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ANNOTATIONS

THE KING AND PREVENTIVE MEDICINE

THE appointment of six practitioners of preventivemedicine to be honorary physicians to the King is aconspicuous honour to the public health services.The official announcement states that the recipientsof this distinction will be drawn " from the membersof the medical profession engaged in public healthwork, both in central and local government," andthat appointments will be made for three years. Infuture, therefore, the leaders of preventive medicinewill have the same royal recognition as has long beenextended to clinical consultants and senior medicalofficers in His Majesty’s Forces. The decision is onethat strikes the imagination, and its rightness is

unquestionable. There has been a feeling that themen who have built up our health administration,so widely copied by other countries, have too oftenbeen overlooked when honours were accorded to theprofession. By his present action the King assuresa continuance of recognition for outstanding servicesby the health officers of central and local authorities.The initial selection of these honorary physicians

establishes the type of services to be rewarded.Sir Arthur MacNalty represents central administra-tion, Sir Edward Mellanby research, Dr. J. C. Bridgeindustrial hygiene, and Dr. J. H. Hebb the ameliorativeservices of the Ministry of Pensions ; while those

responsible for local health administration are worthilyrepresented by Sir Frederick Menzies, medical officerof health for the county of London, and Dr. A. S. M.Macgregor, medical officer of health for Glasgow.To those receiving the honour, and to the publichealth services as a whole, we offer congratulations.

TUBERCULOSIS OF THE SPLEEN

SPLENIC tuberculosis occurring as a clinical entity-apart from involvement of the spleen in generalisedtuberculosis-appears to be very rare. The olderwriters who saw more tuberculosis than we do havevery little to say about it. Matthew Baillie describesone case of tuberculous abscess in the spleen, butRokitansky, despite his vast experience in the post-mortem rooms of Vienna, is silent on the subject.Modern text-books have little to add. Winternitz 1

records 51 instances of extensive tuberculosis of the

spleen without marked disease of the other organs,but he notes only 1 in which the spleen was aloneaffected. Situated as it is in a strategic position inthe circulation, this organ probably receives tuberclebacilli frequently but it evidently has considerablepowers of dealing with them, and some years agoa splenic extract was put on the market as a cure fortuberculosis (though it had a very short and limitedpublicity) on the assumption that such an extractwould have protective properties.

Krause has shown that when tubercle bacilli areinoculated subcutaneously in the guinea-pig theymay appear in the spleen as early as four days after-wards, and there is a general tendency nowadays tobelieve that the bacillus when it gains entrance to thebody of man reaches the blood stream early. Whythen does the spleen show relatively little involvementeven in the late stages of the disease ’? It is notcommon to find it affected even in fatal cases of

pulmonary tuberculosis. This viscus is unlikely tobe the site of a Ghon focus. Such a lesion is generally

1 Quoted by E. H. Pool and R. G. Stillman, Nelson’s Loose-leaf Living Surgery, New York, vol. v, p. 363.

situated at or near a portal of entry and the organwill only receive bacilli when the barriers of defencebetween the primary focus and the blood stream have a

been penetrated. The two instances of tuberculosisof the spleen recorded in our present issue by Dr.Pether are presumably examples of this happening,the primary focus in each case being situated in thefibrotic lesions of the lungs. On similar lines a recordof multiple calcifications of the spleen with healedtuberculosis of the lungs occurring in a case ofbronchial carcinoma has just been published byMoorman,2 who ’gives a short bibliography of thesubject.Apart from splenic involvement in generalised

tuberculosis therefore the spleen may show the

following tuberculous lesions : (1) fibrosis and scarr-ing ; (2) calcification, often with multiple nodules; (3)discrete generally rounded foci probably analogousto the discrete circular foci of other organs and

recently described by the German pathologists in thelungs; and (4) tuberculous abscess resulting from (3).Most writers are agreed that all these forms of thedisease are rare and the inference appears to be thatthe spleen has the same effective powers of dealingwith the tubercle bacillus that it has with other

organisms.

ANXIETY AND THE CIRCULATION

THE somatic disturbances of function that can bedetected in mental disorder are of importance notonly to the psychiatrist but, on practical grounds,to the general physician also. Thus it is not alwayseasy to distinguish the many-named circulatorydisturbances that may accompany morbid anxiety-effort syndrome, irritable heart, pseudo-angina,angina innocens, neurocirculatory asthenia-fromthose of organic disease of the heart or hypertension.The presence of " conflicts " and other possiblepsychogenic causes of anxiety proves nothing as tothe diagnosis since, if duly searched for, they can befound in anyone ; quantitative somatic data are whatis needed in doubtful cases. A number of preciseobservations in this field have been made of late.A contribution by White and Gildea 3 deals with thevariations in the pulse-rate, as measured by a "cardio-chronograph," an instrument ingeniously adaptedfrom the cardiotachometer of Boas. The subjectswere observed at rest, during a minimal emotionalstimulus (threat of discomfort), and during immersionof one hand for a minute in ice-cold water. The latter

procedure was suggested to the authors by the workof Hines and Brown 4 on the response of the bloodpressure to such a physiological stimulus. Theintervals between individual heart-beats as well asthe average heart-rate were recorded ; blood pressurereadings were also taken. The subjects who wereprone to show anxiety symptoms had higher initialheart-rates, and the rates increased more duringstimulation than did those of normal or psychoticpersons free from anxiety. In many of the anxious

patients the pulse-rates taken in the ordinary wayin the ward had shown nothing remarkable, andWhite and Gildea conclude that the cardio-chrono-graph gives a measure of the amount of anxiety andits circulatory effects that cannot be obtained bythe usual psychiatric methods. In a small group of

2 Moorman, L. J., Amer. J. Tuberc. September, 1937, p. 376.3 White, B. V., and Gildea, E. F., Arch. Neurol. Psychiat.,

Chicago, November, 1937, p. 964.4 Hines, E. A., and Brown, G. E., Amer. Heart J. 1936, 11, 1.