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THE SIGNIFICANCE OF DIABETIC FAMILY HISTORY IN LIFE ASSURANCE.
679 "
positivethere were two family histories of THE SIGNIFICANCE OF DIABETIC FAMILY special interest, as follows :1. Two brothers (twins), aged 22 years, both unlicensed HISTORY IN LIFE ASSURANCE.1 grocers, proposed for endowment assurance in October, 1901. BY OTTO MAY, M.D. CANTAB., M.R.C.P. LOND., Family history: Father, 64, healthy; mother, 63, healthy ; MEDICAL OFFICER TO THE PRUDENTIAL ASSURANCE COMPANY. two sisters living; one brother died from diabetes, aged 10 years. The proposals were accepted at tabular rates. Both brothers died from diabetes-one in January, 1909, IT is a commonly accepted belief that diabetes is 30 ; the other in September, 1910, aged 31. aged in many cases a " family disease "-i.e., one which 2. Two brothers-one, aged 22, a carter, and the other, is prone to occur in several members of certain aged 17, a coachman-proposed for endowment assurance in families in greater proportion than would be 1902. Family history : Father, 52, healthy; mother, 48, expected if its distribution were uniform through- healthy; three brothers living; seven sisters living ; one If this be so, it becomes a brother died from diabetes, aged 11. The proposals were out the population. if at how all, one or more deaths from accepted at tabular rates. Both brothers died from diabetesfar, question diabetes in a family history should influence our one in 1911, aged 26, and the other in 1912, aged 32. recommendation on the proposed life. From the actuarial point of view the proper method of investigation would be the comparison of the mortality table from a very large number of such proponents with that from an equal number of " controls"—cases chosen at random. Strictly speaking, the actuary is not concerned with the question of the family nature of the disease; his inquiry is whether such a family history increases the
mortality
from all
tion, senile decay, &c.,
Age at death.-Of the 1143 cases the family history, as mentioned above, was " positive" in 41, negative" in 1102. Below I have arranged "
the ages at death of these two groups in decades for comparison and contrast :-
causes-diabetes, consumpand the investigation just
suggested would afford him this information. The present paper, however, is a much less ambitious affair; it represents merely an attempt to see how far a family history of diabetes may be held to signify an increased risk of the proponent’s death the same cause. While this limitation will impair its value to the actuary, I trust that it will not render it unacceptable to the from
physician. During the
decade from Jan. lst, 1901, to Dec. 31st, total death claims in the " Ordinary the 1910, Branch" of the Prudential Assurance Company Of these, the deaths from numbered 76,333. diabetes numbered 1143, or 1’49 per cent.22 The family histories of these 1143 cases showed a death from diabetes in 41-i.e., 3’6 per cent. A control investigation of 1143 other cases, "picked at random from the same period, showed a positive " family history only in 12 cases-i.e., 1’05 per cent. These figures must be taken as the minimal rather than the actual ones. No case was included unless the word diabetes"or diabetic"figured in the history sheet. A fair number contained causes of death, such as "gangrene of the legs," "carbuncle," &c., of which a considerable proportion were probably diabetic. These were, however, excluded. On the other hand, it is extremely improbable that diabetes would be wrongfully given as a cause; almost alone among diseases, the ultimate confirmation of the diagnosis by a simple chemical test makes a positive statement exceptionally reliable. The following figures for the parents of the two sets of 1143 cases are interesting as showing the vagueness of the histories :—
Among the‘ positive " cases negative" cases it
among the
"
the
percentage under 41
was
21.
was
53’7, and
striking feature of this table is the large proportion (53’7 per cent.) of early deaths in the "positive " cases, in comparison with those (21 per cent.) in the " negative ones. The probable explanation is that diabetes includes at least two different groups of cases : (1) A group in which the The
"
I’ comparatively (2)mild, incidence is
in middle or later life, the course and the " family " factor a group characterised by earlier absent; and incidence, more rapid termination, and a tendency to run in particular families. In the present series
those with a negative history contain a preponderance of the former type, while those with a "positive"history include a large proportion of the latter type. Influence of sex.-In the 41 cases with a ’6 positive " history the affected member of the family and the average age of death of the corresponding proponents are shown in the annexed table :Number of
Number of cases.
Father diabetic Brother Mother Sister ,.............
............
............ ............
Total
............
14 13 7 7
Average
......... ......... .........
.........
