TYPHDS FEYER. 
DAVID CERNA. 
Reprint from St. Louis Medical Review, May 27, 1893. Typhus Fever as Met With in Mexico, 
With Special Reference to its 
Treatment. 
DAVID CERNA, M D., PH.D. 
Demonstrator of Physiology in the Medical Department of the Uni- 
versity of Texas, etc. 
Read by Title before tbe Texas State Medical Association at Gal- 
veston, May 4, 1893. 
The quite recent outbreak of typhus fever in New 
York, and the appearance of the disease in Mexico, as a 
generalized epidemic in several of the States of that 
country, are circumstances which make the subject a 
proper theme for discussion at present. Typhus fever 
has invaded the cities of Mexico, Puebla, Guanajuato, 
Zacatecas, San Luis Potoai, Aguascalientes, Pachuca 
and others, where it has been raging since last De- 
cember. A spread North is naturally to be feared. 
The South of the United States is, as it were, sieged 
at this moment by a terrible enemy, and it behooves us 
especially to be prepared for the encounter. An in- 
vasion by the disease, of this territory, particularly 
across the Rio Grande, is possible and quite probable. 4 
A consideration of the disorder in question is, then, not 
only interesting but absolutely necessary at this time. 
While there appears to exist some differences as re- 
gards the general symptoms and characters of the ty- 
phus fever of this and other countries, and that occur- 
ing in Mexico, and a consideration of this part of the 
subject would be exceedingly interesting and instruct- 
ive, I propose in this cursory paper, putting aside for 
the present at least all other questions, to call attention 
to the treatment of the disease, as followed in that 
country. I will at the same time incorporate whatever 
little experience I have in the matter. 
In Mexico the affection under consideration is com- 
monly called “tabardillo,” and there native observers 
enjoying the largest experience in the study of typhus 
(from the fact that the disease is endemic in many parts 
of the Republic) differ materially, even to-day, as to the 
nature and characters of the disorder. 
The whole subject of typhus fever as met with in 
Mexico, will be dealt with in a forthcoming paper now 
under preparation. For the present, I repeat, I will 
confine myself to a consideration of the treatment of 
the malady, especially of that most commonly observed 
in my country. 
It may be said in general that the whole treatment of 
this affection is mainly symptomatic, the morbid phe- 
mena being dealt with as they arise. 
Prophylactic and Hygienic Measures.—As soon 
as the diagnosis is properly made, based on unmistaka- 
ble symptoms and signs, the patient is, if possible, im- 5 
mediately isolated, placed in a well ventilated room, 
and so as to avoid any draughts of air. The couch on 
which the “patient is put, as well as all bed clothing and 
furniture are kept scrupulously clean; the clothing of the 
patient is changed as frequently as possible, and thor- 
oughly disinfected. And not only the room occupied by 
the patient, but the whole house is subjected constantly 
to as thoroughly a disinfection as possible. 
Care is taken to the effect that the nurse in charge 
of the case enjoys the best of health, and obtains regu- 
larly the proper nourishment and amount of sleep. This 
attendant is recommended to use moderate alcoholic 
stimulation, especially by night. If practicable, the 
same nurse is not allowed to manage a case of typhus 
during the whole period of the disease, with a view to 
prevent contagion. As a rule a nurse who has had ty- 
phus fever is preferred. All persons, particularly 
children, are prohibited from even entering the appart* 
ment occupied bp a typhus patient; this, on the other 
hand, is left alone with the nurse, in order to enhance 
absolute rest and quiet, and to remove all possible 
sources of excitement. All dishes, cups, tumblers, 
chambers, etc., employed by the patient are, before 
and after usage, thoroughly washed with boiling water, 
and other persons are absolutely forbidden to make 
use of such paraphernalia themselves. The hands of 
both nurse and patient are disinfected with antiseptic 
solutions, and care is particularly exercised to disin- 
fect the vessels employed to receive the dejecta of the 
patient. 6 
These general rules are rigidly enforced in private 
cases, but unfortunately they are not, cannot be fully 
carried into effect in hospital practice, or*among the 
poorer classes with whom the dread scourge plays so 
terrible havoc. All in all, proper nursing is of the 
utmost importance, and often this, conjoined with good 
nourishment, is sufficient to carry through safely the 
most serious cases. A close observation of a few spora- 
dic cases, has convinced me of the truth of my 
statement. 
