﻿GANGOSA IN THE PHILIPPINES. 399 



tion occurring in syphilis, and Hutchinson 4 has presented a strong ease 

 for those who maintain that syphilis and yaws are modified forms of the 

 same disease. Neither Mink and McLean, nor Leys, found any syphilis 

 whatever among the natives of Guam where gangosa prevails so widely 

 and they satisfied themselves that there is no casual connection between 

 syphilis and gangosa. Mink and McLean also convinced themselves 

 that the disease is independent of yaws. Fordyce and Arnold excluded 

 syphilis from the diagnosis of their case, because of the long duration 

 of the ulcer in a limited area, the failure of antisyphilitic remedies to 

 relieve the condition, and because they considered it unusual to have 

 the lachrymal duct involved by direct extension of intranasal syphilitic 

 ulceration. In our case, the patient failed to respond to vigorous anti- 

 syphilitic treatment. There were no other signs suggestive of syphilis 

 either clinically or at autopsy, the histological features of the ulcer were 

 not suggestive of syphilis and no spirochaetae coidd be found in the 

 tissues after impregnation with silver according to the method of Le- 

 vaditi. 



Considering both the literature and our case, we think that the weight 

 of evidence is in favor of the view that gangosa is a disease independent 

 of syphilis, but we do not regard this as a definitely established fact. 



Tuberculosis must also be- differentiated. In our case the patient had 

 unquestionably a chronic pulmonary tuberculosis with a few small tuber- 

 cles in various organs, but no tuberculous lesion existed along the ad- 

 vancing edge of the ulcer, and no tubercle bacilli could be found in 

 it. In Fordyce's case the inoculation of guinea pigs and the test with 

 tuberculin proved to be negative for tuberculosis, and, as in our case, 

 the general histological appearances were unlike that disease. At the 

 same time, there were giant cells in Fordyce's sections and in both his 

 and ours there were extravasated red blood corpuscles. According to 

 Stelwagon, 5 lupus not infrequently attacks the mucous membranes, and 

 may affect the soft palate, hard palate, or velum, the mucous membrane 

 involvement taking place in 45 or even 70 or 80 per cent of the cases. 

 Against tuberculosis are (1) the painlessness of the lesion, (2) the long 

 duration, (3) the continued good health of the patient and (4) the 

 absence of symptoms of tuberculosis elsewhere. 



The considerations enumerated above dispose us to take the view that 

 this patient suffered primarily from gangosa, apparently a separate 

 disease, that the tuberculous process was secondary and that he died of 

 a terminal acute broncho-pneumonia. 



4 Framboesial Syphilis (Yaws and Parangi) ; Atlas of Clinical Medicine, 

 Surgery and Pathology of the New Sydenham Society. Part I, Fasciculus XIV 

 (1902). 



