CASE 
OF 
TUBERCULOSIS OF THE PERITONEUM, 
WITH THE FORMATION OF A 
SAC SIMULATING AN OVARIAN CYST, 
BY 
SAM EUL C. BUSEY^M.D., 
Professor of the Theory and Practice of Medicine, Medical Department, 
University of Georgetown; One of the Physicians to the Children’s 
Hospital, Washington, D. C. 
FROM GAILLARD'S MEDICAL JOURNAL, MAY, 1880. CASE 
OF 
TUBERCULOSIS OF THE PERITONEUM, 
WITH THE FORMATION OF A 
SAC SIMULATING AN OVARIAN CYST, 
BY 
Professor of the Theory and Practice of Medicine, Medical Department, 
University of Georgetown ; One of the Physicians to the Children’s 
Hospital, Washington, D. C. 
SAMUEL C. BUSEY, M.D., 
The above title indicates the feature of special interest 
presented by the following case of tuberculosis of the peri- 
toneum, which is considered of sufficient importance to be 
published. 
Maggie C , black, aged 12 years, admitted to the 
Children’s Hospital, August 8, 1879. 
The only history of her previous condition was the simple 
statement that in January previous she was “ sick with a deep 
cold and swelling of the feet,” which swelling disappeared, 
but was followed by enlargement of her belly, which had 
continuously increased. 
Condition on admission, August 8th. (Notes by Dr. S. 
S. Adams, house physician). Abdomen greatly enlarged, 
measuring in circumference at umbilicus 29 inches ; from 
umblicus to superior spinous process of left ilium 7| inches, 
to right 7g inches ; from Xiphoid cartilage to pubis 13 inches, 
to umbilicus 7 inches. 
When the patient was lying upon her back the abdomen 2 
TUBERCULOSIS OF THE PERITONEUM. 
remained pointed, with highest elevation at umbilicus. The 
area of dulness was circumscribed by a line extending from 
a little below the superior spinous process of the left ilium 
in a curvilinear direction upwards, passing one inch above 
the navel to the right near the inner border of the right 
flexure of the colon and thence downwards, rather abruptly, 
to the superior spinous process of the right ilium. Around 
this area the abdomen was tympanitic, especially along the 
descending colon and over right lumbar region ; less so 
over left lumbar region. In the left iliac fossa along the 
lower margin of the dull area there was a narrow border, 
not more than a finger’s breadth, of greatly diminished dul- 
ness, but not resonance. The outlines of this dull region 
was uninfluenced by change of position, either in the sitting 
posture or when lying upon either side. Within the area 
of dullness fluctuation was very distinct in every direction, 
and could be detected, though much less distinctly, on 
either side where the percussion sound was tympanitic, as 
well when each palpitating finger was without, as when one 
was outside and the others within the limits of the area of 
flatness. Over the entire dull region there was soreness, 
and tenderness to moderate pressure. The patient com- 
plained of pain in this region, which at irregular periods had 
been acute. There was some puffiness about the eyes. 
Emaciation was marked ; features pinched ; appetite fair ; 
bowels regular. 
Respiration was frequent. Sounds normal except in 
right inter-scapular region, where there was diminished 
resonance and marked puerile respiration. Cough occasion- 
al and trifling. During the subsequent history of the case, 
without any noticeable augmentation of the cough, or ap- 
preciable alteration in the respiratory sounds, the respira- 
tion continued frequent, occasionally the number of respira- 
tions did not exceed twenty per minute, but usually ranged 
between twenty-five and thirty-five, and several times num- 
bered forty. 
The temperature chart, representing the course of the 
fever from the date of admission till the fatal termination, ex- 
hibits constant daily differences between the maxima and TUBERCULOSIS OF THE PERITONEUM. 
3 
the minima, varying from one to three degrees. Several 
times it was above io4°F. marking periods of inflammatory 
exacerbations, attended with acute abdominal pain and very 
great tenderness. On several occasions the minima were 
subnormal. During the week preceding death there oc- 
curred a gradual and regular defervesence, with daily les- 
sening maxima and minima, the lowest maximum being 
98° with a subnormal minimum as low as 94-5°F. During 
this period the pulse fluctuated considerably, without cor- 
respondence with the temperature excursions. The respi- 
ration also varied, and was less frequent than previously, 
but more uniform in its variations than the pulse. 
The pulse was always frequent and small, and exhibited 
correspondence in frequency to the temperature changes, 
increasing with the rise, and slowing with t-he fall of the 
body heat. 
