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Bright's Disease

( Originally Published 1921 )

Bright's disease is the name given to several different conditions, but they always include some trouble of the kidneys. It is a good name because it describes a fairly definite loss of health and implies a general tendency toward the breaking down of the circulation. In a true case of Bright's disease, the heart is always in danger, and the brain itself is sure to suffer more or less as time goes on if the disease is not checked.

A person who is developing Bright's disease ordinarily has an unhealthful look. There is apt to be a slight swelling of the face, noticeable only by puffiness under the eyes. He often suffers from shortness of breath, even when sitting still. Sometimes he has trouble with the eyesight which takes the form of seeing black specks before the eyes. He suffers from headaches and occasionally can not sleep.

The most characteristic sign of Bright's disease, to which Dr. Richard Bright gave his name by right of discovery, is the existence of albumen in the urine. The test for albumen is simple. Albumen is of the same nature as the white of an egg, and as is well known, the white of an egg coagulates when it is heated. In the same way if urine containing albumen is heated, it becomes clouded from the coagulation of the albumen in the urine, but to make sure that it is not something else that is coagulated, it is necessary to add a little acid which does not dissolve the albumen but does dissolve some other things that might be made to appear by heating. However, not every person who has albumen in the urine has Bright's disease in the sense that he has a serious condition.

The causes of Bright's disease are the abuse of food and drink, inflammation of the kidneys from infectious diseases, damage to the kidneys by high blood pressure; it may also arise, in a few cases, as an acute inflammation of the kidneys. In Bright's disease the heart is always involved; Indeed it is impossible to separate consideration of the heart from consideration of the kidneys.

A person with a tendency to Bright's disease; should be particularly careful as to the quantity of food and drink taken, as to overwork and worry, as to recreation; he should do all those things that tend to relieve the system from strain and to build it up. There are many instances of persons with Bright's disease in an advanced stage who have so taken care of themselves that they have lived twenty-five to thirty years in spite of damaged kidneys. I saw a man fifteen years ago who apparently had advanced Bright's disease and was a heavy drinker. I told him that if he did not stop drinking he would die; he took me at my word and is alive and in fairly good condition at the present time. He has not drunk at all in the fifteen years, and his kidney trouble has not advanced beyond the point where it was when I first saw him.

It is not always so easy to cure drunkards, however, and not every case does as well as the case cited, even when the patient obeys, nor is the sudden and complete withdrawal of stimulants always safe in men who have drunk heavily all their lives. The principle is plain, nevertheless, that in Bright's disease stimulants must be curtailed as soon as possible.

Animal foods put more work on the kidneys than other foods, so that in Bright's disease, these should be limited as much as possible without impairing the strength of the person. The quantity of food should never be in excess of the needs of the body, nor should it be so small in amount as to cause anemia or marked loss in weight. Exercise is important, as it tends to burn up in the body all excessive food products, leads to activity of the respiration, and reduces blood pressure.

A person with Bright's disease should not be too fat, for it has been observed that the people with Bright's disease who are spare and hard are they who survive, while those who are soft and fat are apt to develop dropsy, weak. hearts, and apoplexy.

Persons with advanced Bright's disease can never expect a complete cure, but it is possible for them to get so well that what is left of their disease does not interfere to any great degree with life or happiness. Often enough the outcome of the disease depends upon the character of the patient as much as upon the skill of the physician.

The most important problem that the nurse has to figure out in Bright's disease is that of diet, and this can not be understood without examining some of the principles involved.

The nurse should remember that food fulfils two offices in the body; it acts as nourishment to sustain the health of the tissues, and as fuel to keep the machinery of life going. In Bright's disease, the patient needs food, yet can not make the best use of it; so it is a delicate matter to adjust the diet for the patient's best good.

It is found that there is a certain kind of food ` that is particularly harmful, viz., those containing proteins, because the kidneys, when they are diseased, can not remove the waste products of this food.

Physicians have become familiar of late years with the modification of children's food so that they may have just the right amount of fat, sugar, and proteid. In the same way, the physician must become familiar with the modification of invalids' diet so that they shall have the proper amount of energy-producing food with-out protein excess.

