THE MUTUAL Life Insurance Company OF NEW-YORK. INSTRUCTIONS TO THE MEDICAL EXAMINERS, INSTRUCTIONS TO THE Medical Examiners OF T1IE OP NEW-YOEK. John A. Gray & Green, Printers, Nos. 16 and 18 Jacob Street. I 860. Entered, according to Act of Congress, by the Mutual Life Insurance Com- pany of New-York, in the year 1866, in the Clerk’s Office of the District Court of the United States for the Southern District of New-York. Jo THE JAEDICAL JXAMINERS OF THK Mutual Life Insurance Co. of New-Yoek. Gentlemen : The following Rules and Instructions for the Medical Ex- aminers of this Company are the results of carefully collated experience. They have been mainly prepared by Minturn Post, M.D., who has been Medical Examiner to the Institu- tion in this city from its formation, assisted by Isaac L. Kip, M.D., more recently appointed a Medical Examiner here. We bear willing testimony to the great skill and fidelity of many of our Medical Examiners, freely acknowledging that they have done much to place the Company in its present prosperous state, and need no rules or instructions to qualify them for their duties. Yet others may; and as these exam- inations in Life Insurance are specialties in medical prac- tice, requiring, in addition to skill in auscultation and percus- sion, an accurate and minute knowledge of the human struc- ture, especially of the respiratory and circulatory system, it is thought desirable for the safety of the Company to issue them to all its Medical Examiners, although all do not need them. While science, skill, and experience are all-important in 4 INSTRUCTIONS, the Medical Examiner, and cannot be safely dispensed with by the Company, yet strict accuracy of statement, with per- fect independence and integrity, are equally necessary. The Facts in each case are what the Company need; and without them it cannot intelligently or safely pursue its business. The Medical Examiner, who for any reason fails to give an honest report, by either withholding facts or otherwise, in reply to the questions in the Application, of the cases he ex- amines, is, it will be universally admitted, unworthy his dig- nified position as a member of the Medical Faculty, or to occupy the important and responsible position with which he is intrusted by a Life Insurance Company. Commending the following pages to your attentive perusal, and extending to each one of you the assurance of my confi- dence and esteem, I am, gentlemen, yours respectfully, F. S. Winston, President. New-York, February 1, 18C6 Note. All appointments of Medical Examiners are made at the Central Office, on the receipt of the requisite testimonials. Applications for such appointments should state the age of the physician, the institution in which he graduated and from which he received his diploma, and its date, with the time he has been in medical practice, and a reference to one or more of the Medical Faculty as to skill, character, etc. etc. In case of the temporary absence of the regular Medical Examiner, he will notify this office of the physician he desires to act in his stead. Instructions to the Medical Examiners OF TIIE MUTUAL LIFE IUSUKAUCE CO. OF NEW-YOEK. pENERAL jlEMARKS. The granting of Policies to persons who shall reach at least the longevity designated by the life- tables, is the problem before ns in the selection of parties applying for assurance upon their lives. Now, although it is impossible to foretell whether each in- dividual so selected will reach his expected duration of life, yet experience has amply demonstrated that persons who have inherited a sound constitution from their parents, who live in a salubrious climate, who pursue a healthful occupation, who are of tem- perate habits, who carefully observe the laws of health, and who, in short, present in their personal conformation the mens sana in corpore sano, will, as a class, attain to greater age than those who ex- hibit opposite characteristics. Enough of this class will live beyond their expectation, to compensate 6 INSTRUCTIONS for the death of those who do not reach this period ; thus the Company will obtain, as a safe basis of cal- culation, a knowledge of the average duration of life which attaches to each respective age—a most important element in the Science of Life Insurance. In order to assist our Medical Examiners in the selection of such risks, the following remarks are subjoined : It is required that the person selected for this office shall be well instructed in the principles of physical exploration and diagnosis ; that he shall be well in- formed as regards the signs which mark a state of health, and those changes from the normal condition which indicate the various lesions of the animal econo- my ; and that for the accomplishment of this end, he shall be well acquainted with the methods of auscul- tation and percussion. The Medical Examiner should remember that his relation to the Company is pi’ecisely opposite to that which he ordinarily occupies in his professional capa- city. In the latter instance, the party who seeks his aid lays bare his symptoms and infirmities, and even intensifies their character; in his application for life assurance, it is his desire to lessen their importance or conceal their existence. INSTRUCTIONS. 