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GLYCOSURIA AND LIFE ASSURANCE.

RECENT letters in our columns have raised thequestion of the correct attitude of the life insuranceoffice to clients whose urine contains a copper-reduc-ing substance. Formerly it was thought that such asubstance must be dextrose and therefore that thepatient had diabetes mellitus. The recognition thatthe urine may contain other copper-reducing sub-stances has led to more careful investigation. Evenif the copper-reducing substance be dextrose, this isnot sufficient to prove that the patient has diabetesmellitus, and insurance offices who do no more thanthis test are not dealing quite fairly by their clients.It is now recognised that the blood-sugar is notconstant throughout the day, but may rise as high as0.18 per cent. after a carbohydrate meal. The blood-sugar in healthy persons has usually returned to normalafter one to two hours, and unless the blood-sugar risesabove the level of the threshold of the kidney for sugar,none can be detected in the urine by ordinary tests.The threshold of the kidney is set at 0.16 or 0.19per cent. in the great majority of persons, but it may beeither higher or lower than this level. If it be lower,sugar may be present either after each meal or

throughout the day, depending on the level of thethreshold. Patients who have a normal sugar toler-ance, but have a lowered kidney threshold for sugar aresaid to have a renal glycosuria. In the past thesepatients have been diagnosed as having diabetesmellitus, but this mistake should no longer bemade. Admittedly the condition has not long beenrecognised, but there are some patients whose blood-sugar curves have been under observation for overten years, and whose condition has not undergone anychange. There does not seem any reason why suchpersons should not be accepted at ordinary risks bythe insurance offices. Some offices, it appears, arealready doing this, but others either refer the patientto his medical attendant or defer the examination fora short period. In the light of our present knowledgethis attitude does not seem correct. It would be anadvantage to such a client if he (or his medicalattendant) were told that he could not be accepteduntil his sugar tolerance had been proved normal bycareful tests. If the blood-sugar curve was absolutelynormal, the patient could well be accepted at ordinaryrates. If it was not quite normal the patient shouldbe deferred for a period of three months and thenre-examined. Such a procedure entails a good dealof work, but the results should go far to remove anygrounds for criticism of insurance offices.

THE VALUE OF CARDIAC AUSCULTATION.

IN the mind of the public the doctor is as inevitablyassociated with the stethoscope as is the cobbler withhis last or the mason with his trowel. And thenecessity of this conjunction is apparently feltalmost as widely in the ranks of the profession itself,for we recently met an obstetrician who held that itwas as futile for a physician to be without a stetho-scope as for an accoucheur to be without forceps.To all those believing in this necessity the words ofDr. Otto May, in his address to the Assurance MedicalSociety printed in another column, will come as

rank heresy. " say," he writes, " in all seriousness,that it was a bad day for life assurance when thestethoscope was first applied to the heart ; that ithas done more to confuse the issues betweenproposer and company than most of us can realise.Conceive, if you can, the enormous number of per-fectly good lives rejected, and, what is worse, madeunhappy and invalided, by the discovery of a perfectlyharmless murmur ’ ! Conceive, on the other hand,the number of thoroughly bad lives accepted as aresult of the examiner’s ... acceptance of the stetho-scope as the practical arbiter of the heart’s condition- ‘ no murmur, therefore a good heart.’ I repeatthat, on balance, the harm done, not only to life

1 THE LANCET, Dec. 19th, 1925, p. 1307 ; Jan. 2nd, 1926,p. 48 ; and the present issue.

assurance, but to medicine generally, by the ausculta-tion of the heart, immeasurably outweighs the good."These are very strong words, but whether we agreewith the writer’s conclusions or not there can be littledispute concerning his facts, of which the most seriousis that healthy people are constantly led towardsa permanent neurosis by the discovery of some peculiarbut unimportant cardiac sound. The same resultwas produced during the war, when many thousandsof healthy men were rejected for military servicefor the same reason, and it is unhappily true that oncea man believes his heart to be unsound he will seldombe dissuaded even by the efforts of many cardiacspecialists. But, accepting this, would we be rightin rejecting the use of the stethoscope on the heart bystudents ? Surely not. There is no reason to rejectthis most useful instrument in cardiology, becausefor a considerable period after the interpretation ofmurmurs had first been attempted an exaggeratedvalue was placed on their importance by clinicalteachers. This is a natural sequence of all medicaldiscoveries, and it may well be that reaction there-from may be pushing modern opinion too far in theother direction. In France, as in many Europeancountries, the stethoscope is still used with less

frequency than in our own ; but it is doubtful whetherthe general knowledge concerning the essentials ofcardiac examination is greater abroad than in GreatBritain. No doubt the foreign student will emphasisethe evidence obtained by his eyes and fingers where ourown will tend to exaggerate that given by the stetho-scope, but the well-trained and intelligent studentwill, in all countries, have learnt to obtain a widerseries of facts from which to draw conclusions. Inthe next paragraph of his address Dr. May givesdeserved praise to the advance in knowledge whichhas followed the discovery of the significance ofvarious types of cardiac irregularity. But can it besaid that a practitioner who condemns a patient onaccount of a simple systolic murmur at the apex,will not make equally grave mistakes when con-

fronted with some marked but benign type of cardiacirregularity ? It is true that here again mistakes arefrequently made by the inexperienced, but they arelargely due to the fact that the detection of slightphysical signs, whether by the use of the eye, thefingers, or the ear, or by any instrument which aidsthese senses, can only be arrived at after years ofintelligent study. A house physician recently com-plained of the number of gastric cases admitted tohis wards, " What is the interest of a gastric ulcer,"he said,

"

you can’t listen to it ! " For such melo-maniacs there is scanty hope, but we believe thatassurance authorities may reasonably expect to seea steady improvement in diagnostic and prognosticskill as regards cardiology, without the abandonmentof the physician’s silent friend.

GROUP STETHOSCOPY.

A FORM of multiple electrical stethoscope, presentedto the Royal Free Hospital, was recently described byDr. Jenner Hoskin in our coJumns.1 A similar instru-ment was demonstrated to the Faculty of Medicine inParis by the Dean, Prof. Roger, and Drs. Le Mee,Helie, and Rist. The apparatus was devised by theu’estern Electric Company, of America, and loaned toDr. Le Mee, who, with Dr. Helie, visited the UnitedStates to represent French medicine and promoteFranco-American medical relations. This apparatus,appearing for the first time in France, permits at least600 persons to hear normal and abnormal cardiac andpulmonary sounds by means of numerous receivers,to which stethoscopes are attached. The sounds arereinforced microphonically and also produced by aloud speaker. They are heard preferably with thestethoscope since the general amplifier does notreproduce them so exactly. The apparatus is selective.The periods, or frequencies, of cardiac and pulmonarysounds range from 0 to 1100 vibrations per second.

1 THE LANCET, 1925, ii, 1164.