Charles Lyman Greene.

The medical examination for life insurance and its associated clinical methods : with chapters on the insurance of substandard lives and accident insurance online

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1



EXAMINATION FOR



LIFE INSURANCE




GREENE'S







THE LIBRARY

OF

THE UNIVERSITY

OF CALIFORNIA



PRESENTED BY

PROF. CHARLES A. KOFOID AND

MRS. PRUDENCE W. KOFOID



THE

MEDICAL EXAMINATION



1 1 >w



LIFE INSURANCE



GREENE



GREENE'S

MEDICAL EXAMINATION

LIFE INSURANCE

v\l> 11^

ASSOCIATED CLINICAL METHODS



Chapters on the Insurance of Substantial
Lives and Accident Insurance



CHARLES LYMAN GREENE, M.D.,
ST. PAUL

CHI rHBOBI U»D PHACTICJ OF M i.im'iSK IS CHE inivkimiv .,i m \ ■.
MEMBER OF CHE I8S0CLATI0N OF AMERICAN PH7SICIAN8, LMERICAN IIEDIOAL L8S0CIATI0N,
S1DEN1 "i riii NATIONAL 18SOCIATION OF LIFE [N8DRANCE EXAMINING
HUROBONS, FORMERLY MEDICAL DIRECTOR 0] I ill. MINNESOTA H0TI7AL
LIKE IN8I RANCI CO., ETC., ETC.

SECOND EDITION, REVISED AND ENLARGED
WITH 99 ILLUSTRATK >NS






gfei



L< >ND< >N
REBM \\. LIMI1 ED

MIAMI SBI RY AVI M I . w I

1905



COPYRIGHT, 1905, BY P. BLAKISTON'S SON & CO.






DEDICATED

T( I

DR. WILLIAM OSLER

Kindest and most helpful of friends, as a slight token of the admiration,
affection, and respect of

THE AUTHOR



,



PREFACE TO SECOND EDITION.



Pressure of professional work has made it impossible to issue
this volume at an earlier date and the author regrets that it should
have been OUl of print for more than two years. He has felt,
however, thai every effort should be made to justify the cordial
reception accorded the firsl edition and has spared no pains in
re writing, re-arranging and amplifying the various sections.
The general arrangement has been slightly modified; a report of
the collective investigation of the Actuarial Society of America has
been introduced and its findings freely applied throughout the
text. Much has been added to the rules governing selection, and
the sections dealing with such important topics as appendicitis,
the insurance of women, pulmonary tuberculosis and diseases of the
heart have been re-written and enlarged. Much also has been
added to the section dealing with occupational hazards, with par-
ticular reference to the acceptance, special rating, and rejection
of such lives.

The consideration of the physical signs of diseases of the chest
has been placed by itself as "The Student's Section."

The author believes more firmly than ever before that life
insurance examiners must understand something of insurance
problems if they are to adequately protect the insurer and do
justice to the insured, and while sincerely grateful for the praise
and encouragement received from medical officers h< quite

as highly the many kind and appreciative letters that In- has re-
el from examining physicians.

Special acknowledgment is due Frederic!: L. Hoffmann,
statistician of the Prudential Life, and ti. of that company,

for their kindness in permitting th< t number of valuable

graphic plates included in this editi

Ch w Iam \\ < I
St. Paul, Mi ,05.



PREFACE TO FIRST EDITION.



Within the past two years a considerable number of medical
schools have introduced into their curriculum a special course of
lectures dealing with the medical aspect of life insurance. This
action lias been taken in response to the general request of life
insurance companies, and is undoubtedly a step in the right

direction.

Jt may not be true that this department of medical work
>hould rank as a specialty, but it can not be denied that in his
capacity as an examiner the physician is confronted by many
problems quite distinct and apart from those encountered in the
ordinary practice of medicine. That examiners have felt the
need of special instruction in this branch is proved by the wide
circulation of the older insurance manuals, and it is certain that
never was this need greater than at the present time.

The insurance companies complain that, because of a lack of
thorough knowledge and intelligent appreciation of their require-
ments, the service rendered by physicians is in many respects
disappointing. In this manual an attempt has been made to
supply all information necessary to the undergraduate or the
examining physician and yet to give only such as i> of real and
practical value.

