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with proper help are able to recover their former qualitiesand avoid relapses. A few people take small doses,usually of morphine, daily for years ; they have nowish to increase the dose, appear to be none the worsefor it, and indeed only work their best while it is con-tinued ; but they are rare. Of all methods of treatment," cold turkey " is the cruellest, and the most likely toprevent a relapsed patient from ever taking a cure

again. Sudden withdrawal supported by palliativetreatment, and especially by narcosis, is good and

effective ; and so is rapid withdrawal, in which thedose is reduced much faster than the patient realises.The dread of the last dose is overcome by telling himthat he has had no morphine for 48 hours at the momentwhen, in fact, the final minute dose has just been given.Slow methods of withdrawal merely spin out the agonywithout alleviating the dread of the last dose ; and

ambulatory methods are quite useless, since the doctorhas no means of checking whether the patient is gettingadditional supplies from elsewhere. Moreover, accordingto S. D. Hubbard, in most cases " all that can be doneis to reduce the amount of drug taken to a minimum,after which the doctor becomes in effect a legalisedpurveyor of his drug to the addict."Addicts must always be treated in an institution ;

but it will seem strange to British readers to findDr. Wolff advocating legislation to compel them toremain there until they have completed their cure-strange, because we do not welcome the idea of com-pulsory treatment even for those who can infect otherswith, say, the organisms of venereal disease, or tubercu-losis. It is usual to think of the addict as dangerousto no-one but himself ; yet it must be recognised thataddicts are found mainly among criminals and thatthey often take an active part in the" dope " trade.The Modinos method of treatment consists in blistering

the patient and injecting him with the blister fluid,on the theoretical assumption that he will then become"

hypersensitive " to his drug and reject it. The method

is painful but simple, and some people report good resultsfrom it ; others have done as well with injections ofnormal saline. Wolff concludes that the value of themethod lies not so much in the contents of the blisteras in the mystery attached to it. Since addicts areoften highly accessible to suggestion (which increasestheir liability to relapse) he insists that a cure is not

complete until adequate psychotherapy has helped thepatient to overcome the emotional difficulties whichlie behind the addiction. The earlier the case, the

greater the chance for such moral reablement.

PSYCHIATRY IN THE GENERAL WARD

THE drawbacks to treating mental patients in thewards of a general hospital are so readily imagined thatthe advantages seldom get much of a hearing. Manydoctors, and even more nurses, oppose the idea outright.Dr. James Carson and Dr. Howard Kitching, whodescribe on another page a successful experience of

psychiatry in a general ward, were faced at the outsetwith a good deal of opposition from the nursing staff.This derived, as might be supposed, from an abstractfear of mental illness, but it melted in the presence ofactual patients. As commonly happens where treat-ment is active and doctors keen, the nurses became

warmly interested and ready to take responsibility whichat first they had shunned.

Since the patients were admitted to a general ward,they had to be very carefully selected. The well-beingand peace of the other patients had to be considered, andunsuitable mental patients,-if admitted by mistake, hadto go. This must be considered a weakness of thescheme, for a patient does not cease ta be a problembecause he is discharged from a hospital ward, and

responsibility for -his further treatment must rest some-where. Dr. Carson and Dr. Kitching, however, werenot in a position to solve this problem : they had to dowhat they could, with the chance presented to them,choosing depressed and psychoneurotic patients whowould not disturb others and who were likely to respondquickly to physical methods. Electrical convulsant

therapy was largely used ; sedatives, prolonged narcosis,and modified insulin therapy were also available ; but

any deep psychotherapy was out of the question. Twomonths after treatment some 70% of 106 patients withaffective disorder described themselves as recovered orimproved. The experience has justified the experiment,Dr. Carson and Dr. Kitching believe, for the patientshave greatly valued the chance of being treated likeother sick people in a general hospital, and without thisopportunity some at least would have remained untreatedtill much later in their illness.

