44 MEDICAL EXAMINATIONS. MEDICAL EXAMINATIONS. BY AN EXPERIENCED EXAMINER. Until the establishment of the present prac- tice of appointing a medical officer to look after the interests of a life-insurance company, great uncertainty existed in relation to the insura- bility of many lives that were taken as good risks. This uncertainty became often the cause of protracted litigation ; and the opinions of learned jurists on the bench, and the decisions of juries were not unfrequently founded upon imperfectly ascertained facts, and loose and careless opinions supplied by an agent or bro- ker : such as, " he believed it to be a good life," or that, " the party was in a reasonably good state of health," and a host of similarly express- ed opinions—as vague as they were unsatisfac tory.* Often these would arise from positive * Stackpole v. Simon. Sitt. at Guildhall Hall. Vac. 1779 Ross v. Bradshaw, 1. Blac. Rep. 312.MEDICAL EXAMINATIONS. 45 ignorance, at other times, from collusion or carelessness on the part of one who was repre- sented as being the usual medical attendant of the party whose life was proposed to be in sured.* A remarkable instance of the effect of an ab- sence of a personal examination by an officer of a company, occurred in England in the year 1824. The Duke of Saxe Wiemar insured his life for £5,000 sterling, and died in a year or two after effecting the insurance. After the amount of the policy had been paid, it was as- certained that he had been wounded in the spine, and that he was both idiotic and para- lytic at the time of effecting the insurance, but had furnished the office with two certificates, tie from a physician and another from a sur- geon, stating that he was at that time in sound health: on which certificates the policy was is- sued. In a suit to recover the money paid, the company was non-suited, as the transaction was in accordance with their method of busi- ness. Had there been a medical examiner at- * Aveson v. Lord Kincaird and others, 6 East,4b MEDICAL EXAMINATIONS. tached to the company, a policy on such a life never would have been issued. The certificate of the usual medical attend- ant is often of little importance beyond furnish- ing information as to the past state of health of the party, or as to his family predisposition, for the simple reason that he may never have had an opportunity of investigating the condi- tion of his patient in the mode needed for life- insurance. The writer has known instances of physicians giving certificates of good health, and upon having their attention directed to the results of a physical examination, frankly ac knowledge that they were ignorant until that time of any predisposition to disease in their pa- tients. An instance worthy of note occurred to the writer where the physician had been an inti- mate friend of the applicant for twenty years, during which time he had not experienced any indisposition, but had always had the appear- ance of ruddy health. An examination of the chest detected unequivocal symptoms of the ex- istence of incipient phthisis. The attention ol the medical friend, who had accompanied him to the office, was directed to them; he at onceMEDICAL EXAMINATIONS. 47 admitted the accuracy of the diagnosis, and ac- knowledged that the case was not an insurable one. He subsequently-reported that this indi- vidual had, about six months after his examina- tion, suffered from severe pulmonary haemor- rhage with every prospect of phthisis. Other instances could be given where the parties died of the same disease—the predisposition being unsuspected by the physician solely from his not having had occasion to investigate the con- dition of his patient with reference to pulmona- ry diseases. The experience of the London Equitable In- surance Company furnishes some very striking facts in illustration of the importance of a per- sonal examination by an officer of the company. At an early period of their business, when the deaths amounted to 331, those caused by con- sumption were 122, at the rate of 7. 7 per thou- sand. In the year 1832, the total number of deaths was 4,095; while the number from con- sumption was 339. In the first period the appli- cations were very carelessly investigated, while during a part of the last mentioned period a careful personal examination was made by a48 MEDICAL EXAMINATIONS. suitably qualified person appointed by the of- fice. It has happened also that persons have pre« sented themselves for examination who never nave had any medical attendant, and who never suspected the existence of any disease in them- selves, and yet have given evidence of such a state of system, that there existed no reasona- ble presumption that they would ever reach the period of their "expectation." An early death has proved the accuracy of this opinion in many an instance. It was formerly required of the party, in case he had no physician, to procure a certificate from « some other " medical man; but it is evident that but little information of value could be obtained from such a source. The medical officer appointed by the company supplies now any deficiency in the medical tes- timony, and offers the best security both for the insured and the insurers—to the former as fur- nishing to a certain extent a warranty, and to the latter a security that every means has been used to obtain none but good risks. When a person applies for examination he should bring with him, 1st, a declaration signed MEDICAL EXAMINATIONS. 