﻿388 MUSGRAVE AND MARSHALL. 



His statements about the time of the onset of his present illness 

 differed very much, but Dr. Ariston Bautista y Lira, who saw him, thinks 

 it was probably about five years ago that he first noticed sore throat 

 and that the disease had been gradually growing worse since that time. 

 He had taken many kinds of medicine during the last two years without 

 any improvement. On admission to the hospital the patient was consider- 

 ably emaciated and anaemic, the voice had the intonation peculiar to 

 destructive conditions of the larynx and soft palate and there was an 

 opening about 1 centimeter in diameter in the bridge of the nose. Upon 

 closer examination it was found that the uvula was partially destroyed 

 and the palate had two dirty, grayish-appearing, perforating ulcers. The 

 pharynx, upper larynx, palate, posterior nasal structures, both bone and 

 soft tissues, were partially destroyed by a chronic type of ulceration and 

 there was a considerable amount of scar tissue, showing some evidences of 

 repair. The margin of the upper lip was also destroyed, leaving a grayish, 

 gfanular surface. The odor from these lesions was exceedingly offensive 

 and there was at tunes a slight discharge of granular, necrotic material. 

 Microscopic examination of fresh and stained smears, made by scraping 

 the surfaces of the wounds, were negative for acid-fast bacilli and for 

 treponema. During the period of observation the nasal wound increased 

 in size, there was more deformity due to destruction of bone, and the 

 destructive lesion on the upper lip progressed slowly until death. Plate 

 I is from a photograph made about one month before the fatal termina- 

 tion. There was diminished sensation over the surfaces of the wound, 

 which in places amounted to local anaesthesia. 



The skin was otherwise rough but apparently free from disease or 

 scars. About five weeks before death a dull, chronic-appearing skin ulcer 

 developed on the outer side of the left shin and this continued slowly to 

 extend until death, at which time it was about 1 centimeter in diameter 

 and extended through the skin. The superficial lymphatics were slightly 

 enlarged in the groins, but not more so than is commonly seen among 

 the lower classes of barefoot people here. The muscles were wasted, the 

 joints were free from . disturbance and except as above noted, no bone 

 lesions could be found. Xo abnormalities were found in the circulatory 

 system except an anaemic murmur of the heart. Temperature was normal 

 and there was but slight fever at any time during which the patient was 

 under observation, which was nearly three months. Two days after ad- 

 mission there developed an irregular, intermittent fever varying between 

 normal and 38°. 5, which lasted for a few days, and again, just preceding 

 the fatal termination, there was slight pyrexia. A blood examination 

 on admission showed no leucocytosis and no abnormal elements. A blood 

 examination five days before death showed no malaria; leucocytes 11,600, 

 haemoglobin 80 per cent. 



