified by the name of disease yet still contribute to the death rate in the middle and later periods of life. With our present broader knowledge of the conditions actually ex- [25] isting among average groups of people and even among selected insured lives and of the actual per- centages of impairments found among the groups of lives examined by the Institute, a substantial margin of possible improvement among standard risks is clearly shown. That the figures derived from the Life Extension Institute's examinations of industrial groups and of policyholders are not the reflection of a hyper- critical or exaggerated viewpoint is shown by the results of the recent draft examinations. Acting for one of the committees of the Medical Section of the Council of National Defense, the Medical Director of the Institute made an investi- gation of the results of the examinations in a num- ber of representative boards and collected the data exhibited in the table shown below: ANALYSIS OF SEVEN LOCAL DRAFT BOARDS IN DETROIT, BROOKLYN AND NEW YORK PERCENTAGE NUMBER OF MEN EXAMINED Number of men called 8,875 .... Number of men examined 7,61 1 .... Number of men discharged for physical reasons 2 > 2 3 2 2 9 Prominent Causes of Rejection: Defective Eyes 462, 6 . Defective Teeth 366 4 . 8 Underweight 350 4.6 [Continued on page 27] [26] Hernia 223 2 . 9 Defective Heart 184 2.4 Defective Feet 180 2.3 Injured or amputated limbs 169 2.2 Defective Ears 88 1.2 Tuberculosis of lungs 77 1 . Tuberculosis of joints 2 .... Undersize 53 .7 Genito-urinary, bladder, etc 37 .5 Varicose veins 3$ .4 Overweight 32 .4 Syphilis 32 .4 Varicocele 28 .3 Deformity of trunk 38 .5 Asthma, bronchitis, etc 21 .3 Mental and insane 14 .2 Debility and poor physique 16 .2 Miscellaneous injuries 15 .2 Hemorrhoids 13 .2 Kidney disease 10 .1 Rheumatism 8 .1 Miscellaneous defects 7 .1 Epilepsy 7 .1 Fistula 5 .06 Alcoholism 4 .05 Hydrocele 4 .05 Diabetes 4 .05 Goiter 6 .08 Deaf mutes 6 .08 Skin affections 4 .05 Liver and gallbladder disease 3 .04 Drug habit 3 .04 Injury to nervous system 3 .04 Kidney removed 2 .02 Neurasthenia 1 .01 [17] The rejection rate in these local boards, 29 per cent., was exactly in agreement with the rejection rate found for the entire country, as shown by the Provost Marshal General's preliminary report of the first draft, subsequently issued. Total called 3,082,946 Total examined by local beards 2,510,706 Total rejected by local boards for physical reasons 73°>756 Percentage of those examined 29 . 1 1 Add 5.8 per cent, rejected at cantonments (estimated) 33 . 1 The following table appears in the second report of the Provost Marshal General, February 19 19. PER CENT. Percentage of rejections by local boards in 191 7 29.11 Percentage in 191 8, groups B, C, D [Table 49] 2 9-59 Percentage of camp rejections of local board accept- ances, 1917 5.80 Percentage in 191 8 [Table 56] 8.10 It will be noted that approximately 38 per cent, of the total number examined in the second draft were declined for active service for physical reasons. Examinations in the U. S. Navy and Marine Corps are even more emphatic in their testimony as to the degree of physical impairment that exists in the population. [28] ANALYSIS OF PHYSICAL CAUSES FOR REJECTION FOR MILITARY SERVICE U. S. NAVY AND MARINE CORPS (Report of Surgeon-General, 1916) Number of applicants 113,932 Number of men examined 82,592 Number of men rejected for all causes 51,167 Causes of Rejection: Eye defects 9,45 2 Underweight 5,397 Flatfoot 5,028 Defective teeth 4,878 Deformities 3>533 Varicocele or varicose veins 3,105 Heart affections 2,302 Height, under 2,124 Poor physique 1 ^ > 33 Ear defects I >37^> Genito-urinary- venereal i j347 Hernia, or tendency to 1,312 Skin disease 1,094 Height and weight, under 921 Tuberculosis or suspects 909 Pyorrhea 896 Tonsillar conditions 588 Genito-urinary, non-venereal 548 Nasal abnormalities 476 Febrile conditions 381 Mental disorders 302 Goiter or tendency to 294 Defective speech 132 Miscellaneous causes 2,820 PERCENTAGE OF MEN EXAMINED 62 II 6 6 5 4 3 1 2 2 1 1 1 1 1 1 1 6 o 7 6 6 3 1 1 08 72 66 51 46 S^ 35 l 5 41 When we reflect that these rejections cover in- dividuals impaired to a degree that made them unfit even for training or remedial treatment at the camps, as then equipped, an even larger estimate is possible of the actual degree of impairment that exists. Notwithstanding the close of the war, there can be no question as to the tremendous importance of conserving our man power. World conditions at the present time and for generations to come im- peratively demand that we give this matter seri- ous consideration. The best minds in the country- are now busy with these problems, striving to es- tablish methods of physical education and train- ing for the young, rehabilitation for the wounded or impaired soldier, and medical care and physical