It is not important that the loi al examiner should be a medical
director as well. The function- of the two off) quite

separate and distinct, and although many companies ask tor an
opinion as t<> the advisability of accepting the risk, other- ask
only that the essential given, and are themselves willing

jsume the whole responsibility involved in an acceptan
a rejection.

The proper presentation of any case must necessarily demand
a thorough appreciation, not alone of the medical problems
involved, but «>f the practical side of tin- question .1- well. The



PREFACE TO THE FIRST EDITION.



author has endeavored, therefore, to interest readers in the his-
tory and development of life insurance, and to briefly set down
the fundamental principles upon which it is based. He has tried
to cover thoroughly all of the minor questions that are likely to
arise and prove sources of misunderstanding or friction between
the home office and the examiner, or unfavorably affect the
relations of the latter with the agent in the field or the applicant
for insurance. A special effort has been made to explain, defi-
nitely and clearly, such questions as appear upon a medical
examination blank, and to show why they are there, what they
demand, and how best to secure correct and satisfactory
answers.

Realizing the fact that many readers will be undergraduates,
no effort has been spared in writing the chapters devoted to the
examination of the heart and lungs, to outline a correct technic,
and explain clearly the best means of eliciting physical signs,
and of giving to them their proper interpretation and value. So
also, in the chapter relating to the examination of the urine, an
attempt has been made to emphasize the necessity for correct
methods of procedure, and show that the use of an up-to-date
technic is quite consistent with rapid work and simple tests.

Special chapters have been written upon such important sub-
jects as "occupation," "heredity," "the role of inspection in
diagnosis," and upon that interesting topic, "conspiracies to
defraud life insurance companies."

Through the kindness of a veteran medical director, Dr. J. B.
Lewis, we are able to present a chapter upon "accident insur-
ance" that can not fail to interest both the surgeon and the gen-
eral practitioner; and, finally, an attempt has been made to state
in a conservative way the present status of that much-debated
question, "the insurance of substandard lives."

The amount of work involved has been out of all proportion
to the apparent difficulties of the task, and the completion of the
book would have been impossible, but for the kind and ready
assistance of many friends, both lay and professional. Wherever
possible this obligation has been acknowledged in the text, but
to the many whose names can not be here set down, the author
desires to express his earnest thanks. Special mention must be
made in the case of Drs. Wra. Osier and Chas. E. Simon, to



PR] ] .\( I rO Mil FIF l EDITH >N.

Medical Directoi E. J. Marsh, E. \\ . Lambert, Brandreth
SymondSj 0. H. Rogers, \. B. Bisbee, and Geo. R. Shepherd,
and to v David Parks Fackler and Jacob L.Greene, all

ni whom have rendered the greatesl assistance by the reading
and criticism of manuscript or through valuable suggestions.
Acknowledgment is also due to the officers of the Equitable
Life Assurance Society for special favors extended in connection
with the use of their valuable insurance library. Finally, the
author would be lacking in gratitude did he fail to acknowledge
the unvarying courtesy and generosity of the publishers.

Chas. Lym \.\ Gri i

St. Pat i Minn., November, 1900.



TABLE OF CONTENTS.



Till \ ami mi I. hi [NSURANCl

An. ient Gilds. Thi '

Vrch. Unsettled Condition of
Hon Early Nineteenth Century Sanitation. The

■!,; The I I be Red Cn

dity." Curious Medii al I Smallpox,

gevity. The Statistics of Gambling. Period of Speculative In-
Dawi of i New Era. Early Requirements and
Rating. Grading of Premiums and Employment of Physicia
American Life Insurance Companies. The Elementary Principles
surance. Medical Selection. Differences in the Selection
sed by the American and British I The Ni

shy for and Value of Medical Selection.

Tin M \aminkk and His Problems

onal Qualifications. ral Attitude of the Examiner.

Dangers. Responsibility. The Mental Attitude of the Examiner.

