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Medical Examinations for Life Assurance.
375 however, called upon to state on oath that he believed himself to be a "good life." In process of time it was found desirable to exclude manifestly unhealthy applicants ; hence the proposer was required to appear before the board. Some directors were shrewd in their judgment as to the value of a life but it soon became apparent that a medical inspection was required for the selection of " first-class" lives. According to Dr. SYMES-THOMPSON the first medical officer
was,
THE LANCET. LONDON:
SATURDAY, FEBRUARY 6, 1904.
appointed to the "Amicable"in 1855 and to the "Equitable"" in 1858, but we believe that other offices had made similar appointments previously to that date. We have before us the proposal form of one of the societies which adopt the system of dispensing with the medical examination of applicants for policies. The sum assured must The questions do not materially and upwards. be :&500 differ from those asked by other companies except that descriptions of previous illnesses and the details of the family history have to be given by the proposer instead of by the medical examiner. The disadvantages of this procedure are obvious. The applicant has then to sign a declaration to the effect that the statements in the proposal
was
Medical Examinations for Life Assurance. THE medical examination of individuals
for life interest and the
applying
presents many problems of medical advisers of life assurance societies work under conditions different from those which are the rule in dealing with patients. Instead of having to meet the frail and the abnormal their interviews in the majority of instances are with the sound and the robust. Occasionally cases of latent disease are encountered, more particularly phenomena associated with arterio-sclerosis and glycosuria. The powers form are true and correct and that if any untrue averment is of observation and the ability for estimating differences in contained in the said statement, or if it is afterwards shown temperament are taxed to the uttermost, the great element that any material information has been withheld, then the of success in this branch of medical practice being the contract shall be void and all moneys which shall have capacity to make correct forecasts and a sound prognosis. been paid on account of the assurance shall be absolutely A thorough knowledge not only of his profession but of forfeited to the society. As Sir DYCE DUcKWORTH said, human nature and mankind in general is therefore a this practice is both precarious and troublesome and is most valuable qualification for a medical examiner for life Until a comparatively recent period there has certainly designed to attract persons who have no just claim assurance. been no organised endeavour to utilise the wealth of experi- to exemption from the ordinary and proper examination. If an individual is aware that he has some organic defect ence gradually accumulated by medical practitioners who have especially studied the medical side of life assurance. which may render him ineligible for assurance at ordinary in other societies it is a great temptation to him to go Fortunately, however, this defect no longer exists, for the rates to a society which offers him assurance without medical Life Assurance Medical Officers’ Association now provides find it impossible to opportunities of collating and discussing the many questions examination. He will then, of course, constantly presenting themselves in this branch of profes- avoid making false statements in filling up his proposal form Sir DycE DucKWORTH in delivering the and if it is afterwards discovered that he has knowingly sional duty. committed a fraud he meets with just punishment in presidential address before that society on Jan. a report of which will be found in another column, having the contract annulled with the loss of the referred to the valuable work which the association has premiums which he has already paid. Instead of running him to have applied already accomplished and which has fully justified the this risk it would have been wiser of as a sub-standard life and to have submitted expectations of its originators. He pointed out that some for a policy to a medical examination, for many assurance companies of the most profitable discussions that have taken place related to the subjects of albuminuria and glycosuria and now accept such lives under certain conditions. Another much information has been elicited which has enabled the excuse for wishing to escape a medical examination is the members to gauge the significance of such symptoms in a trifling loss of time which is entailed by a visit to the We cannot, however, consider it as medical examiner. more precise manner than had previously been the case. time it insures a policy granted in circummisspent, for He also touched upon other subjects of medical interest stances which in certain offices render it practically in connexion with life assurance. There is a further objection and a very One of these seems to us to deserve very careful con- unassailable. one to assuring without medical examinationsideration-namely, the practice recently adopted by certain strong societies of accepting applicants for assurance without namely, that if the applicant should die from disease assurance
