﻿398 MTJSGKAVE AND MARSHALL. 



McLean the ulceration became quiescent after from one to seven years, 

 the average time being two years, while in seven cases the advance was 

 continuous for from ten to thirty-five years. Periods of advance and 

 quiescence may alternate. During quiescence there is an abundant, very 

 offensive discharge. It is remarkable that the general health is hardly 

 affected, even with extensive and long continued ulceration. An excep- 

 tion to this rule is to be noted in the case of children under 5 years, in 

 gangotic families, who may die within forty-eight hours from a fulminat- 

 ing type of the disease, almost like diphtheria. The ulceration in gangosa 

 is limited to the throat and adjacent parts. Xo similar ulcers are found 

 in other parts of the body. 



We had no opportunity to determine the etiological factors in our case. 

 Mink and McLean analyzed 125 cases at Guam and estimate that about 

 two per thousand of the native population are affected, whereas Arnold 

 gives a higher estimate. Xo cases have been seen in white people or 

 in those of mixed blood. The majority of all cases develop during the 

 second and third decades, and more during the second than at any other 

 equal interval ; but the disease may appear at any age from* three to sixty 

 or eighty. Women are attacked more frequently than men. Gangosa is 

 not hereditary, but is probably infectious. The natives think that it 

 comes from eating fish. The degree of infectiousness must be low. 



Gangosa must be differentiated from other forms of chronic ulceration. 

 Leprosy can be excluded by the absence of nodules, infiltrations and 

 anaesthesia, the fact that the characteristic bacilli can not be found in 

 the ulcer, by the sudden onset of gangosa, and by the general good con- 

 dition of the patient. From the other granulomata, the differential 

 diagnosis should not be difficult. Epithelioma may be excluded by the 

 wide prevalence of gangosa in a small community, by the early age of 

 onset, the protracted course, the absence of metastases, the softer base of 

 the ulcer and the histological features. 



In certain respects the disease resembles an unchecked Vincent's angina 

 or noma. The protracted course and the absence of general symptoms 

 exclude noma. In our case, tissues stained by Levaditi's silver method, 

 by Gram-Weigert and by the carbol-fuchsin methylene blue method for 

 tubercle bacilli failed to show the spirocha'ta of Plaut and Vincent. 



The differential diagnosis from syphilis and yaws is difficult. We do 

 not wish to enter into the syphilis-yaws controversy at this time, and we 

 will merely state that we have never seen any lesions of yaws which pre- 

 sented the faintest resemblance to gangosa, although the typical fram- 

 boesial skin lesions are not uncommon in this region. However, it is 

 obvious that gangosa bears a strikingly similar appearance to the ulcera- 



