The principles underlying the dietetic treatment are essentially the same for the different varieties of subacute and chronic Bright's disease. One important essential in treatment is to bear in mind that the appropriate dietary for these cases frequently depends more on the general nutrition of the patient, and on the state of his cardiovascular system, than on the condition of the kidneys as revealed by the results of urinary analysis. The great indication in treatment is to relieve the strain on the kidneys so far as possible, compatible with the maintenance of a good condition of general nutrition and a satisfactory blood-pressure. In this connection reference may be made to the great importance of efficiently promoting the vicarious excretions of the skin and bowels in all forms of chronic nephritis. The dietetic treatment of a typical case of subacute or chronic nephritis will first be considered, and thereafter the modifications in this treatment that are called for in certain cases will be referred to.
The chief indication in treatment is to diminish the strain on the renal function by restricting the amount of animal protein food, especially meats, and by pro-hibiting the use of alcohol in all its forms. In sthenic individuals a prolonged course of a milk diet, or a lacto-vegetarian diet, should be recommended, the diet for these patients being similar to that recommended in cases of arterio-sclerosis(p.394). The favourable results from this regime may be seen in an improved state of the urine, a lowering of the blood-pressure where that has been increased, and an improvement in the general condition of the patient. A suitable diet of a largely lacto-vegetarian character, appropriate to a working-man who is off work, or engaged in light work only, is as follows: -
Milk, egg, bread and butter, cheese or jam, and vegetables or fruit, if these were not taken at the midday meal. Eggs should be partaken of sparingly, and should not form a part of each day's dietary. White meats may later be added to the dietary, in the form of fish, chicken, tripe, or sweetbread. (See also Light Diet, p. 548).
In the case of well-to-do patients a good alternative dietary is as follows: -
Cafe au lait, with plenty cream; Vienna rolls or toast and butter, marmalade.
1 Made entirely from vegetable stock.
To be selected from the following (not more than two courses to be taken): - (a) Vegetable soup, (b) Steamed fish, fish souffle (made up with cheese or savoury sauce); or eggs occasionally in the form of omelet or souffle, (c) Light farinaceous pudding or stewed fruit, with cream.
Repetition of the midday meal, three courses, however, being allowed. Sweetbread, tripe, chicken, rabbit, or game may occasionally be allowed.
The use of red meats should be restricted, as there is no doubt that red meats are decidedly less suitable than white meats. Highly seasoned foods should also be avoided, since they tend to over-eating. Meat of any kind should not, as a rule, be allowed more than once daily. It will be noted that vegetable soups are recommended in the above diet sheets. Soups made from rich meat stocks should be avoided, because of the large amount of extractives present. Special attention may be, drawn to the value of made-up dishes, in which an animal protein food is combined with carbohydrates, such as rice or macaroni, in proportions. Other vegetable savouries are given on page 528. By this means the patient gets a meat dish, but, on account of the smaller amount of animal protein, he gets it in a form which exerts a lesser strain on the tissues. The nature and amount of fluid to be allowed is important. Care must be taken that the diet should not be such as to induce a state of hydraemic plethora, which would react unfavourably on the heart and circulation, and further aggravate and complicate the patient's general condition. Alcohol in all its forms should be prohibited; tea and coffee should only be given in small quantity, but the patient should be encouraged to drink fluids in the form of plain water, carbonated water, Salutaris, or Apollinaris water, preferably to be taken on an empty stomach. A good system is the administration of a large tumblerful of hot water, to be taken the last thing at night and first thing in the morning, and again an hour before the midday meal. Care must, however, be taken not to overload the system with fluid, the amount of fluid to be ordered being gauged from a study of the amount of urim excreted and the condition of the blood-pressure. Special care must be taken in this direction in cases associated with a distinct increase in the blood-pressure, and also in cases with general dropsy. Finally, it should be emphasised to patients with chronic nephritis that they should continue to have regard to their diet along the lines laid down above, even although all the subjective symptoms of renal disease may have disappeared. Attention will now be directed to the treatment of special cases.
