16o 
The right arm is occupied from the elbow to half-way up the 
humerus, and over the inner and front half of its circumference 
by a swelling, rising with an abrupt and overhanging edge from 
the skin to a height of i J to 2 cin. The skin immediately round 
the edge has a dark pigmentation about 2 cm. broad, but is 
otherwise healthy. I'he surface of the growth is mammillated, with 
ulcerated patches where the skin has worn off the tops of the 
projections, and divided by skin-lined cracks containing a foul 
fluid. I he upper part moves freely on the deep tissues, the lower 
is anchored to the condyle. I'he arm is fixed at an angle of 85°, 
with scarcely any flexion or extension, but pronation and supination 
arc ircc. No glands in the axilla. At the operation the upper part 
of the growth peeled easily from the deep fascia, lower down it 
surrounded, without invading the ulnar nerve, and involved the bone 
just above the internal condyle. This area— the only one where 
there was any deep invasion — was scraped out and packed with 
sulphur; the remaining surface was grafted; and in spite of the 
filthy condition of the arm, most of the grafts took well. The 
ulnar nerve, which lay bare and isolated beneath the grafts, 
preserved all its motor and sensory functions. He was discharged 
with a small sinus leading to the bone. 
Pathological Report (A.R.F.) 
Microscopical search in films, treated with Giemsa’s stain, 
shewed no Leishtnania tropica. Very numerous bacteria, diplococci, 
short streptococci, and an undetermined species of bacillus, were 
present. 1 hese, when present in large numbers, seem to determine 
the disappearance of the parasite. 
Case IX. PI. XV, fig. 9. A third year medical student, 
crcssin to fen Mi. Richards, complained of two patches, one on hi 5 
orearm, the other on his wrist, slightly elevated, flat, soft, pinkish, 
s an-covered, sharply limited, and freely movable. They had been 
present about a year. They were both excised under cocaine- 
adrenalin anaesthesia. 