41
age of
proponents at
.........
death. 394 38-5 54-0 50-0
43-4
striking feature here is the apparently great, difference in the age at death according as the affected relative was male or female. Of the 41 " positivecase, 36 were male and 5 female, as follows :The
1 Part of a paper read before the Life Assurance Medical Officers’ Association on March 4th, 1914. 2 The actual percentage is really higher, as 1143 represented the number of deaths from diabetes, while 76,333 was the number of policies, representing a smaller number of individuals.
Father diabetic ............... Brother " ...............
Mother Sister
"
Male. 13 11
6
Female. .........
1 2
.........
1
...............
6
.........
.........
1
Total ............... TT 3
36
.........
5
...............
680 Of the 36 males the average age at death
was as
follows :Number of
Average
cases.
Father or brother diabetic Mother
sister
or
"
......
......
Total ............
Of the 5 females the
24 12
36
........ ..
....., ..
age at death. 38’3 49’3
43-0
........
corresponding figures
The work is based on some 700 thyroids obtained from post-mortem examinations during the last five years, together with some from guinea-pigs after inoculation. There is no wish to be dogmatic from the appearance of single sections, and doubtful ones have been as far as possible eliminated. It is proposed to take the micro-organisms in alphabetical
order. Bacilli.-B. aerogenes capsulatus : Nothing can cases. at death. be said with certainty from the thyroids obtained Father or brother diabetic 3 43’6 Mother or sister 2 680 0 from 2 cases of spreading traumatic gangrene taken 36 hours and 4 days after infection. B. anthracis: Total............... 5 53’4 The thyroids obtained from 5 guinea-pigs after Without attempting to dogmatise on such com- inoculation showed a complete hyperplasia with paratively slight data, one cannot help suspecting intervesicular hæmorrhage. The change took place that the hereditary factor comes out more strongly within 2 days. B. coli communis : 3 guinea-pigs in the male-that the death from diabetes of a received 2 intraperitoneal injections 16 days and father or brother is more ominous than that of a 24 hours before death-total colloid absorption, mother or sister, and that the male is more likely to marked cell hyperplasia, and intervesicular hæmorsuffer from "family" diabetes than the female. rhage were found. B. coliformis: Cultures of this Unfortunately, the sex was not shown in every one organism, first described by McCarrison,6 were of the 1143 cases investigated, so that one cannot obtained from a patient with endemic goitre. The say whether 36 to 5 represents an undue proportion organism merely decolourises sucrose-litmus and of males among those with a diabetic family produces no indol. The induction of a coliform history. It is, however, interesting to see that, so septicæmia produces total colloid absorption and far as they go, the Registrar-General’s returns for cell hyperplasia. B. diphtheriæ : The thyroids from 1911 bear out the relatively greater incidence of 8 cases show stages of a complete hyperplasia and diabetes at younger ages in the male sex. B. dysenteræ : will be described in full later. Total deaths Deaths at Flexner’s organisms were Emulsions of and Shiga’s percentage from diabetes. 40 or under. injected into 6 guinea-pigs ; an acute hyperplasia 462 23’8 Male............ 1936 From 9 cases of asylum dysentery was produced. 1917 400 20-8 Female it was found that colloid absorption occurred after The above analysis therefore suggests (1) that the fifth day, and that later a complete hyperplasia there is a form of " family diabetes " tending to was produced. B. Gaertner : An active hyperplasia occur at an earlier age, and proving fatal more was found in 12 cases of infantile diarrhcea, the rapidly than the ordinary " acquired " type of the degree of which varied with the duration of the disease ; and (2) that this family diabetes is more disease. B. mallei: 3 guinea-pigs were inoculated with glanders and a complete hyperplasia was found likely to occur in the male than in the female. I should like to take this opportunity of ex- in 24 hours. B. tetani: 3 guinea-pigs were inpressing my thanks to the Board of Directors of the oculated with tetanus and an acute hyperplasia was Prudential Assurance Company for permitting me found ; this in borne out by a thyroid from a child the use of the claims dealt with. 12 days after an injury and 4 daysafter tetanic convulsions. B. tuberculosis : The thyroid changes have been gauged from 48 cases; the acute miliary THE PATHOLOGICAL CHANGES OF THE causes a complete hyperplasia, the chronic a colloid hyperplasia. B. typhosus: Practically no change THYROID IN DISEASE.* was found in 2 cases, 4 weeks and 9 weeks after infection. BY RUPERT FARRANT, F.R.C.S. ENG., SURGICAL REGISTRAR TO WESTMINSTER HOSPITAL. Cocci.