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 [Reprinted from Journal or Cutaneous and Gemito-Urinary Diseases, April, 19 a \ 
 
 TWO CASKS Ol' lU.ASTOMYCETlC DERMATITIS, ONE 
 
 OF WHICH WAS CURED 15V lODID OF 
 
 POTASSIUM.* 
 
 1 
 
 By Francis J. Shki-heru, M.D., CM., 
 of Montreal. 
 
 WISH If) ])Iacf on record before this Association notes of the two 
 foUowinpf casts of blastomycosis which have already been ex- 
 hibited several times to the Montreal Medico-Chirurgical So- 
 ciety. 
 
 Jas. S.. jet. thirty-eipht. married, came to the dermatolopical clinic 
 at the Montreal (ieneral Hospital in the month of March. 1900. with 
 considerable ulceration of the face and nose. The disease l)epan seven 
 months before (August. 1899) as two small papules on the right ala 
 of the nose. The papules were hard and flattened, of a pale red color, 
 and, he says, never became pustular. Gra<lually these papules enlarged 
 into tubercles, the lower one spreading downward and the upper one 
 outward. The skin over the area which the growth i -ivaded l>ecame 
 raX and ulcerated, the ulceration going deeply and destroying the right 
 ala nasi and. part of the upper lip. The edge of the ulcer was red and 
 inflamed with a gray sloughy base, and small abscesses appeared at 
 intervals, and this ulceration caused him considerable pain. The ul- 
 ceration gradually extended until it involved both cheeks, the whole 
 nose, and part of forehead and upper lip. 
 
 When I saw him first both alie nasi am! ')art of the upper lip were 
 destroyed by ulceration and on both cheel ^ continuous with the nose 
 was a large, bat's-wing shaped scar with ;, raised ulcerating edge. At 
 the right and lower edge of the eruption the ulceration was still ex- 
 tending and here there was much redcL-ning and thickening with inter- 
 venir.i; patches of ulceration. Irregularly over the scar area were 
 scattered small ulcerations from the size of a grain of wheat to the 
 size of a large pea. 
 
 The patient had always been a healthy man, never had syphilis 
 and shows no signs of it anyw.iere: has several children, all perfectly 
 healthy, and wife never had a miscarriage. I saw the children and 
 wife and they all were quite healthy; there is no history of tuberculo- 
 sis. He had been treated with tuberculin on the supposition that the 
 disease was lupus at one hospital for a month, but no reaction or bene- 
 
 * Rrad before the American Dermatologic?' Association. 
 
a ['ntiuis J. SItcphi-ni, M.D., CM. 
 
 fit n'siiltid. At aiiniluT lM-.|iii;il lu- was iiluTi/i'il spiral times and 
 the i)arts scrap.,! witli a sliarj) >\»'nu ami aitirwanls eaiiterized, but 
 tliis treatnietit lunl iin clVni in eluekiiii; the sjiriad nt" the disease. 
 
 \\ lien I saw him I sn^|>eeied hlastumveosjs fmni liis appearance, 
 and had cidtures tai<en, Iini nnfiiriuMaiil_\ tlu\ were mi>iaid ; I also 
 reninved some of tlu- tissue, and Dr. Wxatt Johiistuii. who examined 
 it. said lie found yeast hnds : his reiiori is appeiide<I. Tlic patient was 
 
 Fi(i. I. 
 
 Case J. 
 
 put on larjje doses of i)otassium iodide and rapidly improved. He pre- 
 viou.sly had had mercury and small doses of iodide without cfifect. I 
 did not sec him for nearly a month, when he came hack much im- 
 proved; the ulceration had ceased spreadin^^ and in ever\- way he was 
 better. When last seen, in September, iS<)(). he was i)ractically well. 
 