supervision for the industrial employee. The war has given an immense stimulus to such activities. The Institute is participating in this work in various ways and particularly in its services to large industrial concerns through which the health, working capacity and morale of the workers are improved. The insurance companies have channels of direct communication with practically every household in the land. Their influence on these households can be greatly increased by fully utilizing these channels of communication. The public will regard such activities as a wholesome and legitimate func- tion of life insurance, if the information is safe- [3°] guarded and held as confidential and utilized solely for prolonging life. Also the psychological effect of this system on the policyholding body is entirely favorable, especially if it be operated through a public service institution like the Institute, which can give guarantees that its interest is primarily directed to the benefit of the policyholder. Many who do not take the examinations nevertheless ap- prove of the company's action. Others, influenced by the company's action, take these examinations through their own physicians. A self-selected group in the policyholding body will actually take the examinations offered by the company. This group is, of course, the one most needing such a service and affords the largest opportunity for conveying relief and lowering mortality. These psychological factors automatically limit the acceptances in pro- portion to the size of the company. We feel that because of the broad work that the Institute is doing throughout the population it is entitled to the cordial co-operation of the life in- surance companies. Many of our individual mem- bers are life insurance risks, and in any industrial or commercial group that we examine there is a large proportion of life insurance risks. Our service is favorably influencing these lives and rendering them more desirable risks. We feel, therefore, that there is every reason why life insurance companies should be willing to take a cordial interest in our work and critically examine our facilities for serv- [30 ing them, or at least consider in what way they may individually contribute to the improvement of national vitality. As we have said before, we are making exami- nations of employees in hundreds of business con- cerns. There are thousands of concerns that should have this service. In every concern which we exam- ine a majority of the people are policyholders. Your company is getting its share of the profits that result from the help we give these people, without one cent of expense to you. Is it not sound business policy to encourage the extension of this work? We find the best recommendation we can have with industrial concerns is the endorsement of old-line insurance companies. Another reason why the Institute should command the good will and active support of insurance companies is that after allowing 5 per cent, on its preferred stock two-thirds of its profits are used for public health propaganda. [32] PLANS AND METHODS The Institute has arranged three types of services for insurance companies. First — Urinary Analysis, Personal Questionnaire, Hygienic Counsel and Educational Service We have designed a very economical low cost service that companies can use who wish to do something along this line but desire to keep the amount expended down to a minimum. This service consists in offering the policyholder a membership in the Institute which entitles him to a confidential review of a personal history ques- tionnaire, a urinary examination at our head office laboratory and a quarterly magazine containing the essentials of our monthly magazine. Policyholders desiring the service fill out an ap- plication slip which has been received in the prem- ium notice and forward it to the insurance com- pany. The company then forwards to the policy- holder the blank questionnaire, with instructions to fill it out and forward to the Institute, together with a specimen of urine in a container which the Institute, on notice from the company, has sent to the policyholder. All the data derived from this source is reviewed at our Head Office, and a report sent to the policyholder with appropriate recom- mendations and Keep-Well leaflets of instruction. 