Diet, Etc.—Alimentation, throughout the course 
ofthe disease, should be of a liquid nature. It should con- 
sist chiefly of boiled milk, cow’s or goat’s, to which tea, 
coffee, or orange-leaf water may be added. The free use 
of tea and coffee, especially the former, is allowed. These 
beverages, however, though frequently given, are ad- 
ministered in small quantities at a time. Milk, the 
chief article of diet, by itself or mixed with small quan- 
tities of tea and coffee, or still with peppermint water, 
to suit the individual taste, is ingested at intervals of 3 
or 4 hours, so that the patient may take at least from 2 
to pints during the 24 hours. Later in the disease, 
and especially during convalescence, chicken and other 
animal broths, eggs, beef tea, are given. The latter ar- 
ticle diet is administered twice a day, at noon and at 
night, with all due regularity. Fruit, such as baked 
apples, oranges and the like, is sometimes allowed 
with, of course, the necessary precautions. In all cases 
particular care is taken not to overload the stomach. 
The hygiene of the mouth is rigidly observed, a 7 
method to which very properly a great deal of atten- 
tion is given. Before and after the ingestion of food, 
the mouth of the patient is thoroughly cleansed with 
a soft cloth moistened in a mixture of distilled water 
and lemon juice, equal parts. Between meals mouth 
washing with alkaline solutions is frequently resorted 
to. Thirst is allayed by means of acidulated drinks. 
Above all, in typhus fever a good deal of attention is, 
as it should be, paid to alimentation. A typhus fever 
patient must be fed. The more I recall to mind the 
famous inscription ordered to be engraved on his tomb- 
stone by the wise English physician, the more con- 
vinced do I become of the truth of the three simple 
words of which such inscription consisted. And in no 
other febrile affection does the classical axiom of 
Graves hold so good as in typhus fever. I verily be- 
lieve that the high mortality which this disorder is 
apt to reach, not only during epidemics but also at 
other times, is due chiefly to the lack of proper nour- 
ishment before and during the process of the disease. 
The prevailing terrible epidemic of typhus fever over a 
large portion of the Mexican Republic, bears me out in 
this statement. The Russian-like famine which has of 
late visited the poorer classes of the people of that 
country (Mexico) is intimately linked with the outbreak 
and prevalence of, and the high percentage of deaths 
caused by, the scourge in country-town and city, in both 
of which the population has been decimated almost. 
But it may be stated that typhus is not necessarily a dis- 
ease of the destitute only. The highly contagious 8 
character of the disorder in question is well exempli- 
fied by the fact that it does not respect age, sex, or 
station in life. Thus, Dr. Manuel S. Soriano, of the 
city of Mexico, in charge of the Hospital Juarez, and 
who has been kind enough to furnish me with some 
valuable data, writes me that just now the scourge 
reigns supreme over the poor as well as over the wealthy 
classes. The disease has made no discrimination. In 
fact, it has apparently never done so in Mexico. I may 
also remark, in passing, that, according to the statement 
of Soriano, the constant number of patients of typhus, 
in Hospital Juarez alone, is, in normal times, 60. At 
present the daily existence of typhus patients in that 
hospital, has often been 350! 
The general therapeutic treatment of typhus fever, 
let me reiterate, is mainly expectant. The chief object 
is to keep up the strength of tfie patient, and thus the 
symptoms and the complications are perforce combatted 
as they arise. Such will be considered in the para- 
graphs that follow. 
Drugs and Other Therapeutic Measures.—Alco- 
hol is one of the principal agents employed from the 
onset of the disease. It is given in the form of wines 
or brandy, well diluted and in small quantities frequent- 
ly repeated according to indications. A common and 
efficient combination is as follows: 
Distilled water - 700.00 grammes; 
Good brandy - - 250.00 grammes; 
Sugar, s. q. to make the mixture tasty 
but not too sweet. 9 
This quantity is to be given every 24 hours, and 
should be pushed especially when the patient is un- 
willing to take food. Later in the course of the disease, 
the amount of the brandy in the above combination, 
may be increased to 300 grammes or more. Alcohol is 
also used with advantage in the form of eggnoggs and 
milkpunches. 
The two most common forms of the disease, met 
with in Mexico, whether the cases be sporadic or epide- 
mic, are the ataxic and the adynamic. In both of these, 
especially in the adynamic type, is alcohol indicated. 
I have notes of cases . in which this agent, freely used 
but not to produce a saturation of the system (when it 
is then more apt to act as a depressant), has been the 
chief means of saving life. On the other hand, I have 
seen fatal results follow the indiscriminate use of this 
substance. And I have also seen some of the worse 
cases recover under good nursing and the ingestion of 
forced alimentation, to the exclusion of alcoholic and 
other medicinal agents. 
I may state, in general terms, based on experience, 
that in the treatment of typhus fever each individual 
case requires almost absolutely a special management. 
