HERNIA OF THE AND TUBE. of ovary and tube. T. W. Hulke8 described the tear- of a FRANK T. ANDREWS, M.D. ing hernial sac by taxis and the subsequent finding at of the in a CHICAGO. autopsy the contents, including , new-formed extraperitoneal space. Schillbach9 describes an on hernia of the Having already published article an incarcerated right ischiatie hernia, with details of the tube without the and a ovary,1 having presented paper autopsy. Observations were published by Maisonneuve, on hernia of the uterus to the American Gynecological Guersant, Wibaille and Loumaigne. Society, I wish now to submit, tabulate and analyze the In his thesis dwells at consider- hernia (1869) Loumaigne recorded cases of of the ovary and Fallopian able on and and in 1870 the of hernia of the without length symptoms diagnosis, tube, leaving subject ovary Frank Hamilton and twelve new ob- the tube for a future Terry10 published paper. servations, followed more works. Cullen of shortly by complete Through the kindness of my friend, Dr. Antonin Martin reported a case of inguinal hernia of Baltimore, I am able to present the following case with the right ovary before the Societe de Medicine, Nov. 3, a contents sac. drawing of the of the 1871, and Courty11 mentions three cases of ovarian M., Cambridge, March 26, 1902. Child eight years of age hernia. In 1871 Englisch12 collected thirty-eight cases suffering from left inguinal hernia. The hernial opening was of ovarian hernia, of which twenty-seven were inguinal. about 1.5 cm. in diameter. The was with consider- ring exposed His work contains interesting deductions on the path- able difficulty. A small oval mass was felt in the ring and of and In 1873 the of the of. On ogeny congenital acquired hernia. presence ovary immediately thought opening Puech13 his first memoir. In 1874 Wibaille the sac the ovary and tube were found adherent to it (Fig. 1). published out a on It was impossible to return them to the abdomen without re- (Paris) brought thesis the subject of the various of of moval. They were tied off and removed with the adherent sac. forms hernia the tube and . In 1878 (No- The operation was completed in the usual way vember) and in 1879 (June) Puech published a second HISTORICAL SKETCH. The first mention of hernia of the pelvic organs was made by Soranus, of Ephesus, early in the second cen- tury. His work on "Diseases of Women," written in Greek, was translated into Latin by CasKus Aurelianus in the fifth century. It is the only gynecologic work pre- served from antiquity. He describes a case in which "the intestine, preceded by the ovary, descended into the labium," evidently an inguinal hernia. The literature of the subject really begins with Dor- ing,2 followed by Oelhafen3 and Oneidas.4 In 1716 Louis Leger de Gouey, of Rouen, described a case of in- trahernial tubal pregnancy. In 1755 Haller5 quoted a case of Bessiere, a celebrated surgeon of Paris a cen- tury before, who found the ovary and the fimbriated por- tion of the , together with intestine, in an inguinal tumor. He also cited a case of ischiatie hernia of the uterus, ovary and tube on which Papen operated. Petit, in his anatomic works, also quotes an early case by Verdier. A case of double inguinal hernia successfully operated on by Percival Pott in 1756 has Fig. 1.—T. S. Cullen's case. Ovary and tube in an inguinal been freely quoted. In 1759 Camper, at Amsterdam, hernia showed the left ovary escaping from the abdomen by the ischiatie notch, and, according to M. Rougemont, he article in the Annates de Gynecologie, which is without noted a case in 1765 of the ovary in an ingninal tumor. doubt the most complete work ever published up to this In 1768 Balin0 speaks of the ease of a woman on whose time on this subject. body an autopsy was performed at the Salpetriere. One In 1882 Barnes read a paper before the Medical and of the ovaries, in which there was "a germ of fecundity," Surgical Society of London on the physiology of ovarian was found