In the first place, rest in bed is of absolute importance. We fre quently have opportunity to observe the favorable effect of rest in bed, when these patients are brought to the hospital. The aseitic exudate becomes absorbed with no otter treatment; and the general condition improves, with eventual gain in weight. In the second place, proper nourishment is of great consequence. Since these children usually suffer from digestive disturbances and loss of appetite, the problem of their dietetic treatment may be extraordinarily difficult. Milk and foocls prepared with milk; starch gruels, besides the infants' foods; plasmon; and similar preparations, must be tried. Sotne physicians ascribe especial value to carefully prepared dishes of meat ; fresh beef-juice and the artificial foods prepared from meat. When persistent diar rhoea is present, the diet requires especial vigilance.
A prolonged sojourn by the sea contributes powerfully to success; but since the children from inland districts cannot often have this advantage given them, I would emphasize the fact that excellent results may also be obtained by a stay in mountainous districts under suitable conditions. Medium altitudes are to be preferred, as a rule; but even very elevated health-resorts, such as St. Moritz, Davos, Arosa, and Ley sin (1500 to ISO° metres), are well tolerated by children that are not too much reduced in strength. The prejudice against sending children to these resorts is not justified. They may spend a large portion of their time resting in the open air with great advantage.
Inunctions of green or barrel soap, I use for local treatment. Like Heubner, I order the soap to be spread on thick, rubbed in, and allowed to remain for a quarter of an hour; then it is washed off. To avoid irritation of the skin, the treatment must be omitted every other day. Applications of ichthyol also appear beneficial. Internally, I usually give thiocol, in closes of 0.25-0.5 Gm. (four to seven grains), three times a day.
According to my views, the value of operative treatment is now rather underestimated; whereas, before, too much value was ascribed to it. Without doubt, many children improve rapidly after abdominal section, with disappearance of the ascites, fever and pain. When the
ascites is very niarked, the mechanical hindrance to respiration furnishes a definite indication. Most authors consider puncture of the abdomen to be of subordinate value, as compared with abdominal section. Since laparotomy is performed so much more frequently, there is not sufficient material to institute comparisons. Theoretically, it would appear that evacuation of the exudate by puncture ought to produce as good results as the same operation for serous pleurisy; but the conditions are essen tially- dissimilar. -While the pleural cavity may be tapped without danger, abdominal puncture for the relief of ascites the needle may penetrate adherent intestinal walls. On the other hand, the aseptic opening of the abdominal cavity is scarcely more dangerous than puncture and has an advantage in that We can study the extent of the lesions.
Operation must be advised in tuberculous peritonitis accompanied by exudation, when the latter does not permanently disappear on medical treatment. However, when there is no positive indication for surgieal intervention, medical treatment should be given a fair trial. When no fluid exudate is present, the indications for operation are usually not so clear. We know that this dry type of the disease may heal without operation, so that some entirely reject laparotorny; whereas, others claim good results from it. When we are justified in assuming that tuberculous organs (tubes, ovaries) may be removed at the operation, a definite indication exists. Kocher has reported good results from such operations. Circumscribed collections of pus niust he treated on general surgical principles; also complicating fistula), intestinal occlusions, etc.
Concerning the technique of the operation, most surgeons make a short incision in the linea alba, below the umbilicus; evacuate the exudate; and immediately close the abdominal cavity again. Care must be taken not to injure coils of intestine that may adhere to the abdominal wall. Professor Tavel (Berne) usually flushes the abdominal cavity thoroughly with a solution of vioform and normal salt solution.