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.
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ACUTE AND CHRONIC NEPHRITIS 363
Hunger is apt to be prominent at this stage of the treat-
ment 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 re-
quired 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 prepara-
tion 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 neces-
sity 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
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364 DIETETICS FOR NURSES
with the foods allowed anjl 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.
PROBLEMS
(a) Outline a salt-poor diet for patient in which the fluids
are limited to 1500 c. c. per day.
(6) Formulate a diet for child of ten years with nephritis
following scarlet fever,
(c) Write a diet order, using a salt-free diet.
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CHAPTER XIX
DISEASES OF THE HEART
The dietetic treatment in diseases of the heart has been
the subject of much study, especially during the past few
years.
The Diet. — In this pathological condition, as in many
other diseases in which one or more of the functions of the
body have become impaired, there can be no hard and fast
rule covering the treatment or diet for all cases, but, as in
nephritis, the condition of the individual, his symptoms,
and the progress and extent of the disease must be taken
into consideration in order to formulate a diet calculated to
adequately nourish the body, while at the same time im-
posing the smallest amount of work with the least expendi-
ture of labor upon the part of the diseased organ.
Division of Treatment. — The treatment of the disease
then may be said to be divided into three stages: first, the
stage of compensation ; second, that of moderate compensa-
tion; third, that of decompensation. The diet is directed,
first, toward relieving as far as possible the strain which is
imposed more or less by all the food eaten; and second,
keeping up the general nutrition of the body.
Dietetic Treatment. — No matter what has caused the
impairment of the heart functions, the treatment must
necessarily remain the same as far as diet is concerned.
The patient is no longer able to handle a full and unre-
stricted diet. As long as compensation is good, the restric-
tions are scarcely noticeable; alcoholic beverages and pos-
sibly tobacco may have to be, to a certain extent, curtailed,
and in some cases avoided altogether. However, if the in-
365
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366 DIETETICS FOR NURSES
dividual desires to live and be comfortable while so doing,
he must lead a wholesome, simple life, since he cannot with
safety indulge in any excesses, either in diet or in any other
particular.
Diet in Second Stage. — When the second stage sets in,
that is, when the heart muscle is unable to perform its nor-
mal function, attention must be directed toward two main
points; first, the work of the heart; second, the pressure
upon that organ from other sources, namely, the stomach
and intestines. As long as the food does not disagree, that
is, so long as there is no fermentation or putrefaction of the
food material in the stomach and intestines the flatulence
arising from the evolution of gas in those organs is slight
and the pressure upward upon the heart inconsiderable.
Restricting the Fluids. — The heart must be spared all
unnecessary work. This can only be accomplished by limit-
ing the amount of food and fluids ingested. The latter im-
poses an extra burden upon the impaired organ to eliminate.
Consequently, the amount of fluid should be limited to 1500
c.c. a day at most, and in many cases considerably less than
that quantity.
Regulating the Meals. — The meals should be small and
the intervals of feeding regular. It has been found best to
give the fluids between meals rather than with the food,
in many cases of heart disease, as in certain nephritic con-
ditions, edema is a prominent symptom, so that it is neces-
sary to direct our efforts toward overcoming that particular
condition. The Karell Cure ^ and the salt-poor diet are used
with excellent results. The latter is not so low as the
former, and in many oases will accomplish all that is re-
quired. A modified Karell diet is used in the Michael Reese
Hospital - in Chicago as follows:
* Sec Karell Cure, p. 342.
""Food for the Sick," p. 150, by Strouse and Perry.
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DISEASES OF THE HEART 367
" MODIFIED KARELL TREATMENT "
(Salt free)
" Milk 200 c.c. at 8 a.m., 12 m., 4 p.m., and 8 p.m., for five
to seven days.
Eighth day — Milk same as above.
10 A.M. one soft ^g; 6 p.m. 2 slices of dry toast.
Ninth day — Milk as above.
10 A.M. one soft egg and 2 slices of toast.
Tenth to twelfth day — Milk as above.
12 M. chopped meat, rice boiled in milk, easily digested
vegetables.
6 p.m. one soft-boiled egg.
The diet is gradually increased until a full tray is
reached. All meats and vegetables should be chopped or
scraped at first, and the heavier foods should be given only
when the heart is practically compensated."
Rules and Regulations. — There are a few general rules
which it has been found advisable to impress upon individu-
als suffering from a disease in which the muscles of the
heart have become weakened. The compensation of the
organ may improve, but there is still a danger of a re-oc-
currence or a further development more or less serious, and
at times fatal. So for this reason, certain rules must be ob-
served throughout life:
First: the necessity for keeping the meals small, simple,
and digestible. Death at times occurs with symptoms of
gastric disturbance, which is, after all, due to the heart.
