- Email: [email protected]
THE SIGNIFICANCE OF GLYCOSURIA IN LIFE ASSURANCE
732
CORRESPONDENCE THE SIGNIFICANCE OF GLYCOSURIA IN LIFE ASSURANCE
To the Editor
of THE
LANCET
SiR,-The leading article on the significance of glycosuria in life assurance in your issue of August 18th (p. 365) is based very largely but not entirely upon said at discussions before the Assurance (not Insurance) Medical Society at two meetings held in London on Nov. 1st, 1933, and Feb. 7th, 1934. Members of this society particularly, and members of the medical profession in general when they have perused the reports to which you call attention, can but warmly approve of and appreciate this endeavour of THE LANCET to give publicity to discussions which, as you truly maintain, are of such great importance and which but for your action would have remained known to a limited number of people. Alas !you give me credit for establishing certain very important facts; this credit should be given to three American actuaries who carried out close studies from which the figures quoted by me were drawn and which were published 20, 9, and 3 years ago. These studies proved that there is no reason whatever for the highly alarmist current impression that cases of symptomless glycosuria should be regarded from the insurance and therapeutic points of view as cases of prospective diabetes mellitus. At the time these discussions took place no public medical library in Great Britain possessed a copy of the papers in which these facts are recorded. All that I have done in the matter is to help to make known the existence of these studies to those who are responsible for the erroneous teaching to which I have referred. My only original contribution to the discussions was to prove from observations carried out on the blood-sugar contents of my own patients and of those of others and upon candidates for life assurance that the curves based upon the blood-sugar analyses, and the levels of renal tolerance of sugar, vary from time to time in the same individual, under observation by the same or by different biochemists, and that these mutations may be spontaneous or may be artefact. In face of these facts, I am anxious to give expression to my objection to your statement that " those who have worked at sugar-tolerance curves believe that
what
was
a renal glycosuria or with a typical lag should be accepted at the usual rates." As sugar curves and renal thresholds are mutable the same advice should be given with regard to cases showing a diabetic curve ! I should like to add that should any reader care to avail himself or herself of one of the few reprints I still possess, and in which certain serious printer’s errors have been corrected, I shall be glad to forward
patients with curve
one on
application.
I am, Sir, yours faithfully, H. BATTY SHAW. 122, Harley-street, W., Sept. 21st. ERYTHEMA NODOSUM
To the Editor
of
THE LANCET
the leading article in your last issue quote Dr. Slot’s note on erythema nodosum published the week before. May I offer the following criticisms of his paper (1) No report of the X ray was his cases of given or the skin reaction appearances to tuberculin, or H.S.E. (haemolytio streptococcal "endotoxin "), or Dick toxin. (2) Erythema nodosum
SIR,-In
you
if left alone, in from one to the injection of serum into four cases without controls ’is completely valueless and misleading. Besides, theoretically, there is no reason why the ordinary antistreptococcal serum should be of any use. In the streptococcal cases which I fully investigated and reported the patients were all definitely negative to the streptococcal exotoxin (Dick toxin) and strongly positive to the endotoxin (better termed "extract," a substance akin to tuberculin). One patient had six attacks of erythema nodosum and was investigated in two. She was always negative (before, during, and after attacks, over two years) to tuberculin and Dick toxin, but so sensitive to the haemolytio streptococcal endotoxin that an attack could be simulated by an injection
usually clears up, Hence seven days.
of this substance. I would willingly, however, give up ever mentioning these rare and comparatively unimportant cases of the streptococcal (wrongly called rheumatic) type, if thereby I could persuade my colleagues of the necessity of regarding every case of erythema nodosum as potentially tuberculous until proved otherwise. In London, when specially working on streptococcal diseases and being in touch with some 700 children suffering from such states, my percentage of strepto. coccal cases was 29 as opposed to 71 per cent. tuberculous, although I was not working on tuberculosis at the time. Here in Dublin during the last two years I have seen some 20 cases of erythema nodosum, only 1 of which was streptococcal. In children I feel entitled to say now, and I am glad to see Dr. Donald Paterson takes the same view, that the majority of cases of erythema nodosum are tuberculous. I would like to state also in connexion with your leading article that I am in almost complete agreement with all the points made by Drs. Forman and Whitwell. I use the sedimentation time (Payne’s method) as a routine in my wards and find it a very great assistance when assessing the. " activity " of tuber. culous and rheumatic disease. I am, Sir, yours faithfully, W. ROBERT F. COLLIS. Dublin, Sept. 25th.
