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The Investigation of Symptomless Glycosuria with the Galactose and Cortisone Modified Glucose Tolerance Tests by R

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The Investigation of Symptomless Glycosuria with the Galactose and Cortisone Modified Glucose Tolerance Tests by R J Clin Pathol: first published as 10.1136/jcp.11.5.428 on 1 September 1958. Downloaded from J. clin. Path. (1958), 11, 428. THE INVESTIGATION OF SYMPTOMLESS GLYCOSURIA WITH THE GALACTOSE AND CORTISONE MODIFIED GLUCOSE TOLERANCE TESTS BY R. B. GOUDIE, W. P. STAMM, AND S. DISCHE From the Royal Air Force Institute of Pathology and Tropical Medicine (RECEIVED FOR PUBLICATION OCTOBER 21, 1957) Glycosuria is sought in routine clinical exami- Joslin and Lawrence are two leading authorities nations in order to detect patients with early or who are representative of the two main schools of mild diabetes mellitus. There is good evidence thought. Joslin, Root, White, and Marble (1952) that early treatment may avert deterioration and gave the following criteria for the diagnosis of lead to a lower and later incidence of the vascular, diabetes mellitus with the 100 g. glucose tolerance renal, and ophthalmic complications (Dunlop, test (" true glucose " technique, capillary blood): 1954; Ricketts, 1947). a fasting blood glucose over 100 mg./100 ml., Certain occupations are unsuitable for the dia- or a peak glucose value over 170 mg./100 ml. He betic, and early diagnosis is of particular im- considered that the two-hour level was " of greatcopyright. portance in the Royal Air Force because a value " but that " one cannot disregard the height diagnosis of diabetes is a ban on aircrew duties. to which the curve goes. In borderline cases it is Since other conditions may give rise to glycos- well to be conservative and to repeat the test on uria, its discovery must be followed by a careful a later occasion." investigation in every case to determine the cause. On the other hand, Lawrence (1947) attached Precision in diagnosis is important in view of the maximum importance to the two-hour level, irre- social and economic consequences of a diagnosis spective of the peak value of the curve. Using a of diabetes mellitus, and to provide reliable data 50 g. glucose tolerance test (capillary samples and http://jcp.bmj.com/ for assessing the natural history of the disease and " total reducing substances "), his figures for the the effects of treatment. upper limits of normal were: fasting 120, peak The glucose tolerance test is the most widely 200, and two-hour 120 mg./100 ml. Subtracting used method of determining the significance of 15 mg. /100 ml. for conversion to "true glucose" symptomless glycosuria. It is based on the fact values, these figures become fasting 105, peak 185, that after ingesting glucose most patients with and two-hour 105 mg. /100 ml. He considered frank clinical diabetes have high blood glucose that abnormal peak values were of no importance on September 29, 2021 by guest. Protected concentrations which are conspicuously abnormal, in the presence of a normal two-hour value, and i.e., they have an impaired tolerance to glucose. was convinced that diabetes could not be diag- By analogy, patients with symptomless glycosuria nosed without a raised two-hour value. He cited who have a frankly impaired glucose tolerance as evidence 80 cases observed by himself (1936) when compared with a normal control group are and the fact that normal persons given glucose by presumed to be diabetic if no other cause for im- duodenal tube and post-gastrectomy cases had pairment of tolerance can be found. Patients in abnormally high peaks but normal two-hour whom glycosuria is due to a low renal threshold values. He attributed these " oxyhypergly- usually exhibit a glucose tolerance which is com- caemic " or " lag " (Maclean, 1922) curves to rapid pletely normal. In some cases of glycoEuria the gastric emptying. glucose tolerance curves are abnormal in certain Joslin did not recognize oxyhyperglycaemic respects only; in others the curves are abnormal curves as constituting a separate group and but border on the normal. Controversy exists as claimed that he had seen such patients with nor- to the interpretation to be placed on these curves mal two-hour values whom time had shown to be owing to lack of agreement between authors on diabetic. the diagnostic criteria to be adopted. The present authors felt that although some J Clin Pathol: first published as 10.1136/jcp.11.5.428 on 1 September 1958. Downloaded from THE INVESTIGATION OF SYMPTOMLESS GLYCOSURIA 429 " oxyhyperglycaemic " curves were due to rapid that the intravenous glucose tolerance test was absorption of glucose, it was likely on a priori unlikely to detect impairment of glucose tolerance grounds that there would be a group in which the of very mild degree and hence would probably be same shaped curves were produced by true im- of little value in the diagnosis of patients showing pairment of glucose tolerance, and that there was borderline glucose tolerance