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This malady, while rare, seems to be increasing in our country, especially in the western portion. About fifty cases have been reported in which the disease has been demonstrated in a satisfactory manner. Out of this number, fourteen have been seen in Chicago. In my own clinic two other cases have been seen, one presented by Dr. Duncan of St. Louis, where there was one lesion of the leg; the other case was in an elderly lady who presented one small patch on left thumb. This case was lost sight of after second treatment.

The case reported is of unusual interest because of the fact that the lesions were so typical and so very extensive. One case alone has been reported in which more body tissue was involved. This was in a case where the whole left side of body was affected. The history of the case is as follows:

Wm. B., colored, age 52; miner by occupation; family history negative. After careful inquiry no evidence of any disease was disclosed other than malarial fever, and no injury of any description could be ascertained. Being a miner he was very frequently in water and mud to his knees. The first lesion began three years ago in the form of a small split pea-sized nodule, located on the anterior surface of right leg, midway between the knee and ankle. In a month's time this

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took on the appearance of an abscess. In a very short time it began to enlarge peripherally, forming an ulcer with elevated edges and in the center there were numerous papilliform elevations separated by small fissures, giving, as patient. described it, the appearance of a cauliflower. From between these elevations and in these fissures, quantities of pus and blood could be squeezed out, and under this regime the lesions seemed to improve for some two or three months, when they began to enlarge. New ulcers formed and by their coalescing one immense ulcer was formed.

One month later a nodule appeared on the left side of the face, acting in the same manner as the initial lesion. Two years after the initial lesion, the left leg became infected, no doubt from crossing his limbs while lying in bed. The first patch commenced immediately below the knee and in six months time the ulcerations numbered twenty-seven, extending downward to the ankle and upward along the lymphatic vessels to the hip. Next, the right arm showed some nodules in the folds of the elbow and in a short time six distinct ulcerations were present.

On April 15th, when I saw the case in consultation at the General Hospital, he presented the following: An ulcer on right leg, 30 mm. long, 19 mm. wide, extending from the knee nearly to ankle on

anterior and lateral surfaces, with marked oedema of foot. On left leg there were some twenty-seven lesions, extending from foot to the hip, measuring from two to five mm. in diameter. All the lesions having marked papilliform elevations in the center, separated by small fissures from which exuded large quantities of thick, yellowish, and very offensive pus. The patch on the face covered the entire left side including the nose ear and tissues beneath the chin. It destroyed the eyelashes and hair, producing some conjunctivitis without any apparent injury to the ye proper. The nose was, greatly enlarged and the outgrowths were very marked from this one lesion. The scarring on the face showed there had been some tendency to healing; it was of a thin, parchment-like character, white in color, showing destruction of the pigmentary cells.

On the right arm and forearm six ulcerations were present, ranging in size from a dime to a half dollar. The patient was emaciated and showed evidence of a severe toxemia; temperature not much elevated, no adenopathy of any marked degree, appetite good, urine normal and no undue constipation. He was able to

be up and around in the ward after the dressings were applied. Treatment was begun in the form of iodide of potassum in 30 gr. doses t. i. d., and gradually increased. Externally, iodoform powder was used. Smears of the discharge and sections of the tissues were taken and examined, the blastomycetic fungus being found in abundance. April 22d, one week after treatment was begun, patient seemed brighter, the exudation decreased, and in some places new granulation formations were present. The treatment was continued, the iodides increased. Patient was presented before the Academy of Medicine on April 29th. On May 3d, all nourishment was refused, as the stomach was disarranged by the iodides. May 4th, patient was delirious and difficult to manage. May 5th patient died, evidently from a marked case of systemic toxemia produced by the blasto-myces. Postmortem held May 7th, with the following report:

Appearance-Elderly, emaciated, body covered in areas with peculiar lesions, which, in a general way, appear ulcerous, vegetative, sclerotic smooth central areas irregularly gyrate at periphery map-like limited by rounded wall of tuberculations,

appear as if engraved by corrosive acids. (worm eaten). Lesions cover entire left face including nose, left ear, and tissues beneath chin, mouth not included; similar areas found on both legs, on left inner thigh apparently following lymphatics and great vessels. Right arm and upper part of forearm also involved. Lesions on right leg are probably most marked of any. Largest lesion on leg measures 30 mm. long, 19 mm. wide, and is broadly oval; this lesion has a wall of warty vegetations at periphery averaging 2.5 cm. wide, elevated 0.5 cm. Right foot very edematous. Left leg lesions not so advanced and presents area of dark rugose skin about them. Lesions following lymphatics of left thigh not well marked as others. No lesion on back of trunk, but are present on back of right thigh. Conjuctiva both lids left eye practically destroyed by lesions.