 Tlic second case, AI. 1).. a I'rench Canadian, a-t. seventy-two, a !a- 
 txirer. came to the dennatolopical clinic at the Montreal (ieiicral Hos- 
 pital May 14, i()oo. He has always lived in the Province of Quebec; 
 married, and has had children, all healthy: no history of venereal dis- 
 
♦ 
 
 Plastom \cctic Dermatitis. 
 
 : no tulKTCul()Ni> in family, or any disease that h<- 
 montlis iKlun- jiatiint imtiii'il a ri'<l l)lush over the 
 
 ease nl any kimi 
 knows of. I'hrei 
 
 ri«ht Che- >. and in tliree or four days the wiiole rijfht cheek was red 
 and MillanuMl an<l soon afterwards a no<hde the size of a i)ea appeared 
 in troiit of tile ri),'lit ear. ( Uiur nodnles ai)iH'ared from time to time 
 over the rifiht cheek and ri^ht side of the nose, liiese nodules soon 
 hecame pustular and later the surface liecame covered with thick crusts. 
 The juistulation and eru>tinj; )j;radually extended until it involved the 
 whole of tile ri),du eheek. rijjh* ear and ri),dit side of nose. Never has 
 iK'eti ])ainful or ver> itchy, except at first. 
 
 His condition on enteriujr the hospital was as follows: 1 airly 
 noiirisiied old man of seventy-two: no evidence of syphilis, hut over 
 left sterno-inastoid were two .scars as if from the stii)puratioii of tuher- 
 culous trlands. He says these scars are very old. Over right side of 
 face the skin w red. 'liiiy and smooth, showing,' existence of previous 
 iikvratiou. In this >luMy skin are several areas half an inch in diam- 
 eter which are raised above the skin. pnstul.:r and covered with crusts. 
 The right ear is much intiltrated and part of the lohe has disappearetl ; 
 there is also coiisiderahle scarring in front of the ear an<l over temporal 
 region, which has destroU'd the hair. I'.elow the ear and in the ear 
 are a nuinher of i>ustitles covered with scabs from which a purulent 
 secretion exudes. Just in front of the np))er part of the ear is a more 
 su])erticial area of piistulation the size of a fifty-cent piece. The nose 
 is covered with a group of i>ustules and scabs and the right ala has 
 been almost completely <lestro\ed There is ectropion of the right eye, 
 due to the contraction of the scar tissue of the cheek. Over part of 
 the iipi)er lij) the hair has bei • ' ;'' .ed and the skin here is covered 
 with scars and there is sol. , >n. Cultures were taken and 
 
 ])ieces of tissue removed an ' > ..le pathologist. 
 
 The di.ignosis of blastomyi . w i> suspected from the first, cul- 
 tures were taken and pieces of tiss le excised, and the patient was put 
 on gr. XX. I'ot. lod. t.i.d. In a week there was decided improvement, 
 the crusts were clearing otT the nose: there was less inistulation, and 
 main- ulcerated spots were healing. In a mcMitli of continued treat- 
 ment bv iodi<le of potash, much improvement resulted; the pustular 
 nodules had almost all disapjieared from the cheeks and nose, leaving 
 a shiny scar behind. ( )n the side of the nose and about the ear some 
 pustules with crusts remained. Dr. W. Johnston's re])ort on specimens 
 removed showed the budding imstules with double contour. 
 
 I"or some time the patient was lost sight of, though searched for 
 evervwhere, his name being a common one and the address he gave 
 not existing, but on October 22, lyoo, he came back to the hospital fur 
 
4 Francis J. Shepherd, M.lh. r..U. 
 
 tnatmcnt in a iiuich worso coiuliiioii than whin he Uft. thmi^jli iv* "^n 
 bad as when ho fir>t caino under ohstTvatiim. lie saiil he had Imii in 
 the country, hut it transjiired afterwards that he had U'en an iiKlrxir 
 |»atieiit ill another hi)S|)ital durinjj the whole sumnur. I could not 
 make out in what nianner ho was treated. He was ajjain jnit under in- 
 
 FlG. 2. 
 
