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eased tonsillar crypts. The catarrhal secretion coming from them is often filthy in the extreme. This infectious matter constantly bathes the oropharynx. Naturally the teeth are exposed to infection from this source, thus favoring caries or decay.

One of the most important conditions of tonsillar disease which gives the patient great anxiety is tuberculosis. In tubercular adenitis of the neck it is the tonsil that is almost invariably the first to become affected, the infection traveling from the crypts to the cervical and the bronchial glands. Several investigators have found tubercle bacilli in the crypts of the tonsils. The tubercular process develops mainly in the cavity of the crypts; the ulceration does not, as a rule, come to the surface at all. The bacilli are sometimes present in large quantities (Kafeman). "The tonsillar tissue of the throat, because of its peculiar anatomic construction and its topographical relations, is more liable to become infected by tuberculosis than any other part of the upper respiratory tract." (Wood.) Tubercular infection through the crypts gains access to the lymphatics, then to the blood stream, sometimes becoming scattered and producing miliary tuberculosis. Dr. Towler of Brooklyn reports a series of twenty-one experiments where the cheesy, fetid material expressed from tonsils was injected into guinea pigs. Fourteen pigs developed tuberculosis. In the opinion of quite a number of laryngologists that in tuberculosis of the apex of the lungs infection gains access through the tonsil.

There are a number of cases on record of tuberculosis of the tonsils prior to the involvement of the lungs, or the lungs may be involved first and the tonsillar tissue become infected later. Patients having no tubercular lesions, but diseased tonsillar crypts, may, as a result of irritating emanations, suffer from congestion and obstruction of the nose interfering with free respiration, and through undue mouth breathing, expose themselves to tubercular infection by inhaling tubercle-laden dust. It is the diseased tonsillar crypts that predispose patients to tuberculosis. Thus in a case of fissured or partially destroyed tubercular tonsil the general symptoms of incipient tuberculosis may disappear through removal of all crypts, with speedy restoration of the individual's health.

If diseased crypts are left in the throat, recurrence of inflammation will always follow, and foul breath persist in spite of mouth washes and gargles. The treatment of the gums or the filling of the teeth will not remove a foul breath due to diseased tonsillar crypts.

PAINLESS LABOR

Edgar, in the Journal of the American Medical Association of September 2, 1916, expresses his belief that as an intermittent analgesic or anesthetic, the nitrous oxide-oxygen mixture is well adapted to the second stage. Webster and his associates have done much to make this method of painless labor popular. In the second stage it does not interfere with uterine contractions as does ether and chloroform, but by arresting pain prevents shock and exhaustion, and resistance not being lowered the patient is the better able to stand subsequent infection or complication. His experience has been limited entirely to its use in the second stage, and in all the mass of recent literature on the subject he gathers that it is of no value in the first stage, or else the authors avoid mention of its status in this stage.

In the hands of inexperienced hospital internes results with this method have been deplorable, if not dangerous to the patient. Under the management or supervision of a first class anesthetist, the method works out most satisfactorily. Edgar has experimented with three gas machines, and has finally settled on a simple single bag instrument.

He dissents from the statement that the administration of nitrous oxide-oxygen is safe in unskilled hands. It is difficult to reconcile the state.. ment of the recent advocates of nitrous oxideoxygen analgesia and anesthesia, and the teachings of some of our most expert users of this gas combination. On the one hand, we are repeatedly told that the use of nitrous oxide and oxygen for analgesia and anesthesia is a simple matter for one to become proficient in after a few trials.

In other words, in analgesia work, there is danger that the patient coming out from under the influence of the gas may suffer from the effects of shock due to the acuteness of the suffering, or, on the other hand, the danger of anesthesia in the hands of the novice. Some of the best obstetricians are confessedly poor anesthetists.

Nitrous oxide-oxygen analgesia or "obstetric" ether or chloroform for the second stage of labor pushed to anesthesia for the perineal stage, and, possibly, forceps delivery with vapor anesthesia to eliminate part of the second stage, is a satisfactory procedure.

