941DIFFICULT POINTS IN LIFE INSURANCE.—POOR-LAW MEDICAL RELIEF. [

and instructive. The patient was a man, aged 34 years, whofor the past six years had not been able to empty his bladderexcept by catheter. As in the previous case, there was noevidence of mechanical obstruction, of nerve disease, or ofsyphilis. The age of the patient excluded the diagnosis ofsenile bladder, and the actual nature of the case remainedobscure until Professor Casper showed the patient to his

colleague Dr. Th. Mayer on account of a peculiar condition ofthe skin over both knees and hands. This was recognised asan atrophic condition of the skin, and was found to be asso-ciated with some atrophy of the interossei and lumbricales ofboth hands. These atrophic processes led Professor Casperto attribute the inefficiency of the bladder to a similar con-dition of its musculature, and cystoscopic examination lentsupport to this view, since a number of diverticula were foundto be present. Apart from congenital diverticula, such appear-ances are only found in cases where the pressure of the urinecauses the bladder wall to yield, and their occurrence in a youngman without mechanical obstruction of the urinary passagesled to the conclusion that the bladder wall was partlyatrophic and had therefore yielded to the ordinary pressure.The case was therefore regarded as a tropho-neurotic affec-tion with atrophy of various structures. This diagnosisexcluded the use of operative measures for treatment, whichtherefore consisted simply of catheterism. It will be

interesting to see if Professor Casper’s communication servesto bring forward records of similar cases.

DIFFICULT POINTS IN LIFE INSURANCE.

One of the most frequent obstacles to the passing of livesfor insurance is the presence in the urine at the time of theexamination of albumin or of sugar or some other substancewhich reduces Fehling’s solution. All medical examiners

must be familiar with the type of case in which everythingappears satisfactory-family and personal history, physique,and physical examination-until the urine is tested and thisis found to contain one of these substances. The presenceof albumin or sugar on one occasion may be purely anaccident, but it is only possible to judge of this after exami-nations of other specimens of urine. It is the usual practiceof medical examiners for insurance at a little interval to

examine other specimens of the urine passed either in theirpresence or in that of some agent of the insurance com-pany. If these specimens prove to be normal the life

may usually be accepted at ordinary rates, but if they beabnormal there is no alternative but to postpone acceptanceor to decline the life. Sometimes an immediate acceptance isdesired without waiting for further tests and then an extrarating may meet the case, and this ’rating may be removedif it is found later that the albumin or sugar was purelytemporary. This matter has been brought to our attentionby a medical correspondent who considers, and, we think,with some ground, that he has a grievance against aninsurance company and its medical officer. The facts appearto be as follows. A medical practitioner of over 20 years’standing wished to insure his life for .f.500 and was examinedby the medical officer of a first-class company. For severalweeks he heard no more about the matter, and then oninquiry of the agent he was told that the medical officerhad advised that the proposal should lie over for threemonths. He subsequently ascertained that the medicalofficer reported that the urine had a trace of albuminand phosphates and a specific gravity of 1012. Examina-tions of the urine by the candidate for insurancebefore the medical officer’s examination had failed to

reveal any abnormality, and the same healthy result was

obtained afterwards. The candidate for insurance then sub-

mitted himself for examination by a leading practitioner inthe town where he resides, and was reported to be sound inevery way, the urine being quite normal. As far as we can

judge from the facts put before us, our correspondent seemsto have been treated somewhat severely in having his casepostponed for three months on the gro und of one examina-tion of the urine showing a trace of albumin. Butwe see no reason to think, as our correspondent does, thatthe medical examiner made any mistake in testing theurine. There is no reason why albumin should not be

present with a specific gravity of 1012. Indeed, it is

usually with urine of low specific gravity that traces of

albumin are found. Moreover, the fact that albumin hasnot been found before or since does not make it less

possible that a trace of albumin was present at the examina-tion for life assurance. The applicant meanwhile has with-drawn his proposal, but we have no doubt that if he wishedto proceed with it he would now find no difficulty in gettingacceptance at the same or another office. We suggest thathe apply to the same office again.

POOR-LAW MEDICAL RELIEF.

A CIRCULAR nas been issued, recently by tne Locamxovern-ment Board to boards of guardia ns concerning the adminis-tration of out-door relief to the poor. The short section

concerning medical relief is couched in general terms, butshould encourage guardians to take a more generous view of £their responsibilities in this matter than has always been thecase hitherto. The recommendation reads as follows : "In

the administration of out-door medical relief the same careshould be observed by the guardians as in the case of ordinaryout-door relief. While there should be precautions to preventan undue resort to medical relief at the cost of the rates,it is important that every facility should be provided toenable the sick poor to obtain the medical assistance ofwhich they stand in need. For this purpose themedical relief districts should be so arranged that theservices of the district medical officer may be readily avail-able, and steps should be taken to ensure that there is nounnecessary delay in obtaining a medical order. It is

especially important that the guardians should be able tosupply the services of nurses in case of need. Nurses are

generally best provided through the agency of local nursingassociations, and the Board are willing, as in the past, tosanction subscriptions by the guardians for this purpose. In

a recent circular letter the Board made a similar suggestionas regards midwives. The Board recognise that much goodis done by means of provident dispensaries and medicalclubs, and they consider it desirable that the guardiansshould avoid action which may have the result of dis-

couraging membership of such societies."

THE VARIETIES OF TUBERCULIN.

IN THE LANCET of March 26th, p. 844, we published a lectureby Dr. Nathan Raw on the Treatment of the Surgical Formsof Tuberculosis by Tuberculin. In it the writer drew attentionto some of the various forms of tuberculin now employed.We have received a pamphlet containing the report of adiscussion which took place at the German PharmaceuticalSociety in February of last year. The discussion was intro-duced by Professor W. G. Ruppel with a paper entitled" Tuberculin and other Specific Preparations as an Aid to theDiagnosis and Treatment of Tuberculosis. " Professor

Ruppel related the history of tuberculin from the timeof its introduction by Professor R. Koch in 1891.He then gave a brief account of the method of manu-

facture of the substance and the modifications whichwere subsequently introduced. He showed that the failuresmet with in the earlier days of its use were due to the largedoses employed. Now that it has been demonstrated thatan immunising response can be evoked by minute dosesnumerous observers have again employed the remedy both inmedical and surgical cases. Professor Ruppel’s remarks will