[Reprinted from the Transactions of the Association of American Physicians, 1899.] 
ANOMALOUS ERUPTIONS IN TYPHOID FEYER. 
J. M. Da COSTA, M.D., LL D , 
OF PHILADELPHIA. 
The characteristic lenticular eruption in typhoid fever has been so 
well studied that there is little to be added to our knowledge of it; 
but, irrespective of the significant rose-spots, there are rashes which 
are comparatively rare, imperfectly understood, and become the cause 
of confusion and error. The two that I shall specially examine are 
a diffused erythema simulating scarlet fever and an eruption like that 
of measles. Let me take up the scarlatiniform eruption first and 
illustrate it by a few cases. 
Case I.—Sarah V. (No. 2647), aged fourteen years, was admitted into the 
Pennsylvania Hospital on February 11, 1898. She was in the seventh day 
of typhoid fever; the temperature was 103.2°, the Widal reaction was 
positive. From the first the mottled look of the skin attracted attention ; 
the characteristic rose-colored spots of typhoid soon became unusually pro- 
fuse; they were seen on the abdomen, back, chest, and even on the face. 
The case did not prove a severe one. A remarkable feature was the appear- 
ance on the night of the twelfth day of the disease of a bright red erythe- 
matous eruption, readily affected by pressure and very generally diffused, 
but especially marked on the face and back. There were blotches of more 
vivid hue than others; there was no itching. No rise in temperature or 
abnormal state of the urine was observed in connection with the rash; the 
highest temperature attained was only 100.2°. No sore-throat existed, and 
the symptoms did not become aggravated by the occurrence of the eruption, 
which passed away by morning. The case went on uninterruptedly to re- 
covery. 
A yet more striking illustration of the scarlatiniform rash, and one 
in which this lasted very much longer, was afforded by the next case. 
Case ll.—Katie F., a young wpTTmn-was.jidmitted into the Pennsylvania 
Hospital on March 6, 1897, having ill 'Jot SJae had 2 
DA COSTA , 
been previously in good health, and had never had either measles or scarlet 
fever. On admission to the hospital her temperature was noted at 103°, but 
it soon rose to 106°; the urine showed a trace of albumin, and one finely 
granular cast was found. The skin was very fair, so that any spots could 
have been readily detected, but none were observable. The next day there 
appeared on the face and arms a bright red, erythematous rash, which les- 
sened somewhat after sponging, and was not always equally distinct, seeming 
to come and go, though never wholly leaving. There was no rash of the kind 
on the body, but it was specially observed that pressure on the skin every- 
where produced a red spot which only slowly faded. The temperature ranged 
between 103° and 101.2°. On the 9th great disturbance of respiration was 
perceived, the breathing fell to twelve in the minute, and was jerky and 
irregular, and the erythematous rash which had disappeared showed itself 
again on the face and arms, giving the patient the appearance of scarlet 
fever—an appearance which was increased by a redness of the tonsils and 
the pharynx, the latter being covered with tenacious mucus. She was very 
ill, but the temperature was not materially different; during the night it 
ranged from 103.2° to 104.6°, and she was very delirious 
On the 11th the rash was still visible, and still could be made to disappear 
temporarily on pressure. It was again noted that none was to be seen on the 
body, though it now showed itself on the hack of both legs; around the 
elbow-joints it was much less marked than on the back of the hands and 
forearm. Few of the characteristic lenticular typhoid spots were discernible; 
there were two doubtful ones on the chest. The Widal test gave a positive 
reaction The influence of cold sponging was very irregular. At one spong- 
ing the temperature fell as much as six degrees ; at another, of similar length 
and thoroughness, but four-fifths of a degree. As the case advanced the urine 
contained rather more albumin, and red corpuscles and quantities of hyaline 
and pale granular yellow casts were found. The patient died six days after 
admission into the hospital, near the end of the second week of typhoid fever, 
the rash being evident to the last. At the autopsy a great number of promi- 
nent and swollen solitary glands and Peyer’s patches were seen, hut none 
were ulcerated. The spleen was large and soft and weighed ten ounces. The 
lower surface was slightly mottled; the posterior portions of the lungs were 
congested ; the kidneys were large, weighed seven and a half ounces; the 
substance was firm, the capsules adherent. The rash was not discernible on 
the surface of the body. 
