Just as with oriental sore one or more pruriginous papular lesions appear on the uncovered parts of the body. In a few days it develops a pustular summit. This undergoes ulceration and after several months or even after the primary lesions have healed nodules may make their appearance in nose and mouth. These ulcerate and form fungoid granulations. Even the larynx may be involved. The nasal septum and other cartilaginous portions of the nose are often destroyed and the overlying tissues become swollen and often eroded by ulceration, so that the patients present the appearance of similar cases where syphilis, tuberculosis or leprosy may be the cause. A point of distinction between syphilitic and leishmaniasis lesions of the nasal mucosa is that the latter do not involve the bony structures. Rabello noted that a positive Wassermann may be present in cutaneous leishmaniasis which is in agreement with Sutherland’s findings of 27% positives in cases of kala-azar. The patients suffer from fever, joint pains, bronchitis and general symptoms. After a long period of ten to twenty years, during which they often die of some intercurrent affection, there may be a terminal cachexia. [Illustration: FIG. 57.—A case of _Leishmaniasis_ from Brazil showing lesions in the mouth. (After Carini; from Mense.)] =Diagnosis.=—The diagnosis in either oriental sore or in American leishmaniasis can only be made surely by the finding of _Leishmania_, either by scrapings from the edges of the ulcer or by culturing in N. N. N. medium the blood from the immediate site of the sore. Cultures were once obtained from the blood of a finger where the sore was located on the arm of the same side but usually the parasites are absent from the peripheral circulation. Gland puncture in American leishmaniasis may give positive findings of parasites. =Prophylaxis and Treatment.=—Knowing that the application of material from a sore to a scarified surface will bring about infection, it would seem advisable to cover any abrasions or open wounds with flexible collodion or other protectives so as to prevent flies, which may have fed on oriental sores, from having access to the wound. It has been recommended to paint the spot of insect bites with tincture of iodine. Atoxyl and salvarsan have been tried in oriental sore and American leishmaniasis without any particularly striking curative results. Attempts have been made to excise the early lesions but unless one goes well beyond the infected area, severe recurrences may result. Bier’s passive congestion method has been tried without success.