engaged in the ring. In 1779 Desault found hernia. This was inspired by observations already made in the cadaver of a woman the left ovary, the tube of by others. In the same year appeared a work on hernia the same side and the womb enclosed in one sac. Again, of the ovary by G. Langton," based on sixty-seven twenty years elapsed before Lallement makes a similar cases which he had observed almost exclusively among observation at the Salpetriere. Then Lassus, in 1809, children, of which twenty-seven were accompanied by cites three examples of hernia of the ovary in the in- . In 1887 Thomas made inguinal and ovarian guinal canal. hernia the subject of his inaugural thesis (Paris), and The illustrious surgeon, Deneux, in 1813, having suc- devotes a few pages to the differentiation of ovary and cessfully treated an inguinal ovarian hernia, made it testicle in subjects suffering from a vicious conforma- the subject of a treatise, in which he cites twelve cases, tion. Microscopic examination justified the discussion. In of which nine were inguinal. He lays special stress on 1889 Lejars15 published a work on neoplasms of the congenital nature of the affection and the difficulties the herniated ovary. Brunner16 published a very com- of diagnosis. In 1840 Velpeau described this condition plete work on hysterocele in 1889, and in the same year under the name "ovarioncie." Hagner17 published an article on the same subject. In Eduard Hufschmid7 reported a case of femoral hernia 1890 Boudaille (Paris) made a further mention of in- guinal hernia. Roux,18 of Lausanne, an arti- Read in the Section on Obstetrics and Diseases of Women of published cle on in which was one the American Medical Association, at the Fifty-seventh Annual hysterocele 1891, followed by Session, June, 1906. by Ed. Schwartz19 in 1892. Works on the same order

Downloaded From: http://jama.jamanetwork.com/ by a University of Pennsylvania User on 06/15/2015 have since been published by Jules Boeckel,20 by Brohl,21 mobile that it may be forced into that port. This deter- by Defontaine, Rosanoff22 and Legueu. mines also the contents of the hernial sac. In 1893 Lejars23 published a second article on hernia 3. There must exist a force sufficient to move the or- of the Fallopian tube without the ovary. The history of gan into the port. This force is the intra-abdominal a patient operated on by Jaboulay comes next in order, pressure. It is present in all individuals, but is subject the histologic examination having demonstrated the com- to sudden and extreme variations. It may be termed the plete absence of ovaries. Inguinal hernia of the ovary immediate cause. was the subject of a memoir by Manega,24 and in 1895 Since a weak or patulous ring is the primary cause of of an interesting treatise by Kousmine, of Kasan. Work hernia, it is of interest to note that the inguinal and um- by de Vaucher,25 of Lyons, and others followed. bilical rings are frequently patulous at birth, and that In recent years special attention seems to have been a large proportion of hernia? through these rings are con- given to hernia of the genital organs in children. In genital or occur at an early age. On the other hand, the 1897 Menciere26 published five observations on hernia femoral, obturator and ischiatie hernise are usually ac- in very young children and laid special stress on the quired at a late period of life. Of particular interest facility of mistaking the diagnosis. In three articles, are the causes which determine the entrance of the ovary, published in 1897 and 1899, Wiart makes a special study tube or uterus into a hernial sac. The testis in its of the pathogeny of hernia of the adnexa, particularly descent normally passes through the inguinal ring, but that of the tube. In 1897 Charon records a case of her- the descending ovary passes the orifice on its way to its nia in a child 3 years of age. He speaks of the absence position in the pelvis. Sometimes this descent is very of danger attending an