27th,
medical examination. From a professional point of view there can scarcely be two opinions on this point. Dr. E. SYMES-THOMPSON writing in Professor CLIFFORD ALLBUTT’S
the first year following the date of assurance the amount payable is only one-third of the sum assured, if he
during
should die during the second year two-thirds of the sum, of Medicine" that the states but on a claim occurring at any time after two years from "System (vol. i., p. 476) medical selection of lives was not attempted in the early the date of assurance the full sum assured is payable. If days of life assurance. The first society, the Amicable, death is due to accident of course no deduction is made. was founded in 1706 and existed for some years before a In the case of assurance with medical examination if death medical officer was appointed. The same premium was paid takes place at any time after the policy is issued the claim by each applicant, whatever his age or apparent health. He is paid in full. We cannot understand therefore where the
376
advantage
to the
whether as holders of eventual beneficiaries, is to be policies found under the conditions of the practice which we are assurance
general public, as
or
discussing. With regard
to the society itself, also, it is difficult to see Doubtless a large number of where the benefit can lie. but the risk of fraud and be received applications might deceit must be constant and if many claims are contested this method of insurance would quickly become unpopular. Sir DYCE DUCKWORTH suggested that the practice had its origin in the same causes which so gravely affect the conduct of all business transactions in these days-namely, hurry, pressure, and furious competition. The business aspect of this question has little concern for us as members of the medical profession but we shall watch with interest the results of a step which we can only consider as retrograde.
"
Eye-strain."
OUR esteemed editor of
colleague Dr. G. American Medicine,
strenuous endeavours to
arouse
M. GOULD of
Philadelphia, pursuit of his
in further the medical
profession
to
a
complete consciousness of the frequency, the nature, and the consequences of "eye-strain,"has sent us a paper upon the subject which is appearing in the current number of that journal. In this he repeats many of the assertions with which his former writings have rendered us more
or less familiar, although they
have not
as
yet
command the entire assent of which their writer believes them to be
large
number of
temper, defects of
worthy.
Dr. GOULD tells
come no
us
to
doubt
that
a
of neurotic character, defects of digestion, incapacity for sustained work
cases
objects, migraine, and a large catalogue of the peculiarities which have been sometimes described as the defects of genius, are mainly due to unrecognised "eyestra.in" produced by astigmatism, generally of the hypermetropic character, and he gives us quite a long catalogue of illustrious sufferers, including people of characters so diverse at
near
the CARLYLES, GEORGE ELIOT, HUXLEY, DARWIN, and Our readers will remember that Dr. GOULD NIETZSCHE. contributed a lengthy article to our columns last autumn,l in which he endeavoured to prove by extracts from the life of WAGNER, and by photographs showing an outward deviation of his left eye, that he also should be added to the long list of illustrious sufferers from eye-strain, and he dwelt upon the as
London ophthalmologists upon the questions to which Dr. GOULD directs attention. It must be remembered that I I eye-strain " or, as he called it, weak sight or asthenopia, was quite clearly known to, and described by, MACKENZIE in 1830, but that he knew it only as an ultimate fact, had no conception of its nature, and had no other treatment than the abandonment of near work to suggest. Its cause was first made known when DONDERS discovered the existence and the frequency of hypermetropia, and was still further elucidated by his subsequent discovery of the frequency of astigmatism-a condition which, although it had been discovered by YourrG and again by AIRY, in their own persons, had not been generally recognised by surgeons. A few years were required before the fruits of these discoveries were at all generally realised ; but the possibility of curing asthenopia by spectacles was fully present to the minds of English ophthalmologists in the early " sixties," and the careful use of spectacles for visual discomfort has never since been neglected in this country. Some of the examples of real or supposed eye-strain selected by Dr. GOULD had endured their fate, whatever it might be, before the time for scientifically selected spectacles had arrived ; and it is now but a vain speculation to consider