IC-NRLF SB 3b University of California, ( r! KT < >K MEDICAL EXAMINATIONS FOR LIFE INSURANCE. BY J. ADAMS ALLEN, M. D., LL. D., Prof. Principles and Practice of Medicine and Clinical Medicine in Rush Medical College; Formerly Prof. Physiology and Pathology in the University of Michigan. REVISED AND ENLARGED EDITION WITH NEW INTRODUCTORY CHAPTER AND' AN EXTENSILE APPENDIX. CHICAGO: J. H. AND C. M. GOODSELL, Publishers of THE SPECTATOR. 1*69. Entered according to Act of Congress, in the year 1866, By J ADAMS ALLEN, In the Clerk's Office of the District Court of the United States, for the Northern District of Illinois. HORTOX & LEONARD, PRINTERS, CHICAGO, ILL. PREFACE TO THE FIFTH EDITION. The exhaustion of four editions of this brief manual within a few months, sufficiently demonstrates the want which has been felt for some work of the character. The Author tenders his sincere acknowl- edgements for the kindly terms in which many of the most distin- guished Medical Examiners throughout the country have been pleased to welcome its publication. He is fully sensible of the difficulties necessarily incident to the effort to take an intermediate course be- tween the voluminous and elaborate treatise and the mere tractate. This little book is published as a chart, and not as an exhaustive volume. The effort has been to bring fairly before the Medical Examiner the salient points of his business, in as concise a form as perspicuity would possibly permit. In the present edition there has been but little change, save in the addition of an Appendix containing matter, which, it is believed, will add considerably to the value of the work, and also an Intro- ductory Chapter, calling the especial attention of Examiners to th" importance of the relations they sustain to their respective Companies ; to the parties examined, and to the profession. Attention is called to the Index of the Appendix, on page 169, which indicates the general character of the additions made. The contained tables are believed to be valuable. IV In the preparation of these additions, the Author begs leave to acknowledge the important services of I. N. DANFORTH, M. D., of this city not only a medical examiner of large experience, but an accomplished professional scholar and writer. Under the pressure of his own multitudinous affairs, the Author has delayed publication of a new edition until the previous one was long out of print. Advantage has been taken of this delay to seek for the opinions and suggestions of professional Life Insurance men, both lay and professional. These have been regarded in this edition, so far as they have appeared correct and feasible. In order not to make the volume too bulky, the Appendix and Introductory chapters have been given in smaller type than used in the text. J. A. A. UNIVEESIT7 INTRODUCTION. It is now about one hundred and fifty years since life insurance first established itself on anything like an enduring basis. Com- mencing with the " Amicable Society," of London, it has steadily grown in public favor, until, at the present day, no form of investment is regarded with greater favor, by even the shrewdest and most sagacious business men, than the stocks of life insurance companies, and policies of insurance on their own lives. At every step of its progress, this noble institution has sought the aid and counsel of the medical profession. It has its very basis and foundation, in fact, in the established laws of mortality, as carefully and patiently worked out by medical men. The first life company was only started after Dr. Halley, of London, had made that series of observations regard- ing the duration of human life, out of which grew the " Breslau table of mortality." Every important step in life insurance has been preceded by a pioneer corps of physicians, who have carefully marked out the way; and, in no single instance, has future experience proved the falsity or unreliability of their conclusions. If all this be true, it follows that the relations of the medical profession to the interests of life insurance are vastly important ; and that they are certainly quite as important to the insured party, as to the company insuring. For our present purposes, it will be conven- ient to consider the relations of Medical Examiners to life insurance, and life insurance interests, under three heads, to-wit : Their relations to the companies employing them, or to the companies' agents. Secondly, to applicants, or parties seeking insurance ; and thirdly, to the medical profession. VI First : their relations to companies, or agents of companies. It is scarcely too much to say that the ultimate safety and stability of every life insurance company rests in the hands of those who decide upon the character of its risks: for, however great may be its resources, or with however much of financial skill and sagacity its affairs may be managed, or