REPRINTED PROM THE “ CANADA MEDICAL & SURGICAL JOURNAL.” 
JUNE, 1885. 
A CASE OF TUBERCULAR PERITONITIS WITH 
ENCYSTED COLLECTION OF FLUID, SIMULA- 
TING OVARIAN CYST. 
Professor of Gynaecology, McGill University; Gynaecologist to the 
Montreal General Hospital. 
WILLIAM GARDNER, M.D., 
S. 8., set. 28, unmarried, domestic servant, belonging to a 
remote country district north of the Ottawa River, who had 
lived in the city during the previous six months, was sent to me 
about last midwinter by my friend Dr. George Ross for exami- 
nation, as the suspicion of pregnancy had arisen in consequence 
of extensive abdominal enlargement. She admitted a preg- 
nancy terminating at six or seven months a year and a half 
previous. She could give no definite account of the date at or 
about which the present abdominal enlargement began, but her 
mistress noticed it three or four months previous. It had 
rapidly increased since then. The girl complained of abdomi- 
nal pain; menses had been absent for three or four months; 
general strength, health and appetite had declined, and she had 
become emaciated. The tongue was red. 
Examination.—The belly much enlarged ; the skin below the 
navel presenting recent pinkish striae, as well as old silvery 
streaks. Well-marked fluctuation over the whole of the ante- 
rior and antero-lateral aspects of the abdomen. Dullness on 
percussion over the same area. In the lumbar region (flanks) 
and epigastrium the bowel note present No solid._paxt to be felt anywhere. The anterior aspect of the abdomen quite 
uniform. The perineum slightly lacerated and the posterior vagi- 
nal wall partially prolapsed. The uterus, measuring two inches, 
pressed upwards and forwards, lay immediately behind the 
pubes. The patient was admitted to the Montreal General 
Hospital and kept under observation for a few days, when it 
was found that she had fever of septic type, the temperature at 
times running very high, with profuse sweating and occasional 
attacks of vomiting. During this interval she was seen by Drs. 
Fenwick, Ross, Roddick, Shepherd and J. C. Cameron, who 
concurred in my diagnosis of suppurating ovarian cyst. Another 
symptom, red blush and oedema of the central anterior part of 
the abdominal wall, seemed to support the view. Operation was 
resolved on, but delayed on account of the difficulty in commu- 
nicating with the girl’s relations, so far distant from the city. 
Operation.—The ordinary incision for ovariotomy was made, 
but on reaching the peritoneum no separation of parietal from 
visceral layer could be made ; the knife entered the collection 
of fluid, passing through what seemed to be a thickened, closely 
adherent cyst wall. The fluid was amber-colored, contained 
flakes, and in the last portions an obvious admixture of pus. 
The cyst wall did not collapse as the fluid escaped, but appeared 
to be adherent everywhere, even to the bottom of the pelvis. 
Acting on this view and with the concurrence of my friend 
Prof. Roddick, who was assisting, I decided to make no attempt 
at separation of the supposed cyst, but to drain and irrigate, as 
affording the patient the best chance. A large glass tube was 
passed through the wound into the Douglas pouch, and irriga- 
tion practised every two hours, night and day. At first weak 
carbolized water, then corrosive sublimate solutions, and finally 
solutions of iodine, were used for this purpose. The general 
condition at once improved, and this was maintained for a period 
of ten days. Fever diminished and appetite improved. After 
a few days the reflux water during irrigation contained enor- 
mous quantities of fibrinous, flaky material. Soon, however, 
her condition again declined- Temperature ran high ; sweats 
were profuse. The discharge always somewhat foetid, became 3 
more so. Soon after the operation the patient suddenly deve- 
loped a cough with expectoration, which soon became purulent, 
and was at times bloody. Three weeks after the operation a 
large rubber drainage-tube was passed through the Douglas 
pouch and out by the vagina, being carried a few inches beyond 
the vulva. This did no good. She gradually sank, and died 
exhausted six weeks after the operation. Two days before 
death she complained of sore throat, and on examination the 
fauces, tonsils and posterior wall of the pharynx wTere found to 
be covered with a diphtheritic membrane. Until the autopsy, I 
adhered to the original diagnosis of suppurating, universally 
adherent, ovarian cyst. Dr. R. J. B. Howard, acting patholo- 
gist to the Hospital, made the autopsy. I append his report: 
—“ On opening abdomen a large globular mass presents, of the 
size of a man’s head, occupying false pelvis ; this and the pari- 
etes are everywhere covered by a grey, rough membrane about 
one-eighth of an inch thick. The transverse colon is firmly 
adherent to the upper surface, and is also bound tightly down 
to the liver. A collection of pus is found below and by the side 
of the spleen, and another, smaller, under left lobe of liver in 
middle line. The anterior peritoneal cavity is thus converted 
into a suppurating cyst, extending from liver down into true 
pelvis, nearly filled by the mass, which is found to consist of all 
the intestines, except the transverse colon, closely matted toge- 
ther by recent slight adhesions, which are studded with miliary 
tubercles. The cyst wall is apparently much older than the 
inter-intestinal adhesions, and looks like an unhealthy granu- 
lating membrane. The walls and viscera of true pelvis are 
covered by the same membrane. The great omentum has 
quite disappeared ; but no doubt had been spread out over the 
intestines, and formed part of the membrane covering them. 
All the abdominal viscera adherent to one another and to 
parietes. Liver fatty; contains a few gray granulations. 
Kidneys contain a few gray granulations. Lungs universally 
adherent; abundantly studded with gray granulations. Tonsils 
and pharynx—surface gray and sloughy-looking. No loss of 
substance; same appearance involves oesophagus opposite 
cricoid cartilage, and about four inches lower down.” 4 
Remarks.—The principal interest of the case lies in the diagnosis. 
It well illustrates how difficult it may be to definitely fix the real 
nature of an abdominal fluctuating tumor. The fact that the 
abdominal enlargement was uniform, central, and occupying the 
anterior and antero-lateral parts of the abdomen, to the exclu- 
sion of the flanks, where the clear percussion note shewed the 
presence of bowel, added to the difficulties. A similar case 
occurred to my colleague, Dr, Fenwick, some years ago. The 
same error of diagnosis was made by all who saw the case. 
This patient died some months after operation, probably also of 
tuberculous disease, as she develo led a pleuritic effusion before 
leaving the hospital. Other sir ilar cases are reported by 
Spencer Wells, Erich, Ewing Hears and Atlee. The well-known 
dangers of tapping ovarian tunr *s, in my opinion, make that 
procedure for obtaining fluid for microscopical examination 
unjustifiable, especially as there is no concurrence of opinion of 
microscopists as to the certainty of that means of diagnosis. 
Happily, the treatment in my case leaves no room for regret, 
as under the circumstances it was the very best that could have 
been applied. It clearly prolonged life, and if the peritonitis 
had been simple it would almost to a certainty have saved the 
life of the patient.