operation at this age. slow, in which event the organ remains for a consider- able period in a position favoring hernia. The Fallo- pian tube and even the uterus may follow the ovary into a sac or may precede it. Congenital hernia? of the ovary other than inguinal do not occur, for the reason that the anatomic relations do not favor patulous orifices and that the ovary comes near to these openings only at a considerable period after birth. That the position of the ovary may be a factor favoring hernia is evidenced also by the large number of ovarian hernise occurring in cases of congenital mal- formation, as in cases of hermaphroditism, bicornate uterus, absent uterus, etc. In these cases the descent of the ovary is retarded or arrested in a position favoring entrance to the inguinal ring. In some cases of hermaphroditism, in which the indi- vidual approaches the male type in other respects, it may also approach that type in this, that the ovary is affected by the same influences that determine the nor- mal descent of a testicle into the inguinal ring. Indeed, this is a reasonable supposition when we consider that many of the ovaries resemble testicles so closely that a microscopic examination is necessary to make a differen- Fig. 2.—Gusenthal's case of obturator hernia of the ovary and tiation. Many times in such cases have supposed ovaries tube with intestine. The uterus is drawn down toward the ring. been to be testicles. The drawing was made from findings at the operation and at the proven autopsy. D, Strangulated intestinal loops; O, Ovary; T, Tube; In an older person atrophy of the tissues with fat m. p., Pectineus muscle; B. W., Abdominal wall; Bl., Bladder; reduction, as in the connective tissues about the vessels, U, Uterus; aD, Abducent portion of the intestine; zD, Deferent accounts for the of the various hernial portion of the intestine. weakening orifices, in which case muscular exertion, either long continued or a hernia. or tumor In 1898 Professor Bernier27 published a compre- violent, may produce Pregnancy by hensive all the works of his distension of the abdominal wall may favor hernia for- work, embodying predeces- and sors and two new observations on hernia of the ovary. mation through the usual rings even produce diasta- sis of the muscles of the with a ventral At the same time Moser, of Berlin, made this the sub- wall, resulting ject of his inaugural thesis, and H. Bernard Browne28 hernia. Pregnancy, tumor or uterine displacement may made his valuable contribution to the subject. also so displace the ovary, tube or fundus uteri that its entrance into one or other hernial orifice is facilitated. In 1899 Martin29 published an elaborate article on hernia of the ovaries and adnexa. An extensive thesis By to intestine or omentum the pelvic organs a entrance a on hernia of the uterus and adnexa was delivered in may be fixed in position favoring into pre- 1900 In 1901 Dr. Paul F. Morf30 existing sac. It is probable, also, that in many cases of by Oge (Paris). pub- or lished a valuable article. He cases, hernia, either acquired congenital, the intestine and reports twenty-four omentum have the sac for a including one of his own. may occupied period, and, having slipped back into the abdominal cavity, may have ETIOLOGY. allowed the ovary, tube or uterus to occupy the sac pre- It is self-evident that three factors are necessary to pared for its reception. the production of any hernia: It is not impossible, when the Fallopian tube is the 1. There must be a port, sufficiently patent or suffi- organ first herniated, that the hydatid of Morgagni is ciently dilatable, through which an organ may be- the object first crowded through the ring. This small come herniated. Such an opening is the primary cause cyst is more freely movable than the tube and is of a of every hernia. size and consistency well adapted fo be forced through a 2. There must be an organ so situated and sufficiently small opening. The tube would readily follow.