Consequently it is not wise to invite such disaster by over-
eating, or by the partaking of any food which is liable to
bring about indigestion, either in the stomach or in the in-
testines. Most authorities advise four or five meals a day
rather than the regulation three, and limit the fluids at
meal time to a few ounces only, when^ny are allowed, and
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368 DIETETICS FOR NURSES
to a maximum amount of 1500 c.c. during the day, chiefly
between meals.
Second: the need for limiting the amount and type of
exercise taken, especially after eating, since the work of
digestion requires all the power and strain of which the
heart is capable, and since an additional tax placed upon it
by muscular exertion might readily be just the final straw,
the added fraction which weighs down the balance on the
scale of life.
Third: the advisability of abstaining from alcoholic
beverages, unless specially prescribed by the physician in
charge.
Certain elderly people suffer from a condition known as
senile heart, which is more or less associated with arterio-
sclerosis and high blood pressure. These individuals should
be prevailed upon to take the precaution of regulating their
habits of life, avoiding excesses of all kinds, not only on ac-
count of the weakened condition of the heart, but also on
account of the condition of the arteries. They should avoid
excitement and worry, since the very fact that they are
worrying increases the blood pressure. Simple foods in
limited quantities, five meals a day instead of three, and an
avoidance of too much fluid, should be the keynote of their
daily regime.
Tact on the part of the nurse is necessary in all cases,
both young and old. It is often more difficult to instill good
dietary habits in heart patients, after acute symptoms have
subsided, than to carry them out during the acute attack,
when the life itself depends upon a rigid adherence to the
diet prescribed. But as these rules and regulations are essen-
tial to the future welfare of the patient, he must be taught
with care, and in such a way that he will not be alarmed to
an extent when more harm than good will come of the
teaching.
The diet should consist chiefly of milk, eggs, rare meat in
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DISEASES OF THE HEART 369
moderation (mutton, chicken, fish, and oysters), well-baked
bread, well-cooked cereals, potatoes and green vegetables,
and simple desserts. All foods which in any way cause
gastric or intestinal disturbances must be avoided. If these
disturbances arise during the course of the disease, the
patient should be promptly returned to the strict milk diet.
When edema is prominent, it is treated as already described
in the treatment for the like condition in nephritis by the
Karell or salt-free diet.
The dietetic treatment given here is merely a guide to
be used under certain conditions. The physician formu-
lates the diet, and the nurse must understand what to ex-
pect and how to apply the treatment as the symptoms arise.
SUMMARY
Dietetic Treatment, adjusted to relieve the weakened
heart muscles and to save the organ from all possible strain.
Three Stages, during which the treatment changes ac-
cording to the extent and progress made by the disease.
First Stage: The diet is practically normal. Compensa-
tion is good, consequently no dietary measures save the lim-
iting of alcoholic beverages are necessary.
Second Stage : The compensation is only moderate and the
heart cannot perform its normal functions, hence the diet must
be directed toward relievingany pressure upon the organs from
other organs and toward lessening the work of the heart itself.
Third Stage: In which the compensation is decidedly
impaired and for this reason the dietetic treatment under-
goes a decided change.
Digestional Disturbances in which there is an evolution
of gas in the stomach or intestines may cause a pressure
against the heart which is distinctly bad for it.
Limiting the Fluids in the diet in heart disease is neces-
sary when the compensation is only moderate, as they im-
pose an extra burden upon the organ to eliminate them.
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370 DIETETICS FOR NURSES
Amount of Food must also be limited. The meals must
be small and taken without fluid. The latter should be
taken between meals.
Edema occurs in a number of cases and must be treated
as in nephritic conditions by limiting the fluids and by con-
fining the diet to " salt-poor " foods.®
Karell Cure or modification thereof has been used with
good results in many cases of heart disease.
Exercise must be limited in amount and confined to
types which will not impose a tax upon the weakened heart
muscles. Exercise after eating is especially to be discour-
aged, as this, together with the efforts required for the diges-
tion of food, might readily prove too much for the heart to
accomplish.
Elderly Patients must be warned against exercises of all
kinds, not only on account of the condition of the heart,
but also on account of the condition of the arterial walls.
These harden with age and break down under undue pres-
sure.
The Nurse should instruct the patient on the points
necessary for the saving of the heart. She should teach the
necessity for keeping the meals small and having them more
frequently if necessary; of limiting the fluids at meals to a
few ounces or leaving them out altogether at this time.
She should know how necessary is the reduction of the fluid.
