A Comparative Study of Tsutsugamushi Disease And

OriginalArticles. liberal view taken of the matter by General Wood, the Acting Surgeon-General, and the War Depart- A COMPARATIVE STUDY OF TSUTSUGAMUSHI ment, we were ordered; and this report is based DISEASE AND SPOTTED OR TICK on the observations on tsutsugamushi disease FEVER OF MONTANA. made on that trip and the observations made by one of us in 1904 and 1905 on the BY P. M. ASHBURN, M.D., (Ashburn) Captain and Assistant Surgeon, U. S. A., cases of spotted fever occurring in those years in AND the Bitter Root Valley in Montana. CHARLES F. CRAIG, M.D., The that we were to to deter- First Lieutenant and Assistant Surgeon, U. S. A., specific point try Constituting the United States Army Board for the Study of Tropical mine, and which we think we have determined, Diseases as They occur in the Philippine Islands. was the question of the identity or nonidentity of I. Synonymy. II. Introduction. III. History of the two diseases and most emphasis will be laid on both Diseases. IV. Etiology. V. Symptoms, Tsutsu- that in this Spotted Fever. VI. Blood Examinations. point report. gamushi, both so re- VII. Mortality. VIII. Immunity Conferred by At- However, diseases, being closely as are to tack. IX. Susceptibility of Animals. X. Prog- stricted to locality, necessarily unknown nosis. XI. Pathological Anatomy. XII. Diagnosis. the very great majority of medical men, and a XIII. Prophylaxis. XIV. Treatment. XV. Case brief description of each will therefore be given Histories of Tsutsugamushi Disease. XVI. Con- and an effort made to run the par- clusion as to the Nonidf.ntity of the Two Dis- descriptions so eases. XVII. Does Flood Fever Occur in the Philip- allel, that the resemblances and differences may pine Islands? be brought out more strikingly. The descrip- I. SYNONYMY. tions to be given are based on personal observa- and Tsutsugamushi Disease : Japanese River Fever. tions of some 22 cases of spotted fever Flood Fever. Island Fever. Kedani Disease. 7 cases of tsutsugamushi disease, as w^ell as on the Akamushi Disease. Shimamushi Disease. Yo- writings of other men who have studied one dis- chubio. Shashitsu. ease or the other more carefully than we could or Mushi is a Japanese word meaning bug, and the did. compounds ending with it all relate to the etiology Both diseases are still subjects of earnest and of the disease. Tsutsugamushi is the term em- careful investigation by expert workers and it is ployed by most Japanese people and professional therefore unnecessary and would be futile, in a men as it has the derived from paper of this kind, to attempt the thorough con- and, prestige will ancient and specific usage, it will be employed in sideration of them which they deserve and this paper. receive later. Montana: Mountain Spotted Fever of Rocky HISTORY OF THE TWO DISEASES. Fever. Tick Fever. Pyroplasmosis Hominis III. (Wilson and Chowning). Tick Fever of the Rocky According to Tanaka the name tsutsugamushi Mountains. Rocky Mountain Spotted Fever. has been known since the earliest historical times, As so-called fever has been described in while the name shashitsu occurs in old Chinese spotted a A various parts of the Rocky Mountain region and writings of more than thousand years ago. from one such indicates that at as it has not been determined that the same dis- quotation writing that time the disease was as a distinct ease in all those parts, the term Spotted or recognized prevails and was ascribed to the bite of a mite Tick Fever of Montana will be used in this paper, affection to that in which occurred in summer time in certain dis- the disease referred being occurring rains. western in the Bitter Root tricts that had been flooded by the spring Montana, particularly statement made in Missoula and Ravalli counties. The bite was described and the Valley, that after three days high fever developed and a II. INTRODUCTION. pustule appeared at the site of the injury. It was For years kedani or tsutsugamushi also recognized that only certain regions were in- many past in disease has been an annual subject of the most fected and that the disease only appeared per- active and painstaking investigation on the part sons entering them. of Japanese physicians and the Japanese govern- The disease was brought to the attention of the ment. Western world by Palm, in 1878 and Balz, in 1879, One of the leading investigators of late years is and since that time it has been the subject of Dr. M. Miyajima, of the Institute for Researches much painstaking wrork by Japanese medical men of Infectious Diseases, of Tokyo. Dr. Miyajima and of numerous articles in Japanese and some in had read of the work of Wilson and Chowning, foreign journals. Numerous micro-organisms, have Anderson, Stiles and others, on the study of including cocci, bacilli and protozoa, been " " " " cause the several spotted or tick fever in Montana, and he described as the of disease, and had found so many points of similarity in the two investigators are working at the present time, diseases that he thought it quite possible that each with what he thinks the causative factor. these workers has they were the same. Consequently, when he It cannot be said that any of came to Manila as a representative of his govern- yet established his claim. ment to the Philippine Islands Medical Associa- Three hypotheses at present divide the workers tion and we met, he was desirous that we should and rule the work of investigation: visit at the season and determine, if 1. That the disease is due to a bacterium, a Japan proper Institute for possible, whether or not such be the case. Thanks belief favored by the workers of the to the representations of Dr. Miyajima and the Infectious Diseases.