Downloaded From: http://jama.jamanetwork.com/ by a University of Pennsylvania User on 06/15/2015 MORBID ANATOMY, COMPLICATIONS, SIGNS, SYMP- ducible by dorsal position. Final attack, irreducible and pain- TOMS AND DIFFERENTIAL DIAGNOSIS. ful. Operation. Sac contained right ovary and tube, Meckel's diverticulum, appendix and intestines in a pus cavity (organs These have so authors been thoroughly treated by the partly necrotic). Removed organs, including about six inches mentioned in the historical sketch and others, and fur- of intestine. Recovery. thermore are so diverse, that I shall speak only of the Bloodgood:34 Case 1.—Patient, aged 45; acquired inguinal general facts involved. hernia; operation; sac contained right tube and ovary; re- Morbid Anatomy.—The morbid is that of duced; recovery. anatomy Case 38; any hernial sac into which an ovary, tube or uterus has 2.—Patient, aged acquired inguinal hernia; opera- tion; sac contained left and The in the sac and those in the abdo- ovary tube; reduced; recovery. passed. genitals Boeckel:33 Patient, aged 6 months; left ir- men be as to or of the inguinal hernia; may normal, except position, any reducible; operation; sac contained left ovary, and a known conditions There be portion pathologic may exist. may of the corresponding tube. The herniated mass was removed malformation, strangulation, adhesions, inflammation, and patient recovered. infection, suppuration, serous or sanguinous exudation, Bbaun:** Case 1.—Right inguinal hernia in a child aged 6 tumor or pregnancy, either tubal or uterine. Also these weeks; irreducible. Sac contained right ovary and fimbriated conditions may be the of other extremity of tube. Right ovary in state of degeneration; re- complicated by presence moved. organs, normal or pathologic, in the sac. Recovery. Several weeks later a swelling (probably the was noticed on the left side. The child are the of in a containing ovary) Signs.—The signs presence something died later of an intercurrent disease. hernial sac that be a verified in- might pelvic organ, by Case 2.—Right inguinal acquired hernia; woman, 47 formation as to the of those organs years position gained by old; irreducible. Contained right ovary and tube. Excised. bimanual and instrumental examination. Recovery. Symptoms.—The symptoms are the general ones usual Bristow:37 Patient, aged 44; acquired left inguinal hernia; in patients suffering from pelvic disturbances and those strangulated; operation; sac contained ovary, tube in which due to the special conditions. These special conditions there was an abscess cavity, and round . Sac and are so various that their symptomatology can not be de- contents removed. Recovery. tailed here with on the Broca:33 Case 1.—Patient, aged 11; congenital hernia of the profit. They depend (1) variety left of hernia, the inguinal being the most frequent; (2) the tube and ovary; inguinal; herniotomy. Both organs were replaced, This case was the ovary oftenest found and being healthy. Recovery. hereditary, genital involved, being both mother and grandmother having had an inguinal hernia. being the organ that during functional activity gives Case 2.—Child, aged 3; double most the congenital inguinal hernia; the characteristic symptoms; (3) age of the left hernia of the tube and ovary; excision of sac and between and adnexa; patient, because puberty the menopause the the tube was surrounded by tuberculous granulations; the symptoms are likely to be most pronounced. right hernia was reducible. Death. Autopsy: No peritonitis. Any of the special morbid conditions, as malforma- Peritoneal and pleural granulations. tion, adhesion, infection, strangulation, tumor or the Case 3.—Patient, aged 2; left congenital inguinal hernia of presence in the sac of other organs, will often the tube and ovary; radical cure of hernia. produce Case such marked disturbances as completely to overshadow 4.—Patient, aged 4; double inguinal hernia; left hernia and mask those produced by the incarcerated uterus, of the ovary and tube; at the operation the tube was found near the internal ring and the ovary below the these tube or ovary. just tube; conditions which organs being healthy, were replaced. Recovery. Differential Diagnosis.—The may Case 5.