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A FATAL CASK OV BLAtXVIIIYOOSlS. 
 t, WmMMm J. Bmwnum,, M J>, LLJ>, airf L. I. iij>^ 
 
 MM. M., an Italian, twenty-five year, of age, came to our 
 clinic on Aug. «, 1910, compUining of an .rupUon on tht 
 • no»e and side of the fact. TlmkiBff the eMt looktd Hlw 
 «>»MtoByrc€«. wt admittwl him into our wards for observation 
 
 HnrosT. Hk pamts are living and healthy; his brotbert and 
 sisters are also healthy. When he came to this countiy two ,mn 
 
 I!L" *° months\r 
 Heha. hmn wvMag m • rdhray nawy, but lately has lived in Mon- 
 
 tl.*t°ll."ri • '"^'''TJ" "."^ th. day after «baiMion, we found 
 2^ addition o the erupti* « fch ft«, t|«. wm . .i„u. di^ 
 
 «Ki of the ngfat cUvicle; also a fluctuating ,^ Umg over the iec«d 
 lumbar vertebra. The growth on the f^Teo, ^^ upvlrZ^ 
 
 canthM of fte eye, and wa. continuous with a fungating nowth 
 below the nght lower eyelid, the size of a twenty-five-c«,lSi. 
 mparts, over the noM. wa. dceratmg «,d dLha^g^ ^^SJ 
 ^ spo^, evid«c«l by which .howed healinV^^in^^le 
 
 STJ^^i "M? covered the ulceration and in the tghborhooHf 
 the growth, on the right cheek, were eome nodule, of • mfcUAerf^ 
 Thich had not yet ulcerated. naatMb color 
 
 Portkm of tinue were removed and sent to the -i 
 «jh«j» w«, deo nu^ ,rom pus taken f rT^ ^tL* tS^^t 
 *nd that coming from the sinus at the upper cad of tht rt^u» 
 j^examination of the h««t «.d l^^^Tm^^J^Zti^ 
 «Kll*.iiriB.w«d»fb«BdtobeBonn5: "•^ «* 
 
 examination, both culture, and wetieii.. havhw 
 
 Jor^S^;™^ 
 
 t«ipe-«ta« row to lOf F. and a dull are. aiJ^ml „!!; frif^ 
 of the right lung with diminished hZh Z^Ttn^^l^.'Z 
 Wuj^t no hl^g breathing. There was Z'iE::^^1f 
 « (Be ligM tide, its aepirating needle wa. tiimmt ti^ j 
 fc"* Uoedr frid mi.ti. l -^^TT ^ wa. uirwt mte th. duU area, 
 —y oiooay MM Hndted, whfeh prodnoad no eakona of the 
 
fl 
 
 ORIGINAL COBflftJNICATIONS 
 
 blwtonyew. Hit ^vtwH wUdi •! thk timt wm vtry prafuM, aIm 
 TMiM bo •fidtnet of UMtoaTcoaii oa txambatioB. 
 
 His condition growing worse, to our ■orruw, he left the Hoapltel 
 on October 8th, promuing to report his condHioB from time to time. 
 We hMund Botteff Iran Un wifl Oelobtr Mti^ whn ht again appUed 
 for admiifion. 
 
 On again examining him, we found that the lesion on hi* face had 
 increased in size and new spots had appeared below the oM obm. 
 kft lung continued to be clear and healthy, but his right lung was 
 •mnewhat worse than before. The sinus over the upper part of the 
 sternum wns much the same, but the fluctuating swelling over his lum- 
 bar spina had increased in un and was red and shiny. A red, swolltn 
 •mhndnnMftndoTvrOierii^wrirt. The pube was now 90 to IM, 
 respirations S5 to 80 and the temperature, 98° to 101° F. 
 
 The tumor in the lumbar region was opened and much pus evacu- 
 ated; the bom waa net iofotni, Oalhwm Aannd Uaatonyeom. 
 He had become very emaciated and tre .tment with iodide of potasaitm 
 was of no avail, even in doses of forty grains three times daily. 
 