She should also warn against the taking of alcoholic bev-
erages except with the permission and advice of a physician.
Excitement and Worry increase the blood pressure,
hence must be avoided by individuals suffering with any
form of heart disease.
PROBLEMS
(a) Write a diet order for an elderly patient with severe
cardiac disturbance.
(6) Outline the method of administering the Karell diet.
'See Salt-poor Diets, p. 341.
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CHAPTER XX
DIABETES MELLITUS
Definition. — Diabetes is a disease which is character-
ized by an inability on the part of the body to utilize the
carbohydrates, in consequence of which there is abnormal
excretion of glucose in the urine.
Sugar in the Urine. — The appearance of sugar in the
urine may not necessarily signify diabetes, it may be merely
a temporary glycosuria due to certain pathological condi-
tions, such as infectious diseases, diseases or trauma which
affect the pancreas, and which disappear upon the recovery
from the disease. But any appearance of sugar in the urine
should be looked upon with suspicion, since the future wel-
fare of the patient depends largely upon an early diagnosis
in any form of diabetes.
True Diabetes. — Allen claims that true diabetes may
always be distinguished from nervous glycosuria by the ap-
plication of the laws governing these conditions (Allen's
Paradoxical Law *), which is " whereas in normal individu-
als the more sugar given the more is utilized, the reverse is
true in diabetes."
Manufacture of Sugar from Other Foods. — If the
carbohydrate foods alone caused all the trouble in diabetes,
the disease might be more easily controlled. This, we found,
however, not to be true, since in certain conditions the body
utilizes the protein foods for the manufacture of glucose
also. Consequently in diabetes if the absolute sugar output
of the body is to be controlled, the intake of nitrogenous
foods must be likewise adjusted.
* Allen's Paradoxical Law, quoted from "Treatment of Diabetes Mel-
litufl," p. 18. by Jodin.
371
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372 DIETETICS FOR NURSES
Functions of Carbohydrates. — In the chapter describ-
mg the functions of the carbohydrates in the human body
it was demonstrated that their energy-producing properties
did not cover the extent of their usefuhiess. It has been
proved that this food constituent normally acts as neutraliz-
ing «gent for the toxic acids produced within the organism
&A a result of the breaking down of the fats, fience, when
this function of the carbohydrates becomes impaired, these
acids, Oxybut3rric add, Diacetic acid and Acetone, fail to be
neutralised and are consequ^itly absorbed into the blood
stream, giving rise to a form of intoxication known as aci-
dosis. When acidosis becomes extreme, the diabetic patient
is apt at any time to succumb to the dreaded diabetic coma.
Keeping Urine Sugar Free. — Thus it is seen that the
treatment of diabetes mellitus consists not alone of freeing
the urine from sugar and keeping it free, but of controlling
the acidosis which may at any time develop.
Diabetic Cures. — Numberless so-called diabetic cures
have been brought forward and more or less tested for years,
but whether they have really accomplished cures has not
been satisfactorily proved. Not until Dr. Allen instituted
what is known as the Allen's Starvation Treatment has the
disease been so universally treated, at least by one method
or modification of one method. Dr. Joslin, who has used
this treatment most successfully, does not claim to have
accomplished a cure, but states that he is watching the
results of the treatment in his patients with interest.
Starvation Treatment. — The Allen Starvation Treat-
ment consists of first a period of about forty-eight hours in
which the patient is given an ordinary diet, during which
time the daily weight is taken and the urine examined and
recorded.
Acidosis. — It has been found in some cases, such as
with elderly patients or those in whom there is an evident
Digitized by CjOOQIC
DIABETES MELLITUS 373
acidosis, advisable to precede the period of starvation by a
preliminary treatment.
Method of Treatment. — Joslin ^ suggests the following
method of procedure:
" Without otherwise changing the diet omit fat. After
two days, omit protein, then halve the carbohydrates daily
until the patient is taking only ten grams, then fast.''
In the Michael Reese Hospital, the following series of
test diets are given to determine the severity of the diabetes:
Diabetic Test Diets*
breakfast
Grapefruit . . • . } Butter 10 grams
Eggs 2 Cream 16 cc
Bacon 20 grams Coffee Icup
Bread 25 grams
DINNER
Cream soup ... 3 oz. Bread 25 grams
Koast beef ... 75 grams Butter 20 grams
Spinach .... 100 grams Wine gelatin ... 4 oz.
Kohl-rabi .... 100 grams Coffee
Lettuce salad . . 50 grams Cream 15 c.c.
Hipe olives . . . 15 grams
SUPPER
Lamb chop ... 1 Coffee
Asparagus tips . . 50 grams Cream 15 cc.