however many or perfect may be its " tables of mortality," it is absolutely certain to come to a disastrous end, unless its risks are selected with care and discrimination. And so many, and so insidious are the diseases whereof the end is only too cer- tainly fatal, that this car* only be done by the skilled and experienced Physician. To render the office of Medical Examiner to the greatest degree useful, three things seem to the writer absolutely essential; (ist) That the best talent be secured, (zd) That perfect harmony be maintained between the Examiner and the company's representative or agent. (3d) That the Examiner be appointed from the central office : that he be recognized as an officer de facto of the company, independent, and therefore self-reliant, in his sphere ; and responsible for the proper management of the interests committed to his charge. (ist.) It is an absolute and palpable wrong for any company to appoint as its Examiners men deficient in knowledge, in high-toned honesty, in devotion to the interests of their profession, or men who are wanting in that practical wisdom which can only be acquired by actual experience. It is wrong, in that it must, to a greater or less extent, militate against, rather than contribute to, the safety of the company ; it is wrong, in that it needlessly places in jeopardy the interests of those who are entirely unable to protect themselves, namely, the policy-holders, or those who are dependent upon them ; and lastly, it is wrong, in that it must inevitably bring undeserved odium and disgrace upon the medical profession. Notwithstanding the hordes of quacks and charlatans which infest every community, competent and faithful Medical Examiners can almost everywhere be found ; but while the former are forever seeking appointments, the latter must generally be sought ; the former are only too apt to foist their services upon the unwary agent ; the latter very properly regard their services as worth seeking, if worth having. Every Vll company ought to be held to a stern and rigid accountability for the character and ability of its Examiners ; it is the custodian of vastly important interests, which, from the very nature of the case, cannot be looked after by those most interested in its integrity. Its policy- holders are scattered over every State in the Union, and they, as well as the Examiners upon whose recommendation they are accepted, must of necessity be entire strangers to the Managers and Consulting Physician. But these facts furnish not the least excuse for appointing or at all events, for retaining incompetent Examiners ; rather do they render it more imperatively the duty of those selecting them, to exercise the greatest care in obtaining honest and skilled physicians to fulfill this most important trust ; and, so perfect and complete are the means for acquiring information at the present day, that no company can plead ignorance regarding the qualifications of its Examiners, and at the same time, maintain a creditable reputation for shrewdness and good management. (zd.) Unless perfect harmony be maintained between the Exam- iner and the Agent under whom he is acting, the company's interests must necessarily suffer. The former is not unfrequently compelled to reject risks upon which the latter has expended no inconsiderable amount of time and labor, and which, in case of rejection, must go for nothing. Moreover, applicants are often rejected for reasons which are only apparent to the Examiner ; and, to the uneducated ear, or unskilled touch of the Agent, this seems an unwarranted stretch of power on the part of the former. With the Agent it is a question of commissions ; with the Examiner it is a question of safety ; and these two interests sometimes stand diametrically opposed to each other. But it is for precisely this reason that the Medical Examiner is employed at all ; and, unless he resolutely stands, like an alert and faithful sentinel, between the company on the one hand, and the unsafe and undesirable applicant seeking admission thereto on the other, he signally fails of fulfilling his obligations to the former, and renders his office not only 'useless, but positively harm- ful. This course, however, although exceedingly desirable and important so far as the company is concerned, must of course some- times array him in direct opposition to the pecuniary interests of the Vlll Agent. But with this the Examiner must and can have nothing to do ; it is no concern of his whether the Agent is remunerated by stated commissions or a regular salary : he has only to do with the safety or unsafety of the risk ; and, while he must disregard all else but this, he must, at the same time, maintain harmonious relations with the Agent. We propose to indicate, in the next place, how, in our judgment, this can best be done. (3d.) The Medical Examiner, at least in every situation involving