In these instances nothing is more disastrous than a 
routine practice. As has been wisely said by a com- 
petent authority (Dominguez, Hare’s System of Thera- 
peutics art. Typhus.), typhus is so insidious a foe, that 
it is not judicious to combat it always with the same 
weapon. 
In the adynamic form, besides alcohol, other stimu- 10 
lants and tonics are often of great service. Ammonia, 
nux vomica, and quinine are indicated. If the nervous 
symptoms are especially prominent, accompanied with 
marked excitement and an elevated temperature, as in 
the ataxic type of the disease, the remedies just alluded 
are of little or no value, nay, they often do harm if 
their employment is persisted in. In these cases, the 
excitability of the nerve centres, made worse by those 
agents, yields like a charm almost to the use of antispas- 
modics, and particularly the bromides. 
On the contrary, in cases of typhus in which, instead 
of excitability a state not of depression but of ex- 
haustion is plainly manifest, as evidenced in the per- 
sistent elevation of the bodily temperature, a tem- 
perature that will yield temporarily only to the cold 
bath (a parallel condition frequently observed in typhoid 
fever, for instance), nothing produces better, happier 
results than the administration of musk in full doses. I 
have had opportunity to observe this brilliant action of 
musk in cases of both typhoid and typhus. 
Like diarrhea in enteric fever, in typhus constipation 
is the rule. Exceptions, however, occur. I have seen 
one typical case of typhus in which diarrhea was a 
prominent symptom from the very onset; but whether 
such phenomenon belonged to the disorder in question, 
or was the manifestation of another concomittant, 
masked affection, I am unable to say. Dominguez and 
other Mexican authorities speak of diarrhea as occuring 
in the latter stages of typhus fever. The constipation, 
as well as the marked meteorism accompanying it, are 11 
combatted chiefly by saline purgatives, preferably the 
sulphate of magnesium, or by mechanical means. Cal- 
omel in fractional doses is sometimes employed for this 
purpose, but more often, perhaps, cold water enemeta 
or suppositories of glycerine are resorted to with good 
effect. A popular remedy among the laity, and which 
in common parlance is called tianguis pepetla, is large- 
ly employed particularly in mild cases, even by regular 
physicians. Dominguez favors it. This tianguis is 
nothing more than a decoction of a plant whose techni- 
cal name is lllesebram achyrantha. An enema of the 
decoction acts as a mild but effective purgative. 
Intestinal antisepsis is likewise attended to carefully, 
and is cnosidered as an important measure. Salol, by 
the mouth and by the rectum, is used, provided the 
kidneys are in good condition. The latter method of 
administration of this drug is being practised to a con- 
siderable extent by Soriano. This author also speaks 
highly of rectal injections of the permanganate of po- 
tassium. 
A symptom more frequently met with than is gener- 
ally supposed is epistaxis. It is usually controlled by 
coid applications to the forehead, a measure which is at 
the same time of great service in relieving the intense 
headache. Often, however, the bleeding becomes almost 
unmanageable, and it is then absolutely necessary to 
resort to plugging of the nose. 
A very troublesome symptom occurring particularly 
at the beginning of the disease is catarrh of the stom- 
ach, and as a consequence of that this organ is apt to 12 
become highly irritable. In such conditions no medic- 
ament gives more satisfactory results than ipecacuahna. 
The drug serves the purpose desired without depressing 
the system. Other emetics are, and should be avoided. 
Depression, whether by drugs or other remedial meas- 
ures, should not be induced in typhus fever in which the 
system, more than anything else, needs a constant sup- 
porting aid. If the irritability of the stomach is par- 
ticularly marked, sedation is called for, and the inges- 
tion of food by the mouth, for the time being at least, 
dispensed with. Nourishment must then be given by 
the rectum. 
The severe headache, the delirnm and the insomnia, 
so frequent in typhus, are relieved by the judicious em- 
ptoyment of opiates, and particularly by the use of 
chloral hydrate. Hyoscine is indicated especially, and 
sometimes used with markedly good effect, when the 
delirium is of a violent nature. I, myself, have used 
opiates quite rarely. I am opposed, and strongly so, 
to using these medicaments as a matter of course, so to 
speak, and never give them unless severe pain is present. 
I also warn against the use of tartar emetic in any 
shape or form, even though this agent has been recom- 
mended by no less an authority than Graves. In Mexi- 
co it is rarely, if ever, used. When the insomnia is 
unaccompanied by severe cephalalgia, being only asso- 
ciated with ataxic phenomena, it can then be easily 
controlled, not by hypnotics but by depresso-motors 
such as valerian and camphor. 
