Appendicitis.--There never was a case of appendicitis that was not preceded by constipation and colitis. Indeed, appendicitis is sequential to these two affections. It will be necessary to consider them as different stages of one disease.

Bowel obstruction in appendicitis is not so complete as in the disease known as complete obstruction, the difference being a lack of intensity, The pain is not so great. Yet, after the first clearing-out of the bowels from drugs, enemas, or perhaps a slight diarrhea, enemas fail to bring anything more than mucus. The same is true of complete obstruction. If food of any kind, even liquid food or milk, is taken, vomiting will take place, and intense pain will follow almost immediately after the ingestion of a very small quantity. This is due to the stimulating effects of the food, creating peristalsis. If food is withheld, these patients become very comfortable. There will be a dullness on percussion in the lower anterior right side of the abdomen, to the right of, and two inches below, the umbilicus. This part will be sensitive on pressure. But, indeed, an experienced physician will use no pressure; he will diagnose his case from what subjective symptoms the patient describes, and the objective symptoms that he himself can see, without submitting his patient to the dangerous procedure of deep bimanual examination. Nearly every case of rupture of the appendiceal abscess has been brought about by the surgeon in his zeal to diagnose the disease and determine if the usual tumor-like development--pus sac--can be found. The obstruction in appendicitis is due more to muscular fixation than to accumulation in the intestine; indeed, most of the obstruction is caused by the inflammatory process--irritation, determination of blood, swelling, and the exudation which is for the purpose of walling in the forming abscess. Muscle fixation guards the intestine and secures quiet. Motion is dangerous; there is danger in using physic, or doing anything that will stimulate peristaltic action, because of a possibility of a rupture or perforation of a necrosed bowel.

The highly sensitive state of the bowels obtaining in this disease puts the muscles in the region on guard, and the parts are fixed for the very definite purpose of conserving the life of the patient. If nature is not meddled with, the abscess will form and rupture will take place along the line of least resistance, which will be into the bowel. In this way the abscess will empty, and in a very short time after the pus has gained entrance into the bowel, inflammation, swelling, and obstruction will subside, and within twenty-four hours the patient may be given fluid nourishment.

Colitis

Discomfort in the lower bowels and pelvic region, sometimes amounting to distress. The discomfort of this disease is so great and so constant that thousands have been subjected to operations for appendicitis, ovaritis, and other diseases, without the least suspicion that the real disease was nothing more than gaseous distention of a chronically inflamed colon. Many more have been subjected to ovariotomy--in fact, all the operations peculiar to the pelvic region--because of this discomfort in the lower bowels. Patients frequently complain of pain in the lower right frontal region of the abdomen. At first they are suspicious of appendicitis, and too often the medical man is willing to confirm this suspicion and recommend an unnecessary operation.

Obstruction

Distressing pain in the lower bowels, with inability to secure a movement. The taking of laxatives or physic creates great nausea and vomiting, but fails to cause the bowels to move. Large enemas may be used, which return without carrying with them any fecal matter, after the rectum, and perhaps the signioid flexure, are cleared of their contents. If the obstruction is complete, the symptoms become very grave, the stomach will not tolerate anything, not even water, and the distress caused by taking food, or even taking water, is so great that everything by way of the mouth has to be suspended. The pulse increases in frequency, the breathing is hurried, the skin clammy, all the symptoms of collapse gradually set in, and within forty-eight to seventy-two hours death relieves the sufferer.

Treatment

In colitis anything that has a tendency to create inflammation of the mucous membrane must be overcome. The bowels must be emptied every day--constipation must be overcome. This can be temporarily relieved by a very light saline laxative, or laxative foods, or small enemas--not more than a pint of water placed in the rectum and left there for five or ten minutes; then solicit a movement. This should be carried out regularly every night. On account of the great tendency for carbohydrate foods to cause gas in the bowels, these foods should be either proscribed entirely or given in very limited quantities. Meat, non-starchy vegetables, and fresh fruits are the proper foods for those who have chronic colitis. For chronic colitis very little starch should be used--none whatever by the obese. Until all the symptoms are under control, no food should be given except fruit three times a day. When the patient is better, the noon meal may be meat, one or two cooked, non-starchy vegetables, and a combination salad. This should be kept up for weeks, if necessary, to overcome the disease. The stools should be watched. If there is much catarrhal discharge, this is evidence that the disease is not yet under control. No starch should be given until the bowels are moving without any mucus in the stools; in fact, the mucous discharge must be overcome before a cure can be accomplished. Then white-flour bread thoroughly toasted, is the best form of starch to be given at first. The coarse bread has a tendency to irritate the bowels, and should not be used until the patient is quite well. During the time when the symptoms are most intense the seeded fruits should not be eaten; or, if they are, they should be run through a sieve or colander that will exclude the seeds.

For complete obstruction, a surgical operation at once is the only remedy. In this matter there must be no delay. Yet those interested in the case should not lose their head. Unfortunately, surgical insanity is so, general that it is a very difficult matter to find professional men who will not fly off at a tangent and recommend an operation for almost any severe pain in the bowels. But there is a great difference between obstruction caused by appendicitis and complete obstruction, which latter may be due to invagination, or telescoping of the bowels, or to a twist, or to mesenteric, mesocolic, omental, or any visceral hernia.

The treatment for appendicitis amounts to a wise letting-alone. The patient should be put to bed, with hot-water bottles to his feet. If in great pain, and running a temperature above 103° F., ice should be put over the region of the appendix. If the temperature is below 103° F., heat should be put to the abdomen. The mouth must be closed to everything, even water, until comfort is established, which will be within about three days. Then the patient may have all the water desired. A copious enema, or as much as can be introduced into the bowels, should be used every day, either morning or evening; but positively nothing else needs to be done until the bowels move without assistance, except for the enema which is used daily to wash out the lower bowels. There will be a large amount of accumulated fecal matter, blood, and pus above the portion of the bowels involved. The movement will be copious, because it will not take place within seven to twenty-seven days. Of course, the longer the patient lingers before the bowels do move, the greater the accumulation will be above the cut-off. Then, within three or four hours after the first copious evacuation, the patient will have another movement, which will show more or less pus. It will be well to wash out the bowels once or twice with simply warm water. Let the patient alone. He may have fluid nourishment for four or five days; and, to be really safe, he should confine his eating to fluid foods for the first week after the evacuation. Then gradually return to the accustomed style of eating. However, if a permanent cure is desired, such patients should live correctly ever after, having one meal of fruit, one of starch, and one of meat and vegetables.