any considerable number of examinations, and especially in the large cities and populous towns, where almost every applicant is more tnan likely to be an absolute stranger to both Agent and Examiner, should be appointed by the authorities at the home office, after they shall have satisfied themselves that he is precisely the man for the place, and unless they are well convinced of this, he should be dismissed and another and more satisfactory appointment should be made. Whatever may be the actual merit of the Examiner, unless he is fortunate enough to possess the entire confidence of the Managers especially the Consulting Physician at the central office, he cannot resign too soon. For, unless the central authorities implicitly confide in him, it will be impossible for the Local Agent to respect either him or his decisions in regard to applicants especially if they happen, as they sometimes must, to be adverse to the interests of the Agent. For this reason, the Examiner should stand in the attitude of an officer, recognized as such by the company ; his department should stand by itself, subject only to the control of, and responsible only to, the home office. He should not be a mere " tenant at will," subject to ejectment at the pleasure or caprice of the Agent ; for such an equivocal position would be derogatory, not to the man only, but to the position he vainly attempted to fill. The general adoption of this course on the part of the companies, will most certainly enable them to secure and permanently retain the best medical talent, and also insure harmonious action between the Agent and Examiner both of which conditions are exceedingly important and desirable. Secondly. The relations of Examiners to parties seeking assurance. The Examiner is of course bound to consider the interests of the company by whom he is employed and paid, as paramount to all IX others ; else would he absolutely endanger, rather than contribute to the company's safety and stability. But while this is undenia- bly true, it is also true that the applicant has claims which he cannot properly disregard. Life insurance has now become some- thing more than a mere privilege ; it has come to be almost a sacred and "inalienable" right to every person who is eligible there- to ; and no applicant should be lightly or needlessly rejected. Every applicant coming before the Examiner is entitled to a fair and impar- tial examination; if obscure or unusual symptoms present themselves, he is fairly entitled to a second examination, or even more than that if necessary to a proper understanding of the case. Frequently does it happen that some apparently grave symptom depends upon a merely temporary cause ; for example, applicants in perfect health some- times present themselves with an unusually rapid pulse, or with the respiration unaccountably frequent, or with the countenance flushed and excited and all this may be the consequence of excitement or perhaps fear ; for, to very many people, a Physician's office is as terrible as the dungeons of the Inquisition ; and the very best insur- ance risks are those who are least familiar with the sanctums of Doctors, and therefore most likely to give full scope to their imagina- tions. Individual peculiarities or " idiosyncracies " are sometimes met with, which, though generally indicative of some grave and per- haps incurable disease, are quite normal as regards the persons pre- senting them; these exceptional cases demand a fair hearing at the hands of the Examiner ; though it must be admitted, as a general rule, that absolute strangers, presenting symptoms which are ordina- rily associated with organic disease of any important organ, must be rejected, even though they may be in other respects desirable. In making examinations preliminary to life insurance as well as in all other investigations of this character, the Physician is likely to become acquainted with matters of a strictly confidential nature, which if divulged, might prove seriously detrimental to the party. The same standard of high-toned professional honor should guide the Examiner in his relations to applicants for life insurance, as he feels constantly bound to observe in his relations to patients under his care ; no excuse can be found for disregarding this matter in the one case, that will not apply with equal force to the other, except, of course, that the Examiner is bound to disclose to the Consulting Physician all facts essential to a correct understanding of the case. Finally, the Examiner should not forget that, however unimportant it may be to him, individually, whether an applicant be accepted or rejected, it may be and often is a matter of vast importance to the latter. Many a man turns to life insurance as the only means by which he can provide- for the necessities of those he expects to leave behind him, when he shall have passed away ; many