INSTRUCTIONS TO THE MEDICAL EXAMINERS OF THE Provident Life and Trust Company OF PHILADELPHIA OFFICE: NO. iii SOUTH FOURTH STREET. 1868. OFFICE OF The Provident Life and Trust Co., 111 South 4TH Street. Philadelphia, 1st Mo., 1st, 1868. To the Medical Examiners of The Provident Life and Trust Company, of Philadelphia. Within, we hand you, a series of rules and suggestions prepared by our Examiner, Dr. Thomas Wistar. Written with a special view to the needs of the case, we commend it to your careful atten- tion. The success of the Company will be largely dependent on the reliability of its examinations 5 and it is, therefore, of the first im- portance, that our physicians should appreciate the responsibility of their position. We have reason to believe that thus far we have been faithfully and skillfully served. An attentive study of this little vol- ume will enable you to bring to your investigations the full light of recent experience, and we may hope will enable us to escape any departure from the most favorable conditions of mortality. The success of the Company thus far in this as well as other respects, has been most gratifying. Respectfully your friend, SAMUEL R. SHIPLEY, PRESIDENT. INSTRUCTIONS MEDICAL EXAMINERS TO THE 8j jOoMFANY OF THE OF PHILADELPHIA. INTRODUCTION. Experience having proved the necessity of something like a standard of health, and freedom from natural or hereditary tendency to disease, by which the Medical Ex- aminers of our Company, in different parts, may be guided in the selection of risks, the following instructions have been prepared with a view to promote a greater concert of action on their part, and, by better acquainting them with the requirements of the home office, to prevent un- necessary correspondence. They are derived from experience, from the published rules of the best companies, and from other acknowledged authorities on the subject. In thus addressing our Medical Examiners, we mean not to depreciate the character of their past services, nor 6 INSTRUCTIONS. to underrate their skill hitherto displayed. On the con trary, we have ample cause to commend the professional accuracy and faithfulness of many of our physicians, as shown both in the papers heretofore presented, and in the exemption from undue loss by death in the history of our Company thus far. We desire merely to point out clearly the facts required by the Company in each case, to awaken a due sense of the responsibility which attaches to the Examiners as the “ Police” of our institution, and to mark out, in general terms, such a limit to the insura- bility of risks as will tend to diminish inconvenience and anxiety on their part. Let not the Examiner look to these pages for that de- tailed information and scientific instruction, which can be attained only by study and experience. The most extended rules on the medical examination of lives for insurance, could not supply the place of medical education. These advices, therefore, are designed less to instruct than to guide—less to impart new knowledge, than to apply that already attained. It is required of our Physicians that they be skilled in their profession, and especially that they be acquainted with the means of physical exploration, and well versed in the art of auscultation and percussion. The Medical Examiner may be compared to a watch- man at the gates of a city, the inmates of which may have no concern if he is faithful to his post; but if, through deficient knowledge, care or moral courage, or from paltry motives, he admits risks below the required stand- INSTRUCTIONS. 7 ard, he admits so many enemies within the walls, and loss and injury must result. In the performance of his duties, the Examiner will necessarily lose many of the aids available in general practice. He will rarely have the opportunity of watching the case, or of the light which a reliable medical history would afford. The subject under examination will often be disposed either to suppress important symptoms alto- gether, or to under-estimate them. Or he will, per- haps, be deceived by the too flattering statements of his family physician—given more with a design to save his feelings, than to acquaint him with the exact truth. The general practitioner, for the most part, has to deal with the open manifestations of disease,—the Medical Exami- ner with the hidden causes, remote tendencies, and unsus- pected signs. He should be capable, therefore, of detect- ing the earliest symptoms of decay ; of ascertaining the weak points, and of forming correct judgments on the general vitality of the cases that present. Above all, he must constantly bear in mind that his relation to the ap- plicant for examination is precisely opposite to that which he bears to his private patients—that his obligation is now not to the individual, but to the Company—not to inter- mediate officials, who may be impatient and exacting, but to his own conscience. 8 INSTRUCTIONS. PREDISPOSITION TO DISEASE. “ 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 be predisposed to the disease of which his parents died—as, for instance, where the death of both those persons was the result of con- sumption. Second.—When one parent and a large num- ber of brothers and sisters, or other relatives, have so died, conjoined with personal predisposition to the disease. In these cases we consider the liability to phthisis so great that the rule is to reject such risks. “ Other instances occur, in which one parent may have died of the disease, the predisposition to which in the off- spring 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 well to re- member that consumption is more likely to be transmitted by a mother than a father. A strict examination and con- sideration of all the facts of the case, is expected. But if, after these conditions have been complied with, the ap- plicant 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 shall be for a moderate amount, and that the party shall have at- tained 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 follow- ing 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 believes 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. INSTRUCTIONS. 