49 by himself; 2d, another signed by a friend; and 3d, one from his medical attendant; all giving an accurate statement of his health. These documents are furnished in blank by the com pany. An error has arisen on the part of some medical gentlemen in supposing that when they fill up the blank that is intended for them, that they are furnishing the information they impart, at the request of the company. This mistake has doubtless arisen from a common practice of the officers and agents, who, in wishing to save the applicant a little trouble, send the blank certificate to the physician; the latter supposing it to come from the company are in some instances unwilling to furnish the required information without a fee. All these docu- ments, however, being the proofs which the ap- plicant is required to supply and to bring with him to be filed in the office, must be obtained by him at his own expense. In addition to these evidences, the agent is supposed to be- come to some extent responsible, and in one company at least, he is required to fill up an of- ficial certificate embracing his knowledge of 350 MEDICAL EXAMINATIONS. the party, and his opinion as to the safety of the risk in question. In no case should a person be examined un- less all these papers are submitted, complete, to the medical examiner; for they might contain some important fact necessary to a correct de- cision. With these documents before him he will proceed to a personal examination. The external form and general aspect often convey a vast amount of information to one ac- customed to associate these with health and sickness. The habits of life, which may be as- certained by a few questions, will naturally lead to others ; the trade, occupation, profession, etc., of the applicant come under this head of exam- ination, and will enable the examiner to draw his inference as to their effects on the general health. The condition of the brain and spinal marrow will also be thus learned; for this can be ascertained to a sufficient extent by the gait, manner of speech, and want of control over the muscular system, exhibited in tremor, and other irregular movements, together with questions on these points which may suggest themselves.MEDICAL EXAMINATIONS. 51 [ In the examination of the chest, although it is \ of great importance, yet it is not necessary to 1 ascertain anything more than that there is a de- parture from health ; it is not required that any detail of unfavorable symptoms be recorded, if any appear. The first step in the investigation, is to percuss the chest in all its parts, and then I to apply the Stethescope, or the ear, to ascer- tain whether or not there exists a healthy res- piration. Consider the capacity of the chest, whether narrow or expanded—whether there is any unusual depression in the subclavian re- gions—whether the chest expands equally on inspiration—any Bronchophony, particularly in the subclavian and mammary regions. The action of the heart is also ascertained by aus- cultation : ascertain whether the rythm of the heart is natural, and confined within the natural limits—whether the impulse of the heart is co- incident with the first sound, and of natural in- tensity. When making a report, the state of the heart may be recorded "Normal," or "Ab- normal," as the case may be. The pulse, besides being regular, should never beat over 90 in a minute : if it cannot be re- 52 MEDICAL EXAMINATIONS. duced to this by changing to a recumbent posi- tion, rest, and time being given for the com- posure of the nervous system, and if necessary, two or three examinations, on different days— the applicant is to be rejected. A very careful investigation into the condition of the heart and lungs should be made, whenever the pulse is found to beat uniformly over 80. An habitually rapid pulse is generally indica- tive of some organic affection. The pulse should always be regular in its beats, and never intermitting. Spitting of blood, if it arise in a person of a consumptive family, must be a reason for re- jection. If, however, it arises from a mere congestion of the mueous membrame of the bronchial tubes, it need not be a cause for declin- ing the risk; a sufficient time, however, must elapse to ascertain, together with an examina- tion of the chest, that it is of this nature. Bleed- ing from the lungs from violent straining, need not be a reason for rejecting the applicant__al- lowing, as in the former instance, a long time to pass to prove that it is but a local and tempo- rary affection, and has not produced any diseaseMEDICAL EXAMINATIONS. 