an unfortunate man, whose life may have been one constant struggle with adversity, sees in a policy of insurance the only means by which he can protect his family from actual want, after he has ceased to live. Such cases must not be lightly rejected ; they are always entitled to a careful and candid examination, made under circumstances which are not unfavor- able to the applicant ; symptoms which are merely the result of trepidation or of the excitement of the occasion, should be cleared up, and, in all regards, the examiner should give the applicant a fair and impartial hearing, with the fixed resolution of rendering a decision which shall be just to both parties ; and while this rule applies with peculiar force to the class of cases just cited, every applicant, whether high or low, rich or poor, fortunate or unfortunate, has the unques- tionable right to expect precisely the same kind of treatment ; and, when it is added that a needless rejection is a permanent and irrepara- ble injury, inasmuch as it must always stand as a grave objection perhaps an insuperable bar to the acceptance of the rejected party by other companies, it will be seen that these observations are based upon principles which cannot be lightly disregarded, without doing violence to the demands of justice and equity. Thirdly: the relations of the examiner to the Medical Profession. Every Medical Examiner is, in an important sense, a " representative man," to the company employing him, as well as to parties seek- ing insurance. He is to them the exponent of the present standard of medical excellence ; for, it cannot reasonably be supposed that a powerful corporation would deliberately appoint, or, at all events, * long retain, as the custodians of its safety, inferior or incompetent men, when the best talent is quite as easily accessible, and involves XI no greater outlay of expense. Let no Medical Examiner for a moment suppose that he has a merely personal interest in acquitting himself creditably and honorably ; that his individual interests are alone to suffer if he fails to perform his duties satisfactorily ; but let him always remember that he has been selected on account of his presumed ability and acquirements ; that every blunder he commits, and every unprofessional or undignified act he allows himself to per- form reflects with damaging force not on himself only, but on the Profession as a whole. It is just as imperatively his duty to main- tain a high standard of professional honor in the discharge of his duties as Examiner for an insurance company, as it is in any other duty connected with his vocation ; just as much his duty to examine an applicant carefully, as to diagnosticate a case he proposes to treat carefully ; just as much his duty to frown upon and discountenance quackery and charlatanism in this matter as in any other. And this is due to the insurance companies, no less than to the medical pro- fession ; ever since its origin, the interests of life insurance have been, to a great extent, committed to the hands of Physicians, and, from the very nature of the case, this state of things must continue ; they alone are capable of deciding as to the safety or unsafety of risks, and they alone are capable of making the observations necessary to a correct understanding of the laws of mortality. But in still another and no less important direction do the investigations of medical men subserve the interests of life insurance, namely, in observing the laws and conditions of health, and disseminating inform- ation thereupon among the people ; in arresting the progress of con- tagious diseases, and rendering them comparatively harmless, and in enforcing salutary regulations for the preservation of the public health in cities and towns. The tendency of all this is to enhance the value of human life ; to render the business of life insurance less hazardous, and therefore to bring it more directly within reach of those most likely to be benefited thereby ; thus making it not only theoretically, but really a boon and a blessing to those who are unable to make any other provision for the prospective necessities of their families. To such a work as this, the medical profession ought to yield an active and hearty support, not only in the persons of a few Xll of its members, but as a compact and united whole. To this end let Medical Examiners so discharge their duties as to increase the confidence of the companies in the profession ; let them remember that, to the companies, they are the acknowledged exponents of the standard of professional acquirement, honor and integrity, and let them remember that they have their part to perform towards making life insurance, in a larger sense, the institution of the people. NOTE PREFATORY. Life Insurance is rapidly growing in public favor, and it is not extravagant to say that the time is coming when it will be