—Inguinal hernia of the left ovary in a child several be mistaken for hernia of tube or uterus are ovary, months old, operated on for inguinal hernia of left kidney. (1) undescended testicle in an hermaphrodite; (2) Microscopic examination showed the supposed kidney to be the small intestinal hernia; (3) epiplocele; (4) tumors in left ovary accompanied by the tube. the sac, as fibromata, lipomata, carcinomata, etc., espe- BtrcTJRA:38 Patient, aged 34; acquired right inguinal hernia; tumors of the round of operation; sac disclosed besides small intestine, atrophied right cially ligament; (5) hydrocele and the ; (6) inguinal or femoral tumors. ovary, over two-thirds of the distal portion of the right tube. hernia was left-sided The treatment should be the radical cure of the hernia Recovery. This discovered during conditions may make reduction ovariotomy. by operation. Special Bullitt:40 woman, who had never menstruated; the use of a truss or Young by taxis and subsequent abdominal double inguinal tubo-ovarian hernia, with congenital absence in un- supporter advisable. The results of operation of ; the right ovary contained small blood cyst and complicated cases should be good. The danger of opera- was enlarged about three times its usual size. The ovary and tion in complicated cases will usually be much less than tube were tied off and cut away. The left tube and ovary the danger involved in the persisting condition. were returned into abdominal cavity. Recovery. Cahen:41 Patient, aged 2 months; congenital right inguinal CASES OF INGUINAL HERNIA CONTAINING BOTH hernia; operation; sac contained right tube and discolored OVARY AND TUBE. ovary; both organs were removed; the pedicle of the ovary was twisted to an angle of 180 degrees. Balin:" The case of a woman on an whose body autopsy Championniere:39 Patient, aged 52; right inguinal hernia; was at the Saltpetriere, and where one of the performed small, always painful; left; voluminous, containing ovary, ovaries, in which there was a of was found germ fecundity, tube, and a small of first for in the a tubal portion epiploon. Operation engaged ring (evidently pregnancy). right; no organs in sac. Six months later Belbin:51 Patient, 7 months; irreducible Recovery. operation aged inguinal for left. Sac contained left ovary and tube, as well as the hernia, opening the sac; bloody fluid strangulated; operation; round ligament. These organs were excised. and left was found in the with Recovery. escaped, ovary sac, engorged Charon:43 Patient, aged 3 months; left inguinal hernia; blood; sac contained also the fimbriated extremity of the irreducible; operation; sac contained left ovary and Fallopian tube, which was black and swollen. The entire mass was tube; they were returned into the abdomen. removed. Recover}'. Recovery. Chiarelli:43 Patient, aged 35; had worn a truss since child- Bilhaut (M.) :32 Infant of 3 months; left inguinal hernia. hood for right inguinal hernia; irreducible; operation; bloody Strangulation and mortification of ovary and tube. Ovariot- serous fluid in sac containing ovary and abdominal end of tube. omy, salpingotomy, radical cure. Recovery. They were removed with sac. One-third of the extirpated Black (Carl) :™ Patient, aged 40; six children. Attacks ovary was normal in structure; the rest was converted into a of pain in right inguinal region, and small tumor. Usually re- blood cyst. Recovery.

Downloaded From: http://jama.jamanetwork.com/ by a University of Pennsylvania User on 06/15/2015 Coote ( Holmes ) :" Young woman; symptoms of strangu- Hoi.st and Tiling:58 Patient, aged 38; right inguinal hernia; lated hernia; left ovary and part of Fallopian tube were found irreducible; herniotomy; sac containing tube and ovary re- hernia in the in sac. Similar formation on right side. Left ovary removed; moved; recovery. Recurrence of inguinal right thickened omentum cut away; patient died on fourth day. side about nine months later; radical operation; recovery. Both ovaries were developed; uterus quite absent. Hulke:5'' Patient, aged 20; congenital hernia; inguinal of Damianos:45 Infant, aged 14 months. Left inguinal hernia, both ovaries; atresia of the vagina; left was reducible; truss on side. containing ovary and tube with torsion of the pedicle. Brown- support. Operation right Sac contained right ovary ish-red fluid in the sac. Excision. Recovery. and Fallopian tube. They were ligatured close to the uterine Duplay and Wiart:43 Patient, aged 33; left inguinal hernia; horn and cut off. Recovery. Probably bicornute uterus. first noticed at the age of 7; irreducible; operation; sac con- Jordan:"0 Patient, aged 37; left acquired hernia; operation; tained left ovary and tube; both organs reduced; sac excised; hernial sac was formed from ruptured tubal pregnancy; fetus recovery. 