THE VALUE OF CARDIAC AUSCULTATION.
1
87 GLYCOSURIA AND LIFE ASSURANCE. RECENT letters in our columns have raised the question of the correct attitude of the life insurance office to clients whose urine contains a copper-reduc- ing substance. Formerly it was thought that such a substance must be dextrose and therefore that the patient had diabetes mellitus. The recognition that the urine may contain other copper-reducing sub- stances has led to more careful investigation. Even if the copper-reducing substance be dextrose, this is not sufficient to prove that the patient has diabetes mellitus, and insurance offices who do no more than this test are not dealing quite fairly by their clients. It is now recognised that the blood-sugar is not constant throughout the day, but may rise as high as 0.18 per cent. after a carbohydrate meal. The blood- sugar in healthy persons has usually returned to normal after one to two hours, and unless the blood-sugar rises above 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 0.19 per cent. in the great majority of persons, but it may be either 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 the threshold. Patients who have a normal sugar toler- ance, but have a lowered kidney threshold for sugar are said to have a renal glycosuria. In the past these patients have been diagnosed as having diabetes mellitus, but this mistake should no longer be made. Admittedly the condition has not long been recognised, but there are some patients whose blood- sugar curves have been under observation for over ten years, and whose condition has not undergone any change. There does not seem any reason why such persons should not be accepted at ordinary risks by the insurance offices. Some offices, it appears, are already doing this, but others either refer the patient to his medical attendant or defer the examination for a short period. In the light of our present knowledge this attitude does not seem correct. It would be an advantage to such a client if he (or his medical attendant) were told that he could not be accepted until his sugar tolerance had been proved normal by careful tests. If the blood-sugar curve was absolutely normal, the patient could well be accepted at ordinary rates. If it was not quite normal the patient should be deferred for a period of three months and then re-examined. Such a procedure entails a good deal of work, but the results should go far to remove any grounds for criticism of insurance offices. THE VALUE OF CARDIAC AUSCULTATION. IN the mind of the public the doctor is as inevitably associated with the stethoscope as is the cobbler with his last or the mason with his trowel. And the necessity of this conjunction is apparently felt almost as widely in the ranks of the profession itself, for we recently met an obstetrician who held that it was 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 of Dr. Otto May, in his address to the Assurance Medical Society 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 the stethoscope was first applied to the heart ; that it has done more to confuse the issues between proposer 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, made unhappy and invalided, by the discovery of a perfectly harmless murmur ’ ! Conceive, on the other hand, the number of thoroughly bad lives accepted as a result 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 repeat that, 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 agree with the writer’s conclusions or not there can be little dispute concerning his facts, of which the most serious is that healthy people are constantly led towards a permanent neurosis by the discovery of some peculiar but unimportant cardiac sound. The same result was produced during the war, when many thousands of healthy men were rejected for military service for the same reason, and it is unhappily true that once a man believes his heart to be unsound he will seldom be dissuaded even by the efforts of many cardiac specialists. But, accepting this, would we be right in rejecting the use of the stethoscope on the heart by students ? Surely not. There is no reason to reject this most useful instrument in cardiology, because for a considerable period after the interpretation of murmurs had first been attempted an exaggerated value was placed on their importance by clinical teachers. This is a natural sequence of all medical discoveries, and it may well be that reaction there- from may be pushing modern opinion too far in the other direction. In France, as in many European countries, the stethoscope is still used with less frequency than in our own ; but it is doubtful whether the general knowledge concerning the essentials of cardiac examination is greater abroad than in Great Britain. No doubt the foreign student will emphasise the evidence obtained by his eyes and fingers where our own will tend to exaggerate that given by the stetho- scope, but the well-trained and intelligent student will, in all countries, have learnt to obtain a wider series of facts from which to draw conclusions. In the next paragraph of his address Dr. May gives deserved praise to the advance in knowledge which has followed the discovery of the significance of various types of cardiac irregularity. But can it be said that a practitioner who condemns a patient on account of a simple systolic murmur at the apex, will not make equally grave mistakes when con- fronted with some marked but benign type of cardiac irregularity ? It is true that here again mistakes are frequently made by the inexperienced, but they are largely due to the fact that the detection of slight physical signs, whether by the use of the eye, the fingers, or the ear, or by any instrument which aids these senses, can only be arrived at after years of intelligent study. A house physician recently com- plained of the number of gastric cases admitted to his 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 that assurance authorities may reasonably expect to see a steady improvement in diagnostic and prognostic skill as regards cardiology, without the abandonment of the physician’s silent friend. GROUP STETHOSCOPY. A FORM of multiple electrical stethoscope, presented to the Royal Free Hospital, was recently described by Dr. Jenner Hoskin in our coJumns.1 A similar instru- ment was demonstrated to the Faculty of Medicine in Paris by the Dean, Prof. Roger, and Drs. Le Mee, Helie, and Rist. The apparatus was devised by the u’estern Electric Company, of America, and loaned to Dr. Le Mee, who, with Dr. Helie, visited the United States to represent French medicine and promote Franco-American medical relations. This apparatus, appearing for the first time in France, permits at least 600 persons to hear normal and abnormal cardiac and pulmonary sounds by means of numerous receivers, to which stethoscopes are attached. The sounds are reinforced microphonically and also produced by a loud speaker. They are heard preferably with the stethoscope since the general amplifier does not reproduce them so exactly. The apparatus is selective. The periods, or frequencies, of cardiac and pulmonary sounds range from 0 to 1100 vibrations per second. 1 THE LANCET, 1925, ii, 1164.
Transcript of THE VALUE OF CARDIAC AUSCULTATION.
87
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.