more gen- eral even than Fire Insurance. All men have lives not all have houses, stores, or barns. The system of endowments, non-forfeiting policies, etc., has gone far toward making what before was consid- ered extra-prudential and exceptional, a matter of ordinary business caution and common usage. That the Insurance Companies and the holders of their policies should have the highest possible advantage, it is clearly necessary that none but lives selected with great care should be assured. Hence the MEDICAL EXAMINER becomes their indispensable agent. To aid him in the performance of his important work, is the object of this little Manual. It is not its intention to be argumentative, statistical, or rhetorical. Neither originality in substance nor method is sought after but only that more clearness, definiteness, and certainty may be achieved, by attention to the suggestions herein contained. A prime object has been to concentrate to the smallest possible bulk. Hence, conclusions only are given reasons and authorities are rarely alluded to. Justice to myself compels me to add that, while the urgent press- ure of professional duties has obliged me to write during brief and scanty intervals only nevertheless, the ideas advanced are the re- sult of matured convictions, strengthened by several thousand personal examinations of applicants for life insurance. CHICAGO, 1867. J. A. A. THE APPLICATION. The Medical Examiner should first read carefully, point by point, the interrogatories proposed by the Company for which he is acting, and the answers of the applicant. This will save time, and indicate those circumstances which require especial investigation. The form generally adopted, proposes twenty -five questions twenty-three of which demand the scru- tiny of the Examiner. For the purpose of brevity, we adopt the order of the form. I. Name, Residence, and Occupation. The name identifies* The residence will suggest at once the na- ture of the causes of the diseases prevalent, and the relative salubrity of the locality. The moist atmos- phere and variable temperature prolific of phthisis ; ochlesis, the products of animal decomposition, and foul air, fertile in typhoid fevers and cachexiae ; ma- larious districts involving endemic diseases which may especially prove noxious to the party, etc., etc. THE OCCUPATION healthful or pernicious? Sta- tistics show the relative longevity of the different occu- pations of men, but the Examiner should superadd to i6 these the inquiry : What is the probable effect upon the applicant himself? for that which is salutiferous to one, is often prejudicial to another. Statistics establish certain general propositions, to which, it must be recollected, many exceptions can be taken. PROFESSIONAL MEN. Teachers exhibit the greatest longevity. Next come Clergymen, who are subject to few diseases save those incident to sedentary habits. Contrary to the vulgar opinion, they are not more liable than others to pulmonary affections. Dyspep- sia, with its incidents, is their principal affection. Lawyers rank next. Then professional Lecturers, and next, Physicians. Of the latter, it may be said, as a class, they have not the ordinary expectation of life, by from one-third to one-fifth subtraction. Nev- ertheless, the variety of exposure and habits is such that each case requires isolated investigation. ARTISTS. Painters and Sculptors rank among the best risks, particularly when the former sketch from nature, and the latter merely model. Portrait paint- ers, and sculptors who cut marble themselves, are not as good risks. Photographers and Daguerreotypists rank second class. ARTISANS AND MECHANICS. Painters using lead and oil are undesirable risks, yet need not be wholly rejected. Workers in phosphorus and quicksilvei stand upon the same level. Stone cutters and millers, and similar occupations, where insoluble or irritant particles find constant access to the pulmonary surface, are les-s desirable, but improved methods of ventila- tion, now in vogue, render them less objectionable than '7 formerly. Glass blowers are poor risks. Compos- itors in printing offices signally demand caution in acceptance. Blacksmiths, Furnacemen, Carpenters, Coopers, and Cabinet Makers range among the most healthy operatives. Shoemakers and Harness Makers, mainly from their sedentary habits, are second class risks. The same remark may be made of Tailors. Butchers and Market men, aside from the chances of accident, ( to the former particularly, ) are good risks. Machinists, Plumbers, Tinsmiths, Tallow Chandlers and Barbers, and similar occupations, are generally good risks. Engravers, Jewelers, and the like, are liable to the diseases of sedentary life, but are other- wise unobjectionable. Brewers, Confectioners, Dyers, Hatters, Bakers, and others whose business involves constant exposure to warm vapors, often impregnated with medicinal