STRONGYLOIDES IN EX-PRISONERS-OF-WAR

FIRST discovered by Normand in 1876, the nematodeStrongyloides stercoralis has since been recognised as acommon parasite in hot moist climates ; and it is particu-larly prevalent in the areas of the Far East invaded byJapan in the late war.- British workers have hitherto

regarded bowel infestation with this worm as of little,if any, pathological significance, whereas elsewhere and -

notably in the U.S.A. it is believed to have considerablepotential importance. ’ ,

To man the infective stage of the parasite is normallya filariform larva which develops from - a rhabditoidlarva outside the host ; this actively penetrates skin ormucous membrane and enters the blood-stream, in whichit is carried to the lungs. Here it settles in the alveoli,where mature male and female worms may develop, thelatter ovipositing in the bronchial mucosa ; but more

commonly the larvæ ascend the respiratory passagesand descend the oesophagus to the small intestine,where the gravid female worms burrow into the mucosaof the gut wall and deposit eggs which rapidly hatchrhabditoid larvse. These rhabditoid larvae usually escapeto the lumen of the intestine and are passed in the fiecesto the exterior, there to undergo an exogenous cycle insoil. It seems, however, that some do not escape inthis way and do not even leave the intestinal -mucosa,but are carried in blood-vessels to the lungs, from whichthe cycle is repeated-a process called by Napier 1" direct endo-autoinfection." Alternatively, the rhab-ditiform larvæ, though not escaping into the lumen, maydevelop into filariform larvae which repenetrate themucosa lower down the bowel, again recommencing thecycle of infection ; this Napier refers to -as ? indirectendo-autoinfection." Or the rhabditoid larv2e in fæcalmatter contaminating the skin of the perianal andperineal regions may develop to the infective filariformtype and penetrate the skin, once more initiating a cycleof endogenous reinfection (" exo-autoinfection ").The significance of these various means of auto-

infection is that the worm population in the host may beincreased without exogenous development of the para-site ; no other human helminth parasite is known toincrease in man in this way. As Napier says, thevariations in the cycle of S. stercoralis in man aresuch that larvae may sometimes be absent from thestools of an infested subject ; detection of the wormthen depends on repeated examination. The exogenouscycle is also subject to variation. The rhabditoid larvaewhich escape to the exterior in the stools becomefilariform wheu they reach soil. They may remain inthis form, and are of course infective if they gain accessto unprotected skin or mucous membranes. Or these

free-living filariform larvae may develop to free-living1. Napier, L. E. J. trop. Med. Hyg. 1949 52, 25, 46.

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adult male and female worms which produce furtherbroods of larvae in soil ; and this cycle may be repeatedseveral times.Under the conditions in which prisoners lived and

worked in Japanese internment camps, many becameinfected with S. stercoralis, particularly among the militaryprisoners working on the railway in Siam ; and on repatri-ation a high percentage of these were found still to harbourstrongyloides. The symptoms of which these men com-plain are indefinite ; but both Napier and Caplan 2comment on curious cutaneous eruptions in associationwith the parasite. These eruptions have recurredperiodically, and in some cases the recurrences have nowcontinued for several years. The mechanism of their

production is uncertain, but in view of the usual distribu-tion of the lesions in the bathing-drawers region it issuggested that " exo-autoinfection " affords the mostsatisfactory explanation, even though no larvae have beenrecovered from any of these skin lesions. Unhappily themethods of eradicating this parasite are unsatisfactory.

ANÆMIA IN RHEUMATOID ARTHRITIS

IN the study of rheumatoid arthritis attention hascentred mainly on the articular and visceral lesions ;and little work has been done on the anaemia that

commonly accompanies this condition. Nilsson,3 in acomprehensive study, suggests that this anaemia is akinto that of chronic sepsis. Formerly haemolysis wasthought to play a large part in the production of anaemiain chronic sepsis, but quite recently the hypothesis ofimpaired haemoglobin synthesis has been put forward.Some of those who favour this hypothesis have demon-strated increased excretion of coproporphyrin i and III

in the urine and faeces 4; while others have recordedan increased erythrocyte protoporphyrin, which, theysuggest, reflects disordered haemoglobin synthesis. The

haemolysis theory still has its exponents, however, thechief of whom is Heilmeyer. He attributes the anaemiato haemolysis largely- because of the increased urinaryexcretion of urobilin and urobilinogen and the erythro-blastic bone-marrow and raised reticulocyte-count.Nilsson confirms these findings in respect of rheumatoidarthritis, but he suggests other causes.

Nilsson’s series of polyarthritics includes 27 cases

of rheumatic fever, though he does not name the

diagnostic criteria and there is no mention of an associatedcarditis. His differentiation between rheumatic fever andrheumatoid arthritis is not so precise as in this country ;and, like many other Continental workers, he findsthat the two conditions overlap considerably. Hisstudies of the bone-marrow show that with the diseaseat the peak of activity there is an increase of immatureerythroblasts, while in the recovery phase mature

erythroblasts predominate. These observations are

confirmed by serial reticulocyte-counts ; at the peak ofactivity the reticulocytes remain low, but coincidentwith, or immediately before, a rise in haemoglobin thereis slight reticulocytosis.The serum-iron, as with chronic sepsis,s is consider-