There are in this case some points for special study. First, the 
scarlatinal rash appearing in the first week and at a time in advance 
of the characteristic rose-spots. The rash was uniform, was not, as 
in the first case, preceded by mottling, was easily influenced by press- 
ure, did not apparently modify the temperature, and persisted to the 
last. In its early appearance it was like a case described by Murchi- 3 
ANOMALOUS ERUPTIONS IN TYPHOID FEVER. 
son,1 in which a delicate scarlet rash all over the body preceded for 
two or three days the lenticular spots of enteric fever. The scarlatini- 
form rash may remain through the fever, though it rarely does so. 
Irrespective of its appearance in the first week, it may come on late 
in the disease, and I have known it to manifest itself even in con- 
valescence (case of Thomas G., Pennsylvania Hospital, December, 
1880) and to return in a relapse. Its character may be thus de- 
scribed: It is a uniform red rash, like scarlatina; it is seen all over 
the body, though not so in every instance. It is more distinct in 
some places than in others. It is easily influenced by pressure. It 
has its periods of greater or less intensity, of partial disappearance, 
of vivid return. It lasts generally a week or somewhat longer. It 
passes away without desquamation—at least I have never seen this 
happen. It does not perceptibly influence the course of the tempera- 
ture. It is for the most part unconnected with sore-throat or with 
albuminuria. As regards albuminuria, I have observed this in some 
of the cases I met with, but it was a prior condition connected with 
the typhoid fever. With reference to sore-throat, this was in a mild 
form in Case 11., and Jenner mentions an instance in which slight 
sore-throat was an accompaniment, and typhoid fever was mistaken 
for scarlet fever. Save under the exceptional circumstances of attend- 
ing sore-throat and desquamation, there is no difficulty in determining 
the two diseases, or in diagnosticating that scarlet fever is not inter- 
current in typhoid. 
Rarer than the scarlatiniform eruption, and much more misleading, 
is an eruption like measles. This case may serve as an illustration : 
Case lll.—Richard G., aged twenty-eight years, was admitted on Novem- 
ber 26, 1886, into the Pennsylvania Hospital on the eighth day of typhoid 
fever. The face was flushed, the temperature 103.4°; there was marked 
hebetude. The abdomen was tympanitic and its surface covered with a 
coarse, slightly papular eruption, not crescentrically arranged and not disap- 
pearing on pressure; besides, there were a few rose-colored spots. In the 
course of the fever the eruption faded slowly and imperfectly, and was still 
perceptible when convalescence was reached. It retained its coarse appear- 
ance, and never showed itself on the limbs or thorax or the face. The notes 
speak of its similarity to the rash of typhus. There were also numerous 
sudamina. The temperature at one time reached 105°. The urine was free 
from albumin, though once a trace of albumin and a few hyaline’casts were 
observed. 
1 Case XLV., Treatise on Continued Fevers. 4 
DA COSTA, 
In this case the measly eruption was limited in its extent. It was 
much more diffused in the next case, which, moreover, afforded a good 
opportunity of studying the question of its association with any tem- 
perature changes. 
Case IV.—John McO., a soldier, aged nineteen years, was sent to the 
Pennsylvania Hospital on November 15, 1898, suffering with typhoid fever. 
He had been ill for two weeks, and there were many rose-spots on the chest 
and abdomen. The temperature was 104.6°, the face very flushed, the spleen 
much enlarged; the urine contained albumin as well as a few hyaline casts ; 
the Widal test gave a positive reaction. Five days after admission an erup- 
tion closely resembling measles appeared on the chest, abdomen, back, 
and upper part of the thigh, and, later, more sparsely on the legs, and 
yet more sparsely on the arms. On the face there were not many; they 
showed themselves late, and were less distinctly measly in appearance; in 
the notes they are described as blotches. Nowhere was there a crescentic 
arrangement of the raised red spots, which, however, in many places co- 
alesced, and did not disappear on pressure. They passed away in five days, 
without itching or desquamation, the blotches on the face first, those on the 
legs last. The eyes were slightly injected, but no catarrhal symptoms ex- 
isted. There were many places on the chest and abdomen in which the rose- 
colored spots were perceptible near the measly rash. Much hebetude was 
observed while the rash lasted, but as hebetude had been noticed from the 
time the patient was first seen, it could not be associated with the occurrence 
of the rash. 
