18 ASHBUKN AND CRAIG. 



of the superficial lymphatic glands, more marked in the left axilla. Physical 

 examination is otherwise negative. 



August 2: The patient looks and feels well, has a good appetite, no pain, no 

 eruption, and sleeps well. The ulcer on the head has healed. 



August 3 : The patient looks and feels well. The systolic roughening persists 

 unchanged. 



August 4 : Discharged from hospital, recovered. 



Case V. — T. Suzuki; male; farmer; age, J(4 years. 



Family history. — One son had this disease two years ago. 



Personal history. — The patient had an attack of tsutsugamushi disease at the 

 age of 17 years and a second one at the age of 25 years. Lately he has visited 

 the infected region, but he does not know when he was bitten by a mite. On July 

 2S he began to suffer from malaise and he came to the hospital on the 30th. At 

 that time he had fever (see Chart 5) and the right inguinal glands were enlarged, 

 painful and tender. At the right margin of the umbilicus was a very small ulcer 

 with red, puffy edges and covered with a thin crust. There were no other 

 symptoms. 



August 1 : Enlargement of the epitrochlear glands is noticed, but they are not 

 tender. Patient feels well and appears so. Physical examination is negative. 



August 2 : There has been no change since yesterday. The spleen is not de- 

 monstrably enlarged, the tongue is moist, clean at the edges, and shows a white, 

 central coat; there is no eruption; the bowels are sluggish. 



August 3: There is no change in the general appearance or condition. 



August 4: There is no marked change. The patient eats and sleeps well, and, 

 except for his fever, the ulcer at the umbilicus and the lymphatic enlargement, 

 appears to be well. The bowels are moving naturally. 



August 5 : The patient to-day insisted on leaving the hospital, and did so 

 notwithstanding the persistence of fever and the remonstrances of his attendants. 

 The subsequent history of the case is unknown to us. 



Case VI. — Male; age, S years. 



Family history. — The patient's mother had tsutsugamushi disease twelve and 

 his father two years ago, both recovering. An employee living in the same house 

 also had it at one time, but the date is unknown. 



Personal history. — The patient has at times been fishing in the infected region, 

 but does not know of having received any bite from a red mite. On July 30 he 

 had a chill and since that time has had fever. 



August 2 : The patient was this morning brought to hospital for the first time 

 by his father. He has a temperature of 39°. 5 C. (103°.2 F. ) and severe headache. 

 The post auricular and upper cervical glands of the left side are enlarged, tender 

 and painful. Examination shows a mite bite just to the left of the sagittal suture 

 at the vertex. It is a small, brown circle of necrotic skin, about 2 millimeters 

 in diameter. The brown, necrotic tissue is loose at the margins, but most inti- 

 mately adherent by its under surface to the sound scalp. The tongue has a white 

 coat, through which the papillae project red and prominent. The eyes are not 

 red or inflamed. Scattered over the face is a slight eruption, which first appeared 

 last night. It is most prominent on the cheeks and consists of faint, dusky 

 macules, 2 to 5 millimeters in diameter, which fade on pressure and return very 

 promptly when the pressure is relieved. The spots present the slightest percep- 

 tible degree of elevation. There is no eruption in the mouth or throat. The 

 spleen is enlarged, the appetite poor, the bowels constipated ; there is no cough 

 and the heart and lungs are normal. Removal of the necrotic area of the bite 



