Between well-marked cases of the two diseases there should be no difficulty in making a prompt diagnosis. Relapsing fever is distinguished from typhus clinically by the severity of the initial chill; the rapid elevation of the pulse and temperature; the comparative infrequency and mildness of cerebral symptoms, despite the intense fever; the severity of the gastric symptoms, nausea and vomiting; the enlargement of the liver and spleen, with marked abdominal pain and soreness; the frequency of jaundice, of epistaxis, and of other hemorrhages, and of anæmic murmurs over the heart and large vessels; obstinate insomnia; vertigo; peculiar rheumatoid pains and perversions of sensation; the frequency of sweating during the high pyrexia; by the occurrence of crisis, subnormal temperature, apyretic interval, and relapse; the rarity of measly eruption and of bed-sores; the frequency of pneumonia, diarrhoea, ophthalmia, oedema, and desquamation as complications and sequelæ; the usual occurrence of abortion in pregnant females; the protracted course of the disease, and its remarkably low mortality despite the severity of the symptoms, except in cases of complicated or typhoid type; and, finally, by the modes in which death occurs. Of course to this must be added the specific result of examination of the blood in relapsing fever.
Doubt will arise only in very rare cases where a measly eruption appears on or before the fifth day of relapsing fever, with headache and mild delirium, but without severe gastric symptoms, epistaxis, or jaundice. If no relapsing fever were prevalent at the time, such a case might well be regarded as one of mild typhus until the crisis and the relapse disclosed its real nature. But if the two diseases were known to be prevalent in the community, examination of the blood would properly be made at once and the diagnosis be established.
The diagnosis between ordinary cases of relapsing fever and typhoid is readily made by the gradual onset and peculiar course of the pyrexia in the latter disease, as well as by the frequency of delirium, of abdominal distension, and of diarrhoea, and by the characteristic eruption. The occurrence of epistaxis, bronchial irritation, and splenic enlargement is common to both, and an eruption of small rose-pink spots has been noted by some observers (Carter, pp. 194, 317). But jaundice, enlargement of the liver, hypochondriac pain and soreness, excessive nausea and vomiting, severe rheumatoid pains, and numbness and tingling of the extremities, are very significant symptoms of relapsing fever. Attention has already been called to the grave type of relapsing fever in which the typhoid state is fully developed, and to the fact that in such cases the pyrexia is often modified, the onset less abrupt, the crisis imperfect, and the interval occupied by an irregular post-critical symptomatic fever. It is altogether probable that such cases have not rarely been regarded as of true typhoid character; and indeed the attempt has been made by Griesinger to establish as a separate and independent affection, under the name of bilious typhoid fever, a group of cases which close examination seems to show to be chiefly composed of grave complicated relapsing fever with a certain proportion of true typhoid fever, complicated with jaundice.
The recognition of the bilious typhoid type of relapsing fever is based upon the history of the case; the mode of onset; the greater severity of the pains, arthritic and abdominal; the early appearance and intensity of the jaundice; the more marked enlargement of the liver and spleen; the marked tendency to hemorrhages from various surfaces; the peculiarities which careful study of the temperature curve will show, especially about the time of crisis; the rarity of eruption; the characteristic spirillum;36 and the totally different anatomical lesions, which are, unfortunately, often demonstrable, as this form of relapsing fever is fatal in from 33 to 50 per cent. of cases.
36 As first demonstrated by Motschutkoffsky.
Since the discovery of the spirillar test for relapsing fever it may be said that Griesinger's bilious typhoid must be stricken from medical nosology as an independent affection.
The case of Charles Hood, [above], is a good example of the bilious typhoid form which occurred not rarely in the Philadelphia epidemic.
Murchison points out that, owing to the frequent occurrence of jaundice in relapsing fever, this disease has been mistaken for yellow fever by such good observers as Graves, Stokes, and Cormack. Difficulty in diagnosis would be likely to arise only in regard to the bilious typhoid type of relapsing fever, and since its clinical history has become so well known, a mistake is not likely to occur. The geographical distribution of the diseases is widely different. Yellow fever is influenced powerfully by season and temperature, while relapsing fever is independent of both. Negroes are but slightly liable to yellow fever, while relapsing fever attacks them with special violence. Yellow fever is not contagious, but infectious, and second attacks are extremely rare; relapsing fever is one of the most contagious of the zymotic diseases, but one attack does not protect against a subsequent one. The mortality, the anatomical lesions, the course of the pyrexia, the leading clinical symptoms, are all widely distinct in the two affections; and, finally, no spirillum has been found in the blood in yellow fever. Yellow fever is an extremely fatal disease; the ordinary form of relapsing fever has a mortality of 2 to 10 per cent.; the bilious typhoid form, one of 33 to 50 per cent. In yellow fever the spleen is but slightly enlarged, and the liver is pale and softened; in relapsing fever the liver and spleen are greatly enlarged, and there is great tenderness over the hypochondriac region. In yellow fever albuminuria is much more common, and the urine more frequently suppressed, than in relapsing fever.
The sudden onset, the severe headache and pains in the limbs, the vomiting, jaundice, epigastric tenderness, enlargement of the liver and spleen, occasional epistaxis, hematemesis, or hematuria, absence of characteristic eruption, liability to herpes facialis, pneumonia, and diarrhoea; the occasional occurrence of remissions in the pyrexia, and even of more or less fully-developed chills for several successive days during the initial paroxysm or the relapse, suffice to explain the difficulty which may arise in distinguishing the bilious form of relapsing fever from bilious remittent fever. But the latter disease arises exclusively from malaria, and is therefore powerfully influenced by season and locality; is not contagious; does not present anything approaching to the crisis, the apyretic interval, or the abrupt relapse of relapsing fever; presents pigmentary changes in the blood, instead of the spirillum; and lesions of the spleen and liver totally unlike those characteristic of relapsing fever; can be promptly controlled by antiperiodic doses of quinine, and therefore should have a mortality far less than that of the grave form of relapsing fever. It is not necessary to pursue this subject further, but a reference to the temperature charts of Carter37 or of Litten38 will show that in some epidemics single paroxysms resembling those of quotidian ague might occur during the interval between the initial paroxysm and the relapse, or a series of two, three, or more such paroxysms of quotidian or tertian type might represent an entire relapse. Such phenomena are wholly uncontrollable by quinia, and are presumably dependent upon irregularities in the specific infection, instead of upon a blending of malaria with the poison of relapsing fever. There is some ground for believing, however, that those who have recently passed through an attack of the latter are highly, perhaps unusually, susceptible to malarial infection, as we have already seen they are liable to contract typhus.
37 Op. cit.