The Boston Medical and Surgical Journal as published by The New England Journal of Medicine. Downloaded from nejm.org at UNIVERSITY COLLEGE LONDON on June 26, 2016. For personal use only. No other uses without permission. From the NEJM Archive. Copyright © 2010 Massachusetts Medical Society. 2. That it is a protozoal infection. Professor phatic glands becoming enlarged and painful and Ogata is the leading exponent of this idea. an attack of fever succeeding. 3. Tanaka thinks the disease due to a toxin It is the experience of practically all who have contained in the body of the red mite. carefully studied the disease, and they are numer- Spotted fever of Montana has been recognized ous, that every case of it is preceded by the mite for only a few years, twenty-five at the most, while bite and in the great majority of cases the bite is the literature relating to it has practically all been located by an examination of the region drained made since 1902. At that time Wilson and by the lymphatic glands which first became Chowning published their first account of it and enlarged and tender. So far as could be learned their ideas as to its cause and method of trans- in Japan, Bälz's contention that such is not the mission, in a preliminary report to the Montana case has not received support, and later investiga- State Board of Health, which appeared in the tors agree that the bite of the mite is the sole Journal of the American Medical Association. It means of infection. The mite in question is the is true that Major Wood, in 1896, and Maxey, in larval form of a trombidium, species unknown. 1899, had reported a similar, or the same, disease The larva bears a great resemblance to that of in Idaho, but the form occurring there presents Leptus autumnalis. It is so small as to be almost such points of difference, particularly in regard to invisible to the naked eye, bright red or orange in mortality, that it is not considered in this paper. in color, and is found on land that has been sub- Since the work of Wilson and Chowning in 1902, merged by flood. Here it is best collected by the disease has each year been the subject of tying a monkey out over night or by catching the careful investigation and report and the prospects field mice (Arvícola hatanedzumi, Sasaki) occur- now are that its etiology will soon be well under- ring in such regions. The mites collect in groups stood. on or about the eyelids of the monkey, while they The total number of cases occurring each year are always found attached in large numbers to the is small and that, considered in connection with inner surfaces of the ears of the mice. Mites the further facts that the disease occurs in such a resembling these in size and color occur in many limited and relatively isolated region and that it parts of Japan but they do not attack persons. has been known for so short a time, makes it The akamushi of other than infected regions do remarkable that the present knowledge con- not transmit disease. Several supposed causative cerning it should be as great as it is. organisms have been described for this disease, the latest and probably the one calculated to IV. ETIOLOGY. excite most interest being Ogata's plasmodium. Tsutsugamushi disease occurs along certain None of these alleged discoveries has been con- limited parts of the banks of a few rivers on the firmed, and, judging from what we heard and west coast of the main island of Nippon, being what blood examinations we could make in Japan, limited to Echigo and Akita provinces. The it appears that Ogata's plasmodium does not distribution of the infected areas is irregular and, exist. The causative organism is yet unknown. up to the present time, unexplainable. They are Spotted or tick fever of Montana, as known by all subject to submergence by floods which occur Wilson and Chowning, Anderson, Stiles, Ricketts in June, but not all flooded districts are infected and Ashburn, occurs also in very strictly limited nor does the relative location of an infected dis- areas, particularly in a strip of country about four trict, up or down stream, seem to influence a non- to ten miles wide and fifty miles long, lying on the infected. The floods usually occur in June and west side of the Bitter Root River and the eastern last but a few days. Immediately after their side of the Bitter Root Mountains and partly on subsidence the infective regions are not danger- the slopes of those mountains. The country in ous but after a few weeks or a month and synchro- question has a considerable snowfall and the snow nously with the appearance of the akamushi or red remains on the mountains until mid June and on mite, they become so and any person entering the highest peaks for two or three weeks longer. them takes a considerable risk of contracting the The Bitter Root River is largely fed from this disease. Consequently, they are then avoided by snow, and, as it begins to melt in Marchand con- all whose poverty does not drive them there to tinues to do so with increasing rapidity until most work or gather mulberry leaves. As a general of it has disappeared, the stream is in a state of rule no right of ownership is exercised over such freshet during that time and does not again reach land and the very poor do, therefore, cultivate " low water " until July. hemp on it in some places and in other parts visit During the same period ticks, D. occidentalis, it to gather mulberry leaves to feed silkworms. which before and after it are infrequently seen, In either case they are apt to be bitten by red appear in great numbers, particularly in the mites and it is customary for them to search woods, thickets and uncultivated regions, and are carefully for such bites after leaving the places. very apt to get on any person or animal going into However, the mites are so minute as to be very such parts. Likewise and, as a rule, during the difficult of detection, and, if the bite does not same period, cases of spotted or tick fever cause pain, it is frequently overlooked. Not all appear, and in almost all cases there is a history of mites are infective and many bites therefore cause a recent visit to, or residence in, the infected no trouble. A certain proportion of them, district, and, in many cases, of tick bites received though, do so, the point bitten becoming an there. Wilson and Chowning incriminated the eschar and later an ulcer, the neighboring lym- tick as the carrier of the disease as early as 1902.

The Boston Medical and Surgical Journal as published by The New England Journal of Medicine. Downloaded from nejm.org at UNIVERSITY COLLEGE LONDON on June 26, 2016. For personal use only. No other uses without permission. From the NEJM Archive. Copyright © 2010 Massachusetts Medical Society. From a study of all the cases occurring in 1904 always Dermacentor occidentalis and usually the and most of those occurring in 1905 Ashburn adult. came to the conclusion that a considerable pro- Tsutsugamushi disease occurs always after portion of them gave neither history nor signs of floods and it is contracted on ground which has tick bite and for that and other reasons which it actually been submerged by the swollen river. is not necessary to detail here, agreed with Stiles Fields immediately adjoining the infected areas that the tick was not concerned in transmitting and but a few feet higher are considered safe. the disease. However, the more recent and very The Montana disease may precede the flooding excellent work of Ricketts and of King and their of the streams or, more usually, accompanies it. apparent success in transmitting the disease to It is very commonly contracted on ground which monkeys and guinea pigs by means of the tick, has not been submerged but is on hillsides high seem to indicate that Wilson and Chowning above the level of the river. The cases begin in were right in their belief as to the method of March and rarely appear after the middle of July. infection. Tstitsugamushi disease is beginning to appear at It may therefore be said that the disease is that time and continues to do so into October. introduced by the bite of D. occidentalis. This Spotted fever regions are uncultivated, either bite cannot always be located, possibly because because of the elevation and roughness of the land the first symptoms of the disease do not indicate and the difficulty of irrigating it, or because of the its location as in the tsutsugamushi disease. Cer- relative newness of the country. The tsutsu- tainly an ulcer and lymphadenitis do not always gamushi infected regions are uncultivated because follow it. of their low and flat positions subjecting them to Ricketts' recent observation that nymphal annual floods which destroy most crops and ticks may transmit the disease and his suggestion because for an immemorial period they have been that larvse f may do so, may account for the recognized as dangerous. absence of a history of tick bite in some cases, as the lesion resulting from the bite of a larva may v. SYMPTOMS. be insignificant and may possibly leave no trace Tsutsugamushi disease is not commonly pre- after a few hours or a day and the larva itself may ceded by well-marked prodromata. Occasionally be overlooked. Most persons in the infected there may be a few days of malaise and indis- regions carefully watch and examine themselves position, but the usual history is that in from five for tick bites and it is improbable that the bite of to twelve days, rarely less than five, after the the adult tick is often overlooked. In nearly all receipt of a bite from a red mite the patient has a cases the disease is contracted on the hill sides or chill; headache and fever come on and one group " bench," high above the river, and some persons of lymphatic glands, usually those of one axilla or long resident in the region say that the bottom groin, is found to be enlarged, painful and tender. lands and islands which are subject to submersion Examination of the region drained by these are free from danger. glands leads to the discovery of the lesion re- Wilson and Chowning named the disease sulting from the bite. This lesion is small, circu- Piroplasmosis hominis. Later investigations, ex- lar and usually 2 to 4 mm. in diameter. It is cept that of Anderson, have failed to confirm their stated by some writers that in its early stages the view and the disease is not now considered a lesion is a small vesicle. In most instances it is a piroplasmosis. The causative organism is not black or brown area of necrosis of the derma. known. The dark necrotic skin is very adherent, but after A consideration of the etiology of the two dis- a varying number of days it loosens and is cast eases shows many points of resemblance, but also off, leaving a circular, punched out ulcer of slightly some important differences. Both occur in small greater diameter. The periphery of the ulcer is and usually strictly limited areas along certain pinkish in color and slightly infiltrated and is not streams running through mountainous country. usually painful or tender. Enlargement of the The country in each instance is subject to heavy lymph vessels connecting the lesion and the large snowfall in winter and the streams to spring or and painful glands cannot be detected. summer floods. Along each infected stream the The glands, while enlarged and inflamed, do dangerous spots are usually more or less unculti- not present great swelling, are not fused together vated and the soil overgrown with underbrush, and are movable beneath the skin. trees or weeds, while the immune spots are well The temperature at this early stage ordinarily cultivated. In each instance the disease is runs from 101° F. to 103° F. Tanaka states that it attributed to the bite of an Acariña and in each a may reach its maximum in twenty-four hours. supposed protozoan blood parasite has been de- The pulse is from 80 to 100 and strong. scribed as the cause and has not been confirmed as The conjunctival vessels are apt to be injected, such. Contagion is unknown in either disease. slight cough may be present, the tongue is moist The differences in the etiology of the two are and slightly coated, the bowels constipated, and equally well marked. The Acariña whose bite slight or moderate splenic enlargement demon- causes tsutsugamushi is always a six-legged, larval strable. The urine may contain albumin and Trombidium, whose adult form is unknown. the diazo reaction is present. The patient That causing spotted or tick fever of Montana is ordinarily feels comfortable except for headache, t Since the above was written Ricketts (Jour. Am. Med. Asso., and the appetite may be surprisingly good. Oct. 12, 1907) has published reports of successful transmission of As disease advances the above spotted fever to guinea pigs by means of larval D, occidentalis. the symptoms