ably reduced ; and in peroral iron-loading experi-ments with 0-5 g. of iron lactate, the level rises lessthan in normals. Intravenous iron-loading experimentswith injection of 10 mg. of iron and ammoniumcitrate also show an abnormally rapid disappearanceof serum-iron. These findings suggest that ironis stored more rapidly in rheumatoid arthritics thanin normal subjects. The possibility that defective

absorption from the gastro-intestinal tract causes thelow serum-iron and the abnormal result of peroral2. Caplan, J. P. Brit. Med. J. March 5, p. 396.3. Nilsson, F. Acta. med. scand. 1948, suppl. 210.4. Vaughan, J. M., Saifi, M. F. J. Path. Bact. 1939, 49, 69.5. Cartwright, G. E., Lauritzen, M. A., Jones, P., Merril, L. M.,

Wintrobe, M. M. J. clin. Invest., 1946, 25, 81.

iron-loading experiments, is to some extent ruled out

by the abnormal findings in intravenous iron-loadingexperiments. However, achylia has been described inrheumatoid arthritis, and impaired iron absorption hasbeen demonstrated experimentally in dogs with turpen-tine abscesses by following radioactive iron after

ingestion 6; moreover, in such animals the storage ofiron in liver and spleen is increased. 7 Nilsson has alsofound that in rheumatoid arthritis iron therapy has noeffect on peroral iron-loading tests or on the haemoglobin,red blood-cell count, colour-index, mean cell diameter,or reticulocyte-count. It has been known for sometime that iron is bound by proteins in the serum-anaction for which the Bl globulin fraction is almost

completely responsible. Cartwright and Wintrobe 8 haveshown that in chronic infections the iron-binding capacityof serum is diminished. They have, however, alsoshown, by giving iron-binding protein intravenously,that this is not the cause of the low serum -iron. Moreover,they found no correlation between the lowered iron-binding capacity of serum and the level of the serum-iron ; and thus they suggest that factors other thanreduction of iron-binding globulin are responsible forthe hypoferraemia of chronic sepsis.

Nilsson concludes from his survey that anaemia inrheumatoid arthritis is probably due to impaired bone-marrow activity and defective hæmoglobin synthesis,but he does not discard the possibility that increasedblood destruction may play a part. It should not beforgotten, however, that Mollison 9 found that in patientswith anaemia from chronic sepsis the survival oftransfused red cells was no shorter than normal.

RADIOTHERAPY

AN Inquiry into the extent to which Cancer Patientsin Great Britain receive Radiotherapy 10 has been madeby Dr. Margaret Tod, who was acting secretary of theRadium Commission at its dissolution last year. Sheestimates that new cases of cancer in England, Scotland,and Wales in 1946 (population 46,560,500) numberedabout 98,000, of which about 30,000 were treated inradiotherapy centres. These 30,000, she believes, were77% of the cases needing radiotherapy : probably mostcases of accessible cancer now receive treatment, butits quality requires improvement, and too few patientshave palliation. She favours the commission’s policyof centralising radiotherapy in large centres.

THE JENNER BICENTENARY

ON May 17 the Royal College of Physicians and theRoyal College of Surgeons are commemorating the 200thanniversary of the birth of Edward Jenner. During theafternoon at the Royal College of Surgeons Sir EdwardMellanby, F.R.S., will deliver a commemorative lectureentitled Jenner and his Impact on Medical Science. Inthe evening there will be a reception at the Royal Collegeof Physicians. Admission to both these functions is byinvitation only.

The MEDICAL REGISTER, which had become too cumber-some for easy handling, now appears in two volumes :part 1 containing surnames A-L ; and part 2 M-Z,Commonwealth list, and foreign list. The register as awhole contains 76,292 names of doctors. The numberof newly registered names was 3968 in 1948, comparedwith 2787 in 1947 and 3556 (the highest previous number)in 1942. The Commonwealth list totals 6081, and theforeign list 1803. England and Wales account for almosthalf the names.

6. Whipple, G. H., Robscheit-Robbins, F. S. J. exp. Med., 1939,69, 485.

7. Greenberg, G. R., Ashenbrucker, H., Lauritzen, M., Worth, W.,Humphreys, S. R., Wintrobe, M. M. J. clin. Invest. 1947, 26, 121.

8. Cartwright, G. E., Wintrobe, M. M. Ibid, 1949, 28, 86.9. Mollison, P. L. Clin. Sci. 1947, 6, 137. 10. Altrincham : John Sherratt & Son. Pp. 48. 3s. 6d.