Moreover, nitrous oxide-oxygen analgesia or anesthesia is superior to any other during labor, because of its oxytoxic action.

Eventually an established method of painless labor may be considered among public health questions.

Lessening or abolishing the pain of labor may in the future limit birth control and criminal

abortion.

THE CONSIDERATION OF RECTAL AND COLONIC DISEASES IN LIFE INSURANCE EXAMINATIONS.*

By ALFRED J. ZOBEL, M. D., F. A. C. S, San Francisco, Cal.

When making a life insurance examination the careful examiner does not rely upon any of the applicant's statements regarding his present physical condition, but by inspection he notes whether the general appearance is healthy or unhealthy; by inspection, palpation, percussion and auscultation he secures accurate information concerning the heart and lungs; by examination of the reflexes, etc., he seeks evidence of disease or functional derangement of the brain and nervous system; by palpation and with the sphygmomanometer he determines the condition of the blood vessels; by an urinalysis he sees if the kidneys and bladder are free from any tendency to disease; by the thermometer he notes the untoward rise in temperature which betrays latent disease; and by the scales and the tape he finds variations from normal in weight and measurements. All this important data is obtained only by direct examination and by precise methods.

It is evidently not deemed of much importance by the life insurance companies that their medical examiners need determine accurately the condition of the rectum and colon-not to mention the balance of the alimentary canal-for they seem willing to assume that these organs are free from disease solely from the favorable answers given by the applicant to routine printed questions asked by the examiner. That this is a fallacy, inasmuch as it paves the way to the acceptance of poor risks, and occasionally to the rejection of a good one, I shall endeavor to show in this paper. Among the routine questions which the applicant is required to answer are: "Have you now or have you ever had (1) chronic diarrhea; (2) a fistula, or any disease of the rectum." The replies to these queries might perhaps be taken at their face value were it not for several adverse reasons. One is that the answer may be given honestly, but is often not worthy of consideration on account of the applicant's ignorance of what is really meant by the question. Another is that the questions are usually asked perfunctorily, and even casually, by the examiner, and are answered -almost invariably in the negative-in a like manner by the applicant.

*Read at the Annual Convention of the American Pathological Society, June, 1916.

In a fairly long experience as an examiner I can recall only one time when I received an affirmative reply. That was from a man 54 years of age. He freely volunteered the information that he had bleding from his rectum, at intervals, for a number of years. He was otherwise safely insurable. A recto-sigmoidoscopic examination. showed the presence of small hemorrhoids only. He was accepted by the company upon my statement that there was no malignancy, and that the hemorrhoids were not such as to demand an operation.

This remarkable absence from recto-colonic troubles in applicants for insurance is rather surprising. One would imagine that the proportion of sufferers from these ailments would be about the same among them as among other persons seen in family or general clinical practice. The suspicion therefore arises that perhaps the main reason for the general denial is the ease with which these affections can be concealed from the examiner unless he makes an examination.

As an illustration I recollect the case of a gentleman who was at the time under my care for an amebic colitis, yet he passed an examination and received a policy. Though previously having suffered for many years, he could be freed for long periods from all symptoms of the disease by a course of emetin injections. Still at intervals there were sharp recurrences. During a time when the disease was quiescent he passed the examination. It is probable that had more attention been paid to the questions and answers concerning the condition of his bowel and rectum the suspicions of the examiner would have been aroused. If a rectal examination had been made the presence of the disease would have been discovered, for at no time was the rectal mucosa without some evidence of amebic ulceration.

It cannot be said that this man was entirely at fault in the matter. While it is true that he had the disease for years, still, being a layman, he thought he was practically cured when his dysentric symptoms yielded so readily to a few injections of a seemingly harmless drug, and particularly so as he otherwise felt and looked in the best of health. A history of former dysenteric attacks naturally was of no importance in his

mind, so he could see no reason voluntarily to acquaint the examiner with all the facts about himself, especially as no very great effort was made to secure that information.

