Diagnosis and management of diabetic autonomic neuropathy.

SIR,-It is refreshing to read so much of interest and value in Dr Christopher Page's short paper on his experience of applying five preventive activities in his practice (4 June, p 1787). Among the important problems raised are those of how and when to carry out such activities. In my own experience there is a poor response to all efforts to interest women of child bearing age in rubella immunisation until they are on the point of considering starting their families. The acceptance rate is much higher during their last few months on the contraceptive pill (or whatever other contraceptive measure is used). Furthermore, after considering the questions raised by the more intelligent women as to why they should have a needle stuck into them for blood tests, to be followed by an injection of the vaccine, it seemed reasonable to give the vaccine to all those who could not produce evidence of a proved attack of rubella or of vaccination, without adding to the work of the local laboratory. Interestingly, the offer of contraceptive advice is the only other truly preventive activity listed by Dr Page. The other activities are essentially those concerned with an equally admirable aim-the early detection of disease processes, as in the case of taking cervical smears, or in looking for possible underlying emotional or psychological stress in those who smoke or overindulge in alcohol or food. The remaining activity mentionedthe measurement of the blood pressure-is concerned with the finding of an abnormal physical sign. This may or may not be of any significance on one reading, but certainly it requires further examinations and possibly investigation so that a firm diagnosis of the underlying cause can be found. I have used three other routine activities during the first consultation of all new patients for some years, as well as in old patients coming with new problems. The first requires one of the many available "dip stick" urine testing agents in order to identify undiagnosed diabetic patients, who are supposed to equal the number of known diabetic patients on the list. Occasionally, an early case of hepatitis or cirrhosis is found too! The other two activities require no special equipment: routine palpation of the breasts and examination of the skin. I expect to discover one or two previously unnoticed breast cancers each year and rather more skin cancers. In addition, I find a steady procession of premalignant lesions; such as cutaneous horn, leukoplakia, and lentigo maligna, to say nothing of the hundreds of warts, including plantar warts, which are so easily spread to others using the same changing rooms at swimming pools and gymnasiums. Similarly, genital warts, which may not bother their owners, may cause much concern to sexual partners when they become infected. All these lesions are highly amenable to treatment with liquid nitrogen cryosurgery, which I use regularly. Since a recent visit to America convinced me of the value of immunisation against mumps, especially in boys, I have added this preventive measure for all infants at the age of 18 months. Finally, Dr Page raises the important and highly relevant factors of list size and time. Now is the moment fo? every general practitioner to write to his new member of parliament urging action to increase the number of principals in general practice. This would allow more time for each patient and so enable the primary care team to provide the high standard of medical care described by Dr Page, which should be available for all.