FOOTNOTES:

(a) Write a diet order for patient operated upon for gastric ulcer.(b) Formulate diet to be used after a gall bladder operation.(c) Outline diet used after operation upon the kidney.

(a) Write a diet order for patient operated upon for gastric ulcer.

(b) Formulate diet to be used after a gall bladder operation.

FOOTNOTES:[106]“Some Gastro-intestinal Notes,” “The Medical Clinics of North America,” Vol. I, No. 1, pp. 192-193, by Thomas R. Brown, Johns Hopkins Hospital.[107]See Formulas for Nutrient Enemas, p.145.[108]See Albumen Water with Brandy, p.141.[109]“Diet in Health and Disease,” p. 555, by Friedenwald and Ruhräh.

[106]“Some Gastro-intestinal Notes,” “The Medical Clinics of North America,” Vol. I, No. 1, pp. 192-193, by Thomas R. Brown, Johns Hopkins Hospital.

[107]See Formulas for Nutrient Enemas, p.145.

[108]See Albumen Water with Brandy, p.141.

[109]“Diet in Health and Disease,” p. 555, by Friedenwald and Ruhräh.

The importance of the kidney functions has been clearly demonstrated. Urine, which is the fluid secreted by these organs, is one of the most important sources of information, not only as to the manner in which the body utilizes food in health, but as an index to certain pathological conditions, the processes of which are more or less indicated by the products excreted in the urine.

Function of the Kidneys.—The kidneys, as has already been stated, furnish a means by which the greater part of the waste products of the body are eliminated and in addition to this function they adjust the salts in the body. In an early chapter the function of the salts in food was explained. A certain amount of these substances, we know, is absolutely necessary to carry on the work in the body, but harm comes when a surplus is retained in excess of that which can be used in performing the various processes. Consequently the function of the kidneys to adjust the salts balance is by no means their least important one.

Elimination of the Toxins.—The toxic substances manufactured in the body and those resulting from bacterial action upon unabsorbed proteins are likewise eliminated in the urine. Thus it can be readily understood how necessary it is to keep these organs in good repair, that they may continue their work in an efficient manner.

It is necessary from a pathological standpoint for the nurse to understand the making of some of the simpler tests, that she may simplify her own work and that of the physician.

Excretion of Carbon Dioxide and Water.—We have already spoken of the combinations of carbon and hydrogen compounds. These substances being oxidized, the carbon dioxide produced is eliminated by way of the lungs and the water is excreted partly by way of the lungs and skin, but chiefly by way of the kidneys.

Oxidation and Excretion of Nitrogenous Substances.—When the nitrogenous substances are oxidized, the used-up oxygen products are eliminated by the kidneys in the form of urea and more or less highly oxidized substances, such as ammonia and other salts, purin bases, and creatinin.

Uric Acid, the chief of the oxidation products of nucleoproteins, is produced in the body and from food, and is always in the urine, being one of its normal constituents. It is only when this substance is in excess in the urine that a pathological condition is indicated.

Examination of the Urine, then, is made for several different purposes: (1) to ascertain whether the kidneys are doing their work properly; (2) to find if the kidneys, or any part of the urinary tract, are either temporarily or permanently diseased; (3) to be able to judge from the various substances in the urine whether there is any abnormal process taking place in the body.

Tests.—In the examination of the urine for the above purposes, certain definite tests are made. These tests differentiate between the abnormal and the normal.

(1) Color.(2) Amount in twenty-four hours.(3) Odor.(4) Specific gravity.(5) Reaction, acid or alkaline.(6) Albumen, indican, acetone bodies.(7) Sugar.(8) Microscopic examination for casts, cells, bacteria, etc.

The Colorof normal urine varies, especially with the amount voided.

The variations in color range from the pale straw color of individuals who are voiding large quantities to the deep lemon or amber of those who void much less.

Pathological conditions are indicated to a certain extent by the color of the urine. Fevers heighten the color, small quantities of blood cause a smoky appearance, while bile changes the color of the urine to a greenish yellow.

Precipitates in the Urine.—When the urine has been allowed to stand for a time there is sometimes a brick-red deposit due to the precipitate of urates. This disappears upon heating and is not an evidence of any diseased condition.