As amebiasis has been considered a disease which is met with only in the tropics, or in certain localities in our southern states, outside of these zones the average practitioner is not apt to consider the possibility of its presence. But those who are interested in recto-colonic diseases have learned that individuals who never have been in any of these localities often become infected; that amebiasis occurs more commonly than is generally suspected, and that the organism may be harbored in persons whose outward appearance shows no evidence of it.

It is common knowledge among rectal surgeons that the average individual knows little about his ano-rectal region, and that no matter what the pathological condition in his rectum may be, he generally attributes every symptom to a "slight attack of piles." Unless there is severe pain or itching, alarming bleeding, or annoying dysentery, he thinks it of little importance and unworthy of any attention.

Patients not rarely come under observation who. look and feel in the best of health (outside of their "little attack of piles'), yet who are found victims of well-advanced malignant disease of the rectum or colon, which in all probability will soon end their days. The growth has progressed so insidiously that, outside of a little bloody and mucous discharge, which seemed but a trifling matter, no other symptoms betrayed the presence of the deadly destroyer. These individuals sometimes honestly disclaim any loss of weight. They appear to be healthy otherwise, so that a life insurance examiner, not learning of their "little attack of piles," would find nothing to cause him to reject the risk.

I am not in possession of any statistics on the subject, so I am unable to quote what percentage of those insuring at the age of 30 years and over have died from cancer of the rectum, say, within the first five years after their policy was issued. I presume that the total number of deaths from rectal cancer, even among all who took out insurance at any age, is indeed very small. Yet the question might be asked whether it could not have been possible for the examiner to have saved his company from some of these losses if more consideration had been given to the possibility of the applicant having some rectal disease at the time the examination was made.

As I have said before, it is quite surprising how little the average person is concerned about any ano-rectal trouble, unless the symptoms are very annoying. A little fistulous tract which causes

no pain and discharges but little secretion is never considered to amount to anything. That they ever had a marginal abscess, from which the. fistula had its origin, often is forgotten. But it is exactly such a type of fistula which is most apt to be tubercular, and a person having it would be a far worse risk for the insurance company than one having a fistula of a florid type, which was the remains of a well-marked ischiorectal abscess. I have seen a number of these cases in otherwise apparently healthy individuals, where small marginal abscesses were followed by a little fistulous tract persistently discharging a very slight amount of thin secretion. I recall that in one of these cases the tubercle bacillus had been found in the sputum. He had no active symptoms and was apparently healthy. He was passed by an examiner, who, so the applicant informed me, did not ask if he had ever had any rectal trouble. Should this man die later of tuberculosis, probably no blame will be attached to the examiner, yet the company could have been saved an exceedingly bad risk had a rectal examination been made and the condition recognized.

Many competent observers, according to Tuttle, believe that fistula is frequently the primary manifestation of tuberculosis, and that when the disease limits itself to the ano-rectal area it may remain localized for long periods of time. The same author stated that in his experience nearly 50 per cent of the fistulous that had come under his observation in the different hospitals with which he was connected have either suffered from tuberculosis at the time or afterwards, and, further, that fistula in the tuberculosis is much less frequent proportionately than tubercle in the fis

tulous.

All of us, I apprehend, have seen severe strictures of long standing in the rectums of individuals who otherwise appear in good health. Outside of difficulty in securing a bowel movement-unless they take a cathartic which will liquify their feces -they suffer from no other symptoms. About a year ago I saw a case in which, when the examining finger was inserted into the rectum, it was stopped by a hard, fibrous stricture about an inch above the sphincters. The opening was so small and so rigid that, in order to examine above it, it necessitated the use of a No. 24 urethral speculum. The man was outwardly perfectly healthy and insurable, but in all probability the time was near when the stricture would so close up the bowel that nothing would be able to pass through, and it would be necessary to make an artificial anus. If this man desired to take out a life insurance policy and had failed to mention his condition, he could have passed readily any insurance

examiner who failed to make a rectal examination.

