STUDY OF TSUTSUGAMUSHI DISEASE. 19 



by means of forceps and scissors leaves a small ulcer with steep margins and a 

 whitish or grayish lining, the appearance of which is said to be very characteristic. 

 August 7 : The patient did not enter the hospital and we have seen him but 

 the one time. We are told that his fever is high and his condition serious. The 

 subsequent history is unknown to us. 



Case VII. — Sakuma; male; farmer; age, 20 years. 



Family history is negative as regards tsutsugamushi disease. 



Personal history. — The patient has not had this disease previously. On July 

 27 he was bitten by a red mite. On August 3 he was taken sick with fever and 

 a feeling of uneasiness. He continued feverish, but had no great discomfort, nor 

 any marked symptoms, and came to the hospital- on August 5. The maximum 

 temperature that day was 40° C. (104° F.), the highest pulse rate 94. On 

 August 6 the highest temperature was 39°.5 C. (103°.2 F. ), the highest pulse 

 rate 107. 



August 7 : We saw the patient for the first time this morning. He has a 

 temperature of 39° C. (102°.2 F. ), and a good pulse of 95. There is slight enlarge- 

 ment of the superficial lymphatic glands, most marked in the left axilla, where they 

 are also tender. The bite is located in the left axilla and is an ulcer with a mass 

 of black, necrotic tissue still attached to its central part. It is larger than usual, 

 being about 1 by 0.5 centimeter. The conjunctiva? are congested, the tongue moist 

 and white and an eruption is present this morning for the first time. This is 

 most marked on the right cheek and consists of six dusky, very slightly elevated 

 papules which fade on pressure. The bowels are regular and the patient has 

 neither cougli nor pain. He sleeps and eats well, bvit his expression is somewhat 

 dull and listless. The spleen is slightly enlarged, but neither tender nor palpable. 

 The examination of heart and lungs is negative. 



We did not see this patient again and know nothing of his subsequent history. 



XVI. CONCLUSION AS TO THE NONIDENTITY OF THE TWO DISEASES. 



We think that a consideration of the facts concerning the two diseases, 

 as at present known and set forth above, justifies the opinion that 

 they are separate and distinct disease entities. They present many 

 points of resemblance, but those are not sufficient to overbalance those 

 of difference. 



XVII. DOES TSUTSUGAMUSHI DISEASE OCCUR IN THE PHILIPPINE 

 ISLANDS ? 



The ready answer which the large majority of medical men in the 

 Islands would give to the above- question would be in the negative and 

 it is probable that they are. correct. Nevertheless, certain cases are 

 seen which should lead to a more complete investigation of the subject. 

 In these Islands there occur a great many eases of anomalous fevers 

 and these are probably of several kinds. In our report for the quarter 

 ending June 30, 1906, we made passing reference to two which were seen 

 by one of us at Camp Connell, Samar, in the preceding February and 

 we are in possession of the temperature charts and the notes made on 

 them by First Lieut. Earl H. Brans, assistant surgeon, United States 