The appearance of the rash was not combined with any marked tempera- 
ture changes; on the 18th the temperature ranged around 108°. On the 19th, 
the day preceding the eruption, the temperature at 9.20 a.m. was 101.6°. It 
rose during the day to 103°, modified, however, by sponging. During the 
night it continued to rise, until by 9.30 A.M. of the 20th, the day the measly 
eruption appeared, it reached 103.8°. On that day the temperature slowly 
fell, except for occasional rises, which were kept in check by sponging, until 
by 8 p.m. it had declined to 102.6°. During the night it continued to fall, 
the rises still being kept in check by sponging, until by 9.10 A.M. on the 
morning of the 21st it had reached 101°. During the 21st it went up slowly, 
passing to near 102° by 9 30 P.M., and continued to rise during the night 
until, by the 22d, at 9.20 A.M., it had passed to 102.6°. During the 22d the 
line was gradually downward, with the exception of one decided rise at 4.10 
p.m., when it reached 103.8°, this rise being promptly influenced by spong- 
ing. On the 23d the range of temperature was, on the whole, lower than 
on the 22d, the highest attained being 101.6° at 7.40 p.m., and the lowest 
reached being 100° On the 24th the temperature again went up, and on 
one occasion, at 1,40 p.m., reached 103.6°. During the night it steadily 
fell, and on the 25th, the day of the disappearance of the eruption, it was 
98.6° in the morning, though once in the day it reached 101.8°. These details ANOMALOUS ERUPTIONS IN TYPHOID FEVER. 
of temperature are given that we may ascertain if the eruption exercised any 
influence on it. On the whole, the temperature showed only the zigzag which 
is common at this stage of typhoid fever, and did not appear to he influenced 
by the eruption. If any other inference were drawn it would be that the 
temperature was somewhat higher in the twenty-four hours preceding the 
eruption, and fell slowly on the day of its occurrence. The patient soon en- 
tered upon steady improvement, and was entirely convalescent sixteen days 
after the disappearance of the eruption. 
The similarity of these cases of typhoid fever with measly eruption 
to typhus fever is very great, and, when we have cases in which the 
nervous symptoms are pronounced and enteric symptoms absent, it is 
very difficult to come to a conclusion, unless the malady has been 
seen and the temperature been studied from the beginning, for the 
measly rash common in typhus fever and very uncommon in typhoid 
has in both much the same appearance. How much alike typhoid 
with measly rash may be to typhus is proved by the following case: 
Case Y.—John O’R. (No. 2457), aged eighteen years, previously in excel- 
lent health, living in good surroundings and not known to have been exposed 
to any disease, was admitted on December 12, 1898, into the Pennsylvania 
Hospital with a fever of a low type, stated to be of eight days’ duration and 
to have begun with epistaxis and vomiting. His face was flushed, he was 
delirious, the tongue was dry and brown, the pulse weak, the temperature 
103.6°, the spleen large; albumin and granular and hyaline casts were found 
in the urine; rose-spots were seen on the abdomen ; the Widal test was posi- 
tive. He presented altogether the picture of a case of typhoid fever, with 
marked prostration and cerebral symptoms. The delirium was the most 
striking feature, and in it he got out of bed and attempted to throw himself 
out of the window, but was fortunately caught. Two days after admission, 
and on the tenth day of the disease, he was covered from head to foot with a 
profuse eruption. On the face, hands, and feet it was as evident as on the 
rest of the body, and, though influenced, it did not disappear on pressure. It 
was composed of numerous spots of irregular form, very slightly elevated 
above the skin, and precisely like the measly eruption often seen in typhus. 