The Boston Medical and Surgical Journal as published by The New England Journal of Medicine. Downloaded from nejm.org at UNIVERSITY COLLEGE LONDON on June 26, 2016. For personal use only. No other uses without permission. From the NEJM Archive. Copyright © 2010 Massachusetts Medical Society. become more marked. General slight enlarge- complications, while coma, cardiac weakness and ment of superficial glands occurs, the temperature pulmonary edema may be terminal features. reaches 104° F. to 105° F. and is continuous. Spotted or tick fever, as it occurs in the Bitter The pulse weakens and quickens and may become Root Valley, begins in from one to eight days after dicrotic, the first heart sound may be impure. the tick bite, in cases where the history of bite is The presence of albumin and the diazo reaction obtainable. As in tsutsugamushi disease, pro- are more marked in the urine and casts may be dromata are unusual, the disease commonly com- numerous; injection of the conjunctiva and mencing with a chill. There is not the constant lachrymation are more evident. Respiration is signal symptom of localized lymphadenitis which accelerated, the breath sounds are harsh, cough enables one to find the tick bite, and when present increases and may be harassing, though the ex- it is usually due to pyogenic or other infection of pectoration is scanty. The entire surface of the the wound and lymphangitis may accompany it, body is apt to be hypersensitive and this causes while the margins of the lesion are more inflamed complaint. Constipation usually persists but and indurated than in the other disease. In many diarrhea and abdominal pain and tenderness occur cases no tick bite can be located. When found it exceptionally. The tongue becomes dry, brown does not present the constant appearance of a in the center and glazed at the tip and edges, small round necrotic area succeeded by an ulcer as sordes collect and the gums may become spongy in the case,of the mite bite. The temperature is and bleed. In such cases the breath is particu- not essentially different, although it does not larly foul. show the constancy of type shown by that of Partial deafness occurs, the patient becomes tsutsugamushi disease; the eye symptoms, con- stuporous and may pass into coma before death. stipation and splenic enlargement may be the At some period of the disease, usually from the same. fifth to the seventh day, though it may be a little As the disease progresses the symptoms in the earlier or later, an exanthem appears, showing main bear a great resemblance to those of tsutsu- first on the face and later on the chest, the fore- gamushi disease, with the following exceptions: arms, the legs and the rest of the trunk. The a. The fever in the latter disease is more palate and buccal surfaces also show it occasion- typically continuous; in the former more ir- ally. The eruption consists of irregular, rather regular. faint, dusky or pink macules or flattened papules, 6. The pulse rate in spotted fever is apt to be 2 to 5 mm. in diameter, which may become con- relatively high, as compared with the tem- fluent on the cheeks and give an appearance of perature; in tsutsugamushi disease it may be swelling. On the relatively dark skin of a Japa- relatively low. nese this eruption is not well shown and on other c. Most spotted fever patients are dead before parts than the face the lesions bear a great re- the end of the second week. semblance to flea bites, with which they may be d. The exanthem in spotted fever appears confused. They fade on pressure but at once earlier, as a rule, than that of tsutsugamushi dis- return when it is removed. The eruption does ease. It shows first on the wrists and ankles and not itch and the duration of it is usually from four rapidly spreads to cover the entire body. It is to seven days, although it may be more or less. much more abundant and more plainly visible It never becomes hemorrhagic or petechial. than that of tsutsugamushi disease, though the Tanaka states that in rare instances it may be- latter fact is doubtless related in part to the come vesicular or pustular. This is probably darker color of the skin in Japanese. It usually rarer than he implies. consists of macules or petechiiE, although it may This period of exanthem marks the height of resemble the rash of measles or of rötheln; but the disease, and as the eruption begins to fade, in practically all cases it soon becomes petechial or usually about the end of the second week, the hemorrhagic and large extravasations may be pro- fever remits and in a few days the temperature duced by the confluence of neighboring hemor- reaches normal, while the general condition also rhagic spots. Instead of disappearing in from improves rapidly. The patient then speedily four to seven days this eruption usually persists recovers, although the little ulcer resulting from until after the patient has died or recovered, and the bite may be long in healing. slightly pigmented stains may mark for weeks its The above presents a recovering case of average location on the bodies of persons recovering. severity. In more severe cases death may result Some of the points of extravasation may pass on from the ninth to the fifteenth day, or in more to gangrene and sloughing, a thing unknown in severe cases which recover, the fever may last tsutsugamushi disease. longer and the symptoms be very marked. e. Hemorrhagic extravasation not infrequently On the other hand very light cases may show takes place into the scrotal tissues of male subjects but slight and ephemeral fever, very trifling or no of spotted fever, never in cases of the other dis- exanthem, and may not be bedfast. The ulcer ease. and lymphatic enlargement are always present /. The tongue and lips of the spotted fever case though, and the former may be larger than usual, may become dry, cracked and bleeding, but the as much as 1 cm. in diameter. The duration of gums do not become spongy and ooze blood as the disease is usually about three weeks. It may they sometimes do in tsutsugamushi disease. be as long as a month or as short as one week. g. Parotitis, malena and mania have not been Parotitis, melena and mania have been noted as noted as complications.