7% cm. long, was removed, with its envelope; then tube and Englisch:1* Patient, aged 39; acquired inguinal hernia; ir- ovary of this side were removed; death twenty-four hours reducible; symptoms of strangulation; herniotomy; sac con- later; at autopsy adhesions between the abdominal ostium of tained cystic degenerated left ovary and tube. Both were re- the left tube and a loop of small intestine were found, and moved. Death from peritonitis. on the right side a similar condition existed. Fleischmann:47 Patient, aged 8 days; congenital left in- KOssman:" This author reports the case of left inguinal guinal hernia. At postmortem found to contain tube and ovary. hernia. Sac contained ovary and tube. They were reduced Gatjgele:48 Patient, aged 8 months; congenital inguinal and the sac excised. The right ovary was converted into a hernia; operation; opening of sac, serous contents escaped, dis- large cystoma; the uterus was greatly displaced; recovery. closing left ovary; abdominal end of tube with firmbriae; tor- Krieger:83 Patient, aged 26; right congenital inguinal sion of the pedicle; ovary and end of tube were excised, on ac- hernia; irreducible; symptoms of strangulation; herniotomy; count of beginning neurosis; recovery. sac was found to contain ovary, tube, intestine, ileum, Genth:4' Patient, aged 34; left inguinal hernia; congenital; omentum majus; recovery. The sac was extirpated. operation; sac contained extrauterine fetus, also outside of the Larimore:63 Patient, aged 35; left oblique inguinal hernia, abdominal cavity. Since this operation tumefaction still felt, probably congenital; irreducible; operation; sac contained which is without doubt an ovary. ovary and tube and vermiform appendix; the entire mass was Gofey:™ Patient, aged 34; left inguinal region tumor size removed and recovery followed. of a hen's egg, painful. Had tumor since childhood, small, Launay and Wiart:04 Case 1.—Patient, aged 2 months; movable and gave it no attention. Had three previous preg- right congenital hernia of the ovary and tube; dissection; tube nancies; no menstruation for last two months; in two months and ovary were reducible. Condition found postmortem. more the tumor increased to five inches long and four inches Case 2.—Patient, aged 33; left inguinal hernia of the tube wide. Operated. Removed a four months' fetus (female). and ovary; observed since the seventh year; operation; the Recovery. Afterwards a body could be felt, probably ovary. tube and ovary were reduced, the sac dissected and excised; Grtjnert:45 Infant, aged 5 months. Congenital left inguinal recovery. hernia of ovary and tube. Torsion of the pedicle and strang- Le Nouene (Leopold) .k1 Patient, aged 39; acquired right ulation. Excision. Recovery. inguinal hernia; pain and swelling at menstrual epoch; opera- Guersant:51 Patient, aged 10; inguinal hernia; operation; tion; sac revealed right ovary and tube; organs were reduced sac contained an ovary and part of the tube; it was removed and sac removed; recovery. and organB found cystic. Peritonitis and death. Lentz:™ Patient, aged 6 months; left congenital inguinal Guinard and Dudefoy:52 Patient, aged 24; acquired in- hernia of the ovary; irreducible; operation; the ovary with guinal hernia; celiotomy; a sausage-shaped mass adherent to ly2 cm. of the tube, was first dissected, then extirpated; re- peritoneal sac; mass connected with left uterine horn by a por- covery. tion of healthy Fallopian tube. Traction on tube drew down Lockwood:87 Patient, aged 6 months; inguinal hernia found corresponding ovary. Tumor was enucleated together with at operation to be a cystic sac containing right ovary, with ovary, sac ligated and resected. Recovery. Examination fimbriae of the tube and ligamentum latum. All these organs showed tube to have the volume of a large sausage and to have infiltrated with blood. They were excised and recovery ensued. undergone the changes of