curves. a need for further investigation of patients with Research on the use of galactose tolerance tests this type of curve. It was considered that the in parallel with glucose tolerance tests (Dische, group of patients with borderline glucose toler- Stamm, and Goudie, 1958) showed that the peak ance tests could conveniently be investigated at the galactose value tended to reflect the rate of absorp- same time. tion of ingested glucose, thus allowing a more Mosenthal (1947) considered that the intra- specific estimate of glucose tolerance independent venous administration of glucose for tolerance of absorption. testing was advantageous in difficult cases, since Fajans and Conn (1954) described a cortisone- irregularities of absorption of glucose from the modified glucose tolerance test, which, they alimentary tract were avoided. High oral toler- believed, might unmask the potential diabetic who ance curves associated with normal intravenous had normal glucose tolerance by the conventional tests do not necessarily indicate rapid intestinal test. absorption, since Moyer and Womack (1950) In the present investigation an attempt has been demonstrated that the intravenous glucose toler- made to assess the value of the galactose and the ance test was specific for impairment of glucose cortisone-modified glucose tolerance tests in the tolerance but not very sensitive. There is evidence diagnosis of patients with glycosuria showing that the intestinal mucosa may exert an endocrine oxyhyperglycaemic and other types of borderline hyperglycaemic effect during glucose abEorption. curves in oral glucose tolerance tests. The results and MacCallum (1932) extracted a copyright. Laughton of a follow-up on a small series of oxyhypergly- hyperglycaemia-producing substance from the caemic patients are also reported. duodenal mucosa of animals. Loubatieres (1954) showed a rise in an alloxan-like substance in the Galactose Tolerance Test blood after oral administration of glucose; in Material and Methods.-Both glucose and galactose diabetes a much greater rise occurred. Much tolerance tests have been performed on 65 patients less of this substance appeared in the blood of with a history of glycosuria. Eleven were patients normals and diabetics after intravenous glucose. requested by us to attend because their previous In view of these observations it was considered glucose tolerance tests had shown equivocal results, http://jcp.bmj.com/ TABLE I DETAILS OF CASES WITH DIABETES, PROBABLE DIABETES, AND PRONOUNCED IMPAIRMENT OF GLUCOSE TOLERANCE 1 %Family| Duration [ 50 g. Glucose' Peak Level % Duration Tolerance Test Galactose Case ~~~~~amly ot (mg. Tolerance on September 29, 2021 by guest. Protected NumberNumber Age~ ExpectedWeight Dibeesof 1 Glycosuria Symptoms F P.100 Ml.) 2 Test (mg./ Diabetes F. P. 2 ~~~~~~~~~~~~~~~~~100ml.) GJroup A: Definite Clinical Diabetes I 21 91 Neg. I month Polydipsia, polyuria 65* 222 191 32 2 24 102 ,, 18 months ,, ,, precoma 87 191 156 54 3 19 93 ,, 4 , Polyuria, loss of weight 285 440 404 76 4 36 81 ,, 4 , ,, polydipsia, rapid loss of weight, 226 389 320 78 ketosis 5 22 94 I,1 month Ketosis, polytoria, loss of weight 318 492 492 63 Group B: Probable Clinicial Diabetes 6 39 95 Neg. 2 months Heart block and ketonuria 108 212 135 42 7 51 112 ,, 2 years Mild thirst and polyuria 122 222 142 43 8 25 92 ,, 3 ., Loss of 7 lb. in weight in 6 months 179 394 276 86 9 50 127 ,, 13 ,, Recurrent urinary infection 106 252 137 27 Group C: Pronounced Impairment of Glucose Tolerance (peak over 185 mg., two-hour level over 135 mg.) 10 40 110 Neg. 4 months None 125 274 184 70 11 44 102 Mother 8 years ,, 160 284 233 25 12 48 94 Neg. 4 months ,, 98 204 157 57 13 36 127 ,, 6 years ,, 192 300 266 9 14 44 83 , 16 ,, Perspires excessively 72 255 167 130 * Received insulin 24 hours before G.T.T. F.=fasting level; P. =peak level; 2=two-hour level. J Clin Pathol: first published as 10.1136/jcp.11.5.428 on 1 September 1958. Downloaded from 430 R. B. GOUDIE, W. P. STAMM, and S. DISCHE and the remaining 54 were referred for investigation Results-Tables I, II, and III give a classified of glycosuria found either during a routine examina- list of the most recent glucose tolerance results tion or as a result of complaint of symptoms possibly obtained in the 65 patients with a history of glycos- caused by diabetes mellitus. Included in the study peak galac- were five patients with obvious clinical diabetes, four uria investigated, together with their on whom a diagnosis of " probable clinical diabetes " tose values. A brief account of the clinical aspects could be made, and eight who were referred because of each is included. of glycosuria but who showed no glycosuria during In order to facilitate comparison between the the glucose tolerance test. glucose findings and the galactose tolerance tests, On each patient a 50 g. oral glucose tolerance test the patients have been classified into groups was carried out using capillary blood and "true" according to the glucose tolerance results.
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