IV. The Principles Underlying The Dietetic And Physical Treatment Of Acute Nephritis

If we take into consideration all the facts that have been enumerated so far in regard to the diet in acute nephritis we arrive at the following conclusions :

(a) In severe cases of acute nephritis in which the secretion of urine is greatly reduced (anuria and oliguria), in which oedema is increasing, and in which there is impending danger of uraemia, the diet should be limited to the smallest possible quantity, and should consist of about half a liter of milk a day. The ingestion of fluid nourishment should be avoided as much as possible; in order to combat the thirst small pieces of ice may be sucked, or very small quantities of water (tablespoonsful) may be swallowed. Both these restrictions aid in sparing the kidneys, a precaution that is particularly important at this time. It may be desirable under certain circumstances (see above) to add small quantities of alcohol (brandy or the like) to the water. The surplus water in the tissues should be removed by diaphoresis.

It is impossible to persist in this scanty diet for any length of time, certainly not more than for four or five days, for otherwise the strength of the patient may become impaired. This short period of restriction is, however, sufficient, for the dangerous stage of pro nounced oliguria rarely persists longer. The patient either succumbs to uraemia during this time, or develops symptoms that point to an improvement in the functional activity of the kidneys.

(b) Cases in which the secretion of water by the kidneys is reduced but in which anuria does not threaten; moderate oedema - occurring with particular frequency in the course of acute infectious diseases, and quite as frequently after acute infectious diseases. The chief article of diet in these cases should be milk, to which a small quantity of carbonate of lime should be added, for reasons that I have stated above. The amount of milk need not exceed 1,500 c.cm., particularly if about three-eighths of a liter of sweet cream are added, and the nutritive value of the mixture is thereby increased. By the administration of this quantity of milk and cream the demands of the body for nutriment are completely covered. In case the patient demands more food, or if the patient is very much reduced so that increased feeding is desirable, it is better not to give more milk but to add certain other articles of diet that possess a high caloric value, and at the same time contain little protein. These additions moreover should contain no substances that can irritate the kidneys, and nothing that is difficult to eliminate. Among such articles I might mention rice, groats, maizena (made into soup, porridge or pudding with a part of the milk and cream, and with butter and sugar), then bread, (Albert cakes, or fine zwieback) made of very fine white flour with butter, and finally fruit syrups, particularly sterilized grape juice (see above).

The following is a sample of a daily menu containing the smallest possible quantity of protein, and still possessing the greatest possible nutritive value:

This quantity of food is not difficult to master, and is very digestible; it contains 2,900 calories. If we attempted to administer the same number of calories in the form of milk we would have to give from four and a half to five liters, and this quantity of milk would contain more than 180 g. of protein. It will be seen that even if we give up the rigid practise of a "strict milk diet" in the treatment of nephritic cases, we can arrange a suitable diet that is well borne, contains any desired quantity of calories, and a small percentage of protein. It will rarely be necessary in recent forms of acute nephritis to administer a dietary containing as many calories as the menu given in the above table.

It is impossible to fix any definite limits in regard to the amount of water that should be given in excess of the water contained in the mixture of 1,500 c.cm. of milk and cream. If oliguria and oedema are prominent the amount of water must be limited, and the elimination of water from the body favored by sweating. If, however, the kidneys are capable of excreting water (as in many instances of acute nephritis throughout the course of the disease), it is better to administer abundant quantities of fluid for the reasons that I have discussed above (compare page 53). Whether or not it is advisable to produce sweating besides will depend on the effect of abundant diuresis on the oedema. If, despite of good diuresis, oedema persists, sweating may be indicated. If oedema disappears sweating becomes unnecessary. In the latter case we may even say that the administration of abundant quantities of water (for the purpose of increasing diuresis) and sweating are antagonistic to one another.

(c) The convalescent stage of acute nephritis. In this stage the administration of food should be more abundant, particularly if the diet was insufficient before, or if it is desired to improve the general nutrition of the patient. A part of the dietary may consist of milk, but more than two and one-half liters (containing about 80 g. of protein) should not be given, for otherwise the amount of protein ingested becomes so large that there is no room for other articles of diet. In this way we are prevented from offering the patient variety and from increasing the nutritive value of the diet.