J Attitude Reversed. "G I Health" vs. "Average

Health." The Application Blank. The Physical Examination.
Selection of Examiners. Medical Ref< - of Multiple

Appointments. Support of Home i lem.

feiture of Appointment. Disgruntled Examiners. What the
tor Requires. The Agent. The Vgent's Rights.
Antagonistic Examit reful Work. Omissions. Nothing

Taken for Granted by Medical Director. Division of Commission

plicant. Minor Faults that may '

Temporary Indisposition. Forwarding th< tion.

The 1

Importan 'rimary Ira

pies in A( ute and ( 'i Tremor.

Syphilis. Bright
bolism. Valvular Disease of the Hi
Tricuspid Regurgitation. Aneurysm. the

■ Bi I!- " Morphinisn
sonin^. Aner

and The Fit .

nails.

:

Companies 7°~ l i°

per Completion of an Examination Pa] and

ipation. Insurance ii mtemplated

i ilx-n ulosi
rantee. Applii

Applicant. ma.

• Adder Trouble. Blindnt

and Difficulty in Breathing. Dysuria.



TABLE OF CONTENTS.



charge from the Ear. Dizziness and Vertigo. Dropsy. Drug
Habit. Dyspepsia. Edema. Erysipelas. Eyes. Fainting. Fis-
tula. Fits. Glandular Swellings. Gold Cure. Gout. Habits.
Headaches. Height. Hemoptysis. Hemorrhoids. Hernia. Hodg-
kin's Disease. Hysteric Tremor. Hystero-epilepsy. Identification.
Injuries or Surgical Operations. Insanity. Insurable Interest.
Jaundice. Kidney Trouble. Knee-jerks. Knowl-
edge int. l..ad Colic. Liquor, Use of. Lumbago. Leu-
kemia. Malignant Disease. Masked Epilepsy. Muscular Cramps.

ilPolypi. Nervous Exhaustion. Neurasthenia. Otitis Media.
Palpitation. Paralysis. Paralysis Agitans. Pension. Petit Mai
and Masked Epilepsy. Physical Defects. Physical Development

Applicant. Piles' Pleurisy. Pneumonia. Polypi. Privacy.
Pupils. Race. Reflexes. Rejections, Previous. Renal Colic.
Rheumatism. Rupture. Sex (Insurable Interest). Scrofula.
Shortness of Breath. Sores (Open Ulcers). Stricture. Sunstroke.
Surgical Operations. Swelling of the Feet and Face. Syphilis.
Temperature. Tobacco, Use of. Tremors and Convulsive Seizures.
Truss, Wearing of. Tumor. Ulcers. Underweights and Over-
weights. Uremic Convulsions. Vaccination. Weight and Height.
Waist Measurements. Women, Insurance of.

Collective Investigations of Actuarial Society of America, i3 I_I 39

Heredity, 140-155

The Family History. Long-lived Families. Short-lived Families.
Heredity in Apoplexy. Insanity. Diabetes. Rheumatism. Gout.
Hemophilia. Tuberculosis. Conditions that Affect the Rating.
The Inheritance of Syphilis. The Unreliability of the Reports upon
Family History Commonly Seen upon Insurance Examination
Blank's. Health of Surviving Family Members.

Occupation as Affecting Longevity and the Incidence of

Disease, 156-179

The Moral Hazard Involved in Certain Occupations. Excessive
Mental Strain. Sanitary Conditions. The Occupations Involving
Risk of Poisoning: Arsenic; Mercury; Lead; Phosphorus; Cop-
per; Zinc and Tin; Chromium; Chlorin; Bromin and Iodin; Sul-
phur; Carbon Bisulphid Anilin; Turpentine; Tea; Dust; Heat.
Occupations Involving Injurious Exercise. Risk from Accident.
General Rules Governing Acceptance and Rejection. Deformities
Due to Occupation. Stigmata of Occupation.



The Examiner's Decalogue, .



