DISEASED TUBES AND 
OVARIES. 
' BY 
ELY VAN DE WARKER, M.D., 
Syracuse, N. Y. 
[Reprint from Annals of Uyimccoi.ogy, Boston, August, 1SS9.] [Annais of Gynaecology, Boston, August, 1 SS9.I 
Fig. i; 
Fig. 3. 
Fig. 4. 
Fig. 2. 
Plate I., Fig. i, Case I., left ovary. Two-thirds natural size. A, Rupture of cyst. 
. Plate L- KiSs- 2 and 3. Case II., left ovary and tube. A, dubbed extremity of tube. 
B, Disintegrated ovary. C, Omental adhesions. D, Remains of pus sac. 
fig. 3. Right ovary and tube. T, Clubbed extremity of tube dilated into sac. O, Ovary. 
Plate I., Fig. 4, Case III. Right ovary. A, Ruptured cyst. B, Indurated outgrowth. ' 
EXPLANATION OF PLATES. [Annals of Gynaecology, Boston, August, 1SS9.] 
Fig. 1. 
Fig. 2. 
Plate II., Fig. i, Case IV. Left ovary and tube, f Clubbed extremity of tube, dilated 
into closed sac. o, Ovary. 
Plate II., Fig. 2, Case V. Cyst of Wolffian body, one-half natural size. [Reprint from Annals of Gynaecology, Boston, August, 1SS9.] 
DISEASED TUBES AND OVARIES. 
(Plates I. and II.) 
BY ELY VAN DE WARKER, M.D., SYRACUSE, N.Y. 
The most conservative gynaecologist must admit that laparotomy for 
the removal of diseased Fallopian tubes, and for diseases of the ovaries 
unaffected by aggressive tumors, has a legitimate place in the surgery of 
women. The operation has had to contend with a strong spirit of con- 
servatism, but also — and this was the more serious obstacle — with a 
theory of pelvic pathology that by many was regarded as settled. In fact, 
in 1S57, had the technique of abdominal surgery of the present day been 
brought to equal perfection at that date, we would have been better pre- 
pared for it than in 1881. At the former date Bernutz had given us his 
careful study of the pathology of pelvic, ovarian, and tubal inflammation. 
It was, however, lost sight of. For twenty years other ideas prevailed. 
Duncan, Emmet, Churchill, McClintock, and many others— the men who 
were forming opinion from 1S60 to 1S80 — familiarized the minds of all 
with an imaginary pathology. The cellulitis, the parametritis, and the 
phlegmon were heard of to the exclusion of the tube and ovary. The 
most radical gynaecologist never expressed more than doubt concerning 
the real nature of the condition described under these terms. The ad- 
vanced surgery began to work in advance of the pathology of its time. 
The true pathology had advanced, and like a wave had receded, for the 
reason that it had advanced beyond the frontier of the current ideas of the 
period. What makes a fact such a priceless thing is the difficulty of find- 
ing it, —clearing it from the strata of ignorance and error in which it lies 
buried. 
Battey, in America, and Hegar, in Germany (1872), began work on 
independent lines, and both, as we understand it now, on a misconception 2 
ANNALS OF GYNECOLOGY\ 
of the pathology of the ovary. It was a true advance, however, and the 
way was opened. In 1877 Tait practically admitted the inefficiency of 
the removal of the ovaries in the production of the change of life in bleed- 
ing myoma, and showed the necessity of removing the tubes to arrest the 
haemorrhage and modify the growth. Attention was thus practically 
called to the fact of the great change induced in pelvic neoplastic and in- 
flammatory processes by the extirpation of the tubes and ovaries. The 
opposition came from the pathological school. The observations of Ber- 
nutz and Goupil were lost sight of, and the idea that the indurations, ad- 
hesions, and inflammatory masses felt in the pelvis were the result of an 
infiltrate into the cellular spaces, had gained the ascendancy of an estab- 
lished fact. The theory was given greater force by the unfortunate terms, 
coined by Mathews Duncan, of peri- and para-metritis, designed to explain 
what were regarded as two well-defined conditions, the causes of one of 
which resulted in fixation of the uterus, and the other in the mass or phleg- 
mon. That these various pathological states could be the result of an in- 
flammation of tubal origin, and thence invading peritoneal surfaces, and 
a condition practically incurable without operation, was by some clamor- 
ously denied. One reason must not be overlooked, injustice to the pathol- 
ogists. The laparotomy school had become offensively aggressive. It 
almost reached the pass that the non-operative gynaecologist had no place 
left that entitled him to respect. But this active tendency among the 
extreme surgical school crushed out opposition by what we may term a 
series of vivisections. By the actual removal of inflamed and disorganized 
appendages, the adhesions and phlegmons disappeared, and the woman 
was restored to health, and thus a place for the new surgery was self- 
created, and pathology was restored back to the period of Bernutz and 
Goupil. By the year 1884 a multitude of operators were at work in the 
adventurous field, and to-day there is practically no opposition to laparo- 
tomy for the various forms of tubal and ovarian disease of inflammatory 
origin. 
