In cases which are seen and recognized from the first, food should be given sparingly. The ideal state, in which a perforative lesion of the appendix may be best sustained, requires an empty, motionless stomach and a stationary intestine. The dissemination of bacteria throughout the abdominal cavity is greatly influenced by the degree of peristaltic activity. Starvation is the lesser of two evils. In every case, however slight the early symptoms may be, the treatment should be conducted on the hypothesis that perforation or gangrene has certainly occurred. Such fluid, however, may be given as will serve to maintain the secretion of saliva. A complaint of thirst should not lead to extravagance, and it may be met if necessary by small injections (6 oz.) of saline solution by rectum. Water hot or cold (the former if there is much vomiting), in 1 oz. doses every hour is ample at this stage, or a similar amount of barley-water or of milk diluted with one-half of soda-water. If the patient is fortunate enough to come under treatment at the onset of symptoms and the appendix is at once excised, the subsequent feeding will be conducted as after any other abdominal operation.

If the first 48 hours have elapsed without operation and without signs of general peritoneal infection, milk can be given in greater quantity, perhaps 4 oz. diluted (4-1) with soda-water every 2 hours for 9 doses in the day. And there should be but little extension of this diet in the next few days, during which observation is directed to the appearance of signs of localized suppuration or of a late general infection of the peritoneum. When this period of danger is past, the diet can be rapidly increased by the addition of more milk in less dilution, of carbohydrates, beef-tea and clear soup, and later of eggs, custard and fish.

After the subsidence of an attack, if for any reason excision of the appendix is refused, a request is often made, for a diet which shall prevent subsequent trouble. The prevalence of appendicitis in all its grades has greatly increased in the last twenty years. Severe perforative and gangrenous lesions of the appendix have shown a greater increase of frequency than the milder types, so that notwithstanding better and quicker surgery, the percentage mortality is higher or shows no fall. The cause of this increase and change of type is unknown, but it is not more mysterious than the rise of influenza in 1888 and its subsequent fluctuations and decline. There is no reason to suppose that these changes have any dependence on alterations in the national diet, and they are not confined to this country. I believe that, if a patient declines to have a diseased appendix removed, his best chance for the future lies in the prevention of constipation and the avoidance of all causes of catarrhal enteritis. Some such healthy diet as is suggested in the treatment of constipation should serve him well. Considering the possibility of checking the activity of putrefactive organisms in the caecum by means of the acidity of the contents of the small intestine, carbo-hydrates and vegetables should be taken freely, while meat is diminished.