The Examination with Special Reference to Heart Disease and

Tuberculosis, [81-211

Paucity of Requirements. Present Selection Imperfect.
Heart Disease: Statistical Evidence; Clinical Evidence. Arterio-
sclerosis. Causes of Error; Matters Essential to Good Work;
Must Know the Normal; Thoroughness and Dexterity; Necessary
Equipment; Essential Preliminaries; Light; The Applicant's Atti-
tude; Stethoscopic Pressure. Best Methods in Cardiac Examination.
The Pulse: When to Take It; Technic; Points to be Determined;
Tachycardia; Bradycardia; High Tension; Insurance Heart.
Pulmonary Tuberculosis: Its Early Detection; Importance;
Poor Selection Proven; Vital Error; Early Symptoms; Physical
Signs; Suggestions as to Correction of Present Poor Selection;
Tubercle Bacilli; Their Detection in the Sputum.

The Diagnosis of Pulmonary Tuberculosis, 205-2 1 1



I \l:l I 01 C0NT1



CON

The Examination "f the Chest,

lerations and Rj gional Vnati i I i

iphic Anatomy "i the Chest. The 1

Heart and Blood-vessels,

Inspection. Percussion. Auscultation. The !!•

mrs. Rhythm. Chai
of the Systolic Valvular M rhe Chara fmp-

. • : toli( Val\ ular Murmur
jing.

The Lungs,

Inspection: The Form of the C ■ I I mph} i P

alar ( )hest. Tri< hterbru I tion. Life I

urements. Chest Movements. Counting the Respiration,
mea and Cyanosis. The I >iaphragm Phenomenon of Litten.
■u: Hypem Tympany.

Resonance. Tympanic Note in Pneumothorax. Amphoric
I liminished i ■■■> ial

Modifications of the Percussion-note. Friedreich's Phenome-
non. Wintrich's Phenomenon. Gerhardt's Sign. Biermer's
Sign. Coin Sound. Auscultation: itory

omena. Interposition of Air or Fluid between Lung and
Mediate and [mmediate Auscultation. N
Instructions of Applicant. Attitude of Applicant
During Auscultation. Pulmon; «cial

Attention. Vesicular Breathing. Puerile or Harsh Respiration,
d Breathing. Cog-wheel Breathing. Bronchial
onchovesicular Breathing. Tubular Breathing.
Breathing. Voi al Reson-
Bronchophony. ! uv - Increased V

nance of Heightened Pitch. Egophony. Diminished
in e. Echoing Resi inance. Rales.

Physical Examination of the Abdomen,

Technic. Attitude. Points to be Determined. General Ins
tion. General Distention. Localized Distention or Swelling,
sral Retraction. Method of Examination. The Liver.
The Spleen. The St >n of the Appendix,

portanl Points. The Umbilicus. luid.

Th« Ider.



I Rea tion. Tl
rest Fats. Fibrinuria. Indi( an.

Albuminuria: Testing for Ubumii titial Nephritis.

Glycosuria: i ner*s Duty. Diabetes M llitu


i lri< A( id. < 'I:.
The Examination of Urinary Sediments: ind

in Urinary Sedimi

■ ■
iithelium <
• the Urine for Tubercle Bacilli. Ehrlich's I
tion.



Wh

cult..



TABLE OF CONTENTS.



PAGES

Relation, Frequency and Prognosis of Heart Murmurs:
Prognosis in Valvular Disease of the Heart.

Tuberculosis: Points Especially Affecting Prognosis. Death-rate
from Phthisis. Sex. Race. Weight. Physique of an Applicant.
Family History. Chest Expansion. Degree of Consumptive Taint,
lired Tuberculosis. Environment. Habits. Occupation. Past
Illnesses. Cancer and Consumption. Syphilis. Pleurisy. Some
iated Conditions and Complications. Relation of Hemoptysis
to Consumption. Death-rate from Consumption. Body-tempera-
ture. Individual Predisposition.

The Acceptance of Applicants Presenting Albuminuria as a
Symptom: Albuminuria. Established Bright's Disease.
Various Conditions— Rating. Alcohol. Asthma. Gout. Heart
Lesions. Insanity. Marine. Military and Naval Risks. Obesity.
Residence in Tropical Countries. Syphilis. Tuberculosis. Con-
sumption in the Family History. Vaccination.

Attempts to Defraud Insurance Companies, 384-407

Their Great Diversity. Minor Frauds. Major Frauds. Substitu-
tion and Mythical Insurance. Forgery. Feigned Death. Grave-
yard Insurance. Mysterious Disappearance. Suicide. Illustrative
Cases. Homicide. Self -Mutilation.