53 If either of these should be followed by cough or occasional difficulty of respiration, the party of course, must be rejected. It is needless to men- tion that more than usual care must be taken in the physical examination of such persons. Occasional difficulty of breathing, or asthma, must always be rejected. The causes of these affections are often obscure, and as they arise from some obstruction in one or other of the vital organs, as the lungs or heart, safety re- quires that such cases should not be received. There is an affection of the bowels which is often suddenly fatal; a person affected with it is by no means a safe risk: it is an obstruction, sometimes known as colic, bilious colic, or spas- modic colic; any person affected with this, ought to be rejected. In making up a report to be transmitted to the parent office, there need be no remark made beyond the conclusions at which the examiner has arrived, a brief statement and expression of opinion, which ought to be unqualified, is all that is required. Whenever there is any state- ment of positive disease, it would be well for54 MEDICAL EXAMINATIONS. the examiner to refer to it in a note to show that it has received his special attention. The existence of tumors, hernia, hemorrhoids, fistula, &c, should be ascertained, and their condition ascertained by inspection. Fistula is a good reason for rejection. A hernia need not render the party incapable of availing himself of the benefits of life-insurance provided it be properly secured by a truss, and the occupation of the individual be such as not to endanger its protrusion by excessive straining. When inquiring into the usual occupation of the applicant, the questions relating to exposure to insalubrious climates will naturally arise. If the party has been within the tropics, or in any part of the world known to be at times un- healthy, it will be necessary to inquire whether or not he has had any endemic diseases which have prevailed—and if so, if they have left any enlargement of the liver or spleen, or any other permanent effection of an important viscus. Hereditary tendency to disease is an impor- tant part of an examination. There are how- ever, but four that appear to have a bear- ing upon the duration of life; these are conMEDICAL EXAMINATIONS. 55 sumption, disease of the heart, insanity and epilepsy. Although diseases are termed heredi- tary, yet they are, more properly speaking, pre- dispositions. Hence, the actual development of disease requires some co-operating circum- stances, and it is not in every instance of the parent having either of the above named dis- eases that the applicant should be pronounced ineligible to life-insurance. Consumption.—Consumption does not always descend from the parent to the child. But if either parent has been effected with it, and the offspring exhibits a slender form, or has a nar- row or badly formed chest, or an habitually rapid pulse, the predisposition is evidently so strong, that some slight exposure or irregularity of living, or a constrained occupation in a close atmosphere, will almost surely develop the dis- ease. Many persons exhibit no such tendency, and, therefore, ought not to be rejected, because one of the family may have had the disease. It is different, however, if two parents have died of it or one parent and one child. Under these56 MEDICAL EXAMINATIONS. circumstances the applicant ought not to be in- sured until he has passed the period at which he is likely to be affected with the disease. Now it appears from records carefully made, that more persons die of consumption between the ages of 18 and 35 years than at any other age, the mortality from this cause sinking very rapidly to comparatively a small number after the last mentioned age. Hence, it is advisable that the party should have reached the age of comparative exemption. Forty years, there- fore, is a good age that he should be required to attain before he is examined ; some have lim- ited the period to thirty-five years. It is of course supposed that all symptoms, both rational and physical, which indicate a predisposition to phthisis, be absent. Disease of the Heart—There are many ex- amples on record of this predisposition inherited from parents. One of a family of high rank in Italy, which, for four successive generations, were effected with aneurism, or morbid en' largement of the heart. When a parent has died of this affection, it would be safe to examMEDICAL EXAMINATIONS. 57 ine an applicant with more than ordinary care ; advancing age in this disease will be more likely to aid in the development, than tend to lessen the predisposition, as is the case in phthisis. Insanity.—The hereditary predisposition in this affection is so strong that it has been dis- tinctly traced in six sevenths of the cases in a lunatic asylum. One instance of insanity in a family must be a cause of rejection. Epilepsy.—Epilepsy in a parent need not be in every instance a cause of rejection. Its ex- istence should lead to a very scrutinizing in- quiry into the present condition of the party and his mode of living and occupation. No positive rule can be laid down ; it must be left to the sound judgment of the examiner. General Indications of Longevity. A well proportioned stature without being too tall, but rather of the middle height, and tolera- bly stout. The complexion not too florid; too much ruddiness, at least in youth, is seldom a sign of longevity. The hair should not be58 MEDICAL EXAMINATIONS. black, but rather approaching to fair ; the skin strong, but not coarse. The head not too large. He should have prominent veins on the limbs and the shoulders rather round than flat. The neck is neither very long nor short. The stom- ach of such a person does not project—the hands are large, but not too deeply cleft. The foot is rather thick than long, and the inferior limbs are firm and round. The chest is broad and arched—the voice strong, and the faculty of re- taining the breath for a considerable time with- out inconvenience or difficulty, is one of the most marked signs. In general there is a com- plete harmony of proportion among all the parts of the body.44 MEDICAL EXAMINATIONS. MEDICAL EXAMINATIONS. BY AN EXPERIENCED EXAMINER. Until the establishment of the present prac- tice of appointing a medical officer to look after the interests of a life-insurance company, great uncertainty existed in relation to the insura- bility of many lives that were taken as good risks. This uncertainty became often the cause of protracted litigation ; and the opinions of learned jurists on the bench, and the decisions of juries were not unfrequently founded upon imperfectly ascertained facts, and loose and careless opinions supplied by an agent or bro- ker : such as, " he believed it to be a good life," or that, " the party was in a reasonably good state of health," and a host of similarly express- ed opinions—as vague as they were unsatisfac tory.