34

may, he suggests, be related to monocytes and plasma-cytes, and/or to

" abnormal " lymphoid precursors witha range of lymphocytoid, monocytoid, or plasmacytoidfeatures. This concept, as yet somewhat vaguely formu-lated, involves questionable assumptions concerning therole of reticulum cells in lymphopoiesis, and CARTERacknowledges its speculative nature.At least during the acute phase of the disease, some

5-10% of the atypical mononuclear cells in the blood aresynthesising, or have very recently synthesised, cellularD.N.A. A certain amount of cell-division may be seen inthe blood, but the bulk of mitosis among these cellsapparently takes place in the lymphatic tissues. D.N.A.

synthesis on this scale by circulating cells is suggestiveof leuksemia. But CARTER believes that it is rare for anindividual atypical cell in glandular fever to resemblea leukaemia blast morphologically; and, viewed as a

population, glandular-fever cells have a more varied

appearance than leuksemic cell populations under thelight microscope. Other features which differentiate

glandular fever, even at its height, from leukaemia arethat the architecture of the lymphatic tissues is not

completely disrupted, and that involvement of the bone-marrow (with its associated depression of haemopoiesis)is usually slight or absent. Moreover, chromosomeabnormalities are not seen in glandular fever.The cell proliferation in lymphatic tissues has the

aspect of a particularly violent and prolonged immuneresponse. There seems to be no convincing evidencethat the circulating abnormal mononuclear cells them-selves synthesise immunoglobulins, and they are prob-ably not responsible for the Paul-Bunnell antibody orfor the raised IgM levels in glandular fever. AsDAMESHEK and Gurtz 1 pointed out, the abnormal mono-nuclear cells are somewhat similar to the cells whichappear during the immune response to an allogeneic skinhomograft-a response in which circulating antibody isnot essentially involved, and which may be classifiedwith the delayed-type hypersensitivity reactions. In thisconnection, RAPAPORT and his colleagues have reportedthe formation of heterophile antibodies by humansubjects rejecting skin allografts: this is a further featurewhich may connect glandular fever with graft rejection.One may speculate that glandular fever involves a

hypersensitivity reaction, predominantly of delayed type,against an antigen or antigens unknown. The presentevidence suggests that the antigens may be viral.DAMESHEK and GUNZ 1 suggested that the reaction mightbe autoimmune, mounted by abnormal lymphoidcells " genetically or somatically different from the tissueof the ’ host’ patient", but they adduced no directevidence in support of this concept.

3. Rapaport, F. T., Kano, K., Milgrom, F. Lancet, 1966, ii, 1131.

Annotations

THE HEALTH OF STUDENTS" There is a need to provide a comprehensive health service

for all students receiving higher education. This should includein addition to medical staff and auxiliaries, adequate premisesfor consultation and the provision of a sick bay."

" A student health service should be concerned withenvironmental hazards to students and staff working ininstitutions of higher education."

" Special provisions must be made for mental health prob-lems, which should include psychotherapists in the studenthealth service, and a close liaison with the local psychiatricservices of the National Health Service."

" Special facilities should be available for students with

long-term illnesses."" There is need for a special unit for training student health

officers and others concerned with student care. The unitwould also undertake research."

THESE are the main recommendations of the new reporton student health from the Royal College of Physiciansof London. The report points to a steady increase bothin the number of universities and colleges in this countryproviding health services and in the number of studentsenrolled; and " there has also been a major changein emphasis between the different facets of studenthealth work itself". These developments had combinedto move student health services from the limited role of

detecting and preventing " incipient constitutional dis-ease " (the phrase used by the University Grants Com-mittee in 1952) to a place where they had a much widerresponsibility, not merely in providing clinical services,but in contributing to the entire social process wherebystudents adjust themselves to the demands of the university

and the university adjusts itself to the needs of thestudents.

Student health services have developed along two mainlines; those which run a consultative advisory service,where each student has his own general practitioner; andthose which offer a complete comprehensive serviceunder the National Health Service, where studentswho have not already got a family doctor can registerwith the student health physician, and where part of thecost is offset by the N.H.S. The report favours the

comprehensive service, run from a central, well-equipped,and well-staffed building, with a sick-bay where shortand minor illnesses can be treated when the student livesin " isolated flats and lodgings in which adequate nursingand medical care is almost impossible ". It also emphasisesthe importance of student health services in the care ofmental health. There is no more emotional or mentalillness in the student group than in the rest of the

population of the same age, the report maintains, and" no real evidence that psychiatric disorders have become

more prevalent in students than they were, nor thatstudents as a group are psychiatrically more unhealthythan other young men and women ". Yet when thesedisturbances do arise, their effects are more seriousbecause " they impede, indeed often prohibit, effectivestudy ... This is not only harmful for the students’ owncareers, but is a waste in time and money of the nation’sresources ". Student health physicians, therefore, shouldnot only be able to diagnose these conditions early, butthey should also be able to treat many of them, andthey should have prompt and easy access to skilledpsychiatric help. The report refers to the other " tra-

ditional and valuable sources of help ... chaplains,tutors, hostel wardens, lodgings officers... A closeliaison between them and the medical services is essential,

35

and the training of such colleagues in the recognition ofpsychological disturbances and their proper managementeither by themselves or by referral is an importantaspect of the mental health work ..."