whether he may have lighted upon a correct interpretation of their symptoms. At the present day, unquestionably, both physicians and the public are fully aware of the occasional, or even frequent, dependence of various forms of headache upon errors of refraction ; and there is no ophthalmologist who is not constantly consulted upon the questions hence arising both in children and in adults, sometimes spontaneously by the patient, more frequently at the suggestion of physicians or teachers. So much is this the case that the ophthalmic consultant is often compelled to give the eyes a clean bill of health, and to say that the causes of the trouble must be sought elsewhere. Nor is it found, generally speaking, that the symptoms attendant upon proved astigmatism are so serious as Dr. GOULD would have us believe. DONDERS was probably not far after wrong when, pointing out the almost universality of the condition, he said that a degree of less than a dioptre was rarely disturbing to vision. Nothing is more common in than to see astigmatism first become manifest at the age pf 40 years or thereabouts, and then to call for correction not so much for the relief of discomfort as for the improvement of sight. In London con-
presbyopic hypermetropes
sulting rooms and hospitals, degree of
and
at
least, refraction is tested with
accuracy which
could
not be and we surpassed, Philadelphia anywhere else, are quite unable to accept Dr. GOULD’S opinion to the contrary. We recognise that he has done good work in to which he desires to call attention is rampant and un- calling the attention of the profession in America to conchecked, that ° the vast majority of so-called refractiong is ditions which there m3,y possibly be as much neglected as worthless,"and that in Europe" all refraction (? refraction he believes them to be; and we cordially endorse his testing) may be said to be unscientific, inaccurate, and opinion that the eyes should be examined by an expert without power to cure the symptoms and sequels of eye- in every case of migraine. In London this condition is strain." In the opinion of our friendly monitor Europe is generally fulfilled ; and, if Dr. GouLD’s opinions b3 correct, it is certain that our future CARLYLES and DARWINS clearly called upon to take a back seat. ELioTS will be able to pursue their work in life the views of We have been at some pains to ascertain without hindrance from the painful difficulties which he
assertion that the pains and troubles of genius, with which all the world becomes familiar, are daily passing unrecognised among thousands of the obscure. Not very felicitously, perhaps, he assures his readers that the evil
a
care
either in
or
and
1
THE
LANCET, August 1st, 1903, p. 306.
’, describes... , _.....,
was,
THE LANCET. LONDON:
SATURDAY, FEBRUARY 6, 1904.
appointed to the "Amicable"in 1855 and to the "Equitable"" in 1858, but we believe that other offices had made similar appointments previously to that date. We have before us the proposal form of one of the societies which adopt the system of dispensing with the medical examination of applicants for policies. The sum assured must The questions do not materially and upwards. be :&500 differ from those asked by other companies except that descriptions of previous illnesses and the details of the family history have to be given by the proposer instead of by the medical examiner. The disadvantages of this procedure are obvious. The applicant has then to sign a declaration to the effect that the statements in the proposal
was
Medical Examinations for Life Assurance. THE medical examination of individuals
for life interest and the
applying
presents many problems of medical advisers of life assurance societies work under conditions different from those which are the rule in dealing with patients. Instead of having to meet the frail and the abnormal their interviews in the majority of instances are with the sound and the robust. Occasionally cases of latent disease are encountered, more particularly phenomena associated with arterio-sclerosis and glycosuria. The powers form are true and correct and that if any untrue averment is of observation and the ability for estimating differences in contained in the said statement, or if it is afterwards shown temperament are taxed to the uttermost, the great element that any material information has been withheld, then the of success in this branch of medical practice being the contract shall be void and all moneys which shall have capacity to make correct forecasts and a sound prognosis. been paid on account of the assurance shall be absolutely A thorough knowledge not only of his profession but of forfeited to the society. As Sir DYCE DUcKWORTH said, human nature and mankind in general is therefore a this practice is both precarious and troublesome and is most valuable qualification for a medical examiner for life Until a comparatively recent period there has certainly designed to attract persons who have no just claim assurance. been no organised endeavour to utilise the wealth