The man who first began to open the abdomen for a purpose other 
than the removal of an aggressive tumor performed the first act in this 
surgical evolution. The man who first demonstrated the natural history 
and morbid structure of pelvic inflammation cleared the way and made a 
permanent abiding place for the new surgery. Who these men were, we 
may each have an opinion ; but it matters little. History is not the act of 
one individual, or the date of an event; it is the record of the moral and 
intellectual evolution that culminates in the man and the event. Not one 
pair of hands, but many ; not one mind alone, but the intellectual evolu- 
tion of a generation, worked out the problem of tubal inflammation and 
surgery. DISEASED TUBES AND OVARIES. 
3 
But while the morbid condition of the tubes is freely admitted, the 
question, What are diseased ovaries? is discussed with but little agreement. 
To what extent an ovary inflamed, enlarged, contracted, or indurated, 
will affect the general health, or how necessary its removal, is very far 
from being settled. My own idea is, that the condition of the ovary has 
not so much to do with the question as the importance of the organ as a 
source of influx disturbance would seem to indicate. The condition about 
the ovai'y, — the peri-ovarium, — the adhesions, the exudate, appear to 
be the factors in the local disturbance. It is not the normal ovaries that 
we are removing now, unless the organs are involved in diseased surround- 
ings. Small cysts scattered over the surface of the ovary, and in some 
cases encroaching on the parenchyma of the organ, would not warrant 
extirpation. I have in mind three cases in which the ovaries were in this 
condition, in which the histories of the patients gave no evidence of 
ovarian disease. Such an ovary is capable of performing its proper 
function, and when free from peri-ovaritis, and the tube in a normal con- 
dition, it is doubtful if the circle of reflex disturbance would be either wide- 
spread or serious. In Case II., in which we find the ovary invaded by a 
large cyst that appears to have had its origin in the coalescence of a num- 
ber of smaller cysts, ovarian disease was masked in the symptoms of 
salpingitis, and a diagnosis to that effect was made. It was embedded in a 
mass of exudation, the tube was occluded and distended with fluid. It 
was impossible to get an idea of the condition of the ovary until it was ex- 
cavated from its bed. In several instances in which I was induced to 
make what, in my ignorance, I called Battey’s operation for the relief of 
serious menstrual neuroses by causing the change of life, I had cause 
to give another name to the operations before I was through with them. 
In every case I found the ovaries firmly bound down by adhesions, with- 
out any antecedent history of so-called pelvic cellulitis. In such a case I 
believe the symptoms were due to the peri-ovaritis, and not to the condi- 
tion of the ovary itself. 
Many able physicians make the practical objections to laparotomy for 
diseased tubes, that patients may make perfect recoveries from serious 
attacks of pelvic inflammation ; that phlegmons disappear without suppu- 
ration, and that adhesions melt away. Cases of this kind are within the 
experience of every one. Here the question comes up, How are we to dis- 
tinguish between a case that will reach a spontaneous cure and one that 
will never recover without extirpation of the diseased ovaries and tubes? 
There must be a pathological difference either in degree or kind. I say 
there must be, because I have never seen an instance of pyosalpinx that 
got well spontaneously. We hear occasionally that galvanism, or mas- 4 
ANNALS OF GYNECOLOGY. 
sage, or puncture cured cases of this nature ; but we always have the 
suspicion that there was a mistake somewhere. I have an explanation of 
this seeming pathological contradiction, that to me, in my present knowl- 
edge, is a reasonable one. I would reapply the terms of Mathew Dun- 
can, not as explaining cellulitis and the board-like induration of this 
author, but as applied to all the pelvic genitalia, and not confined to the 
uterus. I would have peri- and para-salpingitis and like terms applied 
to the ovaries. As an example of this take the condition in Case I. as an 
illustration ; here the tube and the ovary were enclosed in a mass of exudate, 
so that when the fingers were introduced a smooth, uniform mass was felt, 
but neither tube nor ovary. It was possible to enucleate them by tracing 
the mass outward from the uterus. Conceive of such a state of affairs 
existing without the element of salpingitis or without disease of the ovary 
other than its adhesions. Such a condition might typify a form of pelvic 
inflammation that would tend to spontaneous cure. Associated with a 
distended and occluded tube we have another state that could not conform 
to the law of resolution or absorption, but would persist, for months or 
years, a depot of inflammatory material, always ready for renewed ac- 
tivity. The form then of pelvic inflammation in which spontaneous cure 
takes place is that of peri-salpingitis and peri-ovaritis, and in which the 
tube and ovary are left comparatively uninjured. In such a condition we 
would have masses of considerable dimensions terminate without suppu- 
ration in resolution and absorption, a termination that is familiar to us all. 
