COLL CAT- > I r ? MARYLAND LIFE INSURANCE COMPANY OF BALTIMORE t INSTRUCTIONS TO MEDICAL EXAMINERS 1897 Frestnted to th* Statistical Division, Surgeon-General's Library, United States Army Washington, D. C. The Prudential Instance Co. of America Newark, New Jer»ey SURGEON GENERAL'S OFFICE LIBRARY VEBK1WKT PBDiTWO OII1CI INSTRUCTIONS TO MEDICAL EXAMINERS OF THE Maryland Life Insurance Company OK BALTIMORE. ♦---------- "No sound company can afford to insure unsound lives, but whether an applicant is unsound can be dis- covered only by the report of the Medical Examiner who makes the examination of such applicant. The Examiner is the retained and trusted adviser of the company, and upon its confidence in his integrity, skill and experience its action is largely based." ♦ BALTIMORE GUGGENHEIMER, WEIL & CO. PRINTERS. INSTRUCTIOXSTO MEDICAL EXAMINERS TO THE MEDICAL EXAMINERS OF THE MARYLAND LIFE INSURANCE COMPANY OF BALTIMORE. Gentlemen : I. These instructions are necessarily to a large extent general in their character, for it would be manifestly impossible to prescribe rules which would apply to every case which might be presented to you for exami- nation. Therefore, when in the case of any applicant questions arise which are not covered by these instruc- tions, we request that you will communicate with the Home Office before completing the examination. 2. Medical Examiners are appointed by the Home Office and not by agents, and no one other than an offi- cer of the company is authorized to direct Examiners concerning their duties. 3. The qualifications for the position of Medical Ex- aminer are adequate skill and experience, good judg- ment, integrity, independence, and a readiness to re- spond promptly to reasonable requests to make exami- nations. You will readily recognize the importance of this last item when you reflect that unless an applicant is examined soon after his application is signed, he may change his mind, and abandon his intention of procur- ing insurance. Bear in mind that in most instances the agent has only by hard work been able to induce the ap- plicant to consent to an examination. No matter how much persons may need insurance, it is generally dif- ficult to persuade them to make the application and stand the examination. 4. The Home Office depends greatly upon the Medi- cal Examiner; he is its representative, and should con- sider the importance of his work; his decision as to the 4 fitness of the applicant for insurance is made after a personal interview and a thorough and scientific inspec- tion. Moreover, he can in the privacy of his own office, or at the applicant's home, no third person being pres- ent, obtain information of a private or delicate nature which might be withheld if asked for in a more public manner. 5. The regular fees allowed by the company for medi- cal examinations are as follows: $3 in each case where the amount of insurance applied for is $2,500, or less, and $5 for an amount greater than $2,500 of insurance. These fees include the compensation for microscopical examination of the urine in such cases as the company may deem it necessary to require such examination. 6. The examination is always to be made in private, no third person being present, and no one other than the Examiner must fill up any part of the second and third pages of the application form, nor must any one dictate any answers recorded by the Examiner. 7. Taking up the application form, we will notice, seriatim, the various portions of it. The Examiner should carefully inspect the first page of the form, as there may be in it statements that would call the atten- tion of the Examiner to special questions which it would be necessary for him to ask. 8. Give the full name of the applicant. In stating his occupation, do not say "merchant," "clerk," "salesman," but specify the exact nature of the business which he conducts. 9. In question No. 9, second page of the application form, "Yes" or "No" should be written opposite to each of the diseases named in the list, and if any are an- swered "Yes" the particulars of the disease, especially its date, its duration, and the present condition of the applicant with regard to that disease, should be given in the blank space left for such particulars. 5 10. The several questions with regard to the use of alcoholic or other stimulants should be answered posi- tively and definitely. For instance, when it is asked to what extent the applicant uses stimulants, the reply "moderately' or "occasionally" will not answer the question, for in order to define the extent of the indul- gence both the quantity and the frequency of the use must be stated. While it is difficult to establish a fixed standard in a matter of this kind, it seems that in order to get at what is "over-indulgence" the line may be drawn at "Anstie's limit," which is a daily allowance equivalent to one and a half ounces of absolute alcohol. This would be represented in the case of ardent spirits by three ounces; of sherry or strong wine by three wineglassfuls; of claret, champagne, or other light wines, by one pint bottle; of strong ale or porter by three tumblerfuls; and of light ale or beer by four tum- blerfuls. Any indulgence in excess of these respective quantities may be regarded as "over-indulgence.' The Examiner should so question the applicant that the manner of drinking as well as the amount is clearly brought out. Whether he be an occasional or a regular drinker it is most important to ascertain the average number of drinks per diem, and also the kind of bev- erage used. An occasional drinker is often a more dan- gerous risk for life insurance than one that drinks more regularly, if the occasional indulgence means excessive potations. The user of strong drink in large quanti- ties is less able to resist intercurrent diseases, and more liable to accidents and to violent death. Even reformed drunkards are not entirely desirable risks, as with them the seeds of disease have often been