The acute form of tubercular peritonitis is often puzzling, especially if, as in the case referred to above, the abdominal symptoms are limited to some swelling and pain. In such a case, typhoid fever is often suspected, and the pyrexia, wasting, and increasing weakness may seem to give strength to this opinion. No evidence is to be derived from the state of the bowels ; for whether confined or relaxed, either condition is perfectly compatible with enteric fever. Even if more distinct evidences of peri tonitis occur, these may be attributed to perforation and consequent in flammation. Still, the absence of rash and of splenic enlargement, the comparatively moderate pyrexia, and the more haggard aspect of the patient are not in favour of typhoid fever ; and if fluctuation can be de. tected in the abdomen, or slight oedema of the legs and face is noticed, this disease may be at once excluded.
Prognosis.—Tubercular peritonitis is not invariably fatal, and there. fore we should not at an early period of the illness act as if the case were a hopeless one. Tension and tenderness are important symptoms, and if the child lies in one position, with his knees raised, apprehensive of the least movement, the sign is not of favourable import. A profuse cliarrhcea or the passage of stools indicating ulceration of the bowels must be viewed with apprehension. If the tenderness is extreme, and solid tubercular masses can be felt underneath the abdominal parietes, recovery, although possible is very unlikely. Also, the presence of signs indicating tuber cular disease of other organs is of course to be taken as of serious omen.
On the other hand, increased regularity in the stools, improvement of appetite, reduction of pyrexia, diminution or subsidence of abdominal ten derness, and return of cheerfulness are all encouraging signs. We must remember, however, that alternations of improvement and relapse are common in this disease, and that recovery, although not exactly uncommon, is, at any rate, an exceptional termination to the illness.
Treatnient.—Absolute rest, hot applications to the abdomen, and opium internally, form the most useful means at our disposal for promoting the subsidence of the disease. The child should be put to bed, and his belly should - be kept covered with hot linseed-meal poultices, frequently re newel. If the weight of these be complained of, and there is much pain and tenderness, great relief is often derived from smearing the surface with a salve composed of extract of belladonna and glycerine in equal pro portions, and covering this with a thick layer of cotton-wooL The child should take a draught containing a few drops of laudanum every night, and if his stomach will bear it, cod-liver oil may be administered. Diar rhoea should be treated with full doses of bismuth and a drop or two of tincture of opium two or three times a day ; or three or four grains of ex tract of hmatoxyluna may be combined with three drops of laudanum and three of ipecacuanha wine in a chalk mixture for a draught to be taken several times in the twenty-four hours. Purging will also be re lieved by a small injection of starch and laudanum, given at night. If there be constipation, it is better to avoid aperients and trust to injections to relieve the bowels. When necessary, the accumulation can be cleared away by a good enema of soap and warm water.
The diet of the child should be regulated to suit his powers of diges tion. Strong beef-tea and other broths, milk, yolk of egg, minced mutton or chicken, fish, bread and butter, and light pudding should be given. But great attention should be paid that excess of farinaceous matter is not allowed, as acidity and flatulence will increase the discomfort of the patient and be decidedly injurious. A stimulant is required as the strength begins to fail. The brandy-and-egg mixture of the British Pharmacopoeia is the best form in which this can be administered.