Turbidity of Urine.—The turbidity of fresh urine then is the only kind which need be considered, since standing in the cold often brings about this condition, due to the growth of bacteria and deposits of both phosphates and urates.

Requirements in Testing Urine.—Urine to be tested should be fresh, and when it is not possible to make the examination at once it should be preserved with chloroform, or some other harmless preservative, until ready to use.

Bacteria in Urine.—The changes due to bacterial growth in the urine are manifested not only by the turbid character of the urine but also by the odor of ammonia.

The Amount of Urine.—The amount of urine voided in twenty-four hours varies with the individual in health as well as in disease. Many individuals void a great quantity during the twenty-four hours, chiefly because they drink a great quantity of water and other beverages. The average amount of urine passed in twenty-four hours by anadult, or a child over eight years, is from 1000 to 2000 c.c. It represents from 60% to 70% of the amount of water ingested.

Collecting the Urine for Testing.—In measuring the urine it is necessary to begin collecting it after the bladder has been emptied the first thing in the morning. The patient should void just before the end of the twenty-four-hour period to be sure that the amount formed by the kidneys during this time is accounted for.

Diseases in Which Urine Is Diminished.—In certain diseases the amount of urine passed is diminished. This is found to be true in diarrhea and dysentery, when water is lost in the feces, in hemorrhage from any part of the body and from vomiting. It is likewise at times the case after abdominal operations and in nervous conditions, such as hysteria. The urine is diminished when there is an organic obstruction in the urinary tract and certain obstructive diseases of the heart, the lungs and the liver. In these latter cases, there is seen to be a retention or suppression of urine. In both acute and chronic nephritis and in certain fevers, the bladder at times must be emptied by means of a catheter. At other times, the condition is relieved as far as possible by limiting certain articles of food in the diet. At any rate, these points must be kept in mind when examining the urine.

Effect of Food upon the Urine.—The odor of normal urine is changed after eating certain foods, such as onions and asparagus. In disease, the odor of urine has a distinct value as a means of diagnosis; cystitis gives a foul odor, certain bacteria bringing about a decomposition in the urine and giving rise to an odor of putrefaction. In cases where there is a fistula connecting the bladder and rectum, the urine has a fecal odor.

Specific Gravity of Normal Urine.—The density or specific gravity of urine means the weight of any volume ofurine as compared with that of equal volume of distilled water. The specific gravity of normal urine varies from 1012 to 1024, that is, in a thousand cubic centimeters of urine there are found from 11 to 18 grams of solid material. In health it is necessary to know the amount of urine passed in twenty-four hours, to be able to judge whether the amount of solids is too high or too low.

Specific Gravity of Diabetic Urine.—In conditions like diabetes mellitus, where there is a wastage of sugar taking place in the body—that is, instead of being oxidized to carbon dioxide and water and glucose, the sugar is passing into the urine without completing its oxidation—the specific gravity rises in these cases to 1030 and over, showing distinctly that a greater amount of solid material is in the urine than is present normally. In chronic Bright’s disease and diabetes insipidus, the specific gravity is low.

Method of Determining Specific Gravity.—The specific gravity is determined by the use of an instrument known as a urinometer. The urine is poured into a tube and the urinometer is dropped into it. The different figures are marked upon the stem of the instrument and it is a simple matter to read off the figures of the level to which the stem sinks.

Reaction to Litmus.—In a former chapter it was stated that normal urine was, as a rule, acid, that is, it turns blue litmus red. Certain diseases render the urine alkaline. A like result is brought about upon the ingestion of sodium citrate or bicarbonate of soda. Urine which stands and becomes decomposed is alkaline in reaction, due to the bacterial action, with the production of ammonia.

Albumen in the Urine.—The presence of albumen in the urine is important, since normal urine does not contain this material in quantities sufficient to be recognized by ordinary tests. Hence in disease its presence is an indication of pathological processes taking place either in thekidney or the urinary passages. The chief abnormal condition indicated by the presence of albumen in the urine is nephritis. Traces of albumen may occur in patients with fever or a heart weakness. Blood and pus in the urine likewise indicate albumen. When the nephritic condition is chronic, the kidneys themselves are diseased and the presence of albumen may be in traces only, while during the acute attack large quantities may be passed, but the urine will clear up after a time.