of experi- to exemption from the ordinary and proper examination. If an individual is aware that he has some organic defect ence gradually accumulated by medical practitioners who have especially studied the medical side of life assurance. which may render him ineligible for assurance at ordinary in other societies it is a great temptation to him to go Fortunately, however, this defect no longer exists, for the rates to a society which offers him assurance without medical Life Assurance Medical Officers’ Association now provides find it impossible to opportunities of collating and discussing the many questions examination. He will then, of course, constantly presenting themselves in this branch of profes- avoid making false statements in filling up his proposal form Sir DycE DucKWORTH in delivering the and if it is afterwards discovered that he has knowingly sional duty. committed a fraud he meets with just punishment in presidential address before that society on Jan. a report of which will be found in another column, having the contract annulled with the loss of the referred to the valuable work which the association has premiums which he has already paid. Instead of running him to have applied already accomplished and which has fully justified the this risk it would have been wiser of as a sub-standard life and to have submitted expectations of its originators. He pointed out that some for a policy to a medical examination, for many assurance companies of the most profitable discussions that have taken place related to the subjects of albuminuria and glycosuria and now accept such lives under certain conditions. Another much information has been elicited which has enabled the excuse for wishing to escape a medical examination is the members to gauge the significance of such symptoms in a trifling loss of time which is entailed by a visit to the We cannot, however, consider it as medical examiner. more precise manner than had previously been the case. time it insures a policy granted in circummisspent, for He also touched upon other subjects of medical interest stances which in certain offices render it practically in connexion with life assurance. There is a further objection and a very One of these seems to us to deserve very careful con- unassailable. one to assuring without medical examinationsideration-namely, the practice recently adopted by certain strong societies of accepting applicants for assurance without namely, that if the applicant should die from disease assurance
27th,
medical examination. From a professional point of view there can scarcely be two opinions on this point. Dr. E. SYMES-THOMPSON writing in Professor CLIFFORD ALLBUTT’S
the first year following the date of assurance the amount payable is only one-third of the sum assured, if he
during
should die during the second year two-thirds of the sum, of Medicine" that the states but on a claim occurring at any time after two years from "System (vol. i., p. 476) medical selection of lives was not attempted in the early the date of assurance the full sum assured is payable. If days of life assurance. The first society, the Amicable, death is due to accident of course no deduction is made. was founded in 1706 and existed for some years before a In the case of assurance with medical examination if death medical officer was appointed. The same premium was paid takes place at any time after the policy is issued the claim by each applicant, whatever his age or apparent health. He is paid in full. We cannot understand therefore where the
376
advantage
to the
whether as holders of eventual beneficiaries, is to be policies found under the conditions of the practice which we are assurance
general public, as
or
discussing. With regard
to the society itself, also, it is difficult to see Doubtless a large number of where the benefit can lie. but the risk of fraud and be received applications might deceit must be constant and if many claims are contested this method of insurance would quickly become unpopular. Sir DYCE DUCKWORTH suggested that the practice had its origin in the same causes which so gravely affect the conduct of all business transactions in these days-namely, hurry, pressure, and furious competition. The business aspect of this question has little concern for us as members of the medical profession but we shall watch with interest the results of a step which we can only consider as retrograde.
"
Eye-strain."
OUR esteemed editor of
colleague Dr. G. American Medicine,
strenuous endeavours to
arouse
M. GOULD of
Philadelphia, pursuit of his
in further the medical
profession
to
a
complete consciousness of the frequency, the nature, and the consequences of "eye-strain,"has sent us a paper upon the subject which is appearing in the current number of that journal. In this he repeats many of the assertions with which his former writings have rendered us more
or less familiar, although they
have not
as
yet
command the entire assent of which their writer believes them to be
large
number of
temper, defects of
worthy.