The Boston Medical and Surgical Journal as published by The New England Journal of Medicine. Downloaded from nejm.org at UNIVERSITY COLLEGE LONDON on June 26, 2016. For personal use only. No other uses without permission. From the NEJM Archive. Copyright © 2010 Massachusetts Medical Society. VI. BLOOD EXAMINATION. Not enough differential counts have been made No complete studies have been made, so far as to enable us to form an opinion as to their value in we know, of the condition of the blood in tsutsu- prognosis. Anderson reports such a count in a gamushi disease. Tanaka states that the red recovering case, the percentages being as follows: cells usually run from 4,800,000 to 5,200,000, small lymphocytes, 9.9; large lymphocytes, 10.6; the leucocytes from 6,000 to 8,000 and the polymorphonuclears, 78.7; eosinophiles, 0.8. hemoglobin from 40% to 75%. Wilson and Chowning and Anderson described On the other hand Dr. Miyajima informed us what they considered a piroplasma in the blood of that the red cells fall during the course of the spotted fever cases. Later observers have not disease to 3,000,000, or 4,000,000, while the confirmed this and we do not think that any or- hemoglobin is reduced proportionately and that ganism can be seen. leucopenia obtains. He had not made differential VII. MORTALITY. were in counts of white cells. We disappointed The of disease has been not for blood counts mortality tsutsugamushi having apparatus making estimated at from 15% to 70%, or more. and were forced to content ourselves with ex- variously Statistics of 567 cases recorded Dr. aminations of fresh and stained films. From carefully by show an average of 27%. such examinations we that the red cells are Miyajima mortality judge The rate shows a and increase that and that steady progressive not deformed, they stain normally from 12£% in the first decade of life to 57% in the the differential white cell count is not apt to be of seventh. much assistance in There is diagnosis. apparently The mortality statistics of tick fever are not a well marked leucopenia. based on such a number of cases, and it is The number of cases examined us is too large by probable that many of the cases included in small to enable us to draw any general conclusion Wilson and tables, but as to the value of differential counts in the prog- Chowning's occurring prior to 1902, were not fever. They nosis, but if indicate it is that really spotted they anything, they nevertheless figure the percentage of mortality as have such value. 75 and that is correct. This dis- It will be noticed that Case re- approximately IV, discharged ease is therefore more fatal than the other. So and Case from a third attack covered, V, suffering far as the statistics at hand and not both had low give any indication, apparently very sick, poly- the does not increase with the and counts; mortality steadily morphonuclear high lymphocyte age of the patients. while cases I and II, both ending fatally, and III and VI, both serious, if not fatal, did not show VIII. IMMUNITY CONFERRED BY ATTACK. either. So far, then, as a general deduction might One attack of tsutsugamushi disease does not be drawn from the consideration of differential confer permanent immunity against another. counts on six cases, it would appear that a relative Probably a temporary immunity is always con- decrease of polymorphonuclear and increase of ferred, but second and third attacks, in later mononuclear cells, particularly of lymphocytes, years, are not rare. One of the cases seen in constitute a favorable prognostic omen. We were August was suffering from his third attack. As a unable to recognize parasites in either fresh or rule the later attacks of the disease are milder than stained specimens of blood, except one body in a the first. fresh film from Case VI. The body was intracellu- In tick fever second and third attacks are un- lar, ameboid, unpigmented and about 1 micron in known and it seems probable that they do not diameter. We thought it a young tertian parasite. occur. The number of living persons who have (Malaria is common in the district.) had the disease is so small, however, as to make The following table shows the results of our generalizations on this point dangerous. Ricketts differential counts. They were all made on blood states that active immunity of at least two or drawn Aug. 2 and in each case at least 400 white three months' duration is produced in the monkey cells were counted. or guinea pig by an attack of the disease. IX. SUSCEPTIBILITY OF ANIMALS. >ti HS Ogata states that tsutsugamushi disease is in- Oh 1§ gi* o oculable into kittens, apes, mice and guinea pigs. Small lymphocytes, 7 5 8 8 18 18 Dr. Miyajima, who has done much work on the Large lymphocytes, 11 L0 7 L2 21 27 subject, states that it can be produced in monkeys Polymorphonuclears, 74 80 84 77 54 45 either mite bite or inoculation from a 5 1 3 9 by patient, Trans, and large mono., but not in mice or Infected Eosinophiles, 1 guinea pigs. monkeys show fever but not the skin or genital involvement In spotted fever, as in tsutsugamushi disease,, described by Ricketts as occurring in monkeys the blood condition has not been sufficiently inoculated with spotted fever. studied to permit the drawing of general deduc- Wilson and Chowning thought that rabbits and tions. Wilson and Chowning and Anderson spermophiles were inoculable with spotted fever. agreed that the red cell counts were reduced about Stiles and Ashburn were unable to produce the the somewhat more ; while the disease in them. 20% ; hemoglobin it in leucocytes were increased. In one fatal case, in a Ricketts and King have produced monkeys pregnant woman, Ashburn found a leucocyte and guinea pigs, and more recently Ricketts count of 15,600. appears to have produced it in the horse.

geographical distribution. Confined to Echigo and Akita provinces in Japan. Confined to parts of the Rocky Mountain region. Contracted on ground that actually has been submerged. Contracted on ground that has not been submerged. season. First of March to end of June, usually. End of June to October. etiology. Due to bite of infected larval trombidium. Due to bite of infected Dermacentor occidentalis. incubation. Five to twelve days usually. One to eight days. symptoms, early. ! Onset. Usually by chill, followed by headache, malaise. Same. Headache and backache more common. Pain and swelling of lymphatic glands on first or second Not so. Tick bite, if present, may be inflamed. day leads to discovery of bite. Bite always present and demonstrable. Shows small Not so. When present it is usually a red mark. black area of necrosis. Superficial lymphatic glands elsewhere than near wound Not so. become enlarged.

