With reference to prophylaxis the swallowing of fruit pits, of very small bones, and coarse, indigestible matter in the food was formerly strictly forbidden. Nowadays, however, we know that the above-named substances play no part whatever in the etiology of appendicitis. Regulation of the bowels or, more practically speaking, correcting constipation has been believed to be of importance in preventing appendicitis. This maxim can likewise not be maintained on the ground of recent researches. Regularity of the bowels is in itself of importance, and hence it will be advisable to pay attention to this factor. The only means we possess of preventing an attack of appendicitis is the removal of the appendix. While this suggestion is not generally practicable, for it requires an operation which is not entirely without risk, it may, however, be carried out in cases requiring a laparotomy for other diseases, provided that this additional operation does not demand too much time.

The medical treatment of appendicitis consists in absolute rest of the entire body, especially of the intestinal tract, and in appropriate diet. The patient must be kept strictly abed from the commencement of the disease until it is entirely over. He should not be permitted to leave the bed for a moment. He must lie perfectly quiet; even turning from one side to the other should be avoided, or if done, performed with the greatest care. In taking nourishment the head may be slightly raised; the urine should be voided in a glass, and an evacuation of the bowels should take place in a bed-pan. During this act the patient must be forbidden to strain or exert himself in any way. The utensils needed must be handled by the nurse, who must also attend to the cleansing of the patient.

The principle of rest must also be applied with reference to diet. During the first few days of illness there should be either total abstinence from food (only small quantities of water being given now and then), or liquid food in small portions. Thus strained barley water, or this with the addition of a little milk, oatmeal water and rice water given in the same way, chicken soup, very weak tea. In the very severe forms of appendicitis, especially when perforation has taken place, or when symptoms of ileus and fecal vomiting are present, absolute abstinence from food and also drink is necessary. In accordance with Penzoldt, Ewald, and Boas, rectal feeding appears to me to be con-traindicated in these cases and the only way of supplying the organism with nutritive material is a subcutaneous injection of saline solutions, sugar solutions, and also perhaps small subcutaneous injections of olive oil.

Small pieces of ice may from time to time be given to the patient. He must, however, keep the ice in his mouth until it melts before swallowing. This often alleviates the nausea and retching. The first two or three days of sickness being over, the patient may be allowed to have milk, an egg beaten up in bouillon or milk, in addition to the above-named food. The diet should be kept up in this way until the pains and fever have entirely disappeared. At this period soft-boiled eggs, crackers, small portions of meat (squab) or chopped beef may be given, and still later mashed potatoes, bread and butter, and light vegetables added.

Medicaments

The use of cathartics is mentioned here only in order to condemn it. Even injections into the bowels should not be administered too frequently nor in large quantities. A small enema of one-half to one pint of water or one-half pint of olive oil may occasionally be given.

The remedy par excellence in the treatment of appendicitis is opium. Its use was originally recommended by English physicians (Graves, Stokes) and later by French clinicians (Petriquin, Grisolle); in Germany this remedy found a fervent advocate in Volz and in America in Alonzo Clark. During the last decade the administration of opium has met with great opposition especially on the part of many surgeons. Their reasons against the use of this remedy are, first, that opium masks the true picture of the disease, and secondly, that it gives rise to paralysis of the intestines.

Some of the foremost clinicians, Nothnagel, Penzoldt, Ewald, Sahli, Boas, and others, are even nowadays enthusiastic admirers of the opium treatment. The principal element of importance of opium as a remedy is its action in lessening or arresting the peristalsis of the intestine, and besides in alleviating pain. I myself have always used and still use the opium treatment with great satisfaction. It is of course understood that the opium should be given only in sufficient amount to allay the pain, while excessive doses should be avoided. As soon as the active stage of the disease is passed, the opium must be entirely discontinued. The best way of administering it is that suggested by Sahli. Ten or fifteen drops of tincture of opium are at first given every hour until there is a decided subsidence of the pain. Then five to six drops are given every two or three hours until the pains disappear completely. As soon as there is an exacerbation another large dose is administered, but if the patient is entirely free from pain no opium is given.

If the administration of the drug excites nausea or vomiting, it may be given in the form of a suppository:

Medicaments 40

Extr. opii......

0.05

O1. theobrom...........

1.00

M. f. supp. One suppository every four hours until subsidence of pain.

Or belladonna extract, 0.005-0.01 gm., may be added to the opium in the same suppository.

Boas recommends the administration of opium subcuta-neously. (Extr. opii aquosi sterilis. 0.3 to 10.0 water; 1 Pravaz syringe [1 gm.] three times daily.)

In cases in which the pains are very intense and a quick action is desired, morphine may be administered subcuta-neously in doses of gr. 1/6 to 1/4. The action of this remedy is, however, not so satisfactory as that of opium, as it has but a very slight influence in diminishing the peristalsis. When morphine is used, opium should be given in addition.

Poultices

The application of ice over the painful area is often beneficial at the beginning of the disease, especially if the temperature is quite high and symptoms of peritoneal irritation are present. If the patient, however, complains of great discomfort from the application of ice, it must be discontinued. In the latter instance a cold Priessnitz poultice may be tried. Cases not accompanied by high fever often derive great relief from the application of a hot-water bag or plain warm poultices. The latter are especially to be recommended in that form of appendicitis which is called appendicular colic of Talamon.