Aspect of Genitals-Penis, long; large, smooth glands, no scars about corona nor urethra, no evidence of venereal disease, no glands palpable except possible slightly of one inguinal gland.

On Section-No subcutaneous fat; cartilage very hard; omentum is this and

fat free, containing no nodules of any size, but small, yellowish deposits in gastro colonic omentum, some of which are elevated like buttons, these lesions. being distributed to a considerable number along attachment of omentum to stomach. Position of intestines is correct.

Anterior Mediastinum-Occupied above by large blackish lymph nodes,... which on section, appear to possess blackish interior and yellowish white peri-: phery. Region of thymus is occupied by bunch of tissue of unknown character.

Lungs-Both lungs intensely anthracotic-left lung bound by old adhesion to upper, lateral and posterior surfaces. of chest. Left lung at apex shows broad area with linear center occupied by whitish nodules the size of a split pea. Radiating from this area are lines resembling photo of sun spots-extreme apex has lost substance on removal, being adherent to subclavian artery and the apical region of the chest. Base of lung tightly adherent to diaphragm-the two lobes are cemented together by firm adhesions. Covering surface on posterior aspect are many white lines like minute riverslung crepitates except extreme base,

Thoracic Aorta-Shows few yellowish slightly elevated areas.

Pericardial Sac- Discharges small quantity brownish fluid; lining smooth and glistening; coronary arteries of heart distended with blood.

Posterior surface small lymphatics (?) show white translucent grain-like bodies size of mustard seed; all veins at base of heart are varicose.

Heart-Right cavity empty; valves normal, no vegetations, smooth endocardium.

Left heart, interior over smooth, small clot; mitral opening admits tips three fingers, no vegetations; appear patent; walls average 2 cm. thick; cut parallell to outer surface shows myocardium dappled yellowish red (specimen taken). Specimen including small mustard seed bodies taken for miscroscope. At junction of aortic valve cusps in an area of calcareous degeneration; right auricle holds fair sized ante-mortem clot. Heart appears normal size of clenched fist.

Gall Bladder-Small, free from liths. Stomach Contracted; upper margin surrounded by slightly enlarged lymph nodes; mucous membrane shows rugose and bluish normal (section).

Duodenal Papilla-Normal. Pancreas-Adherent at tail to spleen; head shows several nut size enlargements (one taken).

Spleen-Diffluent, normal (section (section

taken).

Liver-Right side fifth interspace, left side sixth interspace. Dark mottled brown; smooth surface; consistency,

elastic, showing through capsule are many pebbly areas of whitish color outCut surface shows coarse mottling yellow and brown, small mustard seen white points show through cut surface of liver. On lifting intestines, large numbers of whitish, greatly enlarged elastic peritoneal and omental lymph nodes ranging from size of split pea to 4 cm. by 2 cm. by 1 cm. are seen. Quite distinct adhesions of colon to upper liver and abdominal wall.

Appendix-Long, firmly imbedded in peritoneum, curved over anterior crurai nerve, slightly enlarged at head; deposit resembling lymph nodes found in tip of appendix.

Illium-Peculiar superficial aspect, contracted, chronic passive hyperesmia, wall feels thickened as though by increased Peyers patches. On section these thickened areas are found to be fecal matter; close inspection reveals postmortem softening only.

Kidneys-Left kidney and adrenal normal, apparently. Right kidney, size and position are normal, right adrenal is postmortem cystic.

Pelvic Viscera-Appears normal.

Haemo lymph nodes from aortic bifurcation taken for examination. Chains of enlarged lymphatics each side aorta reach to diaphragm. Thyroid appears normal (section).

Besides the skin, the next structures most notably involved are the mesenteric lymph nodes. These showed, on section, broad areas of coagulation necrosis, resembling the early degeneration of tuberculous glands. Here and there, present in this area, were giant cells similar to those in the corium of the dermal specimen, and in these cells a scant number of blastomyces were found. The lung is markedly anthracotic; here and there are areas of necrosis, peripherally are the giant cells containing the blastomyces.

There are no evidences of infection in the heart section nor in the spleen. In the liver several giant cells are present, showing the fungus. Not so in the kidneys, nor in the adrenals.

Cultures were made on agar plates from skin lesions and from mesenteric