•«YMPTOMS, LATER. Fever to 104° or 105° F., continuous. More irregular and may be higher or lower. Pulse may be slow but usually rapid and weaker. May be Almost always rapid and weak. May be dicrotic. dicrotic. Exanthem usually fourth to seventh day. Usually second to fifth day. First on face and temples. Usually first on wrists and ankles. Indistinct or absent on thighs and arms. Not so. Macules or papules, dusky. Macules or petechiae. Usually lasts four to seven days. Fades more slowly. Does not become hemorrhagic. Becomes hemorrhagic. Frequently shows in mouth. Not so. Hyperesthesia common through disease. Often present. Partial deafness frequent. Less frequent. Tongue and lips may crack and bleed. Same. Gums spongy, may ooze blood. Not so. Cough may be severe and paroxysmal, expectoration tena- Cough common and edema of lungs common at end. cious. Perspiration common. Not noted. Skin often dusky or marbled. Remission at end of second week. No constancy. Most patients dead before that. Ulcers may be long in healing and glands remain'tender. No such condition. COMPLICATIONS Parotitis, melena, mania. Not noted. Coma, cardiac weakness, pulmonary edema. Frequent.

MORTALITY. Thirty per cent. Increases steadily with age. Seventy-five per cent. No steady increase with age. PATHOLOGICAL ANATOMY. Ulcers, lymphadenitis, large spleen, hypostatic conges- No ulcers. Lymphadenitis not noted. Large spleen, tions. May be nephritis. hypostatic congestions. May be nephritis.

IMMUNITY. Not conferred by attack. Probably conferred by one attack.

XIII. PROPHYLAXIS. The clinical symptoms of both diseases and the results of in clinically similar diseases, measure to practice The only prophylactic yet put any such as and indicate that each either disease is avoidance of typhoid typhus, general use against offers a field for a more extended use of hydro- the infected regions. This is much easier in the therapy than either has yet received. case of flood fever than in that of spotted fever, as so much and the dangerous regions are smaller XV. CASE HISTORIES OF TSUTSUGAMUSHI the are so plainly marked off by very flooding that DISEASE. makes them dangerous and because they are not residence sites. Some of the Japanese investiga- The following are such histories and notes as tors are recommending that persons who have to could be obtained in regard to the cases of tsutsu- enter the dangerous regions should wear clothing gamushi disease seen by us this year (1907) : saturated with petroleum. The use of carbolic oil of and Balsam of baths, benzine, peppermint Case I. S. Igarashi. Male, age seventeen years. Peru are also advocated. The effectiveness and Farmer. applicability of these measures remain to be Family history.—Negative as regards tsutsugamushi proved. It is stated that cultivation of the soil disease. and the use of human feces as manure will free an Personal history. Patient had been in the infected at — and does know when he infected area from the disease in about three years, locality various times not if its submersion be meanwhile was bitten by mites. This is his first attack of the prevented. disease. Present illness. The disease began on July 24,1907, XIV. TREATMENT. — with a chill. The next day the patient entered the At that time the of one axilla were So far as observation enables us to hospital. glands personal and tender and examination of the on indicates that enlarged region form opinions this subject, it drained them showed the small ulcers from divisible into two by resulting the treatment in both diseases is three bites. There was no skin and the 1. 2. eruption spleen classes: Expectant, symptomatic. Hoped- was not demonstrable. The pulse was strong, fre- for specifics, which are apt to be the result of guess- quent and regular, appetite decreased and the bowels work or of reasoning from false premises or constipated. Urine was normal. The temperature is erroneous observations. shown by Chart I.

Chart I.

On July 26, an eruption of rose-colored macules appeared on the face. Later it gradually spread over the body and limbs. The diazo reaction was well marked in the urine of the 28th and the pulse was that day dicrotic. The eruption showed on the hard palate and the fauces and some cough was present. Aug. 1. The present condition is indicated by the foregoing notes, there having been no change. Aug. 2. The patient is sluggish and stupid. The eruption is still present but is not prominent ; the eyes are injected and suffused ; the spleen is tender but not palpable; respiration is rapid and the pulse feeble. The patient sleeps well and has had no delirium. Aug. 3. The urine contains considerable albumin and numerous coarsely granular casts. The patient sleeps much and perspires freely, the pulse is 85, but very weak, the heart sounds feeble. There is no cough ; breath sounds everywhere harsh. The eruption still shows on the face and chest but is fading. The eyes are much injected. The tongue is dry, white in the center, glazed at the margins, the papillae prominent; gums spongy ; spleen tender but not palpable. Aug. 4. The general appearance and condition are about as yesterday. The gums are very spongy and are bleeding. Cough is present and produces a scant, tenacious sputum, much discolored with blood from the gums. Respiration is rapid and somewhat irregular, Chart II.

