712 ARTHUR ISAAC KENDALL 



larly if the partial starvation diet principle be adhered to. Shaffer and 

 Coleman sought to prevent this large loss of body nitrogen. They were 

 led to prescribe a diet moderately rich in protein dnd fat, and extremely 

 rich in carbohydrate, through a consideration of the well-established physi- 

 ological dictum that carbohydrate spares body protein. They were able 

 to keep several typhoid patients in approximate nitrogen equilibrium, 

 but little below the normal, upon such a high calorie diet, and this form 

 of dietary treatment has been rather generally adopted since the appear- 

 ance of their studies. 



The sparing action of the carbohydrate for body protein was mani- 

 fested by the relatively slight losses in weight experienced by their pa- 

 tients. Another, and perhaps unexpected, result was observed. The 

 toxic appearance, the "typhoid facies" of older days and accompanying 

 symptoms of toxemia were noticeably reduced in those patients who were 

 obviously benefited by the carbohydrate-rich diet. Among their conclu- 

 sions, they state: "The 'toxic' destruction of body protein, as well as 

 the destruction due to simple pyrexia in this disease [typhoid] may be 

 either prevented or compensated for." "If, as seems probable from our 

 results, the 'toxic' destruction of body protein may be prevented by a 

 large carbohydrate intake, the mechanism of this 'toxic' destruction can- 

 not be a direct [poisonous] injury to body cells and protein." 



Bacteriologically, typhoid fever exhibits several similarities to bacil- 

 lary dysentery. Both are initially intestinal infections. The dysentery 

 bacillus rarely penetrates beyond the mesenteric lymph nodes, but typhoid 

 bacilli usually invade the blood stream and may enter all the tissues. 

 From the viewpoint of bacterial metabolism, a carbohydrate rich diet 

 would be quite as much indicated to induce a reestablishment of the 

 intestinal flora, and a reformation of the metabolism of the typhoid 

 bacillus in typhoid fever as is the case correspondingly in bacillary 

 dysentery. The careful study of Torrey upon the intestinal flora of 

 typhoid patients receiving the high calorie diet indicates that there is 

 a clearly discernible change of the intestinal bacteria very similar to that 

 observed in bacillary dysentery cases fed upon a lactose-protein diet. 

 Torrey says, "On a diet consisting of a daily average of 50-100 grm. of 

 protein, 75-100 grm. of fat, and 250-300 grm. of carbohydrate, including 

 lactose, the intestinal flora tended to become converted into a fermenta- 

 tive type in which the dominant organism was Bacillus acidophilus. 

 Patients exhibiting an initial fermentative flora of the aciduric type 

 adapted themselves more readily to the high calorie diet of Coleman 

 in such patients the disease showed a marked tendency to run a mild 

 course." 



In addition to the changes noted in the types and metabolism of the 

 bacteria of the intestinal tract, there is the additional possibility that 

 a reformation of the metabolism of typhoid bacilli in the blood stream, 



