Within two or three days, one of three conditions exists: the patient has either been operated upon, when the dietetic management should be as after intestinal operations generally; or sepsis or gangrene or both have developed when the diet will depend upon the decision for or against operation under unfavorable circumstances; or the patient will be practically out of danger though not necessarily on the way to permanent cure.

It will be noted that the diet appropriate to septic fevers must be somewhat modified when the integrity of the bowel is impaired. Indeed, if perforation is probable, feeding by mouth and even by rectum is contraindicated. Clear coffee may be given by the mouth and inunction - not in the abdomen - and hypodermoclysis with dextrose added, may be employed but time should not be wasted in "building up the patient's strength."

When the evidence is in favor of resolution, milk and cereal diet may be begun after the third day, unless the course is unusually slow. The cereal should be of a fine and soft nature, free from chaff and gritty particles.

After about a week, all cases of appendicitis may be placed on approximately the same diet, with obvious modifications according to individual requirements and peculiarities, especially in the way of complicating diseases, such as the various forms of indigestion, obesity - which is mechanically serious in all persons liable to require deep operations - hepatic sclerosis, renal degeneration etc.

Three principles should be observed: Avoid the use of foods favoring intestinal sepsis; avoid mechanically irritating food residue and especially small particles which may enter the disabled appendix; keep the bowels moving freely but not in a state of diarrhoea.

The first of these principles requires that the patient should be nearly a vegetarian. Tainted meat and such meats as are digested with difficulty are especially to be avoided. Not over 100 grams of meat should be allowed daily. Even eggs and milk should be used in moderation, milk being especially liable to colon bacillus infection. As a rule of thumb it may be said that not over 20 grams of egg and milk protein should be allowed nor over 30 grams from animal foods generally. Remembering that 100 grams of meat contains about 20 grams of protein, 100 c.c. of milk about 4 grams, and each egg about 8.5 grams, the proper allotment can be made.

The second principle necessarily restricts the vegetable diet and must be remembered in applying the third. Oatmeal and all chaffy and gritty cereals must be excluded, as well as tough skins, cores, and fine seeds. Raspberries, blackberries, currants and grapes must not be taken in their natural state. Figs must not be used as laxatives although prunes and dates, as well as most succulent fruits may be. While much nonsense has been taught regarding the frequency of the origin of appendicitis from seeds, the possible danger from such bodies after susceptibility has been established and after inflammatory processes of the appendix itself and adhesions around it prevent its ready discharge of matter entering it, is a real factor. The coarse, nearly innutritious vegetables, if finely cut or chewed, favor peristalsis and their cellulose is not a traumatic factor but not enough should be used to produce diarrhoea nor marked intestinal fermentation. Dry beans and peanuts seem to be especially frequent exciting causes of appendicitis though green beans, lima beans and peanut butter do not.

Irregular meals, especially at night, are frequently exciting causes of appendicitis, possibly because at such times, cheese, lobster, crabs etc., are eaten more than at regular meals.

Moderate but not excessive use of sugar and fats should be allowed.

Water should be used freely but not beyond the physiologic standard and the xanthin beverages should be allowed only in small amount.

Exacerbations of appendicitis sometimes occur so promptly after rectal injections as to suggest something more than a coincidence, thus they should be used cautiously to secure movements of the bowels and rarely if ever as a means of nutrition.

Acute Peritonitis is now recognized as mainly a secondary, septic condition, requiring surgical intervention. Especially when the lesion is in the wall of the alimentary canal, or when there is mechanic obstruction of the canal, projectile vomiting usually occurs and may even be regarded as conservative, in preventing attempts at introduction of food and in more or less completely emptying the contents already present. While, if the lesion involves the internal genitalia or, otherwise, leaves the alimentary canal free from danger of perforation or obstruction, there is no direct contraindication to careful feeding, there are obvious indirect contraindications to feeding by either mouth or rectum, during what should always be considered as the preoperative stage. Other emergency methods of nutrition may be practiced if necessary, though not usually required in the average case. After operation, the general principles of postoperative feeding should be carried out. If operation proves to be unnecessary, the resumption of feeding should usually be gradual, and on the lines already discussed for appendicitis excepting, of course, that if the peritonitis has no connexion with lesions of the alimentary canal the diet after the first week or so requires no special modification.

In hopeless cases, vomiting and gastric and intestinal distress usually add to the sufferings of the patient, if feeding is attempted and, indeed, it is usually tetter to administer even water hypodermatically or, if there is no contraindication, by enema. Even if the case merely appears hopeless, it is doubtful if recovery is assisted by attempts at feeding.

Without regard to the question of operation in cases of peritonitis due to pneumococcic and other diffuse infections, including chronic forms due to tuberculosis etc., the diet is not especially limited by the peritonitis itself, although it should obviously be of a very simple and bland nature, in acute cases as in fevers in general; in chronic cases, as appropriate for tuberculosis and other wasting diseases. Considerable difference of opinion exists as to whether the intestinal movements should be allowed to progress as usual or whether by starvation or the use of foods leaving as little residue as possible, and the use of opium, peristaltic movements should be restricted.