The Boston Medical and Surgical Journal as published by The New England Journal of Medicine. Downloaded from nejm.org at UNIVERSITY COLLEGE LONDON on June 26, 2016. For personal use only. No other uses without permission. From the NEJM Archive. Copyright © 2010 Massachusetts Medical Society. Aug. 1. Eruption appeared this morning for the Case III. H. Itagake. Male, age fourteen years. first time, showing on the face. It is rubeolar in Family history negative as regards this disease. appearance, but scanty. Diarrhea has ceased under Personal history. The patient has visited the in- treatment. The pulse is growing weaker. Cough is fected regions and —was bitten by a mite on July 19. present but unproductive of aught save pain; breath This is his first attack of tsutsugamushi disease. sounds everywhere harsh. Present illness. The disease began with a slight Aug. 2. The patient slept well last night and is not chill on July 27, since— that time the patient has had delirious. The pulse is rapid and feeble; cough per- moderate fever and enlargement of the lymphatic sists and causes abdominal pain ; hyperesthesia is very glands, particularly of the right, axilla, but has felt marked and pain causes the patient to moan a great comfortable and has not appeared very sick. The deal. The abdomen is particularly painful and tender temperature is shown by Chart III. but is not distended or rigid. The bowels arc loose. Aug. 1. Patient has had no symptoms except the There is a dusky, faint, scattered, macular eruption on fever, slight headache and constipation and does not t lie face, arms and legs. Tenacious mucus in the throat look or feel very ill. There is no eruption and the excites cough and nausea. spleen is not demonstrably enlarged. The right axillary glands are swollen and tender and the skin of the same axilla shows a small ulcer with pinkish, slightly indurated and tender margins. Aug. 2. Face clear and bright. No eruption present and the patient looks well. The tongue is white, slightly dry and tooth-marked. The pulse is of good st rength. Aug. 3. The face is flushed, the eyes injected, a faint eruption present. The patient looks sicker 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 arc harsh, especially at the apices of the lungs. The urine shows a trace of albumin and very numerous, coarsely granular casts and small round epithelium, but no blood. Examina- tion of the feces shows ascaris eggs but is otherwise negative. Aug. 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 expectoration. 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. Aug. 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, 0. His subsequent history is unknown to us. Case IV. S. Asai. Male, age seventeen 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 hn< I fever (see Chart IV), his face was flushed and he com- plained of headache and pain in the pharynx. The lymphatic glands in the left axilla were swollen and painful and careful examination revealed the presence of two small ulcers, one in the left axilla and one back of the hair line of the left frontal region. Aug. 1. Condition as at time of admission. No eruption has shown and the patient looks and feels well. Chart III. Spleen not palpable or tender. Slight systolic roughening is noticed over base and apex of the heart. There is slight enlargement of the superficial lymphatic glands, Aug. 3. Face dusky, eyes congested, eruption less more marked in the left axilla. Physical examination distinct; tongue dry and glazed and its papilla; promi- is otherwise negative. nent. Hyperesthesia, abdominal pain and diarrhea Aug. 2. The patient looks and feels well, has a good persist. Patient slept poorly last night and is delirious. appetite, no pain, no eruption and sleeps well. The Respiration rapid and moaning; breath sounds harsh; ulcer on the head has healed. cough less severe and distressing. Pulse recorded as 85 Aug. 3. The patient looks and feels well. The but during examination it was 140 and weak. Heart systolic roughening persists unchanged. sounds rapid and weak but clear. Aug. 4. Discharged from hospital, recovered. Aug. 4. Patient died at 6.00 a.m., to-day. Case V. T. Suzuki. Male, farmer. Age, forty-four Delirium had but diarrhea and the years. ceased, persisted '*- heart became rapid and weaker until death occurred. Family history, One son had this disease two years Autopsy was not obtainable. ago. —

Chart V.

Chart IV. Case VI. Male. Age, eight years. Family history. The patient's mother hail tsutsugamushi disease twelve — and his father two years ago, when he was bitten by a mite. On July 28, he began both recovering. An employee living in the same house to suffer from malaise and he came to the hospital on also had it at one time but the date is unknown. the 30th. At that time he had fever (see Chart V) and Personal history. The patient has at times been the right inguinal glands were enlarged, painful and fishing in the infected— region but does not know of tender. At the right margin of the umbilicus was a having received any bite from a red mite. On July 30, very small ulcer with red, puffy edges and covered with he had a chill and since that time has had fever. a thin crust. There were no other symptoms. Aug. 2. The patient was this morning brought to Aug. 1. Enlargement of the epitrochlear glands is hospital for the first time by his father. noticed but they are not tender. Patient feels well He has a temperature of 103.2° F. and severe head- and looks so. Physical examination is negative. ache. The post-auricular and upper cervical glands of Aug. 2. There has been no change since yesterday. the left side are enlarged, tender and painful. Ex- The spleen is not demonstrably enlarged, the tongue is amination shows a mite bite just to the left of the moist, clean at the edges and shows a white, central sagittal suture at the vertex. It is a small, brown coat ; there is no eruption, the bowels are sluggish. circle of necrotic skin, about 2 mm. in diameter. The Aug. 3. There is no change in the general appear- brown, necrotic tissue is loose at the margins but most ance or condition. intimately adherent by its under surface to the sound Aug. 4. There is no marked change. The patient scalp. eats and sleeps well, and, except for his fever, the ulcer The tongue has a white coat, through which the at the umbilicus and the lymphatic enlargement, papillae project red and prominent. The eyes are not appears to be well. The bowels are moving naturally. red or inflamed. Scattered over the face is a slight Aug. 5. The patient to-day insisted on leaving the eruption, which first appeared last night. It is most