Benedict’s Qualitative Sugar Test.—Boil 5 c.c. of Benedict’s solution; add 8 drops of urine to be examined; hold the tube over the flame and allow to boil vigorously for 3 minutes and set aside to cool of itself. In the presence of sugar the entire solution will be filled with a precipitate which may be greenish, yellow, or red, according to the amount of sugar present. When the percentage of sugar is low (under 0.3%) the precipitate will form only upon the cooling of the solution. If there is no sugar present, the solution will either remain clear or show a slight turbidity, due to the precipitation of urates. The nurse must remember that to be useful the test must be made accurately. There must never be more than 10 drops of urine and 8 drops is the usual quantity. The boiling must be vigorous and the solution allowed to cool spontaneously.

Fehling’s Test for Sugar.—Fehling’s alkaline solution and Fehling’s copper solution must be kept in separate bottles until ready for use. Then about 2 c.c. of Fehling’s alkaline solution is poured into a test tube and 2 c.c. of Fehling’s copper solution is added. This is diluted with hydrant water to 8 c.c. Half of this quantity is sufficient for the test. The upper half of the solution is boiled over flame (gently agitated while heating), and while still boiling a few drops of urine are added. If no change appears, it is boiled again and a few drops more of urine are added. If areddish precipitate appears, sugar is present. The chemical reaction taking place is the reduction of copper sulphate to cuprous oxide. Sometimes a partial reduction occurs when urates are in excess, but once having seen the real reduction, a partial one cannot mislead the examiner.

Haines’s Test.—Pour 1 teaspoonful of Haines’s solution into a test tube and boil gently over a Bunsen burner; add 6 or 8 drops of urine and again heat to boiling. A yellow or red precipitate will indicate the presence of glucose.

Benedict’s Test.[110]—The simple quantitative test for sugar is the one devised by Benedict. This is simpler than the polariscopic examination and better suited for ordinary use.

Place 5 c.c. of Benedict’s quantitative solution in a small dish, add a little less than one-fourth of a teaspoonful of sodium carbonate and one-eighth of a teaspoonful of talcum and add 10 c.c. of water. Dilute urine (1 part urine to 9 parts water) except where the qualitative test showed a low percentage of sugar, that is, when the precipitate turns green instead of yellow, in which case it will be unnecessary to dilute the urine. Place dish over burner and bring the contents to a boil. Pour the urine into a graduated pipette. Now add the urine drop by drop to the contents in the dish until the blue color entirely disappears. This test should be done over several times to assure an accurate calculation. The calculation is made as follows: 5 c.c. of Benedict’s quantitative copper solution are reduced by 0.01 gram of glucose, consequently the quantity of undiluted urine required to reduce 5 c.c. Benedict’s solution contains 0.01 gram of glucose.

Example; 1500 c.c. urine in 24 hours. 5 c.c. used to reduce (decolorized) Benedict’s solution.

1500 × 0.002 (0.2 per cent.) = 3 grams of sugar in 24 hours.

Example: If the urine had been diluted with 9 parts water, in other words, 10 times, the calculation would be 5 c.c. diluted urine = 0.5 c.c. actual urine.

1500 × 0.02 (2 per cent.) = 30 grams of sugar in 24 hours.

Hill and Eckman perform the Benedict’s quantitative test as follows:[111]

Measure with a pipette 25 c.c. Benedict’s solution into a porcelain dish, add 5 or 10 grams approximately of solid sodic carbonate, heat to boiling, and while boiling, run in urine until a white precipitate forms, then add urine more slowly until the last trace of blue disappears. The urine should be diluted so that not less than 10 c.c. will be required to amount of sugar which 25 c.c. of reagent is capable of oxidizing.

Calculation: 5 divided by number of cubic centimeters of urine run in equals per cent. of sugar.

Fermentation Test for Quantity of Sugar in Urine.—If the urine is 70° F. (room) temperature when the specific gravity is taken at both the beginning and end of the test, it will assure accuracy.

To 100 c.c. of urine of known specific gravity, add one-fourth of fresh yeast cake thoroughly broken up. Mix thoroughly and set aside at a temperature between 85° and 95° F. for twenty-four hours, after which time test with Benedict’s or Fehling’s solutions. If reduction is obtained, it will be necessary to allow the fermentation to continue until it is complete. When no further reduction is obtained, the specific gravity is taken after the urine has reached a temperature of 76°. The difference in the specific gravity at the beginning and end of the test multiplied by 0.23 gives the percentage of sugar in the urine.

