Nephritis is a disease of the kidneys, in which changes occur in the tissues of the organs themselves; these changes may be caused by inflammation of the kidneys and renal passages brought on as results of the retention of certain poisonous substances in the blood, or from the action of specific bacteria. The disease may be acute or chronic in form and develop as a result of prolonged exposure to cold and wet, of tonsillitis, scarlet fever, typhoid fever, and to a less extent of malaria, syphilis, pregnancy, and tuberculosis, as well as from the effects of certain irritating drugs, such as cantharides and turpentine.

Directing the Treatment.—In any case the treatment must be directed toward the relief of the acute symptoms in the beginning and followed up by a general treatment which will tend to strengthen and relieve the overtaxed organs and to increase their power to functionate normally.

Causes and Effects.—In acute nephritis, the chief symptoms are uremia, and edema; the urine is materially diminished in quantity and at times suppressed; it is often found to be rich in albumen and containing hyaline and blood casts, red and white blood cells, and various pigments.

In chronic nephritis, which may be the result of an acute attack, or as a sequel of other diseases already mentioned, there is seen to be a progressive loss of flesh and strength, marked anemia, gastro-intestinal disturbances, increased blood tension and edema, the latter especially in the face on arising in the morning. Uremia may develop at any time. Limiting the Work of the Kidneys.—In both acute and chronic nephritis, great effort must be put forth to relieve the tax upon the kidneys and to stimulate their functioning power.

In other diseases, in which definite organs are involved, the treatment consists chiefly of resting the affected parts (1) by starvation, (2) by deflecting the work to other organs when it is possible, chiefly by changing the diet until the disturbance is overcome. This is generally effectual in most cases, as has been specially demonstrated in the treatment of gastro-intestinal diseases.

Problems to Be Considered.—But in nephritis, there are other problems to consider, which make it impossible to institute such a treatment as will effect a perfect rest of the renal organs. The kidneys represent the chief source whereby the waste products of the body are eliminated. This waste consists not only of the end-products of the nitrogenous foods ingested, but also the end-products of tissue metabolism, which is the inevitable result of the wear and tear of life. Hence, when the functions of the kidneys are disturbed, these products, often toxic in character, are retained instead of excreted. Thus instead of forming normal constituents of the urine they find their way into the general circulation, exerting a damaging effect upon the tissues, especially of the kidneys with which they are brought into such direct contact.

Substances Difficult of Excretion.—It has been proved that the kidneys in nephritis find it difficult to excrete certain substances, namely, urea, water, salts, and the purin bodies. Many authorities claim that the uremia manifested in acute nephritis is the result of the retention of end-products of the protein metabolism already mentioned and that the edema is due to a like retention of water and salts. The greatly diminished quantity of urine voided during the acute attack would seem to prove this theory. Martin Fisher,[114] however, claims the condition to be due to an acidulation of the tissues with a consequent osmosis of water, and directs his treatment to overcome this condition, not by restricting the quantity of water and salt, as is generally practised, but by injecting a saline solution into the body in large quantities with the effect of increasing the flow of urine by concentrating the salt content of the blood and therefore its osmotic power. The fluids are withdrawn from the tissues, thus adding fluidity to the blood stream, which in turn flushes the kidneys, ridding them of the poisons which interfere with their normal functioning.

Adjusting the Diet.—The uremia and edema must be relieved. Since it is an undisputed fact, in the majority of cases, that good results from the regulating of the diet so as to minimize as far as possible the work of the kidneys, the various diet cures will be included here.

Milk Cure.—Milk, as a rule, forms a basis of most of the nephritic diets chiefly because of its low salt and protein content and on account of its non-toxic end-products.

The percentage of water in milk is likewise known and for this reason the fluid content of a milk diet can be easily calculated. However, it is also true that the greatest drawback to a diet consisting solely of milk is the large amount of water therein compared with its nutrient value.

