426 FAMILY: TRYPANOSOMIDiE 



organisms, though undoubtedly many arguments could be raised in support 

 of their inclusion in a single species. 



SYMPTOMOLOGY. — ^The cutaneous lesion due to L. tropica commences 

 as a small, red papule, which is usually supposed to be the result of an 

 insect bite. Instead of disappearing, however, it persists and increases 

 in size, and may eventually give rise to a nodule an inch or more in diameter. 

 After persisting for about a year, shrinking commences. The nodule 

 finally dries into a scab, which eventually falls off, leaving a thin depressed 

 scar. More usually, however, after a variable period of growth, the surface 

 breaks down, and an ulcer with round edges is formed. Secondary 

 bacterial infection takes place, and the ulcer may become as large as the 

 palm of the hand. In the non-ulcerating variety, fluid obtained by punc- 

 ture is found to contain large numbers of parasites, but in the ulcerating 

 form these may be more difficult to detect, as scrapings from the granu- 

 lating surface contain many pus cells and extraneous organisms. In such 

 cases the best procedure to adopt in order to discover the parasites is to 

 puncture the surrounding red margin of skin and run in a fine glass pipette, 

 so as to obtain the tissue below the contaminated surface. Without the 

 finding of the parasite, certain diagnosis is impossible, for the lesions often 

 appear in remarkably atypical form, and even when they appear typical 

 they resemble certain tropical ulcerations of quite another nature. If 

 parasites cannot be demonstrated by direct examination, the culture 

 method may be of assistance. In one case seen by the writer, an undiag- 

 nosed lesion on the ear contracted in South America had been treated 

 unsuccessfully for several years. Though scrapings from the sore and 

 puncture of the margin failed to reveal leishmania in stained films, yet 

 flagellates grew in cultures inoculated with material obtained by puncture 

 after sterilization of the skin. The organisms must have been very scanty, 

 for it was not till after the lapse of three weeks that the characteristic 

 organisms had multiplied sufficiently to be detected. 



The lesions in oriental sore are usually confined to exposed surfaces 

 of the body — e.g., hands, wrists, feet, legs, and face. They are often single, 

 but two or three sores are quite common. More rarely a larger number 

 are present, and these may be scattered over the surface of the body. 

 Cardamatis and Melissidis (1911) record a case in Greece in which there 

 were thirty-five sores distributed about the hands, arms, and face, while 

 Torres (1920) in South America observed one in which 248 distinct lesions 

 occurred on various parts of the body. As a rule there is no constitutional 

 disturbance, except in those South American cases in which naso- 

 pharyngeal involvement occurs, when the patient is often very much 

 reduced in health. Lymphangitis in the lymphatics and glands draining 

 the infected region is not uncommon, and organisms have been obtained 



