In Dr. Gerhard's cases, the eruption appeared from the sixth to the eighth day after the commencement of the disease, and gradually faded away and disappeared from the fourteenth to the twentieth.

The importance of this eruption, as one of the diagnostic marks of typhus, induces me to add to the foregoing the minute and precise description of Dr. Jenner. He calls it the mulberry rash, peculiar to typhus fever. "The eruption was never papular. Its characters varied with its duration. On the first appearance of the rash, it consisted of very slightly elevated spots of a dusky pink color. Each spot was flattened on the surface, irregular in outline, had no well-defined margin, but faded insensibly into the hue of the surrounding skin, disappeared completely on pressure, and varied in size from a point to three or four lines in diameter. The largest spots appeared to be formed by the coalescence of two or more smaller, and the shape of the former accordingly was more irregular than that of the latter.

แ Second Stage.-In one, two, or three days, these spots underwent a marked change; they were no longer elevated above the surrounding cuticle; their hue was darker and more dingy than on their first appearance; their margins rather more, but still imperfectly defined, and now they only faded on pressure. In this stage, they were usually darker, less affected by pressure, and their margins more defined on the posterior than on the anterior surface of the body. In some cases, the spots after this grew paler, passed into faintly-marked reddish-brown stains, and then disappeared.

"Third Stage.-In others, a third stage was reached; the centres of the spots became dark purple, and remained unaltered by pressure, although their circumferences still faded; or the entire spots, the circumferences as well as the centres, changed into true petechiæ, i. e., spots presenting the following characters, a dusky crimson or purple color, quite unaffected by pressure, a well-defined margin, and total want of elevation above the level of the cuticle. This alteration was most frequently observed to take place on the back, at the bend of the elbow, and in the groin. At the bend of the elbow they were generally oval, their long axis lying in the direction of the long axis of the arm. In a large majority of the cases, the spots were very numerous, close together, sometimes almost covering the skin. In a few instances, however, they were comparatively few in number, very pale, and situated at some distance

from each other.' The usual situation of the spots was the trunk and extremities; but occasionally they were limited to the trunk, and now and then were observed on the face. Their number reached its maximum on the first, second, or third day, no fresh spots appearing after the latter date, and each spot remained visible from its first eruption till the whole rash vanished.

"When very numerous, the whole of the spots seen together on the surface had not an equal depth of color; many were much paler than the others, and had a dull appearance, as if seen through the cuticle. In my notes, I have been in the habit of distinguishing these collectively as the subcuticular rash. It often, by its abundance, gave a mottled aspect to the skin, on which ground the darker spots were seated. Variations in the absolute or relative amount of the subcuticular rash and of the spots, as well as in the depth of their respective color, cause much difference in the general appearance of the rash. Sometimes it resembles measles so closely as to be distinguished from it with difficulty; at others, it presents that appearance which has been called spotted rash; and, again, it is sometimes so pale that, unless carefully looked for, it might be passed over altogether. When the spots on the back were of a much deeper hue than those on the anterior surface of the trunk, the skin covering the posterior surface was generally considerably congested. Slight pressure of the finger, leaving a white mark, which slowly returned to its previous dusky red color.

"To sum up:

"1. The mulberry rash was present in all the cases.

“2. The rash usually appeared from the fifth to the eighth day of the disease.

"3. Fresh spots never appeared after the second or third day of the eruption.

"4. The duration of each spot was from its first appearance till the death or recovery of the patient from the attack of typhus. "5. The rash disappeared between the fourteenth and twenty

1 In these cases, on the first day of their appearance, they occasionally bore so close a resemblance to the rose spots that although they were never altogether identical with the best-marked specimens of the latter, yet the most tutored eye might be in some doubt as to the order to which they belonged; and when the general symptoms were at the same time equivocal, the diagnosis was impossible till a day or two had elapsed, when some or all the spots passed into their second stage; whereas, if they had been the spots peculiar to the typhoid fever, they would have retained the characters they presented on the first day till they disappeared altogether on the third or fourth day after their eruption.

first days of the disease; when death ensued after the latter date, it was the result of local disease, which either complicated the progress of the fever, and continued after that had run its course, or sprung up anew, connected or not with the enfeebled state of constitution, the consequence of the fever.

“6. In no case was there any return of the eruption, and, therefore, no true relapse."