Resting the Kidneys.—During the acute stage of nephritis the kidneys are given as much rest as possible by eliminating all food and restricting the amount of water entering the body. The thirst is relieved by small sips of plain or carbonated water or by ice pellets held in the mouth, or, as is sometimes necessary, by injections of water into the rectum.

Adjusting the Fluids.—The amount of fluid, however, must be adjusted to meet the condition of the patient, taking into consideration the amount of urine voided and the uremic symptoms manifested. If the urine is not suppressed the amount of water taken may be slightly in excess of the urine voided, thus promoting diuresis. In many cases an excellent diuretic drink consisting of one pint of water and one teaspoonful of cream of tartar with a half a lemon and perhaps a little sugar, serves the purpose of relieving the thirst, which is at times acute during this period.

The extent of the starvation treatment must depend upon the patient himself. As a rule, however, it is not carried out longer than two days, after which milk may be substituted, allowing from twenty to thirty ounces per day, which is as much fluid as an ordinary nephritic patient can handle.

The regulation nephritic diet, which is bland in character, contains nothing that will tend to increase the irritation and inflammation of the kidneys, and furnishes a certain amount of nourishment when the symptoms of the disease warrant the giving of any food other than milk.

The following diets used in cases of high urea or severe hypertension:

Low Protein Diet[115]

Protein Free Diet

Doctors Chase and Rose advise farina used more frequently than oatmeal, and the plain cream soup, rice or potato, more often than soups made of celery or asparagus (the latter used to break the monotony). They also advise the more frequent use of green string beans and asparagus in preference to other vegetables.

Elimination of Salt.—In many cases of nephritis, especially those belonging to the parenchymatous type, the kidneys manifest a difficulty in eliminating salt, and instead of excreting the normal quantity, find it impossible to eliminate more than two or three grams or less a day. The retained salts pass into the fluids of the tissues, giving rise to or increasing the already existing edema. Tests[117] have been devised to find the extent of the kidney function to excrete salt. The following diets are among those commonly used:[118]

If the kidneys are able to excrete the amount of salt contained in these diets, salt may be added in quantities of from 5 to 10 grams.

Salt-poor Diets.—When the kidneys are unable to eliminate the normal amount of salt, some of the salt-poor diets should be advised. Coleman claims,[119] however, that these diets have not fulfilled the promises held out by them. Coleman groups the salt-poor diets under three headings:

(1) The strict salt-poor diet, of which Widal’s diet is an example.

(2) The medium strict salt-poor diet, allowing from 2.5 to 5 grams of salt a day. Under this heading the milk diet was placed, in which 2 to 3 grams of salt is served a day at table.

(3) The moderate salt-poor diet, in which from 5 to 10 grams of salt are allowed each day. In using this diet it is not necessary to prepare a special menu for the patient, but take precautions to leave the salt shaker off the tray and exclude bacon, ham, and other salty foods from the dietary.

Limiting the Amount of Food.—It must be kept in mind that the nephritic condition makes it imperative to fall below rather than exceed the food requirements of the individual.

Widal’s Diet[120]

Contains 60 grams of protein, 1 to 2 grams of NaCl, and furnishes approximately 1500 calories.

Strouse and Perry arranged a dietary from the above diet as follows:

8 A.M. Bread, 60 grams; lamb chop, 50 grams; butter, 10 grams; rice, 100 grams; sugar, 40 grams.

12 M. Bread, 60 grams; roast beef, 100 grams; butter, 20 grams; beans, 150 grams.

5 P.M. Bread, 80 grams; butter, 20 grams; chicken, 50 grams.

HALPIN’S SALT-FREE NEPHRITIC DIET

Milk, 1500 to 2000 c.c., white salt-free bread, 400 to 500 grams; salt-free butter, 40 grams; eggs, 4 to 6. This diet contains from 5 to 6 grams of salt.

KARELL CURE

Karell has devised the milk cure, which is used possibly more than any other diet. It not only furnishes a dietary rÉgime, which is used in nephritis, but it is likewise advocated in organic diseases of the heart and blood vessels.

