operation causes hypenrinia in the sense of Bier's procedure. With this idea aceepted, the question would arise whether it would not be desirable to exert a more intense irritation upon the serosa. According to my experience mere laparotomy is sufficient in pure ascites in children, while in ascites with formation of knots and nodules I give the pref erence to Tavel's method, who follows up the operation with an irrigation of vioform.
His technique is as follows: On the eve of operation Gin. of vioform and 5 c.c. of a 1 per cent. lysol solution arc mixed to make a thin uniform paste which is allowed to stand until the following day, when the vioform prep aration will be perfectly sterile. The excess of lysol is poured off and the remaining mass well mixed with 1 litre of salt solution.
I have seen very good results in suitable cases. Mere puncture of the exudate is to be deprecated, since it is not without danger and quite uncertain in effect.
Circumscribed collections of pus should be evacuated; complicating fecal fistuhe, intestinal occlusions, etc., are treated in aecordanee with general surgical principles.
Medicinal treatment is chiefly hygienic and dietetic.
The foremost indication which follows from the local inflammatory process is absolute rest in bed. This in itself has a favorable effect, similar to the immobilization of a joint, and can he well observed in the hospital when aseitic exudate recedes without any further treatment, and the temperature becomes normal.
In the second place, a suitable diet is of great importance. The nutrition of these patients often involves considerable difficulties, since they usually suffer from digestive disturbances and anorexia, so that the physician's skill will be greatly taxed.
It is, of course, impossible to establish hard and fast rules. Milk and milk preparations (also sour milk, koumiss, etc.), gruel, cocoa, farinaceous food and other nutritive preparations are advisable. If milk is not borne well, skint milk may be tried, both for drinking and prepa ration of food. Some patients digest fat well in the shape of butter, and it is then of great benefit.
Many physicians attach great weight to well cooked and finely minced meat, freshly expressed meat juice, and other preparations made from meat.
In obstinate diarrinea the selection of the diet of course requires special care.
A powerful factor in the cure is a prolonged stay in free pure air, and the rest treatment should therefore, whenever possible, be combined with a suitable climatic change.
A sojourn at the sea-coast has long been recommended, and at the coasts of many countries bhere are numerous recreation stations and small hospitals which do considerable good.
Tbe opinion is still widely held that mountainous districts of medium altitudes are preferable for children, but I do not consider the prejudice against high altitudes justified. Children as young as two and three years bear the mountainous elirnate very well indeed. Furthermore, the climatic treatment in the mountains can he continued during the winter, which is a matter of the greatest importance.
The mountain eure is furthermore powerfully supported by local and general sun radiation. It is the great merit of Dr. Bernhard, of St. Moritz (Engadin), to have been the first to use the sun's rays in the treatment of wounds, and later also in the treatment of other surgical affections, and to have developed this method systematically. Since then, Dr. Rolher, the director of a pediatric sanatorium at Leysen, Canton Waadt, has used the same method systematically and with brilliant success in surgical tuberculosis.
Considering the intensity of the sun's rays and the dryness of the air in the Alps, these regions are particularly adapted to this method of treatment, although in plains it can also bc carried out with great benefit. Local radiation has become a regular therapeutic measure in our (Jenner) hospital, the terraee of which has a southern aspect, and I can thoroughly confirm the good results achieved by Dr. Bernhard and Dr. Rollier, and I advise the more general application of radiation by the sun.
Technique: Radiation. of the affected region of the body for ten to fifteen minutes daily, until the skin turns dark, after which the time may be extended as long as desired. Gradually the rayed surface is extended until a general sun-bath is taken.
The reports on X-ray treatment are contradictory (Allaria, Bireher), improvement having been observed as well as exacerbations.
I have for a long time been in the habit of prescribing thiocol in doses of 0.25 to 0.5 Gm. three times daily. The guaiaeol preparation is gener ally taken very well, and it favorably influences the quality of the stools.
Arsenical preparations may cause diarrhcea, and arc best injected subcutaneously combined with iron. Cod-liver oil may have a very good effect, but in some children it causes diarrhcea.
Following Ganghofner's example, I have recently made tuberculin injections, giving small doses and thus avoiding reactions. Ganghofner uses Koch's old tuberculin, while I am using Koch's tuberculin as well as Beranek's tuberculin, and the favorable effect is undeniable in suitable cases.
Should the body temperature rise in the evening, we administer pyrarnidon or euquinin, for diarrhma phiocol, tannalbin, salol and opium preparations. Constipation is relieved by enemas.