 In November, the condition of the lesions was as follows : 
 
 "The large growth on the face now involves the upper and lower 
 eyelids of both eyes and the tissues over both malar bones and nose. 
 The edges of the ulcerated areas are sharply defined, raised and 
 irregular in outline and covered by a dry, brown enut. When the 
 ennt ie remwcd tile edgaa <rf At idetn Men to be tolndated and deeply 
 fissured. The ulcer over the malar region extends to the bone. The 
 left lower eyelid is much retracted, exposing the eydball. The diaeaae 
 has now affected the left noetrO and the left vpptr Up and kaa 
 extended to the adjacent mucous membrane. The lesions on the lip 
 are, as yet, quite superficial. New areas are beginning to involve the 
 chin and under the chin is a new lesion about 1 cm. in diameter. 
 
 "On the back of the neck, just below the lower margin of the hair, 
 thtre are several niperfieial, red^th spots of disease, sharply out- 
 lined. The sinus at the sternal end of the clavicle has increased in 
 size and a new sinus has opoied above the old one, which also leads 
 to a cavity in the tteraal end of the davfall. Botii ■innaea <&- 
 charge pus freely. 
 
 "Over the posterior border of the deltoid muscle, near the axillary 
 fold, an ulcerated area, S cm. in diameter, has appeared, with raised 
 undermined edges. Over the upper lumbar region where the abscess 
 WM opened, there is a deep ulcer discharging pus; there is alstf an 
 
A lATAL CASB 09 JttjmmfOOm 
 
 «la«r M mA hiilluuh aad ever tht right gnat trodMater. There 
 Mt •nrasw in front of the left tibia, on the inner lurface of the lower 
 Md of tht right humcnu and over tha middle of the right tarw^ 
 ■ttatarMd articulation, all kadfaig dowB to iBmml boM. 
 
 "Before death, a Urge fluctuating .welling appeared in the left 
 popliteal epaet aad right mguiaal region. The condition of the right 
 MBg became worw until tht whole organ wai involved. 
 
 "Bjr tht btgiaaiiig of DMMibtr, the patient became much more 
 •marnttd. p«Im ef ttiwJ to bt rapid, high temperature, pre- 
 vailed and the patient graduaUy grew weaker and died on E 
 trth, about nine montbt from tht first onstt of tbt distatt." 
 
 MONTREAL GENERAL HOSPITAL. 
 
 UuCMia Awu tit Sa*(4 
 
4 
 
 ORIGINAL COMMUNICATIONS 
 
 The autofwjr rtport •ubjointd herewith hu been furniihed me Ij 
 Dr. !<. J. Rhea, Director of the Pathological Laboratory of the 
 Montreal General Hospital, mmI to wimm I Ml sIm WlklMl for ^kt 
 excellent pbotomicn^praphe. 
 
 AvTonv. 
 
 (10— tSl.) 
 
 The chief interest in this case, from the pathological viewpoint, 
 i(t the wi«le diiitribution of the lesion*, the character and extent of 
 ttwMc lesion* and the baettriological study. The following is a brief 
 extract of the poet-nortcm fadincs. No reference is made to the 
 cutamou.H lesions, as these kvn him dtMrftad fa the clinical pmcn- 
 
 tation of thr cuse. 
 
 Pr»iT<>vr»i. Cavitv. The pnrlifal peritoneum, jtrrnt imirntiim. (TBitro-hcpntlr 
 oiiH-nfuni, iiihI thr in|»iilr<i of the IIvit and s\,\tTn, nrr thirkly mmIiiI with Mniill. 
 discrelp, \rlliiuish-Hhitr, ftrm arena, whU'h \iiry in ^lx^• from I mm. to 3 or 4 
 mm. ill (liiiini trr. They nrr nimt numerous in th<- (freaf omentum, the pouch of 
 Doufrlas mid in thr rrn-sses on earh side of the lower lumbar vertrbre. The 
 inc»ent« rlr lymph nodes nn- sllnhtly rnlarifrd. On swtlon, they show »oft, pinkish 
 pulp in wMch are numerous small, rounded, soft, yellowish areas. 
 
 PurSAL CsriTiM. Doth plrural ravitirit show flbrinous adhesions between the 
 parietal and vtseeral toyew- The ImH aiMl pe ri c a rd t iiw riMw no cridsiwe af 
 UaatoNqmisis. 
 