7 Predisposition to piSEASE. In reference to predisposition to disease, we regard it under two aspects for the purpose of life assurance. First, where the family history is such that from it alone the applicant is considered to he predisposed to the disease of which his parents died—as, for instance, where the death of both these persons was the result of consumption. Second. When one parent and a large number of brothers and sisters, or other relatives, have so died, conjoined with personal predisposition to the disease. In these cases Ave consider the liability to phthisis so great that the rule is to reject such risks. Other instances occur, in Avdiich one parent may haA’e died of disease the predisposition to which in the offspring is considered hereditary ; and yet the party, by reason of age, conformation, and sound state of the vital organs, with an affinity to a healthy parent, may be fairly entitled to a policy of assurance. It may be avcII to remember that con- sumption is more likely to be transmitted by a mother than a father. A strict examination and considera- tion of all the facts of the case is expected ; but if, after these conditions have been complied with, the appli- cant be recommended by the Medical Examiner, our practice is to entertain the consideration of such risks, the only condition being, that the policies so issued 8 INSTRUCTIONS. shall bo for a moderate amount, and that the party shall have attained at least the age of thirty-five years, and by reason of showing a just proportion of height to weight, a normal condition of the vital organs, a natural state of the various functions of the system, by firmness of tissue, by following a healthful employment and by habits of temperance, in eating and drinking, etc., shall demonstrate that he possesses a sound organization. In these applications the Medical Examiner must weigh all the evidence before him, direct, indirect, and collateral; he must state that, notwithstanding the family record, he be- lieves the party to possess a healthy constitution, and to be free from any predisposition to disease, as far as can be discovered after a rigid scrutiny of the case. In many instances predisposition to disease may be acquired independently of hereditary tendency, as from habits of life, occupation, exposure, accidents, unhealthy residence, previous attacks of disease, etc. It will be the duty of the Medical Examiner to weigh the testimony resulting from a close examination of all the facts bearing upon the case, and to be cautious in recommending risks which present to his mind cir- cumstances unfavorable to longevity, even though no active disease be present. INSTRUCTIONS. 9 GE. It is proved by experience, that while the assurance upon lives during the middle portion of existence has been attended with better results in the United States than in Europe, the reverse holds good in reference to risks taken in the earlier periods. The same general fact has been observed as regards the advanced ages of life ; but of late years such risks are understood to be improving. "Whether this result be due to climate, to our institutions, or social state, it is of importance, as indicating to our Examiners that great caution must be exercised in the selection of risks at both these terms of life. It is quite probable that the vital or- gans, being prematurely called into great activity, and goaded by the stimulus of intense excitement, may in- vite disease or be unable to resist its power ; so of the older ages; it seems unquestionable that, even in con- stitutions naturally robust, death or decay has been induced by over-exciting and over-tasking organs that, but for these causes, would have enabled their possess- ors to protract their lives to a more advanced period, enabling them to enjoy many of the pleasures which Cicero graphically depicts in his treatise on old age, and which are so vividly portrayed by Cornaro. 10 INSTRUCTIONS. Peneral Jnstructions. Observe carefully whether any predisposition exists in the applicant to the disease of which either parent may have died. If the party has suffered from any severe attack of illness, postpone the application until another season corresponding to that in which the party was attacked shall have intervened, without any inter- ruption to his health. If haemoptysis has occurred, and five years have elapsed without a recurrence, and the examination reveals a healthy state of the vital or- gans, a policy may be issued. The occurrence, how- ever, of this symptom should always excite suspicion in the mind of the Examiner, particularly if it can be. connected with a phthisical diathesis, even remotely. Nor should it be looked upon as accidental, unless distinctly coincident with some injury inflicted, or some violent physical effort made at the time. If the party has suffered from inflammatory rheuma- tism, especially during the earlier pexfiod of life, care- fully examine the condition of the heart, and if any abnormal sounds occur or changes have taken place, mark the fact. It is important in mentioning rheu- matism, always to state whether it was acute, or sub- acute, how recently the attack occurred, and its dura- tion. The hereditary predisposition to this disease has often been passed by without notice ; its exist- ence, however, is now well established. If rheuma- INSTRUCTIONS. 