The bowels were usually moved once daily, but during 
the week immediately preceding death there was a moder- 
ate diarrhoea, the stools consisting of a dark, tarry, and ex- 
ceedingly offensive liquid. 
The urine was scanty, frequently the daily quantity did 
not exceed eight ounces, and occasionally was much less. 
Examination of urine by Dr. E. M. Schaeffer Sept. 13th : 
“ Color natural ; turbid and frothy. Reaction acid ; sp. 
grav. 1028 ; Phosphates with heat ; no albumen or sugar. 
Large number of granular casts, for the most part straight 
and narrow. No blood, pus or oil globules. An excess of 
renal epithelium. A few crystals of oxalate of lime.” 
From Sept. 23d to Oct. 5th, the average daily discharge 
of urine was much increased, amounting one day to forty- 
two ounces. After this the abdominal distention was great- 
ly diminished, and though it subsequently increased, it did 
not again reach the extent as previously stated at the date 
of her admission. 
After this period of considerable increase in the daily aver- 
age amount of urine the entire abdominal region became 
tympanitic, the dull area, as previously described, markedly 
so. For a time no fluctuation could be recognized. Sub- 
sequently, however, the partial refilling of the sac with fluid 4 
TUBERCULOSIS OF THE PERITONEUM. 
was apparent, as fluctuation could be detected by palpita- 
ting from side to side at the outer lateral borders of the pre- 
viously described area of flatness, whilst over the surface of 
this region tympanitic resonance was pronounced. At no 
time during the after-life of the patient was there any cir- 
cumscribed area of flatness within the previously described 
limits, or anywhere in the abdominal region, except in the 
localities of the solid organs. This tympanitic resonance 
of the summit surface (patient lying upon her back) of the 
circumscribed dull region is explained, as shown by the dis- 
section, by the escape of gas from the intestines into the 
sacculated space. 
On.August 28th the lips became cedematous, and, several 
days afterwards, the pudendal labia and nymphae were enor- 
mously swelled; The oedema extended to the abdominal 
integument. These infiltrations subsided spontaneously. 
During her residence in the hospital she suffered several 
severe exacerbations, characterizd by rigors, abdominal 
pain and tenderness, and sudden high elevation of tempera- 
ture. 
From the date of admission the case was regarded as one 
of tubercular peritonitis and, consequently, hopeless. The 
treatment consisted in rest, a nutritious and easily digested 
diet, tonics, cod liver oil, and the syrup of the iodide of iron. 
The iodide of potassium was given for many days. It 
seemed at times to produce a very marked diuresis. To it 
was ascribed the great increase in the quantity of urine 
which relieved the distention from fluid accumulation in the 
abdominal cavity. She died on Nov. 5th. 
Post-mortem six hours after death by Dr. Adams : Body 
emaciated ; rigor mortis well marked. Circumference of 
body at umbilicus 22 inches. Heart pushed upwards, large 
and flabby. Right auricle contained a white clot as large 
as a pigeon’s egg, extending into the right ventricle. Right 
ventricle normal. 
Lungs pale anteriorly, congested posteriorly (hypostatic). 
Adherent to diaphragm on both sides. In the posterior, 
inner angle of the upper lobe of the right lung was a case- 
ous mass larger than a walnut, which approached the sur- TUBERCULOSIS OF THE PERITONEUM. 
5 
face, and may, perhaps account for the altered physical 
signs recognized in the right inter-scapular region on Aug- 
ust 8th. 
Upon opening the abdominal cavity a quantity of very 
offensive gas escaped. The walls of the abdomen were 
closely adherent to a mass which occupied the entire cavity 
and could only be separated by a careful dissection. No 
portion of the intestines could be seen, only a small part of 
the stomach being in view. At the lower border of this 
mass was a pouch which was partly adherent to the abdom- 
inal walls above the pubis and dipped down between the 
uterus and bladder. It contained about a quart of most of- 
fensive, black, faecal-looking, granular, semi-solid material. 
Pressure upon this pouch caused a discharge through the 
anus of fluid similar in character to that which' filled it. A 
similar sac was located in the left inguinal region and 
another in the left hypochondrium, but were much smaller. 
The large tumor could not be separated from the abdominal 
viscera and it together with all the organs were removed 
en masse as shown in the accompanying figure. (Next page.) 