It is, to my mind, easier to explain this spontaneous cure as a different 
thing from the relapsing or incurable form, than as different degrees of 
the same thing. 
The only difficulty in the way of this explanation is the theory that 
the i*oute of the inflammatory invasion is always through the tube ; but I 
cannot see why we may not assume that the tube could act as the conduc- 
tor of the infecting agent with comparative safety, while the pelvic peri- 
tonaeum, less able to withstand the infection, would at once become 
involved in adhesive inflammation and exudate. My explanation also 
allows for difference in the infecting agent. Some causes, like the gonor- 
rhoeal poison, for instance, expend their force upon the mucous membranes, 
in which case tubes and peritonaeum would suffer alike. Other forms of 
bacterial infection pass over mucous surfaces without damage, but attack 
the peritonaeum with avidity. One form would subject the woman to 
hopeless invalidism or salpingotomy; the other would tend naturally to 
cure. In this way we are able to explain contradictory clinical facts 
with the very practical bearing, that knowing the nature of the infecting 
agent, as we sometimes do, in one case we can temporize, and in the other 
resort to laparotomy. DISEASED TUBES AND OVARIES. 
5 
The following report of cases will serve to illustrate some of the points 
already noticed: — 
Case I.—Married; unipara; aged 31. A patient of Dr. Lamb, 
of Georgetown, N.Y. She had been for six years crippled by left-sided 
pelvic pain and tenderness on very slight exertion. At irregular intervals 
for a long time had attacks of muscular spasms, which had been regarded 
as epileptic, but which were hysteroid. Menstruation profuse, moderately 
painful. Nutrition unimpaired. Received treatment of some kind at 
the Woman’s Hospital in New York. Admitted to the Syracuse Women’s 
and Children’s Hospital. Examination revealed a mass limited to the left 
broad ligament, immobile, sensitive, with no fluctuation apparent. 
Movement of uterus partially restricted. Cervix lacerated bilaterally. 
A diagnosis of salpingitis was made. 
Operation.—The left Fallopian tube convoluted, distended, thick- 
ened. Left ovary degenerated into a thick walled cyst, one and a half 
inches in diameter, all deeply embedded in a mass of organized exu- 
dation. Enucleation difficult. Uneventful recovery. (Plate I., Fig. 1.) 
May 21, 1889. Her physician reports a continuance of hysteria. 
Local symptoms improved. 
Case II. — Mrs. B., aged 28 years ; sterile. Patient of Dr. Magee, 
of Syracuse. For five years prior to seeing patient, she had presented 
symptoms such as usually attend pelvic cellulitis, attended with intervals of 
relapse, during which she was confined to her bed with pain and moderate 
fever, followed by escape of pus from the vagina. The pus was supposed 
to escape through a fistulous opening into the vagina. Careful exami- 
nation failed to discover such an opening. Thickening and induration was 
proved to exist in the direction of both tubes. Moderate uterine fixation. 
Careful search, at favorable moments, proved that the pus escaped from 
the os externum. Diagnosis of pyosalpinx. Laparotomy was suggested 
to the patient, and eagerly accepted. Admitted to the Women’s and 
Children’s Hospital, and operation done. (Plate I., Figs. 2 and 3.) 
Aside from suppuration in the abdominal wound, recovery was with- 
out event. Both tubes and ovaries i*emoved. June 1, 1889, Mrs. B. 
called upon me, walking over a mile. Has gained greatly in flesh and 
perfectly restored to health. She menstruated after the operation, and 
has continued so to do every month since. 
Case III. — Miss W. ; single ; age, 25 years ; a patient of Dr. Magee, 
of Syracuse. A delicate, anaemic girl. Able to do no work or take ex- 
ercise, from the presence of a severe wearing pain, with tenderness in the 
right ovarian region. Examination revealed the uterus anteverted, of 
normal dimensions, with moderate cervical catarrh. Bimanual palpation 6 
ANNALS OF GYNECOLOGY. 
gave great tenderness in the right iliac fossa. From the chronic nature of 
the ailment, and its sudden onset in an acute attack of pelvic pain and ten- 
derness, the diagnosis of salpingitis was made and laparotomy advised. 
