THE {NFLUENCE OF EMPROVED DIET ON CERTAEN BLOOD CONSTITUENTS 'OF MEN ANQ WOMEN WITH ACTIVE TUBERCULOSIS Thesis hr the Dara of Ph. D, MECHIGAN STATE COLLEGE Eva ‘femhwa Hwang igfié TH'nblfi This is to certify that the thesis entitled The Influence of Improved Diet on Certain Blood Constituents of Men and'Jomen hith Active Tuberculosis presented by Eva. Yen-‘nwa leang has been accepted towards fulfillment of the requirements for ELLE—degree in._ NUtl'ition Major professor DateM 2 7; /’j¢ 0-169 lit: leLUiNCr,C ‘LfiulnCVnnllflfiflftji'qul IN ELAIIJEZUnQTllIugfitj CW ""“\1 "".'.‘.‘v"..r'-~.:-‘ .1... 'r‘-.-.- “LA nun hbuum NlTn lbich TbsnnJULuulg Eve icn—hwa .‘ll (vi; iu‘Q;Ll-‘ U1 Su 'amitted to the School of Greduete otudie es of h ichiren State College of Lgriculture and applied Science in partial fulfillment of th3 requirements for tne degree of DOCTCH OF PHlLoSCinI Department of Foods and Sutrition .. .. r‘d leer l9)u x" {\L . e . .- fl \\ \' bppI‘OVBd _ J W63“ A; t \ . \\ ._ \ ._., ._ I <."' ll‘w . ,',. v ,-v lu'f'c: 1 t: Ila-111%; 11 $381.15), fil" “W ‘ ' """l " l .s w -_ 1 L‘ l I, , -~l L \l -Mw’.--“ The influence of an imnroved diet on the fasting blood content 01 hemOglobin, serum total protein, vitamin i, carotene, ascorbic acid and alkaline nhosnhatase of 19 women and 3h men with moderately advanced, and far advanced, active tuberculosis was studied. The average daily dietary intake wzs calculated and the fasting blood constituents of hemOglobin, total serum protein, vitamin n, carotene, ascorbic acid and serum alkaline nhosnhatase were deterrined for each subject during a seven-day control period, modifications were made in the regular hospital diets of the subjects so that a generous intéke of nutrients was supplied to all subjects during the exycrimcntal period which lasted for four months and was divided into three periods of six weeks each. L vitamin supplement containing vitrmin 1, ascorbic acid, thiamine, riboflavin, and niacin was given daily Purim; the exrerimeh'al periods. Lt the end of each period, a seven-day food record was obtained from each patient and the dietary intake was calculated. :lso at the end of each period a blood sample from each patient was analgzed for hemoglobin, serum protein, vitamin L, carotene, ascoroic acid and alkaline phosnhatase. Statistical analgsis indicated that there was an increase in the concentration of hemoglobin in the blood of men and women patients with far advanced, active tuberculosis during the experimental period in comparison with the control period. hean ulood hemoglobin values of patients with moderately advanced, active tucerculosis Ware conpzraole to that of healthy adults in the control period and there was no t~ ‘.‘> L " " ‘V f' 7 £510 ijn-ll‘d'CL AJT‘TCLI] r significant change during the experimental period. There was no change in mean serum protein values in the experimental periods as compased with the control period, The average mean serum vitamin L values for all groups were comparable to those of healthy adults in the control period although there was wide individual variations. no difference between the control and the 7xperi- mental periods was found for any group except for the women with moderately advanced, active tuberculosis; the mean serum vitamin l for women with moderately advanced, active tuberculosis was significantly higher in the experimental periods than in the control period. The daily dietary supplement of 150 milliframs of ascorbic acid during the experimental periods resulted in a statistically significant increase of serum ascorbic acid values in comparison with the control period. There was not a signif'cant difference between the mean serum alkaline phOSphatase values in the control period and the experimental periods for any group except for the women with moderately advanced, active tuberculosis; this group had a higher mean serum alkaline phOSphatase in the control period than in the experimental periods. There was an increase during the experimental period in the concentra- tion of the particular blood constituent for patients who had low initial values of blood hemoglobin, serum vitamin e and/or serum ascorbic acid. There was also a reduction in serum alkaline phosphatase activity during I_J the experimental period for those patients whose initial va ues were higher than for healthy adults, The concentration of the various blooi constituents at the end of the experimental perioo was similar to that of healthy ults for all patients, -2- Tm IlaFLUQ-ICE oz“ LEROVLD 131133) or; cumin DL ECU cogsrl;rusal‘s ox Rafi LED HOQQH WITH LCTIVQ TtfigmGULCSIS H" .—J V‘ '0'. ‘va VL-v r LUVE}. L(,311"i 'n . ;L‘n'.T(_inf-. Q A TJJSIJ Submitted to the School of Graduate Studies of hichiqan State College of agriculture and hpplicd Science in partial fulfillment of the requirements for the degree of DOCIOR OE PAILCSQPHI Department of Foods and Hutrition LChnCFLQDQLLNJJ The author wishes to expres her sincere gratitude to Dr. Wilma D. Brewer for her patient guidance, advice and encouragement throughout this study; to Dr. C. J. Strin er and Dr. E. W. Gentles who made available the facilities of the Ingham County Senatorium and the rLiczhi._-_}jan State dena- torium, reSpectively, for this investigation. The writer appreciates the solenoid cooperation anu invaluable assiso— ance of firs. Vivian Tranp and Lies Clive Lenderson of the staf of the Ingham County Senatorium and of hiss June Teachout and hiss Elinor Kir"hman of the nichigan State Sanatorium during the course of this experiment. Grateful acknowledgment is also due to t e men and wonen of the Ingham County and the Michigan state Senatorija who served as subjects and whose cooperation made this stud“ possitle. ‘ In addition, the author wishes to thank hrs. Janet Lee for her assistance in this study. ..\I.\l_.v _ - V.‘ v \.:'_.V. A n A A lf‘h a a A A 'l'. o L15 U? C C“. If 2/1 1‘ J IlflifiCJD'UCTIOb-“OQOOOOQo.no.00.0.0.0...coo-ooOooooQQQQOOOIOO' IbVE‘?’ OF LI’lI‘L‘LdiTUILJ-ooo--°°'°°°°°°°°°°°°°°°°°°°°°'°°'°°°° Lutrition in tuberculosis........................... olood constituents in healthy individuals and in tub 1: F3 v' Pfir‘ . (“971; mdbl‘dl“LJ*L P.5Couk/i-u................................... 1“ ' ‘.'.’3 obJVCt............................................. Experimental plan................................... Dietary recordS..................................... Blood sampling.............................-........ Chemical method..;.................................. Clil—lical recor‘dsooooooooo00.00.00.000.-0.00.00.00.00 PL‘JSUL‘l-‘S I~D§D DIEUdSIOIJOooooooooooooooooooooono0.00.0.0... Food intake of subjects: Control period.,.....,..., slood constituents of subject: Control period...... hecommended dietary modification...............,.... Influence of introved diet on food intake........... Influence of improved diet on food constituents..... Diet and tuberculosis............................... Influence of other factors on blood constituents.,.. Clinical pregrsss of the Subjects......,,........,.. sUl'ud‘AI-Y l-IGU CUBHJLUSIL/i‘:b.................................. fi".“;73;'7771i7a 011-1173 “Ambuubuo L.’.J .......................googuoonooaoo00000 V I‘erii‘JJ-Jxoocoo0..ooooooooonooaoooOooooococo-00000000000000 grculosis 10 ll 12 13 """“:.’l "‘1 il‘ ‘ .'.r\ .Lnl J1. LU." {ii-noises) .Fe daily food intake of women with active tuberculosis C) a in control and experimental perioas.,..,,,,,,,,,,,,,,,,,,,,, The distribution of women with moderately advanced, active tuberculosis according to the range of food intate.......... The distribution of women with far aovanced, active tubercu- losis according to the range of food intake................. Lverage daily food intake of men with active tuberculosis in contrOl arid e-Xper‘jmentb‘l I‘)€:rj”0£is I O O O O O O O O I O O O O O O O O O O O O O O O O O O The distribution of men with moderately advanced, active tuberculosis according to the range of food intake.......... The distribution of men with far advanced, active tubercu- losis according to the range of food intake................. The average blood constituents of women and men with active tuberculosis in the control period.......................... Summer“ of analvsis of variance of food intake for women y a With active tuoerculOSis between control and experimental periOdSOO.OCCOOOOOOI...00.0.0.0....00....0.00.0.0....0000... Summary of analysis of variance of food intaxe for men with active tuberculosis between control and experimental periods average fasting blood constituents of women watients with active tuberculosis in control and exrerimental period...... Summary of analysis of variance of blooc constituents for women patients with active tuberculosis between control and exlherilnental I’eriOCE'SOOOOOOOOOOOICOOOOOCOOOOOOOOOOIIOOOO0.... Average fasting blood constituents of men patients with active tuberculosis in control and experimental periods..... Summary of analysis of variance of blood constituents for man patients with active tuberculosis between control and ewerjjnen-tal periOdSOOOOOOQOOOOOOIOO000.00.00.00000000000000 3l 32 ‘UJ \U bl h2 73 "*3 \J 1 7:) 79 LIST UF TLBLLS - Continued TABLE 1h 17 18 19 21 The average concentration according to age of certain blOod constituents of women with moderately advanced, active tuberculosis.‘0.0.0.0....000000000000OOOOOOOOOOOOOOOOCOOOOCO The average concentration accordinf to age of certain blood constituents of women with far advanced, active tuberculosis The average concentration according to age of certain blood constituents of men with moderately advanced, active tub£3rCUlOSiSIOO0.0.00.00000000000000O.0.....l.0...........0 The average concentration according to age of certain blood constituents of men with far advanced, active tuberculosis. Variation of blood constituents of tuberculous women with fever.....................O..OOOOOQOOOOOOCOOOII0.0.0.0...00 Variation of blood constituents of tuberculous men with feverOOOOOOOOOOOOOCOOIO00......0000OOOOIOOOCOOIOOOOOOOOOOO. Summary of analyses of blood constituents data for women patients with active tuberculosis between moderately and far advanced stayes........................................ Summary of analysis of variance of blood constituents for men patients with active tuberculosis between moder tcly and far advanced staveS.................................... \ v-.-1 10¢ 1134 11s \J’I LISE OF FIGUASS Changes in blood hemoglooin of individual patients with lOI‘IiI‘LiJUialVb-1U’3S....o..............o..o................. Graph showing relationship of serum vitamin L and daily vitamin A intake of women with active tunerculosis,,,,,.,, Graph showing relationship of serum vitamin A and daily vitamin A intake of men with active tuberculosis.......... Changes in the serum vitamin A of indivioual patients wit‘lllOVIirfi‘tj-alV8111€BCOOOOOOOOOOIO...OOOOOOIOOOCOOOIOOOOO Regression of serum ascoroic acid upon ascorbic acid intake for women patients with active tuberculosis........ Regression of serum ascorbic acid upon ascorbic acid intaxe for men patients with active tuberculosis.......... Changes in the serum ascorbic acid of individual female patients with low initial values,.,....,.................. hanges in the serum ascorbic acid of individual male patients with low initial value........................... Changes in the serum alkaline phOSphatase of individual patients with hith initial v91ue.......................... U: {:21 93 9h 97 99 THd INFLUENCE OF IMPROVED DIET ON CfihTAlN BLOOD CONSTITUENTS OE hLN AND WOMEN WITH LCTIVQ TUBfihCULOSlS Although a well balanced diet has long been considered an aid for the treatment of patients with active tuberculosis, few controlled studies of the relationship of diet to tuberculosis have been reported. Different approaches to the study of nutritional status of tuberculous patients have been used in research at the Ingham County Sanatorium by the Foods and Nutrition department at Michigan State College. In a study of the dietary habits of women with active and arrested tuberculosis, Brewer and co-workers (19b?) found that a high percentage of patients with active and arrested tuberculosis had average intakes of nutrients less than the amounts recommended by the Food and Nutrition Board of the National Research Council (1953). The metabolism of thiamine, riboflavin, calcium, phosphorus and nitrOgen of tuberculous patients also has been reported from this laboratory. The utilization of nitrogen, phOSphorus, riboflavin and thianine by women with.moderately advanced, active tuberculosis was similar to that of healthy women, but a higher calcium intake was reguired for calcium equilibrium by the tuberculous patients than by healthy women (Brewer, gt __., l9h9; 195L). I Biochemical analysis of the blood has been used as a tool for evalur ation of the nutritional status of tuberculous patients by Getz and co- workers (l9hl, l9h3, l9hb). These workers observed that tuberculous patients had lower blood values for ascorbic acid, serum albumin, hemoglobin, vitamin A, carotene and serum calcium than healthy persons. Cetz at al. (1951) also studied the relation of nutrition to the develOpment of tuberculosis over a period of five years and reported that all cases of clearly active disease occurred in persons who had markedly low blood values of vitamin A and ascorbic acid before the develOpment of tubercu— losis. Shaw and co-workers (1950) studied the dietary intake and blood con- tent of hemoglobin, vitamin A, carotene, ascorbic acid, alkaline phos- phatase and total protein of 25 tuberculous patients and found an inverse correlation between severity of the tuberculous symptoms and the anounts of these constituents in the blood. However, there was little correlation between the food intake of the patients and blood values of vitamin A and ascorbic acid. Although various workers have found low blood values for ascorbic acid, vitamin.A, serum protein and hemoglobin among tuberculous patients, existing evidence does not indicate whether the low blood values may be associated with the disease process or whether the low blood values reflect only the nutritional status of the patients. This study was planned to investigate the possible influence of an improved diet on the amount of ascorbic acid, vitamin A, serum protein, hemoglobin and alkaline phos- phatase in the blood of tuberculous patients. REVIHH OE LITJRATUnE nutrition in tuberculosis It is universally accepted that poor nutrition is one of the major factors in the develOpment of tuberculosis. The well known study of Faber (1938) indicated that there was an increase in mortality from tuberculosis in Denmark following the first world war, and that the nutrient which was most generally lacking in the diet was protein. Protein nutrition.plays an important part in building resistance against infectious diseases including tuberculosis (Cannon,l9h5). Sako (l9h2) and Dubos at El. (l9h8) found that mice kept on low protein diets showed a marked decrease in survival time after inoculation with mammalian tubercle bacilli. The disturbance of the protein fraction in the blood of tuberculous individuals is another evidence of the relationship between protein nutrition and tuberculosis. According to Siebert at al. (19h?) and Marche at al. (1950), a decrease of serum albumin is usually accom- panied by a rise in serum globulin, and a lowering of the albumin-globulin ratio in serum is observed frequently in tuberculous patients. Johnston (19h?) stated that the diminishing ability of the adolescent to retain nitrogen may result in the lessening of resistance to tuberculosis when the nitrOgen intake is not adequate. The inactivity of the individual at bed rest may also be a factor which influences the protein metabolism of the tuberculous patient. From nitrogen balance studies of six healthy adults at bed rest for short periods of time, Miller and co-workers (l9h5) concluded that bed rest alone caused a negative nitrOgen balance in a healthy person even when the caloric intake was adequate and the protein intake was reasonably high. It is true that the subjects studied by Miller and co-workers were studied for only short periods of time and there_was no indication whether adaptation would result after prolonged bed rest. In a study of activity in relation to the retention of nitrogen and calcium in adolescence, Johnston (1950) found that nitrogen retention of six tuberculous children without fever declined after prolonged bed rest but was improved when the children were permitted moderate activity. McCann £1922) studied the nitrOgen metabolism of tuberculous patients and found that nitrogen eQuilibrium occurred at about the same intake of dietary protein for moderately advanced, active tuberculous patients as for healthy persons. Similar findings were reported by Brewer §t_al. (19h?) who recommended a daily intake of 80 grams of protein per day for women with moderately advanced, active tuberculosis as an intake which would permit some retention of nitrOgen and still represent an amount of food acceptable to the patients. According to Sedgwick (l9h6), an intake of 85 to 125 grams of protein daily was recommended by the California State Department of Public Health for tuberculOus patients. Pottenger and Pottenger (l9ho) advocated an even higher intake of 225 grams of protein daily for tuberculous patients. Calcium metabolism also appears to be of particular importance in tuberculosis. Getz and co-workers (l9hL) reported low values of calcium and phOSphorus in the blood of advanced tuberculous patients. .Brewer and co-workers Ll9Sh) concluded, from their study of the calcium metabolism of six.moderately advanced, active tuberculous women, that the daily calcium intake required for calcium equilibrium for tuberculous patients was greater than that required for equilibrium by healthy women. Johnston (l9h7, 1950) stated that the diminishing ability of the adoles- cent to retain calcium may result in the lessening of resistance to tuberculosis and in turn, may retard the healing of tuberculosis when the intake of calcium is not adequate. Considerable information relative to vitamin.n nutrition in tubercu- losis has resulted from the studies of Getz and co-workers. Getz (1939) found that 53 percent of a group of tuberculous patients had vitamin.A deficiency as measured by a biophotometer. In l9h3 and l9hb he reported that vitamin.A deficienCy’ as evidenced by low blood content, was positively related to the severity of the tuberculosis. An inverse re- lation between the development of tuberculosis and the blood concentration of vitamin.£ was reported by Getz in 1951. Recently, Cetz (l95h) stated that night blindness is common among tuberculous patients and that the total content of vitamin.A in blood is always lowered in advanced tubercu- losis, although not necessarily in minimal cases of tuberculosis. A possible explanation of low vitamin.A blood values in tuberculosis may be poor adsorption of vitamin A in the intestinal tract of tuberculous patients, particularly when intestinal tuberculosis also is present. Breese, Watkins and McCoord (l9h2) studied 17 patients with active pulmonary tuberculosis and intestinal symptoms and found that the ability of experi- mental patients to absorb vitamin A was low. When a known amount of O\ vitamin A in the form of concentrated fish liver oil was given to the patients orally, the maximum rise of vitamin.A in their blood was approxi- mately one-half that of healthy individuals. The conversion of carotene to vitamin.A may be depressed in tuberculosis since Getz (195h) stated that a low content of vitamin A usually accompanied a relatively high content of carotene in the blood of tuberculous patients. Relatively little research has been directed toward the metabolism of factors of the vitamin B complex in tuberculosis. Farber and.Miller (l9h3) found that 25 percent of their hOO patients with active tubercu— losis had riboflavin and niacin deficiencies and there appeared to be a correlation between the nutritional status of the patients and the severity of the disease. The advanced tuberculous patients frequently had multiple vitamin deficiencies such as vitamin.A, vitamin K, ascorbic acid, niacin and riboflavin although thiamine deficiency was rare. Conversely, however, Higgins and Feldman (l9h3) found that diets which contsined significantly low amounts of thiamine and riboflavin did not affect the resistance of white rats to the infection of avian tubercle bacilli. Also, Brewer at El. (l9h9) studied the riboflavin, thiamine and nitrOgen metabolism of six women with moderately advanced, active pulmonary tuberculosis and found that the thiamine and riboflavin metabolism of the tuberculous patients was similar to that of the healthy college women. It is possible that the occurrence of riboflavin deficiency in the patients studied by Farber and Miller reflected a poor nutritional state of patients from low socio- economic levels rather than a metabolic disturbance which resulted from the disease. A combination of vitamin C deficiency and active tuberculosis caused a significant shortening of the survival period in guinea pigs and a decrease in body weight (Greene and co-workers, 1936) from that of healthy animals. The lowering of resistance was possibly due to a reduction of phagocytic activity of blood leucocytes in vitamin.C deficiency (Cotting- ham and Mills, 19L7). According to Chiang and Lan (l9h0), the tuberculous patients in China had lower blood and urinary ascorbic acid values than healthy persons. These workers found also that some of the advanced cases showed evidence of diminished amounts of ascorbic acid in body tissues by saturation tests. Similar results have been found in this country; Heise gt al. (1936) and Sweany at al. (l9hl) showed, by means of tissue saturation tests with patients with tuberculosis, that there was a correlation between severity of the disease and degree of tissue saturation with vitamin.C. Kaplan and Zonnis (l9h0) studied ascorbic acid blood values of 2h0 patients with tuberculosis. They found a correlation between stage of disease and ascorbic acid in the blood. Getz EE.E;° (l9hh) also found low blood values of ascorbic acid in tuberculous persons. However, the values they reported indicated little correlation between stage of disease and ascorbic acid ceficiency. NO correlation between the severity of tuberculosis and the degree of ascorbic acid deficiency was reported by Roy at al. (l9hl) and Hurford (l9h8). webb and co-workers (l9h6) determined the blood ascorbic acid content of 150 patients with all stages of tuberculosis who were on a supplement of 100 milligrams of ascorbic acid daily. Again there was no correlation between serum content of ascorbic acid and degree of tuberculosis. ‘With this amount of dietary supplement, however, the average blood ascorbic acid values for all patients were well above 1.0 milligrams per 100 milliliters of serum. Brewer (l9h9) reported that the urinary excretion of ascorbic acid follow- ing a test dose by women with active tuberculosis was similar to that by healthy women when a dietary supplement of 100 to 300 milligrams of ascorbic acid was given daily. In contrast, the urinary excretion of a test dose of ascorbic acid by women with active tuberculosis was very low when there was no dietary supplement of ascorbic acid. Getz (l9Sh) stated that tuberculous patients with fever had low average ascorbic acid values in the blood and that it was almost impossible to bring body tissues to the saturated state even with a large amount of ascorbic acid. He also stated that ascorbic acid has been found repeatedly in the urine of tuberculous patients in combination with various degradation materials and products of tissues destruction. A high ascorbic acid intake may-there- fore be necessary for the detoxification of toxic materials from the disease organisms. Gorden and Flanders (1931) reported from a dietary survey, that tuberculous patients consumed about l,h00 calories in comparison with 2,500 calories daily for a healthy person. Brewer and co-workers (l9h9) studied food habits of women patients with active tuberculosis and found that the caloric intake of the patients was less than that of healthy women. Since the body weight of the tuberculous patient may decrease considerably during the development of the disease, the diet should supply enough calories to provide for weight gain for the underweight patients and also to protect the utilization of protein by all of the patients. In general, dietary practices for the tuberculous patients have been based on studies of the food reguirements of healthy people since there has not been sufficient research to support Quantitative estimations of the nutritional requirements of tuberculous patients. The need for generous quantities of protein, calcium, vitamin.h and ascorbic acid in the diets of tuberculous peOple, however, has been stressed (Getz, 195h; Brewer, 195L). Dietary allowances which have been recommended by the California State Department of Public Health for tuberculous patients include 85-125 grams of protein, 0.8 grams of calcium, 12 milligrams of iron, 5,000 International units of vitamin A, 1.5 milligrams of thiamine, 2.2 milligrams of riboflavin, 15 milligrams of niacin and 100 to 125 milligrams of ascorbic acid and an intake of 2,500 calories (Sedgwick, 19u6). Blood constituents 33 healthy individuals and in tuberculosis It has been only in recent years that microchemical methods have been develOped for the measurement of blood constituents. These methods have provided further information concerning the nutritional status of groups of peOple and have aided in the identification of cases of border line nutrition. For example, a definite relationship between the clinical picture of an early deficiency and laboratory determination of vitamin content in the blood has been reported by muffin, Cayer, and Perlzweig (19th). A consistently significant relationship between ascorbic acid intake and blood content was found by Putnam gt El. (19L9). Also, Narrow and co-workers (1952) reported that the relationship between intakes and 10 serum values of ascorbic acid, vitamin.A and carotene was highly sig- nificant. Thus, the concentration of certain substances in blood, urine and other biological fluids reflect the recent dietary intake of related dietary factors. hemoglobin. nemOglobin concentration in the blood is a widely used index of nutritional status. A number of dietary components including iron, cobalt, COpper, various amino acids and factors of the vitamin B complex are required simultaneously to maintain normal f nationing of the hematOpoietic system Cartwright, l9h7). StorvickIEEIEL. (1951) found that there was a highly significant relationship between vitamin A in the blood and the hemoglobin concentration of the blood of selected pogulation groups of adolescents in Oregon. Blood hemoglobin values may be affected by various factors other than diet. These include age, sex, diurnal variations, seasonal variations and socio-economic factors. .An average of 1h grams of hemoglobin per 100 milliliters of blood for adult females and 16 grams for adult males has been used as standards for healthy peOple (Osgood, 1935; Wintrobe, l9hé§ hchllister at 31., 19h?; Beck 33 21-: 1951, and itegee ESE filo, 1952). Pedly twin) and Ohlson gt 3;. (l9hh) found that the average concentration of hemOglobin for healthy college women was 13.5 grams per 100 milliliters of blood. haworth and co-workers (1952) reported that the mean hemoglobin value was 13.58 grams per 100 milliliters of blood for young college women on an institutional diet. Sheets and co-workers (l9hL) found that the average hemOglobin value for men was 1h.6 grams per 100 milliliters of blood and that the average hemOglobin value for women was 12.h grams per 100 milliliters of blood in the study of hemoglobin concentration of college men and women. A lower average value of 13.5 grams of hemoglobin per 100 milli- liters of blood for men and 12.7 grams of hemoglobin per 100 milliliters of blood for women was reported by Pett 32 £1. (l9h6) in a study of 3,1h8 peeple in Canada. HemOglobin values of 10.1 to 12.0 grams per 100 milliliters of bloOd were considered to be indicative of moderate or slight nutritional anemia and hemOglobin concentrations below 10.0 grams per 100 milliliters Were considered indicative of severe anemia by Kcucher at al. (19h8). The influence of age on hemoglobin was reported by several investi- gators. Guest (1938) found that infants have a high mean level of hemo- globin from birth to ten days, 19.0 grams per 100 milliliters of blood. ht two months of age, the mean was only 12.1 grams, and at one year of age the mean hemoglobin value had fallen to 11.0 grams per 100 milliliters. Thereafter, the mean hemoglobin value increased. Mugrage and Andresen (1936) hack 33 _a__1_. (19M) and Kauc‘ner 33 Egg. (19118) found an increase in mean hemOglobin values for boys and girls from 11.6 grams per 100 milli- liters of blood at one year to 1h.5 grams per 100 milliliters of blood in the twelfth or thirteenth year. Thirteen years is the age at which hemo- globin values for males and females begin to diverge. Girls maintain relatively constant values into womenhood. hemoglobin values for boys increase continuously to a.mean concentration of 16.6 grams per 100 milli- liters of blood at ages of seventeen to nineteen.years. 