-Gonococcus : No change was found in 2 cases, one of which died from an injury, the other IN a publication on hyperthyroidismit was from lobar pneumonia. Meningococcus : A slight shown, as was to be expected, that thyroid hyper- colloid hyperplasia was found in 2 cases that died plasia was not produced by thyroid feeding. In on the twelfth and forty-second day respectively. another papera hyperplasia was demonstrated in Micrococcus catarrhalis : An acute hyperplasia was diseases such as infantile diarrhoea, measles, &c., produced in 3 guinea-pigs by intraperitoneal inand that it could be artificially induced in guinea- jections. Micrococcus melitensis: The thyroids pigs by the injection of diphtheria toxin. Hale varied from a complete to a colloid hyperplasia in Whitefirst pointed out if a large series of thyroids 12 Maltese goats whose serum reactions were were examined they would be found to vary greatly. positive. Pneumococcus: The thyroids from 39 This was confirmed by Simpson,5 who described cases of pneumonia varied according to the type thyroid changes in certain acute disease, and by and cause of infection. Lobar pneumonia produces Marine and Lenhart,’ who examined a series of 73 no change, whilst broncho-pneumonia may cause a from various conditions. No attempt has ever been complete hyperplasia. Staphylococcus: In 8 cases made to separate the diseases according to their of septicaemia due to pyogenes aureus or albus no action on the thyroid. thyroid reaction was present. Streptococcus: The The object of this paper is to point out those thyroids from 41 cases of streptococcic septicaemia diseases and togaemias that do, and those that do and other streptococcic infections show no change, not, produce an alteration in the thyroid, to describe with the exception of those from cases of scarlet and demonstrate these changes, to compare them and rheumatic fevers ; the changes in these diseases with those seen in goitre, and to note when they may be due to other micro-organisms. Acute surbecome associated with signs of thyroid excess. gical infections are found to have no effect on the Number of
.,
are :-
Average age
......
.........
......
....’
........
............
.........
............
............
............
* A paper read before the Pathological Section of the of Medicine on Feb. 17th, 1914.
Royal Society
thyroid. Protozoa.-Coccidiosis : No change
was
found in
positivethere were two family histories of THE SIGNIFICANCE OF DIABETIC FAMILY special interest, as follows :1. Two brothers (twins), aged 22 years, both unlicensed HISTORY IN LIFE ASSURANCE.1 grocers, proposed for endowment assurance in October, 1901. BY OTTO MAY, M.D. CANTAB., M.R.C.P. LOND., Family history: Father, 64, healthy; mother, 63, healthy ; MEDICAL OFFICER TO THE PRUDENTIAL ASSURANCE COMPANY. two sisters living; one brother died from diabetes, aged 10 years. The proposals were accepted at tabular rates. Both brothers died from diabetes-one in January, 1909, IT is a commonly accepted belief that diabetes is 30 ; the other in September, 1910, aged 31. aged in many cases a " family disease "-i.e., one which 2. Two brothers-one, aged 22, a carter, and the other, is prone to occur in several members of certain aged 17, a coachman-proposed for endowment assurance in families in greater proportion than would be 1902. Family history : Father, 52, healthy; mother, 48, expected if its distribution were uniform through- healthy; three brothers living; seven sisters living ; one If this be so, it becomes a brother died from diabetes, aged 11. The proposals were out the population. if at how all, one or more deaths from accepted at tabular rates. Both brothers died from diabetesfar, question diabetes in a family history should influence our one in 1911, aged 26, and the other in 1912, aged 32. recommendation on the proposed life. From the actuarial point of view the proper method of investigation would be the comparison of the mortality table from a very large number of such proponents with that from an equal number of " controls"—cases chosen at random. Strictly speaking, the actuary is not concerned with the question of the family nature of the disease; his inquiry is whether such a family history increases the
mortality
from all
tion, senile decay, &c.,
Age at death.-Of the 1143 cases the family history, as mentioned above, was " positive" in 41, negative" in 1102. Below I have arranged "
the ages at death of these two groups in decades for comparison and contrast :-
causes-diabetes, consumpand the investigation just
suggested would afford him this information. The present paper, however, is a much less ambitious affair; it represents merely an attempt to see how far a family history of diabetes may be held to signify an increased risk of the proponent’s death the same cause. While this limitation will impair its value to the actuary, I trust that it will not render it unacceptable to the from
physician. During the
decade from Jan. lst, 1901, to Dec. 31st, total death claims in the " Ordinary the 1910, Branch" of the Prudential Assurance Company Of these, the deaths from numbered 76,333. diabetes numbered 1143, or 1’49 per cent.22 The family histories of these 1143 cases showed a death from diabetes in 41-i.e., 3’6 per cent. A control investigation of 1143 other cases, "picked at random from the same period, showed a positive " family history only in 12 cases-i.e., 1’05 per cent. These figures must be taken as the minimal rather than the actual ones. No case was included unless the word diabetes"or diabetic"figured in the history sheet. A fair number contained causes of death, such as "gangrene of the legs," "carbuncle," &c., of which a considerable proportion were probably diabetic. These were, however, excluded. On the other hand, it is extremely improbable that diabetes would be wrongfully given as a cause; almost alone among diseases, the ultimate confirmation of the diagnosis by a simple chemical test makes a positive statement exceptionally reliable. The following figures for the parents of the two sets of 1143 cases are interesting as showing the vagueness of the histories :—
Among the‘ positive " cases negative" cases it
among the
"
the
percentage under 41
was
21.