The Boston Medical and Surgical Journal as published by The New England Journal of Medicine. Downloaded from nejm.org at UNIVERSITY COLLEGE LONDON on June 26, 2016. For personal use only. No other uses without permission. From the NEJM Archive. Copyright © 2010 Massachusetts Medical Society. prominent on the cheeks and consists of faint, dusky of us at Camp Connell, Samar, in the preceding macules, 2 to 5 mm. in diameter, which fade on pres- February. sure when the is and return very promptly pressure We are in of the charts relieved. The the possession temperature spots present slightest perceptible and the notes made on those cases First Lieut. of elevation. There is no in mouth by degree eruption the Earl H. Assistant U. S. or throat. The spleen is enlarged, the appetite poor, Bruns, Surgeon Army. As cases bear considerable resemblance to the bowels constipated ; there is no cough and the heart these and lungs are normal. those of tsutsugamushi disease, it seems advisable Removal of the necrotic area of the bite by means of to refer to them again and more at length. forceps and scissors leaves a small ulcer with steep Before relating the eases it is well to mention margins and a whitish or grayish lining, the appearance the climatic conditions under which they oc- of which is said to be very characteristic. curred. Connell is located on the west 7. The did the and Camp Aug. patient not enter hospital coast of Samar and lies but a few feet above sea we have seen him but the one time. We are told that his fever is and his condition serious. level. At one side of it is a low, flat stretch of high land that was a but it has been The subsequent history is unknown to us. formerly swamp, drained made into a In time Case VII. Sakuma. Male, farmer, age twenty and target range. of years. very heavy rains water still covers the range and Family history is negative as regards Isidsugamushi it may be submerged for two or three days at a disease. time, or such was, at any rate, the condition in Personal history. The patient has not had this 1905 and 1906. The annual rainfall at. — ordinary disease previously. On July 27 he was bitten by a red the post is about 110 to 120 inches, and almost mite. On 3 he was taken sick with fever and a Aug. all of the occurs between the first of of uneasiness. He continued feverish but had precipitation feeling June and the first of no nor marked and January. During January great discomfort, any symptoms, to came to the on 5. The maximum the target range is apt become dry and hard. hospital Aug. 1905 temperature that day was 104° F., the highest pulse In the post suffered from drought, which rate 94. On the sixth the highest temperature was began in January and was not fully relieved until 103.2° F., the highest pulse rate 107. late in May. In 1906 there was again very little Aug. 7. We saw the patient for the first time this or no rain in January and a repetition of the con- morning. He has a temperature of 102.2° F. and a dition of the year was feared at the time There previous good pulse of 95. is slight enlargement of the that these cases occurred. The condition of the superficial lymphatic glands, most marked in the left in and where are also tender. The bite is located target range December, January February axilla, they is somewhat similar to that of the tsutsugamushi in the left axilla and is an ulcer with a mass of black, necrotic tissue still attached to its central part. It is infected regions in Japan in June, July and August. larger than usual, being about 1 cm. by 0.5 cm. The One of us (Ashburn) happened to be at Camp conjunctiva? are congested, the tongue moist and white Connell investigating the question of water supply and an eruption is present this morning for the first in February, 1906, and was asked to see the two time. This is most marked on the right cheek and con- cases to be quoted, because of their resemblance sists of six dusky, very slightly elevated papules which to the spotted fever of Montana. The notes to fade on The bowels are and the pressure. regular follow were made Lieutenant Bruns has neither nor He and.eats by eighteen patient cough pain. sleeps before we saw disease well but his expression is somewhat dull and listless. months any tsutsugamushi or considered the between The spleen is slightly enlarged but neither tender nor possible relationship palpable. The examination of heart and lungs is the two infections. negative. We did not see this patient again and know nothing of his subsequent history. Case A. D. L. D. Age twenty-nine. Private, Co. M, 21st Infantry. XVI. CONCLUSION AS TO THE NONIDENTITY OF Family history. Negative. THE TWO DISEASES. Personal history.—— The patient has had the usual diseases of at nine years and at We think that a consideration of the facts con- childhood, pneumonia fourteen years, dysentery in 1901, malaria in 1901, cerning the two diseases, as at present known and gonorrhea and chancroids in 1905. set forth above, justifies the opinion that they are Present illness.—Jan. 29, 1906. For the past six separate and distinct disease entities. They pre- days he has had headache and pain in the back and has sent many points of resemblance but not enough been feverish and constipated, but has had no chill. of them to overbalance those of difference. He was admitted to the hospital this morning with the following symptoms and signs: headache, pain over the XVII. DOES TSUTSUGAMUSHI DISEASE OCCUR IN kidneys, constipation, slight pain in right iliac fossa, THE PHILIPPINE ISLANDS? slight dry cough; heart, lungs, liver and spleen normal. There is an eruption of flat, rose-colored, irregular The ready answer which the large majority of macules scattered over the chest, abdomen and legs medical men in the Islands would give to the and about the anus. General glandular enlargement is above would be in the and it is present, the right femoral glands being also painful and question negative tender. that that is correct. Nevertheless, cer- probable the see Chart cases that are seen should lead to a more com- (For temperature A.) tain Jan. 30. No malarial in blood occur parasites ; leucocyte plete investigation of the subject. There count urine normal. these cases 5,400; in islands a great many and probably Jan. 31. Glands in right femoral region more en- several kinds of anomalous fevers and in our re- larged, tender and painful. There are headache and port for the quarter ending June 30, 1906, we slight abdominal pain. made passing reference to two cases seen by one Feb. 2. Muttering dilirium, nervous twitching and

Chart A. Feb. 9. Improved. Patient looks brighter and feels very well. His mental condition is peculiar, not normal. Chart B. Feb. 10. Delirious all night and to-day. Face flushed; pulse remains fairly strong. Feb. 11. Improved, quiet, no pain. Feb. 3. No malarial parasites. The patient is dull, Feb. 13. Improved, hungry. The pulse is good the face flushed, the axillary and inguinal glands pain- and the rash disappearing. Urine normal. ful. Feb. 16. The patient has improved. He has no Feb. 4. There is no change. Leucocyte count 3,200; pain, the pulse is strong, the eruption and glandular no malarial parasites. enlargement have disappeared. Feb. 5. Patient appears better this morning. The Feb. 19. The Widal reaction is negative after one pulse is of good tension, the eruption fading. There hour. was a marked chill after a plunge bath. Case B. H. D. P. Age thirty-four, teamster. Feb. 6. The eruption is fading, the pulse is good, Family history. Negative. the tongue dark and dry. No malarial parasites in the Peisonal history.— The patient has had diseases of blood. A differential count of white cells shows: small childhood, " typhoid-malaria— " in 1894, dysentery in lymphocytes 20, large lymphocytes 8, polymorphonu- 1903. There is no history of syphilis or gonorrhea. clears 60, eosinophiles 2, transitionals and large mono- Present illness. Feb. 2, 1906. The patient has nuclears 4%. felt badly for five —days and has had headache, pain in Feb. 9. Still improving. A gland was removed the back and limbs and in abdomen and the appetite from the right groin for examination. has been poor. There was no chill and but slight Feb. 10. Improving. Face flushed, eyes injected, cough. Two days ago he noticed enlarged glands in mouth dry and the tongue shows a yellowish coat. the right axilla and right groin. Yesterday he had The pulse is of good tension, the eruption confluent and diarrhea. He was admitted to hospital to-day suffering fading. No malarial parasites in the blood. from fever, pain in the head, back, legs, anus and ab- Feb. 12. Patient is still improving. He sleeps well. domen, enlarged and painful lymphatic glands in the Bacteriological examination of the excised gland was right axilla and groin and diarrhea. negative.