The similarity to this disease became now greater and greater, and was 
heightened by the absence of enteric symptoms and the occurrence on the 
left side of a true pneumonia of the base with rusty sputum—a form of pneu- 
monia much more common in typhus than in typhoid. The eruption was so 
thick over the body that there was scarcely a pin-point free. It was not 
cresceutically arranged; here and there it was petechial. Fearing that the 
case might, after all, be typhus, the patient was carefully isolated and then 
removed from the hospital, as a sorrowful experience of having had cases 
admitted into the Pennsylvania Hospital, some years ago, that proved to be 6 
DA COSTA, 
typhus,1 and that resulted in our having within its walls very many serious 
instances of the disease before we got rid of it, determined me to let the rest 
of the patients and the attendants run no risk. The similarity of typhus re- 
mained great to the end. The temperature, the day after he left the hospital, 
fell by crises, as it often does in typhus fever; the eruption showed merely as 
brownish traces. Another Widal examination gave positive results, and the 
patient slowly recovered. 
Looking back over the history, though the case is still not free from 
doubt, I believe it to have been one of typhoid fever, rendered uncer- 
tain chiefly on account of the peculiar measly eruption here under 
consideration. 
Another error likely to arise is due to the occasional occurrence ot 
true measles in typhoid fever. This intercurrence may he studied in 
the two cases now to be detailed. 
Case Vl.—Gerano L., an Italian, aged seventeen years, was ill with typhoid 
fever for a week when admitted into the Pennsylvania Hospital on January 
17, 1898. Diarrhoea and tympany were absent, but the typhoid eruption on 
the chest and abdomen showed very clearly through his dusky skin. By the 
26th of the month the morning temperature was 99°, but it rose in the evening 
to 102° and slightly beyond. On the 27th and 28th there were the same 
morning remissions and evening exacerbations to between 102° and 103°. 
On the 29th, the morning temperature being 99.6°, the conjunctiva was 
noticed to be injected, photophobia was complained of, there was some cough, 
and an eruption of measles showed itself. The temperature rose to 102.1°, 
and went on rising as the eruption spread over the body, until on the 30th it 
reached 105°. On the 31st it dropped to 102°, and the catarrhal symptoms 
persisted. On February Ist the temperature became normal; the rash was 
fading. The boy was then transferred to the children’s ward, which at that 
time contained a great many cases of measles, and where he convalesced. 
Case YII.—Paul 8., a soldier, aged twenty-one years, admitted to the 
Pennsylvania Hospital on September 20, 1898, with typhoid fever. By the 
26th his temperature had touched normal, he was sitting up in bed, and 
hungry. On the 29th the thermometer marked the normal, or, at the highest, 
99°. He was noticed to have coryza, injected eyes, headache, and cough. 
Soon the temperature began to rise, and on October sth it was at 101°, and 
an eruption of measles appeared on the face. The next day the whole body 
was covered with measles. On the trunk the crescentic arrangement was 
noticeable; severe itching was complained of. It was ascertained from the 
patient by Dr. James C. Wilson, under whose care he then was, that he had 
never had measles, but had been exposed to it thirteen days before the catar- 
1 “ Researches on Typhus Fever.” American Journal of the Medical Sciences, January, 1866. ANOMALOUS ERUPTIONS IN TYPHOID FEVER. 
7 
rhal symptoms appeared, while riding to the hospital train in an ambulance 
with a case of measles. The Widal test, make while the measles existed, was 
negative, but there was a positive diazo reaction. The urine showed uric- 
acid crystals, but neither albumin nor sugar. The temperature on the second 
day of the eruption fell to 99°, and subsequently was subnormal. Desqua- 
mation was noted on the fifth day. The recovery was a good one, except for 
a double phlegmasia dolens which protracted it. 
When we contrast these cases of coexisting measles and typhoid 
fever with cases of typhoid fever in which a measly rash happens, we 
find striking differences. First, in the character of the eruption. 
This in true measles is coarser, more markedly papular, and has the 
well-known crescentic arrangement, which is not seen in typhoid 
fever. Secondly, there is itching and there is desquamation, which 
are also not observed in the typhoid fever rash. Moreover, the pres- 
ence of the coryza and catarrhal symptoms is very significant in the 
intercurrent measles. But of greatest value and meaning is the tem- 
perature record. In the measly eruption of typhoid the eruption has 
no marked influence on the temperature, or greater variations are not 
met with than belong to the stage of the typhoid fever in which the 
measly eruption may occur. It is different, as is seen by studying 
the temperature in both of the cases just described, in intercurrent 
measles. The temperature here rises decidedly in the days immedi- 
ately preceding the eruption, in the prodromal stage, exactly as in 
ordinary measles, and it goes on rising, or remains high, with the 
spreading eruption. This is quite unlike what happens in the measly 
eruption in typhoid fever. Where we are nearing convalescence, and 
the temperature has been ranging around the normal line, these tem- 
perature changes are of greatest value in diagnosis. They are neces- 
sarily less so earlier and while the fever temperature of the enteric 
fever itself is still a pronounced one. 