was
53’7, and
striking feature of this table is the large proportion (53’7 per cent.) of early deaths in the "positive " cases, in comparison with those (21 per cent.) in the " negative ones. The probable explanation is that diabetes includes at least two different groups of cases : (1) A group in which the The
"
I’ comparatively (2)mild, incidence is
in middle or later life, the course and the " family " factor a group characterised by earlier absent; and incidence, more rapid termination, and a tendency to run in particular families. In the present series
those with a negative history contain a preponderance of the former type, while those with a "positive"history include a large proportion of the latter type. Influence of sex.-In the 41 cases with a ’6 positive " history the affected member of the family and the average age of death of the corresponding proponents are shown in the annexed table :Number of
Number of cases.
Father diabetic Brother Mother Sister ,.............
............
............ ............
Total
............
14 13 7 7
Average
......... ......... .........
.........
41
age of
proponents at
.........
death. 394 38-5 54-0 50-0
43-4
striking feature here is the apparently great, difference in the age at death according as the affected relative was male or female. Of the 41 " positivecase, 36 were male and 5 female, as follows :The
1 Part of a paper read before the Life Assurance Medical Officers’ Association on March 4th, 1914. 2 The actual percentage is really higher, as 1143 represented the number of deaths from diabetes, while 76,333 was the number of policies, representing a smaller number of individuals.
Father diabetic ............... Brother " ...............
Mother Sister
"
Male. 13 11
6
Female. .........
1 2
.........
1
...............
6
.........
.........
1
Total ............... TT 3
36
.........
5
...............
680 Of the 36 males the average age at death
was as
follows :Number of
Average
cases.
Father or brother diabetic Mother
sister
or
"
......
......
Total ............
Of the 5 females the
24 12
36
........ ..
....., ..
age at death. 38’3 49’3
43-0
........
corresponding figures
The work is based on some 700 thyroids obtained from post-mortem examinations during the last five years, together with some from guinea-pigs after inoculation. There is no wish to be dogmatic from the appearance of single sections, and doubtful ones have been as far as possible eliminated. It is proposed to take the micro-organisms in alphabetical
order. Bacilli.-B. aerogenes capsulatus : Nothing can cases. at death. be said with certainty from the thyroids obtained Father or brother diabetic 3 43’6 Mother or sister 2 680 0 from 2 cases of spreading traumatic gangrene taken 36 hours and 4 days after infection. B. anthracis: Total............... 5 53’4 The thyroids obtained from 5 guinea-pigs after Without attempting to dogmatise on such com- inoculation showed a complete hyperplasia with paratively slight data, one cannot help suspecting intervesicular hæmorrhage. The change took place that the hereditary factor comes out more strongly within 2 days. B. coli communis : 3 guinea-pigs in the male-that the death from diabetes of a received 2 intraperitoneal injections 16 days and father or brother is more ominous than that of a 24 hours before death-total colloid absorption, mother or sister, and that the male is more likely to marked cell hyperplasia, and intervesicular hæmorsuffer from "family" diabetes than the female. rhage were found. B. coliformis: Cultures of this Unfortunately, the sex was not shown in every one organism, first described by McCarrison,6 were of the 1143 cases investigated, so that one cannot obtained from a patient with endemic goitre. The say whether 36 to 5 represents an undue proportion organism merely decolourises sucrose-litmus and of males among those with a diabetic family produces no indol. The induction of a coliform history. It is, however, interesting to see that, so septicæmia produces total colloid absorption and far as they go, the Registrar-General’s returns for cell hyperplasia. B. diphtheriæ : The thyroids from 1911 bear out the relatively greater incidence of 8 cases show stages of a complete hyperplasia and diabetes at younger ages in the male sex. B. dysenteræ : will be described in full later. Total deaths Deaths at Flexner’s organisms were Emulsions of and Shiga’s percentage from diabetes. 