appeared so that between November 18 and December None of these studies, however, furnished more 15 he lost thirty-seven pounds in weight. Six months than indirect evidence of the influence which the high later his urine contained much less albumin and a few calory diet might exert on the natural history of casts and he looked very well. One and one half years typhoid fever. On account of the wide variations in later and three years later he was seen. The last the course of the disease in different seasons, such time his urine showed a very slight trace of albumin evidence can be obtained only from the study of a and a very rare hyaline cast. His blood pressure was series of cases extending over a number of years. normal and for two years he had been steadily at work A statistical study has therefore been undertaken of in a machine shop running a lathe and feeling per¬ the course of typhoid fever in patients on the high fectly well. calory diet and in an equal number of patients on diets Was this a case of nephritis with a complicating (milk, broths, egg albumin water) furnishing not more purpura or does it belong to the group I have been than from 1,000 to 1,500 calories a day. The num¬ discussing? I must confess I do not know. Abdomi¬ ber of cases available is not sufficiently large to justify nal pain of various types does occur often in typical comparison of the frequency of the rarer symptoms chronic nephritis without skin lesions and I usually and complications ; even with respect to the commoner call my students' attention to this as a type of symp¬ features of the disease, only tentative conclusions are tom in chronic nephritis, that often leads to diag¬ drawn unless the evidence is overwhelming. S nostic errors. On the other hand I am inclined to Material.—The material consisted of 444 patients, think that in many patients hematuria, albuminuria, half of them on the high calory diet and the other half and other renal disturbances occur as part of the dis¬ on a milk diet. All of the patients were treated on the ease entity here under consideration and that these second medical division of Bellevue Hospital except renal disturbances are due to kidney lesions similar forty-five of those on the milk diet. The majority of in nature to those occurring in the skin. In this sense the patients were under my personal care, thus elimi¬ the renal lesions are not truly those of nephritis. This nating differences in the course of the disease which probably explains why in these patients with seem¬ might be attributable to different methods of treatment ingly so severe a renal lesion progression into a true other than diet. The histories cover the years from chronic nephritis is not often seen. 1903 to 1914, inclusive. As far as possible, cases in corresponding years have been selected, but the use of CONCLUSIONS the high calory diet became so general throughout the There is a definite clinical 'intity in which with hospital about 1911 that, in order to complete the milk skin lesions of the erythema group (purpura, ery¬ series, it was necessary to utilize 113 histories from thema, urticaria, angioneurotic edema) visceral lesions 1903 to 1906, inclusive. occur as the result of the same type of lesion. The The histories were taken from the records seriatim. most common of these visceral manifestations are All patients were classified as casesîf~the hematuria and high calory arthritis, gastro-intestinal symptoms, attempt had been made to nourish them liberally, even various disturbances of renal function. The visceral if it failed or was only partially successful. disturbances occur unaccompanied by the skin lesions. A moderate number of histories were unsuitable for of the is The symptomatology group very complex analysis, the reasons being doubt as to the diagnosis, the the skin lesions a and without presence of at entrance into the hospital late in the disease, and death the cases in given time present great difficulties within a week of admission. Of the fatal cases diagnosis. excluded, three were on the high calory diet and twelve on milk. Fifty-five of the high calory, cases THE INFLUENCE OF THE HIGH CALORY were mild, 149 were severe, and eighteen were fatal. DIET ON THE COURSE OF Forty-four of the milk cases were mild, 104 were TYPHOID FEVER severe, and thirty-nine were fatal. Duration of the Disease.—There is no evidence to WARREN COLEMAN, M.D. indicate that the duration of the febrile period of the NEW YORK disease or the range of temperature is affected by diet The various studies concerning the high calory diet except, perhaps, that long recrudescences are rarer in which have been carried out in Bellevue dur- patients who are well nourished. Hospital The total duration of the is the last ten years, have established beyond question disease, however, short¬ ing in some months. That the the value to the individual typhoid patient of the ened, instances, by is, long so have not been maintenance of an optimal state of nutrition.1 Con- convalescences, formerly common, observed. The records with to convalescence trary to the common belief, it was found that large respect of selected foods could be taken without are by no means complete, but a number of patients quantities have back to the from time to time. disturbance of Likewise, it was found that reported hospital digestion. All of them have stated that felt is absorbed the typhoid patient practically as they perfectly well food by and were able to follow their as healthy men. Under the high calory physically occupations completely by of the were even a diet the febrile loss of is reduced to a (many patients laborers) within body protein short time after their minimum or altogether prevented. Investigations of discharge. the total metabolism of have shown Condition of the Mouth.—While it is recognized typhoid patients that the condition the that large amounts of food are consumed with avidity, of mouth, including the tongue, in fever is on the amount of atten¬ any excess over the immediate needs being laid by for typhoid dependent on the be future use. tion bestowed it by nurse, it may stated that the mental condition of patients who are well nour¬ Read before the Section on Practice of Medicine at the Sixty\x=req-\ ished is so good that they themselves their Eighth Annual Session of the American Medical Association, New keep York. June, 1917. mouths clean. The only histories containing notes to 1. For the bibliography of the papers by Drs. Shaffer and Du Bois, the effect that the and were in poor condi¬ Mr. Gephart, and the author, see Arch. Int. 1914, p. 168; lips tongue Med., August, were May, 1915, pp. 882, 887. tion found in the milk group. Downloaded From: http://jama.jamanetwork.com/ by a University of Manitoba User on 06/14/2015 Nausea and Vomiting.—Nausea and followed the attempt to increase the food beyond occurred in 19.3 per cent, of the high calory cases and 1,000 to 1,500 calories, in spite of frequent alteration in 22.6 per cent, of the milk cases. The difference is of the proportions of protein, fat, and carbohydrate. negligible. Nausea and vomiting were more frequent Reference may be made in this connection to 3 among the earlier high calory cases when the diet was Torrey's study of the intestinal flora of some of the limited to milk, cream, lactose, and eggs ; these symp¬ high calory cases of this series and of other cases on a toms became less common as other articles of food milk diet. Torrey found that patients who were able were added to the diet. Nausea and vomiting did not to take large amounts of food without digestive dis¬ always coexist in' the same patient. Lactose at times turbances possessed a flora dominated by the Bacillus caused vomiting without nausea. Most often nausea acidophilus, and that patients with an initial putre¬ and vomiting followed attempts to increase the food factive flora were capable of developing a favorable too rapidly or when the food mixtures were too rich. fermentative flora, with disappearance of tympanites Some patients vomited the high calory diet and milk or diarrhea, under the influence of the diet. Excep¬ indifferently. A few patients had persistent and un¬ tionally, the putrefactive type of flora persisted in spite controllable vomiting due either to recent excesses in of alteration of the diet—these were the patients who alcohol or to the disease per se. could not be liberally nourished. The therapeutic Tympanites and Diarrhea.—Though often asso¬ application of these results was at once apparent and ciated, these did not always occur together. Tym¬ at my request Dr. Torrey prepared a pure culture of panites occurred in 17.6 per cent, of the high calory Bacillus acidophilus for administration to typhoid cases and in 31.5 per cent, of those on milk. Extreme patients. The bacillus was used first for patients enter¬ grades of tympanites were rarely observed among the ing the hospital with tympanites and diarrhea in order high calory cases. Diarrhea occurred in 16.2 per cent, to hasten the transformation of the flora; later it was of the high calory cases and in 48.6 per cent, of those given more or less as a routine measure. The results on milk. Temporary diarrheas of one to several days' have been satisfactory. duration have been included in the percentage for the Through the investigations of Torrey, and of Hull high calory cases but not in that for the milk cases.