B. If so, how long Did you ever have any form of "nervous prostration," or disease of the digestive organs caused by the use of alcoholic stimulants? If so, give full particulars as to date, duration, symptoms and results. C. D. Have you ever been under treatment for the use of alcohol or Do you drink Or before luncheon? E. F. If you have no daily habit, but occasionally use alcoholic drinks, do Do you drink in exces of the above, but not to intoxication?. G. How often have you been intoxicated? was the last occasion?__ When I warrant the above statements to be material and true, and agree that they shall form a part of the consideration for insurance applied for by me. Dated at. the. (Signature of applicant.) 190 (Address, No. and street.) Drug habits, such as opium and cocain, are more disastrous in their effects than alcohol, and much more difficult to establish. Previous Rejections-A very important question, and one an examiner is apt to pass over lightly. Men do not like to admit rejections, and consequently they believe most willingly any excuse an agent offers in explanation as to why they did not get a policy they had applied for. For instance, they are told the papers were not forwarded to the Home Office, or "the agent had some trouble and quit his company," and therefore the policy was not issued. The question should be: Have you ever made an application for insurance to any company when the policy was not issued as applied for? Applicants never gain anything by trying to keep hidden from an examiner the fact that they have been declined. The different companies keep each other posted about bad risks just as the merchants of the country keep others posted about customers who buy on credit and never pay. The applicant simply makes a bad impression on the Medical Director, and may by his duplicity put a stumbling block in the path of the examiner, which will cause him to make a bad impression, too. In answering questions relative to past diseases a comprehensive view should be taken of the pathology of each affection inquired about. Suppose, for instance, an examiner takes an answer from an applicant like this about colic: "Occasional attacks of colic due to imperfect digestion." That sounds simple, but it is only the applicant's statement and his opinion. It may be correct, and he may give reasons that will convince the examiner that it is correct, but the reasons have not been given in the answer recorded. The examiner should ask himself: What are the pathological conditions which may produce pain like an attack of colic? And he will be surprised when he begins to count them on his fingers, and thinks of the gravity of some of the diseases they suggest: Appendicitis, gall stones, strangulated hernia, passage of renal calculi, floating kidney, aneurysm of abdominal aorta, locomotor ataxia, lead colic, etc. All of these must be eliminated, and satisfactory reasons given why we agree with applicant in the statement he has made. Frequent headaches may come from a dozen different causes, and if he does not run them over in his mind and ask questions enough to eliminate the possibility of their having an origin which would suggest a grave disorder, he is doing imperfect and unsatisfactory work. I do not wish to convey the impression that an examiner should write a lecture on the blank about each disease applicant has had, but he must go over in his mind the whole subject as if he were about to write a lecture on it, and then in a few words write his conclusions and give his reasons why. The personal added to the family history brings out the tendency of the individual to certain diseases, those we call hereditary, such as syphilis, insanity, cancer, phthisis, rheumatism, diabetes and asthma. It is of the utmost importance that the facts be made clear about the existence or non-existence of these diseases in the family, and if they belong to the record make it full enough to take it all in. The Medical Director will know its importance without any comments from the examiner. An examiner will do good work in getting up the family history if he thoroughly understands why the questions are asked. In addition to the above seven diseases, just mentioned as hereditary, a tendency in the family to alcoholism should not be overlooked. An examiner should avoid terms that are not explicit in giving the cause of death, such as "grief," "broken heart," "don't know,' "fever," "malaria," "old age," etc. These are not direct causes of death. They may help to prepare a fertile soil in which seeds of disease are sown. It is true the applicant may truthfully answer a question "don't know," but if it is important that the query should be answered correctly the examiner can procure the answer if it can be secured at all. It often costs him trouble, but it is a part of his duty and can not be shirked. Somebody can answer the question, and he must find out who that somebody is, and turn to them. He may write a short note and ask them to answer the query appended to the note, and return the sheet to him in an enclosed stamped envelope. This will in nearly every case bring a satisfactory reply. When to take the pulse? The best time is just after the family history has been recorded, before beginning the physical examination, in order to avoid nervous influences as much as possible. It is well to attract the applicant's attention to something foreign to pulse taking, and then in a casual way count the number of beats, and note the character and rhythm. Intermission, very rapid, very slow and atheroma are points to watch carefully for. In studying the heart, first inspect the chest, note the apex beat and the general shape of the thorax. Place the ear over the site of the different valves; keep it there long enough to make out both sounds. and see that they are normal. The most common murmurs are the mitral regurgitant, heard near the apex, and are systolic in time. The hemic murmur is also systolic, but heard