202 An Introduction to Medical Mycology 



if one examines the small abscesses at the periphery of a cutaneous lesion. 

 Pus is expressed on a clean slide, and a cover slip is dropped on it. Bud- 

 ding cells should be readily observed, but if they are not the preparation 

 may be ringed and left for a few hours, after which budding will probably 

 be noted. The organism is more difficult to isolate from sputum or from 

 secondary ulcers on the skin. 



Tuberculosis verrucosa cutis lacks the peripheral miliary abscesses and 

 is usually of firmer texture. Verrucous areas due to the ingestion of bromides 

 develop more quickly and do not show minute abscesses. Prickle cell epi- 

 thelioma, in contradistinction to the ulcerative variety of blastomycosis, 

 shows a rolled border, more rapid development and usually absence of 

 systemic symptoms; the histology is characteristic. According to jacobson, 

 the systemic form of blastomycosis resembles granuloma coccidioides so 

 closely that a differential diagnosis is made possible only by laboratory 

 methods, i.e., examination of the organism and inoculation of guinea-pigs. 

 (A guinea-pig is usually not infected with blastomycosis; the animal dies 

 of invasion of C. immitis. ) The systemic forms of the disease may simulate 

 tuberculosis. In lung tissue, however, there is less tendency to cavitation 

 (Stober). Osseous involvement is multiple and occurs usually in small 

 bones, with rapid spread and concomitant involvement of the lungs and 

 the skin. Pain is commonly present. A positive reaction to vaccine or a 

 fixation of complement denotes an infection when either is obtained; these 

 reactions are not invariably present in patients with blastomycosis. Smith 

 has pointed out the main features which differentiate true blastomvcosis 

 from blastomycosis-like infections. In granuloma Paracoccidioides the in- 

 testinal tract is commonly affected and the cutaneous lesions are usually 

 in the region of the mouth. 



(f) Prognosis.— If the diagnosis is made promptly, before there is dis- 

 semination to internal organs, the prognosis is usually favorable. Even after 

 being neglected, the lesions may remain localized and respond to treat- 

 ment. No one can determine whether or when the disease will become 

 systemic; when this occurs, the outlook is not promising, and, according 

 to Jacobson, 90 per cent of such cases terminate fatally. When the central 

 nervous system becomes invaded, the disease is always fatal. 



(g) Treatment.— (i ) Surgery.— If the lesion is small and accessible, i.e., 

 cutaneous, surgical excision is probably the surest way of eradicating the 

 disease. Other destructive measures, such as surgical diathermy or actual 

 cautery, may be substituted. 



(2) Roentgen rai/s.— Lesions not suitable for surgical excision should re- 

 ceive filtered roentgen rays in semi-intensive or intensive dosage. 



(S) Iodides.— Saturated solution of potassium iodide is the usual ve- 