Methods of Administering the Karell Cure.—The cure is begun by giving from 3 to 6 ounces of milk three or four times a day. Karell makes a point of using small quantities to begin with and having the milk skimmed. The milk is given at regular intervals, is warmed in winter and given at room temperature in the summer. It may be given plain or diluted with limewater. After a week if the stools remain solid, the daily allowance of milk is increased to two quarts. Constipation is an indication of the agreement of this diet and the patient’s utilization of the milk. If, however, he manifests gastro-intestinal disturbances, resulting in diarrhea, the amount must be temporarily reduced. Karell advocates boiling the milk and relieving the constipation with enemas or mild laxatives. The addition of small quantities of coffee to the morning portion of milk, or of stewed prunes or a baked apple to the afternoon feeding, also tends to overcome the condition.

Thirst.—The extreme thirst may be relieved by adding plain water, limewater, or seltzer to the feedings.

If during the second or third week of the cure the hunger becomes too great for the patient to endure, a small piece of herring or stale bread may be given.

Once a day a milk soup thickened with a cereal may be given. The above diet is carried out from five to six weeks, after which the patient is gradually returned to a normal diet. Milk, however, should still constitute an important part of the diet. The Karell cure is modified more or less to meet the condition of the patient, the amount of milk administered in some cases being more and in others considerably less than mentioned in the above rÉgime.

Limiting the Proteins.—The extent of the damage caused by the end-products of protein metabolism cannot be easily estimated, but it is wise not to err on the side of an over-supply, since the retaining of these materials in the body gives rise to a certain type of intoxication (uremic poisoning).

Relative Toxicity of the Animal Proteins.—The difference between the various animal proteins as to their relative toxicity has been the subject of much discussion. As far as their nutrient value is concerned, they are practically the same, that is, the protein of beef and the protein of chicken show very similar analyses. The beef contains, however, more extractives, which we know are high in purins. These substances have proven detrimental to the welfare of a nephritic patient.

Selection and Preparation of Foods.—For this reason the so-called red meat is sometimes boiled instead of roasted, as the latter mode of preparation increases the formation of purins on the brown outer surfaces of the meat. Chicken and fish contain less purin bases and for this reason are often included in the diet when beefsteak and lamb chops are excluded. Meat soups and broths contain little nutrient value, consisting as they do chiefly of water, salt, and extractives, all of which are looked upon with disfavor, and classed with the offending articles of food in the nephritic diet. Cream soups, except bean or pea soup,[121] may be given in moderation. They are non-toxic in character and of high nutrient value, furnishing a valuable addition to the diet when the gastro-intestinal symptoms permit of such addition.

CONVALESCENT NEPHRITIC DIET[122]

Advisable Foods.—The following foods are used in the formation of diet for an advanced convalescent nephritic patient when not otherwise contraindicated:

Cereals, potatoes, rice, green vegetables and salads, fruits, fresh and stewed, ham, bacon, or beef once or twice a week, chicken, lamb, or mutton[123] several times a week, simple desserts, such as junket, prune or fig whip, orange, lemon, grape, pineapple or apricot gelatin, bread, rice or tapioca pudding, plain vanilla ice cream.[124]

Foods to Be Avoided.—The following foods are avoided except the meats, which must be given not more than once to three times a week, as directed by physician:

Meat broths, especially those made from commercial meat extracts, bouillon cubes, etc.

Strong tea or coffee.

Alcoholic beverages, unless especially prescribed by the physician.

Liver, kidney, sweetbreads.[125] Meat croquettes and other made dishes.

Rich sauces or gravies.

Condiments and spices of all sorts.

Rich pastries.

The salt must be limited and water and other fluids restricted.

Sample Diet Sheets.—The following menus[126] formulated from the above diet list are suggested:

No. 1.—8 A.M. Sliced oranges, cream of wheat with cream, buttered toast, cocoa.

10:30 A.M. 6 ounces of milk with crackers.

12:30 P.M. Cream of spinach soup, rice, string beans, orange gelatin, bread and butter.

