ered, the spots showed distinctly. I have seen them in a case twentyfour days after discharge.

When convalescence is well advanced desquamation begins and extends over the entire body. In very severe cases there may be gangrene of the fingers or toes, and still more frequently of the skin of the scrotum and penis. The skin is always jaundiced to a greater or less degree. This is usually first noticed in the conjunctivæ, the vessels of which are congested from the outset.

DIGESTIVE SYSTEM.

The tongue at first has a heavy whitish coat, with red edge and tip; later the coat becomes dark brown and the teeth are covered with sordes. At first there may be a little nausea, but the appetite is often good throughout the first week. In fatal cases nausea becomes more persistent during the second week and lasts until the end. Constipation is present throughout the course of the attack. Tympanites is never excessive; gurgling in right iliac fossa occasionally. The liver is usually moderately enlarged. The spleen is enlarged early and may extend 1 or 2 inches below the costal margin.

URINARY SYSTEM.

The urine is decreased to about one-half its normal amount for the twenty-four hours; small amount of albumin in all cases examined; granular, hyaline, and epithelial casts.

RESPIRATORY SYSTEM.

The respiratory rate is always increased, usually varying from 26 to 40 per minute, in some cases reaching 50 to 60; regular, but often shallow. In the second week there is always a slight bronchitis. Lobar pneumonia is a frequent complication in fatal cases. Epistaxis is usually seen from the end of the first week.

NERVOUS SYSTEM.

Pain in head and back is usually severe during the first week. Soreness of the muscles and bones causes the patient to change position often in the endeavor to find a comfortable posture. The muscular soreness is often very severe, even in mild cases, and lasts until recovery. The mind is usually clear, even in severe cases, until within a few hours of the end. Pupils react normally to light and distance; no opisthotomus or other irritative symptoms.

HISTORY OF CASES.

CASE 115, 1903.

O. C., age 8 years, residence about 3 miles west and 1 mile south of Hamilton, about 1 mile east of case Mrs. J. D., case 89, 1902. map, p. 8.)

(See

About April 1 two ticks were removed from right side of head, near middle line. The wounds became quite sore on the following day and the child complained of headache during the ensuing week. April 7 or 8 the child complained, in addition to headache, of soreness from site of bite down the side of head behind right ear and neck to shoulder. The post-cervical glands were enlarged, particularly on right side. At this time she complained of being chilly, though she did not have a marked rigor. She was feverish April 8, 9, and 10. On April 10 spots began to appear, first on the extremities.

She was first seen by Dr. G. B. McGrath, of Hamilton, on April 13. Patient was seen by Drs. McGrath and Wilson April 24. Child seemed pale, weak, and easily tired, but otherwise well and able to play outdoors. Over the forearms, legs, thighs, and back there was a distinct mottling of the skin. Pressure over these areas increased the distinctness of the spots. Examination of fresh blood showed a few ovoidal bodies within red blood cells. Count showed

Red blood corpuscles..
Leucocytes

Hemoglobin (Tallquist)

4, 720,000

4,500

per cent..

80

Post-cervical glands on right side still enlarged. Patient examined again May 5 by Drs. Anderson, Hanbidge, and Wilson. Feeling much better, not as pale as on previous examination, and able to play longer without tiring. Pulse, 112; temperature normal.

Fresh blood showed a few red blood corpuscles which contained the ovoidal bodies similar to those seen at first examination.

CASE 116, 1903.

Mrs. F. D., age 18 years, married one and one-half years, mother of 7-months-old child. Residence on left bank of Lolo Creek, 1 mile west of Lolo store. (See map, p. 8.)

On April 12 or 13 Mrs. D. was with her husband with team in grove of small poplars 300 yards north of residence. On this day she was perhaps also across Lolo Creek, south of house; accurate information on this point could not be gained. Certainly the horse