190 FRANKLIN C. McLEAN 



special measures for its relief. Diet, with particular reference to the 

 limitation of fluid and salt intake, is of first importance. 



Considerable progress has been made within the past few years in 

 the treatment of the edema of chronic parenchymatous nephritis. Rest 

 and limitation of fluid and salt intake are effective in many cases, and 

 should be given a thorough trial. The dietetic treatment advocated by 

 Epstein and the administration of thyroid extract, as advised by Eppinger, 

 liave given good results in some cases, and may be instituted if the simple, 

 restriction of fluid and salt intake fails to afford relief. Both of these 

 methods are discussed below. 



Dietetic Treatment of Edema. The nature of the diet prescribed is 

 important. In nearly every case milk should form a large part of the 

 diet. It may be supplemented by well-cooked cereals, including, if ex- 

 treme salt restriction is not required, those already cooked, such as 

 shredded wheat biscuits and corn flakes, by starchy foods, such as toast 

 and unsalted crackers, and unsalted butter. Later soft boiled or poached 

 eggs, chops, fowl, fresh fish, and oysters may be added. A more liberal 

 diet may be permitted as the edema disappears. 



Restriction of the fluid and salt intake is of great value in many cases, 

 and often proves the turning point in the control of edema, whether due 

 to heart failure or to nephritis. Unless a patient responds promptly to 

 the simpler methods of treatment the salt intake should at once be 

 reduced to a minimum. Moderate restrictions should be imposed in 

 every case by avoiding the addition of salt in the preparation and serving 

 of food. When, however, a strictly salt-free diet is advisable substitutions 

 must be made for the articles of diet suggested above. The cereals obtained 

 already cooked contain salt, and must be avoided. Potatoes, green vege- 

 tables, fruit, and sugar are acceptable constituents of a rigid salt-free 

 diet, when prepared and served without the addition of salt. 



The fluid intake should be measured and restricted to the least possible 

 amount without causing actual discomfort to the patient. In the case of 

 patients with only slight edema this procedure is less important, but it 

 should be rigidly adhered to if there is pronounced or particularly ob- 

 stinate edema. From 800 to 1,500 c.c. in twenty-four hours, including 

 all fluids and not water only, given frequently and in small amounts, 

 usually is sufficient. The common method of procedure is to start with 

 an amount fixed arbitrarily at about 1,200 c.c. This amount can be 

 increased if necessary, or decreased if possible. The absence of salt from 

 the diet makes restriction of fluids result in less discomfort to the patient 

 than when salt is not restricted. 



Karell Regime. The reduction of intake of both fluid and salt may 

 be accomplished very simply, and in edema of heart failure often with 

 remarkable results, by instituting the Karell regime. This consists in 

 giving 200 c.c. of skimmed milk, which is sipped slowly, at eight, twelve, 