most frequently at the base, over the pulmonary area, and is associated with anemia. A few years ago all applicants with heart murmurs were rejected, but now many companies are offering some form of insurance to cases where compensation is good, particularly in the mitral form, as damage due to them comes on more slowly than in the case of other organic heart murmurs. The points in regard to heart murmurs are: The time, the point of maximum intensity, direction of transmission, the rate of the pulse before and after exercise, the location of the apex beat and history of cyanosia. It is hard to do thorough work in examining the lungs for want of opportunity. So many applicants have to be examined at their place of business, where it is difficult to get quiet surroundings in a private apartment. The outer shirt should be removed. It is not safe to roll it up from below, because to incipient phthisis, the worst foe to life insurance companies the examiner has to combat, first appears in the apices of the lungs, and this part of the chest must be carefully examined both front and back, and at the upper part of the axillary space. Generally this can be done in the toilet room when we go there to get the specimen of urine. Applicants do not object to what agents may call "unnecessary trouble," for they like to feel that the doctor has made a thorough examination. They remember all the details perhaps for the remainder of their lives, and like to tell about how the doctor, after a most careful examination, recommended them as a "first-class risk." The danger signals to watch for in beginning phthisis are light weight, expansion on the affected side less than on the other, rapid pulse rate and slight elevation of temperature. It takes a little time to take the temperature, but if the examiner will put the thermometer in applicant's mouth, show him a bottle, and ask him to step out in the closet with him and fill the bottle with urine, the temperature will be recorded by the time he has urinated, and he has had no opportunity to say, "It is not convenient now to give the urine, please call again." A wide mouth two-ounce bottle is the best to get the urine in. The sources of annoyance along this line are very low or very high gravity, a small specimen of urine, albumen or sugar. Look at the urine, as if the gravity is low the examiner may at once make arrangements for a second specimen, that he may see if the trouble is temporary. Heat and nitric acid are the best tests for albumen and Hanes' Solution for sugar. If eight drops of urine in a drachm of boiling Hanes' Solution. change the blue color in a moment or two to orange that applicant's hopes of insurance are about nil. The presence of albumen is often not so serious, as in very many cases it does not mean Bright's Disease, as a further study of the specimen will show. For several years I have been teaching the students of the college where I lecture how to make life insurance examinations. The first thing taught them is that their interest and that of the company is identical, that they must conduct the examinations and do all they are expected to do exactly in the same spirit that they would manifest if they were making a trade by which they agreed for a consideration, of say $50 paid to them each year, to pay to applicant's heirs $1,000 if he died before the end of twenty years. I teach them to feel that they are on friendly, confidential terms with the Medical Director, and that they must give him all the advice they think will help him in deciding whether or not it is safe to sell a particular applicant a policy. Then, after going over with them the ground I have tried to cover in this paper, I teach them that while as physicians they sre expected to be good diagnosticians; that they must become, through observation and study, good prognosticians, not for what will likely follow in a few days, or a few weeks, or even a few months, but for what is likely to take place in a given individual's health in the next twenty yeaas. In order to do this accurately and well, they must weigh many factors. Occupations, present and past, count; environments and habits count, and so do past diseases with their sequela. Family history with the hereditary tendencies, particularly tuberculosis, diclosed by it, must be carefully considered. The build and complexion of the individual, together with the rate and character of the pulse, help them in their prognosis. It is in the power of medical examiners to do more to protect the treasury of a life insurance company than any other of their employes. On the ether hand, they may do great harm. Therefore, if they have any pride in work well done; if they have any pride in demonstrating their value to the life insurance world, they will work carefully and conscientiously, remembering always the relation they bear to the success of the company whose interests they are employed to protect. TONSILLAR HYPERTROPHIES.* BY JOHN K. MORRIS, M.D. Professor of Physicology; Assistant Professor of Ophthalmology, Otology For any one practicing special lines of medicine, I consider it rather a difficult matter to select and write on a subject which shall be of interest to members of this Society. This is partly because of the fact that our daily routine work is so different from that of the general practitioner, but mainly, however, because it will necessarily be a somewhat difficult matter to avoid any semblance of pedantry in my calling your attention to certain organs in health and disease, the evils of which in the latter condition I belief as professional men we are not familiar enough with, or if so, are in a measure negligent of, if we do not insist on an early and vigorous attempt to abate those evils. I refer, of course, as the title of this paper indicates, to tonsillar tissues; how we shall recognize their diseased conditions, and what those * Read before the Louisville Medical and Surgical Society, November 21, 1904. |