11 tisra has occurred more than once, ascertain whether it is hereditary, or whether an acquired rheumatic diathesis exists. It should be remembered that the age of the individual, at the time of the rheumatic attack, has much to do with determining the Cardiac disease, a large proportion of these complications occurring between the ages of fifteen and thirty years ; very few before the age of fifteen, and comparatively few after the age of fifty years. Give the rate and quality of the pulse, and note any irregularity or in- termittence, which examination should be in the sitting posture. If either exist, postpone the case for future trials. If the aberration be persistent, state the fact. It often happens that the pulse, from exercise, or tak- ing food or stimulants, just previous to examination, becomes much excited, so as to beat one hundred or more in a minute. It will frequently become un- steady, or even intermit at intervals from such causes. The use of tobacco, or even strong coffee, tea, or the loss of a night’s rest, will often produce the same results. It is better to postpone such cases for subsequent examination, when, the cause being removed, the circulation will often be found to be perfectly regular and steady. In case frequency alone be the objection, and that due to nervousness, by prolonging the interview, and diverting the ap- plicant’s mind from the immediate subject in hand, the pulse will often become fuller, and the num- 12 INSTRUCTIONS. ber of its pulsations decrease, at least for a time, pi'oving that the quickened circulation is due simply to excitement, and thereby relieving much of the em- barrassment which is frequently experienced by the examiner in this particular. A preternaturally slow pulse, under sixty, especially in a young subject, should always excite the attention of the Examiner. The same remarks will apply in case of a heart functionally excited, where the whole pra3cordia is agitated, giving rise to a rushing sound, almost adven- titious in character ; and when the force of the im- pulse against the thoracic parietes is so great, that it may be at first mistaken for hypertrophy. It is only by allaying mental emotion, and by calling to our aid the several methods of physical exploration, that we are able to determine the true nature of the case, and satisfy ourselves that the inordinate action is due to morbid excitement alone. If there be reason to sus- pect disease of the urinary function, it is desirable, if attainable, to subject the urine to microscopic inspec- tion and to analysis. In cases of nephritic colic, state whether gravel or calculus has passed. In case of retention of urine and stricture, whether there is disease of the prostate gland. If the applicant is over the standard weight, state the particulars of his figure, whether it is caused by an ac- cumulation of fat, or by the development of bone and muscle; whether the party is of active or sedentary INSTRUCTIONS 13 habits; and whether, from his temperament and con- formation, he is liable to apoplexy, paralysis, or disease of the heart. If, on the contrary, the party applying for assurance be under the standard weight, it is important to know whether his fibre be firm or re- laxed, and whether he possesses sufficient vigor to perform the vital functions or resist the attacks of disease, and be free from complaints of the respira- tory and assimilating organs. If the party has gained or lost flesh rapidly, state the fact. If the same be easily affected by atmospheric changes, pro- ducing cough, mention the circumstance. If the ap- plicant is affected with varicose veins and require mechanical support, take notice of same. If any ill- ness has occurred, state the nature of the disease, and duration, whether the recovery be complete, the length of time that has elapsed, and whether convalescence was attended by any sequelae. Inquire particularly in reference to the habits of the applicant as regards temperance; whether addicted to the taking of opium, excessive use of tobacco, etc. If not always temper- ate, require that a sufficient period shall elapse, in order to test his reformation. If the party resides in a locality which is subject to endemic or epidemic sickness, inquire whether he has been acclimated by reason of long continuous residence, or by having had the disease incident to the locality. And particular- ly in all doubtful cases let the attention of the Medi- 14 INSTRUCTIONS. cal Examiner be given to the weak points of the case, and let his certificate express, in a precise manner, his views upon these points. If the answers to the queries seem to be indirect or evasive, call the atten- tion of the applicant to these interrogatories, and write down his explanations after