CHAPTER XIV

ARTERIOSCLEROSIS IN ITS RELATION TO LIFE INSURANCE

The value of the early recognition of cases of arteriosclerosis and hypertension has been spoken of within, but it needs to be further emphasized. There is perhaps no class among physicians to whom is afforded a better opportunity of seeing early cases than the medical examiners of life insurance companies.

The relationship between a patient and the physician whom he consults, and the applicant for life insurance and the examiner are diametrically opposite. In the former the patient desires to conceal nothing and the physician is called upon to diagnose and treat disease. In the latter the applicant, a presumably healthy person, may have much to conceal and the examiner is there to pass upon the state of health. The question is this--"Is the applicant now in good health?" It becomes then of vital importance for the examiner to be able to detect among other abnormal conditions the incipient signs of arteriosclerosis and of hypertension. Parenthetically it may be stated that arteriosclerosis and hypertension are not one and the same disease as has been so frequently insisted upon within; the former may occur without the latter but the latter can not from its very nature be present for long without arterial thickening supervening. It is necessary in discussing the question here to group the two conditions together in order to prevent needless repetition.

Such a case as the following is common. A successful business man of forty-four years was brought to me by an agent in 1905 for examination. The man was six feet tall, weighed 218 pounds, had a ruddy color and looked to be the picture of health. He was not strictly intemperate, he never became intoxicated, but every day he drank three or four whiskies and often he had a bottle of wine for dinner in the evening. When he was examined his pulse was of good quality and owing to the fleshiness of the wrist it was difficult to say positively whether the radial artery was sclerosed or not. In the heart no murmurs were heard, and it was difficult to be sure that the left ventricle was enlarged. There was, however, a slight but definite accentuation of the second sound at the aortic cartilage which might readily have been overlooked had the patient not been stripped and a careful examination made with the stethoscope. Upon taking the blood pressure it was found to be from 170-175 mm. of Hg. The urine specimen examined at the visit was normal, no casts were found. The applicant was seen at his home and the blood pressure measured. It was again the same. He was seen a third time and practically the same systolic blood pressure was found. Under protests from all the agency staff the man was declined. Two years later he died of apoplexy. The man was angry at being refused. Instead of looking the matter squarely in the face he thrust aside the idea that there was anything the matter with him. He had never had one ill day in his life, his forebears had lived to ripe old age, and he was sure that he knew more about himself than the examiner.

Had this applicant showed a sense of reasonableness he should have been grateful to the doctor for calling his attention to a condition which surely would sooner or later prove either fatal itself or lead to some fatal lesion. It was learned that this man had gone directly to his family physician who laughed at such nonsense as had been told the (now) patient by the examiner.

Another illustration of a slightly different type of case is afforded in the following history.

A man of fifty years of age, five feet ten in height and 164 lbs. in weight, was brought for examination. In his youth there was a history of a mild attack of scarlet fever. He was almost a total abstainer, rarely taking liquor in any form. Physically he appeared to be an excellent risk. However, on examining the heart it was found that there was slight hypertrophy with an accentuated second aortic sound at the base, and the blood pressure was 180 mm. of Hg. Some sclerosis of the radial arteries was found. One company had refused him on account of albumin in the urine. There was none in the first specimen which was passed while in the office. The specific gravity was 1014. A morning specimen was obtained and contained a trace of albumin. Several specimens were then examined. Some contained albumin, some had no albumin content. The man was declined; no protests from the agent as albumin had been found. There was something tangible in that. Had the applicant been refused on account of his high tension, sclerosis of the radials, and slightly enlarged heart there would undoubtedly have been protests. And yet an applicant revealing such a state of the cardiovascular system without albumin in the urine should unhesitatingly be declined. Attention has been called to hypertension as an early, and some think an invariable, sign of chronic nephritis. My own experience has confirmed me in the belief that in hypertension the kidneys are often the seat of chronic interstitial changes. Careful palpation of the radial and brachial arteries will in every case reveal more or less thickening.

There is yet another group of cases which the examiner sees as healthy subjects, namely those cases of sclerosis of the peripheral arteries without sclerosis of the aorta and without high tension. In such cases the radials, brachials, temporals and other superficial arteries are readily palpable, sometimes even revealing irregularities along the course of a vessel. Such cases are not subjects for insurance. The recognition of such a condition is of great importance to the one who has it and he should be urged to go to his regular physician for thorough examination. Should the physician ridicule the idea, as has happened to me more than once when I was actively engaged in insurance work, the examiner has done his full duty to the company, the applicant, and himself.

A life insurance examiner has a difficult position to fill. He has four people to satisfy; the applicant, the agent, the medical director and himself. The straight and narrow path of strict honesty is his only salvation. By being honest with himself he necessarily gives a square deal to the other three parties.