* Often these would arise from positive * Stackpole v. Simon. Sitt. at Guildhall Hall. Vac. 1779 Ross v. Bradshaw, 1. Blac. Rep. 312.MEDICAL EXAMINATIONS. 45 ignorance, at other times, from collusion or carelessness on the part of one who was repre- sented as being the usual medical attendant of the party whose life was proposed to be in sured.* A remarkable instance of the effect of an ab- sence of a personal examination by an officer of a company, occurred in England in the year 1824. The Duke of Saxe Wiemar insured his life for £5,000 sterling, and died in a year or two after effecting the insurance. After the amount of the policy had been paid, it was as- certained that he had been wounded in the spine, and that he was both idiotic and para- lytic at the time of effecting the insurance, but had furnished the office with two certificates, tie from a physician and another from a sur- geon, stating that he was at that time in sound health: on which certificates the policy was is- sued. In a suit to recover the money paid, the company was non-suited, as the transaction was in accordance with their method of busi- ness. Had there been a medical examiner at- * Aveson v. Lord Kincaird and others, 6 East,4b MEDICAL EXAMINATIONS. tached to the company, a policy on such a life never would have been issued. The certificate of the usual medical attend- ant is often of little importance beyond furnish- ing information as to the past state of health of the party, or as to his family predisposition, for the simple reason that he may never have had an opportunity of investigating the condi- tion of his patient in the mode needed for life- insurance. The writer has known instances of physicians giving certificates of good health, and upon having their attention directed to the results of a physical examination, frankly ac knowledge that they were ignorant until that time of any predisposition to disease in their pa- tients. An instance worthy of note occurred to the writer where the physician had been an inti- mate friend of the applicant for twenty years, during which time he had not experienced any indisposition, but had always had the appear- ance of ruddy health. An examination of the chest detected unequivocal symptoms of the ex- istence of incipient phthisis. The attention ol the medical friend, who had accompanied him to the office, was directed to them; he at onceMEDICAL EXAMINATIONS. 47 admitted the accuracy of the diagnosis, and ac- knowledged that the case was not an insurable one. He subsequently-reported that this indi- vidual had, about six months after his examina- tion, suffered from severe pulmonary haemor- rhage with every prospect of phthisis. Other instances could be given where the parties died of the same disease—the predisposition being unsuspected by the physician solely from his not having had occasion to investigate the con- dition of his patient with reference to pulmona- ry diseases. The experience of the London Equitable In- surance Company furnishes some very striking facts in illustration of the importance of a per- sonal examination by an officer of the company. At an early period of their business, when the deaths amounted to 331, those caused by con- sumption were 122, at the rate of 7. 7 per thou- sand. In the year 1832, the total number of deaths was 4,095; while the number from con- sumption was 339. In the first period the appli- cations were very carelessly investigated, while during a part of the last mentioned period a careful personal examination was made by a48 MEDICAL EXAMINATIONS. suitably qualified person appointed by the of- fice. It has happened also that persons have pre« sented themselves for examination who never nave had any medical attendant, and who never suspected the existence of any disease in them- selves, and yet have given evidence of such a state of system, that there existed no reasona- ble presumption that they would ever reach the period of their "expectation." An early death has proved the accuracy of this opinion in many an instance. It was formerly required of the party, in case he had no physician, to procure a certificate from « some other " medical man; but it is evident that but little information of value could be obtained from such a source. The medical officer appointed by the company supplies now any deficiency in the medical tes- timony, and offers the best security both for the insured and the insurers—to the former as fur- nishing to a certain extent a warranty, and to the latter a security that every means has been used to obtain none but good risks. When a person applies for examination he should bring with him, 1st, a declaration signed MEDICAL EXAMINATIONS. 