 Lvxes. RigM, MO gms.| left, MO gni . The right vinrrral pleura is thirlcened, 
 Tsryinf from 9 to i nna. in H i ek as sa , ii firm, opaque and tense, especially over 
 the lower lobfc Tks lung tissw eats icaAljr, luu s fleshy appearance and Nhows 
 diffase (ons^dation. Tiw nmrter part of the right lung consists of grsyiih areas 
 of different slars, Ut w saa wMek tht tiuae i* pak rsd. Tlw lower Ma is mch 
 smaHer than norauil. The irienra corering this Me aad that hetweea the ^per 
 and lower lobes arerages » to A mm, fai tWrkaess and IhroMghiHil. these are 
 numemiis sharply outlined, freneralljr oral, jfcMowlsh aseas of softe alB g. whM 
 vary from 1 mm. to 1 cm. in length. 
 
 The bronchi are wide and are generally surrounded by ■ tone of pale, wWIS, 
 gli»tenlng, Ann tissue. The rut surface of the lung shows several hoa^cairibed 
 areas, in which are numeroiis cavities varying from • to t naa. hi dloaieler. T^Hf 
 contain a greenish-gray, puriform material. 
 
 - The left lung is larger than the right and its pleura contains Jl lhialsh wMlS. 
 slightly elevated areas, which vary from 1 to 4 mm. In rfiameter and are apparently 
 in the underlying lung ti-ssue. The cut surface is darlc red and shows very many 
 discrete and confluent yellowish-white areas, which vary from 1 to A nmi. la 
 diameter. These areas contain thicic, yellowish, puriform material. The hmMi 
 do not show the peribroncl;lal thickening present in the right lung. 
 
 Snnnr. Weight, 930 gms. t*.-. t. . . 
 
 nodaie seen la the capsule. 
 
 ^"N^ i'as. The only gross lesions are seen In the capsule, where 
 ttereare maMroas yellowish areas similar to those seen elsewhere in the peri- 
 
 Kianws. We^ht. 990 gms. SMning through the capsule are several sharply 
 eatttied. small, raokl to aval. y^MMMridte aieaB. These are scattstcd over tte 
 
A FATAL CASB OP BLAlTOICyOOUS 
 
 . ^ -.— -T 7-* '^'■♦•« nuiniToui rcUowtob-whlu, Mft 
 
 g"* '" jL*! ?** * * ■■• " " MiBnt w. Thejr contbt of puriform iMtoriaL 
 ™» am mmm mmmnm in IIm cortex tkaa to tht oMdnlU. 
 
 marnMropIt Mm 
 
 .. u ..^^^^f^ ^?*' *! — '■^_*!— P* -wplMifM, T cm. from 
 
 Jwt bMiMtk tin OMMOW nwmbraiie. ~— t » owMiar, 
 
 Omk v« SmiM. The right darkle, ri|rht attow JctaL Ml IW« Mi bfl tmtma. 
 metsUnrI bone* were rcmoT«d and later examtecd. The ctov Jital MilSfe 
 
 were Mwed tungitudinalljr with a ImumI taw. 
 
 * «•'•»•«••• «• thkkcnedi t4 IkM 
 
 the artlrular surface it I. 9.8 cm. thicli, the articular surface b Doraal. ■ 
 from the articular surface there i> an oval hole. l.I cm. hmg and • MB. bM& k 
 the bone, which communicates with the medullary cavity The mlntji mrHm 
 w'l^'' »»>c 1 rni. is roughened, due to narrow, caamnl. 
 
 catinf bands of bony :l«ue. (.etween which are depressed, elastic, pak^ cUstenlM 
 turn, apparently i;.. periosteum, beneath which the bone has been destroyed 
 
 : "^"f ^r.". t»» •*»». described 
 
 riiMmiiMcatc e. have lost their periosteum. Their external surfaces are irranular. 
 "" "•'•■■■■'I *•»«■ there U a thick, purulent fluid. 
 
 f"*^ longitudinally, ju«t to one side of an opening In 
 
 11» MAUIWT cavity, bennth the bone sinus shows a marked change. Through- 
 out w'JS.^*3Jr*.l2 *• >'»»''''»^*Wt«. fT^nSlar materfal. 
 ttane to the mcdaUaijr csfttar mdwllr renii toto a - 
 beyond which the B«Slto bWSTwJc •*■■»•« tUM^ 
 