12 Diurnal variations in hemoglobin were studied by Brown and Goodall (19h6) who found the hemOglobin values varied as much as 1.0 grams per 100 milliliters of blood for an individual during the period between 9:00.AJ£. and 6:00 P.M. The average variation during this time was 0.5h grams per 100 milliliters of blood. Johnston (19h5) however found that the blood hemoglobin concentrations varied relatively little during the course of the day. 1 hack at 31. (19b1) andjhegee 23.3i- (1952) have demonstrated that peOple from a higher socio-economic level tend to have higher hemoglobin concentrations than those from a lower socio-economic level. Tuberculous patients have been found to have a lower content of hemo- globin in the blood than healthy individuals; this has been.particu1arly true for patients with far advanced, active tuberculosis (Getz et 31., 19th, 19h93 Shaw'gt 31., 1950). According to Getz at 21. (19bh), approxi- mately to percent of the male tuberculous patients which he studied had hemoglbbin values less than.12.h grams per 100 milliliters of blood. Getz 919 El- (19th) 8180 reported that statistically significant relation-— ships were observed between hemoglobin and other blood constituents in- cluding plaSma vitamin A, ascorbic acid, carotene, serum albumin, albumin- globulin ratio and serum phosphatase. Getz found too that hemOgiobin values were related to the severity of tuberculosis. Thus, other nutri- tional deficiencies may be expected to be associated with low hemOglobin values in the tuberculous patient. Serum protein. The range of total serum protein for healthy adults has been found to be from six to eight grams per 100 milliliters of serum. 13 Values for serum albumin range from h.0 to 5.5 grams and values for serum globulin range from 2.0 to 2.5 grams (Bruckman et 31., 1930; Youmans 3:9 3:5,, 1915; idamson 5-33 3%., 19M}; I-iilan 933 31., l9h6). The concentra- tion of total serum protein is influenced by the albumin and globulin content in the blood. Peters and Eisenman (1933) stated that the measure- ment of the total serum protein was not as significant as measurements of the serum albumin and serum globulin for evaluation of protein nutrition since, in certain diseases, an increase in serum globulin may mask a corresponding reduction in serum albumin. In a_study of 1,200 subjects, Youmans 33 31. (19h3) found that 89 percent of the subjects with hypoalbuminemia had a concentration of total serum protein within the range from six to eight grams per 100 milliliters of serum. There was no correlation between the dietary intake of calories or protein and serum protein. This study indicated that the concentration of serum protein may be relatively constant for a long period of time even under conditions of dietary deficiency. The disturbance of the protein fraction in the blood of a.tuberculous individual was observed by Seibert 23': E‘l- (1%?) and I-Zarche 213. _e_:_L_. (1950). A slight rise of gamma-globulin in the serum and a decline in serum albumin occurred in the early stages of tuberculosis. As the disease progressed the alpha-globulin fraction simultaneously increased. In the mean time, the serum albumin showed a‘further decrease. These changes were more in- tensified in far advanced tuberculosis. There was no difference in the blood of the healthy person and the tuberculous patient as far as the total serum protein is concerned Lil (Getz gt al., 19Lh; Shaw at al., 1930). however, a considerable re- duction in the albumin-globulin ratio has been found in tuberculous patients. If the disease is well advanced, a decrease of total serum protein might be expected also (Getz at 31., l9h9). Vitamin §_and carotene. Ranges of hO to 200 International units of vitamin.A and 50 to hOO micrograms of carotene per 100 milliliters of plasma have been reported for healthy people (Kimble 1939; Abel at 31., l9hl; Youmans §t_al,, l9hh; Adersbery at 51., 19L5; Anderson and.Milam, l9h§3 harris at al., 19h6; and Iiengst and Shock, l9h9). Bessey et a1. (l9h6) has suggested that a range of 30 to 70 micrograms of vitamin.A per 100 milliliters of serum represented an adequate nutritional state with reapect to vitamin A. In the interpretation of his data, Getz 23 g}., (l9hh) selected 110 International units of vitamin A per 100 milliliters of plasma and 110 micrOgrams per 100 milliliters of plasma for carotene as "normal" values. A sex difference in vitamin A and carotene content of the blood was reported by Kimble in 1939. In general, the average value for vitamin A in the blood of males was higher than the average value for females. The average for the males was 127 International units per 100 milliliters of plasma; the average value for the females was 91 International units per 100 milliliters of plasma. 0n the other hand, the average carotene con- tent of the plasma for males, 166 micrograms per 100 milliliters, was considerably less than the average carotene content of 157 micrograms per l00 milliliters of plasma which was found for females. Sex differences in vitamin.A and carotene values of the blood were reported also by Abels 33.3;. (19u1) and Storvick €2.2l- (1951). Anderson.§t El. (19b5) found that the vitamin A values in blood of negro peOple were less than the vitamin A values of blood of white persons of both sexes.. no age‘ differences in serum content of vitamin.£ were found by Iiengst (l9h9). The vitamin.A content of the blood is fairly stable and is not affected by the addition of small amounts of vitamin A and carotene in the diet; however, blood carotenoids decrease rapidly over a period of one week when a diet low in carotene and vitamin.A is given (Brenner and Roberts,l9h3). ‘Malnourishment and febrile disorders have been associated frequently with low serum vitamin.A. May and co-workers (l9h0) found that low blood values of both vitamin A and carotene occurred in cases of acute infection associated with fever. A positive correlation between serum vitamin A and other blood constituents such as carotene, ascorbic acid and hemOglobin was found by Storvick gt El. (1951) in studies of selected pOpulation groups of adolescent in Oregon. Getz gt_§l. (l9hl, l9b3) stated that in blood of recently diagnosed tuberculous patients, vitamin A was lower than in the blood of those who have been receiving treatment for some time. The percentage of tubercu- lous patients who had blood vitamin.A values which were considered to be within a pathological range (less than 30 micrograms per 100 milliliters of serum) was greatest for the patients with far advanced, active tubercu- losis and least for the group with minimal tuberculosis. Moore (1937) found Cthat IOW'V vitamin A values in plasma occurred in tuberculous patients with fever. But Gets (19th) stated that the 16 average vitamin.A in plasma was only slightly decreased in the tuberculous patients because of fever. A low plasma carotene in the tuberculous patients is not often found unless the stage of the disease is far advanced. Values of carotene in the blood similar to those for healthy peeple may be maintained in the tuberculous patients even when the values of vitamin.A in the blood are abnormally low (Getz,l95h). This condition would indicate that the ability of the body to convert carotene to vitamin A is affected. Ascorbic acid, Much research has been done on blood ascorbic acid, and there is perhaps better knowledge of the ranges of blood ascorbic acid in health and in disease than of other vitamins. Ioumans (l9h9) found that the concentration of ascorbic acid in blood of healthy persons was above 0.7 milligram in 100 milliliters of serum. Values in the range of O.h to 0.7 milligram per 100 milliliters were considered to represent borderline nutrition with reSpect to ascorbic acid. Values below 0.5 or 0.h milligram per 100 milliliters of serum indicated that tissue stores of the ascorbic acid were deficient. Similar interpretations of ranges of blood ascorbic acid values have been reported by Qyorgy (19h2) and Johnson (lauS). The dietary intake of ascorbic acid has been found to be related significantly to the blood content of ascorbic acid (Kyhos gt 31,, 19th; Johnston gt 2%» l9h6; Putnam gt al. l9h9). A rise in serum ascorbic acid occurred immediately following a test dose of ascorbic acid; the peak value was reached about three hours after the test dose (Kyhos gt 31. l9bh). 17 According to Johnston (19L6), a marked change in the intake of ascorbic acid is also reflected in the fasting blood plasma.ascorbic acid content in a period of only one or two weeks. Values for ascorbic acid, vitamin A and carotenoids in the serum were significantly correlated in the study reported by Storvick at al. (1951). no correlation was found between ascorbic acid and hemOglobin concentration by hchellan at al. (l9hé),.hoyer et al. (l9h8) and Storvick g: 3;. (1951) . Low'blood ascorbic acid values have been found in tuberculous patients by numerous investigators. Getz at al. (l9hl and 1951) found that 75 per- cent of their tuberculous patients had less than 0.6 milligram of ascorbic acid in 100 milliliters of blood. In a study of 2h0 patients with chronic pulmonary tuberculosis, Kaplan (l9hC) showed a correlation between the degree of ascorbic acid deficiency and the stage of develOpment of the disease. The average‘values of ascorbic acid in lOQ milliliters of plasma from control, moderately advanced, active and far advanced, active tubercu- lous patients were 0.78 milligrams, 0.70 milligrams of O.h2 milligrams reapectively. Similar results also were reported by other workers who have found that the depression of ascorbic acid in the blood of tuberculous patients was related to the severity of the disease (hiese andliartin, 1936; Sweany at al., lthj and Chang and Len, lQhO). According to Getz (l9hl), tuberculous patients who had received treatment usually had a higher content of ascorbic acid in the blood than recently diagnosed cases of tuberculosis. Webb, Storvick and Olson (l9h6) on the other hand, did not find that the serum content of ascorbic acid was related to the degree or extent of tuocrculosis. haplan (lQhO) found that the concentration of ascorbic acid in blood plasma in most of the patients could be 'Cised to "normal" values by oral administration of synthetic ascornie acifi with a dosage of 200 milligrams daily from one to six months. no significant difference in the ascorbic acid content of UlOOd of negro and of white persons has been found in tuberculous patients (detz, l9hl). Female patients of both ne ro and white peeple showed a higher serum ascorbic acid than male patients. in regard to the ov~rwcight patients, it has been repo ted that 26 out of 37 subjects showed low ascorbic acid in the plasma (cetz, lth). Low ascorbic acid values in blood were found in the tuberculous patients with fever and softening of lung tissue and it was found to be almost impossiele to saturate the O F. L. tissues of these patients even with large Quantities of ascoreic a Serum alkaline phosp;:tase. The function of serum alkaline phos- A .L t“ phatase is the release of incr' nic phosphorus from organic phOSphoric acid esters (sodenshy, 193L). nocison and Seames (l92h) believed that serum alkaline phOSphatase was important in promoting ossification through deposition of calcium phOSphete from soluble calcium salts of phOSphoric ester which was present in blood. high serum alkaline phOSpnatase values are observed in early rickets and hypovitaminosis D, and the serum alka— line phOSphatase is probably diffused from the osseous tissue (sedansky, (193L). The range of serum elk: ine pLOSphatase in the human adult has been reported as 0.6 to 2.3 nitrOphenol units (geese; and Lowry, lids) or l9 1.5 to h.0 Bodansky units (hedansky and Jaffe, l93h); in children, the range of serum alkaline phOSphatase had been reported as 2.8 to 7.7 nitrOphenol units (Bessey and Lowry, 1916) or five to 1h Bodansky'units (Bodansky and Jaffe, 193w . no significant change in serum alkaline phOSphatase in healthr per- sons after 18-hour fasting and a high protein diet or a high fat diet has been found by Bessey at El. (19hé). Getz gt 3;, (19L?) and Shaw et 3;. (1930) reported that the concentration of serum alkaline phosphatase in the blood of tuberculous patients was similar to that of healthy persons. 2O EXPLRIMENTAL PROCEDURE Sub'egts The subjects in this study consisted of 53 hOSpitalized patients with active tuberculosis; thirty-one of the subjects were patients at the Ingham County Sanatorium, Lansing,.Michigan and 22 were patients at the Michigan State Sanatorium, howell, Michigan. The subjects, classified according to the degree of tuberculosis were: ten men and twelve women with.moderately advanced, active tuberculosis and eight men and one woman with far advanced, active tuberculosis at the Ingham County Sanatorium; twelve men and four women with moderately advanced, active tuberculosis and four men and three women with far advanced, active tuberculosis at the Michigan State Sanatorium. According to age and sex, the subjects were as follows: thirty-four male subjects ranging in age from 18 to 68 years and 19 female subjects from 15 to 55 years. among 53 subjects, there were seven negroes (four males and three females) and L6 white persons. All patients who were selected as subjects had positive sputum reactions. an attempt was made to select only those patients as subjects who were expected to require sanatorium care for at least four months. Prior to the beginning of this study, streptomycin had been given to all subjects; however, four individuals were allergicf to the drug and the treatment had been dis- continued for them. Streptomycin was continued for the rest of the patients throughout the study. Chest x—rays were taken at three-month 21 intervals. During this time, three subjects received thoraCOplasty and lobectomies were performed on six subjects. Experimentalyplan This investigation was begun in October, 1952 at Ingham County Sanatorium and in may, 1953 at the Michigan State Sanatorium. The study was terminated in December, 1953. A personal history of food likes and dislikes and the customary pattern of eating was obtained during the first interview with each patient. A seven-day diet record also was collected from each subject. During this seven-day period, blood samples Were obtained from the sub- ject in the fasting state for the analysis of blood hemOglobin, total serum protein, vitamin A, carotene, ascorbic acid and alkaline serum phOSphatase. Thus, the food intake and blood constituents were determined for each patient on the customary hOSpital routine. This represented the control period for the individual patient. after the control period, modifications were made in the diet to improve the dietary intake of individual patients. All subjects were encouraged to eat all protein foods such as meat and cheese which were served on the hospital tray. One or more eggs for breakfast and at least four glasses of milk were provided for each patient daily. Vitamin tabletsl which contained 5,000 International units of vitamin A, 1,000 International units of vitamin D, 2.5 milligrams of thiamine,2.5 milligrams of riboflavin, 50 milligrams 1Abdel, No. 218, Parke, Davis a 00., Detroit of ascorbic acid, 20 milligrans of nicotinamide, five milligrams of pantothenic acid, 0.5 milligrans of pyridoxine, one microgram of vitamin BIZ: and 100 milligrams of ascorbic acid were also given to each subject daily. One serving of beef liver was added to the usual heapital diet weekly throughout the study. Two subjects who could not eat meat and liver were given a protein supplement1 and twelve milligrams of iron2 daily. At six-week intervals, seven-day food records and fasting blood samples were obtained from each subject for a period of four months. Patients were visited by the author once a week during this time and a dietary recall record was obtained for the day previous to the visit. The medical history of each subject was examined at the end of the experimental period. Certain irregularities develOped during the process of the experi— ment. One of the women with moderately advanced, active tuberculosis transferred from Ingham County Sanaterium to hichigan State Sanatorium at the end of period I and another was discharged to her home in period III. 0f the 15 women in this group who commenced the study, 13 continued throughout the three experimental periods. There were four women patients with far advanced, active tuberculosis at the beginning of the investigation. One patient died immediately after period I. This was the patient who formerly had been studied at Ingham County Sanatorium as a patient with moderately adv need, active 1'Protenum,head Johnson.a 00., Evansville, Ind. ‘3 “‘Ferrous sulfate, No. 7, Eli Lilly & 00., Indianapolis R} V J tuberculosis and then transferred to Michigan State Senatorium. When this study was initiated at Michigan State Sanatorium, the degree of tuberculous involvement for this patient was clasSed as far advanced. She participated again in the experiment an was studied during another control period and the first period preceding her death. Of 22 moderately advanced, active tuberculous men patients, 16 cooperated throughout the entire study. Two of the other patients had surgical treatment in period I; one of these c00perated during period II but left the sanatorium in period III. Two patients left the sane- torium against medical advice in period II. Another patient had an Operation in period II but resumed cooperation with the experiment in Of 12 men patients with far advanced, active tuberculosis, only seven Were able to participate continuously until the end of this in- vestigation. One patient had an Operation in period I but rejoined the experiment in period III. Two men left the sanetorium against medical advice in period II, and two left the senatorium against medical advice in period III. Dietary records The nutritive values of the diets wore calculated according to the table of food values published by Donelson and Leichsenring (1951). Elood sampline A fasting venous blood sample was taken from the forearm of each subject by venipuncture; the blood was drawn into a syringe and then {\D g- +_ transferred to a fifteen milliliters centrifuge tube. Samples ior the etermination of hemoglobin were taken immediately and the remaining‘ blood was allowed to clot for thirty minutes, The blood then was centri- fuged and the serum was removed. In order to protect the ascorbic acid from possible destruction, an aliQuot of serum was frozen with dry ice, taken from the hospital to the laboratory in the frozen state, and kept in frozen storage for the determination of vitamin L, carotene, ascorbic acid and serum alkaline phOSphatase. another aliquot of serum, which was not in the frozen state, was used for the determination of serum protein as soon as the serum samples reached the laboratory. Blood hemo- globin was determined within four hours after the sample was collected. Chemical method The blood hemoglobin values were determined by the alkaline hematin method (Sanford and Sheard, 1930) with the use of a photelometer.l Duplicate blood samples of twenty cubic millimeters were diluted with ten milliliters of 0.1 percent sodium carbonate in a fifty milliliter flask. The percent transmission was measured on the photelometer; the photelometer was adjusted to 100 percent transmission with distilled water. Serum protein concentration was measured from a ten cubic millimeters serum sample by the method of Lowry and Hunter (1915) which applies the gradient principle for the measurement of specific gravity. The Specific gravity of the serum was determined from a graph showing the position of rest of drOplets of potassium sulfate solutions of known densities. 1 Cenco-Sheard-Sanford photelometer, Central Scientific Co. The carotene and vitamin A values of the serum sample were determin- ed by the micro-method of Bessey, LOWI'y and Brock (19M) . The blood serum was saponified with alcoholic potassium hydroxide and the carotene and vitamin A were extracted with a mixture of one volume of kerosene ‘ and one volume of xylene. The Optical density of carotene was measured 1 and the at a wave length of tee millimicrons with a SpectrOphotometer, Optical density of vitamin A was measured at a wave length of 328 milli- microns. The sample then was removed to a soft glass tube and irradiated under an ultra violet lamp2 in order to destroy the spectral absorption of vitamin A at 328 millimicrons; the Optical density of the irradiated solution was measured at 328 millimicrons to obtain an estimate of the compounds which interfere with vitamin.h at this wave length. The con— centration of carotene and vitamin.A was expressed as micrograms per 100 milliliters of serum. analyses of carotene and vitamin A were made in triplicates and 200 cubic millimeters Of serum was used for each sample. Standard solutions of vitamin A acetate and beta-carotene were used to check the procedure for the determination of serum vitamin.A and serum carotene respectively. Ascorbic acid was determined by the micro-method of Lowry, Lepez and Bessey (l9h5, l9b7). This method depends upon the quantitative de- velOpment Of a colored product of phenylhydrazone when dinitrOphenyl- hydrazin reacts with oxidized ascorbic acid (dehydroascorbic acid). One hundred cubic millimeters of serum were used for each determination. 1 Beckman SpectrOphotometer, Model DU, Central Scientific Co. 2 B-hh lamp, General Electric Co. Pa O\ The Optical density of the phenylhydrazone was measured at a wave length of 520 millimicrons and the concentration of ascorbic acid in the sample was estimated from a standard curve prepared from known concentrations of ascorbic acid which were treated in a manner similar to the serum. The activity of serum alkaline phosphatase was determined by the method of Bessey, Lowry and Brock (l9h6), using sodium para—nitrOphenyl phOSphate as the substrate for the enzyme. The Optical density of the enzyme-released parapnitrOphenol was measured by using a spectrOphotome- terl at_a wave length of th millimicrons. Cne nitrOphenol unit is defined as the amount of phOSphatase activity per liter of serum which is reguired to liberate one millimole Of nitrOphenOl per hour from sodium para-nitrophenyl phOSphate under the Specific conditions of the test. A ten cubic millimeters serum sample was used in each determination. Clinical records Information was Obtained concerning body weight, and height, fluctu- ation in body temperatures and X-ray findings from the clinical records and medical histories of the patients. 