848 The Philippine Journal of Science 1915 
surrounded by a dull red areola. The papule soon bursts, and 
beneath it there appears a small, dark area of blackish necrosed 
skin some 4 millimeters in diameter; five to eight days later the 
slough is cast off, leaving a small, round, or oval ulcer with 
steep edges and the floor covered with mucopus. In most cases 
there is slight evidence of local reaction. The ulcer is of indo- 
lent character, shows small tendency to healing, and may persist 
throughout the illness. The typical initial ulcer is distinguished 
from other forms of skin ulcerations by its clean-cut borders and 
from furuncles by the fact that the lesion is only superficial. 
Lymphangitis has not been observed, but the lymphatic glands 
in the neighborhood of the ulcer are enlarged and tender, some- 
times markedly so; in some cases I have noted glands as large 
as a pigeon’s egg. Such glands remain freely movable, how- 
ever, as there-is no infiammation of the periglandular tissue. 
The general lymphatic system shares in the infection, but remote 
from the lesion the glands are only slightly affected. 
The site of the initial lesion varies, but is commonest in the 
regions of the groins, the armpits, and the neck. As the lesion 
is minute, it is frequently recognized with difficulty. In some 
such cases enlarged glands have been sought for and thus the 
bite has been located. 
That the dermal affection is an essential part of the disease 
has been shown in a small epidemic among the Europeans on one 
of the estates. In May, 1909, three Europeans became ill, each 
showing similar symptoms which varied only in severity and 
duration. In all of them I found the characteristic initial lesion 
with its accompanying lymphadenitis. This feature I hold to 
be constant in the pseudotyphoid of Deli; where no such lesion 
has been observed, either it has already healed or has been over- 
looked—this I believe occurred in regard to the former series 
of cases which I reported. Until we learn more of the etiology 
of the malady, it is unwise to admit the existence of two diseases, 
differing as they do only in unimportant clinical details. 
THE RASH 
The second characteristic symptom is an eruption which 
appears on the second or third day of the disease and attains its 
full development on the sixth to eight day; it then presents itself 
as roseola, the raised spots varying in size from that of a hemp 
seed to a threepence. It closely resembles the roseola of second- 
ary syphilis. The rash covers most of the body, being thickly 
placed on the flanks and less marked on the face and extremities ; 
it persists from eight to ten days longer, then changes to a 