The Boston Medical and Surgical Journal as published by The New England Journal of Medicine. Downloaded from nejm.org at UNIVERSITY COLLEGE LONDON on June 26, 2016. For personal use only. No other uses without permission. From the NEJM Archive. Copyright © 2010 Massachusetts Medical Society. Feb. 13. The is the has Transmission and Source of Rocky Mountain " Spotted Fever." patient hungry, eruption Bulletin 20, Hygienic Laboratory, Pub. Health and Mar.-Hosp. is less marked 1905. disappeared, the glandular enlargement Serv, Washington, " and the urine is normal. Wilson, Louis B., and Chowning, Wm. M.: The so-called Spotted Fever" of the Rocky Mountains. A preliminary report to the Feb. 19. Patient is still improving. Widal re- Montana State Board of Health. Jour. Am. Med. Asso., 1902, 131. action was after one hour. No malarial xxxix, p. " negative Report on the Investigation of So-called Spotted Fever." First found in the blood. of the Montana State Board of Health, Helena, Mont., 1903. parasites Report " " Studies in Hominis. Spotted Fever or Tick " Pyroplasmosis (" Lieutenant Bruns made daily notes on these Fever of the Rocky Mountains.) Jour. Infect. Dis., 1904, i, p. 31. cases but when there was no change in the condition or no new examination mentioned the re- marks have been omitted. Both patients received cold baths during the progress of the disease and the charts are prob- A STUDY OF THE VALUE OF MEASUREMENTS ably modified by them. While the notes do not OF CHEST EXPANSION. indicate it, such is probably the explanation of the two BY HARRY W. GOODALL, M.D., BOSTON, marked drops of temperature shown by Chart AND on B. A satisfactory diagnosis was never made J. LYMAN BELKNAP, M.D., BOSTON. either case, though both were reported as typhoid fever. Opinions differ as to the value of the measure of chest in health and in We do not maintain that these cases were expansion early pulmonary disease. tsutsugamushi disease, but they certainly present in- of resemblance to it to make it Cabot says the measure yields very little enough points formation of value and at is worth while for medical men in the to practical present very Philippines we are able to estimate the matter in mind should have the little used. DaCosta says keep they the amount of air received into the but the opportunity of investigating similar cases. lungs, results are not, on the whole, reliable. Sahli and ACKNOWLEDGMENT. Butler attach considerable importance to the and Anders with the We desire to our thanks to those assist- measurement, says growing express of methods of this ing us in this study and particularly to Professor adoption diagnostic precision from most important one, mensuration, deserves at Miyajima and his fellows the Imperial In- and stitute for Researches of Infectious Diseases, to once increasing scientific study practical whom we are indebted for the to see application. opportunity In the routine examination of what we did of and for such supposedly tsutsugamushi disease, individuals Medical Examiners for as we have of the articles on healthy by knowledge published Government insurance and it in as well as for the information service, companies Japanese, they the like, where standard tables of normal in- gave us their own work, and to Lieu- concerning dividuals are used for chest tenant for his notes on the Connell comparison, expan- Bruns, Camp sion receives serious for cases. very consideration, as, BIBLIOGRAPHY. example, in the United States Army and Navy Tsutsugamushi Disease. an expansion of less than two or two and one half Balz, E., and Kawakami: Die Japanische FIuss- oder Ueber- inches may be sufficient cause to the in- Virchow's Arch., 373. reject sehwemmungsfieber. lxxviii, 1879, p. insurance con- Nachtrag zu dem Aufsatz über Flussfieber. Ibid., p. 528. dividual. Many companies do not Ogata, M.: Vorlaufige Mitteilung über die Aetiologie der Tsutsu- sider an with an of less than gamushi (Kedani) Krankheit. Deut. med. Wochenschr., 1906, no. applicant expansion 46, p. 1868. two inches a good risk. Palm, Th. A.: Some account of a disease called Shima Mushi or Island Insect Disease by the Natives of Japan. Edin. Med. Jour., The following study of chest movements shows Aug., 1878, p. 128. of a Tanaka, Keisuke: Ueber Aetiologie und Pathogenese der Kedani that, instead precise, simple diagnostic Krankheit. Centralbl. für Bakt., xxvi, 1899, Nos. 14, 15, p. 432. method, we have to do with one of con- Ueber meine Kedani Krankheit. xlii, No. 2. capable Japanischer Ibid., error There is a quite extensive Japanese bibliography on this disease siderable in technic and interpretation and which is not cited as it was not accessible to us and would not be to one can determine the most of our readers. that undoubtedly mobility Spotted Fever of Montana. of the chest walls, but that this measurement Anderson, J. F.: Spotted Fever (tick fever) of the Rocky Moun- does not necessarily assist us in determining the tains: A New Disease. Bull. 14 Hyg. Lab. U. S. Pub. Health and Mar.-Hosp. Serv., Washington, 1903. true lung expansion. Ashburn, P. M.: Piroplasmosis Hominis (?)—Spotted Fever of in normal Montana. Lancet-Clinic, April 22, 1905. This thoracic enlargement inspira- A Suggestion as to the Treatment of the Spotted Fever of Mon- tion is brought about in two ways, the descent tana. 1905. — Lancet-Clinic, May 20, " Craig, C. F.: The Relation of the so-called Piroplasma Hominis " of the diaphragm and the elevation of the ribs. and Certain Degenerative Changes in the Erythrocytes. Am. Med., In the male the is the chief res- 1904, viii, p. 1016. diaphragm King, W. W.: Experimental Transmission of Rocky Mountain agent and even in the female plays such Spotted Fever by Means of the Tick: Preliminary note. Pub. piratory an not to Health Rep., U. S. Pub. Health and Mar.-Hosp. Serv., 1906, xxi, p. important part that it is be neglected. 863. " In the abdominal are Ricketts, H. T.: The study of Rocky Mountain Spotted Fever" its descent organs pushed (Tick Fever?) by Means of Animal Inoculations. A preliminary com- downward, as is evidenced by the projection of the munication. Jour. Am. Med. Asso., 1906, xlvii, p. 33. The Transmission of Rocky Mountain Spotted Fever by the Bite abdominal walls, and result in an increased verti- of the Wood Tick (Dermacentor oecidentalis). Ibid.. p. 358. cal diameter of the thoracic The Further Observations on Rocky Mountain Spotted Fever and cavity. groups Dermacentor Oecidentalis. Ibid., 1067. of muscles which are brought into play in elevat- Observations on the Virus and Means of Transmission of Rocky for Mountain Spotted Fever. Jour. Infect. Dis., 1907, iv, p. 141. ing the ribs are chiefly responsible the differ- The Rôle of the Wood Tick (Dermacentor oecidentalis) in Rocky ence in the and transverse Mountain Spotted Fever and the Susceptibility of Local Animals to anteroposterior this Disease. A preliminary report. Jour. Am. Med. Asso., 1907, diameter of the chest. xlix. p. 24. Stiles, Chas. Wardell: A Zoological Investigation into the Cause Inspiration being a voluntary act it is at once