1 Beckman SpectrOphotometer, Model DU, Central Scientific CO. RESULTS AND DISCUSSION Food intake of subjects: Control period The nutritive value of the seven-day dietary records was calculated according to the table of food values published by Donelson and Leichsenring (1951). Although the crlculated values are not as accurate as determination of food value by direct chemical analyses, this method has been used satisfactorily by several nutritional r search laboratories (Ohlson _e_t_ _a_J___., 19M}; Brewer 33 31., 19149; Dieckmmnn 23 _a_l_., 1951) for estimation of the food intake of groups of individuals. The average food intake of patients from Ingham County Sanatorium was comparable to that of the patients from Michigan State Sanatorium during the control period. Statistical analyses by the Fisher "t" test indicated that there were no significant differences between the two sanatoria in the average intake of any of the calculated nutrients for either men or women patients. The comparison of the average food intake of patients from the two sanetoria is shown in Table 22 of the Appendix. On the basis of this analysis, patients from the two senatoria were grouped together as follows: women with (a) moderately advanced, active tuberculosis and (b) far advanced, active tuberculosis; men with (a) moderately advanced, active tuberculosis and (b) far advanced, active tuberculosis. V The average food intakes of women.patients with moderately, advanced and far advanced, active tuberculosis on the customary hOSpital routine [\3 CW and after modifications were made to improve the dietary intake are given in.Tab1e l. Intakes of nutrients by the individual subjects are given in Tables 23 to 27 of the Appendix. In the control period, the average daily caloric intake for the fifteen women with moderately ad- vanced, active tuberculosis was 1,73h calories with a range of 1,131 to 2,h66 calories per day. The distribution of these patients according to the range of the food intake is presented in Table 2. There were three patients in the range from 1,000 to 1,399 calories with an average intake of 1,25h calories per day; five patients in the range from l,hOO to 1,799 with an average intake of 1,658 calories per day and six patients in the range of 1,800 to 2,199 with an average intake of 1,989 calories per day. The distribution of women patients with far advanced, active tuberculosis according to graded nutrient intakes is given in Table 3. The average daily caloric intake of the four women patients With far advanced, active tuberculosis was 1,6h6 calories, with a range of 1,067 to 2,556 calories. Two of these patients had daily calorie intakes in the range of 1,000 to 1,399 calories. The other two patients had daily calorie intakes of 1,823 and 2,556 calories, respectively. Caloric intakes for 17 of the women were less than the recommended allow- ance of 2,300 calories established by the Food and Nutrition Board of the National Research Council (1953) for a woman_weighing 55 kilograms. Recently, however, dietary surveys have indicated that the recommendations for calories may be OVerestimated (Winter et 31., l9h5; Ohlson gt al., 19%). Moreover, with continued bed rest, it may be difficult for the 29 The Average Food Intakes Tuberculosis of'Women Patients With Active Degree of no. of Calories Protein Fat Carbohydrate Period Tuberculosis Subjects gjm.) tam.) _Lgm.) Control hod. adv. 15 17eki' 731 77: 180: 90*' 3.2 5.7 5.6 Far adv. h léhéi 59: 68: 19b: 12? lb.h lu.5 h2.3 I hod. adv. 15 195k: 59: 89: loo: 11h 6.8 5.8 9.6 Per adv. k 163a: oo: 70: 177: 306 lb.6 15.0 25.3 11 Mod. adv. it less: so: a9: 190: 130 o.o 7.9 10.5 r .+ Far adv. 3 1519: 9o- 78: 182: 2st 11.6 15.h 26.2 III nod. adv. 13 leak: 82: 90: 175: 99 3.h 5.8 11.7 Far adv. 3 19th: 112: at: 19h: 33b 26.5 33.3 26.9 * Standard error of the mean 30 Table 1 continued ascorbic Calcium PhosPhous Iron Vit ' ‘ ' . an A ‘ . r1 . ' . 3'. . (5g.) #ng. (mg!) (1.3%? (:31? ifiamine hifoflav1n fiacin -.a. .15. mg. reg. 1.22: 1 30+ 8 71+' 1 r + o "' o " 3(L‘2— 101+ 2 [J1 + + + 0.03 0 - ~- 4- 'J4' 3'h2' 20'3‘ .03 0.h2 1071 15.3 0.71 0.69 5 33 + + . 3.33. 5.16. 9.22: 5613: 116: 1.08: 1 79: 7 2+ . .22 1.5h 1673 b9.2 0.17 0:36 2‘2; 1 61: 1 56: 9 78+ " + ‘+ -° ‘ . . ~ 16520- 22?— 91+ 6 ~+ + U01“ 0 ‘ f f U 3.0).. )o‘h9- “l. " olLL 0030 1.308 903 0003 0017 30.31-1- 1 07+ 1 26 9 20+ 6“! + . J . .23- 16398- 292+ 6 + ’ + + 0.2 0 2 , ,4 )“ '12- 0'33‘ h' - b .26 2.27 2185 56.7 2.53 1.97 31 31 1.53:‘ 1 [0* 11 88+ 158 + + 0" "‘ o - 39- 2714‘ b {1+ + + 0.10 c’ - .3 - 5.97- fit 1‘ 0.03 0.92 ~.1650 11.1 0.r9 0.80 )3'83 1.07: 1 30i' 11 09+ 17' 2+ " . . - 493a- Zoo: 6 /+ + 0.2- ‘ , .30- 6.97_ * 8 0.17 2.70 2207 69.2 2.98 2.5h Bi Z7 1.38- 1 L7+ 9 72+ 12036+ ’ + \ . ; ~ . - - 202- J. ('1- .J + 4 z 0.02 x. ’ r“ ' L039“ 50>?“ ‘ ob— 0.02 0.00 1179 33.7 0.55 0.52 3i A6 1 18: 1 53+ 11 06+ 1’9 + ’ o o - o - Z9116.- 220+ H + 0.20 0.17 2 7 - 9.95 6.35- 32.7- . 3 2233 17.6 2.26 0.95 6.81 Tmfle2 The Distribution of Women with.hodera tely Ldvanced, According to the hangs of Food Intake Active Tuberculosis, Lo. of Control Period g_‘ Ran for Pc riod Food Intake Subject nan e J_1 can 1 11 - 111 Calories 3 1000 - 1399 lZSh 2032 1616 1725 S 1200 - 1799 1658 1731 15711030 6 1800 - 2199 1989 1955 20378 1973“ 1 2200 - above 2h66 283 22 2762 Protein 1 Less than SOgms. 85 89 ES 62 2 $0 - 6h 57 87 f8 73 8 ob - 79 7h 87 82. 53“ h {0 - above 85 9b 111‘ 968 Calcium 1 Less than 0.840. 0.52 1.30 1.33 1 w07 8 0.8 - 1.21 1.06 1.L 1.30” 1. 283 o 1.22 - above 1.56 1.81 1.80” 1.569 Vitamin A 0 Less than 3500 - - - - 0 3500 - b999 — - - y - * 13 5000 - above 13702 16520 1:83 ‘ 12036 Ascorbic acid 1 Less than 50mg. 09 182 172 170 h 50 - 78 mg. Ch 209 385- 2‘99 6 75 - 99 mg. 86 232 287“ 27 7”‘ b 100 and above 178 25 237 238 Thiamine 1 Less than 0.8mg. 0.77 3.70 11.00& 8.72y 8 0.8 — 1.19 1.00 3.68 3.25“ 2.72"‘ 6 1.2 - above h.89 8.05 8.58 8.88 Riboflavin 0 Les 35 than 1. 0mg.. - - ~Hx e * 2 1.0 - l.h9 m2. 1.38 5.76 5.38“ b.50 l 1.5-1.99 mg: 1.7h 0.h3 9.25 9.52% 12 2 .00a .nd aoove 3.91 5.36 5.75 5.31 a , . One subject drapped out of experiment. m“ 10. ble 3 \VJ {\J The Distribution of Nemen with Far Ldvanced, Active Tuberculosis, According to the hanje of Food Intake. mo. of Control PeriOd Loan for Period Food Intake Subject nange Lean I 11 111 Calories 2 1000 - 1399 1103 1222 1261* 2813* 0 1&00 - 1799 - - - - 1 1800 - 2199 1b23 1000 2005 15th 1 2200 - above 2556 2281 2190 1735 Protein 2 less than 50 gms. 36 50 77* 170* 0 50 - Cb - — - - 1 OS - 79 77 8 9b 73 1 80 - above 91 122 117 to Calcium 1 Less hen 0.0 0.59 0.01 0.53 2.23“ 2 0.8 - 1.21 0.96 1.18 1.268 0.908 1 1.22 - above 1.50 1.50 l.h3 1.23 Vitamin A 1 Less han 3500 1715 13906 12358 8923 l 3500 - M999 3735 19865 , — —\ 5000 ~ aoove L502 16271 0220 12000 LscorOic acid 1 Less than 50 mg. 29 172 171 193 l 50 ~71: mg. 67 L111 1102 253 0 7S - 99 mg. -, - “.2 ' a 2 100 and above 105 290 231 232” Thianine 1 Less than 0.8 0.66 3.06 3.171 3.59% 1 0.8 - 1.19 0.8. 3.58 - - 2 1.2 - above 1.33 0.92 7.9 7.12 Riboflavin 0 Less than 1.0 mg. - - ~ - u 2 1.0 - 1.89 mg. 1.28 8.13 3.83“ 5.90“ 0 1.5 - 1.99 mrt. - - " “. 2 2.00 and above 2.30 8.63 8.53 6.57 a .. One squect died during the exreriment. 33 patients to consume sufficient food to provide the recommended allowance for calories for healthy individuals. weight, height and age data are given for the individual women sub- jects in‘fables 28 and 29 of the Appendix. Ten of the fifteen women 1 patients with moderately advanced, active tuberculcsis were coxeidered underweight; body weights of these subjects were ten percent or more under the average weight according to standard tables of weight in relation to height and age (Cooper, 1927). The average caloric intake of the ten underweight patients during the control period was 1,06h calories per day. The average caloric intake of the five subjects whose body Weights ranged from -8 to +5 percent of standard weight was l,thh calories per day. 111 of the four patients with far advanced tuberculosis Were underweight. Body weights ranged from 97 to 120 pounds and the deviations from "ideal" bodyweight were -7 to -20 percent. The average protein intake of the moderately advanced, active tubercu- lous women patients in this study was 73 grams with a range of h5 to 93 grams. Although the average daily protein intake compared favorably with the daily allowance recommended by the Food and Nutrition Board of the national hesearch Council in 1953 for women, it was somezlat less than the value of 60 grams of protein per day suggested by brewer at 31. (1989) to provide for nitrogen retention by tuberculous women patients. One patient had an intake less than 50 grams per day; daily intakes of two patients were in the range of 50 to 6h grams with an average of 57 grams; eight patients had intakes in the range of 35 to 79 grams with an average of 7b grams and four patients had intaies which were higher than 80 grams per day. \U fi‘ The protein intake of the four women with far advanced, active tuberculosis ranged from 32 to 91 grrms per day, with an average of 59 grams. Two of the patients had protein intakes less than 50 grams per day. The average daily calcium intake of the women patients with moderate- ly advanced, active tuberculosis was 1.22 grams during the control period; this was similar to the calcium intake which was predicted by Brewer et_al.. L (l95h) for calcium equilibrium of women with active tuberculosis. The range of daily calcium intake of patients in this group was from 0.52 to 1.75 grams. nine patients had average daily intakes less than 1.22 grams of calcium per day. ,One of these patients had an intake of only 0.52 grams calcium per day. The range of daily calcium intake for the four women With far advanced tuberculosis was from 0.59 to 1.50 grams, with an average of 1.16 grams. Two patients had calcium intakes less than 1.22 grams per day, with an average of 1.16 grams. The patient who had the lowest calcium intake (0.59 grams per day) drank no milk. The average daily phOSphorus intake of the patients was 1.30 grams with a range from 0.75 to l.t0 gram . Brewer and co—workers (l9Sh) found that 1.38 grams of phOSphorus daily provided for phOSphorus equilibrium for women with moderately advanced, active tuberculosis; this amount is usually supplied by a diet which is adequate in protein and calcium. Intakes of seven patients in this study were less than 1.36 grams phos- phorus per day. The range of phOSphorus intake for the women with far advanced tuberculosis was 0.70 to 1.33 grams, with an average of 1.16 grams per day. \i; \fl no studies of the iron metabolism of tunerculous patients have been found in the literature. Estimations of the iron reQuirement of tubercu— lous patients thus have been based on recommendations for healthy people and the intakes required for the maintenance of adequate amounts of hemo- globin in the blood of the patients. ”he average daily iron intake for the women with mo”erately advanced, active tuberculosis was b.71 milli- grams. Only one patient had a daily iron intake over 12.00 milligrams which is the allowance for iron reCOmmcnded by the Food and Kutrition Board of the Rational Research Council for healthy women (weight, 55 kilo- grams). In comparison with this allowance, the average iron intake of the patients was considered to be low. The iron intake of three of the women with far advanced, active tuberculosis also was low. The average for this group was 9.22 milligrams per day. One patient however had a daily intake of 13.30 millig'mns. a daily allowance of 5,000 International units of vitamin A has been recommended by the Food and Nutrition doard of the National Research Council for diets of healthy men and women. The_accumulation of data in the literature which indicate a disturbance of vitamin.A metaoolism in tuberculosis indicates also that the vitamin A requirement for tuberculous patients is considerably higher than for healthy persons, although quanti- tative requirements have not been established. The average intake of the women with moderately advanced, active tuberculosis was 13,7L2 International units, with a range of 8,735 to 21,h72 International units daily. The highest daily vitamin A intake of 21,h72 International units resulted because one of the subjects received a vitamin supplement which - r.’ A. .J-r- . “.,s .' > r .3' . .-—' :1.— _',_,' ..—\.. .4 ~V-‘.4‘- .- Contained Vitamin L. Thub, the aVLIQfU intthe aw. noie ,han twice tie \ .. .‘~ , ._ J . 1 ,1 .- . _.. n -| ...r ,- . ‘ g ‘ J 3" v- , . . ['11 ,- ' V‘ “ r .V ‘3 r .0 1" reCommeiuuxlxiuily dileuthfi for lin‘ thy puuélii. inc C/ul-fgfl daily . r- . ‘ . ' ”‘1'" p v \J- 1 ~‘ ‘1 -" I" ‘-—f '.u\-- ‘ f .'."2* |.:, ... - -_‘---. r- ‘7'1 ‘V 1 v Vltwhln a lhtchu oi WOMCH with for odquUUN’ active tiueiculocis Was lover mi I r .LL‘L: L than for the w men with moderately adv heed, acciVe tn crculcsis. average daily intehe of vitamin : for the far auv€nccd tuberculois pcticnta was 5,513 International Units, with a range of 1,715 to 10,3j2 Inter- national units. Thore were two patients with relatiVely low'intahes of 1,715 and 3,735 International units of vitamin A per day, respectively. The aVerage daily ascorbic acid intake of the patients in the control period was 101 milligrams with a range of L9 to 2&8 milligrams. The aver- age daily ascorbic acid intake was similar to the ascorbic acid int“ recommended by Webb ‘t al. (19Lb) but less than the amount (average Oi 200 milligrams) wrich was suggests" by Brewer gt :1. (19L?) as a desirable supplement to the hOSpital diet for women with active tuberculosis. Cne patient had an ascorbic acid intake which was less than 50 milligrams per day; four patients had daily intakes in the range of 50 to 75 milli- grams of ascorbic acid; six patients had ascorbic acid intakes of 75 to 99 milligrams and four patients had intakes which were more than 100 milligrams per day. One patient with far advanced tuberculosis had an o aCld intake of only 29 milligrams per day. This patient did not },Jo ascorb accept citrous fruits or other fruits which supply appreciable amounts of ascorbic acid. Since the patient was a.recent admission to the senatorium, the physician had not prescribed an ascorbic acid supplement so that she U) .9, might be used as a.subject for this study. One woman with far advanced, active tuberculosis had an average daily intake of t? milligrams. The other two patients in this group had ave~ago daily intakes whi“h were higher than 100 milligrams. The average thiamine intake of the women patients with moderately advanced, active tuberculosis was 2.5h milligrams with a range of 0.77 to 8.7L milligrams. The higher thiamine intakes represented the dietary 'ntakes of patients FLO received vitamin supplements. Une patient had a daily thiamine intake which was less than 0.8 milligrams; eight patients had thiamine intakes which were in the range of 0.8 to 1.19 milligrams and six patirnts had more than 1.2 milligrams of thiamine per day. One a 1 patient with far advanced tuberculosis had an intake of only 0.5o mi11i~ grans per day; one woman had an.intake of 0.th milligrams and the other two patients with far advanced tuberculosis had 1.33 milligrams or more per day. There are insufficient data in the literature to provide an estimate for the thiamine requirement of tuberculous patients. Brewer and co-workers (19h9) reported that the metabolism of thiamine oy tubercu- lous women ’as found to be similar to that of healthy women. From that it would appear that an intake equivalent to or slightly above that of the reguirement for healthy women should be adequate for the tuberculous patient. \‘ (p £44 <: (H :3 O (D Q4 (H O C“ '— < (L The riboflavin intake of the women with moderatel tuberculosis averaged 3.h2 milligrams with a range of 0.55 to 3.93 milli- grams per day. Only three of the fifteen patients had intakes which were less than 2.00 milligrams of riboflavin daily. Brewer et a1. (19h?) reported that an intake of 2.6 milligrams appeared to be adequate for women with moderately advanced, active tuberculosis. Six of the fifteen patients had intakes of 2.6 milligrams per day or more. Two of the women patients with far advanced tuocrculosis had intakes of 2.6 milligrams or more per day. One patient received only 0.6 milligrams and another patient with far advanced, active tuberculosis had an average daily in- take of l.&9 milligrams of riboflavin. The average daily niacin intake for the women with far advanced, active tuberculosis ranged from 1.2 to 12.0 milliqrams with an average of 7.2 milligrams. This was considerably lower than the intake of the women with moderately ad‘aneed, active tuberculosis which ave‘Cged 20.3 milligrams per day, and was also less than the allowance of 12 milligrams per day which has been recommended by the Food and Nutrition ooard of the national Research Council (1953) for a hen thy woman, twenty-five years of age, and weighing 55 kilog‘ams. Few studies of the nutritional requirements of men with tuberculosis have been found in the literature. Evaluation of the adequacy of the diets of tuberculous men who acted as subjects in this study has been made on the basis of the recommended allowances of the Food and nutrition Board of the National hesearch Council (1953) with the realization that additional amounts of protein, calcium, ascorbic acid and vitamin I are desirable for tuberculous patients. The average food intakes of men patients with moderately adv need and far advanced, active tuberculosis in the control and experimental periods are gi’en in Table h. Intzkes of nutri nts by the individual Subjects are given in Tables 30 to 33 of the appendix. The distribution Jable h, LVQTC:3 Daily'Food ln eke of hen Tith Letive Tuoerculosis In Control and niperimental Periods Period Degree of no. of Calories Protein Fat Carbohydrate Ta}.rculosis Suqéects K:w) (1m) (i3) ' r ' ‘ \ /\,' + ¢',' + + \ / + Control ‘ med. adv. 22 ad7la a}- 99- 200- 1,1~ 3.8 7.b 9.h « . q .:h+ r.+ ..+ : tar adv. la 1(45. (9- (o- lb “ O ’ ‘ 13:" I" ' + ‘, l ‘ l nod . $3.:ng . cu (30,57- L“)- L. i 20 ( — i . ,.. M. ,p+ , bar adv. ll l9fb— oe— 94- 191— ll Led. cu , 19 2039: 09: 9a: 199- C3 3.7 é.3 10 0 Far a (JV . 9 20m: 9o”: 92;: 2‘5: 119 7.0 5.6 12.6 111 nod. adv. 16 1952: as: 951 197: 105 5.0 7.0 10.9 Far adv. t; 179’: t2- b % Standard error of the mean Iabl ‘ e 39 .0, ,H ”uCOFoic Calcqu (gm) 1 Phesyhorus Iro ~ ( g'm) \m'J) I] VLL Elwin A r . ‘ 1 59:1 ' -+ L I°U° ‘I:%g l‘LLa “lne =.. 0.10 '61- 10 br+ “t) (m,) “looflavi =-. . 0.03 c'”‘" 7293: 11 (my) n “idol“ 1 31: “()3 11MJ 75;}. .L + (In; 0 110:: 6.3 '71." 3 u~+ .15 r. 10 “1: ,_ 0.3- ° " 1‘ -+ . 0.1u O°( (917: ’ 0.33 3'1“ 0.17 1.72: 1 .+ 5'1 0°19- 2-5*: + ° 0.10 }'2b" 13 173* “/0 0 hat) 10'7” 1.62“ “.71 1);,“2 — 207i 3 ' 1 0-721 0 15- 1-70+ , , ”-h '?9‘ b 10* ’ O 12 10°2f: l3 h*2+ U°l0 k.“ou 29']: . , ,Iw _ . ’ifi , W, l.t7- 1 0.3) thO 22“: 3 7c+ U'AS o- .9o~ , 0° '- 1" 5. ”i .90 0.17 13.307]: 1.; 662+ 0.00 hi: 31.0: 1 1’) lei-1f) 9,2]: C111: a 4." 0. lb 0' “ 1.75+ 6.0 J-“O- v vr+ '17 - 100((:-+ 0.1]. 8°))- 0. 1+ 0.111 O J 12316;) n " 0.20 L9.C'" 1 63+ .142 2%?" (7.093; 3 7% C5)? .' - 1 ' + ‘ ‘ “- ~ 0 .06- J -5 a 5.2 + 'lu 0.10 12°L?: 11 ;t3 0'00 0.hg- 31'L: l h9+ l‘h’ :L , - 209‘: 3 0'57 0‘22“ 1.06: 10 ,. 11.3 03$“- 5.29+ M + ' 0.17 'l5- 11 797+ ‘ ° 0 0-25- ’U°L‘ l .27 £12 r;- 225,: 0 .00 J S a 3.99- t + ' 0.33 '91" 30 2i .UO of the patients according to graded intakes of nutrients is given in and 6. k (D U H 1U (11 \Jl ‘ The average daily calorie intake of 22 men with moderately advanced, active tuberculosis during the control period was 2,071 calories, with a range of 1,350 to 2,961 calories. There were two patients whose caloric intakes were in the range f 1,000 to 1,399 calories with an average of l 258 calories. Four patients had an average dailv calori‘ intake of 9 - _ .. f?- l L,‘ a: 5+ Eh “LL. H 5.) CL. CC 1,62h calories, with a.range of l,h00 to 1,799 calories; eigl 1 an average daily calorie intake 01 JJ has C 1,972 calories, with a ranfie of 1,800 to 2,199 calories. The other eight patie ts in this group had daily calorie intakes above 2,200 calories. The average daily calorie intake for the 12 men with for advanced, active tuberculosis was 1,7h8 calories, with a range of 1,075 to 2,6h7 calories. Ten of the 12 patients had caloric intakes less than 2,200 calories per day (Tabla a). Weight, height and age data are given for the individual ma e sue- jects in Tables 35 and 3a of the Appendix. Ten of the 22 men patients with moderately advanced, aetive tuberculosis were evaluated to be under- weight. The average caloric intake of these ten patients in the control period waslw925cmdories per ay. The 12 subjects whose bodyweights ranged from -9 to +16 percent of "ideal" weight had an average intake of 2,217 calories per day. nine of the 12 men with far advanced, active tuberculosis were considered underweight; the average caloric intake of hese subjects was 1,391-calories per day during the control period. The averace caloric intake of the three subjects whose bodchights ranged (3 L1 The Distribution of hen with.nod;rctefly rdvznced, Lctive Tuberculosis [coordine to the hange of Food 1ntahe Nutrient \ L‘- C‘ Q .— “O 11 bj of e ct Control Period rl M itétnz’t} 12-9 been forigfmriuenhl.1wriod l '1" F! ’— 1 ll Calories rotein Calcium Vitamin A iscorbic acid Thiamine hiboflavin U C?) {1" N h 10 lo R) f4 bJUWVD U1 C“O\ 13 21 12L a: lost 1000-1399 lnGG-lYQJ lCCU-2l99 2200-aoove Less than 00 gms 4 ! gms 75-L7 gms 9C--ahove Less tfluxl 0.8 gms -— 0.C-1.21 gms 1.07 1.22-aoove 2.05 Less than 3500 1.0. 3116 3§UC~D999l.U.b151 SUCO-aoove 92L2 Less than 50 mg. to SO~YD ms. o3 75-99 mfi. b? 100 and above 157 Less than 1335 r -% loul 20 9_ 2270 t * \OWNRJ V3k’V; 0015? 1H 9hw 0.8 mm. 0.58 3.65 o.c-1.19 mg. 1.07 3.h5f 1.2-above 2.19 3.t5k Less than 1.0 mi. -- '- 1.0-lo9 n”. l.ht b.39 1.5-1.99 M". -- --.i 0' ' "‘ * Subjects drOpped out of experiment m tab, ‘ ‘-P‘C‘ j * lh,hlfl"n U1 0 \JH \J— l l l 2 \J‘L a"? '7}. ' ~ {4) rlu/ r—IJ; l J _- ,‘ ..>'..". ’xl.)d“ k/h— Otl Nd {‘0 _‘ The Distribution of hen W11 1 per Idvanced, thiVB Tuberculosis nocoraing to tie Lun e of F001 Intake mt: an Food Intake No. of Control Period For Jxfirrlnentc1 P9rio;i Subject hangm 11%;} 1 11 111 Caloric 1 1000-1399 1633 19€SL 1/91 9 "'71 6 1960-1799 1c17 1;29" 1I"””" 1753”" 1 1330—219) ZOUS 172"i 176/ luCDM 2 20 -agove 2b95 2025 25c3 ghov” Protein 2 Less tuan L0 515 L9 91 St: ~43" S oO-Yh 70 Yo“ to: 73“ 3 7D-t9 61 CO t0” C15 2 90-ebove 2d 117 117 125" Calcium 5 s t1cn 0.6 0 L2 .7b 1.33 —-“ c~~39J F’C‘t* n>2 m I H O N’"' H H H C) F‘FJFJ C. Vitamin n Less than 3500 2571 1' 1 Cgéfih 10,12‘ -;* 1 3SOU'L999 92L 6,1v6 9.7h0.1, ”,102 \v 10 5 OO‘GOOVS 9519 lh,6h9*lh,09c*“‘ 12,1tgaww Less than 50 mg 39 lyu” 193' -_ Sc-7h mg so 169" 9f“ 17m" 75-99 mg to 221 219“ 219% 100 and aoove 103 2&1 210 2A9“ Lscorbic acid AJvikad Thiamine Less than C.8 ".07 3.5h 3,39 ”y -‘ ' (\ ' r‘ ‘5‘ ‘1‘“):15‘ ’4‘, O.(-1.19 1.0u 3.13 3.70 3.5m 1.2-above 1.Ll 3.58 3.91 L.b3w «JthJFJ UIO\FJ H (T) U) u’) b Rioofle Vin 1 .0 mg O.t6 --* ~42 5. 7 1 0—1.u9 mg 1.10 5.51 b.00v --" 1.51.99 1.79 5.11 5.37: h.3b:n 2.00 and auove 3.30 p.h5 h.5@‘ 3.61" % Subjects drOpped out of experiment calories per day, \Fe. from -h to +6 percent of "ideal" weight was 2.10 The protein intake of the male patients with moderately advanced, active tuberculosis during the control period ranged from S7 to 11d grams E9 grams per day. (hit; one patient had a U) per day; the average we protein intake less than 60 grams per day. Four pat'enus had protein intakes which ranged from :0 to 7h grams per day and seven patients had protein intakes within the range of 75 to 69 grams per day. Ten patients had daily protein intakes which were above 90 grams. Only two of the 12 men with far advanced, active tuberculosis had protein intakes above 90 grams per d"y. One patient had a very low intake of h3 grams per day; nine of the 12 men had protein intakes within the range of 50 to 89 grams per day. in intake of 65 grams of protein per day has been recom— mended as an allowance for healthy men weighing 05 kilograms by the Food and Nutrition Board of the National Research Council (1953). Getz (19h?) suggested an intake of 90 grams of protein per day for tuberculous men. Six of the men with moderately advanced, active tuberculosis had calcium intakes less than 1.21 grams per day. "he average for the entire group was 1.59 grams per day, with a range of 0.85 to 3.17 grams per day. The calcium intakes of the men with far advanced, active tuberculosis was less than that of the men with moderately advanced, active tuberculosis. The average intake for this group was 1.31 grams of calcium, w‘ of 0.62 to 2.hS grams per day. Eight of the patients had intakes less than 1.21 grams of calcium per day. The average daily phoSphorus intake for the men patients with moderately advanced, active tuberculosis was 1.61 grams with a ranre ‘4‘? r“. D‘ from 0.95 to 2.53 grans. 