49 by himself; 2d, another signed by a friend; and 3d, one from his medical attendant; all giving an accurate statement of his health. These documents are furnished in blank by the com pany. An error has arisen on the part of some medical gentlemen in supposing that when they fill up the blank that is intended for them, that they are furnishing the information they impart, at the request of the company. This mistake has doubtless arisen from a common practice of the officers and agents, who, in wishing to save the applicant a little trouble, send the blank certificate to the physician; the latter supposing it to come from the company are in some instances unwilling to furnish the required information without a fee. All these docu- ments, however, being the proofs which the ap- plicant is required to supply and to bring with him to be filed in the office, must be obtained by him at his own expense. In addition to these evidences, the agent is supposed to be- come to some extent responsible, and in one company at least, he is required to fill up an of- ficial certificate embracing his knowledge of 350 MEDICAL EXAMINATIONS. the party, and his opinion as to the safety of the risk in question. In no case should a person be examined un- less all these papers are submitted, complete, to the medical examiner; for they might contain some important fact necessary to a correct de- cision. With these documents before him he will proceed to a personal examination. The external form and general aspect often convey a vast amount of information to one ac- customed to associate these with health and sickness. The habits of life, which may be as- certained by a few questions, will naturally lead to others ; the trade, occupation, profession, etc., of the applicant come under this head of exam- ination, and will enable the examiner to draw his inference as to their effects on the general health. The condition of the brain and spinal marrow will also be thus learned; for this can be ascertained to a sufficient extent by the gait, manner of speech, and want of control over the muscular system, exhibited in tremor, and other irregular movements, together with questions on these points which may suggest themselves.MEDICAL EXAMINATIONS. 51 [ In the examination of the chest, although it is \ of great importance, yet it is not necessary to 1 ascertain anything more than that there is a de- parture from health ; it is not required that any detail of unfavorable symptoms be recorded, if any appear. The first step in the investigation, is to percuss the chest in all its parts, and then I to apply the Stethescope, or the ear, to ascer- tain whether or not there exists a healthy res- piration. Consider the capacity of the chest, whether narrow or expanded—whether there is any unusual depression in the subclavian re- gions—whether the chest expands equally on inspiration—any Bronchophony, particularly in the subclavian and mammary regions. The action of the heart is also ascertained by aus- cultation : ascertain whether the rythm of the heart is natural, and confined within the natural limits—whether the impulse of the heart is co- incident with the first sound, and of natural in- tensity. When making a report, the state of the heart may be recorded "Normal," or "Ab- normal," as the case may be. The pulse, besides being regular, should never beat over 90 in a minute : if it cannot be re- 52 MEDICAL EXAMINATIONS. duced to this by changing to a recumbent posi- tion, rest, and time being given for the com- posure of the nervous system, and if necessary, two or three examinations, on different days— the applicant is to be rejected. A very careful investigation into the condition of the heart and lungs should be made, whenever the pulse is found to beat uniformly over 80. An habitually rapid pulse is generally indica- tive of some organic affection. The pulse should always be regular in its beats, and never intermitting. Spitting of blood, if it arise in a person of a consumptive family, must be a reason for re- jection. If, however, it arises from a mere congestion of the mueous membrame of the bronchial tubes, it need not be a cause for declin- ing the risk; a sufficient time, however, must elapse to ascertain, together with an examina- tion of the chest, that it is of this nature. Bleed- ing from the lungs from violent straining, need not be a reason for rejecting the applicant__al- lowing, as in the former instance, a long time to pass to prove that it is but a local and tempo- rary affection, and has not produced any diseaseMEDICAL EXAMINATIONS. 