40 or under. injected into 6 guinea-pigs ; an acute hyperplasia 462 23’8 Male............ 1936 From 9 cases of asylum dysentery was produced. 1917 400 20-8 Female it was found that colloid absorption occurred after The above analysis therefore suggests (1) that the fifth day, and that later a complete hyperplasia there is a form of " family diabetes " tending to was produced. B. Gaertner : An active hyperplasia occur at an earlier age, and proving fatal more was found in 12 cases of infantile diarrhcea, the rapidly than the ordinary " acquired " type of the degree of which varied with the duration of the disease ; and (2) that this family diabetes is more disease. B. mallei: 3 guinea-pigs were inoculated with glanders and a complete hyperplasia was found likely to occur in the male than in the female. I should like to take this opportunity of ex- in 24 hours. B. tetani: 3 guinea-pigs were inpressing my thanks to the Board of Directors of the oculated with tetanus and an acute hyperplasia was Prudential Assurance Company for permitting me found ; this in borne out by a thyroid from a child the use of the claims dealt with. 12 days after an injury and 4 daysafter tetanic convulsions. B. tuberculosis : The thyroid changes have been gauged from 48 cases; the acute miliary THE PATHOLOGICAL CHANGES OF THE causes a complete hyperplasia, the chronic a colloid hyperplasia. B. typhosus: Practically no change THYROID IN DISEASE.* was found in 2 cases, 4 weeks and 9 weeks after infection. BY RUPERT FARRANT, F.R.C.S. ENG., SURGICAL REGISTRAR TO WESTMINSTER HOSPITAL. Cocci.-Gonococcus : No change was found in 2 cases, one of which died from an injury, the other IN a publication on hyperthyroidismit was from lobar pneumonia. Meningococcus : A slight shown, as was to be expected, that thyroid hyper- colloid hyperplasia was found in 2 cases that died plasia was not produced by thyroid feeding. In on the twelfth and forty-second day respectively. another papera hyperplasia was demonstrated in Micrococcus catarrhalis : An acute hyperplasia was diseases such as infantile diarrhoea, measles, &c., produced in 3 guinea-pigs by intraperitoneal inand that it could be artificially induced in guinea- jections. Micrococcus melitensis: The thyroids pigs by the injection of diphtheria toxin. Hale varied from a complete to a colloid hyperplasia in Whitefirst pointed out if a large series of thyroids 12 Maltese goats whose serum reactions were were examined they would be found to vary greatly. positive. Pneumococcus: The thyroids from 39 This was confirmed by Simpson,5 who described cases of pneumonia varied according to the type thyroid changes in certain acute disease, and by and cause of infection. Lobar pneumonia produces Marine and Lenhart,’ who examined a series of 73 no change, whilst broncho-pneumonia may cause a from various conditions. No attempt has ever been complete hyperplasia. Staphylococcus: In 8 cases made to separate the diseases according to their of septicaemia due to pyogenes aureus or albus no action on the thyroid. thyroid reaction was present. Streptococcus: The The object of this paper is to point out those thyroids from 41 cases of streptococcic septicaemia diseases and togaemias that do, and those that do and other streptococcic infections show no change, not, produce an alteration in the thyroid, to describe with the exception of those from cases of scarlet and demonstrate these changes, to compare them and rheumatic fevers ; the changes in these diseases with those seen in goitre, and to note when they may be due to other micro-organisms. Acute surbecome associated with signs of thyroid excess. gical infections are found to have no effect on the Number of
.,
are :-
Average age
......
.........
......
....’
........
............
.........
............
............
............
* A paper read before the Pathological Section of the of Medicine on Feb. 17th, 1914.
Royal Society
thyroid. Protozoa.-Coccidiosis : No change
was
found in