or poisonous substances, are not as desirable. Chemists, Assayers, Gilders, Tobacconists, etc., are liable to the same objection. Day Laborers, unless exposed f.o accident, are equally as good risks as mechanics. Agricultural Laborers, in salubrious localities, are the highest order of desirable applicants. The best lives, other things being equal, are those of persons engaged in out-door and yet protected em- ployments, where the occupation is somewhat seden- tary, and yet combined with a certain amount of mus- cular exercise, with pure air, and variation enough to secure a stimulating impression upon the system. Inertia, indolence, and absolute uniformity of me- teorological influences, are as prejudicial as over- exertion and atmospheric vicissitudes. 2 i8 II. The Age, Different ages predispose to particular diseases. So, also, hereditary diseases, according to their kind, may be outgrown, or not yet arrived at. During the period of increase, extending to about the twenty-fifth year, (varying, of course, in indi- viduals,) the tendency to disease and death is propor- tionately very great. One-tenth of all children born die the first month. In large towns, nearly one-half die before the fifth year. Respiratory and strumous diseases are especially fatal between puberty and the age of maturity placed at twenty-five. None should be insured before puberty, except at extra rates. Between that period and maturity, the party demands especial investigation of the respiratory and glandular systems. Continued fevers, of the typnoid type, are also liable to be destructive during this pe- riod. The exanthems readily implant the germs of phthisis and other strumous disorders. Rheumatism, if it now occurs, in consequence, per- haps, of the excessive activity of the sanguineous system, is exceedingly liable to beget organic disease of the cardiac valves, with its subsequent results. From the twenty- fifth year to the thirty-fifth, or fortieth, or age of maturity, the best risks, cseteris paribus, are chosen. During this period, the applicant stands more, so to speak, on his own individuality. Hereditary predispositions affect him less, and external agencies are easiest resisted when tending to disease. The habits and external influences now require most careful survey. From the fortieth year, at latest, decline commences. Hereditary diseases regain their dangerous tendency, and acute affections are met with less power of resist- ance. Yet, acute diseases of various forms are less to be dreaded than during the mobile years previous to maturity. The progress of changes in the system is slower, and the tendency is to congestions rather than inflammations ; to urinary diseases ; to fatty degenera- tions ; to cardiac and other obstructions from undue deposits ; to dropsies, apoplexies, paralyses, and the like. The following table shows the expectations, or average duration of life of each individual, calculated from the Carlisle table of mortality : AGE. EXPECT- ATION. AGE. EXPECT- ATION. AGE. EXPECT- ATION. AGE. EXPECT- ATION. 38.72 18 42.87 35 31.00 52 19.68 I 44.68 1 9 42.17 36 30.32 53 18.97 2 47-55 20 41.46 37 29.64 54 18.28 3 49.82 21 40.75 38 28.96 55 17.58 4 50.76 22 40.04 39 28.28 56 16.89 5 51.25 23 39-31 40 27.61 57 16.21 6 51.17 2 4 38.59 4 1 26.97 58 15-55 7 50-80 25 37-86 42 26.34 59 14.92 8 50.24 26 37-H 43 25.71 60 H'34 9 49-57 27 36.41 44 25.0 9 61 13.82 10 -48.82 28 35.69 45 24.46 62 I3-3I ii 48.04 2 9 35.00 46 23.82 63 I2.8I 12 47.27 30 34-34 47 23.17 64 12.30 13 46.51 31 3368 48 22.50 65 11.79 H 45-75 32 33-03 49 2I.8I 66 11.27 15 45.00 33 32.36 50 21. II 67 10.75 16 44.27 34 31-68 5i 20.39 68 IO.23 17 43-57 Other tables vary this expectation from one to two per cent. ao But it should be recollected that, in individual cases, the expectation of life may be increased by pass- ing beyond certain ages a fact wholly ignored by the tables. Thus, for example, where there is clearly an hereditary tendency to phthisis when parents, or brothers or sisters have died of the disease before twenty-five or thirty, and the party has lived, and is now in good health, at the age of forty, half the danger may be said to have passed ; at fifty, three-fourths or four-fifths ; and at sixty, but a mere modicum re- mains certainly not over one-fifteenth or twentieth, if, indeed, it may be said to exist beyond that of other persons without hereditary predisposition of any sort. On the contrary, the tendency to gout, urinary dis- eases, insanity, apoplexy, paralysis, etc., increases with the progress of declining years. It is safe to say that, when tables indicate a pro- gressive diminution of the life expectation, this idea should be modified and corrected by a full understand- ing of the hereditary, constitutional, or acquired tendency to, or relief from, special forms of disease. III. The Marriage Relation suggests hygienic influences so obvious