9 “ 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 circumstances unfavorable to longevitv, even though no active disease be present.” PERSONAL EXAMINATION. It is important that this should be done in private—so> far as piacticable, out of sight and hearing of all but the t-ivsican and the subject under examination. The apart- ment - or this purpose should be perfectly quiet. In a crowded city a second story or back room is preferable. INSTRUCTIONS. The Examiner, in each case, should see that the applicant is seated and at his ease. Before entering upon the ex- amination, he should read carefully the reports of the Agent, and of the family Physician concerning him, and note whether a general correspondence, or otherwise, ex- ists between the individual and the statements in these respects. Much discrepancy would be cause for suspicion, and should prompt rigid examination. The Examiner should pay particular attention to any recent or periodic disease, if such be noted ; assure himself of entire freedom from all sequelae of the former, and ascertain the exact liability to, and extent of, the latter; inquire if it be of such a nature as to be likely to increase or diminish with years, and how far it would be likely to affect the vitality of the patient, and his consequent expectation of life. If the subject be unusually nervous and excitable, he should divert his attention for a short time from the subject be- fore him, by general conversation, or by questions con- cerning his earlier history and family record. Valuable information above what is directly asked for in the certifi- cate, will often be derived in this way. By the exercise of such tact, the respiration will often become slower, easier and more natural; and the pulse fuller, less fre- quent and more regular. In some cases, as after taking violent exercise, or food, or stimulants, a repetition of the examination will be necessary ; and such should always be the case where the Examiner cannot fully satisfy himself on a single interview. INSTRUCTIONS. 11 THORAX. The thoracic viscera, as being the most frequent seat of serious insidious disease, require the utmost care and cir- cumspection of the Examiner. Heart.—He should ascertain the location of this organ, the extent of dullness, indicating its size, its impulse, and the character of its sounds. He should investigate also the condition of the large bloodvessels, which not unfre- quently show signs of disease when the central organ is healthy. He should remember that the character of the chest walls has an important influence on the apparent impulse and sounds of the heart—thinness of the walls greatly increasing these and vice versa; and that the con- dition of the lung as to inflation, or otherwise, has a modifying effect—as told by the difference in the sounds, as heard during inspiration and expiration. With thin parites the respiratory murmur when mixed with the heart sounds, may closely simulate a bruit, and lead to import- ant mistakes unless due care be observed. The habits of the individual also have a modifying effect—sedentary habits often causing feebleness of sounds and the reverse. Though there may occasionally be found a bruit, or an unaccountable irregularity of the heart’s action, without any symptoms of organic disease, yet the rarity of such cases,, and the difficulty of determining with certainty as to en- tire freedom from structural change, demands their re- jection. 12 INSTRUCTIONS. Cases where mere functional derangements occur, as from indigestion, over work, excessive use of tea or to- bacco, or from other causes, must be, for the same reason, rejected or postponed. Functional being a frequent parent of organic disease, unusual susceptibility to the former is, of itself, an ominous sign. Yet due allowance must be made for that temporary nervous excitement which the mere examination produces in some persons, and which, by causing hurried respiration, great frequency of pulse, and rushing and embarrassed heart sounds, often largely taxes the patience and judgment of the Examiner, and may in- volve repeated examinations before he can be satisfied as to the true character of the risk. Lungs.—Tubercular affections, from their frequency, from the hidden character of their early symptoms, from their ready transmissibility by hereditary taint, and from their numbering the stoutest with the weakest among their victims, require the special care of the Examiner. He should notice, in every case, whether the chest be symmetrical, or whether any irregularities or depressions, particularly under the clavicles, exist. He should state the expansion of the chest. This is indicated by horizon- tal measurements around the chest beneath the outer gar- ments. They should be taken in a line across the nipples and under the inferior angles of the scapulas during forced inspiration and expiration, and the measurement stated for each. The difference denotes the expansion, and should be on an average, for healthy persons, at least three inches. He should state the number of respirations per INSTRUCTIONS. minute. He should then examine by auscultation whether the respiratory murmur be clear, soft and normal; or whether it be impeded, mixed with rales, harsh, or wavy and irregular in character. He should remember that he is not called upon to investigate well marked cases of tuber- cular deposit accompanied with its well known rational symptoms, but to watch for its incipiency ; for it is well known to be the greatest possible source of financial losses. “ Ohsta principiis is most emphatically to be his motto. By the exercise of timely care, skill and sagacity, he will be enabled to reduce those losses to a minimum unexpected before the introduction of physical diagnosis.” The Medical Examiner should observe carefully whether any predisposition exists in the applicant to the disease of which either parent may have died. “Family proclivities to disease are more strikingly manifested in brothers and sisters than between parents and children. The intermingling of opposite tendencies begets, so to speak, in the children a neutralization of the peculiar ap- titudes to disease existing in the parents respectively.” If the party have suffered from any severe attack of illness, the examination should be postponed, until another season, corresponding to that in which the party was at- tacked, shall have intervened without any interruption to his health. GENERAL INSTRUCTIONS. If amputation or other surgical operation has oc- 14 INSTRUCTIONS. curred, the point at which it was done, and the cause, should be stated. Also, if lameness exist, the cause of it should be mentioned. It will be a safe rule to reject cases resulting from scrofulous affections, such as hip-dis- ease, white-swelling, and the like. Such complaints in t-aly'Hife, are often interchangeable with consumption in later years. While the quick vitality and stronger restora- tive power of childhood may have served to carry those subject to them safely through the early manifestation of disease, yet they will be likely to succumb if engaged in a similar conflict, when in the decline, or past the prime of life. Haemoptysis unexplained rejects, and in any case should excite serious suspicion. But if it be obviously the result of injury or violent exertion, accompanied with a healthy state of the organs, without family tendency or phthisical dia- thesis, if the applicant have reached the age of at least thirty-five years, and five years have passed without a re- currence, a policy may be granted. If the party have suffered from inflammatory rheuma- tism, especially in early life, the condition of the heart, for any evidence of organic disease, should be carefully examined. Concerning rheumatism, the Examiner should state whether it was acute or sub-acute ; how recently the at- tack occurred, and its duration. The hereditary disposi- tion to this disease should be considered. If it have occurred more than once, he should ascertain whether it is hereditary, or whether it is the result of an acquired INSTRUCTIONS. 15 rheumatic diathesis. The time of life materially modifies the susceptibility to this disease, most cases occurring be- tween the ages of fifteen and thirty, and few after the age of fifty years. A prematurely slow pulse (under 60), especially in a young subject, should always excite the attention of the Examiner. This, a harmless peculiarity in some indi- viduals and families, who enjoy perfect health, often, es- pecially if connected with cerebral discomfort and lack of vitality, points to incipient ramollissement or other serious disorder. If any irregularity of the urinary function exist, it will be well to subject the urine to microscopic examination. Particularly in the case of advanced risks, entire freedom from calculus, enlarged prostate, etc., should be deter- mined. No case of hernia should be accepted, except on con- dition of wearing a well-fitting truss. The great decrease in the number of cases of strangulated hernia of late years, is largely attributable to the improvement in, and greater prevalence of trusses. It is easy to see how the wearing or not wearing an instrument, may make the difference between an acceptable and an unacceptable risk. The Medical Examiner should enquire particularly, yet with due regard to the natural sensitiveness on such sub- jects, concerning the habits of the individual as to tem- perance and regularity. If his appearance or his occupa- tion be against him, and his answers on these points are slow and hesitating, it may be well to give the Company 16 INSTRUCTIONS. the benefit of a doubt. If he have once been intempe- rate, but there is good ground, from sufficient lapse of time, etc., to believe his reformation established, he may be received. Yet the tendency to return to former habits, and the covert ill-effects of past dissipation, make it true that old drunkards are not good lives ; and prove that great caution should be used. At best an occasional drunkard will be found upon the roll. If the applicant reside in an unhealthy district, inquiry should be made as to whether he has become acclimated by virtue of a sufficient length of time (at least a year) having elapsed without injury to health, or whether he has obtained exemption from further exposure by having suffered from the disease incident to the place. Occupation.—In our land, where industrial pursuits are so numerous and accessible, that one may readily change a hurtful for a healthful avocation, the question of occupation is of less moment than abroad, where opera- tives usually follow one pursuit for life. It is well, how- ever, in making up the general summary of evidence for and against the acceptance of a risk, to consider it. The occupation, of itself, will rarely exclude ; but if taken in connection with a doubtful family record or personal his- tory, it may reasonably turn the scale against him. Under this head, vitiated atmosphere either from admixture of noxious gases (painters and chemists), or of solid particles (millers and grinders), and extreme changes of temperature (bakers, puddlers and glass-blowers), are to be particularly guarded against. INSTRUCTIONS. Age.