 FKMii. Ri iow JoixT A»o Uwra. TiM bMW mm tmmi thnnwh kmgitudinaUr 
 On the inner aspect of the lower end of tte IMMIW tfem to«l?«iSfr a^l a ^ 
 by 8.1 cm., throughout which the bone I. JhSnt^hSi^-SebT^^ 
 whrn m^sericd Info the skin sinus. tM. potat, Ifc. ► ^ ttto o«bK 
 •oft, pale grayish-red and bathed in a thick puriform ms I. The iwdertvln. 
 medulla shows an area. 4 cm. long, throughout whi. h it a s . srwinter, >ra^ 
 white tissue. The synovial surface of the elbow )<ies not .jntw to be 
 and the cavity is free from exudate. ^ 
 
 The brain show* no macroscopical ieshma. The uOddle can Md *- — ■ 
 
 AVATOmCal. DuoKotn. 
 Generalized bUutomycofia. 
 
 Bbstofl^jreodi of the akfai, bonce, peritmeum, lymph nodes, pleura, 
 and lungs. r . 
 
 Generalized blastomycosis of the kidneys. 
 Chronic obKterative pleantit. 
 
 BUstomycosis of the left adrenal, prostate and oesophagus. 
 MienMcopically, the lesions in the varioua organs show the Mne 
 gmtni proeaH ud iBaatmtai fa tiw plwIoiBierognpfaa atid 
 
6 
 
 ORIGINAL COMMUNICATIONS 
 
 drawings. There is necrosis of the tissues, cellular infiltration, giant 
 cdls and many spheres with definite encapsulating membranes. The 
 organisms are very numerous and are seen both eztrscellalarly and 
 within the cytoplaim of the giant cells. The number of the giant 
 cells varies ; some sections contain only one, others ei^t or more. Tlw 
 organisms appear in the tissues as round bodies which have a sharply 
 outlined, limiting capsule. They show various stages of budding. 
 No mycdia, or s]dieres containing spores, as seen in d«Buitit» eoe» 
 cidioides, were found in the tissue. 
 
 The organism was recovered in cultures several times from the 
 subentaneoos abrasions during life and from several vi the lesions 
 at post-mortem examination. It grows best on sugar-containing 
 media, beneath rather than within the thermostat. In five days, small 
 coloni'^s, similar to those of Oidium lactis, are visible. Microscopic- 
 ally, they consist of branching mycdia. The growth bcemnes incor- 
 porated with the superiieial layers of the media. The lesions pro- 
 dnced in nice are weD shewn in the gross specima. 
 
ATE XI.I.— To IlliiarotP Article by Francis J. SiiErHno, M.D, aiid L. I. Rhba. M.D. 
 
 Fio. I. 
 OenersUxed Blutomycosis. 
 Lesioa on face. 
 
 Fio. 2. 
 
 tii'iieralizetl Itlastoiiiynisis. 
 CroM section of mesenteric lymph node. The smmll, inegularHshapedt 
 datk Meat aie mUtoy alwcMWfc 
 
 tm JmnmAL or CmuxMn Dmun, HatmAet, INL 
 
I'LATE XI-11.— To IlluKtrate Artkle b) Fiavcu J, Shcvuiw, MJJ, and U 1. Rum, M.D. 
 
 Fm. 3. 
 
 Oneralixed BlastoroyoMis. 
 I-ow power— showing single miliary abscess of 
 lymph niMle. A large giant cell containing two 
 offanlsms is seen at the npper, righthand border 
 of the abscess, and several other organisms can 
 be seen in the secttoo. 
 
 Fio. 4. 
 
 (icneriilizMl Itlnstiiniyciixis. 
 Ilifclier powcT tlmii I''i(r. % Pcripherul portion 
 of iniiiarA' ah.sress of lyiii|>li iio<lr. Sere/al organ- 
 isms can lie seen. 
 
 Fio. 4. 
 
 GenerHlizeO RluNtomyroKis. 
 Ulaiit cell witii one organism in it. Stained with 
 Miillory's <'oimc'cti\e-tissiie stain. Tlie narraw, 
 white /,(>i'c Moiiiid tile eentnii, circul.ir, fUrker- 
 stnining iireii is tlie periplieral capsule. 
 
 THt Jomrat, or CirraxMHm Dwuam, November, 1911.