parenchymatous . The pedicle was found twisted. Habs:m Patient, aged 5 months; strangulated inguinal Lomer:6" Mature girl; acquired inguinal hernia of the left hernia; operation; sac contained left tube and ovary, with ovary and tube found in sac at postmortem, patient having twisted pedicle, and both were in state of beginning gangrene. died twenty-one days previous from atrophy and gastrointes Herniotomy. Recovery. tinal catarrh. Halley:" Young lady; left congenital inguinal hernia; ir- McCosii:09 Congenital hernia of the Fallopian tube and reducible; symptoms of strangulation followed by operation. ovary; when sac was opened, the round ligament and ovary Sac found to contain ovary, broad ligament and fimbriated ex- were found in it; recovery. tremity of Fallopian tube. The tube was divided by ligature Mace and Moncany:70 Small tumor in the upper part of Mid the entire mass removed. Recovery. the right labium major, flattened, size of a small kidney bean Hawkins:" Elderly woman; death from peritonitis. Au- not tender nor sensitive; did not seem to be continued into topsy revealed elongated uterus, which, with the Fallopian inguinal canal. Cyst of the canal of Nuck diagnosed. Mother tube formed a canal 14 inches long. The tube and ovary had brought child to dispensary one day when tumor mass was been lodged for many years in the hernial sac. enlarged, reddened and painful; local symptoms increased in Heegaard:*" Case 1.—Patient, aged 4 weeks; congenital in- severity, though the general state of the infant was good guinal hernia of left ovary, strangulated on account of torsion Same diagnosis, with addition of infection. Operation; removal of pedicle. Left ovary and tube removed. One month after of strangulated ovary and tube. Child recovered. Microscopic operation there was a swelling in the scar which proved to be examination showed the structure of tube and ovary markedly the right ovary; reduction was effected by incision into canal infiltrated with blood. of Nuck, which was patent. Malherbe:71 Age 34; acquired inguinal hernia; symptoms Case 2.—Patient, aged 6 months; for five days a tumor as of strangulation; herniotomy; sac contained left tube and large as a goose egg has been present in the right inguinal ovary. There was tubal pregnancy. Tube and ovary removed region; tumor uneven, dull on percussion, with normal integu- Recovery. The ruptured tubal pregnancy simulated strangu- ment; irreducible. Umbilical ring open to size of tip of little lated hernia. finger. Herniotomy disclosed dark fluid with discolored ovary. Manega:34 Case 1.—Patient, aged 4 months; strangulated examination of Further the extirpated mass disclosed the left inguinal hernia; operation; in the sac were found left fimbriated end of the tube and part of the broad ligament. inflamed ovary and an adherent tube. Excision. Recovery. Hermann:6' Infant, aged 3% months. Right inguinal her- The excised ovary weighed 2 gm. nia ovary and tube. Torsion of pedicle. Extirpation. Recovery. Case 2.—Patient, aged 30; acquired inguinal hernia. Oper-

Downloaded From: http://jama.jamanetwork.com/ by a University of Pennsylvania User on 06/15/2015 tu- ation; sac contained small portion of epiploon, a portion of the Eheinstaedter:87 Patient, aged 68; sarcomatous ovarian left tube and the ovary. Being healthy, the organs were re- mor in right inguinal hernia excised; tube and portion of round duced and recovery took place. ligament also removed from sac; intestine was likewise found Manley:73 Infant, with right inguinal hernia, hereditary in the sac. No trace of uterus found. Recovery. Hernia of and congenital; irreducible; operation; sac was found to con- the normal ovary, which appeared in the same side, was kept tain ovary, Fallopian tube and part of the broad ligament. up by a bandage. Championniere's operation for* radical cure was performed. Rigby:58 Patient, aged 3 months; previous day mother Recovery. noticed swelling in right groin; painful; increased in size; Mariani:™ Patient, aged 10; acquired inguinal hernia; skin became inflamed. Irreducible. Contents had a narrow revealed dark fluid double; the sac was opened on the right side and found to con- neck. Incision blood; ovary purple. Fal- tube tain the ovary and tube; the latter was separated from the lopian recognized by the fimbria?; neck was