133} We recommend that this service be held as strictly confidential between policyholder and the Institute. The charge for this service is one dollar per annum. Second — Examining and Educational Service for Entering Policyholders. This service is designed to make the maximum use of the information in the application and medi- cal report apart from its use for selection purposes. Heretofore there has been no effort made to change the type of risk as it goes upon the books. It is well known that so-called standard risks vary widely in their mortality, depending upon the type. The Medico-Actuarial Investigation has shown that many types of risks accepted as stan- dard have exhibited a mortality above the Ameri- can Experience Table. The mortality of a company is always derived from these types included be- tween the two extremes of super-standard and borderline risks. There is abundant opportunity favorably to influence the mortality among the borderline risks, and even the standard risks can be greatly improved. Inasmuch as these mortality figures are not fixed by some immutable law, but are, as we have shown, the result of definite mate- rial causes which are subject to modification, fail- ure to attempt the modification must be regarded as a neglected business opportunity. We have innumerable instances of these border- line types; overweights who have transformed their [34] condition by diet and entered a more favorable mortality class. A long range of troubles which have their influence on mortality yet are not suf- ficient to exclude from standard insurance, can be given attention in this service and the life trend of the policyholder often very materially altered for the better. The plan is to forward to the policyholder with his policy a circular offering him a membership in the Life Extension Institute, telling him something of its purposes and personnel; that the company has investigated its standing and can vouch for its management and that every recommendation it may make should receive serious consideration. A personal history form is enclosed in which the policyholder is offered the privilege of a confidential review of his physical condition and manner of living by the Life Extension Institute without charge to him. The policyholder fills out the ques- tions relating to hygiene on this blank, which is re- turned to the company. The company then places a brief digest of the physical findings on the form and forwards it to the Institute. The papers are reviewed by a specialist in charge of this work — the errors in hygiene noted, the physical defects, such as overweight, hemorrhoids, mouth infection, underweight, constipation or other conditions reported, and a personal letter of counsel is written suggesting such modification in living habits as may be indicated orsuchmedical, dental or surgical atten- [35] tion as would improve the condition of the risk. The urinary service described in the previous sec- tion is offered the policyholder at the end of a year and another letter of congratulation or advice sent him, based upon the findings. The policyholder also receives the monthly magazine "How to Live," and in connection with the letter of advice, such Keep-Well leaflets as apply to his case. This educational and life-pro- longing service introduces a special feature which should prove of "business getting" advantage and constitute a powerful "good-will" factor. Inasmuch as the service is not compulsory, only those who have confidence in its good faith will take it, and such people will be co-operative and more likely to benefit by the counsel received. Here again there is a certain psychology of selection, and the benefit of this service will be automatically extended to those who need it most. One interesting feature of this service is the fact that while the application and medical report may reveal very little of importance, the policyholder, when interest in his condition is aroused, will very frankly reveal his so-called minor troubles, such as headache, constipation, and symptoms which are not usually brought out in a life insurance exami- nation, yet point to errors in living and even to physical defects, the correction of which may pro- foundly alter the trend of the individual. At least we are educating policyholders and their families [36] to the need of periodic examinations by competent physicians. Policyholders taking this service are privileged to write to the Institute regarding matters of hygiene and disease prevention. The charge for this service is two dollars for the first year and one dollar for the second. Third — Periodic Examining and Educational Service. The privilege of an examination at intervals varying according to the choice of the company from one year to three years, is the basis of this service. The details of this service are as follows: The company issues with its premium notices a leaflet notifying the policyholder that he has the privilege of a confidential physical examination by the Life Extension Institute for the purpose of prolonging his life and improving his physical con- dition. This leaflet contains a form of application which the policyholder fills out if he desires the examination and forwards to the Head Office of the insurance company. The insurance company then notifies the Institute and a personal history form is forwarded to the policyholder with a re- quest that he