When we recognize every peritonitis, even the diffuse type, in its first stage and treat it at once according to the conservative principles we have just laid down, then we can give a good prognosis in children especially, though with the above mentioned limitations.
In some cases of peritonitis from perforation in appendicitis even the skin-incisions healed by primary intention though we were able to prove the germs from the intestine in the pus, and One case of coli peri tonitis which had been general was able to leave the hospital cured on the tenth day. In two cases we lost the children between the ninth and eleventh clay, after the nausea had ceased, the abdomen was painless, and normal stool had been passed, when fatal collapse set in; we were not able to show an embolism at post-mortem, but the sublethal symp toms indicated this accident; at that time we were still in the habit of draining the abdomen with large pieces of gauze (Mikulicz tampons). (Thrombosis in the mesenteric vessels.) (b) Tubercular Peritonitis (See Stooss, vol. ii.) This affection was frequently mentioned in surgical literature a few years ago. Opening the abdomen and removal of the exudate was considered of great therapeutic value, though this could not he proven later on. The influence of light and air, the reaction of the tissues in healing, all these were given as causes for the disappearance of the symptoms of the disease. Lately this enthusiasm has rightly been stilled k,Borchgrevink), because we can furnish most of these therapeutic factors cheaper and easier.
Tapping the liquid instead of its operative removal, Röntgen rays instead of letting in the light through a small incision, the suction treatment with large bells, venous congestion upon the principle of Momburg's constriction, may easily do the same as an operation. We further found that the exudate, which is usually found to be sterile, contains large amounts of anti-bodies in solation, and that it is therefore a question if we aid nature by its removal.
In our own hospital service the operation has not altered the per centage of cures.
The following case may serve as an illustration: In 1904 we operated on a girl eight years old for tubercular peri tonitis by a median incision above the umbilicus. We found large quantities of liquid, the parietal peritoneum covered with nodules, the small intestines caked together into one lump, from behind which the exudate gushed out. Healing without reaction, child discharged.
Five years later the child returned complaining of pains in the abdomen awl recently inure frequent vomiting, though both these symp toms had been present to sonic extent all these years. Our diagnosis was influenced by the previous operation and we thought of an obstruc tion in the convolution of intestine, to separate which is very difficult even in the dissecting room. We operated on account of the increasing ileus and found strangulation of one loop of intestine around a liga mentous adhesion in the small pelvis. The child could not survive the resection of intestine, and died twenty-four hours after the operation.
On post-mortem we found that of all the considerable changes which had been caused by the tubercular peritonitis only one single caseous nodule, one mesenteric gland and the above mentioned adhesion which occluded the intestine had been left. Nature had so t horoughly loosened all adhesions and exudates. From this we learn that we should only consider those surgical measures in tubercular peritonitis which tend to lessen by the partial removal of the exudate the unnatural and painful distention.
The differential diagnosis will not be difficult when we consider the history of the case, the general condition of the patient, and make use of the diagnostic biologic expedients (Pirquet, skin test).
(c) A ppendieWs (Peritonitis from Perforation) ppendicitis is recognized as one of the most frequent causes of peritoneal infection. (Concerning its symptomatology see Selter, Dis ease i of the Appendix, vol. iii.)