PRACTICAL CONSIDERATIONS : THE PERITONEUM. 1755 



more amenable to surgical treatment than that beginning elsewhere. Pelvic perito- 

 nitis, para-appendical and paracolic peritonitis, subdiaphragmatic and subhepatic 

 peritonitis, and peritonitis limited to the lesser peritoneal sac (vide infra) are all va- 

 rieties that are less dangerous than is peritonitis beginning among the shifting coils 

 of small intestine. 



The anatomical sources of peritoneal infection may therefore be arranged ap- 

 proximately in the order of their gravity, as follows : (a) perforations or wounds of 

 the small intestine ; () perforations or wounds of the stomach or large intestine ; 

 (V) perforations or wounds of other viscera, including kidneys, ureters, bladder, pan- 

 creas, and bile-passages ; (d) entrance of bacteria by continuous growth through 

 inflamed gastro- intestinal walls ; (<?) bacterial migration through strangulated intes- 

 tine ; (_/) infection through the Fallopian tubes ; (g} wounds of the abdominal 

 wall (Fowler). 



This arrangement is based upon two factors : the number and virulence of the 

 bacteria which are likely to gain entrance, and the opportunity which will probably 

 be afforded for the formation of limiting adhesions. The latter factor should be con- 

 sidered from the anatomical stand-point, as the variations in the intensity of the in- 

 flammation due to varying forms and doses of the invading bacteria are influenced by 

 the site of a wound or other traumatism, or of an ulcerative or necrotic process in the 

 abdominal viscera. For example, and for reasons already indicated, penetrating 

 wounds above the level of the umbilicus are less likely to produce fatal peritonitis 

 than are those in the lower half of the abdomen. The differences in this respect be- 

 tween wounds or perforations of the stomach, of the different portions of the small 

 intestine, and of the large intestine have been described in relation to the anatomy of 

 those portions of the gastro-intestinal tract. 



The resistance of the peritoneum to infection is usually in direct proportion to 

 the normality of its mesothelial coat, which is lessened by all forms of traumatism, 

 including handling or sponging, or irrigation with strong antiseptics. To a certain 

 extent the sensitiveness of the peritoneum and the rapidity with which it responds to 

 irritation is a conservative process. The prompt exudation which follows either injury 

 or infection often isolates the affected area and prevents a fatal diffusion of inflamma- 

 tion. The great absorptive power of the peritoneum which should be studied also in 

 connection with the lymphatic system may be alluded to here, as it aids materially 

 in lessening the danger from infection. It has been demonstrated experimentally 

 that from 3 to 8 per cent, of the body weight in fluid can be taken up by the peri- 

 toneum from within its cavity in one hour, which is equivalent to the total body 

 weight in twenty-four hours (Wegner). The current of this process of absorption of 

 peritoneal serum has been shown to set normally from the peritoneal cavity towards 

 the diaphragm, and to be much hastened by elevation of the pelvis and lower abdo- 

 men. Small particles (carmine, bacteria, etc.) are carried through the intercellular 

 spaces in the diaphragmatic peritoneum "the openings made by the retraction of 

 the endothelium" (Kelly) into the lymph-spaces beneath, then into the mediastinal 

 lymph-spaces and glands, and then into the blood-current (Muscatello). This pro- 

 cess goes on much more rapidly in this direction towards the diaphragm and medi- 

 astinal glands than does the similar process beginning in the visceral (intestinal) 

 peritoneum and associated with the mesenteric lymph- nodes, an additional ana- 

 tomical explanation of the greater fatality of visceral peritonitis. 



The close relation of the nerves of the peritoneum and of the abdominal viscera 

 to the nerves supplying the abdominal and the lower intercostal muscles has been 

 mentioned in relation to appendicitis and other intra-abdominal lesions (pages, 528, 

 1683), and is of the highest importance in connection with the clinical symptoms 

 of peritonitis. Hilton compares the peritoneum and the muscles of the abdomen to 

 the synovial membrane and the muscles moving a joint. The rigidity that follows 

 inflammation in either case is due to the reflex muscular spasm resulting from the 

 correlation of the nerve-supply. Thus the six lower intercostals supplying the corre- 

 sponding intercostal muscles and passing through the diaphragm, to which they send 

 twigs, are distributed to the skin over most of the abdomen, and to the rectus, ex- 

 ternal and internal oblique, and transversalis muscles. Through the splanchnics 

 they join also in the innervation of the peritoneum and of the abdominal viscera. In 



