8 ASHBTJRN AND CRAIG. 



the conjunctivae and lachrymation are more evident; respiration is ac- 

 celerated, the breath sounds are harsh, cough increases and may be ha- 

 rassing, although the expectoration is scant}'. The entire surface of the 

 body is apt to be hypersensitive and this condition causes complaint. 

 Constipation usually persists, but exceptionally diarrhoea and abdominal 

 pain and tenderness occur. The tongue becomes dry, brown in the 

 center and glazed at the tip and edges, sordes collect and the gums may 

 become spongy and bleed. In such cases the breath is particularly foul. 

 Partial deafness occurs, the patient becomes stuporous and may pass into 

 coma before death. At some period of the disease, usually from the fifth 

 to the seventh day, although it may be a little earlier or later, an exanthem 

 appears, first on the face and later on the chest, the forearms, the legs and 

 the rest of the trunk; occasionally the palate and buccal surfaces also 

 show it. The eruption consists of irregular, rather faint, dusky or pink 

 macules or flattened papules 2 to 5 millimeters in diameter, which may 

 become confluent on the cheeks and give an appearance of swelling. On 

 the relatively dark skin of a Japanese, this eruption is not well shown, 

 and on parts of the body other than the face the lesions bear a great re- 

 semblance to flea bites, with which they may be confused. They fade on 

 pressure, but at once return when it is removed. The eruption does not 

 itch and its duration usually is from four to seven days, although at times 

 this period may be more or less. The eruption never becomes hemor- 

 rhagic or petechial. Tanaka states that in rare instances it may become 

 vesicular or pustular, but this condition is probably less frequent than 

 his implication would lead one to believe. The period of exanthem marks 

 the height of the disease and as the eruption begins to fade, usually about 

 the end of the second week, the fever lessens and in a few days the tem- 

 perature reaches the normal, while the general condition also rapidly im- 

 proves. The patient then speedily recovers, although the little ulcer 

 resulting from the bite may be long in healing. 



The above descrijotion gives the symptoms of a case of average severity 

 which recovers; in more severe ones which recover, the fever may last 

 longer and the symptoms be very marked. In severer cases still, death 

 may result on from the ninth to the fifteenth day. On the other hand, 

 very light infection may show but slight and ephemeral fever, very 

 trifling or no exanthem, and may not be bedfast. JSTevertheless, the ulcer 

 and lymphatic enlargement are always present and the former may be 

 larger than usual, having a diameter of as much as 1 centimeter. The 

 duration of the disease is usually about three weeks. It may be as long 

 as a month or as short as one week. Parotitis, mela?na and mania have 

 been noted as complications, while coma, cardiac weakness and pulmonary 

 oedema ma}' be terminal features. 



Spotted or tick fever, as it occurs in the Bitter Eoot Valley, begins 

 in from one to eight days after the tick bite, in cases where the history 

 of bite is obtainable. As in tsutsugamushi disease, prodromata are 



