Proceeding with the subject of diet, we will to-day take up the question of diet in typhoid fever, which is one of the acute diseases that often lasts for a long period of time, and requires special attention. In former times, up to about seventy-five years ago, it was the tendency of the medical profession to withhold nourishment from patients with typhoid fever and to give them as little as possible, and that little only in liquid form. The teachings of Hippocrates prevailed especially with regard to this terrible disease, and these patients would get only a . little weak tea or barley water; even milk was kept away from them as it was considered a form of nourishment which might disturb them too much. So the starvation plan was carried out in this disease also, up to the time of convalescence.

The renowned clinician, Dr. Graves, of Great Britain, was the first one to try to introduce some reform in the treatment and management of typhoid fever in regard to diet. He thought that the starvation method was not a good way to treat these patients and that perhaps a great many of them died from lack of nutrition - not so much from the fever as from the lack of nourishment - the body being unable to fight the disease. So he thought he would give these patients light nourishment, and he gave them milk, which is a liquid food that is easily digested. He was the first one to make use of milk in the dietary of typhoid fever in a considerable degree - to give them a good amount of milk. That theory was combated by the clinicians of that day; many thought that he killed his patients, and like all innovators he had a great many enemies. The profession was not ready to accept the great change of giving milk to patients with typhoid fever. Graves fought his battle, however, and finally carried it through. In the meantime, many physicians more and more adopted his plan. Dr. Graves was so proud of this reform of introducing milk into the diet of typhoid fever that in his will he left directions that his tomb should be inscribed: "He fed fevers".

That was the first article of food that was added to the dietary of typhoid fever patients for many years; they were kept on a diet consisting of milk, broths, and gruels. Then came another current from Russia. There are a few clinicians there who tried giving typhoid fever patients an ordinary diet, solid food - anything. I do not remember the name of the man1 who first introduced this treatment, but at any rate some of the physicians took up the plan of treating these patients with the ordinary food - bread, meat, and vegetables - and still they reported results that were not worse than if the patients were treated with very fine food in their diet. They claimed that their patients thrived, felt stronger and better, and got over the disease just as well. Now, you will ask, what shall we do?

In my opinion, we should not give the patient the ordinary daily food. That would be too radical a change. But their experience has shown that we need not be too much afraid of introducing a little more food into the dietary of these patients, and that typhoid fever patients need not always be restricted to strictly liquid food. We may give them a semi-solid diet, and perhaps in some cases may give a little solid food.

1 His name is Bushuyev.

Now another point has emanated from this country. I think the beginning of this was in Germany, but it was not carried out to the extent to which it has been followed out in this country. A great many years ago, Prof. Leyden, of Berlin, who has done so much for the dietetic treatment of diseases, was of the opinion that with typhoid patients, or any patients with fever who lose so much flesh, we might by increasing the nourishment, be able to check the loss. It has been for quite a while a subject of controversy as to whether this could be done. In such fevers, the expenses of the body are increased and the intake is diminished, and it was a question as to whether the digestive system would be able to take up the food, which would balance or outbalance the loss. That question had not been decided until Dr. Warren Coleman of this city took it up and carried the point so far as to prove that you can give a typhoid fever patient enough nourishment to prevent him from losing flesh. Sometimes you can even make him gain during the febrile period. It is, therefore, only a question of the quantity of nourishment introduced, whether he loses or not. Dr. Coleman of Bellevue Hospital really did a great deal of meritorious work in this line. Some years ago I tried to nourish some of these patients in the German Hospital, (now Lenox Hill Hospital), giving them larger amounts of food. We gave them milk and added raw eggs - three or four a day, beaten up in the milk and strained. Dr. Coleman gives still more. He adds cream to the milk, increases the liquids and gives sugar of milk - that is, sugar that is not so sweet. It can be put in the milk or in lemonade and makes a very agreeable drink; and at the same time increases the amount of nourishment, as it contains a large amount of carbohydrate. If you give a tablespoonful of lactose you have sixty calories, and you can put two tablespoonfuls in a glass of lemonade or milk and thus furnish 120 calories. If you give eight ounces of milk with two tablespoonfuls of lactose, and give that eight times a day, you get a fair amount of fluid of nutritive value. Dr. Coleman also gives his patients eggs, farina, rice, and toast. He is not so careful in abstaining from solid food, and gives practically a liquid and semisolid diet. If milk is not well-borne, we have to give other things, barley, broths, and eggs, and so have a good variety.

Last fall I had a patient from out of town with typhoid fever. He had lost twenty pounds of flesh and had headaches, but no one had made a diagnosis of the condition. He came to me for a diagnosis, for everyone thought he had some stomach trouble. He complained of indigestion and his appetite was poor. He was kept in the hospital under observation for a day or two, and we found that he had some temperature, and then the diagnosis of typhoid fever was easy. His previous examinations had been made at a very early stage. In that beginning period before he had high fever, he had lost twenty pounds. When he came into the hospital he said that he could not stand milk, that it disagreed with him. So I started him on plenty of lemonade with milk sugar, and gave him eight or ten eggs a day beaten up with barley decoctions, and butter in addition. That man did not lose another pound during the entire course of his typhoid fever. As soon as the fever was over the nourishment was pushed further, and he gained right away, and we sent him home with a gain of fifteen or twenty pounds. That was an example of what can be done with diet in typhoid fever for a patient who cannot stand milk. If he had been able to take that, it would have been still easier to give him nourishment.