The insurance company does not require a routine rectal examination, but most likely it expects the examiner to make it if there be the slightest reason therefor. Failure to do so results from a dislike for the task or from inability to do it properly, or perhaps from both. The dislike usually comes as much from laziness as from repugnance. The inability often arises from a knowledge of incompetency to interpret the findings. Teaching post-graduate students has shown me that there are many physicians whose knowledge of the recto-colonic region is almost as woefully lacking as is that of the layman. Most of them believe that hemorrhoids, if not seen protruding, can at least be felt. When told that even large piles may exist and still not be felt,

nor seen unless forced into view, it is news o them. Of course, an applicant having hemorrhoids and nothing else is not sufficient grounds for not passing him, but if they are found it may mean that some other condition may exist which would constitute a good cause for rejection. It must not be forgotten that hemorrhoids often accompany liver, spinal cord, genito-urinary and uterine disease.

On the other hand, a suspiciously anemic. appearance of an applicant might be the only reason for his rejection. If, on query and by examination, the anemia would be found due only to the constant oozing of blood from hemorrhoids, the rejection need not be absolute, but a recommendation could be made that the application be held in abeyance for some months, or until a time when the applicant regains his normal condition, which he generally begins to do soon after the removal of the hemorrhoids.

It is perhaps true that an examiner is not expected by his company to ferret out the causes of the condition for which the applicant is rejected, nor is it his duty to suggest a remedy therefor. However, it seems to me that if the cause is recognized during the course of the examination, and it is of such a nature that some minor operative procedure or other line of treatment would restore the applicant to a safely insurable condition, then it ought to be the duty of the examiner gratuitously to offer a suggestion as to how it could be remedied, for by doing so he conserves business to life insurance which would otherwise be entirely lost to it.

In a book of instructions written by the chief medical examiner of a certain company and issued to its medical examiners, it is urged upon the latter that they try to put the applicant at his ease by assuming a confidential attitude towards him, and gradually to draw out the desired

information during the course of casual conversation, rather than by directly plying the set questions. The suggestion might be offered that at such a time the applicant could be asked about the state of his bowels. If constipation exists, especially in a person over 40 years of age, it would be a wise procedure to investigate a little further. While it is true that in the very great majority of instances the cause is purely functional, once in a while a condition may be found which makes the risk a poor one. Little importance is paid to the question of chronic intestinal stasis by life insurance companies. This is hard to understand, for most of these cases are accompanied by intestinal autointoxication, and many of us believe with Boardman Reed that "when we except the exanthems, malaria, syphilis, tuberculosis, and the diseases caused by traumatisms, by metallic poisons, and by a few other toxic agents or infections from without, practically all the remaining maladies which afflict us and cut short our lives are now directly or indirectly traceable to autointoxication."

In otherwise good risks whose blood pressure is higher than it should be, perhaps, if inquiry would be made, the cause might be found in a chronic intestinal stasis. Only recently I saw a man of 39 years who, two weeks previously, had been rejected for insurance on account of a blood pressure of 180 m. m. He became much alarmed and consulted his physician, who, carefully examining him, could find no cause for the hypertension outside of it perhaps resulting from a chronic constipation which existed since boyhood, and which, although it caused at times some severe autotoxic symptoms, had been given no attention. Under strict diet no drop in blood pressure resulted. He was then referred to me for colonic irrigations. Within a month it was down to 145 m. m. and he was then accepted by a second company. Here is an instance where a good risk could have been lost entirely to the life insurance business. To my way of thinking, an individual like this becomes a particularly good risk just because of his previous rejection. The scare he received leaves an indelible impression, and brings home emphatically a realization of the necessity for keeping in the best of physical condition, so that thereafter that person is far more careful about himself than one who has passed easily an examination and feels so secure about his present good health, that, having no warning as did the other, he may neglect himself in the future.