 Case II. 
 creasing doses of potassium iodide and rapidlx improved: at or time 
 lie took one drachm three times a day without inconvenience, j^iven in 
 Iari;ely diluted form. I'.y DecemlKT he was nearly well, and when 
 discliarj^ed from hos])ital on January 22, ii>oi, he was practicallv well. 
 the only trace of the former disea>e iK'iii},^ the scarrinjj and a >niall 
 
Bhtstom \ictic Dermatitis. 
 
 V 
 
 • /f « 
 
 i 
 
 opfiiinK ill fnmt of tlic car, which was tin- nmains of wh.ii ha<l In-cn 
 a fairly larjji- abscess, and a small scab uiuUr ri^ht lower i yclid. 
 
 Tlu- lultiircs in this case at first showed nothing but xtaphylococui ; 
 aureus and then, after a week, the characteristic fundus «>f the b'.as- 
 toinycetf- a)>i)eare<l. 
 
 The fcllowinp are the rep<irts of Dr. VVyatt Johnston, I'atholoKist 
 to the Montreal (ieneral Il()s^)ital, on those two cases: 
 
 Case /.— Jas. S., ;et. thirty-e /lit. Dr. Shepherd, April 23. 1900. 
 
 I'ortions of skin excise<l and cut by freezinp microtome after hard- 
 
 Fio. 3. 
 
 Fig. 4- 
 
 Case II. 
 
 .'Ifti-r niu- iiwiilh witit iodij. .U time of discharge. 
 
 eniiiR in formalin. The sections showed a heaping up of squamous 
 epithelial cells with some cell nests ; the intervening connective tissue 
 is highly vascular and shows infiltration by numerous leucocytes but 
 no <lefiiiite miliary abscesses. Sections stained by eosin and niethylene 
 blue show budding cells without definite double contour, but it cannot 
 be definitely determined whether these are tell inclusions or blastomy- 
 ces fonns — only a few re seen. 
 
 The material was not received in suitable conditio, for culture. No 
 further material vas received. 
 
 C\,sc II.— M. D., xt. seventy-two, Dr. Shepherd, May 16, J900. 
 
 Examination of pus from a small abscess in the cheek shows some 
 
6 Frimit J Slu-fln-rtt. M.n.. CM. 
 
 peculiar ovoiil U><lii> no. V\\v ordinary leucocytes but not characteristic 
 of l)la>t<)niyces. 
 
 Sei-tii>n> iif >kin reninveil and injlH'ildeil in paraffin after hardcninfj, 
 -hiiw decided Ii\i)er|)lasia of the s(|uaino\is epithelium with several 
 <li>tnut cell nests. In the deeiKT jmrt of the cutis and in the sultcutis 
 are miliary abscesses which in the center show two huddinp objects 
 with doulilr .nntonr and vacuolatioii. The structure (as shown in the 
 plu)t()>;raph l)\ Dr. Patrick) corrcsininds exactly with the Inxlies fig- 
 ured by (iilchrist; the .-ize is 15 to \H microns. Thes',' are not adjoin- 
 inj.; any of the lar^fer cell forms, but are situated in the center of the 
 abscess and surrouii iid by leucocytes otdy. 
 
 Cultures on serum showed ' ily sta])hylococci at first, but on the 
 fourth day tlat white colonies appeared, which showed microscopically 
 the characters of blasiomyces with tyi)ical buddinp and formation of 
 sm:dl jrroui)s. These are minjfled with bacillary forms, supj;estin}j an 
 impure cidtue. They >;row Ix'st on meilia containing sujjar and on 
 af^r form a ditYnse whitish ffrowth extending between the media and 
 the tulx'. The size is smaller than the conmion hlastomyces, not ex- 
 ceeding 4 to 6 microns in diameter, but corresjxindinfj with the smaller 
 form as figured by Hekttx-n. 
 
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