Here the dietetic treatment is that given for acute nephritis. Food should be given in small quantity, at a time, and in cases associated with vomiting or sickness should be given pancreatised.
In this class of case it is important not to starve the patient in our attempt to improve the state of the kidneys. Experience has proved that occasionally a milk diet, or a lacto-vegetarian diet, fails to exercise its usual ameliorating effect on the state of the kidneys, as revealed byurinary analysis, and actual benefit accrues to the patient from the administration of a diet which contains a more liberal amount of animal protein food in the form of fish, chicken, and white meat than is allowed in the dietary given above. Those cases are, however, exceptional, and call for careful experi-taentatiori-jvith the diet. In this class of case the writer has found special benefit from the use of buttermilk and lactic acid bacilli.
A special point to attend to here is the amount of fluid to be allowed. This has already been alluded to, as has also the fact that close attention must be paid to the state of activity of the skin and bowels as important adjuvants in treatment.
While alcohol is better withheld entirely in subacute and chronic nephritis, cases are occasionally met with in which the beneficial effects of a little alcohol on the weakened digestive tract or circulation more than outweigh the baneful effects which it exerts on the kidneys. In these patients half an ounce of whisky may be prescribed, to be taken once or twice daily, at meal times; but this should be discontinued as soon as possible.
In recent years attention has been directed to the therapeutic value of a diet prepared, cooked, and taken without salt, in the treatment of chronic nephritis, especially when associated with dropsy. Particular attention has been directed to this subject by Widal, and this system of treatment has been largely used by French clinicians. A salt-free diet is now one of the recognised dietaries in some of the leading Parisian hospitals. The same diet has been recommended for other morbid conditions, notably chronic heart disease associated with dropsy, persistent diarrhoea, and cirrhosis of the liver with ascites. The rationale of a salt-free diet in cases of oedema and dropsy is fairly intelligible. Sodium chloride has a high osmotic equivalent, and it tends to retain fluid in the tissues. Its omission from the diet may therefore be expected to promote the elimination of dropsical effusions. The normal salt requirement in health is from 15 to 30 grains daily, but the majority of persons consume about 1/4 ounce or even considerably more. In the salt-free diet, foods are selected which contain the minimum of inorganic salts, and no salt is used in the cooking, or eaten as a condiment. A practically salt-free dietary is made up from the following articles of food: - Milk, bread made without salt, eggs, chicken cereals cooked without salt, butter, fruits, jellies, tea, and coffee. The results of treatment by a salt-free diet in cases of renal disease associated with dropsy have been by no means uniformly satisfactory in the hands of those who have tried this system. There is no question, however, that the beneficial effects of this treatment in some cases are quite remarkable, the results of treatment leaving no reasonable doubt as to the profound therapeutic value of a salt-free regime in these cases. In cases of nephritis, therefore, in which the dropsy of the tissues persists in spite of the application of the ordinary measures - dietetic and other - a diet which is largely chloride-free should certainly be tried. The following is an appropriate dietary, a little white meat cooked without salt being allowed occasionally.
No salt to be used in the cooking, or eaten at table. The best way to get over the difficulty of giving a salt-free diet is to make milk puddings made with eggs the staple, the flavouring being varied between vanilla, lemon, orange, nutmeg, cinnamon, chocolate.
Porridge and cream, flavoured with syrup or sugar; or Cup of tea with plenty milk; toast or roll specially prepared, and butter.
Cup of tea, with wafer of toast or sponge biscuit.
On same lines as Lunch; chicken not to be taken oftener than once a day.
In cases where a more rigid chloride-free diet than the above is tried without marked benefit speedily resulting from the treatment, the diet should not be indefinitely continued, as the complete withdrawal of chloride of sodium from the food has occasionally been observed to aggravate the condition.