In the medical examiner's report is included the question whether the bladder and urinary organs are in a healthy state and free from any tendency to disease. Probably most examiners base their answers to this upon their urinalysis. If a rectal

examination were made, however, this question could be answered far more authoritatively, for then the prostate gland could be examined at the same time, while any enlargement of the testicles from tubercular or malignant disease also could be discovered.

An anus remaining patulous after withdrawal of the examining finger or instrument will suggest possible involvement of the spinal cord in a syphilitic process. As it may be one of the earliest signs of locomotor ataxia, its recognition will save the company from assuming an absolutely bad risk. The applicant perhaps may be entirely honest in his assertions that he has no knowledge of syphilitic infection, and may otherwise appear as a first class risk.

The proportion of women to men examined for life insurance is quite small. Insurance companies do not demand an examination of their generative organs, but accept their answers to the questions whether they ever had any uterine or menstrual disorder, if the uterine functions are now regular, and if pregnancy now exists. It can be appreciated why a woman might object to a pelvic examination and would rather forego the benefits of insurance. However, in my experience, they rarely object to a rectal examination, especially when an office nurse assists. During the rectal examination the condition of the uterus and its appendages can be noted; should there be a tumor it can be felt, and pregnancy, both normal and extra-uterine, can be made out if existant.

In conclusion, the suggestion is offered that medical examiners should lay more stress upon the questions regarding the condition of the bowel and rectum. Just as they are particular in asking whether the applicant "has or ever has had spitting or raising of blood," so should they inquire as carefully whether there is or ever has been a sanguinous, purulent or mucous discharge from the rectum. A history of chronic constipation or of diarrhea also should be considered worthy' of further investigation. A rectal examination, both digital and instrumental, should follow if there is need therefor, or whenever there is the slightest suspicion that by it something may be revealed.

In the business world the slogan of the day is "efficiency." In the eyes of the public that life. insurance company is the most "efficient" which, having the lowest death loss, returns to its policy holders the largest dividends. That medical examiner is the most "efficient" who not only secures his company from poor risks, but also saves it business which otherwise would be lost. That the utilization of rectal examinations helps attain "efficiency," I trust has been demonstrated in this paper.

DO YOU KNOW THAT-?

A. L. Benedict, in the New York Medical Journal, asks the following pertinent questions:

Do you know that a gain in weight in a series of cases has been alleged for nearly every discarded system of treating tuberculosis?

Do you know that a healthy man cannot assimilate the amount of cod liver oil and other fats often prescribed for tuberculous patients?

Do you know that warm air can be as pure as cold?

Do you know that a window open an inch, with the wind blowing thirty miles an hour and with the outdoor temperature 20 or 30° F. below the initial indoor temperature, will renew the air in a bedroom more quickly than a wide open window on a hot still summer night?

Do you know that a sleeping porch or veranda, inclosed in winter and provided with a gas stove, may contain more impure air than a well heated and ventilated living room?

Do you know that the average healthy physician, compelled to sleep on a cot in a tent, during a snow or rain storm, will forget all about the pneumococcus and insist that he is going to have pneumonia?

Do you know that a cleanly consumptive occasionally sneezes and coughs? Do you know how he is going to prevent the dissemination of bacilli in the resulting spray?

Do you know just what natural factors in disinfection render it possible for us to assure a recalcitrant community of ignorant persons, that a hundred tuberculous patients in an institution in the midst of them absolutely cannot infect their air or water?

Do you know that the same kind of foolishness that a phthisiophobe exhibits is what keeps a great many persons from being run down by locomotives and automobiles?

Do you know that, to insure sufficiently early operation in cancer of internal organs, the surgeon must be called before anything more than a guess as to diagnosis is made?

Do you know that, even then, twenty-five per cent of cures is almost the highest announced under the most favorable circumstances?-and that ten per cent is about the best actual achievement.

Do you know that, after the age of fifty years, absence of hydrochloric acid occurs in many more benign than malignant cases?

Do you know that very few cases in which hyperchlorhydria is demonstrated, are of ulcer, and that very few cases in which ulcer is demonstrated go on to cancer of the stomach?

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