'rhe range of daily phoeptorus intake for the far advanced, active tuberculous men patients was from 0.77 to 2.36 grams with an average of 1.L0 grams. The iron intane of the men with moderately advanced, active tubercu- losis ranged from h.b9 to 10.30 milligrams per day; the iron intahe of the men with far advanced, active tuberculosis 'anged from 6.11 to 18.5 milligrams per day. nine of the men with moderately advanced, active tuberculosis had intakes less than the average intake for the group which was 10.h8 milligrams per day, and six of the men with far advanced, active tuberculosis had intakes less than 10.71 milligrams, which was the average iron intake for that group. Seventy—two percent of the men with moderatelp advanced, active tuberculosis and 75 percent of the men with far advanced, active tuberculosis had iron intakes less than the intake of 12 milli- grams per day which has been recommended by the Food and Nutrition Board of the National hesearch Council for healthy men (1953). There was a wide range of intake of vitamin.a for the tuberculous men. The average for men with moderately advanced, active tuberculosis was 7,293 International Units, with a range of h,016 to 28,209 International Units of vitamin h per day. Six of these patients had intakes less than 5,000 International Units of vitamin L per day. The range of vitamin L intake for the men with far advanced, active tuberculosis was 2,571 to l3,h95 International Units per day, with an average intake of 7,917 International Units. Only two of the twelve patients, however, had in— takes which were less than 5,000 International Units per day. 1:" \I? 1C6 milligrams per day. Only three of the 22 patients were in-the upper range of ascorbic acid intake, that is with intakes above 100 milligrams of ascorbic acid per day. hive of the patients lad asc orcic acid intakes :hich were less than 30 milli rams p“? div. Cnl;v t.m mof the men tith far advanced, active tuberculosis had in— takes of ascorbic acid above 160 millifirems her day. Five patients had daily intakes less than 73 milligrams of ascorbic acid. ‘“hu average for the group was 7o millierams, with a range of 39 to 105 milligrams of ascorbic acid per day. nine men with moderately advanced, active tuberculosis had thiamine intakes less than 1.2 milligrams per d<' y. ‘Ihe average for the group, 1.7 milligrams per day, anneared to be high since one of the men r ceiVeu a vitamin supplement which conte'ned thienine. The range of tnizwinn intake for the group was from 0.58 to 8.55 milligrams per day. Seven of the men with far advanced tuberculosis had thiamine intakes which were less than 1.2 milligrats per day. ‘rhe average for the group was 1.15 milngrams with a re ge of O.(7 to 1.73 milli gre' —ms of th is; ine per day. The intake allowance for thiami ne for a he '1thy nan with a bow“w‘ijnt of 65 1610 rams and an age of 2; yearsw which has been re ”courenVed by the Food and Diu trition sea d of the hational les earch Council (I733) is 1.6 milligrams per day. There is no evidence that there is an increased -— requirement by tuberculous patients. If this amount is used as a baSis ‘l for evaluation of tine adeqxu cy of the diets of these natiants,1t I-m muld r44 "ppear that acout 79 percent of the men with active tuberculosis hat intakes of thiamine which were inzxieCuate, durine the control period. The average daily riboflavin intake was 3,CO milligrams, with a ranze of l.hb to b.oh milligrams. The relatively hi_h riboilavin in;""s resulted from a high consumption of milk. L11 of the patients in this group had daily riboflavin intakes above 2.00 milligrams except for one patient whose riboflavin intake Wis 1.50 mi livruus p9 r daJ. One male patient with far advanced active tuberculosis had an av>ra :e daily riboflavin intake of only o.tt milligrams during the control period. One patient had 1.16 milliframs of riboflavin per dag. Three patients 18d riooflavin intakes witiin the ran 3 of 1.50 to 2.00 milligrams per day and seven of the patients received 2.00 milligrams or more per day. The average for the group was 2.5h milligrans, with a range of 0.;6 to o.73 milligrams of riboflavin per Cfly, Tie daily intalce of niacin for the noderatelr advanced, active tuberculous men patients ranged from L .h to 09.t milliurams with an aver- age of lb.l milligrams. For the far advanced, active tuberculous men, the average daily niacin intake was 10.? milligrams with a ranqe from b.§ to 17.1 milligrams. The average niacin intakes of both grins Were less than the allowance of 16 milligrams per day which has be: nrecommenaed oy the Food a.nd rutrition board of the Lational hese arch Council (1953) for healthy men, 25 years of aqe, and weighing a; kil ra;s . Slood constituents: Control period. The avera.ge concentration oi the blood consti tu€.nts of women and men advanced, active tuberculosis in the J H *4 1» m L- <1 0 1 :3 O (1) r. m l C“ F m t: with mode-rat * control period are given in Table 7. Individual values for the blood C7“ constituents are presented in the appendix in Tables 37 to h . Tne average blood hemoylobin concentration of the 15 women patients with moderately advanced, active tuberculosis was 13.60 grams per 100 milliliters of blood with a range of 11.23 to 16.00 grams per 100 milli- liters of blood. The range of values compared favorably with the azxe reported by Ohlson and co-workers (lyhh) for hea-thy college women, that is, 11.08 to 15.72 grams per 100 milliliters of blood. blood hemo- globin values for the women with far advanced, active tuberculosis were somewhat lower. The average for this group was 11.8b grams per 100 milliliters of blood, with a range of 11.25 to 12.50 grams. Values for the four women with far advanced, active tuberculosis, however, all were within the range of values reported by Ohlson at 31. (l9hh) for healthy college women. The correlation coefficient between blood hemoglobin and the calcu- lated iron intake of the tuberculous women in the control period was 0.015. This was not statistically significant. The correlation co- efficient between blood hemoglobin and the calculated protein intake of the tuberculous women in the control period was 0.15h. There was not a statistically significant relationship between blood hemOflobin and dietary protein. Concentrations of total serum protein in the blood of the women with moderatelyuadvanced, and far advanced, active tuberculosis all were with- in the range of six to eight g~ams ,er 100 milliliters of serum, wlich has been considered a satisfactory range of serum protein for healthy ht em.oumm.m mm.auaa.o mm.aaunoa mfl.muwm ma.oumfi.e oo.onmfi.qa NH mammflzoamQSp e>Hpom oooso>ew 9mm :pfiz o: aH.oHHm.H 0H. “we.o em.aH0m mH.muaa eH.o-ma.o Ha.auao.ma mm maaoa Idobeodp m>flpow «woosm>oo mampm Ihmeoe 29H: Cos ea.ouwe.a mm.ouwe.o am.weumefi ma.mumm ofi.onae.o om.ouwa.aa a mamoasoumosp m>Hpox doocm>ew 9mm apex 20503. am.ouma.m oa.oflmm.o 40.0Huooa He.mumm oa.oflms.o mufl.ouoo.ma ma mamoa IdopeQSP m>flpom omosm>dm maopwpo leos apes nose? mews: Hososgoppfla .HE ooa\.mE .HE 00fl\mos .HE OOd\moe .HE OOH\.Ew .HE 00fi\.ew mmmpmzmmogm mafiamxaq meoa Ofiopooma meopoamo « :HEmpH> sfiopoam senoamosm: mpomnpdm mpoompsm EShmm Renew Edema Edemm awkwm . Mo .03 UOflhmm Hoapsou may ca mHmOHSopmnde obflpoq_:pfim.:enmesm QoEo:.mo mpcmdpflpmsoo eooam mmmao>t may .I-‘t .‘O'J \n’lh . 0 I'll"- h9 peOple by various investigators (firuckman.et 31., 1930; ioumans_et a1., l9h3; fdamson et 51., 19h5; and'hilan gt al., l9ho). The average serum vitamin L concentration for the women with moderately advanced, active tuberculosis was 33 micrograms per 100 milli- liters of serum, with a range of 11 to S9 micrOgrams per 100 milliliters of serum. Six out of the 15 women in this group had serum vitamin.L values less than 30 micrograms per 100 milliliters of serum, he amount suggested by hessey pt 31. (19h6) as an adequate concentration of vitamin A in the serum of healthy persons. The average vitamin.k intake of these women was estimated by dietary calculation to be l2,th7 International units (range, 2,821 to 28,369 International units) per day. tone of the four women with far advanced, active tuberculosis had serum vitamin.A values less than 30 micrograms per 100 milliliters of serum. The women with moderately advanced, active tuberculosis had an aver— age serum carotene concentration of 100 micrograms per 100 milliliters of serum with a range of h2 to 208 micrograms per 100 milliliters of serum. Since the serum carotene concentration is not significant without refer- ence to the concentration of vitanin A in the serum, the concentration of serum carotene is therefore necessarily evaluated in comparison with the serum vitamin A concentration. The average serum carotene concen- tration was 76 micrograms per 100 milliliters of serum for the six moderately advanced, active tuberculous women patients whose serum vita— min_a concentration was less than 30 micrograms per 100 milliliters of serum. One of the six patients had a low serum carotene of E2 micrograms per 100 milliliters of serum. The other five had serum carotene values (range, 68 to 101 micrograms) within the range of 50 to hOO micrOgrams per 100 milliliters of plasma which was found by various investigators (Kimble, 1939; Abel at 31., lth; Ldersbeny at 21., 19h5; Anderson and Milan, 19LS; harris at 21., lQLé; and liengst and Shock, 19h5) for healthy peOple. The averame serum carotene concentration of the far ad- vanced, active tuberculosis was 165 micrograms per 100 milliliters of serum with a range from 60 to 37h micrograms per 100 milliliters of serum. One patient, Subject‘hU had a relatively high concentration of 37h micro- grams carotene per 100 milliliters of serum and a relatively low vitamin A concentration of 32 micrograms per 100 milliliters of serum. This was the only patient in this group those serum values of carotene and vitamin A indicated that there may have been a disturbance of the mechanism for conversion of carotene to vitamin.x. The average serum ascorbic acid value for the women with moderately advanced, active tuberculosis was 0.93 milligrams per 100 milliliters of serum, with a range of 0.28 to 1.73 milligrams per 100 milliliters of serum. Two of the 15 patients had serum ascorbic acid values less than 0.50 milligrams per 100 milliliters of serum, and two of the patients had serum ascorbic acid values which were within the range of 0.50 to 0.70 milligrams per 100 milliliters of serum. Thus, 26 percent of this group had serum ascorbic acid values less than the concentration which is usually associated with adequate ascorbic acid nutrition, that is, 0.70 milligrams per 100 milliliters of serum (Gyorgy, 19h2 and Johnson,19h5). One woman with far advanced, active tuberculosis had a serum ascorbic acid value of only 0.26 milligrams per 100 milliliters. This patient 51 had received an average intake of 29 milligrams of ascorbic acid per day during the control period. One of the four patients had serum ascorbic acid values within the range of 0.50 to 0.70 milligrams per 100 milli- liters of serum; two patients had serum ascorbic acid values above 0.70 milligrams per 100 milliliters of serum. The average for the four women was 0.75 milligrams of ascorbic acid per 100 milliliters of serum. The correlation coefficient between serum ascorbic acid and ascorbic acid intake for the tuberculous women during the control period was 0.1.173. This was statistically significant (P _<_ 0.05;). Bessey and Lowry (l9h6) suggested that concentrations of serum alkaline phOSphatase up to 2.30 nitrOphenol units per 100 milliliters of serum were satisfactory-for healthy individuals. Six of the 15 women patients with moderately advanced, active tuberculosis had serum alkaline phOSphatase values which were greater than 2.30 nitrOphenol units, but all of the values were within the range of 0.90 to 3.b0 nitrOphenol units. Since there have been relatively few studies of serum alkaline phOSphatase in disease conditions other than rickets, and since it is relatively difficult to compare measurements of enzyme activity from one laboratory to another, it is difficult to interpret the significance of the values which were above 2.30 nitrOphenol units. many and co-workers (195U) have reported that the average alkaline phOSphatase concentration of non-pregnant white women was 1.36 nitrophenol units which was slightly lower than the average of 2.12 nitrOphenol units for moderately advanced, active tuberculous women in this study. 211 four of the women with far advanced, active tuberculosis had serum alkaline phosphat“se values which k7 \ {‘0 ("W C C. r— ‘4', §_. U. O U C“ r: L.— o "1 were less than 2.30 nitr ro;w utol units per l‘“ average was 1.7t nitrophenol units. he:e was a wide ran-je ei.‘ blood 1emeglobin concentrations a;"‘:on.g; tne a .L. tuberculous men. he range of Va ues Lor men with mod Wratel :Mtvaneed, .‘ . active tuberculosis was from 12.50 to 19.t0 grams per 100 milliliters of blood with an average oi 15.0u gran" per lLL lilllllu€"3 of blood. The ranbe of blood hemOglobin values for the men with far advanced, active tuberculosis was from 12.00 to 18.30 grams per 100 milliliters of blood, with an average of lh.lh grams. The correlation coefficient ' mtzeen blooo heme lobin and the calculated iron inta e of the tuberculous nen durinz the control period was 0.2c9. This was not statistically significant. There also was not a sivnificant relation his between blood heme lobin and die tarv protein (corr 1 tion coefficient, 0.297). The concentrations of total seer Irotein ior mrn with moijrrtxlv advanced and far awi vanced, active tucerculosis were within the range of six to eight grams per 100 milliliters of serum for all but two of the men with moderately advanced, active tuberculosis. Values for the 33 two pa.tients were 5.17 and 6.10 grams per 100 milliliters of serum, reenactively. Only two men with moderately advenced, active tuberculosis and one man with far advanced, active tuberculosL shad serum vitanin a values which we re less than 30 micro revs per 180 milliliters. The calculated vita 1in h intakes of these men ranged from 2,t2l to 23,309 International Units per day. The average serum vitamin A for the gr cup of LL nwith moderately advanced, active tuberculosis was he micrograms per 100 milli- liters of serum with a r'n"e of 26 to 77 micrograms. The average serum () vitamin A for the men with far advanced, active tuberculosis was 54 micrograms per 100 milliliters, with a range of 19 to 76 micrograhs per 100 milliliters. ' In general, the men patients had lower serum carotene values than the women patients. The average concentration of carotene values in the serum of the men with moderately advanced, active tuberculosis was 90 micrograms with a range of 31 to 150 micrograms per 100 milliliters. r Two patients, DE and ELI, who had low serum vitanin A values (26 and 29 micrograms per 100 milliliters of serum) also had relatively low serum carotene values of 103 and 31 micrograms of carotene per 100 milliliters of serum, reSpectively. Se um carotene values for men with far advanced, active tuberculosis averaged 10c micrograms, with a range of 3b to 192 micrograms per 100 milliliters. Subject dih who had a low serum vitatin A value of 19 micrOgrams per 100 milliliters of serum also had a low serum carotene value (3h micro:rams per 100 milliliters of serum). Serum ascorbic acid velues for the men also were lower than for the women. The average serum ascorbic acid of the men with moderately ad- vanced, active tuberculosis was 0.6t milligrans per 100 milliliters of serum and the ranee of values was from o.oc to 1.9h milligrams per ltO milliliters. Fifteen of the 22 men had serum ascorbic acid values less than 0.70 milligrams per 100 milliliters of serum. Llevan of the 12 men with far advanced, active tuberculosis had serum ascoroic acid values less than 0.70 milligrams ,er 100 milliliters of serum. The average value for this group was only O.LB milligrams per 100 milliliters of serum, and the range of values was from 0.25 to 0.76 milligrams. V‘I I.“ There was a statistically significant relationship between the calculated dietary intake of ascorbic acid and the serum ascorbic acid during the control period. The correlation coefficient was 0.375 (P __ 0.05). Three of the men with moderately advanced, active tuberculosis and five of the men with far advanced, active tuberculosis had serum alkaline phOSphatase values which were above 2.30 nitrophenol units. Recommended dietarx modifications The range of higher intakes of the various nutrients in the diets of both men and women patients indicated that an adequate amount of the es- sential nutrients was supplied in the diets of the two senatoria, in so far as the diets could be judged by available information concerning re- Quirements in tuberculosis and the results of the blood analyses during the control period. The lower intakes of various nutrients by certain of the patients probably can be attributed to rejection of food because of individual food likes and dislikes. It was felt that this could be im- proved by encburagement and education. The low blood values for ascorbic acid, vitamin A and carotene which were obtained for some of the patients indicated that an increased intake of these nutrients was desirable. Modifications in the diet Were therefore recommended to each of the subjects with the support and COOperation of the medical director and the dietitian of the two sanatoria, These modifications which were described in the previous section were planned to (a) provide adequate 55 protein in the diet; each patient was asked to eat all meat, fish, poultry and eggs which were served on the heapital tray, (b) increase the iron intake; one or more eggs for breakfast and one serving of beef liver weekly was added to the usual hospital diet, (c) maintain the adequate amount of calcium and phOSphorus in the diet; four glasses of milk or more were provided for each patient daily, (d) assure he daily intake of vitamins; one vitamin tablet1 and 100 milligrams of ascorbic acid were given to each patient daily for the three experimental periods, (e) supply adequate calories to provide for gains in weight for the underweight patients; underweight patients were encouraged to eat all of the food that was served to them. Influence of improved diet on food intake Evaluation of the dietary intakes for each experimental period has been made from the calculated food intakes of the seven-day diet records which were obtains at the end of each period. The one day dietary recall records which were collected each week were evaluated to ind‘cate how carefully the patients followed the dietary regime, and to provide a basis for advising the patients during the experiment. Dietary intakes esti- mated from the recall diets were not included in the estimates of average intakes of the patients for the three experimental periods. The average daily food intakes of the women with moderately advanced, active tuberculosis in the control and in the three experimental periods were given in Table l, and the graded intakes of the nutrients were given 1 kbdol, do. 218, Parke, Davis & 00., Detroit. ~~..-- ‘ t l 4 u n . . l \ ' a r —.. - —- m -—. —— l , l k I a . 1 . . _.__._.- -‘m \f’ O\ in the Table 2. The average daily caloric in eke of the women in this group was 1,95h calories for period I, 1,855 calories for period II and 1,8hh calories for period III, in comparison with an average intake of 1,76h calories in the control period. The c00peration of the patients throughout the entire study was quite good and those patients who were‘ in the lowest range of caloric intakes in the control period had the highest increase in daily caloric intakes. subjects “U and n8 linited the amount of fat and carbohydrate foods in the diet to prevent further gain in weight, and subjects “CO and PA did not accept the dietary regime in periods II and III as well as in period I. Subject DCO had thorac0plasty once in period II, and twice in period Ill. Subject 1S had lobectomy in period II. Subject LA had asthma during periods II and III. Lower caloric _intakes for these patients occurred during these periods. For these reasons, the average caloric intake was lower for the entire group during; periods II and III than in period I. Six of the ten women patients who were underweight (-10 percent or more of desirable weight) at the beginning of the study were still under— weight at the end of the study though there was an average gain in weight of eight pounds per patient. The average daily caloric intakes of the ten women were 2,173, 1,760, and 1,6o2 calories in periods I, II and III, respectively, in comparison with an average daily intake of 1,6tb calories in the control period. Only one person in this group was considered to be 20 percent less than the average Weight for her age and height at the end of the study whereas six of the patients were at least 20 percent underweight at the beginning of the study. Height losses were 5'! observed for two of the patients; these losses in weight may be axe plained in part at least by the fact that it was necessary for the patients to have surgical treatment during the study. Gains in weight for the group ranged from two to 26 pounds during the experimental periods. Two of the women in this group did not complete the three experi- mental periods. Subject KN was discharged to her home after period II and subject at transferred from the Ingham County Sanatorium to the lv‘lichigan State Saxlatorium at the end of period I. When this study was initiated at the Michigan State Sanatorium five months later, the patient again was selected as a subject. at this time the degree of tuberculosis was classed as far advanced. The average daily food intakes of the women with far advanced, active tuberculosis in the control and in the three experimental periods were given in Table l, and the graded intakes of the nutrients were given in Table 3. The average daily calorie intak.s werel,636 calories for period I, 2,190 calories for period II and 1,9hh calories for period III in comparison with an average of 1,6b6 calories in the control period. Subject HO had a gastro-intestinal disturbance during period I. der caloric intake was only 856 calories per day; for this reason, the average daily caloric intake in this group was less in period I than in the con- trol period. Subject ME who had an average intake of 2,5?6 calories per day in the control period desired to control her body weight by reducing the Quantity of fat and carbohydrate in the diet and the average intakes in the experimental periods were less for this subject than in the control period. Subject no decreased her caloric intake from 2,005 calories in period II to 1,5bh calories in period III. Subject hU, who had an infection between the lobectomic Spaces, lost five pounds during the first six weeks and died after period I. The body weight of the other three patients increased from ten to seventeen pounds during the four-month period, although two of the subjects, R0 and do still were underweight for their height and age at the end of the study. The average daily caloric intakes of these three patients were 1,062, l,tl9 and 1,977 in periods I, II and Ill, reapectively. The average daily protein intakes of the women with moderately ad- vanced, active tuberculosis were 89, as and 62 grams for periods I, II and III, reapectively, as compared with an average of 73 grams per day in the control period. Data for the individual subjects indicated that three of the 13 women who completed the experiment had protein intakes which averaged to grams or more per day for the three experimental periods. Average protein intakes of eight of the women were from five to 31 grams of protein lower in period III than in period I. Subject En who had the lowest protein intaxe (MS grams per day) during the control period was able to increase her protein intake to 69 grams for period I, maintain it at 65 grams for period II but reduced it to 62 grams for period III. The sharp reduction in protein intake in the period Ill resulted because this subject was excited about going home the following month and could not eat. Two of the women with far advanced, active tuberculosis had protein intakes which averaged less than 50 grams during the control period. One of these two patients, Subject nU, died at the end of the period I. Subject we who had a daily protein intake of 39 grams during the control period was given a protein S'upplementl during periods II and III. Lverage protein intakes for this subject were 33, 77 and 175 grams of rotein per day for periods I, II and III, respectively. ‘Ehere was an increase in protein intake during periods I and II for subjects hO and ME but in both cases the protein intake during period III was less than in the control period. The average daily calcium intake of the women with moderately ad- vanced, active tuberculosis was 1.61 grams for period I, 1.53 grams'for period II, and 1.38 grams for period III as compared with an average intake of 1.22 grams of calcium per day during the control period. The reduction in average calcium intahe during periods II and III followed a pattern correSponding to the reduction in protein intake. However, seven of the 13 women who completed the experiment had calcium intakes above 1.22 grams per day in all three experimental periods. Of the three women with far advanced, active tuberculosis who com- pleted the experiment, only one, Subject us, had a calcium intake whicu exceeded the intake of 1.22 grams per day which was predicted by hrewer §t_§l, (l95b) for calcium equilibrium for women_with.moderately advanced, active tuberculosis. Subject we who had an intake of only 0.59 grams calcium per day in the control period had an even lower intake of O.hl grams per day during period I and 0.53 grams per day during period II. was increased to 2.23 grams The calcium intake of the patient, however, Protenum, head dohnson e 00., evanSVille, Ind. per day for the period III since a large amount of milk was conbincd with the protein supplement1 for the patient in period III. mean daily intaaes of phosphorus were 1.56, 1.C0 and 1.h7 grams in periods I, II and III, reSpectichy, for women with mode ately advanced, active tuberculosis and 1.26, 1.30 and 1.5 grams in the periods I, II and III, respectively, for the women with far advanced, active tuberculo- sis. There was a marked increase of the daily intake of this nutrient in the eXperimental periods as compared with the average daily intake in the control period of 1.30 grams for women with moderately advanced, active tuberculosis and 1.10 grams for women with far advanced, active tuberculosis. Average daily iron intakes in periods I, II and III were 9.76, 11.8h and 9.72 milligrams for the moderately advanced, active tuberculous J women patients, and 9.25, 11.h9 and 11.06 milligrams for the patients with far advanced, active tuberculosis. .Ln increase of iron intake was shown in the experimental periods as compared with the average intake in the control period of 5.71 milligrams for Women with moderately advanced, active tuberculosis and 9.22 millierams for women with far advanced, active tuberculosis. hverage daily vitamin A intakes for the moderately advanced, active _,_. C tuberculous women patients were 15,920, 1§,t39 and 12,036 international I m units in periods I, II and III, in comparison with the avertee daily vitamin L intake of 13,7h2 International units in the control ’1 l i . " a n ~'- - s Protenum, mead uonnson_e oo., Lvansv111e, Ind. -a“ cl period. The avcrzwo vitamin A intake in the control period was weighted by the dietary supplement1 which one patient received and which supplied vitamin A. Tiers was a.narkcd increase in the average vitarin A intake in period I for the women with far advanced, active tuberculosis. The average daily vitamin A intakes Were lo,59t, 1L,932 and 12,2to Inter- national units for the three successive experimental periods as compared with an average intake of 5,013 lnternational units per day during the control period. The high averages in periods I and II were influenced by the vitamin A intake of subject hO who had three vitaain tabletsl per day, prescribed for her by the physician, during those two periods. Average intakes of ascorbic acid, thiamine, riboflavin and niacin also were influenced in periods I and II by the intakes of additional vitamins by this patient since the vitmnin tablet was multi—vitamin. Lean daily scorbic acid intakes for the women with moderatelv ,, J m advanced, active tuberculosis were increased to 223, 27a and 202 milli- grams in the three successive experimental periods from an average intake of 101 milligrams in the control period. The high ascorbic acid intakes in periods I and II were influenced by the additional aSCO‘oic acid supplement prescribed for two subjects after surgical treatment. The average ascorbic acid intakes from food sources alone in the three succes- sive experimental periods were 78, 12h and 112 milligrams. The average daily ascorbic acid intakes in the three successive experimental periods were 295, 2o€ and 22s milliyrams for the wonen with 1 hbdol, ho. 21”, Parke, Davis & Co., Detroit. far advanced, active tuberculosis. Subject hO had an additional supple~ ment of 100 milligrams ascorbic acid from vitamin tabletsl during periods I and II by direction of the physician. During period III, however, this patient received the same ascorbic acid supplement as the other subjccts. Subject hO who had a low ascorbic acid intake of 29 milligrams per day during the control period increased her aily intake to values of 172, 171 and 193 millip‘ams in the three successive experi- mental periods. This increase was due to dietary supplement, however, since the average daily ascorbic acid intakes of this patient from food sources alone were 22, 21 and h3 milligrams for period I, II and III, reapectively. Two subjects,.hE and uh, had decreased ascorbic acid in- takes from food sources during the experimental periods. The diets supplied liberal amounts of thiamine throughout the study. 