ol0 REPORT OF THE HARVARD AFRICAN EXPEDITION 
yaws has been demonstrated to be the cause of gangosa, and believes that its 
etiology in many cases is doubtful. 
Gangosa is obviously a condition which occurs only in localities where proper 
treatment is not available or among ignorant and unhygienic people who neglect 
treatment. Some of the older clinicians will remember that cases resembling 
gangosa, particularly the earlier manifestations of it, were occasionally observed 
in the clinics of a number of the cities both in Europe and in the United States 
before the days when the modern, efficient treatment of syphilis had been 
established. 
Secondary infection with different micro-organisms invariably plays a role in 
modifying more or less the appearance of the lesions of gangosa as it does in 
other ulcerative lesions of the mucous membranes of the nose, mouth, and throat 
(noma, for example). 
In more recent years, a number of observers have sometimes attributed this 
condition to Leishmania in different parts of the tropics; probably through in- 
correct interpretation of the microscopical appearance observed or inability to 
recognize and unfamiliarity with the appearance of Leishmania and the lesions 
produced by it. 
Apparently Hallenberger! is the only observer who has recently examined 
the condition from the pathological histological standpoint. He believes that 
rhinopharyngitis mutilans belongs to the syphilis framboesia group of lesions, 
and in the absence of the classical inflammatory changes of the vessels which are 
present in syphilis he regards it as a late lesion of framboesia. 
Photograph No. 233 (Case 531) illustrates a patient, a negro woman between 
thirty and forty years of age, whose arms were thin but who was not particularly 
poorly nourished. The mucous membranes were of good color. Part of the upper 
lip, the nose, including the septum and turbinates, and the hard and soft palates 
were destroyed by the disease. On the posterior surface of the pharynx was a 
pocket-like lesion containing a yellowish slough. There was very extensive scar- 
ring on the cheeks, lips, and around the eyes, causing ectropion, and on the shoul- 
ders, right elbow, and back of the hand. The eyebrows, which were included in 
the areas of scar, were thin, and the lids reddened, and there was conjunctivitis. 
Contraction of the scar had caused the ectropion of the left side, while the eye- 
lashes had disappeared. The right eye was destroyed. There were many scars 
over the shoulders and arms, and over the shoulders and at the bend of the elbow 
there were superficial suppurating granulomatous lesions, 2 to 3 em. in diameter 
and about 0.5 em. in height above the surrounding skin. The right hand was 
greatly deformed; the tissues about the wrist swollen and infiltrated. There 
was loss of the phalanges of the index finger, so that the tip of the finger moved 
loosely on the end of the metacarpus, the tendons being contracted and the nail 
thickened and deformed. The condition suggested leprous deformity of the 
hand. The gross lesion can be well observed in the photograph. 
In No. 234 is illustrated a case of leprosy which was studied by the writer 
in the Philippine Islands in 1899, in which leprosy bacilli were found lat that 
1 Hallenberger: Beihefte, Arch. f. Schiffs-u. Tropen-Hyg. (1916), XX, 28. 