call upon the physician named there- in for examination. The local physician of the Institute then makes the examination and forwards the report, together with the personal history form, to the Head Office [37] of the Institute. The policyholder also forwards a specimen of urine to the Institute. The papers are there reviewed as is the case in the service for entering policyholders, and a report made to the policyholder of his physical condition, with counsel as to his needs. Keep-Well leaflets are also included in this service and a quarterly health journal con- taining the essentials of the monthly journal "How to Live." This examination is along the standard lines established by the Institute, and includes a com- plete bodily survey — eye, ear, nose, throat, blood pressure, heart, lungs, nervous system, physical measurements, and an examination of a specimen of urine at the Head Office laboratory. The charge for this service is four dollars per annum for those who take it. Some companies follow the plan of taking the entering service for policyholders for two years, and on the third anniversary extend the privilege of periodic examination. We have a fifteen dollar service that we feel a company could afford to offer to its policyholders carrying #> 10,000 to $50,000 insurance, and a thirty- five dollar service which could be offered to persons carrying over $50,000. These services provide more elaborate laboratory tests and a much more com- plete report is given than is possible with a four dollar service. The number of important and wealthy business [38] men who have manifested interest and satisfaction in the service rendered them by the Institute, war- rants the belief that such a privilege would be much appreciated, and not without its influence on prospective large insurers. The number of policyholders who will take these various services in any one company, notwithstand- ing the fact that it is offered free, is limited, and the total burden of expense is not heavy, yet the concentration of work on a group of policyholders who are interested in benefiting by it, makes it worth while and materially assists in spreading these principles throughout the population and encouraging the custom of periodic examination whether or not it be secured through a life insur- ance company. The Institute recommends that the information derived from these examinations be held as strictly confidential between the policyholder and the In- stitute and that such information be available to the insurance company only for statistical analysis of the results and not for individual consideration. If this assurance is given to policyholders, it allays any latent feeling on their part that such records might be in any way utilized for impairing their insurance standing. While all who have inti- mate knowledge of present insurance management have no misgivings on that score and are well aware that in all well managed insurance companies the effort is made to prevent lapses and hold policy- l39l holders on the books regardless of whether they are impaired or not, it is impossible wholly to re- move from the public mind a latent feeling of this character, and this applies to the policyholders even of the leading companies. This is an important reason why an organization like the Life Extension Institute should carry on this work wholly dissociated from the ordinary business activities of the insurance company and maintained in an atmosphere devoted solely to the improvement of the physical condition of the policyholder and the prolongation of his life. A much wider utilization of this service can be as- sured where it is carried on in this way. - This does not preclude the investigation by an insurance company of the mortality it sustains among thisclassor from making any scientific analy- sis it may desire of the results of these examinations. The gradual education and training of physi- cians to make these examinations along standard- ized lines, keeping in mind the viewpoint of hy- giene rather than insurance selection, is a fur- ther reason why the work should be done by a central organization wholly devoted to such a task. As the business develops and economies are intro- duced, made possible by such a central organiza- tion, the Institute would expect the cost of doing the work to be reduced, and this saving shared with the insurance companies. For example, the reduplication of examinations, [40] that is, the expense of examining a policyholder insured in a number of companies could be reduced by distributing the charge among the companies taking the service of the Institute. At any time that the volume of such work war- rants adjustment, the savings from this source would be shared with the insurance companies. [41] CONCLUSION WE have found that most insurance officers are genuinely interested in the general