The following formulas represent the various solutions used in the above test:

Gm. or c.c.Copper sulphate (pure crystals)17.3Sodium or potassium citrate173.0Sodium carbonate (anhydrous)100.0Distilled water to make1000.0

(1) Copper Sulphate Solution:34.65 grams copper sulphate dissolved in water and sufficient water added to make 500 c.c.(2) Alkaline Solution:125 grams potassium hydroxide.173 grams Rochelle salts dissolved in water q.s. to make 500 c.c.Keep solution in separate bottles and mix in equal quantities when ready to use.

Copper sulphate (pure)30 grams(dissolved in ½ oz. (15 c.c.) distilled water)Add ½ oz. pure glycerin, mix thoroughly, and add 5 oz. liquor potassæ.

Copper sulphate (pure crystals)18 gramsSodium carbonate (crystallized) (or 100 grams of anhydrous salt)200 gramsSodium or potassium citrate200 gramsPotassium sulphocyanide125 grams5% solution of potassium ferrocyanide5 c.c.Distilled water to make total volume of 1000 c.c.

Dissolve the carbonate, citrate, and sulphocyanide with the aid of heat and enough water to make 800 c.c. of mixture. (Filter, if necessary.) Weigh exactly the copper sulphate crystals and dissolve in 100 c.c. of water, now add it to the first solution; stirring constantly. Add the ferrocyanide solution; cool and dilute to exactly 1 liter.

50 mg. (0.050 gm.) of sugar will reduce 25 c.c. of the above solution.

Gerhardt’s Ferric Chloride Reaction for Diacetic Acid.—To 10 c.c. of fresh urine, add carefully a few drops at a time of undiluted aqueous solution of ferric chloride U.S.P. A precipitate of ferric phosphates first forms, but upon the addition of a few more drops of the same solution it is dissolved. A Burgundy red (red wine) color is obtained in the presence of diacetic acid. The depth of this color is indicative of the quantity of acid present. Joslin[112]records the intensity of the reaction as follows, +, ++, +++, or ++++.

According to Joslin, it must be remembered that similar reaction is obtained in the urine of individuals taking salicylates, antipyrin, cyanates, or acetates, but it is a simple process to differentiate between the color produced as aresult of diacetic acid and that produced by the above-mentioned drugs. If the solution is boiled for two minutes, the color from diacetic acid will disappear, owing to the unstableness of that substance, while that from the drugs will remain unchanged.

Test for Acetone.—Pour 5 c.c. of urine to be tested into a test tube, add a crystal of sodium nitroprusside, acidify with glacial acetic acid, shake well, and then make alkaline with ammonium hydrate. The presence of acetone is indicated by a purple color.

The heat test[113]is the simplest. This consists of first filtering the urine through filter paper, then pouring some of the clear urine into a test tube, holding the test tube in a flame so that only the upper layer boils, then adding a few drops of 2% solution of acetic acid and boiling again. If there is albumen present, a very faint, or a heavy cloudiness (precipitate of coagulated albumen) forms on boiling and persists or becomes heavier on the addition of a few drops of dilute acetic acid (2%) and boiling again. If a precipitate occurs at the first boiling, but clears up again entirely on adding acetic acid, it is not albumen but harmless phosphates or carbonates.

Into a test tube pour a few drops of nitric acid, filter the urine and allow a small quantity of it to trickle from a pipette down the side of a test tube until it comes in contact with the acid. If albumen is present a distinctly formed white ring is seen at the zone of contact.

This material is found in cases of obstinate constipation and in other intestinal disturbances where the passage ofthe food mass in the small intestines is delayed and the putrefactive bacteria exert their activities upon the unabsorbed protein.

Test.—Mix equal quantities of urine and fresh hydrochloric acid and add drop by drop fresh concentrated solution of chloride of lime (5 to 1,000). Indican is indicated by the appearance of a blue color.

Urinalysisrepresents one of the most important means for determining the health of an individual, since it is the urine that shows those substances produced in the body as a result of the breaking down of the body tissues and protein foods.

