The efficiency of a carbohydrate diet in typhoid fever was first demonstrated by Shaffer and Coleman,1 who showed that the ingestion of large amounts of carbohydrate in a medium protein diet may almost maintain the patient in nitrogen equilibrium throughout the disease. The diet consisted of milk, milk-sugar, diluted cream, eggs, and sometimes arrowroot starch. Shaffer writes: "It was only when we gave 60, 70, or even 80 calories per kilogram of body weight - between 3000 and 4000 calories - that the greatest sparing was observed".

The results obtained from two individuals suffering from typhoid are presented in the following table:

Influence Of Carbohydrates On Protein Metabolism In Typhoid Fever Subject I

Subject II.

* Average for last three days of diet.

1 Shaffer: "Journal of the American Medical Association," 1908, li, 974; Shaffer and Coleman, "Archives of Internal Medicine," 1909, iv, 538.

From this it may be concluded that nitrogen equilibrimn may be very nearly maintained throughout the course of typhoid fever on a diet containing 12 to 15 grams of nitrogen, provided an excess of carbohydrate beyond the requirement of the organism be also administered. Very likely under these circumstances the fat in the diet is without influence, except that it is retained in the organism. Upon this basis rests the very notable advance achieved by the Coleman-Shaffer "high calorie diet".

Pioneer work with accurate technic upon the subject of the respiratory metabolism in typhoid fever was first accomplished by Kraus,1 Grafe,2 Roily,3 and Coleman and DuBois,4 but the most complete work upon the subject is presented in the calorimeter studies of Coleman and DuBois which have already been incidentally alluded to. These authors give the following table which shows the correspondence between direct and indirect calorimetry obtained with patients suffering from typhoid:

Ten individuals were investigated. Metabolism records were obtained on sixty-five days. Twenty-four of these were devoted to the study of Morris S., a patient whose metabolism was determined through the course of the fever and two relapses, and one year later when he returned to the hospital in perfectly normal health. This gave the opportunity of contrasting the effect of the specific dynamic action of protein in the same individual in fever and in health.

1 Kraus: "Zeitschrift fur klin. Med.," 1891, xviii, 160.

2 Grafe: "Deutsches Archiv fur klin. Med.," 1911, ci, 209.

3 Roily: Ibid., 1911, ciii, 93.

4 Coleman and DuBois: "Archives of Internal Medicine," 1914, xiv, 168.

Coleman and DuBois state that the average increase in the basal metabolism in typhoid fever is approximately 40 per cent., although figures of over 50 per cent, are frequently encountered. The following table shows the average results obtained during the various weeks of typhoid fever:

Basal Metabolism, According To Periods Of Typhoid Fever

The considerable increase in metabolism during the second, third, and fourth weeks of convalescence is a noteworthy discovery. It is during this period that a regeneration of body protein takes place, and DuBois points out that the heightened metabolism is reminiscent of the increased heat production during the period of growth.

The specific dynamic action of food administered in typhoid fever was found to be almost negligible, although during convalescence it was as high as in normal individuals. The following table shows these results:

Specific Dynamic Action Of Protein And Carbohydrate In. Health, Fever, And Convalescence

* Since the completion of Paper 4 two more normal controls have been given the test-meals. Morris S., on Dec. 18, 1914, showed a rise of 6.5 per cent, after a meal containing 9.6 gm. N.; Albert G., on Jan. 6,1915, showed an increase of 9 per cent, in his metabolism after 115 gm. commercial glucose.

The meal containing protein was as large as the patient could be persuaded to take. The results of the ingestion of large amounts of food caused only a slight increase in the basal metabolism during fever, one of 5 per cent, in the case of protein and only 1 per cent, in the case of commercial glucose. The ancient doctrine of "starving a fever" herewith falls to the ground.

The effect of bodily activity upon the basal metabolism does not appear to be as marked during typhoid fever as in health. Thus, Coleman and DuBois describe how Morris S. was quiet during a first hour, was restless and tossed about the bed during a second hour, and during a third hour was evidently irrational, tossed about, wrote several long notes which he held up to the calorimeter window, telling of animals that were biting him with their sharp teeth. Yet his metabolism, which was 43 per cent, above the normal for the three-hour period, was only 5 per cent, higher than during a quiet period of observation of the basal metabolism made two days later when the body temperature was lower.

The principal cause of the increased metabolism in typhoid fever lies, therefore, in the febrile process itself, and food and restlessness have little influence.

The respiratory quotients were normal, the lowest being 0.72, obtained during fasting, and the highest 1.04, obtained after carbohydrate ingestion.

The large quantities of food administered to the typhoid patients in the "high calorie diet" are as completely absorbed as they would be in health.1

Only a resume of the more important principles involved can be attempted in this book, and those interested in the metabolism of typhoid patients are referred to the details in the original communication of Coleman and DuBois.

An illustration of the course of nitrogen metabolism in a different fever - namely, pneumonia - may also be taken from von Leyden and Klemperer.2 The details are given below:

Metabolism In Pneumonia

In this case it is apparently demonstrated that nitrogen equilibrium cannot be obtained during high fever, and also that the loss of body nitrogen does not cease at the crisis, but rather continues on account of the epicritical elimination of nitrogen derived from the protein of the croupous exudate. During the time of this epicritical elimination the body appears unable to add new protein to itself. About four days after the crisis true convalescence begins, with the upbuilding of new protein tissue.

1 DuBois: "Archives of Internal Medicine," 1912, x, 177; Coleman and Gep-hart: Ibid., 1915, xv, 882.

2 von Leyden and Klemperer: "Handbuch der Ernahrungstherapie," 1904, Bd. ii, p. 345.