family tendency to the late development of the disease must be considered. (b) The Size of the Family.—It is evident that the applicant's liability to inherited taint varies inversely as the ratio of healthy to infected family members. (c) The Degree of Relationship.-On this point authorities are somewhat in conflict, some claiming that parental tuberculosis exercises a much greater effect than does that appearing in brothers or sisters, while others, like Dr. Marsh, believe the two elements to be about equal, and this latter view conforms to the experience of the general practitioner. Aside from the general proposition, many special problems suggest themselves in this connection, such, for example, as requires the determination of the relative importance of the death of both father and mother to several deaths among brothers and sisters. Many complicated questions are thus introduced. (d) Physical Resemblance to the Deceased Family Members.— This is unquestionably a matter of considerable importance, and justifies the question commonly found in the examination blanks of American companies: "Which of the parents does the appli cant resemble?" (e) The Physique of the Applicant.—That hard muscles, a sound heart, freely expanding lungs, and good blood render their possessor to a certain extent immune to phthisis is of course beyond question, but that the physically sound member of a consumptive family is as safe a risk as the healthy man of untainted stock is more than doubtful. (f) Environment of the Individual.—This question often presents points of the greatest interest. Dampness, foul air, lack of sunshine, all favor the development of tuberculosis, and predispose the individual to infection. (g) Was either parent suffering from tuberculosis when applicant was born or conceived?—a question of great importance. (h) Exposure to Infection.-Curiously enough, despite the wellknown infectivity of tuberculosis, insurance companies have until quite recently failed to inquire as to the applicant's association with consumptives. As a result of this omission companies A strange have insured thousands of men exposed daily in their own households to infection through their wives or children. omission. Such might appear as excellent risks with a clean family history, and yet be far more dangerous to the company than others whose family history was such as to have caused their rejection. Thanks to the introduction of better and more efficient means for the early diagnosis of tuberculosis, and still more to the wide-spread knowledge of its transmissibility, both the general and insurance mortality from consumption have greatly diminished, and we may look hopefully forward to a time when this "great white plague" will be as rare as is leprosy at the present day. The Inheritance of Syphilis.-The evil and wide-spread effects of syphilitic infection have already been mentioned, and, as Seldom traced regards life insurance, so many difficulties stand in the way of in life insur ance work. Ignorance or deceit. "Childbirth." proper investigation of this factor as to practically remove it from consideration and oblige the companies to limit their inquiries to syphilis existing in the individual. The Unreliability of the Reports upon Family History Commonly Seen upon Insurance Examination Blanks.— That the statements concerning family history must, in a measure, be indefinite or incorrect is to be taken for granted in securing any case history. The reason for this condition is to be found either in an ignorance of the actual conditions causing the death of family members or in the wilful misrepresentation or suppression of the true facts. In ordinary practice ignorance and perhaps a certain amount of family pride are the influences chiefly operating. In life insurance work there is the added element of falsification. These impediments to a proper consideration of an application for insurance are heightened by the frequent failure of medical examiners to appreciate the importance of definite and reasonable statements, and a full compliance with the instructions contained upon the application blank of every insurance company. Certain frequently used terms are the bane of medical directors and a fertile source of entirely unnecessary correspondence. One of these terms is "childbirth." If one were to judge the mortality of childbirth by the number of cases reported in applications for insurance, he would believe it to be more deadly than the plague. It is a significant fact that those applicants whose mothers are said to have died of childbirth show an astonishing mortality from tuberculosis; one, in fact, that runs curiously paral lel to the increased mortality observed among those whose mothers have died of tuberculosis. H. W. Manly investigated this question and found that out of 226 persons whose mothers died in childbirth, the mortality was 28 per cent. above the expected loss; and, furthermore, that the percentage of deaths from tuberculosis was slightly in excess of that present in cases showing a history of maternal consumption.* All of this proves simply that the cause of death was not truthfully stated, though it must be admitted that very frequently the applicants are uninformed as to the exact conditions present. It becomes the examiner's duty in this and in similar cases to in- The examiner's quire first as to the length of illness; second, the previous health; and, third, as to the symptoms present during the illness under consideration. plain duty. at 50. "Old age " is a term most woefully abused in life insurance applications, occupying a place in the medical director's "index"Of old age" expurgatorius" second only to "don't know." It must be remembered that a person can hardly be said to die properly of senile decay short of three score and ten, and when, as is often the case, important family members are reported as dying of old age in the fifties, the effect upon the application is exactly as if they had been stricken with apoplexy. "Don't know" is some times a wholly justifiable expression; more often it represents in "Don't know." the mind of the medical director a disposition to shirk the truth, and thus unfavorably affects the applicant's chances of acceptance. Hence, if used in connection with the death of near relatives an explanation should always be appended. A great many terms are regarded at the home office as synonymous with tuberculosis and cancer. Medical examiners should know what these are, in order that when, as is sometimes the case, they are properly used, a little foot-note may be inserted, testifying to their correctness, such are "fistula," "malaria," "chills and fever," "decline," "marasmus," grief," fever, Terms synony bronchitis." In the case of almost all of these there is a lack of cancer and "broken heart," 46 66 'chronic definiteness that strongly suggests the need of further investi gation. Health of Surviving Family Members. A somewhat *Journal of the Institute of Actuaries," vol. XXX, p. 97. mous with tuberculosis. "Fair." common error in connection with family history occurs in the description of some surviving relative's health as "fair" or "poor" or, again, "not strong." In all such cases further information is absolutely necessary. In conclusion, one may sum up the requirements of the medical department by saying that it wants direct, concise, and specific information as to the nature of any illness present in a living person or believed to be the cause of a death. It further desires to know the duration of the last illness and the state of health previous to that illness. One of the most easily recognized of the signs that mark the competent examiner is a careful and accurate report upon the family history of his applicants. OCCUPATION AS AFFECTING LONGEVITY AND THE INCIDENCE OF DISEASE. To properly consider “occupation " in its relation to longevity and the incidence of disease, would require a good-sized volume, and one can attempt only a brief summary of some of its salient points. The question must necessarily be considered in the several quite distinct aspects presented by different callings. 1. The moral hazard introduced. 2. The question of excessive mental strain. 3. The general sanitary conditions present, including exposure to heat, cold, and general unhygienic conditions. 4. Special conditions leading to the introduction of various organic or inorganic poisons into the body. 5. The influence of prolonged and unusually severe musclestrain, of cramped positions, or of repeated and excessive activity of certain definite" neuromuscular units." 6. Liability to accident. 7. Stigmata of occupation. Such a classification is necessarily imperfect, and any strict. adherence to its terms is manifestly impossible, by reason of the fact that certain occupations will fall within several of its divisions. For this reason no attempt will be made to adhere rigidly to its provisions, though as far as is possible the general plan of arrangement will be followed. All insurance companies consider in their rating of a risk the occupation of the applicant. Indeed, the immense increase in manufacturing during the present century, and the resultant impetus given to the invention of diverse processes involving the use of dangerous machinery, chemic manipulations, and the continuous handling of poisonous substances by employees; the division of labor, with its inevitable demands upon the individual |