pur- pose of the Institute and are anxious to assist in extending its work. The object of this book is to give a comprehen- sive idea of the lines along which we are moving, in the hope that it may stimulate some companies frankly to join hands with the Institute and take its service, and perhaps others to co-operate in spe- cial ways or to carry on this work themselves in accordance with their best judgment. The field is open and offers vast opportunities for increasing the benefits of life insurance and greatly extending its influence among the people. It is really a higher service to keep a policyholder alive than to pay a moiety of his financial worth to his family after his death. These two services can be combined. What is the argument against it? We would welcome an expression of your views. Bear in mind that it is being done, and has been done, during the past five years — a sufficient an- swer to many former objections on the ground that it could not be done. Our minds are open, however, and we cordially invite suggestions, criticisms, and counsel. u*] Hygiene Reference Board OF THE LIFE EXTENSION INSTITUTE Irving Fisher, Chairman PROFESSOR OF POLITICAL ECONOMY, YALE UNIVERSITY PUBLIC HEALTH ADMINISTRATION Hermann M. Biggs, M.D., Commissioner of Health, State of New York. Rupert Blue, M.D., Surgeon-General, U.S. Public Health Service. H. M. Bracken, M.D., Secretary, Board of Health, State of Minnesota. Admiral William C. Braisted, Surgeon-General, U. S. Navy. Oscar Dowling, M.D., President, Board of Health, State of Louisiana; Pro- fessor of Hygiene, Tulane University, New Orleans. Maj. Haven Emerson, M.D., M. C, U. S. A. Lieut.-Col. John S. Fulton, M.D., M. C, U. S. A., Secretary, Depart- ment of Health, State of Maryland. S. S. Goldwater, M.D., Director, Mt. Sinai Hospital, New York. Maj.-Gen. William C. Gorgas, Surgeon-General, U. S. Army. (Retired) Calvin W. Hendrick, Chief Engineer, City of Baltimore. J. N. Hurty, M.D., Secretary, Board of Health, State of Indiana. Miss Julia Lathrop, Chief, Children's Bureau, U. S. Department of Labor, Washington, D. C. Allan J. McLaughlin, M.D., Assistant Surgeon-General, U. S. Public Health Service W. S. Rankin, M.D., Secretary and Treasurer, Board of Health, State of North Carolina. Joseph W. Schereschewsky, M. D., Assistant S urge on-General, U. S. Public Health Service George C. Whipple, Professor of Sanitary Engineering, Harvard University. MEDICINE AND SURGERY Lewellys F. Barker, M.D., Professor of Medicine, Johns Hopkins Univer- sity. George Blumer, M.D., Dean, Yale Medical School. L. Duncan Bulkley, M.D., Senior Physician, New York Skin and Cancer Hospital. Col. George W. Crile, M.D., M. C, U. S. A., Professor of Surgery, Western Reserve University. David L. Edsall, M.D., Professor of Clinical Medicine, Harva-d University. [43] Rear-Admiral Cary T. Grayson, M.D., U. S Navy. Maj. Seale Harris, M. C, U. S. A., Professor of Medicine, University of Alabama. Capt. S. Adolphus Knopf, M.D., M. C, U. S. A., Professor of Medicine, Department of Phthisiotherapy, New York Post Graduate Medical School. J. H. Kellogg, M.D., Superintendent, Battle Creek Sanitarium. Col. William J. Mayo, M. D., M. C, U. S. A., Ex-President, American Medical Association. Maj. Robert Tunstall Taylor, M. C, U.S.A., Professor of Orthopaedic Surgery, University of Maryland; Surgeon-in-Chief, Kernan Hospital for Crippled Children. Col. Victor C. Vaughan, M.D., M. C, U. S. A., Dean, Department of Medicine and Surgery, University of Michigan; Ex-President, American Medical Association. Maj. William Holland Wilmer, M.D., M. C, U. S. A., Professor of Ophthalmology, Georgetown University, School of Medicine. Col. Hugh Hampton Young, M.D., M. C, U. S. A., Associate Professor of Urological Surgery, Johns Hopkins University. CHEMISTRY, BACTERIOLOGY, PATHOLOGY PHYSIOLOGY, BIOLOGY John F. Anderson, M.D., Lecturer on Personal Hygiene and Sanitation, Rut- gers College, formerly Director, Hygienic Laboratory , United States Gov- ernment. Maj. Walter B. Cannon, M.D., M. C, U. S. A., Professor of Physiology, Harvard University. Russell H. Chittenden, Prof essor of Physiological Chemistry , Director , Shef- field Scientific School, Yale University. Otto Folin, Professor of Biological Chemistry, Harvard Medical School. M. E. Jaffa, Professor of Nutrition, University of California. E. V. McCollum, Professor of Physiological Chemistry, School of Hygiene and Public Health, Johns Hopkins University, Baltimore, Md. Lafayette B. Mendel, Professor of Physiological Chemistry, Sheffield Scien- tific School, Yale University. Richard M. Pearce, M.D., Secretary, Medical Advisory Committee, American Red Cross; Professor of Research Medicine, University of Pennsylvania. Lieut.