“ The anterior wall of the sac was comprised of the pari- 
etal peritoneum, which in some parts was nearly one inch 
in thickness, produced by successive layers of firmly organ- 
ized fibrous exudation. Large yellow tubercles, size of 
peas, were scattered throughout the different layers. The 
omentum, mesentery and mesocolon were also thickened 
by fibrinous exudations. 
“ The coils of the intestines were in some places separated 
by layers of exudation, and in other places glued and 
matted together so that they were fixed in one position. 
“ The mesenteric glands were enlarged and in a state of 
caseous degeneration. Stomach was bound down on all 
sides by adhesions and was separated with great diffi- 
culty. It was free from tubercles. 
“ The duodenum was involved in a mass of exudation. 
It, the jejunum, and the larger intestines were free from tu- 
bercles. The intestines were so bound together by the 
exudation above described, that it required careful dissec- 
tion to free them. The solitary glands and Peyer’s patches 6 
TUBERCULOSIS OF THE PERITONEUM. 
were inflamed and enlarged in all parts of the intestinal 
tract. Tubercles were only found in the ileum. The tu- 
bercles as a rule were in the serous coat, but in many 
places they had extended to the muscular and mucous 
coats. In the ileum perforations were found—upper and 
middle parts—; near the caecum there was a large one. 
L. liver; S. spleen ; G. stomach ; A.C ascending color ; D.C. descending 
color; T. Tumor. Dissection of this mass by Drs. Acker and S. S. Adams. 
These perforations took place in the Peyer’s patches. In 
many places in separating the exudation from the ileum, 
small perforations were occasioned by tubercles being torn 
from the intestine and adhering to the exudation. 
“ Liver firmly attached to the diaphragm by adhesive in- 
flammation : on the under surface were a few large tubercles 
—size of peas. There were also some along the sides of TUBERCULOSIS OF THE PERITONEUM. 
7 
the gall-bladder binding it to the liver. Normal quantity of 
bile. The left lobe of the liver was small and thin and ap- 
peared to form a part of the diaphragm, so intimate was the 
connection between them. The liver substance was normal. 
No tubercles seen. The great liver vessels situated in a 
large tuberculous mass, consisting of tubercles, fibrinous 
exudation and mesenteric glands enlarged and undergoing 
caseous degeneration. The aorta, vena cava, lymph vessels, 
nerves, pyloric and cardiac ends of stomach and duodenum 
were also involved in this mass.” 
“ Spleen was firmly adherent to the diaphragm. About 
5 of an inch between it and left lobe of the liver. Tissue 
normal ; no tubercules.” 
“ Kidney—The left was surrounded and bound down by 
exudation ;* capsule easily removed ; no tubercles. The 
right was adherent by the capsule to the right under sur- 
face of the liver ; capsule easily removed ; Substance nor- 
mal ; no tubercles.” 
Dr. Acker adds that the “ case was one primarily of general 
tubercular peritonitis which had occasioned successive fibri- 
nous exudations. All parts covered by the peritoneum and 
its prolongations were enclosed by this exudation which in 
most places had become organized.” 
“ Secondary eruption of tubercles had taken place in the 
ileum, liver, and pleura and along the diaphragmatic attach- 
ments of the lungs, but in each case the tubercles were few 
in number. In fact, the organs were remarkably free from 
them. He judged in all cases by the naked eye appearance. 
Perforations of the intestines occurred in the ileum—upper, 
middle and lower part. There were not any communica- 
tions between the different coils of the intestines. The ab- 
scesses or sacs were encapsulated by the fibrinous exudation.” 
“ The tubercles were the large yellow variety and were 
about the size of a pea. There were no small gray ones 
seen.” 
The points of special interest in this case relate to diag- 
nosis. The brief and meagre history presented but the sin- 
gle fact—that the disease had commenced eight months 
previous with a “deep cold” with subsequent and progress- 8 
TUBERCULOSIS OF THE PERITONEUM. 
