STUDY OF TSUTSTJGAMUSHI DISEASE. 7 



Spotted-fever regions are uncultivated either because of the elevation 

 and roughness of the land and the difficulty of irrigating it, or of the 

 relative newness of the country. Eegions infected with tsutsugamushi 

 disease are uncultivated because of their low and flat positions, which 

 subject them to annual floods which destroy most crops, and because, 

 for an immemorial period, they have been recognized as dangerous. 



v. SYMPTOMS. 



Tsutsugamushi disease is not usually preceded by well-marked pro- 

 dromata. Occasionally there may be a few days of malaise and indis- 

 position, but its common history is that in from five to twelve days, 

 reraly less than five, after the receipt of a bite from a red mite the 

 patient has a chill; headache and fever follow and a group of lymphatic 

 glands, usually those of one axilla or groin, are found to be enlarged, 

 painful and tender. Examination of the region drained by these glands 

 leads to the discovery of the lesion resulting from the bite. This lesion 

 is small, circular and usually 2 to 4 millimeters in diameter. Some 

 writers state that in its early stages the lesion is a small vesicle. In 

 most instances it is a black or brown area of necrosis of the derma. The 

 dark necrotic skin is very adherent, but after a varying number of days 

 it loosens and is cast off, leaving a circular, punched-out ulcer of slightly 

 greater diameter. The periphery of the ulcer is pinkish in color, 

 slightly infiltrated and generally it is not painful or tender. Enlarge- 

 ment of the lymph vessels connecting the lesion and the large and painful 

 glands can not be detected. The glands, while enlarged and inflamed, 

 do not present great swelling, are not fused together, and are movable 

 beneath the skin. 



The temperature at this early stage ordinarily runs from 38°. 2 C. 

 (101° F.) to 39°.6 C. (103° E.). Tanaka states that it may reach its 

 maximum in twenty-four hours. The pulse is from 80 to 100 and 

 strong. 



The conjunctival vessels are often injected, slight cough may be 

 present, the tongue is moist and somewhat coated, the bowels constipated, 

 and slight or moderate splenic enlargement demonstrable. The urine 

 may contain albumen and the diazo-reaction is present. The patient 

 ordinarily feels comfortable, if headache be excepted and the appetite 

 may be surprisingly good. 



As the disease advances, the above symptoms become more marked. 

 General, slight enlargement of superficial glands occurs, the temperature 

 reaches 40° C. (104° F, to 40°. 5 C. (105° E.) and is continuous. 

 The pulse weakens and quickens and it may become dicrotic ; the first heart 

 sound may be impure. The presence of albumen and the diazo-reaction 

 in the urine are more marked and casts may be numerous; injection of 