3 P.M. 6 ounces of buttermilk with crackers.

6 P.M. Cereal and cream, baked potato, apple sauce, cocoa, bread and butter.

No. 2.—8 A.M. Stewed prunes, wheatena and cream, milk or dry toast with butter, cocoa.

10:30 A.M. 6 ounces of malted milk with crackers or 1 slice of zwieback.

12:30 P.M. Cream of corn soup, mashed potatoes, beet tops or mustard greens, lettuce salad, dressing made with lemon juice and olive oil, rice pudding.

3 P.M. 6 ounces of orange or grape juice with crackers.

6 P.M. Cream toast, sliced peaches, cocoa.

No. 3.—8 A.M. Half a grapefruit, farina and cream, toast and butter, cocoa.

10:30 A.M. 6 ounces of buttermilk with crackers.

12:30 P.M. Cream of tomato soup, creamed potatoes, buttered beets, celery salad, apple tapioca pudding, bread and butter.

3 P.M. 6 ounces of milk with crackers.

6 P.M. Ralston’s Health Food with cream, baked potato, tomato salad, toast and butter, cocoa. No. 4.—8 A.M. Stewed prunes, grits and cream, toast and butter, cocoa.

10:30 A.M. 6 ounces of malted milk with crackers.

12:30 P.M. Cream of asparagus soup, creamed cauliflower, boiled rice, lettuce salad, bread and butter, pineapple gelatin.

3 P.M. 6 ounces of orange juice with crackers or zwieback.

6 P.M. Creamed toast, escalloped potatoes, fruit salad, toast, cocoa, and cocoa junket.

CHRONIC NEPHRITIS (BRIGHT’S DISEASE)

Chronic nephritis may develop as a sequel to an acute attack, and an individual suffering from chronic nephritis may at any time develop acute symptoms. In any case the dietetic treatment would necessarily have to be made to cover the existing symptoms.

Dietetic Treatment.—In cases where the patient has entirely recovered from uremia but still manifests symptoms of water and salt retention, the diet would be naturally directed to cover the latter, at the same time taking care not to strain the weakened functions by giving more food than could be readily handled. The water and salts still have to be restricted, but a certain amount of fat and carbohydrate with small additions of nitrogenous food materials may be added from time to time as the kidneys show improvement. It must be borne in mind, however, that at this time it is very easy to overtax the renal organs and it is safer to err on the side of under rather than over feeding.

The logical treatment, therefore, consists of utilizing the improved functions while those still failing to react are getting further rest.

Adjusting the Proteins in Diet.—If the individual shows a definite anemia, as is often the case after acute attacks, either as a result of the disease itself or the necessarily low diet, which the acute symptoms of uremia and edema made necessary, other measures are necessary to bring the body back to a normal condition. It has been found that in these cases where there has been no permanent damage to the renal organs, but merely a temporary impairment of the functioning power, the treatment must be, first, a rest to the affected parts; second, the temporary restriction of all articles of food which impose a tax on the kidneys to eliminate; the third, the gradual return to normal diet as the acute symptoms decrease and the function of the kidneys no longer shows impairment. Such a case is cited by Strouse and Perry[127] as occurring in the Michael Reese Hospital. Mr. X. recovered from the acute stage of nephritis and all signs of edema and uremia disappeared; the man was kept on a low salt and low protein diet for a long time. His urine was clearing up, but he did not feel up to standard and remained anemic. Thinking in all probability that his symptoms were due to a low protein diet, meat was slowly added to his dietary until he was receiving 60 grams of protein a day. There was an immediate general improvement in his condition with no increased renal disturbance. It is an obvious fact that chronic nephritis, like any other chronic condition, requires a different method of treatment from that practised to relieve the acute stage. The very fact that it is chronic proves that the strenuous methods are neither necessary nor wise.

