90 
invariable appearance on the third to tlie seventh day of a profuse eruption of rose- * 
colored, unelevated spots, first noticeable on the wrists and ankles, and rapidly 
spreading over the entire body, the frequency of constipation, and the marked 
debility noticeable during convalescence all go to make up a clinical picture char- 
acteristic only of spotted fever; in 3 or 4 cases in which I have used Ehrlich’s diazo 
test the result has been negative (Maxey, 1899, pp. 436, 437). Epistaxis (see, how- 
ever, p. 52), diarrhea, iliac tenderness, and gurgling are said to be seldom, if ever, 
present (Medical Sentinel, p. 457). 
Montana . — Generally bad feeling, coated tongue, constipation, accelerated pulse 
and temperature, the expression denoting profound intoxication of the entire system 
with some grave illness, the unusual, intense soreness all over the body, affecting both 
bones and muscles, perhaps more marked along the spine and back of the neck and 
head, the icterus appearing from the fifth to tenth day of illness, and the character- 
istic eruption following, leave little room for doubt regarding the type of illness with 
which we have to contend (McCullough, 1902, p. 226). 
According to Anderson (1903a, p. 508, 1903c, p. 39), cases occurring in infected 
localities and presenting a history of tick bites, chill, pain in head and back, muscu- 
lar soreness, constipation, macular eruption, first on the wrists and ankles, appearing 
on the third day of illness, becoming petechial in character, do not present difficulty 
in diagnosing spotted (tick) fever; blood examination should be made in all suspi- 
cious cases. 
While the diiferent cases of spotted fever vary to no inconsiderable 
degree, this variation in si’iiiptomatolog}" is perhaps not greater than 
it is in many other diseases. As for the blood examination to find the 
parasite, as a test in diagnosis, I must take the position that this is not 
at present upon a firm foundation. Ashburn and I are as expert with 
the microscope as the average pln^sician, }"et we were not able to find 
the parasite in the cases we examined, although we spent a total of 
•too hours of actual microscopic work, equivalent to 80 days’ work of 
5 hours each. 
DIFFERENTIAL DIAGNOSIS. 
Idaho . — This disease differs principally in the occurrence of the symptoms from our 
occasional mountain fever, which seems to be similar to the mountain fever of the 
eastern Rocky Mountain region, a tyi)homalaiia, or at least a modified typhoid 
(Sweet, 1896). “As I have known physicians to call it ‘dengue fever,’ cerebrospinal 
meningitis, typhoid, rheumatic purpura, typhus, and measles, I may be pardoned 
for taking up the differential diagnosis and calling your attention to the salient points 
of difference in support of the theory that this spotted fever is an independent, spe- 
cific disease, and related in no way to any disease described in our text-books on 
practice.” — Maxey, 1899, p. 436. 
TYPHUS. 
Idaho . — Maxey (1899, p. 438) states that he has known one or two physicians who 
invariably diagnosed spotted fever as “typhus fever,” but he calls attention to the 
fact that typhus is an epidemic, contagious, malignant disease, more prevalent in the 
winter season and in thickly populated or crowded districts, and attacks men, women, 
and children alike; the onset is abrupt, with chill, followed by a violent fever and 
pain in the head; the eruption, red and measly, appears on the fifth to seventh day; 
there is also a peculiar mottling of the skin all over the body except the face. 
Montana . — “Spotted fever more nearly resembles typhus fever than any other con- 
tinued fever with which I am familiar, with the exception that it is not conta- 
