1. A very copious, dusky, purplish-colored rash, which often accompanies epidemic typhus. A patient is found with rather a dusky color of face, de pressed countenance, listless, or even partially unconscious expression, eyes suffused, tongue dry and brown, with a thick crust on the centre, lips and teeth covered with sordee, skin dry and hot, but not pungent (the vitality being so much depressed) ; his pulse is quick and weak, and his movements are few and tremulous, or accompanied by subsultus. In such a case, the skin will very often be found covered with a mottled measly-shaped rash of a purplish or mulberry color, with no perceptible elevation, and of more or less persistence under pressure with the finger, becoming fainter, but not disap pearing altogether ; and, in the worst cases, passing into or mingled with ecchymosed spots, which are wholly unaffected by pressure. In the latter case, the coloring matter has actually become extravasated as in purpura, and to this the name of petechim is applied ; in the former there is merely a retar dation or stoppage of dark-colored blood in the cutaneous capillaries.
2. Perhaps in an earlier stage of the same case, or in a similar case, when the fever is not epidemic, this general rash is not seen ; but there are numerous distinct, rounded, scarcely elevated spots, not so dark, of a crimson color, with a similar character of persistence, not wholly disappearing under the finger. Occasionally one or two of these may put on a blacker color, and become altogether persistent by ecchymosis.
These two classes mingle with each other.
3. A third sort of fever spots occurs in cases more commonly of an en demic kind in which there is much less general depression, rarely suffusion of eyes or congestion of face; subsultus is lees frequently seen, the movements may be tremulous, but there is much less apathy and listlessness. The skin is hot and peculiarly pungent ; the pulse, more or less quick, is not so feeble ; the tongue, presenting at first very red edges, soon becomes peeled in the centre, is -sometimes chapped, raw, and glossy, or, occasionally, with a dry, thin crust over the abraded mucous membrane—perhaps it is evenly and thinly coated, or has a patchy appearance, according to the condition of the intestinal tract ; cliarrhcea is frequently present, and in such cases, when spots are found, they are few in number, three or four over the abdomen, rounded, slightly elevated, of a pink or rose color, and disappearing entirely under the finger, but returning rapidly as soon as the pressure is removed.
These are generally of small size, but may sometimes be considerably larger than those already described as dusky spots ; occasionally, too, they are much more numerous, and the color becomes deeper ; they then assume some degree of persistence, but are very rarely, if ever, associated with, or transformed into, ecchymosis. By some mistake of nomenclature, these spots, and the
fever they accompany, have been called typhoid (resembling typhus), because the symptoms of typhus are in great measure The term typhoid ought to be restricted to symptoms resembling typhus, in diseases of hetero geneous type, not to homogeneous diseases with distinctive characters.
4. Petechial spots may occur towards the close, with no previous rash.
b. In addition to these spots, we observe that some epidemics are accom panied by lathery eruption, when there is copious diaphoresis ; just as so often happens in rheumatic fever. They have this general relation to the others, that perspiration is necessary to their development, and appears to be opposed to the existence of true fever spots.
Of this classification it is most important to note that there is no character of disease with spots of any one of the forms noticed, that may not have its exact counterpart in a case where there are no spots at all. Future observation will probably show whether there be any specific virus that produces one appearance or the other, as, in fact, their cause is yet quite undetermined. The coincidence, when they are present, is of great value in diagnosis; for it does not appear that they are ever seen in any other con dition except that which we express by the term fever. What ever light may be thrown by future investigation upon their rela tion to internal organs, whether the hypothesita of two distinct fevers be confirmed or rejected, it is quite certain, from long continued observation, that ulceration of the bowels seldom goes along with copiolis cutaneous eruption ; and, manifestly, the altera tion of the character of the blood in congestive typhus, vrith its dusky color of skin, and suffused conjunctivie, is very different from that which may be so constantly seen as conunon continued fever, in the hospitals of all our large cities. The point at issue is, whether these different conditions are caused by casual modi fications of the same virus, or by antecedent circumstances affect ing the health of the patient, or whether they are only developed by two distinct fever-poison& • The features of these spots in extreme cases, as detailed by au thors who hold the hypothesis of two distinct forms of fever, may be thus summed up. Typhus fever is that in which there is a copious mulberry-colored eruption on the extremities as well as on the trunk, beginning from the fifth to the eighth day of the disease, when there is no diarrho3a or abdominal tenderness. The name typhoid fever is applied to that form which is more or less accompanied by diarrhoea, with abdominal tenderness and disten sion, and in which there is a scanty eruption of rose-colored spots confined to the trunk, beginning from the seventh to the twelfth day of the disease, and appearing, few at a t,ime, on successive days.