sown; so that in every case where an applicant has drunk to excess but has since become a total abstainer, it should always be ascertained and stated how long the latter condition has existed. II. The question with regard to increase or diminu- tion in weight should be answered "No change," if you convince yourself that such is the fact. 6 u. Too much stress cannot be laid upon the import- ance of careful, exact, and positive answers to the va- rious queries under the head of "Family Record." Such answers as "fair," "medium," "moderate," and "tolerable," to the question as to the condition of health of the living members of a family do not give the com- pany the information necessary to form an opinion as to this part of a risk. In all cases of this kind, please state positively the nature of the ailment of the person, and if there is no actual disease, then state in what par- ticulars the health falls short of being good. If any member of the family has died in child-birth, please state how long after delivery the death occurred, and particularly whether there were any tubercular symp- toms, or had been previously any such. In the family history the resemblance of the applicant to father or mother has an important bearing in cases where either parent has had tuberculosis, cancer, or other hereditary disease. The physical resemblance is often an indication that a constitution with its weaknesses or taints has been transmitted from the deceased parent, and may be an important factor in estimating the duration of life of the applicant. 13. Please notice that the form asks that where no brothers or sisters have died that fact shall be stated. Failure to do this leaves the company entirely in the dark, as it cannot then be determined whether none have died, or whether several deaths have occurred which were not mentioned by the Examiner. 14. It not unfrequently happens that an applicant who at first cannot give particulars of the deaths of his par- ents or grandparents will have his memory refreshed if the Examiner will judiciously cross-question him on these points, or suggest that he obtain fuller informa- tion from some relative. If an Examiner, even after pursuing this course, fails to elicit as complete informa- tion as is desirable, at least let him try to ascertain and record whether or not any of the deaths occurred from 7 any hereditary disease. The family record forms such a large factor in determining the probable longevity of an applicant that it deserves the fullest research upon the part of an Examiner. 15. In propounding to an applicant the question as to hereditary disease both in his immediate and collateral family, which question immediately follows the family record proper, please be as searching as possible. The question is intended to bring out not only the facts with regard to any members of the family who have died, but also to ascertain whether any of them who are still living have manifested any symptoms of hereditary disease. It not unfrequently happens that the applicant Avill at first reply "No" to a question of this kind, proba- bly supposing that it refers only to deaths from any of these causes, but upon a little cross-examination by the Examiner, it may be found that there are in some mem- bers of the family symptoms of the diseases named. Where such cases are discovered, please give as full par- ticulars of them as can be obtained. It is quite a re- markable fact that when an applicant has been de- clined for life insurance on the ground of want of knowl- edge of his family record, or of weaknesses in it, he can usually procure a vast amount of information to clear up such points, although at the time of his examination he appeared to be unable to do so. This would seem to indicate that full information can generally be had if enough effort is made to get it. 16. Wherever it is possible to do so, please zx'eigh the applicant yourself, and take the actual measurements asked for by the question relative to these particulars. It very often happens that an applicant will guess at his weight and measurements, and the guesses are some- times, when tested, found to be quite wide of the mark. The question as to figure should be answered in such a way as to show whether the applicant is erect or whether he has in any degree a stooping figure. The question as 8 to general appearance and carriage should be answered so as to convey as nearly as possible the indications of healthfulness and vitality deduced from the eyes, com- plexion, aspect of the countenance, gait, and bearing. 17. In the examination of the heart and lungs much care and accurate work is required. The Examiner should note not only the pronounced alterations of normal sounds, but the slightest variations should be detected. A careful inspection of the chest and heart areas, and a thorough percussion to de- termine change of volume or alterations of pitch and tone, should enable him to discover the hypertrophic re- sults of valvular trouble. In the lungs, he should note loss of function, alteration of respiratory murmur, and the presence of pathological deposits. 18. It is requested that much care and accuracy be given to the examination of the urine. The Examiner should convince himself that the specimen under exami- nation was really voided by the applicant. While sub- stitution is not a frequent deception, still it is practised sufficiently often to render certainty in this matter very necessary. If possible, the urine should be examined immediately after passage, noting the appearance, color, clearness, odor, etc. The questions as to frequency and amount should be made at the time of obtaining the specimen, and if the answers show any marked varia- tion from the normal, the company should be apprised of it. Albumen and sugar should be looked for with care so as to detect minute quantities, as applicants rare- ly apply for examination when gross abnormalities of this secretion exist, they being usually aware of that condition. A careful application of the heat test for albumen, supplemented by the Heller test with nitric acid, is generally sufficient for a life insurance examina- tion, but the tests must be accurately and slowly applied, and enough time allowed for the development of the re- action and for the line of albumen to become defined. 