Dr. GOULD tells
come no
us
to
doubt
that
a
of neurotic character, defects of digestion, incapacity for sustained work
cases
objects, migraine, and a large catalogue of the peculiarities which have been sometimes described as the defects of genius, are mainly due to unrecognised "eyestra.in" produced by astigmatism, generally of the hypermetropic character, and he gives us quite a long catalogue of illustrious sufferers, including people of characters so diverse at
near
the CARLYLES, GEORGE ELIOT, HUXLEY, DARWIN, and Our readers will remember that Dr. GOULD NIETZSCHE. contributed a lengthy article to our columns last autumn,l in which he endeavoured to prove by extracts from the life of WAGNER, and by photographs showing an outward deviation of his left eye, that he also should be added to the long list of illustrious sufferers from eye-strain, and he dwelt upon the as
London ophthalmologists upon the questions to which Dr. GOULD directs attention. It must be remembered that I I eye-strain " or, as he called it, weak sight or asthenopia, was quite clearly known to, and described by, MACKENZIE in 1830, but that he knew it only as an ultimate fact, had no conception of its nature, and had no other treatment than the abandonment of near work to suggest. Its cause was first made known when DONDERS discovered the existence and the frequency of hypermetropia, and was still further elucidated by his subsequent discovery of the frequency of astigmatism-a condition which, although it had been discovered by YourrG and again by AIRY, in their own persons, had not been generally recognised by surgeons. A few years were required before the fruits of these discoveries were at all generally realised ; but the possibility of curing asthenopia by spectacles was fully present to the minds of English ophthalmologists in the early " sixties," and the careful use of spectacles for visual discomfort has never since been neglected in this country. Some of the examples of real or supposed eye-strain selected by Dr. GOULD had endured their fate, whatever it might be, before the time for scientifically selected spectacles had arrived ; and it is now but a vain speculation to consider whether he may have lighted upon a correct interpretation of their symptoms. At the present day, unquestionably, both physicians and the public are fully aware of the occasional, or even frequent, dependence of various forms of headache upon errors of refraction ; and there is no ophthalmologist who is not constantly consulted upon the questions hence arising both in children and in adults, sometimes spontaneously by the patient, more frequently at the suggestion of physicians or teachers. So much is this the case that the ophthalmic consultant is often compelled to give the eyes a clean bill of health, and to say that the causes of the trouble must be sought elsewhere. Nor is it found, generally speaking, that the symptoms attendant upon proved astigmatism are so serious as Dr. GOULD would have us believe. DONDERS was probably not far after wrong when, pointing out the almost universality of the condition, he said that a degree of less than a dioptre was rarely disturbing to vision. Nothing is more common in than to see astigmatism first become manifest at the age pf 40 years or thereabouts, and then to call for correction not so much for the relief of discomfort as for the improvement of sight. In London con-
presbyopic hypermetropes
sulting rooms and hospitals, degree of
and
at
least, refraction is tested with
accuracy which
could
not be and we surpassed, Philadelphia anywhere else, are quite unable to accept Dr. GOULD’S opinion to the contrary. We recognise that he has done good work in to which he desires to call attention is rampant and un- calling the attention of the profession in America to conchecked, that ° the vast majority of so-called refractiong is ditions which there m3,y possibly be as much neglected as worthless,"and that in Europe" all refraction (? refraction he believes them to be; and we cordially endorse his testing) may be said to be unscientific, inaccurate, and opinion that the eyes should be examined by an expert without power to cure the symptoms and sequels of eye- in every case of migraine. In London this condition is strain." In the opinion of our friendly monitor Europe is generally fulfilled ; and, if Dr. GouLD’s opinions b3 correct, it is certain that our future CARLYLES and DARWINS clearly called upon to take a back seat. ELioTS will be able to pursue their work in life the views of We have been at some pains to ascertain without hindrance from the painful difficulties which he
assertion that the pains and troubles of genius, with which all the world becomes familiar, are daily passing unrecognised among thousands of the obscure. Not very felicitously, perhaps, he assures his readers that the evil
a
care
either in
or
and
1
THE
LANCET, August 1st, 1903, p. 306.
’, describes... , _.....,