receiving his confir- mation of them. Be careful to give a clear statement of the circum- stances appertaining to each case. If any disease or disorder has occurred, give the facts precisely, avoid- ing such phrases as “ urinary trouble,” “ kidney diffi- culty,” “ throat disorder,” “ complication,” etc., terms which, being too vague to convey any precise informa- tion, produce an unfavorable impression as to the eligi- bility of the risk, or at least cause delay and addition- al correspondence, which, by its magnitude, is already very onerous. In cases of reducible hernia require, in all instances, that the party shall wear a well-fitting truss. JllSKS. In addition to the above, if the applicant is a fe- male, ascertain whether the functions of the uterine system are normal and regular; if miscarriage has oc- curred, state how often, under what circumstances, and how long since; whether confined since. If parturi- tion has ensued, remark whether the labors have been easy and natural or difficult, and also whether puerperal INSTRUCTIONS. 15 fever or other disease has intervened. If the female applicant is between the ages of forty and fifty years of age, the greatest vigilance must be exercised in de- tecting any latent infirmity that may be likely to pro- duce serious disease. Although it is probably true that women who, at fifty years of age, possess perfect- ly sound constitutions, have a greater prospect of lon- gevity than men at the same period, yet the experience of all assurance companies reveals the fact, that for this purjmse they have not proved profitable risks. This has been accounted for by the difficulty of making thor- ough examinations, by the circumstance that most applications are made at that period of life when the dangers arising from parturition are greatest, and by the belief that the party in whose behalf the policy is issued often possesses knowledge of some weakness or hidden disease tending to the shortening of life. The Medical Examiner must therefore be on his guard in these applications, and should ascertain whether pro- lapsus uteri or leucorrhea exists, or any symptoms de- noting tumor or other diseases of the utero-generative system. In cases of pregnancy, postpone the application until a sufficient time has elapsed, after the delivery, to in- dicate that the constitution of the party has not been affected thereby. 16 INSTRUCTIONS. Examination. Before proceeding to an examination of the appli- cant, (which should in all cases be the Medical Examiner should have before him the form completed, and the queries answered. He will thus be informed of important facts in investigating the condition of organs that may be predisposed to disease. The Ex- aminer should next remark whether the party be erect, well-formed, and of a healthy aspect; whether the cir- cumference of the chest mark the healthy standard— giving the degree of expansion between full inspira- tion and forced expiration. In one hundred and fifty cases recently noted in this office, the average circum- ference of the chest when comparatively free from air was thirty-three and two-third inches, and the average expansion three inches, the circular measurement in both cases being taken under the inferior angles of the scapulse, and over the nipples. Observe also whether the height of the party be in proper proportion to his weight. If not previously done, interrogate the appli- cant in reference to the state of health of the different members of his family; whether they have been noted for longevity or the opposite ; any discrepancy between the answers given and the written statement should be carefully noted. Last in this order should be a care- ful investigation of the attacks of disease from which the person himself may have suffered, including acci- INSTRUCTIONS. 17 dents of such gravity as may he liable to produce con- stitutional effects. The personal examination should be conducted with great care and circumspection. As death from dis- eases of the respiratory organs is so frequent, it is of the utmost importance that the Medical Examiner should exercise great skill in his exploration of the thorax. Place the hands \ipon the chest, (which should not be thickly covered,) and observe whether it ex- pands equally free and full. Carefully note whether there is the slightest depression, especially in the infra clavicular region. Remark whether the vesicu- lar murmur be clear, breezy, and normal, of proper pitch and volume, especially in the left lung ; whether any rales exist, or any indications of asthma, or other disease ; whether percussion of the chest render a clear pulmonary resonance over its whole extent. Observe also that there is no increase of sonorousness without vesicular quality, constituting tympanitic re- sonance and generally denoting emphysema. When from hereditary tendency or personal conformation, the occurrence of phthisis is suspected; if the pulse be chorded and quick, the expiratory murmur prolonged, wavy, jerking, or irregular; the chest dull on per- cussion ; and especially if these symptoms coexist with cough, even slight or haemoptysis, it