Admitted to the Central New York Hospital for Women, and lapa- 
rotomy made Dec. 6, 1889. The right ovary was found hypertrophied, 
hardened ; tube tortuous, occluded, its fimbriae obliterated. The ovary 
and tube removed. Left ovary found normal and not disturbed. Recov- 
ery rapid and cure complete. (Plate II., Fig. 1.) 
Case IV.—Mrs. B., of Central square, N.Y., aged 29; married; 
sterile. Menstruation irregular at intervals of three, six, or, in one instance, 
of twelve months. Nutrition impaired. Suffered for three years from 
cephalalgia, aggravated to intensity on the rare occasions of menstruation ; 
sacralgia ; right and left ovarialgia. Locally the uterus was movable ; 
slightly retroverted ; slightly undersized ; some slight enlargement in di- 
rection ; both tubes, no tenderness on thorough palpation. A diagnosis of 
ovarian neurosis was made, and after a conversance of several months no 
suspicion of salpingitis was entertained. The operation of ovarian extir- 
pation was never suggested to her; but the patient got the idea from some 
one, and requested that it be made in order to induce the change of life. As 
she was hopelessly sterile, and suffering constant misery, the operation ap- 
peared highly proper; to that end she was admitted to the Central New 
York Hospital for Women, and laparotomy made Jan. 9, 1889. Both 
tubes were occluded, fimbriae obliterated, and club-shaped ; left ovary 
softened, friable, adherent to surrounding parts, and right ovary beset with 
a number of small cysts. Recovery speedy and without event. 
May 20, 1889. Patient has gained the appearance of much better 
health. The headaches have nearly disappeared. Has had three attacks 
since the operation, but was not obliged to take morphia. (Plate II., 
Fig. 2.) 
Case V. — Mrs. I., aged 49; married; four children; a patient of 
Dr. Pardu, of Fulton, N.Y. Abdomen enormously distended by what 
appeared to be encysted ascites. Pelvic examination revealed a consid- 
erable mass to the left of the uterus, slightly movable and unattached to 
that organ. No diagnosis was made, but laparotomy advised. As respi- 
ration and locomotion were difficult, from abdominal distention, she readily 
consented. Admitted to the Central New York Hospital for Women, and 
laparotomy made Jan. 14, 1889. Peritonaeum thickened, large patches of 
olive-green discoloration over parietes. Transverse colon and intestines 
adherent. Cavity contained about forty pounds of amber-colored fluid ; 
upon the left, attached by a thin tubal mesentery, was a cyst six inches 
long, by three in diameter, darkly purple, and very vascular. The thin DISEASED TUBES AND OVARIES. 
7 
attachment ligated and cyst removed. Ovary and tube healthy and not 
removed. Right tube and ovary normal. An exceeding rapid recovery. 
When first admitted to the hospital her temperature was subnormal. 
This was attributed to fright, as several operations were being made 
daily in the house, and the patient’s dread was excessive, and without any 
special treatment the temperature became normal. This was probably a 
cyst of the Wolffian body. Its nearly exact counterpart is described by 
Mr. Tait, “Diseases of Women,” Lond., 1877, p. 221. The case is in- 
cluded in this series for its diagnostic value, as previous to laparotomy 
it resembled nothing so much as a distended tube with diffused exudative 
peritonitis. (Plate II., Fig. 3.) 
Case VI. —Mrs. W., aged 32 ; married ; sterile. Excessive dismen- 
orrhoea ; wide-spread neurosis ; mental irritability ; insomnia ; morphia 
habit induced by excessive pain. Patient applied to have ovaries extir- 
pated. As her case had long been familiar, her request was acceded to. 
Declined to enter the hospital. Attended her at her own home in Wolcott, 
N.Y., assisted by Dr. A. B. Breese, of Syracuse. Both ovaries were 
beset of a large number of small cysts ; the fimbriae were adherent to the 
ovaries. Both ovaries and tubes removed. Recovery somewhat delayed 
by abscess in abdominal wound. Menstruation ceased. But little is 
known of the subsequent history of the patient, as her physician has made 
no reply to repeated requests for information. 
Case VII.—Mrs. B., of Marcellus, N.Y., patient of Dr. C. Billing- 
ton ; aged 34; sterile. Spare and much reduced by excessive pain, lo- 
cated in a mass in right pelvic space, evident on both external and internal 
palpation. Tumor indurated and very tender. Uterus mobile and ante- 
verted by tumor, which was slightly posterior. Admitted to Central New 
York Hospital for Women, and laparotomy made in presence of Drs. 
A. B. Randall, C. Hall, and Billington. Right ovary enormously hyper- 
trophied, bound down posteriorly by a meso-ovarium, indurated ; tube 
occluded; fimbria obliterated; ovary removed. Recovery very rapid, 
with subsequently perfect health. Tf-[Ec ANNALS OF GYNECOLOGY 
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