that it is unnecessary to delay in its con sideration. Married men are usually the most desira- ble risks. General statistics show that even with females, the dangers incident to maternity do not ma- terially impair the risk. A woman who has once borne a child with no extraordinary difficulty, is a 21 better risk than the primifara, and married women than those who are unfortunately single. The circum- stances of previous labors, if any have occurred, should be fully understood, and reference had, if possible, to the attending physician. In large towns and cities, applications are frequently made by those neither married nor single^ for insurance. These applications are not infrequently made by "housekeepers," who, having passed the heyday of their years without physical impairment, save that which years may bring, become solicitous of providing by endowment for later old age, or else for the support of dependants. These cases are not desirable, neither is it necessary utterly to refuse them. But the most rigid investigation is requisite before they are recom- mended. IV. & V. Sobriety and Temperance Use of Opium, etc. The habitual drinker of alcoholic spirits, or the ha- bitual opium-eater, should, as a rule, be rejected. The inquiry proposed to the applicant will rarely secure a correct answer. Very few will voluntarily admit either intemperance, gluttony, or other generally recognized vice. The Medical Examiner is expected to guard the interests of the Company and co-insurers, by ob- serving carefully the signs of excessive stimulation, as, unfortunately, too often furnished by votaries of Alcohol, Opium, Chloroform, Ether, Cannabis Indica, and the like. The consumption of other stimulants and narcotics besides alcohol, has notably we might 22 well say enormously increased within several years past. The alcoholic breath is readily detected, but equally clear to the educated perception is the effect of other narcotics and stimulants. Too often the applicant is induced to apply for assurance, by self- consciousness of his indulgence in some pernicious method of excitement, which he knows tends to short- en life, but which he vaguely believes he can abandon or control before it is too late. INTEMPERANCE, by which we mean not merely drunk- enness, but an inordinate, pernicious habit of stimula- tion by something^ is, as likely as rheumatism, gout, insanity, or tuberculosis, to be hereditary. The family history here becomes noteworthy. A tuberculous tendency may be, to a certain extent, con- trolled by hygienic influences ; among which may be numbered the use of stimulants of various kinds. The rule for the Medical Examiner is this : If the stimulant taken invigorates digestion and assimilation, then it is not cause for rejection : if it merely excites the nervous system, it is an objection to the risk. Observe invigoration of digestion and assimilation (real power) is not to be confounded with mere in- crease of adipose tissue, which is often indicative of depression of nutritive energy. Is the party an occasional or an habitual tippler? There are some men who indulge in only an infrequent debauch, and in the interim are strictly temperate. Such a habit, if ascertained, impairs materially the risk. The habitual drunkard is well described by Dr. Brinton : cc The chief characteristics one can briefly express in words, are the fiery, unctuous skin, with its secretions reeking with volatile, fatty acids ; the red and ferrety eyes, with their fitful glare, rather than gleam ; the furred tongue ; the fetid breath, and the trembling limbs, that often announce the impression made by the copious habitual ingestion of alcohol on the stomach and nervous system respectively." Other suggestive appearances are afforded by sunk- en eyes surrounded by dark circles ; pallid, or even waxy complexion ; moist, sticky skin ; emaciation ; tremulousness of the muscles, unless rendered tem- porarily tense by a full dose of the stimulant ; a ner- vous restlessness of the whole person ; often abstrac- tion of mind, etc., etc. Many times the party will temporarily conceal the habit, or even persuade him- self it does not exist to an injurious extent; hence the necessity for great caution. The friend's certificate here becomes indispensable, and the attending physi- cian's testimony should not be overlooked. Habitual opium-eating does not show such easily described and unmistakable marks, yet can rarely be concealed from an observer of ordinary sagacity, whose attention is directed to the point. Notwithstanding the singular character of the testi- mony in the Earl of Mar's case, in England, in 1832, it is safe to say that opium-eating lessens the expecta- tion of life, and is, therefore, a valid reason for de- clining the risk. Undue nervous irritability ; a peculiar, shuffling gait ; flabby muscles ; drooping eyebrows, with dark lower lids, while