severe. As yet the virus of the disease, which doubtless enters in the first instance at the site of the primary eschar, has not been discovered. Mizayima states that shima mushi is communicable to the monkey by the bite of the insect, and also by inoculation from a human patient.
Symptoms.— After an incubation period of from four to seven days the disease usually begins with malaise, frontal and temporal headache, anorexia, chills alternating with flushes of heat, and prostration. Presently the patient becomes conscious of pain and tenderness in the lymphatic glands of the groin, armpit, or neck. On inspecting the skin of the corresponding lymphatic area there is discovered— usually about the genitals or armpits— a small (2 to 4 mm.), round, dark, tough, firmly adherent eschar surrounded by a painless livid red areola of superficial congestion. Occasionally two or three such eschars are discovered. Although a line of tenderness may be traced from the sore to the swollen, hard, and sensitive glands, no well-defined cord of lymphatitis can be made out. The superficial lymphatic glands of the rest of the body, especially those on the opposite side corresponding to the glands primarily affected, are also, but more slightly, enlarged.
Fever of a more or less continued type now sets in, the thermometer mounting in the course of five or six days to 40° or 41° C. The conjunctiæ become injected, and the eyes somewhat prominent; at the same time a considerable bronchitis gives rise to harassing cough. The pulse is full and strong, ranging rather low— 80 to 100— for the degree of fever present. The spleen is moderately but distinctly enlarged, and there is marked constipation.
About the sixth or seventh day an eruption of large dark-red papules appears on the face, tending to become confluent on the cheeks. It then extends to the forearms, legs, and trunk, being less pronounced on the upper arms, thighs, neck, and palate. Simultaneously with the papules a minute lichenous eruption breaks out on the forearms and trunk. This lasts usually from four to seven days; if but
