When there is a tendency to colonic dilatation, the utmost can4 should be taken to avoid retention of contents. On the other hand, frequent purgation does harm and the attempt to avoid retention by administering foods with very little residue defeats the object in view. By gentle massage, encouragement of regular habits of evacuating the bowels, the administration of an abundance but not an excess of water, the use. regularly, of vegetables and fruits containing soft cellulose but not dense seeds, and of purpetrol as a lubricant, a mean may usually be struck between accumulation of residue and constipation due to insufficient intestinal contents.

Chronic Intestinal Ulceration may be directly due to colitis or to syphilitic, tuberculous or other specific processes, the latter group of cases more or less theoretically demanding operation. The diagnosis is not easy and such cases will, for practical dietetic purposes, usually be considered either as chronic colitis or as intestinal obstruction.

Duodenal Ulcers are usually closely analagous to peptic gastric ulcer, with difficulty diagnosed from the latter and requiring the same dietetic management.

Colitis may be more or less limited to certain parts of the bowel. Proctitis and rectal and anal lesions generally, require no special dietetic regimen, excepting to avoid hard, irritating particles, such as seeds, cores etc., and the formation of scybalous masses in the colon by too concentrated and too dry diet. Though not strictly a dietetic point, the importance of avoiding accumulation of faeces on account of the dread of the pain of passage, may be emphasized. Tape-like and macaroni-like faeces may be due to reflex spasm low down in the bowel, or to the pressure of the uterus or of some pelvic mass on the rectum, and not to a true intestinal obstruction.

Typhlitis is a frequent localization of colitis, undoubtedly due to the fact that the caecum and ascending colon act as a stand-pipe so that delay of intestinal contents and bacterial changes, are especially prone to occur in this region. Surgeons commonly ridicule the standpipe theory, forgetting that they usually see the patients after the standpipe has been in a horizontal position for a day or two and after efforts have been made to evacuate it.

Appendicitis, in the general sense, may include various specific inflammations due to tuberculosis, typhoid etc., or local manifestations of cancer and other pathologic processes and may theoretically occur primarily, from lesion from without, within and originating in the interstitial tissue. It may also occur from traumatism of strictly foreign bodies, as sharp seeds, bristles accidentally swallowed from tooth brushes, shot from game, bits of solder from canned goods, fragments of bone etc. More or less anomalous states in regard to the adequacy of the blood supply, length, size of the lumen, direction, situation favoring entrance of material from the small intestine, adequacy of musculature and restriction of efforts to clear itself of entering material by anatomic position with relation to pertoneal bands etc., also determine the vulnerability of the appendix.

The great majority of cases of appendicitis, however, are due to localizations of the essential features of colitis and, in particular, of typhlitis, and the special importance and gravity of appendicitis is due to the small lumen and embryonic condition of the appendix, as compared with the caecum generally and the fact that it is more prone to perforation than the intestine generally, the gall bladder or even the Fallopian tubes. It should, indeed, be remembered that the appendix vermiformis is not an appendix in the strict sense but that, owing to the evolution of man and the change in his habits of eating, especially in the restriction of coarse, bulky foods and the use of fire in preparing foods, it has become unnecessary for him to have a long caecal pouch, so that this part of it does not expand beyond the calibre of the early embryo.

Thus, with the exceptions noted, which are really entirely distinct lesions, appendicitis is essentially a form of intestinal sapro-phytosis, mainly involving increased virulence of the colon bacillus, and resulting in a localized catarrh and sepsis - not, indeed, usually limited to the appendix itself but extending over part of the caecum or even over the whole caecum and sometimes over nearly the entire large intestine. If it were not for the small calibre, preventing ready egress of putrescent contents, for the inflammable lymphoid tissue and poor blood supply and perhaps strictly neurotrophic factors, there would be no special tendency to burrowing inflammation and, were it not for the imperfect protection against perforation, even the invasion of the submucous and muscular coats, would not be particularly dangerous.

Thus, excepting for the inevitable and virtually anomalous predisposing factors, appendicitis is largely due to dietetic causes, as is intestinal saprophytosis and inflammation in general. Among these causes, the use of an excess of proteins and especially of meats, the use of tainted foods, neglected intestinal indigestion, and stagnation of contents - constipation - are the chief ones. Theswallowing of foreign bodies, including seeds, scales, bones etc., is only occasionally a cause of appendicitis. It may be noted in passing that the term appendicitis is utterly indefensible and that scolecitis or some similar word should be substituted.

The diet in acute appendicitis should be nil, not only to reduce bacterial activity, the empty intestine becoming nearly sterile in a day or two, but for the very practical reason that it may be necessary to give an anaesthetic on comparatively short notice. Water, however may be given quite freely. Inunctions and hypodermatic injections of dextrose, salt and water, may be employed if the patient is much reduced but, as a rule, these are unnecessary.