Composition of Normal Urinemust be familiar to the nurse in order that she may recognize any change taking place in the urine of her patient which may indicate pathological conditions in the body.

The Specific Gravityof urine is one of the points by means of which the presence of certain substances more or less abnormal in character is determined.

Other Points, such as color, odor, quantity, reaction, and chemical composition, likewise show any deviation from the normal in the individual.

Urine Testsare necessary to determine the composition of the secretion. The character of these tests and the methods used in making them form an essential part in the training of the nurse.

Testsfor the presence of albumen, sugar, and possibly indican in the urine, should be made by the nurse. The latter substance represents the extent of putrefaction taking place in the body and for this reason should be included in the urine tests.

Collecting the Urinefor testing is important. The amount includes all that has been voided throughout theentire twenty-four hours beginning after the bladder has been emptied on the first morning and ending after the first specimen has been voided on the morning of the second day.

Preserving the Urinefor testing is usually necessary, especially during the warm weather. The specimens should be collected in a wide-mouthed sterile glass jar. This should be kept in a cold place. Some harmless preservative such as chloroform should be added to assure its keeping.

(a) Outline tests used in urinalysis; state when they are used.(b) List the equipment needed for making the simple tests.(c) Make tests in laboratory and list results in note-book.

(a) Outline tests used in urinalysis; state when they are used.

(b) List the equipment needed for making the simple tests.

FOOTNOTES:[110]“Treatment of Diabetes Mellitus,” pp. 182-183, by Joslin.[111]“Starvation (Allen) Treatment for Diabetes Mellitus,” by Hill and Eckman.[112]“Treatment of Diabetes Mellitus,” p. 186, by Joslin.[113]“Chemistry for Nurses,” by Reuben Ottenburg.

[110]“Treatment of Diabetes Mellitus,” pp. 182-183, by Joslin.

[111]“Starvation (Allen) Treatment for Diabetes Mellitus,” by Hill and Eckman.

[112]“Treatment of Diabetes Mellitus,” p. 186, by Joslin.

[113]“Chemistry for Nurses,” by Reuben Ottenburg.

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. MartinFisher,[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:

ProteinCarbohydratesFatsGramsGramsGramsBreakfast:6.716051Cooked Farina(100 grams)Total calories for day, 1192Butter(20 grams)Fruit(100 grams)Lactose(30 grams)200 grams of fruit juice served between mealsDinner:Asparagus(100 grams)Butter(20 grams)Fruit(100 grams)Lactose(30 grams)Supper:Carrots(100 grams)Fruit(100 grams)Butter(20 grams)Lactose(30 grams)

ProteinCarbohydratesFatsGramsGramsGramsBreakfast:Protein-free cookies[116](5)Fruit juice(100 grams)0166.539Lactose(15 grams)Dinner:Protein-free cookies(5)Total calories, 1045Fruit juice(100 grams)Lactose(15 grams)Supper:Each cookie weighs 10 gramsProtein-free cookies(5)Fruit juice(100 grams)Lactose(15 grams)

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]

3 liters of milk (this contains 5 gm. sodium chloride and 100 gm. protein)orStrauss Diet, consisting of ¾ liter milk, 4 eggs, 150 gm. bread, and enough fruit and fruit juice, tea and sugar to make it palatable. (This diet contains about 3 gm. of salt.)

3 liters of milk (this contains 5 gm. sodium chloride and 100 gm. protein)

Strauss Diet, consisting of ¾ liter milk, 4 eggs, 150 gm. bread, and enough fruit and fruit juice, tea and sugar to make it palatable. (This diet contains about 3 gm. of salt.)

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.

Salt-free bread200 gm.Meat (beef, chicken, or mutton)200 gm.Vegetables (beans or rice), salt-free250 gm.Butter, salt-free50 gm.Sugar40 gm.

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:

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

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

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

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 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 stewedprunes 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 oftenincluded 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.

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.—8A.M.Sliced oranges, cream of wheat with cream, buttered toast, cocoa.

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

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

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

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

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

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

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

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

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

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

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

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

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

6P.M.Ralston’s Health Food with cream, baked potato, tomato salad, toast and butter, cocoa.

No. 4.—8A.M.Stewed prunes, grits and cream, toast and butter, cocoa.

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

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

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

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

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 thenecessarily 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”:

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