BLASTOMYCOSIS OF THE SKIN, 397 



right wrist on a thorn. The cut bled a little and he sucked it. A little later 

 the spot became reddened, and itched greatly, and it gradually spread around 

 the wrist. A similar spot appeared upon the palm of his right hand. These 

 spots were treated with various antiseptic ointments and lotions for nearly two 

 years, without much effect until, while at Mount Gretna encampment in 1906, they 

 were healed by the application of a strong alcoholic solution of mercuric chloride. 

 Shortly after, small spots of a similar character appeared upon the left wrist and 

 left leg, and these have persisted and have continued to spread ever since, more 

 rapidly since his return to the Philippines in July, 1907. 



He came to us in March 1908, somewhat anxious about his condition as he 

 had been told by a Spanish physician that the disease was likely to affect his 

 internal organs. The lesions present at that time were situated on the outer 

 side of the left leg near the knee and on the back of the left wrist. There were 

 several areas, each 5 to S centimeters in diameter, irregular in outline, slightly 

 raised, with a well-defined edge and covered with scales which, when removed, 

 left a pink, glistening surface. 



The surface feels rough and indurated. No crusts nor exudate are present. 

 The scales, when removed, treated with a potassium hydrate solution and ex- 

 amined under a high-power lens, show in abundance the organisms illustrated 

 in figs. 6 and 7, a more detailed description of which will be given later. 

 Attempts to cultivate the organism from this group of cases proved unsuccessful. 

 A picture of a section of the skin is shown in fig. 8. 



Prom a study of the sections, the process appears to be twofold. On 

 the one hand there is an overgrowth and widening of the papillary 

 layers. The papilla? show a definite downward growth and often include 

 a small island of connective tissue which appears somewhat like a miliary 

 abscess, but contains no polynuclear cells. On the other hand, the 

 corium in places . infiltrates the epithelium, producing a fibrosis and 

 degeneration of the epithelium so that as the section is moved across 

 the field, one part will show an excess of epithelial elements and the 

 next a loss with an increase of connective tissue. A marked infiltration 

 with round cells appears in the deeper layers of the corium. 



The majority of these cases are of many months', or even of years' 

 standing. The mildest yield to strong local antiseptics, others only to 

 potassium iodide internally. These infections are usually passed over 

 as a variety of "dhobie itch" and even on microscopic examination of the 

 scales often nothing is seen unless the oil immersion lens is used. 



B. The second type of the disease is the one most frequently encoun- 

 tered. In these cases the lesions are in quite large areas, sharply cir- 

 cumscribed and considerably elevated above the surrounding, healthy 

 skin. They are frequently observed to have a border raised above the 

 rest of the patch, this ridge being beset with "miliary" abscesses covered 

 with crusts. The remainder of the area has a red, smooth surface 

 covered with scales. 



Case II. — The patient is a Filipino girl, 8 years of age, from the Tondo 

 district of Manila. No history as to the beginning of or the duration of the 

 disease is obtainable. The lesion shown is irregularly circular in outline, about 

 7.5 centimeters in diameter, situated back of the left axilla. It presents a 



