STUDY OF TSUTSUGAMUSHI DISEASE. 17 



moaning; breath sounds harsh; cough less severe and distressing. Pulse recorded 

 as 85, but during examination it was 140 and weak. Heart sounds rapid and 

 weak, but clear. 



August 4 : The patient died at 6 a. m. to-day. Delirium had ceased, but 

 diarrhoea persisted and the heart became rapid .and weaker until death occurred. 

 Autopsy was not obtainable. 



Case III. — H. Itagake; male; age, lJf years. 



Family history. — Negative as regards this disease. 



Personal history. — The patient has visited the infected regions and was bitten 

 by a mite on July 19. This is his first attack of tsutsugamushi disease. 



Present illness. — The disease began with a slight chill on July 27. Since that 

 time the patient has had moderate fever and enlargement of the lymphatic glands, 

 particularly of the right axilla, but has felt comfortable and has not appeared to 

 be very ill. The temperature is shown by Chart 3. 



August 1 : The patient has had no symptoms except the fever, slight headache 

 and constipation, and does not appear or feel very ill. There is no eruption and 

 the spleen is not demonstrably enlarged. The right axillary glands are swollen 

 and tender and tiie skin of the same axilla shows a small ulcer with pinkish, 

 slightly indurated and tender margins. 



AiTgust 2 : Face clear and bright. No eruption present and the patient appears 

 well. The tongue is white, slightly dry and tooth-marked. The pulse is of good 

 strength. 



August 3: The face is Hushed, the eyes injected, a faint eruption present. The 

 patient appears worse than he did yesterday, but does not complain. The tongue 

 is moist and has a white coating, the spleen somewhat enlarged and tender, but 

 not palpable. There is no cough, but the breath sounds are harsh, especially at 

 the apices of the lungs. The urine shows a trace of albumen and very numerous, 

 coarsely granular casts and small round epithelium, but no blood. Examination 

 of the faeces shows Ascaris eggs, but is otherwise negative. 



August 4: The skin is hot, the face flushed, eyes injected, expression somnolent. 

 The tongue is somewhat dry, red at the margins, and has a thick, yellowish white, 

 central coat. The gums are normal. Cough is present, but there is no expec- 

 toration. Respiration is rapid and regular, the breath sounds harsh. The pulse 

 is rapid, compressible and regular; the first sound of the heart roughened over the 

 base and apex. 



August 7 : On our return to the hospital we learned that the patient had grown 

 worse and had become very nervous, and that he had left the hospital on August 

 6. His subsequent history is unknown to us. 



Case IV. — 8. Asai; male; age, 11 years. 



Family history. — Negative as regards this disease. 



Personal history. — Patient has been in the infected regions, but was not aware 

 that he had been bitten by mites. On July 27 he felt listless and feverish and on 

 the 29th he came to the hospital. At that time he had fever (see Chart 4), his 

 face was flushed and lie complained of headache and pain in the pharynx. The 

 lymphatic glands in the left axilla were swollen and painful and careful exam- 

 ination revealed the presence of two small ulcers, one in the left axilla and one 

 back of the hair line of the left frontal region. 



August 1 : Condition as at time of admission. No eruption has shown and the 

 patient looks and feels well. Spleen not palpable or tender. Slight systolic 

 roughening is noticed over base and apex of the heart. There is slight enlargement 

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