'Uomen with moderately advanced, active tuberculosis had average daily thiamine intakes of 3.t3, L.61 and h.39 milligrams in period I, II and III, reSpectively, in comparison with 2.5h milligrams in the control period. For the women with far advanced, active tuberculosis, the average daily intakes of thiamine for the three successive experimental periods were 6.12, 6.36 and 5.95 milligrams in comparison with 1.0h milligrams in the control period. The average daily intakes of riboflavin for the moderately advanced, crams in the three Ja active tuberculous women were 5.h9, 5.97 and 5.57 milli successive experimental periods. For the far advanced, active tuberculous 1 ibdol, No. 218, Parke, Davis & Co., Detroit. 63 a. women patients, the averame daily intakes or riboflavin in the three successive experimental periods were 6.33, 6.97 and c.35 milligrams. In all individual daily intakes of riboflav1 (J) the experimental period , exceeded 2.60 milligrams which has been re coumcnocu bv brewer et a . (19L9) for moderately advanced, active tuberculous women. The average daily ' mtake of ribo lavin was hL her in the exocrimental periods than in the control period. Lverage dailv niacin int: Les in the control period and three suc- cassive experimental periods were 20.3, 31.3, 35.0 and 35.6 nillifirams for the moderately advanced, active tuberculous women and 7.2, 3h.3, 33.7 and 32.7 milligrams for the for advanced, active tuberculous women patients reapectively. Analysis of- variance was carried out to determine whether or not statistically significant changes occurred betwee en the food inta {e of the women with active tuberculosis in the control period and the experi- mental period. A summary of the analysis of variance is given in.Table o. The average intakes of protein, thiamine, riboflavin and niacin were sig;nificantlv hi “rher in the experimental period the n in the control period for the women patients in both groups. The intake of calories and ascorbic acid also was higher for women with moderately advanced, active tuberculosis in the experimental period than in the control period. The limited number of subjects in the group of women with far wifanced, active tuberculosis and the wide variations in calories and as sco orbic acid intakes ‘of those patients may explain the fact that sign Hf cant di forences '1“ £5 alt; { Sumnary of anlysis of Variancc 0‘ roou intCEe for Human Ti'h rcbivs Tuberculosis befiween Control and ginorimental lcrious A. Source Of Variation P Value Prcuict d Ortained E 0.05 F 0.01 - "r r‘ r ‘V r---\r’\" ‘ 11 “ y W w! r! noucrct‘ly LUVOMvBU luccxcuiOsis Calories é.ho%* 3,17 5 01 Protein le.CU** Fat 1.3; Carbohydrate 1.3n Calciwn ' l.hl Phosr-uhcrus C’ .2]. iron 2.12 Vitamin L 0.2h Ascoruic acid C.l3:* Thiamine 3,96fv fiiboflevin {.355t niacin h.‘%f“‘ Far Ldvencod Tuberculosis " .J. _‘...' frOUs-n l . o“” ‘ .1 8o Caroonyorate Calciwn Phosphorus Iron Vitamin : Lscorbic acid Thiamine fiiboflevin in; :1. EC in o up”. w \JJ 0 w G «3%: b) 11‘ O O 4 . -‘\ l v 1'? , 1:1: 0 I (1%; v a H C‘-1:“I:"w *3 C; CI 0 C.‘ C) }-‘ C) I D g... l q ~ between the caloric and ascorbic acid intakes of the control period and period I were not obtained for this group, The vitamin.h intage of the women with far advanced, active tubercu- losis was significantly higher in the experimental period than in the control period. This was not true for the women with moderately advanced, active tuberculosis, probablf because five of the women had vitamin e intakes which exceeded 15,000 International Units in the control period. The average daily food intakes of the men with moderately advanced, active tuberculosis in the control and in the three experimental periods were given in Table h, and the graded intakes of the nutrients were given inTafleS. There was considerable variation in the caloric intakes of the male patients with moderately advanced, active tuberculosis. everage daily caloric interes of these patients in the three experimental periods were 2,037, 2,039 and 1,952 calories reapectively, These caloric intakes were less than the average daily intake of 2,071 calories in the control period. however, those patients who were in the lowest range of caloric intake in the control period had a consistent increase in daily caloric intake throughout the study. Eight of the patients who had daily caloric intakes above 2200 calories in the control period had caloric intakes which were less than that of the control period in one or more of the experimental periods. Four subjects in this group did not complete the study. Four of the eighteen men patients who completed the study were still underweight at the termination of the experiment. height gains for the entire group ranged from.one to 19 pounds during the four-month period. Only one patient was considered overweight at the end of the four—month period; his body~weight was 20 percent above the averace for his height and age. The average daily food inta es of the men with far advanced, active tuberculosis in the control and in the three experimental periods were given in Table h, and the graded intakes of the nutrients were given in T&fle6. The average daily calorie intake of far advanced, active tuberculous men patients increased from 1,7h6 calories in the control period to 1,976 calories in period I, to 2,0L2 calories in period II and then decreased to 1,797 calories in period III. Ten of the twelve subjects had an increase in caloric intake during period I. 0f the eight who completed the experiment, only one, subject RI, had caloric intake which was con- sistently higher in the three eXperimental periods than in the control period. Three subjects had decreased caloric intakes in periods II and III and the other three subjects had lower caloric intakes only during period III. Subject see, who received surgical treatment during periods I and II, was able to increase his caloric intake for period III above that of the control period. However, he weighed five pounds less at the end of the experiment than at the beginning. In Spite of this case, gains in body weight for the seven patients who completed the experiment ranged from one to lb pounds. Four of these seven patients were still underweight at the end of the experimental period. Variations in protein intakes similar to these in caloric intake were obServed for the men with moderately advanced, active tuberculosis. The average daily protein intakes for these patients in the three suc— cessive experimental periods were 59, t9 and to grams reSpectively. These values were similar to the average daily protein intake of £9 grams in the control period. Only five subjects consumed 90 grams or more of protein in each of three experimental periods. The average daily protein intake for the far advanced, active tubercu- lous men were 88, 90 and 82 grams for the three successive experimental periods, in comparison with an average intake of 79 grams per day during the control period. There was considerable individual variation in pro— tein intake during the experimental period. Only three subjects had pro- tein intakes which were consistently higher in periods I, II and III than in the control period. Two subjects increased their protein intakes above that of the control period in period I and II but had a lowered intake in period III. Average daily calcium intakes for the moderately advance , active tuberculous men were 1.76, 1.87 and 1.65 grams in the three successive experimental periods, in comparison with 1.59 grams in the control period. For men with far advanced, active tuberculosis, the average daily calcium intaxes were 1.c2, 1.66 and l.h9 grams in the three successive experimental periods, in comparison with 1.31 grams in the control period. Both groups showed an increase in the average daily intake of calcium in each experimental period above that of the control period. At the end of the study, 72 percent of the men with moderately advanced, active tuberculosis and 75 percent of the men with far advanced, active tubercu— losis had daily calcium intakes above 1.22 grams. The average daily intakes of phOSphorus for the men with moderately advanced, active tuberculosis were 1.72, 1.96 and 1.66 grams in the three successive experimental periods and l.bl grams in the control period. The average daily intakes of phOSphorus for the men with far ad- vanced, active tuberculosis were 1.70, 1.75 and 1.66 grams for periods I, II and III, reapectively and l.h0 grams in the control period. The low av-rage intakes of phOSphorus in period III correSponded for both groups to the:reduced caloric, protein and calcium intakes which occurred in period III. The mean intake of iron by the men with moderately advanced, active tuberculosis was higher during the experimental periods han during the control period. The average daily intake for periods I, II and III were 11.26, 13.67 and 12.h5 milligrams of iron in comparison with an average intake of lO.hd milligrams of iron in the control period. The average iron intakes in periods II and III were weighted by the iron provided as dietary supplement for four patients in period II and three patients in period III. The ferrous sulfate supplement1 was prescribed by the physician for subjects hi and fine. Subjects HL and 50 were not willing to eat liver and did not like eggs. Therefore additional iron was prescribed for them also. The average daily iron intakes of the men with far advanced, active tuberculosis were 10.25, 10.68 and 10.15 milligrams in the three l Ferrous sulfate, no. 7, Eli Lilly'& Co., Indianapolis. [,0 ()j successive experimental periods. These values were similar.to the average daily iron intake of 10.71 milligrams in the control period. The mean vitamin a intakes in the three successive experimental periods were 13,173, 1h,662 and 11,503 International units per day for men with.moderate1y advanced, active tuberculosis in comparison with a mean intake of 7,293 International units per day in the control period. Of the 18 subjects who completed the three periods of this experiment, 15 of the subjects had an increase in vitamin.a intake for periods I, II and III in contrast to the intake for the control period. Seven of the subjects had higher vitamin k intakes in periods I and II than in the control period but a lower vitamin A intake in period 111. The average amounts of vitamin h obtained from food sources alone for the control period and periods I, II and III were 6,615, 8,173, 9,662 and 6,763 International units of vitamin.A per day, reSpectively. The mean daily vitamin.h intakes of all but two of the male patients with far advanced, active tuberculosis who completed the experiment were higher in the experimental periods than in the control period. The average daily vitamin.L intakes were 7,917, l3,h62, 13,166 and 11,797 International units of vitamin a for the control period and periods I, II and III, reSpectively. The average amounts of vitamin A from natural food sources were 8,h62, b,166 and 6,797 for period I, II and III, reapectively. Mean daily ascorbic acid intakes for the men with moderately advanced, active tuberculosis were 207, 21h and 208 milligrams in periods I, II and III in comparison w’th an average intake of 75 milligrams per day in the 70 control period. The amounts of ascorbic acid which were obtained from natural food sources were 6h, 57, 6h and St milligrams per day resnec- tively for control period, periods I, II and III.‘ Ascorbic acid intakes of all of the men in this group who completed the three experimenta periods were greater than the average intake during the control period. The average daily ascorbic acid intakes for men with far advanced, active tuberculosis Were 22h, 209 and 228 milligrmns in periods I, II and III and 76 milligrams in the control period. The ascorbic acid from natural food sources averaged 7h, 59 and 78 milligrams per day for the three successive experimental periods reapectively. Thus the ascorbic acid supplement provided for the patients resulted in significant in— creases in ascorbic acid intake although the ascorbic acid intake from natural food did not increase. The average daily thiamine intakes in periods I, II and III were 3.70, 3.80 and 3.68 milligrams for the men with moderately advanced, active tuberculosis and 1.71 milligrams per day in the control period. The amounts of thiamine from natural food in the three experimental periods and control period were 1.20, 1.30, 1.68 and 1.37 milligrams reSpectively. The average daily thiamine intakesfor the far advanced, active tuberculous men were increased to 3.7t, 3.78 and 3.99 milligrams in the three successive experimental periods from an average intake of 1.15 milligrams per day in the control period. The actual amount of thiamine supplied by natural food was 1.28, 1.28 and 1.L9 milligrams per day for period I, II and III reapectively. These values were higher than the .( l rage daily thiamine intale of 1.15 milligrams in the control period and indicated that the patients consumed a better dei t with re s.ect to thiamine during the experimental perioos. hean riboflavin intakes from natural food sources only were 2.60, 3.05 and 2.79 milligrams in the three successive eXperimental periods, and 2.83 in the control period for men with moderately advanced, active tuberculosis. The av varaoe total riboflavin intakes were 5.10, 5.53 and 5.29 milli wraps per dc3 in periods I, II and III. Thus the tots l rigo- flavin intake was generous throughout the experimental periods. Tile average dai13 riboflavin intakes for the far advanced, active tuberculous men were 5.36, 5.20 and h.9l milligrams in the three succes- sive experimental periods. The amounts of riboflavin from natural food sources were 2.86, 2.70 and 2.h1 milligrams per day respectively in these periods, and 2. 5L milligrams per day in the control period. The reduction of averae e dailv riboflavin intake from natural food sources in period Ill correSponded to the reduction of protein and calcium intal {es in this period. The average daily niacin intakes for the men with moderately ad— vanced, active tuberculosis were 29.1, 29.6 and 30 ' milli r' s in the three successiVe experimental periods. The average deilg niacin intakes (without vitamin supplement) were 9.1, 9.6 and 10.h milli; ems and ll.h. milligrams in the control period. For the far advanced, active tuberculous men, the mean dai13 niacin intakes were 31.0, 31.h and 30.2 milligrams in the three successive experimental periods. When the intakes were calculated without the 72 addition of the vitamin supplements, the average daily niacin intakes for the three successive experimental periods Were 11.0, ll.h and 10.2 milligrams and 10.7 finxtheiconirdl period” 3 C The summary of the statistical comparison by analysis of variance of the food intakes of the men with active tuberculosis in the control period and the experimental period is given in Table 9. The average daily intakes of all vitamins were significantly higher in the experi- mental periods than in the control period for men with both moderately advanced, and far advanced, active tuberculosis. There was not a signifi— b cant difference in the average daily intake of the other nutrients between the experimental periods and the control period. The lack of a sijnifi- cant change for protein, calcium and phOSphorus intakes may be “xplaihcd by the fact that no attempt was made to increase the intake of these nutrients for those patients whose intake of protein, calcium and phos- phorus appeared adequate in the control period, in so far as evidence was available to indicate the nutritional requirements of tuberculous men. ._‘ «L U encouragemen was given the patients, however, to maintain an adequate intake of these nutrients throughout the four month period. Influence of Improved Diet on Blood Constituents Blood hemoglobin: The average hemOglobin concentration in the blood of the moderately advanced, active tuberculous women patients was 13.60 grams per 100 milliliters of blood in the control period and 13.68, 13.91 and lb.35 grams per 100 milliliters of blood in the three successive experimental periods. For the far advanced, active tuberculous women patients, the average blood hemOfilobin concentration with a value of Table 9 SunmarY of finalfiSis of Variance of Food Intake for he: Lith :c” Iuberculosis setween Control and bxnerimentat Periods Source of Variation F Value Predicted . 1-, _. ’7 , .l.‘ ‘ __ CL) u: -._l_n:;(_}. 1‘ (. .U:: i' Calories 0.12 3.11 ‘arbolgdircte U.CL) Calcium 0.32 Phosphorus 0.6 Iron 1 .11, _V_ n a Vi'bém in :2 ll .M—[M‘ Lscorbic acid lt3.2L** T111811": ine 3 ii . )‘n-h Riboflavin 30.Lyf: Liacin bO.LC”‘ Far Ldvancchnen [‘3- k.) I \; 1. Calories 1 Protein 0. 2 L ascorbic acid 20 Thiamine 13 hiboflavin l niacin 239. C" [A 11.83 grams per 100 milliliters of blood was considerajly lower than the hemoqlobin concentration for the mouerately advanced, active tubercu- lous women in the control period but the concentration increased to 12.L1, ‘ H r" ‘4‘, q ‘ .-x r o a . u r. y o . lu.{9 and 13.60 'amn 0L nemovlooin no led milliliters 01 olooo 1n the Q3 T‘I‘ three e_yerimental periods. These data are summarized in Table 10. 1mm average hemoglobin value for moderately advanced. active tuberculous women patients was higher than for the far advanced, active tuocrculous women patients throughout the studv except in period II. Data were treated stati ' callv b, antlgsis of variance to J ltrmine wheth or or not the improvements in diet of the patients during the experimental periods may have iniluer'ced the hemOglohin values of the subjects. A summary of the analysis of variance for ncmo.los1n anai for the other blood constituents is presented in_Tahle 11. Since the average hemoglobin cor centration for the modera' telv advanced, active tuberculous women was conga Jaole to that of hec 1t h; men in the con,z 0] period, it is not surprising that the averages of hemOglobin values between means of the control and experimental periods for this group were not sifinifi— cantly different. The results 1m) ice that blood hemo looin concentra- tions of the tub‘rculous women can be maintained at v: lues comnaraole to those of healthy woren for a fours: onth period oy a good diet. 'l‘he avera e hemo ;lobin concentration in the blood of women with fai advanced, active tuberculosis was sirnificantly hi her in the tlzre experhnental periods than in the control period (P é-O.Cj). This indi- ca.ted that the LOxlflLdblOfio in tile diet were ef ective in incwr as ing the concentration of hemoqlobin in the blood of patients with far 75 Gems one we hoppo new pm : nfl.ouom.a oo.o-me.H Hm.sHHHm mo. Re mo.ouoo.e 8 .ousi.mH a m .>em 9mm 3H 01H: H OH.OHQA.H OJ.H1HQQH mo. mum N mH.QIHw.o mm.oumm.qH MH .bem .wos HHH 0 l\ o 0.10:- o )J... J|I\r . \al ._ o I. n c. o .l o o a . Om O+um H Jr c+0e H gr mr+uh mm m+m4 0H O+wa w mw D+m~ 3H m bow pom 3H. 0+ om. H oo.oum:. H mm.QHHmOH Hw.mumm 4H.OH00.© 4N.OHHm.mH QH .>em .oo: HH 3H.n+nn.H OH.QHOM.H 4m.meNHH mm.mfl» 0m.OHwH.> OH.DHHw.mH : - .>Um Hmm mH.uHJ:.H oa.onH. H we.auoaa me.mne4 OH.n-me.e mm.o-ts.ma ma .>em .eoa H NH.wuhm.H mm.oum~.o am.menmoH we.muw OH.onee.o om.ouss.HH a .sem hem Om.QImH.m OH.OImm.O Jw.0HIQQH H:.msmm 0H.olmw.o JH.OIOO.MH mH .>ow .Uog. Hohpnoo + + + . + + Na + msHsp Hocm390h+ H: .HE OOH\.uE .HS OOH\mXEH .HE OOH\n#EH.HEVOOH\.Em .HE Dofl\.fiw mHmoH oompm:cmogm ocHHmqu nHoH oHehoomH mmopoemo H GHsmpH> GHmpopm QHDOHsoEo: mpoomndm Izonopda UOHLog Eugen ESLom Edemm Edpom Espem mo .0: mo monmoa UOHLom HmpamsHpodxa new Honpcoo cH memo open: o>a on sea: m moa.mw meson o m cos a moon oo wee we mmmeo>< . ' o r.o§. o I. P o r up rm . OH mHQma Iabla 11 Summary of Inalys s of variance of-clood Constituents for Haven We“: .a a 2‘: 1. ~ ...1 .' "I u - ,. Jr. .‘ 4., 1 r"! fl J- ,,.V ratients with LLULVC iuoer3ulosis snowmen conqul - . .71 .1 - ~ -0 r ’ V-_ ”-1 . 1" _n ‘7‘ 1 HM iii: Uri-r. lineal 1.131.041.) .— “‘_~ M Source of Variance P Value Predicted (I teiJMBd F {3.C5 B‘ (3.01 hoderately Advanced Homen hemo (glob in o .11: 3 .17 S .w; 1. Serum Irouein 0.30 Vitamin A 3.37- Carotene 3.17 iscorbic acid 6.13"” PhOSphatase 6.63%* Far Ldvanced Hemen H b J to I \Q C": N D 3 O hem05lobin o. Serum protein I C.o3 Vitamin L 0.h7 Carotene 1.05 iscorbic acid 0.63 PhOSphatase 0.00 77 .dvanced, active tuberculosis from a value which initially was less than 03 the average hemoglobin concentration of healthy women to an average value comparable to that of healthy women (Ohlson, 19th). The average hemoglobin value of men patients with moderately ad- vanced, active tuberculosis in the control period was 1;.at grams per 100 milliliters of blood (Table 12); his value was similar to the average concentration of 15.h0 glans per 100 milliliters of blood which was re- ported by Gets 33 gl. (l9bh) from a study of 97 male tuberculous subjects. The average hemOglobin values for the three experimental periods Were 16.19, 15.20 and 16.68 grams per 100 milliliters of blood. The average hemoglobin concentration of men with far advanced, active tuberculosis was lh.l3 grams per 100 milliliters of blood in the control period and lh.28, 15.61 and 15.65 grams per 100 milliliters of blood in the three successive experimental periods; these values Were somewhat lower than the values for the men patients with moderately advanced, active tubercu— losis. Getz gt al. (l9hh) also found that‘the hemOglobin concentration in the blood of patients with far advanced, active tuberculosis was lower than the hemoglobin concentration in the blood of patients with moderately advanced, active tuberculosis. analysis of variance indicated that there was no difference in the hemoglobin concentration of the men with moderate- ly advanced, active tuberculosis between the control and the experimental periods. There was a statistically significant increase in blood hemo- glooin between the control and the experimental periods for the men with far advanced, active tuberculosis (Table 13). 4 r7._' Gees mo Moshe Us :1: mH.onn.H ma. me.H as.)Humfla me.muas em. oumm.o we.onmm.ma s .>em emu mm.,am4.m 0H.onam.a as.mnm0H Hm.mumm OH. ou_,m. \ mm.,uwo.oa ea .sea .eo: HHH 4H.ouon.a 4H.omom.fi Vaw$m+uaw a4.mflue mfi.suos.e me.oufle.ma a .>eo has 4H.enow. efl.anmm.a No.0Hme em.muee oa.euem.o em.ouom.efi ma .sem .eo; HH 0m.:ulm.a :H.ouam.a as.9HH~JH mo.~umm Hm.outo.> oe.oHQ:.eH HH sea has aa.ouas.a No.9Hne.H No.0qu ma.mnom m.onam.e mm.onafl.ea 0m .>em so: H em.(nmm.m mo.onsh.o mm.a4:vOH ma.mumm ma.onma.e oe.euma.sa NH .>es nae ea.eu m.fi .ouus. . cm.auom m .uuae ea.-uwa.e mHH.HHeo.mH mm .sem .eo; .Hotpeao widen Hoemzeopwas .He DOH\.ms .HE OQH\moe..HE ouH\moS .flwlooa\.ae .HE OOH\.em mflmoa omm +mzemozm mefidm,Ha fifioa oeenoomw scopesmo 4 QHEmpH> eflepohm QHQOHmoEer mpoonedm Ifiohmesg defipmm geaam enema esnam eaten essam no .03 mo seamen mUOHAeL ampeoeflsemxm cum Hoppcoo CH mHmOHSOLeeda m>fipom :p.w mesmfipmm com mo mpcozpflpmcoo pecan weepmmm mmmnm>a NH oHQmB Tahle 13 Summary of Inalysis of Variance of Blood Constituents for hon Patients Hith.