No applicant who has palpable arteries or hypertension can be considered a first class risk. It can not be denied that men with arteriosclerosis live to an advanced age and may even outlive those who have apparently normal arteries, but the average life expectancy at any age for an arteriosclerotic is less than that for a normal person. The apparently healthy applicant who learns for the first time when examined for life insurance that he has the early or moderately advanced signs of arterial disease, should thank the agent and examiner for showing him the danger signals ahead. The sensible man then orders his life so that he puts as little strain on his heart, arteries, and kidneys as possible and may add many years to his life.

It is on account of this very insidiousness of onset that I have elsewhere urged as a prophylactic measure the examination every six months of all persons over forty years of age. I am more and more convinced that it is of vital importance to the health of the public.

As I have remarked, the average man consults his dentist at least once a year so that no tooth may be so far diseased that it can not be saved. It is purely a means of preserving the teeth. Why not do the same with the whole body? Of what use is it to save the teeth and lose the body? It seems to me that the great army of life insurance examiners are in an enviable position in their ability to add years of life to many men and women. I doubt whether they realize their importance in the campaign for health. I should urge life insurance companies not to employ recent graduates unless they have had at least a year's hospital experience. For the company as well as for the individuals I believe that there is a prognostic sense which the examiner should have and this can only be acquired by experience.

I believe that arteriosclerosis and hypertension are increasing for the reasons which have been given in another chapter. There can be no doubt that when these conditions are recognized long before symptoms would naturally supervene, men and women would not only live longer but also die more comfortably and many very likely would be carried off by some disease having no relationship whatever to arteriosclerosis. Slight enlargement of the heart downward and to the left, accentuation of the second aortic sound at the base, a full pulse, arteries which are palpably thickened, increased blood pressure are signs to which attention must be paid.

When the peripheral arteries are palpable they are not always sclerosed. The radial artery, the one usually palpated, may lie very close to the bone in a thin person. Under these conditions the artery can be easily felt. It is better then to palpate for the brachial as it lies beneath the inner edge of the biceps muscle. Should this artery be felt then very probably sclerosis is present. Opinion as to whether or not sclerosis is present, when it is slight, may differ. It is difficult at times to say definitely. Should such be the case the applicant should be most carefully questioned as to his family and past history, the heart should be carefully outlined by percussion and the blood pressure should be taken, both the systolic and diastolic pressures. The urine should be examined with particular care. I am aware that the average examination for life insurance is not made with the care which is bestowed upon a patient. Yet I see no reason why the same attention to detail should not be given in one as in the other. The examination of the great majority of applicants can he made in a short time, as there is no question of latent chronic disease. When the exception turns up he should be given a searching examination and a full report should be sent to the Medical Director. Only in this way will it be possible to weed out the undesirable risks.

On the surface it does not seem to require any great diagnostic acumen to be a life insurance examiner. In the old days of many of the companies there were no examiners. The applicant was brought before the president or other appointed official and he was passed or rejected on his general appearance. This has changed, and now the medical department with its scores of examiners in the field is a well organized department.

It seems to me that the examiner should be an exceedingly able diagnostician and prognosticator. There is no telling when he may be called upon to pass judgment on a borderline case. From personal experience I know how difficult it is to make a decision in some cases. These suspicious cases after a careful examination had better be passed by the examiner and a supplementary report sent to the medical director containing unbiased details. But no applicant with readily palpable arteries, even though the blood pressure be normal, should be considered a first class insurance risk.

The question of the value of the diastolic pressure reading in examinations for life insurance is not yet settled to the satisfaction of all medical directors. Certain medical directors with clinical experience behind them, lay great stress on the increased diastolic pressure and consider a persistent diastolic of 100 mm. really more significant as an indication of hypertension than a systolic pressure of 160 mm. Other directors pay little or no attention to the diastolic reading. Should an applicant show a systolic above the average normal on several successive readings, he is declined. When one takes into consideration the psychic effect of knowing that he is being examined for high blood pressure, it seems unfair to refuse insurance on such grounds as is constantly done.

Up to the present there are no extensive series of life-expectancy tables in which hundreds of thousands of cases are analyzed from the diastolic pressure values. There are many such tables for the systolic pressures alone. In the tabulation of such statistics one must not lose sight of the important fact that the figures are taken by thousands of men of varying capacity and different degrees of intelligence. Such studies to be of any real value must be taken from records made at the home offices by capable men. We shall await these tables with interest. In the meantime we must be permitted to have the impression that the diastolic pressure has been much neglected. This has no doubt been due to the difficulty of measuring it with any degree of accuracy. Now with the auscultatory method and the correct place to read the diastolic pressure the results of blood pressure estimations should begin to have some value for statistical data.

Clinically the diastolic is probably more important than the systolic. Until proof is brought to the contrary we shall believe that in life insurance examinations it has the same importance.