1 In the toxic and infective forms of acute gastritis where immediate risk to life is involved, the problem consists in the maintenance of strength with absence from food over a much longer period of time, and in such cases rectal feeding becomes neces sary. Chronic Gastritis. The prophylactic treatment becomes more important here than with acute gastritis. The amount and character of the food, the state of the individual while eating. and the rest before and after the meal, with instructions as to mastication and mental repose, all lend valuable aid to the preventive side of this condition. The question of feeding deals more with what not to take than the prescription of a simple diet. Rich foods, spices, condiments, ices, tea and coffee should never be allowed. It must be borne in mind with these cases of chronic gastritis, that digestion of protein is at a low level, and that carbohydrates, on the other hand, are liable to fermentation changes with development of injurious organic acids. The diet demands both of these ingredients, but they should be added in small quantities. Later, eggs, fish, raw meat, toast and butter may be allowed. With continued impairment of digestive power in chronic gastritis, as is sometimes the case, Wegele's diet, supplying some 2.400 calories, is of value: Morning: Pepton-cocoa, 150 Gm. Butter on toast, 25 Gm. Forenoon: One soft-boiled egg. Noon: Oatmeal soup, 200 Gm. Fowl, 150 Gm. Carrot, 200 Gm. Macaroni with toasted bread crumbs, 100 Gm. Diarrhea. Nervous diarrhea may arise from heat, cold, fright, etc. The stools in these cases are rather liquid, yellowishbrown, and soon became watery and of a lighter color. There may be a dozen in the twenty-four hours. A typical case may exhibit loose movements of normal color and odor, and without abnormal constituents. In acute duodenal indigestion, which usually occurs in middle and later childhood, the stools show evidences of undigested food, and in a certain number of cases become clay-colored. In chronic duodenal indigestion, the fecal discharges show, at first, merely the various changes which occur in ordinary indigestion, sometimes manifesting a tendency to constipation, sometimes to diarrhea. The color of the discharges at this early period is not significant, and is usually a mixture of yellow, white and green. As the disease progresses mucus begins to appear, and increases to quite an amount, as shreds or masses, sometimes covering hard lumps of feces. Intestinal indigestion from deficient secretion gives loose, rather large stools usually free from much odor. The color is usually a mixture of yellow, brown and white, the latter caused by various sized curds. They may also be light-greenish, with or without a small amount of mucus. In fermental diarrhea the color of the discharges is commonly some shade of green or greenish-yellow, and the odor is often very offensive, sometimes being excessively sour from intestinal fermentation (acid), at other times extremely foul, indicating albuminous decomposition. There is usually a considerable amount of mucus present. In infectious diarrhea the infecting organisms are found in the fecal discharges, and more especially the different types of the bacillus dysenteria of Shiga or Flexner. The discharges are comparatively small in amount, contain fecal matter at first, but soon consist of mucus, sometimes with pus, blood and shreds of membrane. The odor may be very offensive, but when the mucus predominates there is very little odor. The color and consistency are very variable, but generally the consistency is lessened, and the color is a mixture of green, brown and yellow. The blood is usually from congestion of the blood-vessels and straining. One of the forms of infectious diarrhea from its intense choleriform symptoms has been called cholera infantum. This form is characterized by profuse diarrhea, chiefly serous, serum mixed with epithelial cells and many bacteria, and generally odorless. Bacterial analysis reveals the comma spirillum. Another form of infectious diarrhea is endemic dysentery, caused by the amoeba coli. It is of rare occurrence in children and in northern latitudes. The stools are bloody, fetid, and contain fragments of sloughing mucous membrane. No doubt diarrhea can result from chemical or mechanical irritants, decomposing meat or a meal of unripe apples, but it is more than likely that these products produce their effect not directly, but through bacterial agency, and that the bacteria. normally present in the bowels undergo rapid development upon the introduction of such material. (Sutherland.) Consequently the dietetic treatment of diarrhea is largely bound up with the questions of the possibility of influencing bacterial growths in the intestine by alteration and manipulation of food. The small intestine contains bacteria producing organic acids as lactic, acetic and succinic by their action on carbohydrates, while in the lower two-thirds of the colon we find the coli communis and other protein-decomposing organisms. The region about the cecum is inhabited by both forms of bacteria. As regards the colon, it must be remembered that here digestion proper is at an end, and food has little influence on the bacteria of this region, save indirectly by the choice of a diet leaving little residue and containing no hard or irritating particles. As regards the small intestine, it is probable that diet has some influence on bacterial growth, and as a result of the steady production of acids by bacterial action on carbohydrates, the contents of the small intestine remain active notwithstanding the neutralizing effect of the alkaline succus entericus. This increased acidity, with the inevitable development of gas, accounts for the increased peristalsis and frequency of stools. In most cases of diarrhea, with the possible exception of those of nervous origin, in which the general condition of the patient and not the local irritation is to be dealt with, dietetic treatment involves a recognition of the cause, and a choice between a milk-carbohydrate and a protein diet. The decomposition of protein is best met by a milk diet or a milk-carbohydrate diet in which milk is the chief ingredient, whereas the irritative and inflammatory condition of the small intestine requires a reduction of the carbohydrates and the substitution of protein and fat. In forms of diarrheas it is well to avoid all articles containing cellulose, vegetables, fruit, coarse bread stuffs and grains, sugar, and meat extracts. In some cases of long-continued diarrhea the following diet, nearly pure protein, will bring about speedy improvement: 8 a. m. Cocoa made with water, one or two eggs. : Bouillon with an egg. IO a. m. Noon Chicken or fish, piece of toast, custard. 