the eye itself seems to sink and grow dim ; with general marks of old age ; or else, while the stimulant has full effect, excitement with brilliant eyes, but contracted pupils ; quick, restless movements ; or, sometimes, in differ- ent temperaments, general dullness, lassitude, sleepi- ness, and a relaxed skin, with sticky perspiration, and husky voice. When the applicant says he has a diar- rhoea or dysenteric difficulty which requires occasional doses of opium, when the eyes are hazy, and the tongue has a whitish coat ; when there is a mucous secretion from the eyes, with frequent hawking of mucus from a flabby mucous membrane of the pharynx, and perhaps of the nose. When he is a married man, and with these symptoms, has no chil- dren, carefully observe and reject him. Much must be left to professional discretion but cave canem. VI. Vaccinated ? A person who has never been vacci- nated or had the small pox, should not be accepted. If vaccinated, the inquiry should be : Was the vacci- nation successful ? and then, how recently was the operation performed ? A successful vaccination many years previous, is not sufficient, but if it has been fre- quently repeated without infection, the case may be deemed clear. In doubtful cases, examine the cica- trix, or re-vaccinate at once. If small pox or vario- loid has occurred, it requires especial caution as to the condition of the lungs and intestinal mucous mem- brane. The date when it occurred should be given, and the fact of perfect or imperfect recovery noted. VII. & VIII. Residence in a Foreign Climate, Without ex- act reference to isothermal lines, natives of the zone extending from the thirtieth to the fiftieth parallels of latitude, may be considered as the best risks. An ac- quaintance with the meteorological condition of par- ticular localities, is of great importance. Excessive thermometrical, barometrical and hygrometrical varia- tions, in any particular locality, usually impair risks, by rendering them subject to various diseases. Thus, moist, warm situations usually involve the malarious diseases ; cold, or variable, and moist re- gions are prolific of tuberculous cachexiae; dry (yet variable in temperature) districts, render rheumatic and inflammatory diseases more dangerous. On equal parallels, the temperature of Europe is higher than that of America, and excepting the influence of the changes produced by cultivation, present the diseases of lower climates in higher latitudes. General tem- peraments are varied by persistent climatic influences. (Fid. p. 6 1, et seq.) ACCLIMATION IN THE SOUTH. Whilst men, almost alone of animals, can range from the Equator to the " open Polar Sea," with apparent impunity, by observ- ing certain precautions which their reason and knowl- edge suggest, nevertheless, they subject themselves, sooner or slower, to organic changes which are termed briefly "acclimation." These changes render them less liable to the acute diseases of localities, or endemics. 26 but they are fraught with much significance to the insurance examiner. More than two thousand years ago, the naturalist Pliny noticed that cc those who are seasoned can live amid pestilential diseases." The reason of this may be a matter of speculation, but of its essential truth there can be no doubt. The organic changes thus brought about express themselves in the larger phase of different races of men, begotten through the opera- tion of ages of similar influences acting on parent and progeny. Without descending to minutiae, it may be said the Northerner going South may become, to a certain ex- tent, acclimated by physical changes in the skin, liver and spleen, especially involving their heightened ac- tivity of interstitial change, and, usually, increase in bulk. Increased activity of any organ, according to a well known natural law, involves greater tendency to disease. If, instead of more energetic action of the skin, there is less, from any temporary or permanent cause, then the mucous membrane of the intestine will be called into excessive activity, and the acute or chronic diarrhoea of tropical climates be produced. Else there are the " bloated belly, distorted features, dark yellow complexion, livid eyes and lips ; in short, all the symptoms of dropsy, jaundice and ague, united in one person/' Coming North, the comparatively healthy Southron falls an easy victim to tuberculous, nephritic, and in- flammatory diseases. The rule is to observe the rela- tive activity and development of each organ or apparatus involved whatever the cause of variation. 27 Acclimation to the so-called malarious fevers, etc., of the South, gives no immunity to YELLOW FEVER, any more than does .typhoid fever from variola at the North. Yellow fever is a disease of cities and towns, epidemic usually, and requires its especial prophylaxis not gained by any mere acclimation. As Dr. Nott emphatically writes :