In one case we were able to prove this bacteriologically: This was a case of an abscess on the right of the abdomen of a girl of four years. The appendix was close to the wall of the abscess and was thickened, but its mucous lining showed no signs of inflammatory changes. The ovary and tube were also close to the wall of the abscess. In the microscopic specimen of the pus we found grampositive diplo cocci which were identical with those found in the vaginal secretion before the operation.
This origin of the pus from the genital organs may also explain how the suppuration ascends along the peritoneal folds which lead from the ovaries and the bladdei to the nave], and the predilection of this spot for the perforation of a diplococeus peritonitis.
The true gonococcus peritonitis (see Stooss, vol. iii) demands only rarely surgical intervention; conservative absorbent measures, rest, and application of heat will cause absorption of the exudates.
The prognosis of the cases of peritonitis after gross lesions of the intestine from injury, gangrene, or from occlusion of the intestine, invag ination, or strangulation, is exceedingly bad. As early as twelve hours after the onset of the obstruction the intestinal wall will be pervious to its contents, though the protective powers of the peritoneum will still suffice against this infection, provided the amount of infectious material was not large. The child will be unable to cope with this infection if large amounts migrate through the intestinal wall or the peritoneal cavity is flooded with intestinal contents after gangrene of the intestine.
Another cause for the desperate prognosis in these eases in former times in the diffuse peritonitis of children was to be found in the pre vailing treatment.
fear of the knife as well as the excessive love for it were harmful. Here as in any other abscess it is urgent to empty the pus with which nature tries to get rid not only of the products of inflam mation but also of its causes. The cure of abscesses of the abdominal wall, perforation into the rectum, vagina or bladder, prove to us this attempt on the part of nature; but they also show us the force with which the infection tries to spread.
All surgical interference was avoided during the first period. The next period every case of peritonitis was treated with wide opening of the abdomen, flushing the intestine and washing out the abdominal cavity. The idea was to disinfect the pus cavity and to destroy the germs, but we forgot that it is much harder to injure the well-protected germs than the protective layer of the peritoneum, which is thus incapacitated from its normal function of utilizing the protective powers of the body (Witzel). This method of treatment was hard on the adult, but in chil
dren it was equivalent to a fatal ending, though they would have suc cumbed anyhow, as this was done only in advanced cases of peritonitis.
therefore found it necessary to adopt even earlier for children the change in abdominal surgery which of late has been adopted for adults (Ftehn, Murphy). It is now some years since we began to treat general peritonitis with conservative :lurgery.
We open the abscess in every case of diffuse or wailed-in peritonitis which shows a tendency to spread. In order to avoid shock, we do not make large incisions. Even an otherwise healthy child (e.g., in an opera tion for a tumor) stands a large incision and eventration very badly; in the children who have been pulled down by the suppuration the shock will be directly fatal.
The line of incision is determined by the nature of the original disease (appendicitis, invagination).
We try to find the portal of infection as quickly as possible and close it (appendectomy, intestinal resection). The author does not rinse out the abdominal cavity, because he is afraid he might thus interfere with the natural protective action of the peritoneum.
The surgeons are still divided into two camps: those who wash out and those who do not wash out. Our own experience, which has been gained in children, militates against the washing out; we have never yet been able to observe any good from the washing out, but rather the opposite.
If any pus is accessible through the incision it is removed and the main collection is drained externally with drainage tubes made of glass or of rubber.
The teaching of Echo, to close the abdominal cavity except for the drainage tubes, was a great advance in our treatment of peritonitis. The former open treatment and the packing with large amounts of gauze are now luckily things of the past. By placing the gauze-wicks against the loops of intestine and the mesentery, we frequently caused intestinal and fecal fistulm, either through interference with the nutri tion to the intestinal wall or through thrombosis or lesion of the mesen teric blood-vessels. Since we have given up this method fecal fistulm have become rarer.