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Primary peritonitis, rarely diagnosed preoperatively, is an uncommon disease accounting for 2.1% of all pediatric abdominal emergencies. It is often associated with urinary or hepatic pathology, the former the source of the infecting organism in the majority of cases, and presents with characteristic symptoms depending upon whether it occurs in infancy or childhood. The symptoms and signs which allow for a positive prospective diagnosis are illustrated by comparing this disease to those entities with which it is most often confused, e.g. diffuse peritonitis of other etiologies, and include a short duration of symptoms, associated urinary tract infection and an absence of free air on abdominal roentgenograms. In the past, gram positive organisms were the most common infecting agent; however, in this series gram negative bacteria accounted for 69% or the organisms. Antibiotics with a gram negative spectrum and exploratory laparotomy with appendectomy are the hallmarks of therapy, the latter replaced by abdominal tap only in the patient who satisfies the criteria for primary peritonitis and in whom an associated disease makes the risk of surgery prohibitive.