Eggplant .... 50 grams Butter 20 grams
Tomato salad . . . 50 grams Bread 25 grams
Custard (diabetic)
Diet in Mild Cases. — This diet contains approximately
70 grams of protein, 100 grams of fat, and 70 grams of
carbohydrates, and the patient is kept on it for at least two
days; then the carbohydrates are cut down by taking away
25 grams of bread every day.
â– "Treatment of Diabetes Mellitus," p. 305, Joslin,
»"Fpo<J for the Sick," by Strouse and Perry.
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The Test Diets are designed ' for the period during which the
patient becomes gradually sugar free. On successive days advances
can be made from Test Diet 1 to Test Diet 5, and if on the fifth day
the patient is not sugar free, fasting can be employed for one or
more days.
The Maintenance Diets are for use so soon as the urine of the
patient is free from sugar. If this occurs as a result of Test Diet 5
the patient begins with Maintenance Diet ClPFl. The actual articles
of food representing the carbohydrate in the diet for the first day are
given under the heading of carbohydrate, for convenience described
CI, 2, 3, etc. The articles referred to under protein and fat are under
that heading, which for the same reason is described as PFl, 2, 3, etc.
Certain cases of diabetes can proceed steadily day by day from
ClPFl to C12PF12, without showing sugar. If sugar does appear in
the urine, drop back two days in the carbohydrate group, wait till
sugar free, then advance in the protein and fat group until sufficient
calories are obtained. Thus, if sugar shows on C7PF7 the diet pre-
scribed would be that included in C5PF7 and thereafter progression
could be made in the PF group until twenty-five to thirty calories per
kilogram body weight were furnished the patient.
Occasionally the patient becomes sugar free on Test Diet 2, 3,
or 4. It is then unnecessary to begin with Maintenance Diet ClPFl,
but instead with a maintenance diet which contains a value for carbo-
iiydrate similar to that of the test diet upon which the patient became
sugar free.
If the protein and fat are too high for the individual on a given
day it is easy to advance the carbohydrate and decrease to an earlier
day on protein and fat.
The plan is arbitrary and the majority of cases will demand some
modification. It is arranged to enable patient or nurse to see in
advance the general plan of treatment.
(Courtesy of Dr. Joslin and Thomas Groom & Co., Boston.)
375
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376 DIETETICS FOR NURSES
If the case is a mild one, this may be sufficient to free the
urine from sugar, but the diet is given primarily to enable
the physician to find out by means of urinalysis just how
great is the functional impairment.
In some cases, which are mild in character, the urine is
made free of both sugar and acetone without further dietetic
measures. However, when a severe diabetes is manifested
and a high percentage of glucose and in some cases acetone
bodies are found in the urine a more rigid treatment will be
found necessary.
Preliminary Diet. — Many physicians find it advisable,
as has already been stated, to cut down the food allowance
before stopping it entirely. In the Michael Reese Hospital
this is done by first giving a practically fat-free diet, fol-
lowed by one or two days in which three or four eggs, 250
to 300 grams (8 or 10 ounces) of 5% vegetables are given,
after which it is found safe to institute the starvation treat-
ment.
Sample Menus. — The following menus are given to
illustrate the dietetic treatment which it is deemed advisable
to institute in cases where the starvation treatment cannot
be given at once:
After the test diet of forty-eight hours, the following
regime is instituted:
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DIABETES MELLITUS
377
Third Day
Protein
Om,
Fat
Om.
Carbo-
hydrate
Om.
OaUfries
Breakfast :
J grapefruit . . .
^^g
1 slice bre^id . .
Tea or coffee
80 gm.
180 c.c.
90 gm.
100 gm.
90 gm.
90 gm.
50 gm.
100 gm.
20 gm.
5.3
2.6
4.1
.8
6
15
20
59
73
Total for meal .
Dinner :
Broth ....
Chicken (breast)
Spinach . .
Potato (1 medium)
Lemon jelly . .
7.9
3.7
18.2
2.0
1.8
42
4.4
.17
2.1
.09
20
.34
3.0
15.6
2.7
152
18
92
20
70
27
Total for meal .
Supper :
Lamb chop . . .
Asparagus . .
Bread . . .
Tea or coffee .
29.9
9.3
1.5
1.6
2.3
14.1
.2
21.6
3
10
227
126
18
48
Total for meal . ,
Total for dny . ,
12.4
40.2
14.3
21
13
54 6
192
571
Fourth Day
Protein
Om.
Fat
Om.
Carbo-
hydrate
Om.
1
Calories
Breakfast :