We have thus described a scarlatiniforrn eruption, a morbilliform 
eruption, and also spoken of the mottling of the skin. This mottling, 
as in typhus, is due to a subcuticular rash, and may remain' as the 
only eruption, or precede or attend either of the other kinds. The 
interesting question now arises, Are all these really separate forms, 
or merely different expressions of the same pathological condition— 
in reality one affection ? I believe they are one, for I have seen 
them combined in the same patient and apparently interchangeable. 
Here is a case in proof: 8 
DA COSTA, 
Case Vlll.—Walter R. (No. 1684), a soldier, aged twenty-two years, 
brought from Camp Meade, was admitted into the Pennsylvania Hospital on 
September 20, 1898, with typhoid fever. When a child he had measles and 
scarlet fever. He had also had pneumonia and a previous attack of typhoid 
fever. The day of admission, and as nearly as could be ascertained the 
seventh of the disease, the patient had a temperature going from 103.6° to 
104.8° ; there had been epistaxis ; the bowels were very loose. The next day 
one or two lenticular rose-spots were observed on the abdomen, but what par- 
ticularly attracted attention was a strange general mottling of the skin, espe- 
cially marked on the chest, abdomen, and thighs. By the 24th the mottling 
was nearly gone; a few new rose-spots were observed on the left side of the 
abdomen. The temperature, that had been ranging between 102.5° and 104.4°, 
was somewhat lower—between 102° and 103.6°. On the 27th, though the 
mottling could still be seen, it was very indistinct, but many rose-colored 
typhoid spots were perceptible. On the 28th, the fifteenth day of the dis- 
ease, a curious coarse, granular eruption, like measles, but not crescentically 
arranged, and affected by, but not disappearing on, pressure, showed itself on 
the shoulders and upper part of the arms. It was not associated with any 
rise of temperature; on the contrary, before its appearance the morning tem- 
perature marked 99°, the lowest it had attained at all, and during the evening 
it rose to 104°, about the same that it had been on the two previous evenings. 
The tongue was dry and cracked ; there were no bronchial symptoms. The 
next day the measly rash still persisted ; it was evident on the shoulders and 
upper part of the arm, and there was in addition most marked redness of the 
neck and lower part of the arms, of the hands, and of the chest, closely re- 
sembling scarlet fever. Neither coryza nor sore-throat was present. The 
scarlet fever redness left white traces when the fingers were rapidly drawn 
across the skin, but the hypersemia returned. There was no redness of the 
face. The urine was acid, and contained no sugar, no albumin, or casts. 
The Widal test gave a positive reaction. 
Four days after the appearance of the measly rash it had gone entirely, 
and the scarlet fever redness was only visible on the neck, and even there 
had faded. The general mottling of the whole body remained. On the after- 
noon of the same day the temperature, without any apparent cause, went up 
from 101° to 103°, and the erythematous scarlatiniform rash at once returned 
on the neck, chest, and wrists. There was no recurrence of the measly rash ; 
the flush of the skin vanished in forty-eight hours and came back no more. 
Lenticular typhoid spots remained. The patient now entered upon conva- 
lescence. 
The pathological conditition is, I think, a hypersemia of the skin, 
with here and there in the measly form an exudation in its layers, 
most likely a swelling and thickening of the corium and rete Mal- 
pighii, much as it exists in measles; but I can merely surmise this, 
as I have no anatomical observations to offer. It is not easy to deter- ANOMALOUS ERUPTIONS IN TYPHOID FEVER. 
9 
mine how these eruptions are produced, and while several views sug- 
gest themselves, no definite proof can be given of their absolute cor- 
rectness. That the rashes are not caused by the administration of 
any remedy, which like quinine or iodide of potassium gives rise to 
cutaneous eruptions—a dermatitis medicamentosa—is certain, for they 
may he encountered no matter what the treatment employed. The 
bath treatment is not responsible for them. It was not used systemati- 
cally in any of the cases detailed in this paper, though in some with 
high temperature the bath was at times resorted to. 
