90 
invariable appearance on the third to the 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, ,j 
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 ;j 
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 I 
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). i 
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 difhculty « 
in diagnosing spotted (tick) fever; blood examination should be made in all suspi- q 
cious cases. i 
While the different cases of spotted fever vary to no inconsiderable i 
degree, this variation in s3’mptomatology 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 i 
at present upon a firm foundation. Ash burn and I are as expert with : 
the microscope as the average plwsician, }^et w^e were not able to find 
the parasite in the cases we examined, although we spent a total of 
400 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 Kocky Mountain region, a typhomalaria, or at least a modified typhoid 
(Sweet, 1896). “As I have known physicians to call it ‘dengue fever,’ cerebros]unal 
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 i 
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; s 
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- ? 