Accident Insurance, 4°8-447

Historical. Discussion of Terms and Expressions in Common Use.
The Insurance Contract. Bodily Injury. Visible Signs of Injury.
Accident. Intentional Injuries' Illustrative Rulings. Judicial
Rulings upon Intentional Injury Clause Epitomized. Injuries by
Burglars or Robbers. Self-inflicted Injuries and Mutilations.
Illustrative Cases. Intoxication. Disease. Illustrative Cases. The
Insurance Contract. Liability Insurance. Simulated Injuries.
Manufactured Cases. Spinal Concussion. Compulsory Accident
Insurance. Origin of Compulsory Insurance. Underlying Theory.
Course of German Legislation. Basis of Idemnity. Distribu-
tion of the Expense of Maintenance. The Central Bureau.
Austrian and Norwegian Laws. British Laws. Lack of Interest
Shown in the United States. Voluntary Accident Insurance. Rail-
way Benefit Associations.

INDEX, 449-466



rut



MEDICAL EXAMINATION



LIFE INSURANCE.



THE NATURE AND GROWTH OF LIFE
INSURANCE.

Life insurance, the most beneficent and unselfish of all busi-
ness institutions, owes its present su a study of the hazards
of the gaming table. Nevertheless, it is the- direct outgrowth
of that love of family common to all men, whether barbarous or
civilized; and one may safely assume that in its primitive form
it is older than the pyramids.

Ancient Gilds. Long before the Christian era there existed
in both Greece and Rome mutual or fraternal orders that cared D
for their sick and infirm members.* Some of the ancient gilds,
in addition to requiring their candidates to be holy, pious, and
good, arc said to haw exacted an examination;! and the mosl
admirable characteristic of the older gilds and corporations of
London has ever been the aid and comfort afforded their mem-
in time of sickness and distn

The Anglo-Saxons. The turbulent Anglo Saxon organized
various societies for mutual protection and assistance, both



fraier-



* Pliny, "Epistle XIII '' \.>1. ii, ]> ;

t Holden, "Selet don of Lives for [i



io THE MEDICAL EXAMINATION FOR LIFE INSl'RANTE.



"Gild ol ilic
Thanes of Cam-
bridge."



Curious rating.



Dark days.



Pilgrims and
Crusaders.



before and after the Norman invasion, and certain of the early
English gilds provided for sick benefits, for indemnity for fire
losses, and, indeed, for relief from almost every calamity. The
rules of the "Gild of the Thanes of Cambridge" not only pro-
videdfor the burial of its members, but also contained a curious
provision that serves well to illustrate the then unsettled con-
dition of society: Murder being a common incident, the Gild
undertook to provide a money indemnity in the event of the kill-
ing of one member by another, and their rules contained the
following quaint proviso: "If he [the homicide] be poor, the
Society shall pay: if deceased was worth 1200 shillings, each
member half a mark; but if a hind, two oras; and if a Welshman,
only one."*

Dark Days. — From the simplest organization, as exemplified
by the ancient gilds, to the complicated system of modern times
was a far cry, and the philanthropy and beneficence that charac-
terized life insurance in the days of the early friendly societies
were well-nigh lost in the foul mire of dishonesty and corruption
into which it sank during the succeeding centuries.

The insurers of that period could see nothing in the question
beyond a wager, and such, in fact, it remained until the clos-
ing years of the seventeenth century. Pilgrims seeking a distant
shrine might be insured against slavery or death; adventurous
mariners might be assured of a ransom in event of their capture
by enemies; men might buy annuities for extravagant sums, but
all was pure chance, and the premium exacted by the Jews and
Lombards was always sufficiently great to give the insurers the
long end of the wager. In short, equitable life insurance was an
impossibility under such conditions as prevailed all over the
civilized world during the feudal times, and, indeed, up to the
eighteenth century.

