STUDY OF TSUTSUGAMUSHI DISEASE. 9 



unusual, the sickness commonly commencing with a chill. There is not 

 the constant signal symptom of localized lymphadenitis which enables 

 one to find the tick bite, and when it is present it is usually due to pyo- 

 genic or other infection of the wound, and lymphangitis may accompany 

 it, while the margins of the lesion are more inflamed and indurated than 

 in the other disease. In many cases no tick bite can be located. When 

 found it does not present the constant appearance of a small, round 

 necrotic area succeed by an ulcer as in the case of the mite bite. The 

 temperature in spotted fever is not essentially different from that in 

 tsutsugamushi disease, although it does not show the constancy of type 

 shown by the latter; the eye symptoms, constipation and splenic enlarge- 

 ment may be the same. 



As spotted fever progresses the symptoms in the main bear a great 

 resemblance to those of tsutsugamushi disease, with the following excep- 

 tions : 



a. The fever in the latter disease is more typically continuous; in the former 

 more irregular. 



o. The pulse rate in spotted fever as compared with the temperature is apt 

 to be relatively high; in tsutsugamushi disease it may be the opposite. 



c. The majority of spotted-fever patients are dead before the end of the second 

 week. 



d. As a rule, the exanthem in spotted fever appears earlier than that of 

 tsutsugamushi disease. It shows first on the wrists and ankles and rapidly 

 spreads to cover the entire body. It is much more abundant and more plainly 

 visible than that of tsutsugamushi disease, although the latter fact is doubtless 

 related in part to the darker color of the skin in Japanese. It usually consists 

 of macules or petechia^, although it may resemble the rash of measles or of 

 riitheln; but in practically all cases it soon becomes petechial or hemorrhagic, 

 and large extravasions may be produced by the confluence of neighboring hemor- 

 rhagic spots. Instead of disappearing in from four to seven days this eruption 

 usually persists until after the patient has died or recovered and slightly 

 pigmented stains may mark its location for weeks on the bodies of persons 

 recovering. Some of the points of extravasation may pass on to gangrene and 

 sloughing, a thing unknown in tsutsugamushi disease. 



e. Hemorrhagic extravasation not infrequently takes place into the scrotal 

 tissues of make subjects of spotted fever, never in cases of the other disease. 



f. The tongue and lips of the spotted-fever ease may be dry, cracked and 

 bleeding, but the gums do not become spongy and do not ooze blood, as is 

 sometimes the case in tsutsugamushi disease. 



g. Parotitis, malama and mania have not been noted as complications. 



IV. BLOOD EXAMINATION. 



So far as we know, no complete studies have been made of the condition 

 of the blood in tsutsugamushi disease. Tanaka states that the red cells 

 usually run from 4,800,000 to 5,200,000, the leucocytes from 6,000 to 

 8,000, and the hamioglobin from 40 to 75 per cent. 



On the other hand, Dr. Miyajima informed us that the red cells fall 

 during the course of the disease to 3,000,000 or 4,000,000, while the 