Testing the Kidney Functions.—The authorities of to-day endeavor to ascertain the extent of the damage to the renal organ by testing its functioning power. These renal function tests have been the subject of much interest and investigation. Probably the ones most commonly employed are those devised by Hedinger and Schlayer[128] and adapted for use in the Johns Hopkins Hospital by Mosenthal. Diets Used in Tests.—The diet employed in making these tests consists of different amounts of certain substances known to be diuretic in character. This diet is rigidly adhered to and a careful analysis of the urine passed, the total quantity and specific gravity of each specimen made and in this way the various functions of the kidneys and the impairment thereof are tested. Thus an intelligent adjustment of the diet may be made.

Renal Functional Tests.—The following schedule is used by Mosenthal, of the Johns Hopkins Hospital, in making what is known as the “Two-Hour Test for Renal Function”:

HEDINGER-SCHLAYER-MOSENTHAL DIET[129]

Chart Used in Johns Hopkins Hospital.—The following chart is inserted here to show the method used in the Johns Hopkins Hospital for carrying out the Two-hour Renal Test:

Urine to be collected punctually every two hours and kept in the ice-box, every specimen having twenty drops of tutuol added to insure preservation.

Another modification of the Hedinger-Schlayer diet is used in the Peter Bent Brigham Hospital,[131] Boston, Massachusetts, as follows:

On two days previous to the test the patient usually had a diet containing 2000 calories, 75 grams of protein, 4 grams of sodium chloride.

The test diet is a mixed diet containing known amounts of water, nitrogen, and chloride, together with the food diuretics (purins, salt, and water), as can be seen. The diet is divided into unequal portions containing known but varying amounts of fluid, nitrogen, and salt. Two-hour specimens are collected from 7 A.M. to 9 P.M., and one night specimen is obtained containing all the urine passed between 9 P.M. and 7 A.M. Each specimen is analyzed for volume, specific gravity, total nitrogen, nitrogen concentration, total chloride, and chloride concentration.

Purpose of Tests.—The purpose of the test is to find out to what extent and in what manner the diseased kidney under stimulation by the various diuretics taken in the food reacts in putting out the varying amounts of salt.

Dr. O’Hara likewise describes another test known as The Added Urea and Salt Test, which was first described by von Monakow and also carried out in the Peter Bent Brigham Hospital. The method used was as follows:

ADDED UREA AND SALT TEST

Patient is given 75 grams of protein, 4 grams of sodium chloride, and 1500 c.c. of water, with a caloric value of from 2000 to 2200 calories. After the output of fluid, salt and nitrogen reaches an equilibrium on this diet on one day 10 grams of additional salt is given and several days later the patient receives 20 grams of urea. This order may be reversed. The daily output of urine, salt, and nitrogen is determined and charted. After the salt and nitrogen is added to the diet in normal individuals, their excretion after forty-eight hours returns to its previous level. In diseased kidneys this may not be the case.

Value of Tests.—Thus it is seen that in these tests for kidney functions, an effort is made to determine the extent of damage wrought by the disease upon the renal organs and the manner in which they react under definite circumstances. However, it is not so simple as it would seem to formulate a dietary based on the findings resulting from the renal tests. Notwithstanding this, these tests are coming more and more into use, both in hospitals and private practice, and a nurse must understand just how they are carried out, and must realize that unless her part is performed with absolute accuracy the entire value of the test will be obliterated. Too much stress cannot be laid upon this phase of the test, if it is to be of any value whatsoever in determining the condition of a diseased kidney.

CHRONIC INTERSTITIAL NEPHRITIS

This form of nephritis is more insidious in character, developing more slowly and manifesting different characteristics, than those seen in some of the other types already mentioned. The condition is, as a rule, associated with heart symptoms and high blood pressure. The blood shows an increase in urea and other end-products of protein metabolism, whereas there is no manifest change in the metabolism of salt or water. The great increase in volume of urine voided would show an inability on the part of the kidneys to eliminate a highly concentrated urine. This hypothesis is further demonstrated in the urine tests.

Urinalysis.—Upon analysis the urine in these cases shows less albumen and fewer casts than found in other types of nephritis. The disease is manifested by slight headache, gastric disturbances, and a frequent desire to urinate.