2

[Dr. Thomas B. Peacock, assistant physician to St. Thomas's Hospital, London, in a short series of Lectures, now in the course. of publication, confirms this description of Dr. Jenner. He is emphatic in re-stating the facts, that during the first day or two, the eruption is slightly elevated above the skin, and is of a rose tint; and that the spots at first disappear on pressure. He was able to ascertain the date of the eruption in twenty-eight cases. In two, it appeared on the second or third day of the disease; in three, on or before the fourth; in five, on or before the fifth; in seven, on or before the sixth; in six, on or before the seventh; in two, on the eighth and ninth, each; and in one, on the ninth or tenth. In thirteen of these, its disappearance was also noted, its duration having been five, seven, nine, twelve, nine, eleven, twelve, thirteen, seventeen, seven, thirteen, six, and ten days, in the several instances. Dr. Peacock, however, does not corroborate Dr. Jenner's statement that, in favorable cases, the eruption continues till recovery commences. The interval between its disappearance and convalescence was from two to fifteen days; in those whose fever terminated on or before the twentieth day, the average interval was three days and a half. These, it may be assumed, were uncomplicated cases. In the others the interval was longer, though nothing is said of complications.]

Other eruptions, but none of them at all constant or characteristic, are occasionally observed in this disease. Amongst them is that of sudamina, which is sometimes seen, but not so frequently as in typhoid fever. A miliary eruption now and then shows itself over the whole body, remains for a few days, and then disappears, the elevated cuticle falling off in a fine, branny desquamation. Vibices are occasionally, though rarely, seen near the fatal close of the disease. Dr. Stewart met with them in only two of one hundred and thirty-nine cases, and with purpura spots in only

Jenner, &c., pp. 14-17.

2 [Lectures on the Varieties of Continued Fever, &c.-Med. Times and Gaz., August, 1856.]

three. Dr. Henderson saw only one vibex amongst two hundred patients, and sudamina in only three.

In grave cases, there is sometimes noticed a dark livid or purple color of the skin of the extremities, oftenest in the early, but sometimes continuing through the entire period of the disease.

SEC. V.-Eschars. Gangrenous sloughs and ulcerations seem to be common in some epidemics of typhus fever, and rare in others. At Philadelphia, in 1836, they were present in only three or four cases in a hundred. Dr. Pickels says that gangrene of the hips, nates, and shoulders was frequent during the epidemic at Cork in 1817, 1818, and 1819. Dr. O'Brien, in his Cork Street Hospital Report for 1820, informs us that ulcerations and gangrene of the hips, nates, and sacrum were of very common occurrence, few of the malignant and protracted types of fever being exempt from them. Dr. Percival, of Dublin, says: "Gangrenous extremities were extremely rare amongst my patients."

SEC. VI.-State of the Blood. Amongst these miscellaneous symptoms may be mentioned the condition of the blood when drawn from the body. In the epidemic at Philadelphia, the blood was examined in various stages of the disease, except where the state of the patient was such as to render the operation of bloodletting clearly improper. "At a very early period, it was dark, without the buffy coat, and offered a large but soft and darkcolored coagulum. At a more advanced stage, it presented, in some patients, the dissolved appearance described by various. authors as characteristic of the typhus or putrid fevers." Dr. O'Brien says: "In those instances where blood was taken in the advanced period of the disease, I have always found its texture broken down and dissolved, changing rapidly into a greenish, watery fluid, with little coagulum, indicating great dissolution of the animal fluids, and consequent great debility." Huxham has described quite fully, in his usual rich and excellent manner, the altered state of the blood in typhus.2

1 Trans. of Phys. of Ireland, vol. i. p. 424.

2 Huxham on Fevers, p. 41, et seq.

CHAPTER III.

ANATOMICAL LESIONS.

THE pathological alterations in fatal cases of typhus fever have not been so thoroughly and accurately studied as in those of typhoid fever. Our knowledge of the anatomical lesions and of the condition of all the organs after death, in the former disease, is of course much less complete than in the latter. Although the morbid anatomy of typhus fever has by no means been neglected by British observers, who have the best and most extensive opportunities for its investigation, it is nevertheless true that it has not been subjected by them to such comprehensive, numerous, and detailed examinations, as the lesions in typhoid fever have undergone, at the hands of Louis, Andral, Chomel, Bouillaud, and others.' Amongst the most valuable and authentic materials for this portion of my history of typhus fever, are the results of the investigations of Drs. Gerhard and Pennock, during the Philadelphia epidemic of 1836. The number of autopsies made by these gentlemen during the prevalence of the disease was about fifty, and the fruits of their researches are especially valuable, on account of the entire confidence which we may feel in their competency as pathological observers, a confidence which we are forced to withhold from very many reporters of the morbid appearances in this as well as in other diseases. The paper of Dr. Gerhard does not contain any particular and formal description of the state of the several organs, and this description I shall be obliged to make up from the six individual cases, the anatomical lesions in which he has minutely detailed. During the years 1838 and 1839, Dr. John Reid, of Edinburgh, made careful and thorough examinations of the bodies of between forty and fifty patients who died with typhus fever at the Royal

This remark, made in my second edition, is much less true now than it was then. The remarkable researches of Dr. Jenner have added very largely to our minute and accurate knowledge of the anatomical lesions of typhus.