ive enlargement of the abdomen. At the examination on 
the day of admission, there was no difficulty in marking out 
the immovable, dull and fluctuating area occupied by the 
large sac, and delineated as the tumor in the drawing ; nor 
was there any doubt in regard to the adhesions of the en- 
tire circumference of this fluctuating area to the abdominal 
parietes. These observations, together with the history, 
fever, emaciation, slight cough and rapid progress of the 
disease directed attention to the tuberculous nature of the 
malady. It was believed then, as disclosed by the post-mor- 
tem, and dissection of the tumorous mass, that the walls of 
the sac or abscess were formed in front by the parietal per- 
itoneum and posteriorly by the agglutinated intestines. If 
the drawing of the contents of the abdominal cavity be 
studied in connection with the record of the examination, 
it will be seen that the outlines of the fluctuating area were 
very definitely and accurately described. The tympanitic 
resonance on each side was easily understood, but why fluc- 
tuation was present outside of the margins of the dull area 
where the percussion sound was tympanitic, was not under- 
stood until explained by the dissection of the mass. The 
drawing shows that the ascending and descending colon 
were attached along the borders of the fluctuating and dull 
area, which furnished the tympanitic percussion note along 
the sides. Behind these portions of the intestine the large 
abscess dipped and other smaller ones were found. This 
fact explains satisfactorily, why, as recorded at the examina- 
tion, fluctuation could be “ detected, though much less dis- 
tinctly, on either side where the percussion sound was tym- 
panitic as well when each palpating finger was without, 
as when one was outside and the other within the limits of 
the area of flatness.” In view of the frequency with which 
multiple sacs or abscesses are found in cases of tubercular 
peritonitis this explanation of the phenomena ought not to 
have escaped recognition at the time of the examination. 
It was, however, believed at that time that the fluid was of 
a serous character. But the one cyst was recognized 
during the lifetime of the patient and the outer borders of 
the area of dullness were thought to circumscribe its extent TUBERCULOSIS OF THE PERITONEUM. 
9 
Nevertheless, the memoranda of the examination record the 
fact that resonance was less in the left than in the right 
lumbar region, due, as shown by the dissection, to the 
presence of one of the smaller abscesses. In the left ingui- 
nal region, below the lower margin of the large tumor or 
abscess, as shown in the drawing, and described in the 
notes of the examination, as a border of greatly diminished 
duluess, but not resonance, was located another abscess, 
which was not recognized during life. Nor does the post- 
mortem discover the explanation of a defined margin of 
flatness marking the left inguinal limit of the tumor, (see 
drawing) immediately below and contiguous to-which was 
another abscess as large as a goose’s egg, which gave on 
percussion a note of so much less dulness as to enable the 
examiner to detect the difference. It may be, that the “ bor- 
der, not more than a finger’s breadth, of greatly diminished 
dulness, but not resonance,” as described in the notes of the 
examination, was even below the second contiguous abscess, 
but the drawing (which was made by Professor Kleinschmidt 
without any knowledge of the history or diagnosis of the 
case) does not sustain this supposition. Its proximity to, 
and overlaying of, the sigmoid flexure may, probably, fur- 
nish a more rational explanation. 
In the memoranda of the examination the region exhib- 
ited in the drawing as the tumor is described as a circum- 
scribed, dull and fluctuating area. During the course of the 
disease, after the quantity of the urine had been greatly in- 
creased, ascribed at the time to the diuretic effect of the 
iodide of potassium, this circumscribed, dull and fluctuating 
area became tympanitic. At the time the explanation 
seemed very plain. Under the influence of treatment the 
fluid accumulation, believed to be serous, had been absorbed 
and eliminated through the kidneys, followed by collapse 
of the cyst and consequent coaptation of the posterior wall, 
constituted of agglutinated intestines, with the anterior 
wall or parietal peritoneum. The tympanitic resonance 
was due to the contact of the intestines distended with gas. 
Subsequently this space partially refilled, but its summit 
surface remained resonant. The dissection disclosed the 10 
TUBERCULOSLS OF THE PERITONEUM. 
existence of several perforations of the intestinal walls, 
which suggest the probability that gas escaped through some 
one of these perforations into the original cyst. After 
this, fluid was distinctly recognized in the cyst by palpating 
from side to side, that is, when the patient was lying upon 
the back, the summit was tympanitic, whilst at its lowest 
lateral margins fluctuation was distinctly recognized. It 
was believed, then, that air had escaped into the cyst from 
the intestines ; and this view seems to be corroborated by 
the dissection of the tumorous mass, yet if the original con- 
tents of this cyst was pus and had escaped through a per- 
foration of the intestinal wall, there ought to have been 
some confirmatory proof of its discharge through the anus. 
The current history of the case recorded daily by Dr. 
Adams, the house physician, does not supply such evidence. 