Figures from a pilot survey show that 5 students per1000 miss half a term or more each year because of

illness; of these 2 are psychiatric and 3 medical or surgicalillnesses. In the larger universities educational facilitiesmight be offered alongside medical and surgical care forstudents with long illnesses.A student health teaching unit should be formed in

a medical school or postgraduate medical institute of auniversity in an area with a large student population.Such a unit, in addition to running full-time, part-time,and occasional advanced courses for student-health

doctors, ancillary workers, and other professionals havingcare of students, would be well equipped to arrangelectures and seminars for those members of universitystaff with pastoral responsibilities. The unit would alsofoster and itself undertake research into problems ofhigher education, particularly those that bear upon thehealth, welfare, and capacities of the student.This valuable report shows how the scope of student

health services has grown from the original idea ofroutine medical examinations and annual chest X-raysto the comprehensive services which many-but not all-universities now have. Today about 375,000 studentsare engaged in full-time or part-time higher education,and in some university centres, the ratios-which thereport accepts-is one physician to every 1500 or 2000students. There are now rather more than 100 studenthealth doctors in Great Britain, but to come anywherenear the figures suggested by the report about 200 areneeded. Wide differences still exist in certain areas

between what is regarded as adequate or ideal and theactual position. Much has been achieved, much moreremains to be done; and these periodic reviews by theRoyal College of Physicians are of great value to allconcerned with the health and welfare, in its widest

sense, of the student population.

RADIOLOGISTS AND RADIATION

WHEN Shields Warren suggested in 1956 that radio-logists in the United States had not only been more liableto leuksemia than the general population but hadalso been dying earlier from some non-specific effect, hisfigures were challenged as statistically vulnerable. Therewas no question about the leukxmia, but doubts werevoiced about the " premature aging". It has since becomeclear that there was such an effect in U.S. radiologists, buta new analysis by Warren and Lombard 2 indicates that itstarted to diminish in 1935 and had disappeared by 1960-presumably because maximum permissible dose levelswere being satisfactorily observed. Similarly, the excess ofleukaemia in U.S. radiologists has fallen over the years;and again the implication is that safety precautions werebeing more strictly applied. A striking point in the newdata from Shields and Lombard is the different agepattern of leukaemia in radiologists and in U.S. whitemales over 25: no leukaemia was observed in radiologistsbefore the age of 40, yet in the general population theproportion of deaths attributed to leuksemia is highest in

1. Warren, S. J. Am. med. Ass. 1956, 162, 464.2. Warren, S., Lombard, O. M. Archs envir. Hlth, 1966, 13, 415.

the under-40s. This contrast points to a different mech-anism in radiologists-very likely their occupationalexposure.

HEPATIC CIRRHOSIS AND DIABETES MELLITUS

THE association of hepatic cirrhosis with diabetesmellitus may be becoming more common. For example,an analysis by Bloodworth 1 for the years 1937-44 showedan incidence of only 1-9% of cirrhosis in 5000 necropsieson diabetic patients, which was no higher than theincidence in non-diabetics, whereas the comparable figurefor 1955-60 was 10-5%. The converse figure for diabetesin cirrhosis was 12%. A similar analysis in Germany byMuting et al.2 illustrates the same trend. Here the figures,based on the clinical diagnoses of 15,822 inpatients, total1520 with diabetes, 405 with cirrhosis, and 140 with bothcirrhosis and diabetes; but whereas the number of patientswith the combined diseases numbered only 6 in 1958, thefigure had risen to 47 by 1965, although the number ofpatients per year was virtually unchanged.Of course, two common diseases are sure to be found

together quite often. Thus, from the German figuresshowing an incidence of approximately 1 in 10 for diabetesand 1 in 40 for cirrhosis, a chance incidence of the twotogether would be 1 in 400-about 40 cases compared withthe observed figure of 140. This big increase of doublyaffected patients over the expected number implies thatone disease predisposes to the other. Of the 140 patientsin the German series, 103 had cirrhosis and later haddiabetes, 27 were diabetics who subsequently had cirrhosis,and in 10 the sequence was not established. These figuresare of great value because they indicate the direction of theassociation. Thus, the development of cirrhosis in only 27out of some 1400 diabetics, an incidence of 1 in 50, is nocommoner than that in the general inpatient population.Conversely, the appearance of diabetes in almost 1cirrhotic patient in 4 points clearly to a predisposition ofthe patient with cirrhosis to become diabetic.The diagnosis of diabetes in the presence of cirrhosis

can be difficult because, as Sherlock 3 pointed out,"

glycosuria, weight loss, and an impaired oral glucosetolerance are features of both conditions ". The mostreliable diagnostic feature is the fasting blood-sugar level,which rarely exceeds 120 mg. per 100 ml. in uncomplicatedhepatic cirrhosis. Muting and his colleagues, however,were well aware of these difficulties, and they accepteda diagnosis of diabetes only on rigid criteria, includinga fasting blood-sugar level of not less than 130 mg. per100 ml. Three explanations have been advanced to

account for the progress of cirrhosis to diabetes: thecoexistence of cirrhosis of the pancreas; disturbance of thecontrol of blood-sugar in the liver; and inactivation ofinsulin by anti-insulin antibodies in liver disease. Necropsyevidence of pancreatic cirrhosis is totally inadequate toaccount for the observed connection between hepaticcirrhosis and diabetes; and antibodies to insulin in untreateddiabetics are extremely rare, if they arise at all.4 5 Thisleaves intrahepatic disturbance of sugar metabolism as themost probable mechanism. How this is brought about is

1. Bloodworth, J. M. B., Jr. Archs intern. Med. 1961, 108, 695.2. Müting, D., Lackas, N., Reikowski, H., Richmond, S. Ger. med. Mon.

1966, 11, 385.3. Sherlock, S. Diseases of the Liver and Biliary System; p. 443. Oxford,

1963.4. Mancini, A. M., Zampa, G. A., Vecchi, A., Costanzi, G. Lancet, 1965,

i, 1189.5. Chetty, M. P., Watson, K. C. ibid. p. 57.