£ctive Tueerculcsis ietween Control find dxnerinental Periods Source of Variance F Value Predicted Obtained F U.U5 F 0.01 Roderately Advanced hen hemoelobin 1.67 3.ll h.oe Serum protein C.Co Vlti’hiin j, l . Y ,3 PhOSphatase 1.39 Ear advanced hen \J—L 0 R) E“ hemoglobin 3.9:; 3.55 Serum protein 0.33 Vitamin L 0.73 Carotene 0.0? Ascorbic acid ‘ 36.37 PhOSphatase 2.19 In both the men and women patients, therefore, the average blood hemoglobin values were lower incases of far advanced, active tubercu- losis than in the cases with moderately advanced, active tuberculosis. Increases in blood hemOglobin values to values comparable to those of healthy individuals resulted from improvements in the diet for both men and women. This would appear to indicate that the lower hemoglobin values for the patients with far advanced, active tuberculosis reflected a poorer nutritional status of these patients, rather than a condition associated with the disease process. Blood hemOglobin values less than 12.00 grams per 100 milliliters for women and less than 12.60 grams per 100 milliliters for men were ob- served for nine patients during the control period. Changes in hemoglobin values for these subjects are shown in Figure 1. Subjects no, n0, no, SC, 5n and DA showed an increased concentration of hemoglobin in the experimental period as compared with the control period. When Subject db rwas studied as a patient with moderately advanced, active tuberculosis, .tflne blood hemOglobin concentration of this patient was increased in period 3: above that of the control period. The initial hemOglobin value for Shibject HU was 11.25 grams per 100 milliliten3in the control period when Sine was studied as a.subject with moderately advanced, active tuberculosis, aru1.12.75 grams per 100 millilitersin period I. 'When the same person was Sttldied as a patient with far advanced, active tuberculosis, the value fOI‘ the control period was 12.50 grams per 100 milliliters,and 12.75 graqns per ICC millilitersin period I. Blood hemoglobin values for Subjects DCO, No, no, no. and 53 were 195353 in Period III than in periods I and II. This reduction occurred in Figure (1) Changes in blood htfm();510bln of individual patients with low initial values. 20‘ 20.. WOHEN WOMEN k . \ ‘51 § N0 ‘5‘ ’,,;,’3=:::;:8 HO V \ “grit; ’ R0 8 S DCO ”/:’,.' E s an“ 3: 3 '0‘ to a s\ O W e Fn' 5‘ .5< #:0151501. i ? Ii "Lenin“ i fix PER/003 3 I X WEEK INTiR VALS 201 am HEN SC flEN ‘ ' SH ‘ g ‘5 / ‘5 ,,,,,, 09A §\ - O" ‘ ':::$::":£JA 55 '0‘ IO‘ 0’” a: 2 : ° ‘5‘ .54 E ‘7 cairn 7 1'1 it 9 cam. i i m o—o—o—o "upturn r ADA/mew, ACT! V5 mama/1031s PERIODS---5IX wax mm VALS o---o--o--o FAR ADI/Mal), ACTH! TUBIRCUMSIS m (7" the same period that lowered intakes of calories, protein, phosphorus and other nutrients were observed for subJects no and h0 and lowered intakes of phosphorus were observed for Subjects D00 and SH as well. Subject LO had a higher food intake in period III than in period II, but the food intake for this patient in period II was relatively low. Lower blood values for Subjects Sd and D00 possibly could be attributed to incomplete recovery from loss of blood during surgical treatment. Serum protein: The average total serum protein values for patients of both sexes were within the range of six to eight grams per 100 milli- liters of serum (”ables 10 and 12). This range has been indicated as satisfactory for healthy individuals (Jessey, l9ho). Differences between the serum total protein of the control period and the experimental periods were not statistically significant by analysis of variance. Getz £3.3l- (l9hh, 1950) and Shaw gt 3;. (1950) stated that the serum total protein for patients both with moderate and far advanced tubercu— losis was usually similar to that for healthy people, although the ratio of albumin to globulin is altered in the disease. ‘Nhen reductions in serum albumin occurred, elevations in serum globulin values usually oc- curred simultaneously, and, as a result, no change in the serum total protein was measurable. Thus, measurement of the serum total protein is a less critical measure of the state of protein nutrition of the tubercu- lous patient than measurement of protein fractions, althourh severely depleted protein stores may be indicated by low serum total protein values. Three patients had serum protein values which were slightly higher than 1 8.0 grams per 100 milliliters of serum and six patients had serum protein 63 values slightly less than 6.0 grams per 100 milliliters of serum. The X-ray findings for these patients apparently were as satisfactory as for those who had serum total protein values within six to eight grams per 100 milliliters of serum. One patient, Subject n1, with far ad- vanced, active tuberculosis had a total Serum protein value of 5.65 grams per 100 milliliters of serum in period Ill; X-ray findings for this patient Showed an extension of the cavity in the upper lung at the time of the test period and this patient died five months after the experiment. Subject iU, who died, had satisfactory serum total protein values: 6.70 grams per 100 milliliters in the control period and 7.1t grais per 100 milliliters in the period I preceding her death. Serum Vitamin A and carotene: The average serum vitamin.s of women with.moderately advanced, active tuberculosis was 33 micrograms per 100 milliliters of serum in the control period, and h7, A2 and DS micrograms per 100 milliliters of serum in the three successive experimental periods. The difference between the control and the experimental period was statistically significant (P s. 0.05) . This indicated that the average serum vitamin A was influenced by the addition of a.daily supplement of vitamin A to the diets of these patients. The average serum vitamin.h for women with far advanced, active tuberculosis was 38 micrograms per 100 milliliters of serum in the control period and 37, hS and 63 micrograms per 100 milliliters of serum in the three experimental periods. There was no significant difference between the control period and the experimental periods according to the analysis of variance. This was probably due to variations from period to period in the serum vitamin L values of the patients. Cue patient, subject hO, had a serum vitamin A value of Ll micrograms per 100 milliliters in the control period. Values for this suuject increased to 52, 55 and t5 micrograms per 100 milliliters for the periods I, II and III, respective— ly. On the other hand, subject n0 had a decrease in serum vitamin A values from 36 microorams per 100 milliliters in the control period to 29 micrOgrams per 100 milliliters in the period I, although this was followed by an increase to hl micrograms per ICU milliliters in periods II and Ill. Subject HU, who died after period I, had a serum vitamin n value of 32 micrograms per 100 milliliters in the control period; the concentration was lowered to 26 micrograms per 100 milliliters in the period I. The mean concentration of serum vitamin.h was hither for male patients than for the tuberculous women in both the control and the experimental periods. fiveraqe serum vitamin.A values for men with moderately advanced, active tuberculosis were hh, 50, b6 and 55 micro- grams per 100 milliliters of serum for the control period and periods I, II and Ill, rCSpectively. lvorage serum vitamin L values for men with far advanced, active tuberculosis were 52, S9, hB and ob micrograms per 100 milliliters of serum for the control period and periods I, II and III, reSpectively. There was not a statistically significant dif- ference in serum vitamin L values for the control period and the experi- mental periods for either the men with moderately advanced, active tuberculosis or the men with far advanced, active tuberculosis. ill serum vitamin L values for men with moderately advanced, active tuberculosis were 30 micrograms or more per 100 milliliters of serum with the single exception of Subject hih who had a concentration of 29 micrograms of vitamin A per 100 milliliters of blood in the period I. There was considerable variation in the serum vitamin A of subject Li, a.male patient with far advanced, active tuberculosis. The serum vitamin k for this subject was 33 microsrams per 100 milliliters in the control period, 25 micrograms per 100 milliliters in period I, 3b micrograms per 100 milliliters in period II, and lo micro;rams per l00 milliliters in period III. This patient died follozing the exberiment. Subject d;h, also a.male patient with far advanced, active tuberculosis had a serum vitamin.é value of 19 micrograms per 100 milliliters in period I; the concentration then increased to 50 micrograms per 100 milliliters for periods II and III. With these exceptions, the scrum vitamin A values for the men with far advanced, active tuberculosis were consistently equal to or greater than 30 micrograms per IOO milliliters and, according to Bessey (19h7), comparable to values for healthy individuals. Evidence of previous depletion of vitamin L as report d by Gets (IQSH) for tuberculous patients was not apparent from the blood studies of the patients in this study. oraphs showing scatter diagrams of the vitamin.L content of the serum plotted against the total vitamin 1 intake of the patients are given in.Figure 2 for the tuberculous WOHCH and in Figure 3 for the tuberculous men. Serum vitamin n values were not linearly related to the vitamin k intake. Correlation coefficients were 0.006 for women with moderately advanced, active tuberculosis, 0.259 for rikur Q d ) Graph showing relationship of serum vitamin.A and daily vitanin A intaie of women with active tuberculosis. 4') O\ ,254 FAR ADVANCiD, ACTIVE fUflERCULOS/S I“ V § \ o E E 754 E ‘ o >\ 8‘ o t E .504 o a 0 o ' a N . O 0) o . 25‘ O G .5000 10,000 15,000 24000 25.000 30.000 DAILY VITAI‘IINA [NM/(5 --"I.U. '25 nopmumr 40mm“), acme mam/Lam 0 mo- V ? \ 75‘ E s . : ° 3 g 0 g \ C I Q . \ o 0 s3” .. ' ... O. E :..{...O:.. '.‘.o.o . U) 25‘ o . .0 o 0 4000 14000 [.5000 24000 3000 301000 35,000 DAILY VITA/VIN A INTAKE ----- LU. Graph showing relationship of sermn vitamin.A and daily vitamin n intake of men with active tuberculosis. I25 4 3 3 3580/7 VITA/‘1’” A ”Icy/100 07/ ’5 25‘ 87 m ADVANCED, ACII ve mama/10m O CD [25 l 7.3 '3 SERU” VITA/TIN A Meg/loo 07/ M Q 25« .5000 101000 15000 20000 25000 30000 DAILY VITAI‘IIN A INTAKE ----- 1.0. mnemar ADVANCED, Ac TI v: mama/£0515 ’.J:i-'.§i3::.. ° ”"1””. 0: ' . . 4:000 [0000 15:000 20:000 25000 36,000 DAILY VITAMIN A INTAKE ----- LU. (”v o women with far advanced, active tuberculosis, 0.217 for men with moder- ate " advanced, active tuberculosis and 0.033 for men with far advanced, active tuberculosis. Serum vitamin 1 values for nine individuals who had initial concen- trations less than 30 micrograms of vitamin A per 100 millilitirs and for Subject nU are shown graphically in Figure h. Subject EU had a con- centration of 32 micrograms of vitamin L per 100 milliliters of serum in the control period and 26 micro;rams of vitamin h per 100 milliliters of serum in period I during the tine that she WLS studied as a patient with far advanced, active tuberculosis. Col; one of hi, nine individuals with low initial concentrations of serun vita in a failed to show an in- crease in serum vitamin A during the experiment. Values for this patient, Subject KAI, were 29, 30, 33 and 31 nicrograns of vitamin a per 100 milli— liters of serum for the control period and periods I, I]. and III, re- Spectively. The relativelJ low serum vitamin n values ior this patient could not be associated with recognized factors since the patient showed favorable progress in recovery from tuberculosis during the ex erin nt and had average intakes of lO,tol International Units of vitamin L per day in period I and 17,609 Intern'tional tnits of vitarin.a per day in period II, although his vitamin A intake decreased to o,65h International bnits per day in period III. The sharp increase in serum vitamin A values in period I followed by a reduction in values for periods II and III which 'as observed for subjects DE and PL also could not be associated with other recognized factors. however, the data for this group of patients indicated that even for tuberculous patients with low serum it- -r g; Wm, . Athiw. he serum vitaain A of Eigure (h) Changes in i iatients with low initial ’Uct SERUH VITAHIN A mcg/wo ml sum warm) ,4 may //00 ml 89 100' 100‘ women women 75“ 75‘ so so LA fi 0 ----- awn 25- ' 25- ° "u C ) cairn: 1' n It ‘7 CMTROL z. n n PERIODS 31! WEEK INT£R VA LS :60 law HEN mail 75‘ 76" 50‘ BE 50‘ I ’0' """ OBAK HAY " 25. 25- ,x" V I 6 courkat i 1': 1i animal. i 1‘1 111‘— PERIODS - "SIX WEEK INTERVALS H—H MODEMTELY ADVANCED, ACTIVE ruaERcaLom our—+4 FAR ADVANCED, ACTIVE TUB£RCULOSIS >5, . O ur'i‘.“ .V. £3. a . ; .-‘» /‘ V F vitamin a values, suppleuentation of the diet with vitamin a resulted in incre’ses in serum vitamin A concent*ations to values which corres- ponded to those for healthy peOple. tubercu- 0“”1 The average serum carotene for moderate Ir advanc ei, act_ve \ lous women was 100 micr03ra [s gar lOO millilit: rs of serum in the control period and llo, 105 and ion mic: o,r3r ms oer ldO millilitcis in the three ‘ that (‘Q successive flTerlmqucl pCPiOCS. hnflJSio of variance indicated the difference between the control and the ei,eiLmen 'al periods was , statistically sliniiiccnt (P i O .Oj) for mod rate .y advanced, active tuberculous women (Table ll). No particw ar effort was Mai to persuade the subjecs to eat foods which were hi ;h in carotene during the exherimental periods other 1 the request to eat all of the foods which were serve u to them; the in~ crease in serum carotene durinr the experimental period may have reflected the interest of the subjects in the experiment and therefore, an increased intake of green and yellow vege taoleS. For women with far aova r:ced, active tuberculosis, the average scrhm carotene values were 153, 117, hS and 91 microErans during the control period and the periods I, II and III, reapectivel;. thhough these values indicated a reduction in serum carotene, analysis of variance indicated 'that there was not a statistically signifies nt difference between the CHDntrol period and the eyt1 II..- «‘ 102 necessarily increased for patients who already accepted foods as milk, cheese, meat, eggs, poultry and fish. Thus,the concept of improved diet as defined in the plan for the study was not achieved uniformly for all patients; that an improved diet with reSpect to certain nutrients was achieved for many of the patients was indicated by the analyses of vari- ance which have been discussed previously. The dietary plan for the experiment did appear to accomplish the maintenance for the four-month experimental period of a diet which supplied generous intakes of nutrients. There were a few patients who did not c00perate fully with the experi~ ment; surgical treatment also interrupted the experiment for certain other patients. Mean values for blood hemoglobin, serum vitamin L, caro— tene, protein, ascorbic acid and alkaline phOSphatase at the end of the experimental period were comparable to those of healthy individuals. This appeared to indicate that low blood values among tuber ulous patients such as have been reported previously, may be associated with the plane of nutrition of the individual, rather than representing a condition which is obligatory with tuberculosis. Intakes of the various essential nutrients during the experimental period were generous and allowed a liberal "margin of safety" over the allowances for healthy individuals recommended by the Foods and hutrition Board of the National Research Council (1953). however, the intakes of nutrients were less than have been reported by certain other investi- gators in studies of nutrition in tuberculosis. For example, Gets (19h9) supplied vitamin.a supplements of 150,000 International units per day in his work; Pottenger has advocated the intake of 223 grams of protein, 3,th0 calories, 3,007 millipéams of phosphorus, 29 milligrams of iron, and ht milliqrams of niacin per day for tuberculous patiexts. Insofar as could be judged by the concentration of certain blood constituents and the clinical prorrcss of the patients, the mean dietary intakes suppliedduring the experimental period rere adequate. There would not appear to be a: advanta e for increased intakes and there is the possible disadvantaae of anosinq stress on the oody of the tubercu- lous patient cy "over-loading" with nutrients. however hirier intakes of vitamin a and ascoroic aciu are necessarv ._ J 3 for tuberculous patients than healthy individuals for the maintenance of blood concentrations of these vitamins at values comparable to those of healthy adults. It is uncertain whether this reflects increased re— tention of these vitanins in tuberculosis or possibly greater destruction of the vitamin in the metabolism of the tuberculous individual. Influence of other factors on blood constituents £52: The possible influence of sue on the concentration of the various blood constituents was investigated in an effort to determine whether or not the observations which Were made in relation to the in- fluence of dietary intake on blood constituents were influenced by the age of the patients. For this purpose, the subjects were divided, according to age, into three classes: 15 to 2h years of age, 25 to L9 years of age and 50 to 7h years of age. The average concentration of blood constituents for the women with moderately advanced, active tuberculosis according to are is presented in .t 30‘ .0 mafole lh. L high hemoglooin concentration was found for women patients y from the age of SC to 7) years timoughout the entire study. ihe higher L l C hemoglobin concentration in the older wumen patients probably was re- lated to the cessation of menstruation. Vitamin A and serum alkaline phOSPhatase values also were hirher for the older age group than for the two groups of younger patients. The serum ascoroic acid in the control period was higher for patients in the age ranges of 15 to 2h, and 25 to D? years than for the older patients. The mean serum carotene values for the control yeriod and the experimen al period were less for patients in the age range of 15 to 2L years than for the other subjects. ‘rhgre was no apparent difference in serum protein values which was related to the age of the patients. The average concentration of blood constituents for the women with far advanced, active tuberculosis is presented in Table 15. however, there were only four patients in this group and the age range was from 23 to h3 years. The data have been presented to facilitate comparisons with other groups but no attempt has been made to associate age with con— centrations of blood constituents in this group. The average concentration of blood constituents for men with mod- erately advanced, active tuberculosis according to three are ranfics is presented in Table 16. There was only one subject in the age ranre of 15 to 2b years. Blood values for this subject were similar in the con- trol period to values for other subjects. hean hemoglosin values for 1er in the control and exocri- subjects, 25 to h? years of age, were his mental periods than the mean values for subjects, 50 to 7h years of age. II." ~ I? Forrl u alrfl mpflqD Houmgmoppflz $ Ox.H 44.H mod Hm mm.w m.ma m HHH UOHLQm cm.H o».H moa NJ mu.o mm.nH m HH wowpom ww.fi QQ.H 50H .mm Hw.w 0J.mH m H UOflpo, mm.m m~.o mmH mm mw.o NH.4 m fiOflumm Hoppgoo mm.H mm.H rma ma ”v.0 om.ma o HHH UOHpom 00.H mm.a MHH mm mm.) MN.MH w HH VOHpmm mm.H A0.H pmfi a; ow.w wg.ma 0 H doaamm mw.a mm.o mm gm om.o 44.ma a Uowumu Hopucou mpw;L m4 ow mw Ho.H mm.fi mp m; oo.o 00.4H : HHH weak»; om.a mm.a ow pm Hm.o 00.:H : HH vOflpmm mn.fi mN.H HOH cg mw.w 0H.ma g H wOfigmm H(.m Hm.o 3“ mm mm.> mm.ma d U tha Hoapcoo Luck am op ma mmfimp HomwAQOLPwa .HE OOH..nE .HE Qua mfiéh.fifi OOH_m:éH.HS DQH\.Eu .HE OCH\.Em vOHpmm enmymflpmoam mafiamxaq vac; owmpoomm mcowohmo a cflampfi> Qwopopm aflpoauogm: mpommodm dam Espmm Edpmm ESpmm ESLom ESme mo .02 mpommnsm mo mud mHmOHdUMmpza m>Hpo« «smocmbdq hampmpmvoa :pfl$.c@Eoz mo meQSPflpmcoo wooan Camppoo mo mmw op mnflwpoooq soapmhpsmosoo mmwpm>q mza 4H mfiama ti; 5!} ). O \.I.. \ 1‘: I!!. \II. ). I j) \I} .. w ....., .H v.2...“ .02. Or N (fr ..H m HH.H pkflh L. 1 .. . :1 .. . . . .,\.1 . .11 _.. - ) ...0 Hm.H HRH 0H 0H 0 s 00 H .- 0HL0H .H.H 00.H H.H -a H..0 00.0H m H .0Hu0H z .Iql .\. — .l... .‘FJ . —\I.~.\ q ~.u.l150.\l ').H)Q ) o 0 0w 0 0m. 0. H» N C .H . .0TxCH H-.-H0 u ._ 9-. 3|). via-PRO rl. C.. JQ.N mm.H ox 0m Dm.o mw.qH CH HHH fiowpmm ) . . O In-.. I .1 \. H;.H Hw.4 ; PH am.u mm ma Ha r. o.m:m \ ‘L r .k‘ p .. VA . 0.! I. .1\ .. a) u. -1 <,.).Iu_.)l \flOH DH PI A). .f .. 45/. m \ r. .wr .. ._:.\r.\_p\_.n\..- ! \I' v. . O .. \Illl r\. )0 \Ic‘. \ 0H) :11. .1 41 \J. 0. r - C we ... m a. ”H ma 50fl&-m Ho;-;o: 4 \ ;. )1. 11H .\.J \/o 0H! 4. ...1. .3. H 0. 0 00 i ... b... 00.000 . I I/\ '1 VJ .H) . I11 I) Q0.H 0.0 0w 0. mm 0 m0 OH H HH 00.;0m L ...I1 \W‘. \ {CI “1....H mil.\ II \.I H. H. up H O... :4. L . w 1w 0. H. m H «CHEM Q... 0.-.... R6 0., 0m 00. 0 8. 0H 0. 00-. .1 H0030; . ( . C 5 \ N r 4 l. - mrhhxc..! 40' x .._r 1 [1 I\: I.l\;|v.),.| 4.) {)Ial.‘ . \ I/I‘I . . . ‘ tin-.4 \/ I‘ll ..%"\I .I I111. III \H WW 1.! \A. I. . . ,J '10.. ICI ‘n. 0‘) WL... C: FCC. u. ..LC.\_.+ TH o HE ....r(. r 0 PL... 0 Fr.» .r.(.. ....\ .L LC» 0 hr.» 30 _r\ or. OE . .4er (7V r\ a Ch... 0 re... 0.). .r 0 7.6L _. IOHCFH. .1H mm 9 H,moflm QQHHmHHH flfloH OHmhoomH muo0o.umo H cfiwupfl> afimpomm .Hpoaroaoz mpommfism arm I ‘ f1 .. u. 1} 3 \t. J. Pagan %:$c- fppqm ESLQm fiqum mo .03 mpooqnsm mo c-. mamoadomm:s PH. m>fipoa HUmocm>dq hampmmmcod Gm: M0 m. Caspapuioo Sacra CHQPLQQ mo mm; 04 0§Hdhooo. Go .pmh)c Q03 mm. f> 959 r. r» 3H mHom :H noweVer,the mean values of Serum alke he }fl 05 iatase were higher in both the control and the eAperimentel periods for subgects aged 50 to 7a years than for subjects aged 25 to #9 years, lhere were no apparent 1‘1 differences in mean values of the OM16 blood constituents between the r‘ _1“‘ two age groups, 25 to h9 years and 50 to (hye'.1s. hean concentrations of blood cons;ituents for men with for advanced, active tuberculosis grouped according to age are ores ented in T able 1?. keen values for hemoglOoin, serum protein, vitamin L, carotene and as- corbic acid were hitji er in corre :sonding periods for the men aged 25 to L9 years then the men eyed 50 to 7h yea rs. TleF was not a consistent difference in.mean values of serum a"kaline phosphatase'with age. The number of sutwjects within e: ch awe range was too small for the various groups to justify a.more pre “cis e evaluation of the relationship of ezge to the COHCC ntretion oi' olood constituent. Since difference in clood values corresoon"*n to difierences in age were not consisaent among the grOUps, it is doubtful that the apgflar3nt dif1‘erences were truly V O differences associated with 6:0, BOth t-emr +rcf1r1. Tie nossiole influence of body temperature on L the concen ation of blood constituents was investigated among those patients whose records indicated that an elevation of body temporeture had occurred during the experiment. Records of the moon body temperature for the individual patients durirg the control and experimental periods ‘ V o n u o 3 l and on the test days at tne end 01 eacn period are given in Taoles a? 1r" . .1- ~° and do of the xppchlX. .‘3 ”i 1 l N es.fl em mo mm.o m1.mH m HHH soatoe m am.o H5 as 03.0 00.4H s HH sesame H eo.a Hnfi Na m;.o 01.mfl m H ecuhms m ms.g 90H so mm.» N».NH m echoes Hoosaoo meter is op cm om.a th He efl.e sm.ma m HHH venous m. 1r. 31.. Hm o1... . 00. S J. HH eons. mo.a med e1 mH.e om.mfl m H eoflsmm Hm.o HHH mu mH.e wm.ma o eonsmm H tacos ms mm1m; op mm -- n- a- -1 u- o HHH sesame oH.H am so NH.e 91.3H a HH soups» mm.fi mos mm mo.e wa.3fl H H scheme mm.o us mm oe.~ oo.na H eoflsom Hoooooo memo; 4w 0‘ 1H nope; .He eon ..1 .ma cafl\exah.fie can moe1.fle coa\.:1 .Hq ooH\.ee senses wJHfl Wfloq oflmmoom. mquwohma « swfimpflb swopohm Qfluofluofios mpoomndn one isomn fidsmm Espom Sonar mo .02 mpoomodm mo ems memoasoooosy o>flpo4 «doomsbsg ham 0 mesmSQHpmsoo wooao oflmppoo mo om; op monsooooc soaomoosmosoo mumpe>s one NH eflfloa 'fif a. O 2‘». 911;, . ‘ ,, .. 1 -;1 . .5 ,. . 1 . ,’ — >.,.« ' .-‘\ -- .mgvenr15dt 11L5 1180.1130r11uOLQ t111p r LUi e) vfl11(IIEICI(3 CJJTVolAflJ eLADVe .O I 1", ,- v—‘r‘ 'r. . . 1 .— : _~, 35 ...'»’ ,7 _‘ -1 ‘- ‘tr -1. 1. ‘ " ‘ _ 90.0 had rCnhCit in one 0? pore perious Oi one study. nod; temperatures were measured at three o'clock in the afternoon and 98.60Fz—hren11eit was assumed to be "normal" body temperature. Variations in blood constituents for women and men with active tubercu- losis and with fever are giv n in L'aLl lo and 19, respectively. Three female patients; AGO, Ea and LI had slight elevations of body temperature on certain test days following the various periods, Ltypical values of the various blood constituents did not appear to be associated with these elevations in body temperature. One female patient, LU, had a.mean body temperature which was elevated during the control period and.period I wuen she was studied as a patient with far advanced, active tuberculo- . o sis. der body temperature was lOd,h Fahrenheit on both test days follow- thesc two periods, Lower serum ascorbic acid, vitamin L and caro— tene values were observed for this patient in period I than in the con- trol period. This patient died after period I and the lowered blood values and elevated bocly tem11er 2.ture ooserved for this patient in period I probably were associated with a progressive stage of the disease. Three male patients had slightly elevated bony tense raturcs at v --~ ' vr intervals during the study. One patient, Dlh, had low serum vitamin A , ' O and carotene values whe n ther vies a.mecn bony temperature of 99.3 Fain enheit. erum ascorbic acid, blood hemoglobin and alkaline phos- phatase, however corre snonded satisfactorily with values of other patients. Subjects hi and LB also 119d low serum vits1min A values on the test days when an elevation in body temperature occurre‘. Variations in other blood constituents did not appear to be influenced by body temperature, lll nmocn>em mHopmpoUod \. (\1 .