Malaria Epidemics at Exceptionally High Altitudes

about their unsightliness. They did not irritate, and they showed the usual seasonal variation. Since taking morphine she had been very moody-easily excited, then depressed. She rarely went out, and often made scenes-screaming, etc.-when the morphine allowance was finished. Her son dreaded coming home. She was admitted to the observation unit, St. Alfege's Hospital, on Aug. 7, 1941. She was pale, and the typical brownish branny patches on her skin stood out in contrast. In general the exposed areas were pigmented. There were particularly well marked pigmented patches over the manubrium sterni and nape of the neck, disposed " necklace" fashion, also on the backs of the fingers, wrists, and insteps. Her tongue was pale and very smooth. There was no fur, despite the poor appetite and the fact that she had taken so little food before admission. Her blood pressure was 110/70. There was gross oedema of the ankles All tendon-jerks were absent. The patient said that they had been absent for years. She did not display the classical pellagrous dementia. Cerebration was quick and fairly accurate. She was hypochondriacal, and would resort to any device, from violence to wheedling, to get morphine. She was very self-centred. The blood Wassermann reaction and Kahn test were negative. A barium meal showed evidence of " gastritis " (thickening of rugae), with poor gastric tone and some initial delay followed by rapid emptying. No ulcer was demonstrated. Progress. -The patient remained at St. Alfege's Hospital for 11 days, improving considerably and putting on weight. She had been extremely emaciated, with deep-sunken eyes, but at the time of her transfer had filled out considerably. No morphine was given, and after the first day no sedatives, although her craving persisted and she became very depressed when refused the drug. However, she soon became more reasonable and co-operative, and was willing to discuss other subjects than sedatives. On Aug. 18 she was transferred to Bexley Hospital, where a blood count showed Hb 44%, R.B.C. 2,430,000, C.I. 0.9. The patient was given large doses of iron and liver extract. Subsequent blood counts were as follows: Sept. 23-Hb 48%, R.B.C. 3,390,000, C.I. 0.71; Dec. 3-Hb 88%, R.B.C. 5,000,000. She was given nicotinic acid in 50-mg. doses six times daily, and thiamine in 50-mg. doses twice daily subcutaneously to a total of 1.8 g. Shortly after transfer she collapsed and was very ill for a few days. On recovery from this attack her physical improvement was progressive. She developed a ravenous appetite. There was at first no mental improvement, but four months after the beginning of treatment the mental state also changed for the better, and by mid-January, 1942, she had improved strikingly. She was quick, lively, cheerful, and took an active interest in her surroundings and in plans for her future. She was much less pale and the branny patches had become less evident. She was able to get about well and had put on much weight. There was still some oedema of the ankles on exertion. She was discharged home on Feb. 7, 1942. When visited 16 months later the patient was active, able to walk several miles, and could do her housework; but unfortunately she had not co-operated in out-patient treatment, and was receiving no vitamin concentrates. She had deliberately restricted her diet on account of dyspepsia, and was taking only the small priority ration of eggs and milk which she was allowed, together with a very little bread-and-butter. She again had slight oedema of the ankles and branny patches on face, neck, arms, wrists, and hands; and her memory, especially for names, was poor. She declared that she was not taking morphia or alcohol.