BLASTOMYCOSIS OF THE SKIN. 399 



class. Both in appearance and in microscopic findings their description 

 coincides with those that we have given. 



The histologic picture of type B is intermediate between those of A 

 and C. The papillae show more marked overgrowth and the upward 

 growth of the connective tissue reaches the surface of the skin and thus 

 accounts for the formation of crusts. There is a greater infiltration in 

 the deeper layers of the corium. The infiltrating cells are almost 

 entirely of connective tissue in various stages of growth, but there are 

 some unusual cells, large and round, which when stained by hematoxylin 

 and eosin, have a deep black nucleus and a rim of pink protoplasm. 



C. This form answers clinically quite closely to the descriptions of 

 cases of cutaneous blastomycosis reported from the United States. One 

 well-marked case of this class has been under observation for the past 

 three months, and one other was seen at St. Luke's Dispensary. (Figs. 

 4 and 5.) 



Case V. — B. C, male Filipino, 34 years old, a resident of Pasay, and a 

 coachman by occupation. He was born in Pasay and has lived there all his life. 

 He has been married for twenty years, had five children, two of whom died of 

 smallpox, two of intestinal trouble and one, 11 years old, is alive and well. 

 Ten years ago he acquired a small venereal sore which healed in a week. He 

 has no further symptoms to indicate that the sore was syphilitic. There is 

 no evidence of tubercular infection. Two years ago a sore appeared on the 

 right buttock, near the anus, on the site, the patient thinks, of an abrasion due 

 to horseback riding. This healed after three months of dispensary treatment. 

 One year ago, it reappeared on the right buttock, since which time it has 

 spread gradually to its present dimensions. 



Present condition (fig. 3). — The lesions occupy nearly the whole of the right 

 buttock, and extend several inches over on to the left. They reach downward 

 on to the back and inner side of the right thigh and up into the groin in front 

 on the right side. The greater part of this area is occupied by scar tissue, 

 but the process is still active in a ridge 5 centimeters wide along the left 

 border of the patch, in an oval area 5 by 7.5 centimeters in the median line 

 above, in the extreme right edge, in the lower part of the right side and in the 

 right groin. Over these areas the surface is raised 3 to 6 millimeters above 

 the surface of the skin. In places there is a fine, papilliform growth with deep 

 fissures intervening and in others broad, warty surfaces, dry or covered with 

 large scales. The papilliform elevations are frequently covered by a large, 

 yellow crust, and the intervening fissures contain pus loaded with blastomycetes. 



The patient was put on ascending doses of potassium iodide, and within a 

 week the papilla? began to contract and became smoothed over and ceased to 

 secrete an exudate. In two months the disease was apparently entirely cured, 

 although some induration remained. A culture was obtained from this case. 



A section (fig. 8) from a lesion of this form shows a great overgrowth of 

 epithelium, which superficially resembles an epithelioma. However, the cells 

 are more regular in size, shape, and arrangment. Pearls are occasionally seen. 

 The increase of connective tissue is also very marked and it reaches the surface 

 in wide processes, showing a great deal of exudation of blood cells. The epi- 

 thelium in its growth incloses a great many small areas of connective tissue. 

 The hair and sweat glands are apparently not involved in the overgrowth. 