9 Usually five minutes will suffice. In examining for su- gar it is preferable to use Fehling's test, if the chemical solutions are in perfect condition, mixed at the time of testing, and properly boiled to demonstrate the ab- sence of reaction in the boiling test solution. The mod- ification of Fehling's solution, known as Haines' solu- tion, may be employed. It has the advantage of being always ready for use, and of not being liable to change unless kept on hand too long—say two or three months. 19. Please see that the answers "Yes" and "No," which are the only replies required to many of the ques- tions on page three of the application form, are cor- rectly placed, as sometimes in the excitement of an ex- amination a "Yes" is put for a "No," or a "No" for a "Yes." A review of the application after it is filled out will almost certainly lead to the detection of such unin- tentional errors, and they may then be corrected before the application is sent to the Home Office. 20. In answering the last question on page three of the form, please take into consideration the family re- cord and the personal history of the applicant, as indi- cated by page two of the form, as well as his present physical condition as shown by page three, the former data being fully as important factors in reaching a cor- rect decision as the latter. , 21. If for any reason, you deem it for the interests of the company to recommend that insurance be granted to the applicant for a less sum, or upon a different plan, than he applies for, please mention the amount and form of insurance which your judgment indicates should be issued. It is sometimes the case that when an applicant applies for an ordinary life policy the Examiner will recommend him for a "twenty year policy," or a "ten year policy." This is not as definite a recommendation as is to be desired, for it does not state whether a twenty year life or ten year life policy is suggested, or whether the intention is to recommend endoivment insurance for IO a term of ten or twenty years. If there are weak places in an applicant's record, history, or present condition which render him ineligible for an ordinary life policy, it is not usually the case that a life policy with payments of premiums limited to ten, fifteen or twenty years would be much, if any. more acceptable to the company, for while the premium payments would be completed in a comparatively short time, the company would still be at risk upon such an applicant for the whole period of his life. In such cases, an applicant, if accepted at all, should have an endowment or a semi-endowment in- surance, so that the liability of the company would cease absolutely at the end of the endowment or semi- endowment period. 22. Every Examiner for life insurance knows from experience that there is very frequently an almost in- definable something about an applicant which impresses the Examiner either favorably or unfavorably with re- gard to the risk. It is almost impossible to convey this impression in language, and for that reason there is no question in the application that bears directly upon this point. Examiners are, however, requested whenever an unfavorable impression such as is mentioned above has been made upon their minds in connection with the ex- amination of an applicant, to write a special letter to the Home Office, giving as fully as the nature of the case will admit the exact impression that has been formed, and the reasons which gave rise to that impression. The Examiner sees, hears, and touches the applicant, while the Home Office knows him only by a pen-and-ink de- scription on paper, and therefore points in an examina- tion which are apparent only by personal contact of the Examiner and the applicant may frequently be of the highest importance in determining the value of the risk. The skill, the tact, the discretion, and the experience of the Examiner can in these cases be of very great service to the company, and appreciating these qualities in an Examiner, we ask for the special letter above mentioned where it is deemed necessary. II J3- It will be seen from these instructions that it rests with the Examiner so to question and inspect the appli- cant that by the time he has written correct answers to the questions directed to be asked he has a complete knowledge of the applicant's past ailments and their re- sults; a thorough acquaintance with the family history and the bearing of the information obtained upon the probable longevity and continued good health of the applicant, and he is also fully informed as to the present condition of health. After such investigation he can safely state whether the organs are healthy, their func- tions normal, and if anything is present that will tend to impair the future health of the applicant or shorten his life, all of which information is essential in forming the basis for calculating the kind of policy the company can safely offer him, and the rate he should pay for the insurance protection he seeks. 24. The paragraphs of this pamphlet are numbered, so that if it be at any time necessary to write to an Exami- ner concerning an examination, reference can easily be made to any portion of these instructions by num- bers. 25. The Examiner is earnestly requested to review carefully all his replies to the questions in each applica- tion before it leaves his hands, so that any errors or omissions may be corrected before the application is mailed to the Home Office. Attention to this request will obviate the necessity for return of application for correction, or for correspondence to effect that result, and thus much time and annoyance may be saved.