is more than pro- bable that consumption will follow. It must be ob- served that the Examiner has to deal only with the first 18 INSTRUCTIONS. symptoms of tlie disease, long before its fatal charac- ter have made it apparent to every eye; he must there- fore be thorough in his examination and very cau- tious in recommending risks, when he has reason to apprehend the invasion of this scourge, even though the indications be remote. It is sometimes found best to rate the pulse, and note its qualities before the exploration of the chest shall have excited the nervous system, and thus have changed its char- acter ; but as this depends upon the temperament of the party, or some adventitious cause, it is left to the Examiner to proceed as he thinks best. Proceed next to an examination of the organs of circulation ; ascertain whether the heart be in situ; whether its sounds denote a normal condition; mark whether there be any irregularity or intermittence in its beat; whether any bruits denoting thickness of its valves exist; whether any signs indicating hypertrophy or other changes in the organ are present; and whe- ther there be any lesion of the great blood-vessels. Next proceed to investigate the condition of the brain and nervous system, and the- digestive organs, the ex- amination being directed to the discovery of any latent disease which may undermine the constitu- tion. The investigation will finally embrace an in- quiry into the state of the urinary and muscular sys- tems, carefully noting any symptoms which may de- note affections of the kidneys, the bladder, the organs of locomotion, or the osseous system. INSTRUCTIONS. 19 of Rejection. First. Where both parents have died of phthisis, as before stated. Second. Where one parent has died of this disease, and it has appeared in the offspring, unless the appli- cant posssess a healthy conformation, and has reached at least the age of thirty-five years. Third. Where the party has been affected with par- alysis, apoplexy, epilepsy, hereditary insanity, loss of sense and voluntary motion, or symptoms denoting softening of the brain. Fourth. Intermittence and.irregularity of the pulse or heart’s action, abnormal sounds in this organ, symptoms indicating hypertrophy of the heart, aneu- rism and ossification of the blood-vessels, habitual cough, difficulty of breathing, and asthma. Fifth. If the pulse be persistently over ninety after repeated trials. Sixth. Diseases of the digestive organs materially affecting the health of the applicant, psoas or lumbar, abscess, coxalgia, unless a long period of cure has elapsed. The existence of an open ulcer, scrofula, fre- quent attacks of erysipelas, and colic. Seventh. Gout, fistula, irreducible hernia, disease of the spine, and important tumors, etc. Eighth. Disease of the kidneys, bladder, calculus, gravel, secondary syphilis, blindness, permanent stric- 20 INSTRUCTIONS. ture, and amputation at tlie shoulder-joint, or above the knee. Ninth. Cancer, or other malignant disease ; and where, after any illness, its effect is perceptible in loss of vigor in the constitution, thereby predisposing to renewed attacks of the malady. Tenth. When from any cause the Medical Examiner has a well-founded doubt whether the applicant will reach his expectation of life, it is his duty to decline the risk. Table of the Expectation of Life. AGE. EXP. AGE. EXP. AGE. EXP. AGE. EXP. 10 47.5 33 31. 56 16. 79 5. 11 46.7 34 30.3 57 15.4 80 4.7 12 46. 35 29.7 58 14.8 81 4.4 13 45.2 36 29. 59 14.2 82 4.1 14 44.5 37 28.3 60 13.6 83 3.9 15 43.7 38 27.6 61 13. 84 3.6 16 43. 39 27. 62 12.5 85 3.3 17 42.33 40 26.3 63 12. 86 3.1 18 41.6 41 25.6 64 11.4 87 2.8 19 40.8 42 24.9 65 10.9 88 2.5 20 40.1 43 24.3 66 10.4 89 2.3 21 39.4 44 23.6 67 9.9 90 2.1 22 38.7 45 23. 68 9.4 91 1.8 23 38. 46 22.3 69 9. 92 1.6 24 37.3 47 21.6 70 8.5 93 1.4 25 36.6 48 21. 71 8.1 94 1.2 26 35.9 49 20.3 72 7.6 95 1.1 27 35.2 50 19.7 73 7.2 96 1. 28 34.5 51 19.1 74 6.8 97 .92 29 33.8 52 18.4 75 6.4 98 .75 30 33.1 53 17.8 76 6.1 99 .50 31 32.4 54 17.2 77 5.7 32 31.7 65 16.6 78 5.4 instructions. 21 Table of the Pkopek Proportion of tiie Height of Individuals to tiieir Weight. HEIGHT. WEIGHT. Ft. In. Lbs. 5 1, 120 5 2, 125 5 3,.. 130 5 4, 135 5 5, 140 5 6, 143 5 1, 145 5 8, 148 5 9, 155 5 10, 160 5 11, 165 6 00, 1Y0 The foregoing observations and tables are given, not as requiring an absolute conformity to them, but to assist our Medical Examiners in the formation of a correct judgment, after weighing all the facts of the case. • jSPECIAL JlOTICE. It is hereby expressly enjoined upon the Medical Examiners of this Company, that the answers to the queries proposed in the Medical Certificate shall be wholly written out by them, and that no agent or other person shall fill up or dictate any part thereof. F. S. Winston, President. In cases where the party examined presents any peculiar features of conformation arising from un- usual weight, stooping figure, or deformity of any kind, it will gi’eatly aid this office in deciding upon the application if a daguerreotype, photograph, or carte de visite can be inclosed with the application.