The Keystone of the Arch. — The fundamental principle of
life insurance is indemnification of the familv of an individual



* Walford, "Insurance Cyclopedia," "Friendly Societies."
No if.. — Ulpianus, the Praetorian prefect, published, 364 a. d., a remarkable table
for the valuation of annuities made necessary by the Falcidian law of inheritance.
These tables show conclusively that the Romans of that early period had more accu-
rate knowledge concerning the "expectation of life" at different ages than was pos-
sessed by the moderns up to the last years of the seventeenth century.



I III \ \ li RE \\1» GR( »\\lll OF III I [NS1 RAN( I n

againsl the pecuniary loss incidenl to his death; bul as this musl
be furnished at the lowest cost consistent with safety, it must
be based upon scientific and exact methods. The laws govern-
ing mortality must be thoroughly understood, and influi
Leading to unusual or extreme fluctuations in such mortality be
either absenl or reduced to a minimum.

Unsettled Condition of Early Society. With these facts
in mind one has only to read the history of the social life of
the people during the period prior to the eighteenth century
to realize that before that time genuine life insurance was
impossible.

At a time when every man held, almost literally, his life in
his hand, and had only his personal strength or skill of fence as
a guarantee of longevity; when kings were made and unmade in renure.
a day and dynasties crumbled like houses of cards; 'Alien loath-
some disease stalked unopposed over the land, and love of u r « »ld.
fanaticism, or mere spirit of adventure sent men on perilous
quests by sea and land, it could hardly be supposed that the
insuring of life could be carried on upon terms that would make
it anything more than a grim wager.

It is difficult to realize now what changes have been wrought
not only in the mere pleasure and comfort of living, but in the
stability of life itself.

Ancient Homes and Customs. To appreciate the changed
conditions, we must imagine a people living in houses without
chimneys; walking on floors of dirt covered with rushes, impure air and

' filth.

changed only when caprice dictated; living and sleeping in
drafty or ill ventilated rooms, improperly heated and imperfec
Lighted, and thus offering in their persons and their surroundinj
an inviting soil for the development of disease.

In the "olden time" all sanitary laws were disregarded.

Personal cleanliness was an eccentricity, drunkenness a virtue, " r, ; nl - :

-

brawling the test of manliness, and disease was "sent by Almighty

to chasten the sinful spirit of his people." War devastated •..,
the land, making the poor poorer, the rich richer, and served
not alone to decimate the younger and more robust portion of
the nation, but to withdraw annually thousands <>f men from
productive employment- and send them to death, or make them
serve as Living instruments of infection with the diseases ol



12 THE MEDICAL EXAM INATION FOR LIFE INSURANCE.



Nineteenth

century.



Cleanliness
becomes " the
mode."



Cess-pools un-
der Windsor
Castle.



Merrie Kn^-



land '
nomer.



Evelyn's di;m.



ci^ri countries or the camps. What wonder that life was cheap
and unstable and death ever abroad in the land!

Kven the companies organized in the eighteenth century had
to deal with the greater part of such unfavorable conditions,
for, strange to say, nearly one-quarter of the nineteenth century
had slipped past before these matters underwent a radical change.

Early Nineteenth Century Sanitation. — In an interesting
and recent work* it is written that in the earlier years of this
century "the diminishing of the window tax made light and ven-
tilation possible. Personal cleanliness became fashionable, and
the means of attaining it were cultivated."

After the death of the Prince Consort 48 cess-pools "full of
putrid refuse" were removed from the wards of Windsor Castle.
The whole art or science of domestic sanitation, rudimentary
enough in its beginnings, belongs to this century.

Such being the condition of the better class in the early part
of the nineteenth century, it is not difficult to understand how
deplorable must have been the environment of those living in
the earlier days.

The Ravages of the Black Death.— A writer says of life
in the Elizabethan era: "The most dreadful and destructive
epidemics, the brood of this insanitation, devastated the land and
swept unchecked across continents and over seas."

In the "Merrie England" of romance and history ague was
endemic and cholera a frequent visitor, while again and again
the "plague" repeated its unwelcome visitations.

The Great Plague. — None read unmoved the horrible tale
of Defoe, so true to essential facts as to deceive his contempor-



Online LibraryCharles Lyman GreeneThe medical examination for life insurance and its associated clinical methods : with chapters on the insurance of substandard lives and accident insurance → online text (page 1 of 38)