320 REPORT OF THE HARVARD AFRICAN EXPEDITION 
stances of this nature and are mentioned because they have already been referred 
to in the discussion of treponemiasis and gangosa. 
Another group of cases with macular leprosy showed circinate or serpiginous 
lesions of the skin which somewhat resembled tertiary syphilides. The lesions 
were sharply defined and bordered by small and slightly elevated papules of a red- 
dish color. In some instances the epidermis over the papules was scaly, and in 
others smooth, and showed either increase or decrease of pigment. In several of 
such cases no evidence of anaesthesia could be obtained. Still other skin lesions 
of leprosy suggested trichophytosis or blastomycosis of the skin. 
Sometimes, in parts of Africa, it was difficult without recourse to microscopi- 
cal examination, to distinguish some of the Trichophyton infections from the 
lesions of nerve leprosy. Patches, on the trunk in adult negroes, afflicted with 
nerve leprosy, consisting of slightly raised and itching rings or large segments 
of rings with some scaling, may be particularly confusing and sometimes may, 
from their appearance alone, suggest Trichophyton infection. Especially if such 
leprous lesions of the skin are secondarily infected with blastomycosis may they 
cause difficulty in diagnosis. Photograph 245 illustrates very well a case with 
such maculocutaneous lesions. However, the diagnosis of leprosy in this case 
should be obvious from the inspection of the lesion alone. 
The clinical diagnosis of leprosy is an art in which proficiency depends upon 
experience and knowledge gained from observation of the various manifestations 
of the disease in many cases in different parts of the world, rather than upon 
familiarity with the written description of the lesions. Indeed, the diagnosis of 
leprosy sometimes can be made more correctly from the clinical appearances of 
the condition than from a microscopical examination of scrapings of the lesions. 
BLASTOMYCOSIS AND LEPROSY 
Case 110 was one in which the diagnosis was especially difficult because the 
examination of the microscopical preparations made with material obtained not 
only by superficial scraping of the skin but also by deep scraping, showed always 
numerous Blastomyces and no leprosy bacilli. 
In view of the difficulty of the diagnosis in this case, it is considered of im- 
portance to refer to the clinical manifestations in detail. The patient was a 
young man, probably from 28 to 25 years of age, a member of the Kpwesi tribe, 
apparently in robust condition, and served us for a time as a porter. He, how- 
ever, was apprehensive of the cutaneous lesions upon his face and trunk and de- 
sired treatment for them. The lesions occurred upon the face, particularly on 
the forehead, cheeks, and chin. The alae of the nose, the lips, ears and the neck 
were free. Those on the face consisted of slightly raised plaques measuring from 
5 mm. to about 2 cm. in diameter and 1 to 2 mm. in height. One or two of the 
smaller plaques were circular in outline. The remainder were more irregular and 
their borders merged gradually with the normal skin. On the trunk, the lesions 
were distributed particularly over the shoulders, chest, abdomen, and arms. They 
were not distinctly visible on the forearms and back. They were also present 
on the thighs and buttocksand posterior surface of the legs. On the trunk, arms, 
