CLINICAL 179 



resemble miliary tuberculosis or there may be a few large nodules 

 or abscesses. Small cavities are sometimes found. There may be 

 diffuse or focal consolidation. The bones and joints, spleen, kidneys, 

 prostate and central nervous system are frequently involved. Lesions 

 are found in other organs less frequently. In most cases of systemic 

 blastomycosis skin lesions eventually develop.^- ^^ 



Dissemination by way of the blood stream leads to a development 

 of multiple abscesses throughout the body. These are particularly 

 prone to occur in the subcutaneous tissues, but may also develop 

 in the muscles, under the periosteum of the bones, or in the viscera. 

 The subcutaneous abscesses are quite characteristic and quite differ- 

 ent from the primary skin lesions. They develop painlessly and 

 without much local heat or redness; they are soft and fluctuant, and 

 when opened discharge a considerable amount of pus from which 

 the fungus may be cultivated. The generalized form of the disease 

 is accompanied by a septic type of fever curve and is usually fatal. 



Finally there are cases of primary cutaneous blastomycosis oc- 

 curring most commonly on the face, hands, wrists, arms, or lower 

 legs, where exposure to trauma or repeated irritation may be im- 

 portant factors in permitting entrance of the fungus through the 

 skin. In many of these cases there has been a definite history of 

 injury preceding the development of the skin lesion. 



In primary cutaneous blastomycosis lesions frequently begin as 

 pustules which ulcerate and do not heal. There is usually a single 

 lesion although satellite lesions may follow autoinoculation by 

 scratching. The primary skin lesion may be a papule. Around this 

 secondary nodules develop, slowly enlarge, and coalesce. These 

 break down and discharge pus through a number of small fistulae. 

 As the disease progresses there gradually develops a large elevated 

 mass of tissue with an irregular ulcerated surface that resembles 

 somewhat a breaking down cancer, sometimes a tuberculous ulcer. 

 Slight pressure on the mass will cause pus to ooze from a number of 

 minute openings. There is a considerable development of granula- 

 tion tissue which may be covered with a yellowish oozing crust but 

 which frequently becomes verrucous. The border of the typical 

 skin lesion is elevated and slopes sharply to the normal skin. This 

 active border advances slowly, obliterating the normal structures. 

 The older part of the lesion heals, but the resultant scarring is often 

 very disfiguring. 



The microscopic appearance of the tissue presents some resem- 

 blance to both tuberculosis and cancer. The inflammatory reaction, 

 particularly in the subcutaneous fibrous tissue, is largely gran- 