I come now to the consideration of one of the most 13 
important parts of the treatment of typhus: the man- 
agement of the fever. A continned high bodily tem- 
perature is characteristic of typhus. An extraordinary 
high febrile state has been noticed by various observ- 
ers. Pepper (“An American Text book of the Theory 
and Practice of Medicine”, vol. I, 1893) in a recent ar- 
ticle refers to a case exhibiting a temperature of 109° 
F. on the fourth day of the disorder, and yet the pa- 
tient recovered. I have seen one case, a man 38 years 
of age, who, on the fifth day of the disease, had a feb- 
rile reaction of 42° C. (107.6° F.), and on the sixth 
day afebrile reaction of 42.5° C. (108.5° F.). The pa- 
tient made a good recovery. I believe that this high 
temperature in typhus, whatever its cause, contributes 
largely to fatal results. It not only depresses but fin- 
ally exhausts the nerve centers. 
I need hardly say that the febrile phenomenon is at- 
tended to from the very onset of the disease. If the 
rise of the bodily temperature occurs in exacerbations, 
as it often happens particularly in malarial regions, no 
remedy is more effective than quinine. The adminis- 
tration of this drug is associated with vigorous rubbing 
of the body and sponging with tepid, not cold, water. 
Should the temperature continue high, as is more often 
the case, and especially in the ataxic type of the disor- 
der, other antithermic remedies are employed, such as 
astipyrin, acetanilid and the like. These synthetic 
preparations, however, are cautiously administered, and 
their ingestion is entirely dispensed with if phenomena 
of prostration should supervene as a direct consequence 14 
of their action. In these instances all medication by 
drugs is abandoned, and the Brand system substituted. 
This latter method has of late become quite popular in 
Mexico in the treatment of typhus fever, and the results 
recorded have been most brilliant. The patient is not 
plunged at once into cold but in tepid water, the liquid 
being gradually cooled down to the required degree, 
that is, until the thermometer begins to mark the de- 
cline of the bodily heat. The patient is then taken out 
of the bath tub and placed between blankets. Thus 
chilling of the body is guarded against. The measure 
is repeated as often as is necessary. 
This method, however, is never applied in adynamic 
cases, undoubtedly with good reasons. Under such cir- 
cumstances, the bathing is not only useless, but contra- 
indicated—contraindicated not perhaps because the 
method is harmful in itself, but because, in the first 
place, the manipulation necessarily attached to its ap- 
plication only adds to the exhaustion of the patient, 
while the fever, on the other hand, only temporarily di- 
minished, soon regains its previous abnormal height in 
spite of the bath and the administration of alcohol. It 
is in just such conditions that vigorous stimulation of 
the exhausted nerve centers is called for. This is ac- 
complished by the administration of musk and nutri- 
tious enemata. In my experience, as intimated before, 
musk has given brilliant results. 
Of recent years, Mexican physicians have been em- 
ploying strychnine with excellent effect, especially 
when the prostration of the patient is marked and com- 15 
plete collapse threatened. This drug is highly recom- 
mended by Dominguez. The alkaloid, particularly in 
the form of the sulphate, is given hypodermically. 
Other tonics are given sometimes, such as nux vomi- 
ca, caffeine, and the preparations of cinchona bark. In 
the present epidemic Soriano is using, with apparently 
good effect, the following prescription: 
IJi Infusion of red cinchona, 125.00 grammes. 
Wine of cinchona, - 30.00 grammes. 
Cognac, • - - 30.00 grammes. 
Salicylate of sodium, 4.00 grammes. 
Caffeine, - - - 0.50 gramme. 
Hoffman’s anodyne, - 1.00 gramme. 
Syrup, q. s. 
M. 
Sig. A teaspoonful as required. 
The treatment of typhus fever may be resumed in 
a few words: Good hygiene; thorough disinfection 
of the patient as well as of the apartment he occupies; 
efficient nursing; nutritious liquid food by the stomach 
or rectum; intestinal antisepsis; reduction of the tem- 
perature; general stimulation, and the avoidance of 
the routine practice of administering drugs indiscrimi- 
nately. In these cases it is often better to “throw 
physic to the dogs.” 
If I were asked by a confused tyro in the practice of 
the healing art (not to say by an experienced brother 
practitioner), what to do in a desperate case of typhus, 
I.would unhesitatingly give him the following advice, 16 
taking for granted that he has a fair knowledge of gene- 
ral principles and is able to exercise good judgment: 
“In the first place, feed your patient; look into disin- 
fection and intestinal antisepsis; keep down the tem- 
perature. Secondly, feed your patient; look into dis- 
infection and intestinal antisepsis; keep down the tem- 
perature. Thirdly, feed your patient; look into dis- 
infection and intestinal antisepsis; keep down the tem- 
perature!”