In dealing with children's milk, there are ordinarily only three elements considered, but in the diet of invalids the whole scale of nourishment must be reviewed. 'There are many matters to be considered, but these are not so complicated as they seem when one is willing to refer to tables that chemists have worked out.

The physician first decides how many grammes of protein he will allow the patient ; it is known that for structure repairing a person should have 90 grammes daily, and that it is not safe to go below 50 grammes over long periods of time. It is also known that to keep up the heat of the body, the food must have a certain caloric or heat value. A calorie is the amount of heat necessary to warm one cubic centimeter of water one degree. The average person needs about 2,000 calories (or heat value) in his food.

Patients with hardening of the arteries, heart disease, weak and defective kidneys, And so on, have difficulty with the chemical processes pertaining to protein substances, so it is necessary to keep the supply of such substances down to the lowest point possible without depriving the patient of strength and ambition. At the same time the heat value of the food must be sufficient, or else the patient will gradually run down like a fire deprived of sufficient fuel.

Food is easily divided into two classes: that in which the proteid is most abundant, characterized by meat, eggs, milk, fish, and thick soups ; and that in which the heat elements are most abundant cereal foods, namely, bread, potatoes, rice, and other vegetables ; these contain proteid but less than one-half as much as the others. Of course, fats, sugar, and most fruits contain no proteid at all.

Thus, if I make up my mind that a person may have 70 grammes of protein and must have 2,000 heat units or calories, I give as much strong food as I can and still leave room enough for the proteid contained in the necessary amount of cereal food to make up the heat. If then I find that I need still more heat, I can add pure fat in the form of butter or pure sugar. In doing this the following tables, adapted from an article by Dr. H. D. Arnold, are valuable. (Each portion of food in the first table represents 8 grammes of protein; each portion in the second table represents 4 grammes of protein and as many heat elements as are marked for it.)

From these tables a selection of courses for a meal is made, taking enough portions to add up to 70 grammes of proteid, making the selection in such a way that the heat units add up as nearly as possible to 2,000, then an addition of heat units is made by using food that is practically without proteid. For instance, by using cream, which is a very desirable element of diet, each ounce supplying only one gramme of proteid and 60-90 heat units according to its strength; one ounce of butter furnishes 240 heat units without proteid.

A simple diet given by Dr. Arnold, containing 70 grammes of proteid and 2,000 calories is as follows:

Breakfast—One half orange. Four table spoons of cereal, three tablespoons of cream, and a teaspoon of sugar. One egg on one slice of toast, with one pat of butter. Coffee, with a tablespoon of cream and a teaspoon of sugar.

Lunch L One and one-third tablespoon of scrambled eggs. One slice of toast, with one pat of butter. One piece of cake. One-quarter pound of fruit.

Dinner—Four average sized oysters. Eight tablespoons of a thick soup. A cubic inch of fish, that is, a piece of fish an inch wide, an inch long and an inch thick, or, an inch wide and two inches long. One slice of bread, with one pat of butter. Two tablespoons of boiled rice. One moderate-sized potato. Seven table spoons of pudding. A small cup of coffee with one teaspoon of sugar. (To this meal may be added as much asparagus, string beans, Brus-sels sprouts, cabbage, cauliflower, cucumbers, greens, lettuce, pumpkin, radish, rhubarb, and tomatoes as the patient may desire, these latter substances being without proteid or heat producing power enough to count; if butter and oil are used with them, these may be counted for their heat units.)

I am not dealing in this chapter with digestion, but with food as it affects the heart, blood vessels, and kidneys. If the patient's digestion stands it well, it is allowable to use greater quantities of foods that do not contain proteid, such as sugar, fruit, butter, and so on. If the patient does not take his full quantity at one meal, he may take it later on between meals.

Under such a diet, the patient generally commences soon to feel very much better, and there is often a satisfactory adjustment of blood pressure.

The chemistry of the body is best observed by careful analysis of the urine, and the nurse should not encourage patients in believing that such examinations are useful only in the detection of Bright's disease. Again, the peculiarities of each patient must be observed some people can not digest fat and others can not digest sugar, and so on.

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