PRACTICAL CONSIDERATIONS: THE PERITONEUM. 1757 



confined by adhesions between the coils of gut, the parietal peritoneum, the mesen- 

 tery, and the abdominal or pelvic organs (Osier) ; and {b) enlargement of the 

 mesenteric glands. 



The existence of a superficial periumbilical area of redness and thickening is said 

 to be a symptom of this variety of peritonitis (Fagge), and is even thought to be 

 pathognomonic (Henry). It may follow adhesion of intestine to the inner parietes, 

 or, more probably, is due to extension of the inflammation of the parietal peritoneum 

 along the track of the obliterated umbilical vessels. 



Localized peritonitis should be briefly considered from the topographical stand- 

 point. 



Pelvic peritonitis, usually due to infection by way of the uterus and Fallopian 

 tubes, is of relatively lessened danger on account of (a) the fact that the source of 

 bacterial supply is not large, the endometrium possessing a high degree of vital re- 

 sistance and its secretion rendering its cavity in most instances sterile ( Warbasse) ; 

 (b) the comparatively low virulence of the bacteria most frequently found in tubal 

 infection, the gonococcus and bacillus tuberculosis ; and (<:) the opportunity usually 

 afforded (by the thickness and immobility of the subperitoneal tissues involved) for 

 the formation of competent adhesive barriers, including those which seal the opening 

 of the tube and confine the infection to the latter and its vicinity (Fowler). 



Puerperal peritonitis is much more serious, owing to the anatomical conditions 

 associated with pregnancy — chiefly the vastly greater size and vascularity of the 

 uterus and the enlargement of its lymph-channels — and to the minor traumatisms to 

 the endometrium which occur even in physiological parturition. These offer an 

 opportunity for increased dosage of bacteria and of their toxins. The danger is 

 increased by the fact that the invading organism is apt to be a streptococcus and by 

 the usual post-partum diminution of vital resistance. 



Subdiaphragmatic peritonitis may be confined to the space between the arch of 

 the diaphragm and the upper surface of the liver to the right or left of the suspen- 

 sory ligament. It is apt to assume a suppurative form. It may follow (or precede) 

 a pleural or pulmonary infection. It is commonly mistaken for an empyema. The 

 infection is, of course, at its onset within the greater cavity of the peritoneum, but is 

 often soon shut off by adhesions. When it has followed a perforation of the stomach 

 or duodenum, the abscess usually contains air (pyo-pneumothorax subphrenicus), 

 the diaphragm may be pushed up to the level of the second or third rib, the liver is 

 depressed, there is bulging of the right thorax, and the physical signs are those of 

 pneumothorax (Osier). 



The variety of subdiaphragmatic peritonitis which involves the lesser peritoneal 

 cavity may originate in gastric, duodenal, or colic perforations, in pancreatic disease, 

 or in other ways. The communication with the greater peritoneum is soon cut of? 

 by adhesive inflammation of the edges of the gastro-hepatic omentum at the foramen 

 of Winslow. 



Distention of the lesser sac with serum or with pus follows and first causes an 

 epigastric swelling, extending by gravity to the umbilical region ; on account of the 

 lesser resistance offered by its left boundary — the lieno-renal ligament — as compared 

 with that of the gastro-hepatic omentum, and because the lesser sac extends farther 

 towards that side, the swelling may appear later in the left hypochondriac region. 

 As the floor of the space is formed by the upper layer of the transverse mesocolon, 

 the colon is depressed and never lies in front of or above the enlargement, as it does 

 in cases of renal tumor. As the space lies below and behind the stomach, distention 

 of the latter, if with liquid, will render the swelling less palpable, but may apparently 

 increase its area of dulness ; if with air, will convert the dulness into resonance and 

 prevent recognition of the swelling by touch. 



Spontaneous e\'acuation of a subdiaphragmatic abscess may take place into any 

 of the surrounding ^■iscera or into the general peritoneal cavity, but the pus usually 

 enters the pleural cavity or the thorax either by direct ulceration and perforation of 

 the diaphragm or, more circuitously, through the weakened intervals between the 

 sternal, costal, and vertebral portions of that muscle. 



The apperidiczdar and subhepatic varieties of localized peritonitis have been suffi- 

 ciently described in connection with the organs involved. 



