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226 Guiana, Martinique, Paraguay. Christopherson describes a case of the espundia type which he met with in the Soudan. In Paraguay it has assumed epidemic characters, and a large proportion of the population in certain districts is said to be affected.

Fig. 59.—Ulceration of hard palate and nares in leishmaniasis Americana. (After Splendore.)

The disease begins as a sore on some cutaneous or mucous surface (Fig. 59). The sore is of the chancrous form of the ordinary oriental-sore type. It heals in time, leaving a characteristic scar. After an interval of months or years, fungating and eroding ulcers (Fig. 60) of a most intractable character break out on the tongue, and on the buccal and nasal cavities, destroying and obstructing them, and ultimately, if untreated by antimony, after years of suffering, leading to the death of the patient by