-{ Dr‘ir‘ir—i {JUHH t.) ,~ (\I d.H.' . [—1 r\_ C) r4 H r—i Hr'irrlr—‘i J o I) 7\ O ) r‘i r—" C) C‘\1-\~: O U f. K, ('\ _ ') ‘-._~) .-:J C) x.) I.‘\ I.“ r4 H r-i F'i \? .L L \L J1 ) r... 11 _. .LLL 4; rt (\J ’J m (\J O _.) N r4 0 \O [\ 3 £5 we mH.m :4 0H.» am no.i \ J “H. N :J... .)\.n XV Gin. N no mm.w mu 0m.» R 8.0 m4 ofl.m \ \ Hm v.0 L- I... “N QC mu ‘P.J'\ fl) Ln u.“ . (\J (\l H H D \ if (\I on P+r+r+r4 ) . _,\ O .4. J \O.T. n.e H .4. r. 01!! ”PU .1. .r A... . ALH o«.aa MN.MH o.mHL \l).\ ed nH r ~J . \ ‘4 CH O \O \J _ 'LT\ [\7\ C“ e. s. 0.5m 1% o.mm a.wa s.mm 0? .«.e Honpeon 4; 4- .7 4.x Hoppsoo g: HHH HH H 4.: Happens ch ,, m1...) LOT I 441:4 .TF 0 u \ II I «11.4 bHoe Hpmoom _OH\moE o1.>o:mo cHLHQm H._LL. CH\mOE. HE O..UH\ r& .W Cl. .r_ .».r.( Maggi»? c ormg) OPHm LHDLWGM. :CHSLOW ooH\.Ld fiHHOOHL. ”\(r( L L L; fwd \J LHQLa 1 IO“!!- Table 19 tuents of Tuberculous i Variation of Blood Const f‘ \ serum Ll!allno Y bony I Serum 1 berum ‘4 who Temperath 0) +3 °r—1' 0) £3 U) .33 Cu +3 H G.) O .51 C. .2. G) U) A O C? C? O rl-I rt—1 4.) -H rLj' 0H . 0 Ft! -: L‘ C) :3 0H C. ,Q r-1' :4 \.\ O O o t: <0 ii ‘4 O 9 L Q) ~- +2 if; 0 J. :4 {as C) “O <3 8 I <1; H t; C If? '15:]. fi’ 1‘; “(fl 23’: :> 9 I d L: t4 ‘H G) O +J 3 O {—1 $4\ CLO o E. C rj H L ,C) O '3 r40 {1.. (—1 O \‘ E - m a .43 " 43 U) :3“: (‘5 (U -p'c 3-3.. ° GS C) 'U 9':- m L\- (D U) (‘0 CH 0) O U) 'r“! {3 ":5 O -r-{ 5.4 (2) Cl. 4.) O (D 'l") ,O U) C! Cr C) :1 (\J :3 ‘-.r _;j r4 N H r"! ’\ .de' ') m (”q k\! 0 O 1 A!) 0/“ C ., I _- 3 13 133 13L 1 C \-: .E\ ._I I ‘ .l. 4. 47 "IH 1_.’\ an ;_‘3 In _.A'.; r‘{ m H D—o~r~r~ trva‘omu (\l C; '\ ‘_:‘\ O o o o -i 5/“ V3 (.0 C)\ 3\ C‘\ 1"I\ H O ‘3 H o :4 +3F1FIF4 Q r4+4 0 +4 0 (bfiD'QfiD :1 3f\ L" \ ) O O O 0 r4 H r-I r‘l ‘l r\ m m 1;) fl (\I'Ji)[\1 O O O QQOH "momm LAQJNI (fi '1.“ ‘3’“ \O (Y\ (N (“N r‘! a) (\J (\I ‘|I\ I . ;) '_r\ b— . O O O O r“ O L’\ In '..’\ ‘.r\ w . O O . (V\ _j‘ . :1 LAN _r“l H H H -3? \O \i) (\J o o 0 ca Ox o1) Ch 0\ O\ O\ O\ \0 O 21‘ r-1 0 o o a 0..) Ch .3 C)\ O\ C}\ (.7\ :7\ N O {14 H O 5.4 43 H }--l H 5:: H E-J. O E-i C.) i (\l r~ f—a (-4 .-4 :jofira ONONim r1 1n ,4 .V O O .V\ _ o In 0 ( f_\. 7 'C V107 v 13.30 L,CQ lo,C 4/ 0 L1 \J \ ¢ / ,‘ ' V{{ .1) J 99.2 -3 m C) m o o o (h kL') CA_) CR 0\ CR -PIH}A ill .11 ) 1 i 0 (~ \1 m i.) i r. E.“ 2 l 97.L -_C) Q\ 54 '4 k4 aovance O. V 1 _ mousretely 112 113 Save cTi-lfl of disease: The relation between degree of severity},r of tuberculosis and the concentration of certain constituents in the blood of tuberculous patients has been reported by a number of an’j -stL atcrs . Getz 33 El. (19';} 1) found that alrura vitamin n was related to the sever- ity of tuberculosis, L positive correlation between staxe of disease and asco roic acid in tne blood has been reported by Kaplan and Zonnis (1M0). Lccordinb‘ to may 93 93. (19111-), Liurf rd (13215.), and Shaw 93 93. (1.9310), there was little or no correlation between the stage of tuberculosis and blood constituents. In the study of Shaw at tel. (13 )0) onlv leho,lob1n showed a relationship wi oh the stage of tuberculosis in that lower con- centration of hemoglobin occurred in the patients with far advanced, active tuberculosis. It is recornized that tle clm {ii mo tion 01 tuberculous patie ents as "moderately advanced" or "far advanced" is d epondent u1on various factors and does not represent a sharp distinction in degree or stage of disease as perhaps has been implied in tne nresenta :tion of these data , heverthe— less the classification of patients into two such groups makes it possible to relate, to some extent, the severity of the disease to the concentra tion of blood constituents. Comparison of the blood constituents of patients vith moderately advanced, active tuberculosis with-these of far advanced tuberculosis was made statistically by analysis of variance. Table 20 gives the analysis of variance of blood constituents of tuberculous women. The hemoglobin concentration in the blood was significantly higher (P i 0.05) for the moderately advanced, active tuberculosis women than for the fa -r advanced, 111 19919 20 Summary of analyses of blood Constituents Data for Yemen Patients Hith Active Tuberculosis between moderately and Far 1dvanced Stages Source of Variation F Val 3 Predicted Obtzined B .05 F .Cl For Control Period Ehnuoylobi11 5.2L? h.hl b.2t Serum protein l,CO Vitamin L 3.53 For Experimental Period _,J \fl 0 \ Memoelobin 0,21 3.l9 Serum protein 2,30 Vitamin a . 0.10 Carotene l,ho ascorbic acid O.bb PhoSphatase 2.Ub 115 active tuberculous women in the control period. There was not a sig- nificant difference in any of the blood constituents between the moderately advanced, and far advanced, active tuberculous women in the experimental periods. The analysis of variance of the blood constituents of men with moderately advanced, and far advanced, active tuberculosis is summarized in Table 21. The hemoglobin concentration in the olood w'as signL icant— ly higher (P‘S.0.0S) for the men with moderately advanced, active tubercu- losis than for the men with far advanced, active tuberculosis in the con- trol period. In the enterimental periods, the hemoglobin concentration in the blood was also significantly higher (P‘E.0.0l) for the men with moderately advanced, active tuberculosis than for the far advanced, active tuberculous men. The fact that several men with far advanced, active tuberculosis were lost from the experiment in the last period and the fact that two of the older subjects with far advanced, active tubercu- 108 is who had a comf>aratively low hemorlobin values dur inv the exyeriment may have accounted for the sivnificant diff,rence of hemoalobin in the blood betareen the two groups of men patients in the experimental periods. The serum all :aline pho spl‘. atase was significantly higher (P 5.0.01) for the men with far advanced, active tuberculosis than for the men with moderately advanced, active tuberculosis. Several of tie men wit h moderately advanced, active tuberculosis had higher serum ascorbic acid values than the men with far advanced, active tucerculos is in the control period. The fa ct that the serum ascoroic acid failed to show a statistically significant difference between the two c oups ma.y lave C) r\-‘. f ladle Al ‘ \ «1nd 351‘.“ LUV: need Uta/ES .1..! C.) - of JUEl sis of Variance of cloud Constituents for “en Patients With lctive TerrCulosis setween nederately Source of Variation E Value f V'._,,._V. ,3 wt; valued. Predicted .05 .F .01 For Control Period Hemoglobin 5.3;“ ‘1 . (\ oerum protein l.lc Vibfirnin I (J .‘c-‘L; Carotene 1.53 fscoraic acid 1.50 Phosyhatase 11.3” For prerimental Feriors nemOglobin $.31 Serum protein O.C3 Vitamin 1 .25 Carotene 0.96 ‘ C" r3 117‘ . "A . I} f) r" 'Z .'-qu1. ulC 0-Clu. L- .l w: ya ,- C (/1 '1': h“ w (w (+ C) m (L‘ f“. V O 0 \e 3 .11 l: . 3c L been due to the wide variations of the individual serum ascorbic acid (range, 0.08 to 1.9h milligrams per 100 milliliters of serum) for the moderately advanced active tuberculous men in the control period. ) The fact that observations for a control period and period I were obtained for subject hU as a.patient with moderately advanced, active tuberculosis and again after the tuberculous involvement had progressed to the point that the patient was classified as a patient with far ad— vanced, active tuberculosis made it possible to compare the concentra— tion of blood constituents for a single patient at two stages in the severity of the disease. Values in the control period for subject hU when the tuberculosis was moderately advanced were 11.25 grams of blood hemOglobin, 7.22 grams of serum protein, 33 micrograms of serum vitamin A, 155 micrograms of serum carotene, 1.22 milligrams of serum ascorbic acid per 100 milliliters and 3.00 nitrOphenol units of serum alkaline phOSphatase. nfter period I, her blood hemoglobin and serum ascorbic acid increased to 12.75 grams and 1.68 milligrams per 100 milliliters reapectively, and the serum protein was unchanged with a value of 7.23 grams per 100 milliliters of serum. The vitamin A and serum carotene were slightly decreased to 26 micrograms and 138 micrograms per 100 milliliters of serum and the relatively high serum alkaline phOSphatase value was decreased to 1.30 nitrophenol units which was in the range for healthy peOple. She left Ingham County Sanatorium after period I and transferred to Michigan State Sanatorium. lfter five months, she participated in this study again as a far advanced, active tuberculous subject at the nichigan State Sanatorium. it that time, her condition ll; was quite serious; her body temperature was as high as thO Fahrenheit because of the infection between the lobectomic Spaces. Intakes of all the nutrients in this control period were less than in the control period when the tuberculosis was moderately advanced. her blood con— stituents were comparable to values for the control period when the tuberculosis was moderately advanced except for a relatively high serum carotene (37h micrOjrans per 100 milliliters) and a slightly lower serum protein value (6.70 grams per 100 milliliters). The serum alkaline phos~ phatase had remained within the range of values for healthy people and was 2.20 nitrOphenol units. In period I, her food intakes were increased, ‘4 particularly for iron, vitamin A, ascorbic acid and niacin which here higher than in the period I when the tuberculosis was moderately advanced. her blood hemowlobin and serum protein were increased from 12.50 and 6.70 to 12.75 grams and 7.18 grams per 100 milliliters, reapectivelg. however, there was a reduction of serum vitamin n (from 32 to 26 micrograms per 100 milliliters), serum carotene (from 37b to 219 microqrams per 100 milliliters), and serum ascorbic acid (from 1.28 to 0.59 milligrans per 100 milliliters). Serum alkaline phosphatase (1.66 nitrophenol units was in the range for healthy persons. Serum vitamin A values indicated that there was disturbance of serum vitamin A metabolism in both the moderately advanced and far advanced stares of tuberculosis for this patient. hetabolism of serum ascorbic acid and the ability to convert carotene to vitamin A were disturbed when the tuberculosis of this patient progressed to far advanced stag . The other blood consti ucnts did not show disturbance in this case. Clinical proeress of the subiects medical histories of the patients were examined at the end of the experiment and an evaluation was m aie of the c1:iImi a1 progress of the subjects. Summary of heapital records for each subject are given in T ables A9, 50, 51 and 52 of the ippequix. The disease was arrested for one subject dur'ng the period of study; according to medical records examined one month after the end of the experiment, the disease was arrested for nine additional sruitnts who were disch£1.rged from the senatoria to their homes during this period. Eight of the nine patients who received surgical treatment during the course of the study have progressed favorably in their recovery from tuberculosis and three of them were as Ion: the group who have been dis- charged from the sanatoria. The other subject, hi}, who received sul; ical treatment transferred to a sanetoriun in Detroit in period III and his progress was not followed. The clinical prosress of patients whose food records indicat d particularly poor dietary habits oreccolrc the eXperime nt was examined in relation to Chang es in blood constituent sduring the study. Subject DCU had a record previous to thee experiment of poor food habits, primarily because of bad teeth. She received dentures during the ‘xzeriment. There was a marked increase in food intake in period I. an Operation once in period 11 and wlice in period III; her food inta1:e was lowered at these times although her food intake had increased again by the end of period 111. her blood hemoglobin and serum vitamin A values were low in the control period out iflCTLWE ed in the experimental period; however there was a reduction of blood hemoglobin again in period Ill which probably was associated with the effect of the two Operation U: 0 Subject DU, who did not eat citrUs fruit had a very low serum ascorbic acid of 0,26 millicr ms per 100 milliliters of serum in the control period. after 150 milligrams of ascorbic acid were given to this subject as a dailv ascorbic acid surplement, her serum ascorbic acid val— ues were increased above 1.0 milligram per 1C0 milliliters of serum throughout the Study. Mar progress in recovery from tuberculosis appear- ed to be good. Subject hO was a female patient with far advanced, active tubercu— losis who had low blood hemoglobin and serum ascorbic acid values because she did not eat meat and citrus "ruit. .Lftcr the vitamin supplement and protein mixture were added to her diet, there was an increase in blood constituents. This patient showed satisfactory clinical progress during the experiment. Subject CZ, who disliked citrus iruit, had the lowest serum ascorbic acid of 0.05 milligrams per lOO milliliters of serum in the control period. Lfter the dietary supplement of ascorbic acid was given to this‘ subject, his Serum ascorbic acii was markedly increased. dis progress in recovery from tuberculosis was favorable in the experimental periods. Subject Hi disliked neat, egg, liver and citrus fruits, but was ) 1 very fond of milk and had about ten to l2 glasses a day. His daily iron . ‘ /,’ . ~ . 1 ., ‘ . . . . . y intake was n.09 milligrams, and the daily ascorbic aCid lHtELG was only 33 milligrams in the control period. In addition to the vitamin supplement, 121 he received 12 milligrams of iron during the experimental period. it the end of the experiment, the concentration of blood constituents was similar to that of healthy individuals. This subject was a young man with moderately advanced, active tuberculosis. This was his second sanatorium admission; two years previous to the study he had been ad- mitted as a patient with far advanced, active tuberculosis. His progress in recovery from tuberculosis appeared to be favorable at the end of experiment. During the experiment, the patient developed a willingness to eat eggs but it is doubtful that a.liking for meat was develOped. Another subject SC also did not eat meat, egg, liver and citrus fruits. His blood hemoglobin and serum ascorbic acid were low in the control period. There was a satisfactory increase in blood constituents during the experiment and progress in recovery from tuberculosis was also indicated in the experimental periods. This patient also showed a marked improvement of food habits in that he learned to accept meat and eggs readily. . The healing process in tuberculosis is slow and affected by multiple factors. However, the X-ray findings and case records for all of the other subjects except two indicated that the clinical progress in re- covery from the disease was favorable. The two exceptions were subjects HU and.h£. There were only two subjects whose sputmn tests continued positive throughout the experiment. Subject EU, the 13 year old white house-wife, never felt well after a cold which developed in l9h9. She was admitted to Ingham County Sanatorium an February 19, 1951 after a diagnosis of moderately advanced, 19’) (.4... active tuberculosis. Immediately ajtgr admission, a right phrcnic nerve ’5) was crushed, st1cptom.cin thera;:y was initi ted but discontinued after one month because the oatignt was alicr5-c to the drug. 5 rlfht upper and middle looectomy was done in late ljjl. n tonsillectony was oer- formed on April, 1952; and she had a.tenperature of 1020 Fahrenheit to ‘ 0 V 10h F .r m eit l-ollo ring the tolls iiwtto ihe resected .onsii showed iloro-cultncliou tuberculosis. Productive couzh continued and th; sputum remained positive on routine microscopic examination. The patient joined this study on October 1952; a low seruzl vitamin a value and a relatively high serum alkaline phosphatase value were found for the con- trol pa oil but there was a decrease in Scrum vitamin r, serum carotene and seru: alLali ne lhOSphatase in period I. The patient eft Ingham County Senatorium after period I and transferred to hichigan State Sana- toriun. The LchIOolS at that time was bilateral for advanced pulmonary tuberculosis There was a definite fislulous tr act between the lObGCtOLlC Spaces; th patient felt severe pain in the lateral chest and ha ‘ a L G) temperature of IUhO Fahrenheit. The patient UcTLLClhablu in this study a.gain in.zugust 1933. She showed a low Serum vitamin L and high serum ' carotene in the control period and period I. her serum ascorbic acid was decreased from the control period in p rice I although 1er ascorbic acid intake was high during this interval. She died during surgery after period I. Subject hi was 8.57 year old man poorly nourished and a heavy drinker and smoker; he was admitted to Inghzm County Sanatorium in august 31, r r-r) My, 1' , ,. ,..,._rl.‘ , ‘. . ,, ‘ ,qi.) _ 9,. “(a 1954. in: i—ray UAtminatlun showed active ier arlvanc;:d bilateral cavernous pulmonary tuoerculosis with a lar e cavity in the rifint lung ' n- .‘ . .. 1 . 2 .i i. .- . ->, m. .: , C. -r. ..1.,.., .; -.. eitenoing dean to the tiiro ance ior rio. ine prbdfl has WdlAteJ 5 positive on microscOpic exanination and remained so consistently. t was placed on complete bed rest and given streptomycin therapy. he joined this study in December 1952. he had a slight elevation in bod; \0 temperature to 99.30 Fahrenheit and 9.20 Retranheit during periods I and III reapectively. his hemovlobin value was 13.50 grams per ltO milliliters of blood in the control period and 15.25 grams per 100 milli- liters of blood at the end of the experiment. His serum protein value was in the range of six to eight grams per 100 milliliters of serum in the first three months but decreased to S.QS grams per 130 milliliters of serum at the end of the four—month. he also had lower serum vitamin A and carotene value during the periods when his body temperature was ‘ O 7“ ~ l 1 " t - a o - r o . pahrenheit. his serum ascoroic seid was O.&S millirrams per above 98.6 100 milliliters of serum in the control period and increased to O.&3. 0.73 and 1.38 milligrams per 100 milliliters in period I, II and III reSpectively. nccording to the X-ray film, the cavity on the right lung increased somewhat in Size during the study period. The prognosis of his tuberculosis was quite unfavorable. The patient lost 50 pounds before he was admitted to the sanetorium and did not gain any weight during his stay. The changes in blood hemoglobin and serum ascorbic acid are of interest in relation to the reduction of serum total protein and the failure of this pat’ent to show favorable clinical progress. It is un- fortunate that the serum albumin—globulin ratio was not determined for this patient during the eXperiment. His cooyeration with the experimental plan in terms of food ascertance was quite good. horther n.hey 26, 1953 for this subject. Later, h n.hiohigan Senatorium in Suptemler 1:, 19 ."I l, I / r5”! 1 L38 sxyeriment was s transferred to the 3 and died in October 125 SUfifih I LED CGNULUSIOQS The influence of an improved diet on the fasting blood content of hemoglobin, serum total protein, vitauin a, carotene, ascorbic acid and alkaline phOSphatase of 53 "omen and men with moderately advanced, and far advanced, active tuberculosis was studied. Thirty-one of the sub- jects were bed patients at the Ingham County Sanatorium, Lansinq, hichigan and 22 of the subjects Were bed patients atiiichigan State Sanatorium, fiewell, hichiean. Patients from the two senatoria were grouped tonether as follows: women with (a) moderately advanced, active tuberculosis and (o) f'r advanced, active tuberculosis; men with (a) moderately advanced, active tuberculosis and (b) far advanced, active tuberculosis. Lges of BA male subjects ranged from lb to as years and of 19 female subjects ranged from 13 to 55 years. Irregularities in the experimental plan develOped for fourteen patients; some had surgical treatment, others left the sanatoria against medical advice and one patient died before the end of the study. The average daily dietary intake was calculated and the fasting blood constituents of hem05lobin, total serum protein, vitamin A, caro- tene, ascorbic acid and alkaline phOSphatase Were determined for each subject during a seven-day control period. hodifications were wade in the regular hOSpital diets of the subjects so that a generous intake of nutrients was supplied to all subjects during the experimental period which lasted for four months and was divided into three periods of six weeks each. At the end of each period, a seven-day food record was obtained from each patient and the dietary intake was calculated. Also at the end of each period a blood sample from each patient was analyzed for hemoglobin, serum protein, vitamin L, carotene, ascorbic acid and algaline phOSphatase. A comparison was made of the food intakes of oatients during the l. control period and during the experimental periods. dtatistical analy- ses indicated that the average caloric intake was increased for women with moderately advanced, active tuberculosis and was maintained for the other three groups in comparison with the control period; the averaoe daily protein intake was increased for both groups of women and maintained for both groups of men; the average daily intake of calcium, phOSphorus and iron was maintained in all groups; a vitamin supplement containing vitamin A, ascorbic acid, thiamine, riboflavin and niacin was given daily during (D the experimental periods. Patients who were in the lowest ran; of nutrient intakes in the control period had the highest increases during the experimental periods. Statistical analysis indicated that modifications in the diet were effective in increasing he concentrations of hemoglobin in the blood of men and women patients with far advanced, active tuberculosis. The average values for women with far advanced, active tuberculosis were ll.t8, 12.35, lh.75 and l3.b8 grams per 100 milliliters of blood; for men with far advanced, active tuberculosis, the blood hemoglobin values were 1h.l3, lh.26, 15.61 and 15.65 grams per 100 milliliters of blood in the control period and periods I, II and III reagectively. mean H 3 \1 blood hemOglobin values of patients with moderately advanced, active tuberculosis were comparable to those of healthy adults in the control period and there was no significant change during the experimental periods. There was no change in mean serum protein values in the ex- perimental periods as compared with the control period. The mean serum vitamin a for women with moderately advanced, active tuberculosis was significantly higher in the experimental periods than in the control period. However, no difference between the control and the experimental periods was found for the other three groups; mean serum vitamin L values for these patients were comparable to those of healthy adults in the control period. The daily dietary'supplcment of 150 milligrams of ascorbic acid during the experimental periods resulted in a statistically significant increase of serum ascorbic acid values in comparison with the control period. There was not a significant difference between the serum alkaline phOSphatase values in the control period and the experimental periods for any group except for the women with moderately advanced, active tu- berculosis; this group had a higher mean serum alkaline phOSphatase in the COn rol period than in the experimental periods. Ledical histories of the patients indicated that the clinical progress in recovery from the disease was favorable during the experi- mental periods with the exception of one subject who died during the experiment and one subject who died five months after the last experi- mental aeriod. . 24.1 . llip‘ ; , Frrhhuhr‘ . -") (J I. \1 he results of this investigaLion indicated that the nutritiona status k' l (i ‘i with maintenance of the blood constituents in tubarculous patients at values comparable to those of healthy individuals, M‘Liill‘CL-JS CITLJ fibels, d. 0.. L.ff.tknlun. C. T. Peck, and C. P. Lhoads 19hl: hetabolic studies in patients with cancer of the gastro- intestinal tract. I. Plasma vitamin L. J. Clin. lnvest., 22, 7h9. Adarson, J. D., N. dolliffe, H. D. Kruse, O. h. Lowry, P. E. hoore, 19h52 s. S. Platt, W. n. Seorell medical survey of nutrition in uewfounuland. Canad. m. L. d. s_ 227. Adlersnery, D.. H. Sobatka.and B. Bogatin l9h5: Effect of liver disease on vitamin n metaboliSm. Gastro- enterology, A, lot. Lnderson, R. K. and D. F. hilam lyub: Biomicrosc0py of tne eges in evaluation of nutrition status-- conjunctival changes. d. nutrition, 30, ll. Baldwin, R. W. and C. N. lland 1933: nlectrophoretic studies of the serum protein in tuberculosis. Am. Lev. Tuberc., Ct, 373 Beck, J. and M'. Wishart 1951: The hemorlobin concentration in blood of male and female students. Brit.1kxh J., i ‘ Bessey, O. A. and 0. H. Lowry lib): biochemical methousin nutritional surveys. Lm. J. Pub. health, 35, 9L1. jessey, O. L., 0. H. Lowry and E. J. brock lyhfi: The determination of ascorbic acid in small amounts of blood serum. J. biol. Chem. 1-0, 609-613 0‘ Sessey, O. L., O. H. Lorry and M. J. nrock l9ué: A method for the rapid determination of alkaline phOSphatase with five cubic millimeters of serum. J. 5101. Chem. l;£, 321-329. 1. . LOpeZ te e in small quanti- bessey. O. A., O. H. Lowry, n. J. Brock a . 