—A knowledge of the age is important to the Examiner, so far as, by enabling him to compare the real with the apparent age, he may the better judge of the vitality of the risk. If a man aged forty years, appears to be fifty or sixty, it is so far against his expectancy, un- less his premature appearance be found to be a family peculiarity unaccompanied with corresponding loss of vital power or premature decay. In certain hereditary affec- tions, the age has much to do in determining the liability to disease. Acute rheumatism, e.g., most frequently oc- curs between the ages of fifteen and thirty years, after which the tendency decidedly diminishes ; and, from the small number of cases occurring after fifty, it may be con- sidered as lost after this period. So of consumption : if several members of a family who have died, had the dis- ease in early life, say before the age of twenty-five to thirty years, and the applicant have reached the age of forty-five, without any physical symptoms of the disease, he may be considered to have outlived the hereditary tendency. But, on the other hand, it should be remembered that from the fortieth year, at latest, decline commences. After this period hereditary diseases regain their danger- ous tendency, and acute affections are met with less power of resistance. The tendency to undue plethora, conges- tions, fatty degenerations, to cardiac and other obstructions from deposit, to obstinate ulcers, dropsies, apoplexies, paralyses and the like, is now greater than before. Weight.—A healthy man 5 feet 6 inches in height, 18 INSTRUCTIONS. ought to weigh 143 pounds, and for every inch more or less, a variation of 5 pounds is allowable. While con- siderable variation from this standard is compatible with perfect health and longevity, there is a point beyond which obesity on the one hand, and spareness on the other, may justly be considered to vitiate the risk. Such a limit has been stated at 20 per cent., or one-fifth from the normal weight. Risks exceeding this limit should be few and accepted with great caution. The Physician should as- sure himself of entire freedom from any tendency to feeble nutrition or premature decay, and inquire if the abnormal- ity in question be hereditary and accompanied with a family history of well established longevity. He should ascertain in all cases whether the obesity or emaciation came on rapidly, without apparent cause ; or slowly, as the natural effect of maturity or hereditary tendency. He should not suppose that fullness of habit is a necessary evidence of strength and healthy nutrition. The slow occurrence of corpulence may be, and the rapid almost invariably is, a mark of enfeebled nutrition—the result of, perhaps, newly formed sedentary habits, intemperance, internal organic disease, or of that general cachexia which accompanies fatty degeneration. Sex.—Excepting dangers incident to child-bearing and the catamenia, the same rules apply to the medical ex- amination of women, as of men; and even these dangers are probably more than balanced by the greater amount of exposure which the generality of men undergo. The risk is, therefore, practically the same in each sex. “ The INSTRUCTIONS. undue nervous excitability, abnormality in the menstrual function, the anaemic or chlorotic state, or any evidence of the cancerous cachexia—especially at the climacteric period, should be carefully guarded against.” Since it is ascertained that the mortality from first labors is about twice that of all succeeding labors including the ninth, it is a safe practice to postpone cases of primary gestation until the danger from parturition be passed, or to increase the rate of premium. And we would recommend the same rule of practice for all cases of actual gestation. CAUSES 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 applicant pos- sesses a healthy conformation and has reached at least the age of thirty-five years. Third.—Where the party has been afflicted with par- alysis, apoplexy, epilepsy, hereditary insanity, loss of sense and voluntary motion, or symptoms denoting soft- ening of the brain. Fourth.—Intermittence or irregularity of the pulse or heart’s action, abnormal sounds in this organ, symptoms indicating hypertrophy of the heart, aneurism and ossifica- tion of the bloodvessels, habitual cough, difficulty of breathing, and asthma. Fifth.—If the pulse be persistently over ninety after epeated trials. 20 INSTRUCTIONS. Sixth.—Diseases of the digestive organs materially af- fecting the health of the applicant, psoas or lumbar ab- scess, coxalgia, unless a long period of cure has elapsed. The existence of an open ulcer, scrofula, frequent at- tacks 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 stricture, and amputation at the 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. * NOTICE. It is, moreover, particularly enjoined : First.—That the Medical Examination for this Com- pany shall in all cases follow, and not precede, a care- ful inspection of the application and Agent’s certificate. Second.—That the Medical Examiner only shall write out the answers to the questions proposed in the Medical Certificate, and that no part of them be supplied by agents or other persons. INSTRUCTIONS. 21 1Third.—That they be careful to give clear and com- plete statements in all their answers; avoiding, in the de- scription of disease, such phrases as “ urinary trouble,” “ kidney difficulty,” “ throat disorder,” etc. And, in stating the cause of death, such terms as u fever,” u change of life,” “ complication of diseases,” and the like. (The latter caution will apply also to the Agents of the Com- pany.) Fourth.—That in all cases where risks, exceptional in some respects, are yet recommended by the Examiner, he will both clearly mention the objectionable points, and append a full statement of the reasons why such risks are recommended, notwithstanding.