The following articles of diet in addition to those that we have declared permissible in the earlier stage of the disease, may be added to the ordinary bill of fare - white bread, legumes, cereals (oats and barley), small quantities of mild fresh cheese (cream cheese), some fruits, particularly grapes, small quantities of egg or meat (either white or red meat) (compare below). Care should be exercised in arranging the diet that the quantity of protein is gradually increased and does not exceed about 100 g. pro die, up to the time the nephritic process is healed. I have already stated that the administration of large quantities of fluid is very important at this period. I usually prescribe a bottle a day of unfermented grape juice ("nectar," see above), in this stage, for this beverage is a wholesome and very nourishing article of diet, and in addition possesses the advantage of stimulating the action of the bowels that are frequently sluggish in the later stages of nephritis, and at the same time, as I know from experience, of actively stimulating diuresis.

Sweating is unnecessary, provided diuresis is abundant and oedema disappears. There are cases, however (and they are by no means rare), in which oedema persists or returns intermittently even though diuresis is abundant. This demonstrates positively that in nephritis oedema is to a certain extent dependent on the power of the kidneys to eliminate water (compare v. Noorden, "Lehrbuch der Pathologie des Stoffwechsels," page 364, Berlin, 1893). In cases of this kind stimulation of diuresis by drugs, etc., is of very little value; sweating, on the other hand, is a very useful adjuvant to the treatment. (Edema can only be removed and prevented by stimulating the activity of the skin, not by increasing the action of the heart (for instance, by digitalis, strophanthus, etc.) or stimulation of the kidneys (caffein, calomel, diuretin, etc.). This applies still more forcibly and more frequently to many forms of subchronic nephritis than to the convalescent stage of acute nephritis. Instead of administering forced sweat cures, patients suffering from either condition (that is, patients in the later stages of acute nephritis, and patients with subchronic nephritis in whom diuresis is abundant but oedema does not disappear) may be sent to some dry climate. The climate, for instance, of the Egyptian desert produces a mild and continuous stimulation of the pores, and accomplishes just as much as forced sweat cures at home. In such a climate the patient may be permitted to take abundant quantities of water, and in this way thoroughly to flush the tissues without at the same time having to fear that the water will be retained in the body. oedema, under these circumstances, disappears with extraordinary rapidity, and those forms of nephritis that can heal at all usually recover rapidly if the water economy is regulated in this way. The subchronic forms of nephritis under these circumstances gradually assume the character of chronic nephritis (secondary contracted kidney), a form of the disease that is less dangerous and remains uncomplicated for long periods of time. Nephritics of the class I have described should be advised to spend the winter in Egypt. Good results are almost invariably seen. Patients with chronic nephritis without oedema (genuine contracted kidney and other forms) will also find Egypt a pleasant place to spend the winter because the climate is so excellent and there are so many diversions, and finally because it can be reached in such a convenient manner even by patients who have to be very careful. From a general hygienic point of view, then, a winter in Egypt may be recommended, but at the same time we should not expect marked curative effects in chronic nephritis from such a change of climate.

There is not much choice among the different cities and locations in Egypt. Cairo itself is hardly a good place for the class of patients we are discussing. Helouan, situated immediately above Cairo, however, has a distinct desert climate. The accommodations are sufficiently comfortable and the expense of living is not very great. I am glad to learn that a German physician, Dr. Urbahn, is about to construct a sanitarium in this location. This is particularly important, as the hotel arrangements are by no means suitable for the treatment of serious diseases. The one other place that should be thought of besides Helouan is Assouan. The climatic conditions (in particular as regards moisture) are still more favorable than in Helouan. I hardly think, however, that this place will ever develop into a health resort; the hotels, it is true, offer every imaginable comfort, but they are not suited for housing persons suffering from serious diseases.

In addition to Egypt the steppes of southern Russia enjoy a certain reputation as climatic health resorts for certain forms of nephritis; the conditions here are similar to those in Egypt - that is, the percentage of moisture in the air is very low. Here, too, abundant quantities of fluids (kumyss, kefyr) may be administered to the patients without having to fear that the enormous ingestion of water will lead to a reappearance of oedema. For some of the details (characterization of the different articles of diet and different condiments), and for the rationale of some of the general prescriptions I have given in these paragraphs, I refer to the preceding chapter.