period has been as much as fifteen months, or even longer.
There is very little reliable information about the presence or absence of constitutional symptoms. It is customary to describe the disease as non- febrile. This may be true in most cases, but I am not convinced that it is so in every case. It is obvious that in a disease with, at least in some instances, a very prolonged incubation period, slight or even severe fever might be overlooked or misinterpreted. Oriental sore produces an immunity against itself. There must, therefore, be profound constitutional change. In other diseases attended with similar change fever is almost invariably present at one time or another in their course. In the case just alluded to as occurring in my experience, a severe anomalous fever, of five or six weeks' duration, preceded by eight months the appearance of the local lesions. In Wenyon's case the development of the initial papule was preceded by smart fever supposed at the time to be influenzal. Seeing, as has been pointed out (p. 218), the close connection of oriental sore with kala-azar, this question of the constitutional symptoms in the milder disease is an important one, and should be carefully studied.
Symptoms.—— The local lesion in oriental sore commences as a minute, itching papule which tends to expand somewhat as a shotty, congested infiltration of the derma. After a few days or weeks the surface of the papule becomes covered with fine, papery scales. At first these scales are dry and white; later they are moister, thicker, browner, and adherent. In this way a crust is formed, which on falling off, or on being scratched off, uncovers a shallow ulcer (Fig. 58). The sore now slowly extends, discharging a scanty ichorous material; this from time to time may become inspissated and a crust forms, while the sore continues to spread underneath. The ulcer extends by the erosion of its perpendicular, sharp-cut, and jagged edge, which is surrounded by an areola of congestion. Subsidiary sores may arise around the parent ulcer, into which they ultimately