of THE LANCET SiR,-That certain cases of erythema nodosum will clear after the injection of antistreptococcal serum was pointed out a good many years ago by Dr. A. H. Carter, formerly physician to the Wolverhampton and Staffordshire General (now The Royal) Hospital, Wolverhampton. I have for myself verified the fact that certain cases will clear after the injection To the Editor
of normal horse serum ; whatever serum be used the results in some cases may be rather cataclysmic. The fact, pointed out by Dr. Donald Paterson in your last issue, that many patients suffering from this condition give a positive Mantoux reaction, is, of course, well recognised on the Continent. It is a further fact within my experience that in certain cases the eruption disappears after a positive reaction to tuberculin has been induced. In cases not giving a positive Mantoux reaction it is usual to find a history of sore-throat or of some respiratory infection preceding the appearance of eruption by from two to four weeks. In certain such cases small frequently repeated doses of emulsions of throat organisms appear to expedite the disappearance of the eruption. All these facts taken together gepm to indicate that the eruption of erythema uodcaum is "allergic" ’’
CORRESPONDENCE THE SIGNIFICANCE OF GLYCOSURIA IN LIFE ASSURANCE
To the Editor
of THE
LANCET
SiR,-The leading article on the significance of glycosuria in life assurance in your issue of August 18th (p. 365) is based very largely but not entirely upon said at discussions before the Assurance (not Insurance) Medical Society at two meetings held in London on Nov. 1st, 1933, and Feb. 7th, 1934. Members of this society particularly, and members of the medical profession in general when they have perused the reports to which you call attention, can but warmly approve of and appreciate this endeavour of THE LANCET to give publicity to discussions which, as you truly maintain, are of such great importance and which but for your action would have remained known to a limited number of people. Alas !you give me credit for establishing certain very important facts; this credit should be given to three American actuaries who carried out close studies from which the figures quoted by me were drawn and which were published 20, 9, and 3 years ago. These studies proved that there is no reason whatever for the highly alarmist current impression that cases of symptomless glycosuria should be regarded from the insurance and therapeutic points of view as cases of prospective diabetes mellitus. At the time these discussions took place no public medical library in Great Britain possessed a copy of the papers in which these facts are recorded. All that I have done in the matter is to help to make known the existence of these studies to those who are responsible for the erroneous teaching to which I have referred. My only original contribution to the discussions was to prove from observations carried out on the blood-sugar contents of my own patients and of those of others and upon candidates for life assurance that the curves based upon the blood-sugar analyses, and the levels of renal tolerance of sugar, vary from time to time in the same individual, under observation by the same or by different biochemists, and that these mutations may be spontaneous or may be artefact. In face of these facts, I am anxious to give expression to my objection to your statement that " those who have worked at sugar-tolerance curves believe that
what
was
a renal glycosuria or with a typical lag should be accepted at the usual rates." As sugar curves and renal thresholds are mutable the same advice should be given with regard to cases showing a diabetic curve ! I should like to add that should any reader care to avail himself or herself of one of the few reprints I still possess, and in which certain serious printer’s errors have been corrected, I shall be glad to forward
patients with curve
one on
application.
I am, Sir, yours faithfully, H. BATTY SHAW. 122, Harley-street, W., Sept. 21st. ERYTHEMA NODOSUM
To the Editor
of
THE LANCET
the leading article in your last issue quote Dr. Slot’s note on erythema nodosum published the week before. May I offer the following criticisms of his paper (1) No report of the X ray was his cases of given or the skin reaction appearances to tuberculin, or H.S.E. (haemolytio streptococcal "endotoxin "), or Dick toxin. (2) Erythema nodosum
SIR,-In
you
if left alone, in from one to the injection of serum into four cases without controls ’is completely valueless and misleading. Besides, theoretically, there is no reason why the ordinary antistreptococcal serum should be of any use. In the streptococcal cases which I fully investigated and reported the patients were all definitely negative to the streptococcal exotoxin (Dick toxin) and strongly positive to the endotoxin (better termed "extract," a substance akin to tuberculin). One patient had six attacks of erythema nodosum and was investigated in two. She was always negative (before, during, and after attacks, over two years) to tuberculin and Dick toxin, but so sensitive to the haemolytio streptococcal endotoxin that an attack could be simulated by an injection
usually clears up, Hence seven days.
of this substance. I would willingly, however, give up ever mentioning these rare and comparatively unimportant cases of the streptococcal (wrongly called rheumatic) type, if thereby I could persuade my colleagues of the necessity of regarding every case of erythema nodosum as potentially tuberculous until proved otherwise. In London, when specially working on streptococcal diseases and being in touch with some 700 children suffering from such states, my percentage of strepto. coccal cases was 29 as opposed to 71 per cent. tuberculous, although I was not working on tuberculosis at the time. Here in Dublin during the last two years I have seen some 20 cases of erythema nodosum, only 1 of which was streptococcal. In children I feel entitled to say now, and I am glad to see Dr. Donald Paterson takes the same view, that the majority of cases of erythema nodosum are tuberculous. I would like to state also in connexion with your leading article that I am in almost complete agreement with all the points made by Drs. Forman and Whitwell. I use the sedimentation time (Payne’s method) as a routine in my wards and find it a very great assistance when assessing the. " activity " of tuber. culous and rheumatic disease. I am, Sir, yours faithfully, W. ROBERT F. COLLIS. Dublin, Sept. 25th.
of THE LANCET SiR,-That certain cases of erythema nodosum will clear after the injection of antistreptococcal serum was pointed out a good many years ago by Dr. A. H. Carter, formerly physician to the Wolverhampton and Staffordshire General (now The Royal) Hospital, Wolverhampton. I have for myself verified the fact that certain cases will clear after the injection To the Editor
of normal horse serum ; whatever serum be used the results in some cases may be rather cataclysmic. The fact, pointed out by Dr. Donald Paterson in your last issue, that many patients suffering from this condition give a positive Mantoux reaction, is, of course, well recognised on the Continent. It is a further fact within my experience that in certain cases the eruption disappears after a positive reaction to tuberculin has been induced. In cases not giving a positive Mantoux reaction it is usual to find a history of sore-throat or of some respiratory infection preceding the appearance of eruption by from two to four weeks. In certain such cases small frequently repeated doses of emulsions of throat organisms appear to expedite the disappearance of the eruption. All these facts taken together gepm to indicate that the eruption of erythema uodcaum is "allergic" ’’