THE INFECTIONS OF TUE PERITONEUM (PERITONITIS) (Surgical operations in the abdomen) For the symptomatology see Stooss, Diseases of the Peritoneum, vol. ii.
From the standpoint of surgical therapeutics the etiological differ entiation of the different types of this disease are of the greatest impor tance. While those cases produced by the ordinary pus bacteria—diplo cocci, staphylococci, streptococei, pneumococci, and bacillus coli—differ only very little in their surgical treatment, the gonococcus-peritonitides the adnexa and the tubercular affections occupy a separate position.
(a) Diffuse Purulent Peritonitis This disease used to offer an exceedingly hopeless prognosis. When once the suppuration was somewhat general and advanced, and the peritonitis was recognized as a general diffuse purulent one, then this was considered equivalent to a result in a short time. The mortality was above Si) per cent. In children the prognosis was even worse, because the little patients were unable to survive major operations. Tim reasons for these deplorable conditions were to be found in the etiological and somatic conditions, and, last but not least, in the therapeutical pro cedures.
have divided the peritonitis according to its etiology into the rarer hiematogenous and the more frequent one by contact. In this latter, infection arises either from the suppuration spreading from neighboring organs or from perforation of the intestinal tube through which the germs, which are always living in the intestine, are introduced in the abdominal cavity and infect it. The intensity of the infection varies considerably, and it depends partly upon the kind of germs which prevail and still more upon their virulence.
It is true that a streptococcus peritonitis usually is malignant (Franke), and that bacilli coli and diplococci as a rule give a more favor able prognosis, still we should not forget that under unfavorable cir cumstances a diploeocetis peritonitis, and still more a coli peritonitis, may take a rapidly malignant course.
The mode of infection is also of the greatest importance. The peri
toneal cavity may be flooded suddenly without any warning by consider able infectious material, as in traumatic perforations, or the infection creeps slowly in the peritoneuni, thus giving the body time to call upon its protective apparatus and to repulse the infection. This is one of the reasons why infections which spread from the adnexa are more benign.
Appendicitis furnishes the major part of the peritonitides of child hood and all other etiological factors are of minor importance.
In appendicitis peritonitis not only the kind and virulence of the germ but the rapidity of the infection plays a large role as well. Acute attacks, which lead to perforation within a few hours, arc known to give the worst prognosis in childhood.
The younger the child the less will be the chances of the walling off of the infectious focus, and the reason for this may be found in somatic conditions in the abdomen of the child; the relatively long length of the digestive tract, the smallness of the omentum and the less solid parietal fixation of the intestinal loops surely favor a more rapid spread of the germs.
We have observed many cases in which the intestine was in that stage of development in which the colon with the was still attached to a free mesentery. The appendix was lying free between the cereal loops in the small pelvis. Recently more attention has been given to these anomalies (Wilms) and the more rapid spread of the infec tion has been blamed upon them.
Of the other types of peritonitis peculiar to childhood, we must mention first of all those caused by diplococci and pneumococei, most frequently observed in little girls, and the course of which is determined by the kind and virulence of the germs. The author, from his own observation of eight cases, must agree with Riede], who is convinced that this infection spreads from the genital tract, and like the infection with gonococci it ascends from the genitals though the hymen be intact.