4 p. m. : Panopepton, one egg, piece of toast. Sweetbread, chicken or fish, piece of toast. 10 p. m. Colitis. In general it may be stated that milk alone, either diluted 4 or 6 to 1 of lime water, soda water, or barley water, or as a blanc-mange, is the most acceptable diet. Any departure. from this diet should be postponed as long as possible, and the return to carbohydrate food should be gradual, also the yolk of eggs and plasmon, while the return to meat, meat extracts and vegetables must be made with the greatest caution. Constipation. Spasmodic cases are rare, but should be recognized, as they frequently cause much disturbance of the child's general health. They are usually due to fissures or to an increased size and consistency of the feces. The size of the fecal masses may at times be enormous. The most common of all the causes of atonic constipation is the food, which is insufficient in amount or improper in quality for the digestion of the individual case. In infants being fed exclusively on milk, a low percentage of fat in the milk seems in a number of cases to produce constipation, Feces show increased consistency, and sometimes streaks of blood. Improvement of the mother's milk should be aimed at, and water given the child between feedings. When additional measures are necessary owing to a deficiency of fat in the mother's milk, one or two tea-poonsfuls of cream may be added to each nursing, or half this quantity of olive oil or cod-liver oil. Diet in constipation in children on a mixed diet often means a substitution of cereals and increase of fat, for meat in quantity ; sufficient water between meals to stimulate peristalsis, and the general avoidance of astringents. Consequently graham or whole wheat bread; Scotch oatmeal and Quaker oats; vegetables, such as cabbage, sprouts, tomatoes, salsify, Spanish onions, spinach, and asparagus should be freely used. Fruit, at least three times a day, including apples baked or raw, pears, currants, raspberries, cranberries, prunes, dates, and figs. Butter should be taken freely. Olive oil, either with salad, or on bread or cereal. is a great aid toward the restoration of normal functioning. The foregoing pages have considered the topic of proper nutrition in as simple and direct a manner as possible. There is much to be said from many viewpoints on each individual phase of the subject. The points I especially wish to make, however, are that a properly chosen diet is one of our most valuable resources in the treatment of the gastro-intestinal, and many of the other diseases of children, and that scientific accuracy in diagrosis, and in the correction and selection of diets will be immeasurably increased if physicians will resort as a matter of routine to the making of fecal examinations. To still further emphasize the necessity for a better understanding of the questions involved, and so vital to our growing youth, I will close my paper by giving a summary of the mortality statistics of children, compiled by the Census Bureau for 1908 and 1909, reminding you that it was estimated by Prof. Irving Fisher of Yale in his "Report on National Vitality" that, in the matter of diarrhea and enteritis alone in children under five years of age, 60 per cent. of the resulting deaths were undoubtedly unnecessary and avoidable. Child Mortality. The total number of all deaths returned for the year 1908 from the entire registration area of the United States was 691.574. The figures for age show a somewhat increased per cent. of infants under one year for 1908 as com pared with the preceding year, but the ratio for each of the individual years from one to four is nearly identical for 1907 and 1908. Nearly one-fifth of all the deaths that occurred were those of infants under one year of age, and over one-fourth are of children less than five years of age, that is, there were more than one-eighth of a million (136,432) deaths of babies under one year of age in about one-half the total population of the United States in 1908, and nearly 200,000 deaths of little children under five years of age in the same aggregate of population. Of the total number of 732.538 deaths in 1909, in the Census Bureau's death registration area, representing a fraction over 55 per cent, of the provisionally estimated population of continental United States, no less than 196,534. or 26.8 per cent., were of children under five years of age, and 140,057, or 19.1 per cent.. were of infants under one year of age. In general, one death out of five that occurred during the year 1909 was of an infant under one year of age, and a little more than one death in four was of children under five years of age. The proportion of deaths of children under five years of age to the total deaths that occurred in the year is far greater than that of any other five-year period. The early years of life are of special importance, not only because of the large number of deaths that occur therein, but also because a large proportion of these deaths are preventable. RECORDS OF THE MASSACHUSETTS STATE HOSPITALS, 1909. BY ARTHUR BLAKESLEE, WESTBORO, MASS. Rates of Recovery. Reckoned, as usual, upon commitments of the year from which they nearly all came. About all of the acute alcoholic recover. Are they really of the insane? Deducting them the recovery rates run as follows: |