19L6: The determination of vitamin A and o ties of blood serum. J. diol. Chem. 166, lYY-ltt. 130 Bessey, O. h., 0. a. Lowry and.h. J. Brock l9h7: The quantitative determination of ascorbic acid in small amounts. J. Biol. Chem. 168, 197-205. Bodansky, i. and H. L. Jaffe l93h: Phosphatase studies. Arch. Int.1$ed., “h, L8. Bodansky, A. l93h: PhOSphatase studies. IV hon-osseous origins of serum phOSphatase. J. biol. Chem., 10h, h73. Breese, B. 5., E. Watkins and A. B. thoord l9h2: The absorption of vitamin A in tuberculosis. J. Am. fled. assn., 119, 3. Brenner, S. and L. J. Rdberts l9h3: Effects of vitamin A depletion in young adults. chh. Int. Red. 3;, ma. Brewer, W} D. 19h9: The riboflavin and nitrogen metabolism of six women with active tuberculosis. Ph. D. thesis, nichigan State College Library, East Lansing, Hichigan Brewer, W. D., D. C. Cederguist, C. J. Stringer and H. A. Ohlson 19h9: Studies of food intake and requirements of women with active and arrested tuberculosis. Lm. hev. Tuberc., ég, hSS. Brewer, W. D., D. C. Cederquist, B. Cole, H. Tobey, M. L. Ohlson and l95h: C. J. Stringer Calcium and phOSphorus metabolism of women with active tubercu- losis. J. Lm. Diet. Lssn. £9, 21. Brown, A. and A. L. Goodall l9h6: Normal variations in blood hemOglobin concentration. J. Physiol. 10h, hOh. Bruckman, F. S., L. M. D'Esopo and J. P. Peters 1930: The plasma proteins in relation to blood hydration. h. Malnutrition and serum protein. J. Clin. Invest. §, 577. Cannon, P. R. l9h3: Survey of the nutrition population--protein. J. Am. Med. Assn., 128, 360. CBI'tW'f‘ijliltt, G. 43-;- l9h72 Dietary factors concerrei in erythrOpoesis. blood, lll, 25o. Chang, C. E. and i. d. Lan l9hG: Vitamin C in tubercul osIs. J. in. med. rssn., llh, Bhlk. Cooper, L. I“., 11}. 1‘1. barrier and H. S. I itchell lth: hutrition in health and bi'ees . J. D. Lippincett Co., Pull£., llbh 0d. CO‘LtiIIL :1115 m ,E. and C. 1-. in: ills l9L3: IniIuence of environmental temperature and vitamin- deficiency upon phagocytic junctions. J. Immunology, h7, h/3. Diechnann, W. J., D. F. Turner, a. J. hciller, h. T. Strauoe and L. J. 1951: Savage ObServation on protein intake and the health of the mother and baby. II Food intake. J. 1m. Diet. nssn., 2?, IO 3. Donelson, E. G. and J. E. LeicLSenrin; l9'l: Food comiosition taole for sIort method of dietary anzlus is. J. Lm. Diet. Issn., 27, 3t7. Dubos, R. J. an d C. Pierce l9hé: The effect of diet on experirrlentzl tub arculosis of nice. ' Iev .Tuberc., E37, 2t7. Faber, K. 1938: Tuberculosis and nutrition. iota.Tuherc. Scandinav p. 2&7. vol. 12, ‘3 Farber, J. b. and D. K. Miller 1943: Nutritional studies in tuberculosis. II niacin aid riIOI lavin deficienCV. Im. hev. Tuberc., ht, hl2. Food and Nutrition hoard, fational hsscarch Council, 1933: accommcnueu dietar- allowances (“evised). national Icalcny of Sciences. national heSearch Council, I40. 302, publication. Cetz, a. a. l9hl: Vitamin a and a in . J. or Ila; corbic acid in pulmonei y tuberculosis. L- . U U) C *4 I J C (~— K) H Cetz, n. n. and T. I. Iocrner 19h}: Vitamin nutrition in tuberculosis. gm. hev. Tuberc., £1, 27h. Uetz, h. h., I. S. 'estfail and e. J. hcnderson lino: hutrition in tuberCLlos is as evaluated by blood analysis im. Lev. Tuberc., v0, 9o. I }_J \u IX) Getz, h. h. lih9: The effect of nutrient supplements 0n the course of tuberculosi". hilhank memorial Fund-~hutrition in relation to health and dis- ease. gu 221. Getz, H. 5., E. R. Long and h. J. neneerson 1931: I; S’LLILQ‘ Of the relation ()1: nutrition LO the development Of tuberculosis. in. hev. Tuberc., ég, 3L1. Cetz, H. II. l9Sh: Feeding the tuberculosis. J. Am. Diet. Assn. 30, 17. —~ E—.. Ff] Gordan, s. and . lenders I931: Obscrvati~uson persons with patential vitamin deficiency. hm. Lev. Tuberc.,‘g;, :h-L9. Greene, h. h., h. Steiner and 5. hramer 193C: The role of chronic vitamin C deficiency in the pathogenesis tuberculosis in the guinea pig. em. hcv. Tuberc., 22, 5C3. Guest, G.1i. 1,3C: hematologic methods in detecting nutritional anemia. hilbank Lem. Fund. .march 29, l9jt. lynZ: ‘rhe water soluble vitanins. inn. hev. biochem., ll, 3C9. narris, P. L., K. C. D. nichman, J. L. Jensen and T. D. Spies late: SurVey of the blood plasma.levels of vitamin 1, carotene, ascorbic acid and tocopherols of persons in an area of endenic malnutrition. Im. J. Pub. health, 3e, 155. F. E. and G. J. Fartin 193a: n corbic acid metabolism in tuberculosis. F. S. E. b. h., hignins, o. h. and E. d. Eelcman 19h}: effect of diet low in thiamin and riboflavin on avian tuberculosis in rats. In. nev. Tuberc., LY, 51o. durford, J. V. 193t: Vitamin C deficiency. Lancet, l, his. Johnson, R. 5., C. Henderson, P. a. nobinson and F. C. Consolezio 19:5: Comparative merits of fasting Specimens, random Specimens and oral loading tests in fields nutritional surveys. J. nutrition, 30, C9. Johnston, 0. L. l7t 0: Factors 'fifluencin3 the rztonc on of nitror n ani calcium in the period of growtn: puocrty in the normal :irl and in girl with a minimal reinfection ta.e of tubwrculosis.1m. J. Vis. Child, 22, 237-309. Jonns tone, 3. h., T. U. s. Drake, F. F. Tisdali and F. 2. harvie 172;: s study of the ascoroic acid metanolism of ((uibl young Céqumlions. Can. rial..zssn. J 'w; 591. Johnston, J. L. 19u7: Nutritional requireuent of 3L8 ado lc scent and its relation to the development of (Lismse... 2.31. J. Dis. Chili.” 73;, AW. Johnston, J. L. 133 1950: Factors influencing retention of nitro en and calcium in period of Croth. V111. influence of rest and activity. um. J. dis Cnild., ED, 351. d. M. \ n o , o o . o no 0 3-. ._ .. _ _ ‘_. ~< l)u3: studies on the clinical Signiiicance oi tne burbfi protein.11 lzie relationship between the albumin-globulin ratio, a12 imin, 3looulin and total protein. nrch. int. med., 137. Kaplan, L. and.fl. d. Zonnis 17LO: Vitamin C in pulmonany tuberculosis. Am. hev. Tuberc., 12, QJY. -———< LieuCher , I“; . ’- E . Z . Intou' er , 1'" O let: fl. Lageck and u. F. A nutritional Status of Lssn. 2b, L73. niliren ViI. nemOglobin. J. in. Diet. Kinble,.h. S. 1739: Determination of vitamin L. J. LCb. Clin..hcd. 23, 1075. Kyhos, E. D., E. S. cordon, in. 5. Rituals and id. L. Sevrinquaus 17th: Tne miniral ascorbic acid need of adults. J. Nutrition, 27, 271. Lewis, J m., 0. Bodenskv and C. iiai 17n1: L3v e1 of vitsnin n in the blood as an in(k 3x of vitamin n d2f iciency in infants and in children. im. J. Dis 2,112 Lowry, O. H. and i. n. Hunter Harrison, k. U. Thomas, M. n. uutl3dge, 19LS: The determination of serum protein concentration with a 3radie nt tube. J. biol. Chem. 157, tog—A7u. 13h heck, P. 5., J. m. Smith, C. n. Loren and L. T. O'orien lihl: nemoalooin values in Pennsylvania mass studios in human rnrtriixiorl. tnLLnard m.mHumH.e as.ousa.s eofi duoo.i on.) + - . (+ co. m Om.oH-HH.o ma. oumm. HH as.mHnms.s cm. 0 as., Hess :OLH mw.HIDb.O NJ.OHNJ.H On.HlmN.O OH.QHQM.H mm.mlwb.o OH.OHmm.H mm.mlmm.0 OH. DHJm. H afim msho. SmOJm m ms.H-mm.o 3H.onH.H me.H-mm.o OH.QHOW.H m .m-we.o oH .z+em. 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U'I .pcmivflmadm 0000 00300000 mo .wE .92050M0L5m 0000 owfipoomw Mo .mE Goo 00>Hmomfl a .J \I. pk/I. \ 4 00>00004 m 0.0N 0N.m 00.N m00 0N0.00 00.0 00.0 00.0 000 00 00 0000 00 0.0N 0N.m 00.0 m0N 000.00 0N.0 00.0 00.0 NNN 000 000 N00N 00 0.0N 00.0 00.0 m00 000.0 00.0 00.0 00.0 NNN mm 00. 000N 00 0.00 Nm.0 00.0 000 000.0 Nm.0 00.0 00.0 m00 N0 00 0000 00 0.00 00.0 00.0 mN0 000.0N 00.00 00.0 00.0 000 N00 00 0000 000 0.0N 00.0 00.0 0NN m 0.00 00.0 00.0 0N.0 000 00 00 0000 00 0.00 00.0 00.0 m0N 000.00 00.0 0N.0 00.0 N00 00 N0 N000 00 I I I I I - I I I - I - 00 0.00 Nm.0 Np.0 000 000.00 0 .00 00.0 00.0 000 000 00 000N 0000 0.0N 00.0 00.0 000 mmN.0 00.0 00.0 N0.0 000 N0 00 0000 00 N.0N 00.0 00.0 00N 000.0 mN.0 0N.0 mN.0 m00 00 00 0000 00 0.00 00.0 00.0 N0N 0m0.00 N0.00 m0.0 00.0 0mN 00 00 000N 00 N.mm 00.0 00.0 HNN N00.00 0N.00 00.0 00.0 000 00 00 0000 000 m.00 00.0 00.0 N0N 000.N0 00.0 00.0 Nm.0 000 00 00 0000 00 I I I I I I I I I I I I 33 .mt .4ME .WME .ME .DJH .m5 3%” .Em .EM, :RW .Ew pomdmdm 0000 mdpoza 000005: mam .000 0000000000 00000000 00000000 0.000000> 0000 -0000 0000000 -00000 000 0000000 00000000 000000 000 000000 00000 0000000000 mmflmoazopmpde m>fipo¢ .000Qm>0< hampwhmvoznzpwx amEo: ammpMHb Mo mmmpCH 000m hfiflmm 0N mHQmB Table 27 Daily Food Intake of Four Women with Far Advanced, Active Tuberculosis; Individual Data Niacin iboflevin R Lsoorbic Thiamine Iron Vitamin A Calcium Phos- Carbo- hydrate Protein Fat Calories Periods hcid phorus A, :11) (r I»: . 1T . my ts Control period 0400 O .0 H ~00 (“\l .4 ‘{)O\o\ O O ‘0 (\lr-«IN 1823 1067 R0 hO r12: 5U T“: 3 2556 ll -1; [\— 0\ (fl . 0.64 00 Period I H fix 0 (fl L-;'\ ‘ Q (\J .11 (\J (n ("\ N 0 r! ”If L’\ N CA ‘J\ (VN I.“ r4tn1n03 r4 0.) LA (\I (\l I-‘i MONO 98 \D r—{ 21‘: Ln ‘0 3;) lCSO (\l r—l R01 HO ‘E NU C) (W (\I r-i (\l A C Ari| ’3 ‘ll .21 19,50 é.b 10 ll .1 A. 1.53 o 0: . F4 209 :7 00 O\ 33: 3‘4 O / 0 / f r ‘- V L .A- .77 1.60 .33 1.03 ‘N 130 20.5 99 NI» [\r‘i L 2190 E. . l 0 12,09 003 r“! ‘0 LG I I . ‘uvx r—I (U m ., l [\0. T)“ if) _;j‘ _1\ L\. O O c;n\o\ rd "N (\l m 0\ (IN (Ur4(u IREHCD H U\ ‘._J\ O Hr—{r—l HUZ ct received three vitanin tablets per day ’2. La 1 Subj rr" \0) r. 44H doflpmg @mpmwzo m Adda H VCfiLwQ Ufim goahmm Houpuoo m H woapma gmpmm pcmzfimmpp HwomeZm Um>flm>m2 H mH+ H- oa- OJH mma oma :0 .m om Hg 5+ na- Om- mmH NQH OOH sm .m cm Au N+ 0- w- oma mma oNH :0 .m ma so m+ mH- em- mmH HHH 00H :0 .m mm on m- o- n- 04H NmH mma . =m .m Fm an; m+ mfl- ON- mmH NHH mofi :0 .m Hm mm HH+ NH+ m+ mmH 034m mmH =m .m mm :1- m+ m+ m+ “NH 04H mmH :4 .m mm mar N- :H- HH- ama Add HNH =m .m om Nona m+ Nw- qw- Mdfi HHH mofi =m .m mm sq on- H- QN- NHH sea 2% =N .m ma 4» o~+ H- Hm- «NH mma mm :4 .m mm gm ma+ N+ HH- mma mma ”NH 2m .m cm 004 mw+ 4H+ m- «ma mma cmH :0 .m mm o: m+ m- NH- mNH mafi MHH =N\H .m NJ «3; mga w Hmmflm w fiwflngH mMH m-H mafl :1- mmoq pzmflmz wamucmpm pgw.ox age pom amcflm HmflpfluH pgmflm: 9mg pomnpsm ho Cams £02m COHpmH>mQ pamopmm o:Mflm3 dhqumgm QAMflDB .‘I'Igu 1 l‘ 1 mflmoadopmsz m>Hpow «Umocm>dq mampmpmvog.spflz mpqmflpmm swap? mo coapmfipommm Havamhzm mm mHQmE I'll H UOHpmm dam UOHLmQ Hoppcoo haqo H 3.- NH- «US 8H 3.. a) .m 3 6% m4 7 m3 RH 8a _.m .m mm ,3. ml Oml wJH mma mad :w .m 0m Oi NT 8- mma 8H 8 a .m 3 am w chflb fl HmflpflCH mma mnH moa figfi 235um 33% m5... pom HES HmEEH 23% my. pogo-gm 0- scam-$3 ”-1883 pa.- ..E..-_. Emma-pm 91S...- mflmoadopmnsa wbwpoa nvmocm>wm ham spaz_mp2mflpmm cm503 mo COHpmHhome HmOHmhgm mm mHQMB ll -I-.O -u".l J - I III- : (Ll ‘- ---I .II I‘l- vl-Alf-I-l II -‘I l ‘l‘lk’ mwmanmp aflgmpfi> mm xv Um>fimoma pomngdm a H.NH um.m nm.a on ode-J Om.oa HH.N mo.m mam gHH OHH Hgmm M4: H.JH mm.m Pm.a ow mmm.w mm.HH mq.H HN.H com m» N» Mgma mam m.NH mH.m mm.a mm gwm.~ 0m.HH NM.H qo.a owa :0 we NNQH mg m.HH mo.m mo.H mm qaqqm cm.HH mm.H wo.H qma my ma Houa “wag Q.NH gw.m mo.m Np oanm o-.NH m~.H Wm.H Hmm om cm :HHN mm m.mH wo.m mo.H JN mam.q wq.mfi mo.H NJ.H cam moa ma ommm om ”.0H mfi.m mH.H we mwgam mm.m mm.a NH.H NwH Hm HQ omwa Jag» m.mH HQ.“ um.a a” mam-m Vm.m m~.H mo.H mwm 00H moa Hmmm mo m.HH mm.m 0N.H mp qmw.m om.ma am.H mN.H HHN NOH H0 030m 3: w.ma mm.m po.a NJ Omfiqm mm.mH Ho.m 0m.H mom ONH mHH 400m No w.m- mm.m mm.w wad mom-mm m~.~ ofi.a 0H.H Nod No mm mafia Hgm m.@ om.m mH.H om Nmm“m NH.HH mm.H om.H cow m Hm mmma Hm ”.ma mw.m ON.H mw won-0H 34.MH ~®.H OF.H mmm mmfl moa 050m so m.ma mo.m go.a am New.” oa.w HQ.H mo.a mma Fm mw OJNH a: 0.0H mm.m mw.a Hm Nqum mo.Q mN.H QQ.H mLH my mw mwga ma m.w @4.H gm.o a, mod-4 ow.o um.o mw.o Nma mm Fm NmNH mm mg S. N 3. H 3 33 3. p 84 .3. a m: w 3 8: fig m.w mo.m mm.o mm awn-N aw.m FN.H dm.a mma no no ogma om n.4H @g.m Fm.a H4 ”gm-4 am.HH HQ.H NJ.H wow OOH mm nmflm mm :.3 40.3 mm.o mm wmm.oa m4.q mm.m wa.m Hwa new moa Noam «a N.mH qw.m HN.H moa mNo-NH pm.afi mm.o m4.m mwm mmfi oHH mem 4m H.0H gm.m mH.H oHH cob-o No.HH mm.m Hm.m mum mHH NOH 050m an .ME .ME J-mrM .Hfih .D.H .HE .E-m- .WMH ...m .fim .rmw. Powflflsm ©fio¢ mdaonm mpmnfih; ficm :Howfiz afl>mamopHJ mCHEmwze OHDAOqu 4 swewpflb COAH Imogm ESHOHmo Ionhmo pwm afimpopm mmflpodmo Uofipom uoapmm Houpcoo .mpmm Hmswfl>flbcH mmHmOHjothzB m>flpom .Umoam>fi< aamfimhmvozflzpflz am: ozpumpcmze mo mxmpuH voom hHHmQ om mHDmH 1).; 7 pun-535 Ann-393m Ugflmom: a H.mm No.0 mfl.4 mam Hom.oa oq.HH 0H.m m .m cam maH NHH eagm M4: m.mm mw.g mw.m 0mm oqw.ma mm.HH oo.H Ng.a ogm mm we wmom mmm m.mm H~.q mb.m MON mwwnma ow.oa mq.a om.a mam om ma mama m o.mm mu.m Hm.m HNH Omaha 00.0 5N.o H~.o NNH mg mg NMHH :4: m.om Ha.m ww.m mam mac-ma JQ.HH mo.H HQ.H mmm NF Np 4mma am W.Hm mc.m _w.m mam Nwmaaa om.oa mm.a mg.a Nam ow ND apma on m.:H mo.m cm.m 5mm mfio.na mb.HH ob.H mm.m QHN Fm aw oQoN .aaw N.mm mo.m mm.m mow JNQO N@.HH ON.H mm.H Hm mofl mm Nmmm x0 o.mm 43.q mu.m mam awn-OH -m.w mq.fl mg.a mow mm NF -jma a: m.mm no.4 mm.m mmH mNH.m Ng.m mm.a HN.H mmm No a” oaom No N.wm mm.m m@.m qu ~q4.~ 04.0 mo.a mw.o OmH ob Fm mega an Q.mm mm.g pw.m jNN nmw.aa mo.oH mg.a mq.a New m> mfi QmNH Hm H.qm gm.m Hm.m qma ma .wm OH.NH mw.a Hm.m mm mma OHH 90mm 00 H.mm mw.o mo.q nmw amp-ma cm.HH QH.N mm.m mew jwa NOH Hmmm aa H.mm wfi.m m@.m OHN HQwflmH 4H.oa mm.a mo.m cow pm um swam ma w.om mm.g Ng.m ”ma Hmwap pm.” H~.H mH.H mma ow Hp mama mm - - - - - - - - - - - - fl fig“ a.wfi mm.m mN.H oma HH4.m mo.ma QA.H mm.a mg 05 mm oboa om w.nm om.o mm.q mmm oqm.mm ON.©H og.m mo.m ANN mma mma seam an F.mm m4.o m@.m mwa mw4.ma qm.gfi ma.m No.m mma 30H Hm :mgm -u* I I I I I I I I I I I I H .j-M m.mm op.m mw.m Hmfl mmfiqmfl 4a.; mm.a cg.m mma NQH gm NOHN mm .v& .w; rmh 4mg .3.H .mg .cm .rw .Em .Pa .rm pomflMfim 30,-.“ 359E gag-3 dam cflowfl afl>mamoofim mafihmflge OHmpoomm q CflEmpH> achH nmogm ESflono Iophwo pwm aflmpomm mmflpoamo wOHhmm H GOHpmm .mpme Hmsnflbfiw-H Hm magma mm-mmodwopmoba 96.39» «Coon-$64 hampmpmvoz €53 cm: exp-hang“. mo 8%ch coo-m aaflmm psogmehw Hmoawafim .. . ._ m moH>Om HOONNmE pmcfimmw Ezflmopgcwm pmuq m mflaomwcmfluca «.00 O hflaflq Ham «N .O: «mummafim michpmm OO>Hmoox H H.Nm ON.N mm.q NON OOO.NH mN.HH Om.m Oc.m NON OOH OOH OOHm Han 0.00 OO.O ON.N O-N NNH.OH OO.NH HO.H NO.H ONN NO OO OHON HON N.Hm OO.m OO.O NON OON.OH -O.NH ON.H ON.H OON ON ON OONH 1H O.ON OO.H ,N.m OOH OHO.O OO. ON.H OH.H ONN OO ON NONH OH». I I I I I I I I I I I I 4.40 O.NO NN.O ON.O NON JOH.OH OO.OH HO.H O..H NOH NO m) OHNH «ON H.ON OH.m O0.0 NON HNN.OH OO.OH OO.H HH.H NON ON ON OHOH qua m.Hm Om.m NO.O NON NNO.O ON.OH OO.H OO.H ONN NN OO NOON NO N.HH ON.O O0.0 OHN NNH.HH ON.O Hm.H OH.H NOH ON ON OHOH aw N.ON OH.O ON.N OHN HOO.HH OH.O Om.H OO.H mNN HOH NO OOON NO - - - - - - - - - - - - ONO O.mm OQ.O OO.O JON OOH.OH NN.OH HN.H O.H OON ON HO OOHN HO O.HO NO.O No.4 OON OHO.HH ON.OH OO.H HN.H ON HO ON ONNH OO N.NO ma.m O0.0 ONN HOO. H OH.HH NO.H ON.H ONH OOH HOH OHHN H: o.ON HO.O OO.N NOH OHN.OH ON.OH OH.N .OH.H NOH ON NN HOOH m. - - - - - - - - - - - - NON H.Om NH.O Om.m OOH OO0.0N NN.OO ON.H OO.H NNH NW OO NOOH an: O.NN Nm.m HO.N OOH ON0.0 NO.OH OO.H ON.H NNH NO ON HNNH HON N.Om NH.m OO.m NOH mOH.mH N0.0 ON.H Nm.H ONH ON NO OOOH Om N.ON OO.O NN.O HOH ONO.OH Om.OH OO.H HN.O NNH HOH OO OOON ”HO N.OO O0.0 OO.O NOH NOH.OH NO.NN OO.H ON.N OOH NO NO OOOH HNO O.Om mO.O N0.0 HNN ONN.,H OO.OH NO.N OO.N ONN OOH NO OOON an .m& .mL .mE .NE .:.H .m& .&w .Ew 2mm .mw .Nflw pommmdm Ufloa mdpozm mpmpmhg 6cm aflomfl ,H Cwa-mMOQHv-m m- finmdrw Ounofioomm.‘ .HN GHEmPumH/ HMO-NH ImOJhH :Bfiodmo IOQ..HQO pmh Cflmpohm mmflhOH-mo UOHhmm mmfimoanopmnsa O>Hpo< .Omosm>v4 haopmpmvoz spa: cmz.ozpnhpcm39 mo mePQH Ooom OHHNQ HH OOHNOO .NONO HNOOH>HOOH mm magma . I - h. I no OOHbfim HOOHOOE pmunmm thpOHmmmm uHopHmQ mHHorNcm 09 a HHH H A N . a mummfi _m msopamm zm>Hmomz H O.Om OH.N NH.H OON HOO.. mO.m Hm.m HON OHH OOH OONN H.NN HO.H mm.m OON HON.NH NH.H NO.O HNH ON NO H.0H Io \. o )o\. \- . a ...., o 1..-I. .. O NO mx J ww « LAN Omm n Am H or r HNH Ow mu H_w©H N.HO HN.m HN.N NHN OON.HH cm.H OH.H NNH NO O NOOH H.OO NO.» ON.N NON OON.O NH.H OO.H OOH ON NO OONH N.OO HO.m NO.O OON NOO.HH NO.H OO.H ONN NO ON NOON H.ON OO.H OO.N OOH (HO.HH NO.H NH.H OHN OOH ON O.ON ,0 o o .\ ) a. .1 ,0 \o \. . Om HH O HO O HOH NON OH NO H Ou H OON OOH OO HOON N.NN NH.H NN.O NON OOO.N HO.H mO.H OOH OO Nm OOOH H.OO ON.O HO.N OON ONN.HH NN.H OO.H ONN 0O HO NNNN O.OO HO.H ON.N HON HHN.O ON.H NH.H NNH OO ON ONNH In. I 0 \)o .n .1. )0 I.) .r Om 0m m O: m OHN HNO. MH N; H m H Om NO 0O HONH O.Hm NO.O OO.H NOH OHH.HH HO.H ON.H OJ HOH HOH NOON O.NN OO.H N.m ONN NO3.N LO.H OO.H HNH HO HO OONH o o ). o I.“ J )0 . o \1 \1 O HO OO O O; m ONH ONH ON :- H OH H OON H. 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HOOO O.OO OH.O HN.O OON OHNNNH OO.OH ON.H ON.H ONH ON OO NmOH OOO O.OO OO.O HO.O OON OOHNOH OO.OH NN.H NO.H NHN NO NO ONON ,OO O.NO OO.O No.4 ONN ONONO HO.OH O.N O.N NON OHH OHH OOON Hun o.Om ON.m NO.: ONN OOONOH OH.HH ON.H OO.H OOH OOH Om OOON O; O.OO OO.H OO.O OON ONONNH OH.O OO.H OH.H NOH OO ON OONH HH O.NO OO.m ON.O OmN OOHNO 0.0H OO.H OO.H OOH NN NO OONH 4O O.OO O0.0 O0.0 HHN oQONO N0.0 HO.H OH.H NNH O NN ONNH ,HOH N.NO NN.O OO.O NON OOONNH O0.0 OO.H NN.H NHH OO NO OOOH On OOHNON 0.0 ON.H OO.H NO OOONO OO.N ON.H HH.H OO HO OO ONOH Om H.N O0.0 ON.H HOH NOOONH OO.OH OO.N OO.N OON HNH HOH NOON OOO O.N OH.H NO.O NO HNO.N H.O NN.O N0.0 ONH «O OH OOOH 4O O.O OO.O OO.O NO NOO.N O0.0 NH.H NO.H NNH ON ON NOOH Hun O.O ON.H ON.O NO ONNNN OO.N NN.H OH.H OOH OO ON NOOH ONO N.HH ON.O ON.H OOH OOO.N OH.HH NO.H ON.H NNH NN ON NOO ‘aO O.HH OO.O OO.H NN OO0.0H OO.OH ON.N OO.N NON OHH OOH OOON Ham O.O OO.H OO.O OO OOONN 0.0 HO.H OO.O OOH ~m mm NOOH Ow O.HH HO.N ON.H OO ONO“ OO.NH ON.H HO.H HNH ON NO HOOH HO 0.0 ON.N NH.H OO NONNO ,O.O NO.H HO.H ONH ON ON OOOH 4O 0.0H ON.N NO.H NN OHNNO OO.HH OO.H OO.H ONN OO HO OOON ZOO O.HH HH.N OH.H ON O Ohm m.O OO.H NH.H NON ON NO mONH Om OOHOOA Hoppqoo lflflp .mt .HfiH .mfi JHW .fiw SEW .mm, .mfl‘ Houwufim OH04 mmpoug OHOHOAA Oum CHpmHHOOHA OnHemHgH OHOHOomH H QHEOpr :OHH amogm Osmono IOQHOQ pmm CHOHOLm mmHNono OOHHOA Q HOOOH>HOQH mmHmoHsopunflH oprow Nvmocw>OH 9mm HHHZ 2mm m>Hm39 mo OAOHOH HHHOQ mmwhmbq SM. @400 I. _I rt. 150 1 u { .{.m. 1 . > moaawm Hkowuma pmgwmzm Lsfiuopmcmm pmoq m 0 pamgpmmpp Hwoflmndm Um>flmom£ H o —3’ 0 CU (W m OO\C\J OLUI“ I L f‘~ Q ON C) [\— —:I | o o 0 r4 (‘3 (.7 (fl m m w) "NJ C>r4~+ wwnwnw LI) {\- \O O u) —T r~ (\l O\ D~ U\ (q 0 ‘SD ‘ “\3m 0 -J‘J\1r\ O (fir—i qmux (\l (.\J m ‘1)UQ . . 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H om OO.H ON.N mOH mm mm.N O0.0H I34 oI.H mm.H OOH mN OH.O mw.mH no ON.N mO.H OmH Nm m0.0 OO.OH O:N OO.m mm.H OOH m mm.N OO.HH NO I I I I I I ~H( ON.H Om.H NO OO OH.O ooONH Hm ON.H OO.H H. mm NN.O ON.OH 0O NH.H OH.H Hm mm mO.N Om.NH OO OO.H Om.H mm 3 SO mm.mH do I I I I I I. Hzm OH.N mm.H OOH N Om.N m.OH .anO Om.H Om.H mmH mm OO.N mO.mH OO ON.H OO.H HO Om NN.O O0.0H Om OO.H ON.H ON O4 Om.N mm.OH OOO Om.H mO.H NN mm Om.O O0.0H IOH OH.H mm.H NOH Om Nm.N Om.OH am pHu.Q Home moppHu .HE OQH\OMHT .HO OQH\£WE . E OudN.mO .HE 00H .Em .HL QQflN.N poormzm mmmpwfibmoflm mfiflfimvflfii Ufio4 ndahoomk ®C®P0.Hm0_ OOH GHOOHmPH> fimpOhm GHAOHEOEOL UCHW 56,.me $3th .59th OBLHmOmO :3.me UOHROQ HH OOHOOO .O &O HOOOHOHOOH .mHmOHSOMOQS H m>Hpo< meocmva hHmpmhmooz Jug Cw: osplapcmse mo mpcmdeHmcoo OOOHM MCprwm OO OHOOO III. I, II , 101 0. OQH>UO HO me5 meH 9 O EfiHHopmnmm pmmH m SSHmopmumm pHopme op OOHHHHIOOIH H ox. H IO. H Om Hm R. N o). NH HI: I I I I I I OOO OO.H HO.H OHH OO OH.N OO.OH OH Om.m Oo.m mNH OO mm.N oo.mH H4: I I I I I I IOO OO.H OO.H Om Om NH.O OO.OH mun Om.N HO.H OOH mm HO.N O». H IIa, O0.0 OH.H OHH HO mN.O ON.OH OO Om.N OO.H OOH OH ON.O OO.OH n: OO.H mm.o OOH OO OO.N O0.0H MO OO.H OO.H OOH mm Oo.N mm.mH Om Om.N HO.H OO Hm mm.O OO.OH HO OH.H Om.H NO OO mm.O oo.NH 0O OO.H OH.H Hm mO Om.N oo.NH O: 3. H O OH Om OO OH. N 8.. O O l I l I I I Nfi% I l l I I. I H Add,» OO.H OO.H OHH 0O oo.N ON.OH OO OO.H ON.H OO HO oo.N mm.mH an ON.H OO.H mO HO 0.0 oo.O 4O ON.H OO.H HO HO OH. O oo.OH OOI OO.H OH.H OOH OO mO. O om.OH OO meuD HommOOOLHHa .HL CC4 .mL .HL OOH .nE gm Ou \..m& .HE COH\.Eu .HE Cc.p\.l,c.OO pocmrrm mmmpmmnmogm OQHmOOHH UHoH oHflHoomH mumpohmo a CH” cHH > GHmHohm CHQOHLOO¢2 flaw Ewhmm Edpww ESLOm hmm EShmm UOHHmm HHH OOHOOO “Opmm HOOOH>HOOH mmeOHSOQOQSB m>flpuw nUQOCQ>Ufl NH®PQL®UOE.J$fl3 Gmfl QEHIKPCOEH MO mucm3#flpmfloo UOOHQ mfiflfiwmh mO OHOOH OO.H HO.H Om Om mO.O Om.OH 4O OO.N HH.H NOH mm HO.H OO.HH OO: OO.H ON.H OOH On HO.H Om.mH OH I I I I I I «mum OH.H OO.H HHH Om OH.O OO.HH OOO Om.H H0.0 OO mm N0.0 O0.0H .OO OH.H OH.H Om HH O0.0 OO.OH Ham Om.H OH.H OOH mO OO.m OO.HH Oz OO.H HH.H OHH Om OH.O OO.OH H: OO.H QOOO OHH MO O0.0 OO.NH 2O OH.H HO.H OOH Om mm.O OO.HH OHIO ON.H mm.H ONO HNH OO.H mm.OH Om OOHpOm HOHQOEHOOQNO pmHHm OO.H mm.O HO HO OH.O OO.OH OO OH.H Ow.O Om mm OH.H OO.OH 33m HpoH “OwouO>U< pOm OHH: Ema O>HOBB Ho OHGOSpHpmcoo Ooon may )3 I10 «4 OHLIB 162 HOOEHOOLH HOOHmpfim Oo>HOomx m OOH>OO HOoHOOE HOQHOmO HMOH H _ T cu H '13 r—IoN HI—INr—i p O Q O O O (.3 ‘Lu 9 O) x l "\ V L.) V! "I ‘ I—I (\lr—‘l \O O .3 O\ 1f\ m E‘- N O\ O OO OH.OH Om I I HOOO I I HHO OOH OH O H OH.HH can NOH Om OH H OH.OH OHO mg OH OO.m mm.mH O4 OHH HO OO.H mm.OH H2O I I I I HOO OOH mO . 1O.OH HO OOH mO . OO.HH 4O HNN Om.OH OHOO I I . H Am OOHOOQ HOHQOEHLOONO OOHJB Om Hm O0.0 mm.OH OO Om HO NH.H O0.0H OOO O OH OH.H Om.NH OH I I I I «rum Hm Om OO.H O0.0H OOO OH OH O0.0 OO.HH H2 Om OH H0.0 O0.0H HOO I I I I H 0.; OO HO OO.H OO.OH HO HO HO H0.0 ON.HH HO OOH Om HO.H OO.OH ZOO OOHHOQ HOHQOEHHOQXO Ocoomm Table 6? Variation in Temperaturesl with Active‘Tuberculosis of nineteen Women —— Control Period First Period n b cond Period ‘Third Period 7 Days Test 7 Days fest '(L 2J6 ‘lest 7 flags ’fest five. Day Lve. Day nve. Day Ave. .Dq£_ Moderately advanced, active tuberculosis 6U 98.b:.262 96.2 96.6:;60 96.0 - - - - NO 96.62.23 96.2 96.6:.23 96.6 96.3i.30 96. 96.6i.16 90.6 600 96.01.17 97.6 96.31.21 96.6 96.36.33 99.0 96. 31.30 96.6 D6 96.2:.16 96.0 96. 6:. 23 96.6 96. :.30 96 .h 96: 6:.26 96.6 P; 96.31.33 96.0 96.§:.2 96.6 96.6:.37 96. 6 96.7-. 67 96 .6 L6 96.0i.23 96.0 96.1: .36 96.6 96.06.69 97.6 97. 9: 6 97.6 660 97.76.17 96.0 96.3i.26 96.0 98.2i.37 97.2 96. 3:. 2. 96.0 Km 96.1:.19 96.2 96.6:.ho 97.0 96.6i.26 96.0 ~ - - Eh 95,h:,20 98.0 96.u:.20 96.0 96.3i.27 96.0 96.5i.26 98.6 as 96.26.20 98.6 96.0:.20 97.6 96. 3: 30 96.6 96.31.61 96.0 68 98.0i.56 96.6 98.3i.26 96.6 98. I-.6o 96.0 97.9:.26 96.0 DO 98.6i.26 98.6 96.h:.3l 96.6 98.1i.36 97 O 97.9i.30 98.0 DU 96.56.13 96.6 96.7:.27 96.6 96.66.17 96.6 96.2:.63 96 0 EA 96.7:.20 99.0 96.7:.21 96.6 96.3i.30 96.2 96.6i.26 98 6 MI 96.36.26 96.5 96.61.16 96.6 96.7i.2h 96.6 99.2:.26 99.2 Far advanced, active tuberculosis 60 97.6i.60 97.6 96.7:.36 96.6 96.7i.2s 96.6 96. 6-.31 96.0 no 98.2i.3l 96.0 97.9:.36 96. 2 97.9:.61 96 6 96.1i.56 96.0 MB 96.76.26 96.6 96. 6+. 26 96. 6 96.1:.73 96.6 96.5-.13 96.2 EU 6i.bo 100 .6 100 .5: 66 100 .6 - - - - 1 Degrees Fahrenheit 2 Mean deviation T6018 68 with Active'ruoerculosis Variation inTemperaturesl of Thirty-Four Men Patients 166 Control Period First Period Second Pgriod Third PerioQfl 7 Days Test 7 Days Test 7 Days Test 7 Days Test xTve. Dggr I.ve. D637 Jive. Iii: 7Cve, DfiL' IOrEratelv advanced 83 98. 6. .09~ 96.6 96.2t.23 98.0 98. 2:. 23 96.0 96.6i.l7 98.2 2 61 97.92.13 96.0 - - 97.6-.197.9 97.9i.71 97.6 18; 98.23.23 96.0 97.6i.36 97.6 97.3i.30 97.0 96.2I.26 96 .6 SH 96.3-.19 98.6 '7.6:.31 '6.0 97.96.30 96.0 98.3i.29 96.6 50 97.9;.61 97.8 97.9i.19 97.8 97.7i.69 96.6 97.9t.19 96.2 616 96.0-.16 96.0 — - 98.0i.16 98.6 - - PR 96.6i.37 96.2 98.6:.26 92.2 - - - JE 96.3:.13 98.2 98.2i.36 96.0 98.72.39 96.6 98.0:.16 98.0 66 98.0:.26 97.8 97 .3: .37 97.6 97.9:.30 96.2 98.6:.23 96.0 00 97. 6+ .37 97.6 97.3i.33 97.2 97. 6- 37 97.6 97.62.26 97.2 51 98.6-. 26 98.6 98. 3: 26 96.0 96.2i.29 98.0 98.6i.66 96.0 ST 96.0i.l6 97.6 96.3:.21 97.6 - 98.32.21 98.6 oz 98.0i.20 97.6 98.2i.20 98.2 98. 2.36 96 .6 96.6i.23 96.2 WE 96.3i.21 98.0 98.6i.23 96.6 96.6i.33 96.2 98.6i.20 98.0 CH 98.3i.19 98.2 98.3:.30 96.6 98.7i.66 98.6 96. :.21 98.6 EEK. 96.3:.19 98.2 96.62.23 96.6 96. 9f. 26 96.8 96.3:.16 96.6 60 98. 2:.11 98.2 98.2: .29 96.6 96 .2-.26 96.0 98.7-. 39 96.0 94 96.3-.19 98.6 96.3:.30 8.6 — - - 616 9:1-.30 98.6 98.7i.76 98.0 96.3i.16 98.2 98.3:.61 98.2 LE 98.1- .17 98.0 98.6:.26 98.0 9;.7:.27 98.2 98. 8:.31 99.2 586 96.6:.16 98.2 98 .1:.19 96.0 98.3i.31 98.2 - HAY 96.6:.20 98.0 96. 3-. 29 98.6 98.7:.13 99.5 98. 6-.16 98.6 Far advanced+ 61 96.1-.26 98.0 97.7i.26 98.0 - - - - 616 98.9:.10 98.8 98.S:.10 98.6 96.7i.26 96.0 9C. t 27 98.6 DA 98.7:.27 98.8 98.6:.26 96.6 98.1i.17 98.0 98.3-.27 96.2 RI 98.32.33 98.6 98.0i.20 98.6 98.0:.29 97.6 98.6:.26 98.6 60 96.6:.23 97.6 97.9:.63 <8.0 - - — - 66 97.6:.23 97.6 97.51.66 97.2 97.6:.26 97.6 97.6:.36 96.0 66 96.62.11 96.6 99.0i.19 99.6 96.6i.19 98.6 99.1i.16 99;” 626 99.6i.36 99.2 96.3i.37 98.6 98.0i.20 97.6 98.36.30 97.8 bEfi 98.6:.26 96.8 - - - - 98.5i.13 98.6 86 96.12.66 98.6 98.12.66 97.0 98.0i.69 97.6 — - HUG 98 .0-.36 96.2 98.6i.20 96.2 98.2i.36 97.2 - - SA 96. 6-.09 98.6 9E.1i.19 6 6 98.1:.61 96.0 98.6:.31 98.6 1 Degrees Fahrenheit 2 Mean deviation I ,_ .—u - , ‘ 4 . o -._ w n v . u g... 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Adam: an o: .>wm awn mmamuw mmuwnd a mmng mm o: vowpmm COMmmflfiwd mmoamrwamx mfimoasopmuda puma wflgopmcmm Mo mflmocmmflm mu; pomrpdn st1 Mo 90925) fimdufiua yo yawn r . mflmofiwopmnsa m>flwoq «onCm>dx hmh :pflz :mEo? a can ism mflmomwopmnfie mo mmhqmm mmCOHmm.ud4 mflhonmqmm Mo hmpfidu mo hhmiasm moflhm am magma :10 I III ‘ I. A III). I . . I‘I I: '1 /‘ J /3- r. t— -1- 1 I. \l“? —- 1 x.) ‘ . avorer :I L for .4113 0 q D -0 es rim: ‘- w-“ ro, ‘1. {23C fiecover U A f1“. L13. , I 1 r (1(le . f‘ r: ‘- C) x L V’ . r . ag& the s legn051s 1. D m LUUGTCUlOSiS C'LllCSi vi .~ ,1. . dad I: 2 b 1V8 l of Control ,. A 0 1rd 1‘ 01 lubO :noed, Lct lniti 12- C Table 51 Uevree 2 Jegl H I“ / issions, 9-10-52 lO-é- 2-3-52 -2{‘ eratelv LdV l | A 1 8 1.- r "”1 ma ori It men With number of Seneto .| of Sanat ~4- 1 V ’5 CI aav. t1 f 0513 lnl ‘ LUTIDBI' 1 Far 7-L7 observed at 01 7n081s 0 V l Fell-AH / C oE‘I‘C‘al L 2 ‘. .'\ (N l-ho~Far adv. .L. 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