Dietetic Treatment.—The treatment here depends upon the extent of the impairment of the functions of the kidney. If the damage is not extensive and the diagnosis has been sufficiently early to insure prompt improvement upon treatment, the diet is so directed as to prevent the occurrence of any of the acute symptoms. The patient is warned against overeating and drinking, over-exercise and nervous excitement. When it is possible, a change to a warm, dry climate is advisable with more rest and sleep and less work and worry. He is advised to eat less at meals and if hungry to eat a light lunch of milk or buttermilk with crackers in the mid-morning. The same dietary precautions must be taken in these disturbances as in other nephritic conditions, keeping always in mind the fact that the kidneys are the chief organs of excretion in the body, and through them must pass the majority of all end-products of nitrogen metabolism.

Limiting the Nitrogen.—The nitrogenous foods cannot be eliminated entirely, especially if, as is often the case, the individual suffers from chronic nephritis and is up and about attending to business; but they can be judiciously regulated in the diet. All such foods as fried foods, rich pastries, rich sauces and gravy, spices of all kinds, tea and coffee, celery and asparagus, must be avoided.

Limiting the Fluids.—von Noorden limits the amount of fluid to 1¼ liters per day. This does not include the water content of the various foodstuffs. He advises a period of observation to determine the amount best suited to the condition of the patient and reducing this amount from 250 to 150 c.c. a day until the desired quantity is reached. He advises a drinking day once a week, allowing the patient to drink as much water as he likes.

Development of Uremia.—Whenever evidences of uremia appear the treatment must be changed to meet the condition. It is necessarily more strenuous than that used ordinarily in the chronic nephritis. If the uremia becomes positive, then the treatment laid down for acute nephritis already described must be at once instituted. The patient must be put to bed at once and every effort made to assist the body in getting rid of the causes.

In certain cases of nephritis, in which uremic poisoning is due to the retention of the end-products of nitrogen metabolism, or to the toxins formed as a result of the tissue changes due to the disease, the water then instead of being restricted in the dietary is greatly increased to encourage a free diuresis with a consequent washing out of the accumulated poison. Certain authorities recommend a strict milk and water diet, as has already been described in the beginning of the chapter. A light or soft diet is advised until the condition improves, resting the renal organs as far as possible. This diet may consist of fruit juices, strained cereals with cream, cocoa, milk, buttermilk, toast, butter, strained apple sauce, cream soups, except those made with beans or peas. The above diet is gradually increased by adding a mashed or baked potato, well-cooked green vegetables, stewed or raw fruit, rice and tapioca pudding, and chocolate blanc-mange.

Selection and Preparation of Food.—The preparation of foods for the nephritic differs in certain particulars from that used in other pathological conditions, namely, the restriction of certain food constituents; dishes made with meat and eggs are cut out of the diet, and salt is used as sparingly as possible, when it is used at all. The nurse must weigh or measure out the maximum quantity allowed and divide this in portions for each feeding, measuring carefully any that is not used and charting it. In this way it is possible to increase or decrease the amount according to the symptoms of the individual. The water content of the various foods comprising the diet is, as a rule, not considered, but it is necessary to adhere strictly to the orders of the physician and to curtail the beverages, water, tea, coffee, etc., until the amount conforms to that laid down in the dietary.

The nitrogenous foods, with the exception of milk, are as a rule eliminated from the nephritic diet. The nurse must study the tables and learn which food materials come under this head. It may seem difficult to prepare diet for the sick without eggs, but it is possible and at times obligatory.

Combating Anemia.—In chronic (ambulatory) nephritis the anemia must be reckoned with. It is not safe to upset the nitrogen equilibrium of the body, but it has been proved that this may be maintained on as little as 30 or 40 grams of protein a day. This will be seen not to be difficult to obtain when milk forms an important part of the diet. The wheat and oat cereals, as well as the bread, contain protein, and a judicious use of these foods will enable the nurse to give her patient the necessary quantity to offset, in a measure, the anemia which is at times most troublesome.

