THE INFLUENCE OF THE HIGH CALORY DIET ON THE COURSE OF TYPHOID FEVER
Journal of the American Medical Association
appeared so that between November 18 and December 15 he lost thirty-seven pounds in weight. Six months later his urine contained much less albumin and a few casts and he looked very well. One and one half years later and three years later he was seen. The last time his urine showed a very slight trace of albumin and a very rare hyaline cast. His blood pressure was normal and for two years he had been steadily at work in a machine shop running a lathe and feeling per¬ fectly well. Was this a
... ell. Was this a case of nephritis with a complicating purpura or does it belong to the group I have been discussing? I must confess I do not know. Abdomi¬ nal pain of various types does occur often in typical chronic nephritis without skin lesions and I usually call my students' attention to this as a type of symp¬ tom in chronic nephritis, that often leads to diag¬ nostic errors. On the other hand I am inclined to think that in many patients hematuria, albuminuria, and other renal disturbances occur as part of the dis¬ ease entity here under consideration and that these renal disturbances are due to kidney lesions similar in nature to those occurring in the skin. In this sense the renal lesions are not truly those of nephritis. This probably explains why in these patients with seem¬ ingly so severe a renal lesion progression into a true chronic nephritis is not often seen. CONCLUSIONS There is a definite clinical 'intity in which with skin lesions of the erythema group (purpura, ery¬ thema, urticaria, angioneurotic edema) visceral lesions occur as the result of the same type of lesion. The most common of these visceral manifestations are arthritis, gastro-intestinal symptoms, hematuria and various disturbances of renal function. The visceral disturbances occur unaccompanied by the skin lesions. The symptomatology of the group is very complex and without the presence of the skin lesions at a given time the cases present great difficulties in diagnosis. The various studies concerning the high calory diet which have been carried out in Bellevue Hospital during the last ten years, have established beyond question the value to the individual typhoid patient of the maintenance of an optimal state of nutrition.1 Contrary to the common belief, it was found that large quantities of selected foods could be taken without disturbance of digestion. Likewise, it was found that food is absorbed by the typhoid patient practically as completely as by healthy men. Under the high calory diet the febrile loss of body protein is reduced to a minimum or altogether prevented. Investigations of the total metabolism of typhoid patients have shown that large amounts of food are consumed with avidity, any excess over the immediate needs being laid by for future use. None of these studies, however, furnished more than indirect evidence of the influence which the high calory diet might exert on the natural history of typhoid fever. On account of the wide variations in the course of the disease in different seasons, such evidence can be obtained only from the study of a series of cases extending over a number of years. A statistical study has therefore been undertaken of the course of typhoid fever in patients on the high calory diet and in an equal number of patients on diets (milk, broths, egg albumin water) furnishing not more than from 1,000 to 1,500 calories a day. The num¬ ber of cases available is not sufficiently large to justify comparison of the frequency of the rarer symptoms and complications ; even with respect to the commoner features of the disease, only tentative conclusions are drawn unless the evidence is overwhelming. S Material.-The material consisted of 444 patients, half of them on the high calory diet and the other half on a milk diet. All of the patients were treated on the second medical division of Bellevue Hospital except forty-five of those on the milk diet. The majority of the patients were under my personal care, thus elimi¬ nating differences in the course of the disease which might be attributable to different methods of treatment other than diet. The histories cover the years from 1903 to 1914, inclusive. As far as possible, cases in corresponding years have been selected, but the use of the high calory diet became so general throughout the hospital about 1911 that, in order to complete the milk series, it was necessary to utilize 113 histories from 1903 to 1906, inclusive. The histories were taken from the records seriatim. All patients were classified as high calory casesîf~the attempt had been made to nourish them liberally, even if it failed or was only partially successful. A moderate number of histories were unsuitable for analysis, the reasons being doubt as to the diagnosis, entrance into the hospital late in the disease, and death within a week of admission. Of the fatal cases excluded, three were on the high calory diet and twelve on milk. Fifty-five of the high calory, cases were mild, 149 were severe, and eighteen were fatal. Forty-four of the milk cases were mild, 104 were severe, and thirty-nine were fatal. Duration of the Disease.-There is no evidence to indicate that the duration of the febrile period of the disease or the range of temperature is affected by diet except, perhaps, that long recrudescences are rarer in patients who are well nourished. The total duration of the disease, however, is short¬ ened, in some instances, by months. That is, the long convalescences, formerly so common, have not been observed. The records with respect to convalescence are by no means complete, but a number of patients have reported back to the hospital from time to time. All of them have stated that they felt perfectly well and were physically able to follow their occupations (many of the patients were laborers) even within a short time after their discharge. Condition of the Mouth.-While it is recognized that the condition of the mouth, including the tongue, in typhoid fever is dependent on the amount of atten¬ tion bestowed on it by the nurse, it may be stated that the mental condition of patients who are well nour¬ ished is so good that they themselves keep their mouths clean. The only histories containing notes to the effect that the lips and tongue were in poor condi¬ tion were 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 occurred in 19.3 per cent, of the high calory cases and in 22.6 per cent, of the milk cases. The difference is negligible. Nausea and vomiting were more frequent among the earlier high calory cases when the diet was limited to milk, cream, lactose, and eggs ; these symp¬ toms became less common as other articles of food were added to the diet. Nausea and vomiting did not always coexist in' the same patient. Lactose at times caused vomiting without nausea. Most often nausea and vomiting followed attempts to increase the food too rapidly or when the food mixtures were too rich. Some patients vomited the high calory diet and milk indifferently. A few patients had persistent and un¬ controllable vomiting due either to recent excesses in alcohol or to the disease per se. Tympanites and Diarrhea.-Though often asso¬ ciated, these did not always occur together. Tym¬ panites occurred in 17.6 per cent, of the high calory cases and in 31.5 per cent, of those on milk. Extreme grades of tympanites were rarely observed among the high calory cases. Diarrhea occurred in 16.2 per cent, of the high calory cases and in 48.6 per cent, of those on milk. Temporary diarrheas of one to several days' duration have been included in the percentage for the high calory cases but not in that for the milk cases. For comparison, the statistics of the Hamburg (2,240), and Leipzig (1,875) cases, as given by Curschmann,2 may be cited. Continuous diarrhea occurred in 36.1 per cent, of the cases in the Hamburg epidemic, temporary diarrhea in 29.7 per cent., making a total of 65.8 per cent. In the Leipzig cases, con¬ tinuous diarrhea occurred in 25.6 per cent, and tran¬ sient diarrhea in 37 per cent., with a total of 62.6 per cent. Normal stools occurred in 5.2 per cent, of the Hamburg cases and in 4.4 per cent, of the cases in Leipzig. The practice followed in Bellevue Hospital of giving a daily enema to all typhoid patients has made it impossible to ascertain what proportion of patients would have had spontaneous daily movements of the bowels and what proportion were constipated. With respect to the characters of the stools themselves, those from the high calory cases were notable for their nor¬ mal color and consistence. A large proportion of the stools of the milk cases contained undigested milk curds. Tympanites and diarrhea were observed more fre¬ quently among the earlier high calory cases. After 1911, only nine of these patients suffered from con¬ tinuous diarrhea. Many patients entering the hospital with profuse diarrhea developed normal stools in the course of several days under the influence of the high calory diet. Gradually it was learned that, except in a few patients, tympanites and diarrhea are due to an excess in the diet of one-or another of the foodstuffs. Tym¬ panites most frequently results from an excess of lactose ; diarrhea most often from an excess of cream.