53 If either of these should be followed by cough or occasional difficulty of respiration, the party of course, must be rejected. It is needless to men- tion that more than usual care must be taken in the physical examination of such persons. Occasional difficulty of breathing, or asthma, must always be rejected. The causes of these affections are often obscure, and as they arise from some obstruction in one or other of the vital organs, as the lungs or heart, safety re- quires that such cases should not be received. There is an affection of the bowels which is often suddenly fatal; a person affected with it is by no means a safe risk: it is an obstruction, sometimes known as colic, bilious colic, or spas- modic colic; any person affected with this, ought to be rejected. In making up a report to be transmitted to the parent office, there need be no remark made beyond the conclusions at which the examiner has arrived, a brief statement and expression of opinion, which ought to be unqualified, is all that is required. Whenever there is any state- ment of positive disease, it would be well for54 MEDICAL EXAMINATIONS. the examiner to refer to it in a note to show that it has received his special attention. The existence of tumors, hernia, hemorrhoids, fistula, &c, should be ascertained, and their condition ascertained by inspection. Fistula is a good reason for rejection. A hernia need not render the party incapable of availing himself of the benefits of life-insurance provided it be properly secured by a truss, and the occupation of the individual be such as not to endanger its protrusion by excessive straining. When inquiring into the usual occupation of the applicant, the questions relating to exposure to insalubrious climates will naturally arise. If the party has been within the tropics, or in any part of the world known to be at times un- healthy, it will be necessary to inquire whether or not he has had any endemic diseases which have prevailed—and if so, if they have left any enlargement of the liver or spleen, or any other permanent effection of an important viscus. Hereditary tendency to disease is an impor- tant part of an examination. There are how- ever, but four that appear to have a bear- ing upon the duration of life; these are conMEDICAL EXAMINATIONS. 55 sumption, disease of the heart, insanity and epilepsy. Although diseases are termed heredi- tary, yet they are, more properly speaking, pre- dispositions. Hence, the actual development of disease requires some co-operating circum- stances, and it is not in every instance of the parent having either of the above named dis- eases that the applicant should be pronounced ineligible to life-insurance. Consumption.—Consumption does not always descend from the parent to the child. But if either parent has been effected with it, and the offspring exhibits a slender form, or has a nar- row or badly formed chest, or an habitually rapid pulse, the predisposition is evidently so strong, that some slight exposure or irregularity of living, or a constrained occupation in a close atmosphere, will almost surely develop the dis- ease. Many persons exhibit no such tendency, and, therefore, ought not to be rejected, because one of the family may have had the disease. It is different, however, if two parents have died of it or one parent and one child. Under these56 MEDICAL EXAMINATIONS. circumstances the applicant ought not to be in- sured until he has passed the period at which he is likely to be affected with the disease. Now it appears from records carefully made, that more persons die of consumption between the ages of 18 and 35 years than at any other age, the mortality from this cause sinking very rapidly to comparatively a small number after the last mentioned age. Hence, it is advisable that the party should have reached the age of comparative exemption. Forty years, there- fore, is a good age that he should be required to attain before he is examined ; some have lim- ited the period to thirty-five years. It is of course supposed that all symptoms, both rational and physical, which indicate a predisposition to phthisis, be absent. Disease of the Heart—There are many ex- amples on record of this predisposition inherited from parents. One of a family of high rank in Italy, which, for four successive generations, were effected with aneurism, or morbid en' largement of the heart. When a parent has died of this affection, it would be safe to examMEDICAL EXAMINATIONS. 57 ine an applicant with more than ordinary care ; advancing age in this disease will be more likely to aid in the development, than tend to lessen the predisposition, as is the case in phthisis. Insanity.—The hereditary predisposition in this affection is so strong that it has been dis- tinctly traced in six sevenths of the cases in a lunatic asylum. One instance of insanity in a family must be a cause of rejection. Epilepsy.—Epilepsy in a parent need not be in every instance a cause of rejection. Its ex- istence should lead to a very scrutinizing in- quiry into the present condition of the party and his mode of living and occupation. No positive rule can be laid down ; it must be left to the sound judgment of the examiner. General Indications of Longevity. A well proportioned stature without being too tall, but rather of the middle height, and tolera- bly stout. The complexion not too florid; too much ruddiness, at least in youth, is seldom a sign of longevity. The hair should not be58 MEDICAL EXAMINATIONS. black, but rather approaching to fair ; the skin strong, but not coarse. The head not too large. He should have prominent veins on the limbs and the shoulders rather round than flat. The neck is neither very long nor short. The stom- ach of such a person does not project—the hands are large, but not too deeply cleft. The foot is rather thick than long, and the inferior limbs are firm and round. The chest is broad and arched—the voice strong, and the faculty of re- taining the breath for a considerable time with- out inconvenience or difficulty, is one of the most marked signs. In general there is a com- plete harmony of proportion among all the parts of the body.