Advice to Patient.—One important point must be observed by the nurse and impressed upon the patient when he leaves her care. This is moderation in the amount of food eaten. The kidneys must never be overtaxed, even with foods which in themselves seem harmless. As danger lies in overindulgence, this point cannot be too strongly emphasized.

Advice to the Nurse.—The use of the formulas included in this text is left to the discretion of the nurse. In those calling for seasoning, such as pepper, mustard, etc., the condiments must be omitted. A small amount of celery salt may be substituted in certain instances if the dish is unpalatable without something of the kind. In cases where the salt is restricted the dishes are prepared as directed, with the exception of the salt. The recipes calling for eggs and meat are not to be used unless directed by the physician. Cornstarch, sago, and tapioca may be used instead of gelatin. The following menus may be used as guides in selecting foods to prepare for the nephritic patient after the rigid rÉgime is to a certain extent relaxed:

FULL NEPHRITIC DIET (NITROGENOUS FOODS RESTRICTED)

Breakfast

Grapefruit, orange, prunes, pears, peaches, or strawberries.
Cereals: cream of wheat, farina, Pettijohn’s, Ralston’s, hominy, grits, and oatmeal with cream.
Toast, buttered or creamed.
Cocoa, tea, or coffee, as directed by the physician.

Dinner

Milk or cream soup, well-cooked green vegetables with butter or cream sauce.
Potatoes, white or sweet, baked, mashed, or boiled, with butter, bread or rolls.
Stewed tomatoes, rice.
Salads: lettuce, tomato, romaine, chicory, or fruit salad, with a dressing of oil and lemon, or cream and lemon.
Simple desserts: junkets, cornstarch, sago or tapioca pudding, baked bananas, rice pudding, apple tapioca, orange tapioca, and ice cream.
Beverages: cocoa or tea, as directed by the physician.

Supper

Cereals and cream.
Baked or escalloped potatoes.
Baked or stewed apples.
Salads, excepting those made with meat or eggs.
Junket, raw or stewed fruit.
Toast or rolls with butter.
Cocoa.

Meat, fish or poultry once a day.[132]

Breakfast

Stewed or fresh fruit.
Cereals with cream.
Toast with butter.
Cocoa, milk, or tea.

Dinner

Cream soups.
Boiled chicken or fish.
Potatoes, white or sweet.
Green vegetables.
Salads, except with meat or eggs.
Simple desserts.
Rolls or bread and butter.
Milk or buttermilk.

Supper

Cereals or rice with cream or butter.
Baked or escalloped potatoes.
Stewed or escalloped carrots.
Salads, except those made with meat or eggs.
Fresh or canned pears, cherries, or pineapple.
Bread pudding, junkets, or cornstarch blanc-mange.
Bread, rolls, or toast, with butter.
Cocoa, milk, tea, or buttermilk.

TABLE

Salt Content of Food[133]

According to Leva

Analysis marked thus: * from Atwater & Bryant.

The kidneys find difficulty in eliminating certain substances, namely, the end-products of protein metabolism—urea, water, salts, and purin bodies.

The Urine constitutes the chief point of investigation. Analysis shows the presence of albumen, casts, blood cells, and pigments, with a corresponding deficiency in the normal constituents, water, urea, and salts.

Volume of Urine.—The volume of urine is reduced, and at times suppressed, owing to the difficulty with which the kidneys eliminate water in nephritic conditions.

The Blood shows the presence of the toxic substances on account of the inability of the kidneys to eliminate them properly. Edema is a common symptom and is probably due to the retention of salts and water by the tissues of the body. It is treated and at times relieved by limiting the intake of fluids and reducing the amount of sodium chloride in the diet.

Uremia is the most dreaded symptom and develops as a result of the retained toxins in the blood. Its development is prevented, if possible, by reducing the amount of fluid and food, even of milk, in the diet.