The anomalous rashes may be the result of the irritation of the 
skin from the bacilli in the infected blood, but I believe rather that 
they are the expression of disorder of the cutaneous nerves—that they 
are due to the vasomotor disturbance—but how this is caused is very 
doubtful. It, too, may be from direct bacillar irritation, though rapid 
changes in the eruption, its appearance, often sudden, and disappear- 
ance, equally sudden, are against this view. More likely is it from 
the blood infection, but whether this be due to the toxins from the 
bacilli or the absorption of the broken-down material in the diseased 
intestine must be a mere surmise. Yet we have a strong analogy in 
the production of ordinary urticaria, which we constantly see arising 
from the absorption of products of certain articles of food that are not 
readily digested, but which is also met with from purely nervous 
causes, as from mental excitement or sudden emotion ; and it is a 
remarkable fact that urticaria, too, sometimes happens in typhoid 
fever. I have myself never seen any instances, but they have been 
described by Griesinger, and Dr. Woodbury has recently called my 
attention to a case that occurred in his practice. 
The nervous element and the vasomotor disturbance are certainly 
very strong factors in the production of these typhoid fever rashes. 
Lemaigre,1 who does not believe that they are always due to the same 
cause, cites a case of Siredey’s, in which a man went on having scar- 
latiniform eruptions for years afterward. The first of these rashes 
happened in typhoid fever, and was even followed by desquamation. 
He recovered entirely, but had nine subsequent attacks in the suc- 
ceeding years, each also followed by desquamation. 
The nervous element showed very strongly in this case, which was 
under my care at the Pennsylvania Hospital: 
1 These de Paris, 1888, No. 209. 10 
ANOMALOUS ERUPTIONS IN TYPHOID FEVER. 
Case IX.—Thomas G., aged twenty-five years, a man of excellent physique 
and good habits, was in the Pennsylvania Hospital with typhoid fever in 
September, 1880. During its course marked flushing of the face was noticed, 
and he stated in explanation that he always flushed readily and from the 
slightest cause. There were successive crops of rose-spots, even on the arms. 
During convalescence he had an attack of general erythema, looking like a 
scarlet fever eruption, hut unconnected with sore-throat. He was discharged 
from the hospital November 22d, and returned in December with severe pain 
in the back and the sciatic nerve on the right side, said to have followed 
sleeping in a cold, damp place. It was attended with moderate fever, which 
lasted for nearly two weeks, and concerning which it was doubtful whether 
it was a typhoid fever relapse or not. It was not accompanied by rose-spots 
or enteric symptoms or albuminuria, but as it kept up without apparent cause 
it was looked upon as a typhoid-fever relapse. In' its course it was observed 
that whenever he was spoken to in a decided manner there was flushing of 
the whole surface; indeed, the arms and face especially flushed under the 
least excitement. The flushing in the face was attended with a sense of heat, 
but this was not the case in the rest of the body. After keeping quiet for a 
few minutes the erythema always subsided, leaving a mottled appearance of 
the surface. There was no sore-throat, and no desquamation ever followed 
the erythematous flushings, but engorgement of the capillaries gave to his 
skin the appearance of scarlet fever. It was, however, only in parts uni- 
form ; in others in uneven patches, and it was not attended with any feeling 
of cold or with itching. There was never any evidence of rheumatic affec- 
tion of the joints, muscles, or heart. The temperature, which ranged about 
101°, did not become normal until eighteen days after his readmission into 
the hospital, and he was soon afterward discharged. 
There is nothing in these rashes which seems to add gravity to the 
prognosis. It is true—though there are instances in this paper which 
show the contrary—that they mostly happen in severe cases of typhoid 
fever; especially does the morbilliform eruption, which is much more 
apt to occur later in the disease and to be associated with graver 
symptoms than the scarlatiniform rash. But the prognosis is to be 
determined by these symptoms rather than by the eruptions; and, as 
regards treatment, they call for no special line of therapeutics. As 
febrile albuminuria may coexist we must pay close attention to the 
renal secretions. It is from the point of view of diagnosis and 
pathology that these rashes merit attention and serious study.