-Col. Mazyck P. Ravenel, M. D., M. C, U. S. A., Director Laboratory of Hygiene, Professor of Preventive Medicine and Bacteriology, University of Missouri. Leo F. Rettger, Professor of Bacteriology and Hygiene, Sheffield Scientific School, Yale University. [44] Maj. M. J. Rosenau, M.D., M. C, U. S. A., Professor of Preventive Medi- cine, Harvard Medical School. Edward C. Rosenow, M.D., Professor of Experimental Bacteriology, Univer- sity of Minnesota and Mayo Foundation. William T. Sedgwick, Prof essor of Biology and Public Health, Massachusetts Institute of Technology. Henry C. Sherman, Professor of Food Chemistry, Columbia University. Maj. Theobald Smith, M.D., M. C, U. S. A., Director, Division of Animal Pathology, Rockefeller Institute for Medical Research. Charles W. Stiles, M.D., U. S. Public Health Service. A. E. Taylor, M.D., Professor of Physiological Chemistry, University of Pennsylvania; Assistant to the Secretary of Agriculture. Col. William H. Welch, M.D., M. C, U. S. A., Dean, School of Hygiene and Public Health, Johns Hopkins University, Baltimore, Md. C. E. A. Winslow, Anna M. R. Lauder, Prof essor of Public Health, Yale Uni- versity; Curator, Museum Natural History, New York. Francis Carter Wood, M.D., Director of Cancer Research, Columbia Uni- versity, in the City of New York. STATISTICS Henry W. Farnam, Professor of Economics, Yale University. EUGENICS Alexander Graham Bell, M.D., Board of Scientific Directors, Eugenics Record Office. C. B. Davenport, Director, Carnegie Station for Experimental Evolution, Director, Eugenics Record Office. Winfield Scott Hall, M.D., Professor of Physiology, Northwestern Uni- versity Medical School, Chicago, 111. MENTAL HYGIENE Lieut.-Col. Thomas W. Salmon, M.D., M. C, U. S. A., Medical Director, National Committee for Mental Hygiene, New York. Elmer E. Southard, M.D., Professor of Neuropathology, Harvard Medical School; Pathologist to Massachusetts State Board of Insanity. ORGANIZED PHILANTHROPY Mrs. Elmer Blair, Chairman, Public Health Department, General Federa- tion of Women's Clubs. [45 ] Lee K. Frankel, %rd Vice-President and Head of Welfare Department, Metro- politan Life Insurance Company. Thomas N. Hepburn, M.D., Secretary, Connecticut Society for Social Hygiene Wickliffe, Rose, Director, International Health Commission. Wm. Jay Schieffelin, Chairman Executive Committee, Committee of One Hundred on National Health. Maj. Louis Livingston Seaman, M.D., President, The China Society. Lieut.-Col. William F. Snow, M.D., M. C, U. S. A., General Secretary, The American Social Hygiene Association, Inc. Lawrence Veiller, Secretary and Director, National Housing Association. EDUCATIONAL W. H. Burnham, Professor of Pedagogy and School Hygiene, Clark University. W. A. Evans, M.D., Professor of Sanitary Science, Northwestern University Medical School; Health Editor, Chicago Tribune. Norman Hapgood, Journalist. Maj. Frederick R. Green, M.D., M. C, U. S. A., Secretary, Council on Health and Public Instruction, American Medical Association. J. N. McCormack, Chief Sanitary Inspector, Board of Health, State of Ken- tucky. M. V. O'Shea, Professor of Education, University of Wisconsin. Harvey W. Wiley, M.D., Director, Bureau of Foods, Sanitation and Health, Good Housekeeping Magazine. INDUSTRIAL HYGIENE John B. Andrews, Secretary, American Association for Labor Legislation. Maj. Thomas Darlington, M.D., M. C, U. S. A., Secretary, American Iron and Steel Institute. George M. Kober, M.D., Dean, Medical School, Georgetown University. Miss Josephine Goldmark, Publication Secretary, National Consumers' League. MOUTH HYGIENE Alfred C. Fones, D.D.S., Chairman Dental Committee, Bridgeport Board of Health. George H. Wright, D.D.S., Professor of Clinical Dentistry, Harvard Medical School. PHYSICAL TRAINING Wm. G. Anderson, M.D., Director, Gymnasium, Yale University. [46] George J. Fisher, M.D , Secretary, International Committee, Y. M. C. A. R. Tait McKenzie, M.D., Professor of Physical Education and Director of the Department, University of Pennsylvania Dudley A. Sargent, M.D., Director, Gymnasium, Harvard University. Thomas A. Storey, M.D., Professor of Hygiene, College of the City of New York. Executive Secretary, Interdepartmental Social Hygiene Board, Washington, D. C. FOREIGN ADVISORY BOARD CANADA Col. John George Adami, M.D., Professor of Pathology and Bacteriology McGill University, Montreal. CHILI Carlos Fernandez Pena, M.D,, President, Association of National Edu- cation; Secretary, National League Against Alcoholism. ENGLAND Sir Thomas Oliver, Professor of Physiology, Durham University. FRANCE Armand Gautier, M.D., Professor of Chemistry, Faculty of Medicine, Paris. ITALY Leonardo Bianchi, Professor of Psychiatry, University of Naples. JAPAN Prof. Dr. S. Kitasato, Chief of the Kitasato Institute for Infectious Diseases, Tokyo. RUSSIA Ivan Petrovic Pavlov, Professor of Physiology, Military Academy of Medi- cine, Petrograd. [47] The Marchbanks Press New York RA427 L62 Life extension institute, inc. \