It was from Sept. 23d to Oct. 5th that the quantity of 
urine greatly increased, and immediately after this the dul- 
ness of the umbilical region entirely disappeared, yet not 
until the week immediately preceding death (Nov 3d) was 
there any diarrhoea. At the time of the dissection, this 
cyst, or abscess as the case may be, was empty. These 
circumstances force me to the conclusion that at the time 
of the first examination it did not contain a serous fluid 
which was absorbed ; and that the connection between it 
and the intestinal tract was subsequent, and caused by per- 
forating ulcers beginning in Peyer’s patches, as described by 
Dr. Acker. The fact that the summit surface of the origi- 
nal circumscribed dull and fluctuating area remained, after 
the absorption of its fluid contents, tympanitic, whilst its 
posterior or base gave indubitable evidence of the presence 
of fluid, is conclusive that the cyst was at least partially 
filled with gas, which may have entered it through the per- 
forated walls of the intestines,* but it does not prove that 
the original contents of the cyst escaped through a perfora- 
tion of the intestinal wall. If the contents of the sac were, 
as believed at the time of admission, serous, which subse- 
* It is not, however, impossible that the gas may have been generated in 
the sacculated space, as such cases are recorded. TUBERCULOSIS OF THE PERITONEUM. 
11 
quently, as previously suggested, was absorbed, the tympa- 
nitic resonance of the region which followed was due to the 
contact of the intestines with the abdominal walls. Fol- 
lowing these occurrences, the ulcerated Peyer’s patches 
may have perforated the intestinal wall, gas escaped in the 
cyst, succeeding by the formation and accumulation of a 
purulent fluid. 
The observation of Dr. Acker that the solitary glands 
and Peyer’s patches were inflamed and enlarged in all 
parts of the intestinal tract, and that the perforations took 
place in the agminated glands of Peyer is very interesting, 
inasmuch as it, presumptively, locates the beginning of the 
tuberculous process in the intestinal follicles, and points 
to the secondary formation of the encapulated abscesses in 
immediate connection with the disease of Peyer’s patches. 
This suggestion is corroborated by the fact that tubercles 
were only observed in that portion of the intestinal tract 
(ileum) where Peyer’s patches are largest and most 
numerous. 
During the examination at the time of admission the pos- 
sibility of the presence of an ovarian cyst was considered, 
but was excluded by the facts elicited at that time. A few 
days observation, and examination of the pulse-rate and 
temperature chart confirmed the diagnosis of tubercular 
peritonitis. The probability of the formation of a cyst in 
cases of tubercular peritonitis simulating ovarian dropsy is 
very remote. I have not examined the literature of the 
subject, and can refer only to the one case observed by 
Kaulich, in which “ the partial sacculation t of fluid by 
means of firm membranes produced phenomena which gave 
rise to a similarity to an ovarian cyst.” At page 296 
another case is recorded in which there was found a large, 
thin, purulent “ effusion in the parietal cavity, together 
with numerous adhesions between the abdominal viscera 
producing tumors and encysted masses ; ” and also an ova- 
rian cyst as large as a child’s head. 
The case exhibited another phenomenon worthy of notice. 
\ Zietnsen’s Cyclopedia, Vol. VIII, p. 336. 12 
TUBERCULOSIS OF THE PERITONEUM. 
During the progress of the disease it frequently occurred that 
the temperature fell below the normal. This circumstance 
I have observed very often in phthisical diseases, and have 
learned to regard it as a symptom of unmistakable signifi- 
cance even in cases before I could locate the morbid pro- 
cess. The clinical records of the Children’s Hospital will 
furnish numerous illustrations of subnormal temperatures 
occurring during the progress of phthisical diseases, and some 
instances of prospective diagnoses of tuberculous develop- 
ments were based upon the repeated occurrence of subnor- 
mal temperatures during convalescence from other diseases, 
in the absence of any other symptom worthy of note. I am 
not aware that this fact has been previously stated with so 
much emphasis, but it has been noticed by several writers. 
Bauer, at page 295, Vol. VIII, Ziemsen’s Cyclopedia, sup- 
plies the temperature chart of a case in which a purulent 
fluid was found in the peritoneal cavity, together with nu- 
merous adhesions and encysted masses. During the 
progress of this case the temperature frequently fell below 
98.4°. Ruehle (Vol. V., p. 568, Ziemsen’s Cyclopedia) in 
discussing the febrile phenomena of pulmonary consump- 
tives, says in chronic cases “ the minima are generally nor- 
mal, or a little below the normal.” Again, “ there may be 
high and low minima, subnormal temperatures, and all 
these for a few days only or for weeks together.” And 
again at page 599 he adds, “ equally ominous are high even- 
ing temperatures, or high maxima at any other time, even 
when the minima are normal, and especially if they are sub- 
normal.”