Uremic Poisoning is an acute intoxication due to the abnormal retention of these poisons and the inability of the kidneys to eliminate them. It is combated by instituting a starvation treatment which is followed by the above-mentioned restricted diet.

Gastro-intestinal Disturbances, especially diarrhea, are apt to develop in chronic nephritis. Care must be taken to keep the meals small in size, simple in proportion, and constituted only from the allowed foods.

Anemia follows the acute attack and is especially noticeable in those cases in which a rigid starvation rÉgime has been found necessary. It may likewise be the result of a long-continued diet in which the proteins have been reduced to the lowest possible amount. The simple proteins in the diet must, at times, be increased and the patient advised to take plenty of fresh air and sunshine, in order to overcome this progressive anemia.

Restrictions in the diet are essential. These consist of limiting the amount of food and fluids as well as the type of food ingested.

Restricting the Proteins.—Proteins are restricted on account of the difficulty with which the end-products are eliminated by the kidneys, also on account of the toxic character of these substances.

Restricting the Fluids.—It is necessary, on account of their difficulty of elimination and because they impose an excessive tax upon the circulatory organs.

Treatment is largely dietetic in character by reason of the advantages just mentioned.

Starvation Treatment is instituted in order that the work of the kidneys may be lessened. This treatment consists of abstinence from food with a definite reduction in the fluid intake. It is found to be necessary during the acute stage of the disease.

Extreme Thirst, which is apt to be an annoying symptom at this time, is relieved, as far as possible, with small sips of water or ice pellets held in the mouth.

Nephritic Cures are devised, as far as possible, to relieve the acute symptoms and to prevent the disease from developing into a chronic condition. Milk is the basis of most of these cures. It is given in definite amounts at stated intervals; the quantity and frequency with which it is given being adjusted to the state of the disease and the condition of the patient.

The Karell Cure is one of the best known diet cures used in the relief of acute nephritis. It consists of the giving of skimmed milk three or four times a day in doses ranging from three to six ounces for one week, at the end of which time, provided the stools remain solid, an increase to two quarts a day is made.

Constipation under the circumstances is a favorable symptom, indicating as it does the agreement of the milk.

Diarrhea as a result of gastro-intestinal disturbances has directly the opposite indication. In these cases the milk must be reduced. Karell advises the boiling of milk and relieving the constipation by means of mild laxatives or enemas.

Duration of the Karell Cure is from four to six weeks, after which a gradual return to a normal diet is made. Hunger is apt to be prominent at this stage of the treatment and is relieved during the second or third week by giving a small piece of dry bread and milk, soup thickened with a cereal, once a day.

Functional Kidney Tests are made to determine the character and extent of the impairment of the functions of the kidneys. The diets used in these tests contain definite amounts of certain diuretic substances, and the analysis of the urine voided during the twenty-four-hour period required by the test shows the nature of the impairment and furnishes, in a measure, a means of determining the amount of food and fluid which is safe for the patient to take. It likewise shows the extent to which the restrictions in the salt and proteins are necessary.

Salt-free, or Salt-poor Diets are necessary in some cases. While restriction in the amount of salt used in the preparation of food for the nephritic patient is always advisable, if there is a tendency to edema, the salt shaker should be left off the tray, and when there is a definite amount of salt prescribed, it should be weighed or measured for the day rather than for the meal, and the amount consumed recorded after each feeding.

Special Points for the nurse to remember are the necessity for an early recognition of unfavorable symptoms—of instructing the patient upon leaving her care in the need for keeping the size of the meals small;—of the danger of indulging in alcoholic or other stimulating beverages;—of eating highly spiced foods, or of eating anything which may cause gastro-intestinal disorders.

She should emphasize the need for regular examination of the urine and the value of rest and freedom from nervous excitement, and the need of living in the sunshine as much as possible.

The nurse should study the diet list and become familiar with the foods allowed and those to be avoided. The tables show the foods which are rich in salts and proteins. She should likewise understand and be able to make the simple test for albumen in the urine and the method of collecting the urine for the test made in the laboratory.

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