acutely sac wall and reduced. The ovary and sac were removed. Re- twisted; horn of uterus appeared at the ring. Ovary and tube covery. excised. Recovery. Martin:14 Patient, aged 5 years; right inguinal hernia; Rizzoli:89 Patient, aged 46; symptoms of strangulated in- irreducible; operation; serous contents with discolored ovary, guinal hernia; irreducible; herniotomy; sac contained the tube and left an tube and round ligament. Extirpation; recovery. There was ovary; on reduction intestinal loop was found died six after torsion of the in this case also. becoming gangrenous. Patient days operation. pedicle death due the May:'3 Patient, 7 months; left inguinal hernia of the Autopsy showed to strangulated intestinal loop aged which had been reduced. ovary; irreducible; symptoms of strangulation; herniotomy; de Rotter:90 Patient, aged 44; acquired inguinal hernia; the mass contained ovary and fimbriated end of Fallopian tube, irreducible; Sac was found to contain ft was removed operation. right ovary, completely. Recovery. tube and round As the had J. H.:™ 8 months; ligament. ovary undergone cystic Morgan, Patient, aged congenital inguinal it was removed with the tube. hernia of the Sac contained blood- degeneration, Recovery. right ovary. Operation: Schmidt, Heinrich:91 (Professor Dehner, operator). F. H., stained fluid and right ovary. Attached to upper end of ovary 25 years old; uterus absent; vagina a blind sac. Double in- was a slender twisted on itself, which was found to pedicle, guinal hernia; reducible. Left 20, be the tube and broad The ovary, tube and Operation: side, April right ligament. 1895. Contents: Left ovary and tube and of broad broad were removed as were in con- part lig- ligament they congested ament as Contents closed dition. pedicle. reduced. Ring with silk Recovery. 1895. C.:" 3 (Macewen). Recovery. Operation: Right side, May 7, Muniagtjrria, Aged months; right inguinal hernia; Serous sac found at but traction on same the Sac contained and tube in empty first, by reducible; operation: right ovary and tube as in the other inflamed excision. right ovary (exactly operation) pre- condition, necessitating Recovery. sented themselves. Ring closed. Recovery. DE Nazaris:78 Woman, aged 40; acquired inguinal hernia Schnitzler:8' Patient, aged 6 months, left inguinal hernia, violent fit of After following coughing; irreducible; operation. irreducible; operation. Sac was opened, contained serous of from the sac, the and tube were escape liquid right ovary fluid, ovary, tube and ligamentous latum. Pedicle was twisted found in the bottom of the were removed. sac; they totally to an angle of 360 degrees. Whole mass was extirpated. Re- Recovery. covery. Owen:7* Patient, aged 11 months; right inguinal hernia of Steinel, Nicolaus:" 1892, patient, aged 40; 8-para. In- the and the ovarian ovary tube; irreducible; herniotomy; ped- guinal hernia for twenty years, increasing in size; no truss. icle was found twisted inside the hernial the re- sac; part On left side size of child's head. Operation: Replaced ovary, moved consisted of ovary, Fallopian tube and parovarium, of tube and broad ligament. Recovered. i#iich the ovary comprised about two-thirds of the entire mass, Sutton, Bland:93 Patient, aged 4 months; inguinal hernia; and the rest one-third. Recovery. irreducible; operation. Serous fluid escaped, when sac was Panas:"0 7 Aged months; strangulated inguinal hernia; cel- opened; at the bottom left ovary and tube were found. They and tube were found in the sac. Reduc- iotomy; right ovary were removed with the adjacent parts. Recovery. A oc- tion of the followed Patient cyst organs by recovery. died later, cupied the uterine pole of the ovary and the ampulla of the after leaving the hospital, from enteritis. tube. Parker, Rtjshton:81 Patient, aged 24; double inguinal her- Tait, Lawson:94 Patient, aged 26; first observed rupture nia of and ovary Fallopian tube; absence of vagina and when six years old; irreducible. Operation; sac was removed; no reduction was uteri; menstruation; herniotomy; impossible, it contained fluid and several cysts, the walls of which were therefore the entire sacs were removed. Hernias probably con- found to be those of an ovarian tumor and the end of the genital. Fallopian tube protruded through the ring at the base of the Pinkerton:82 Patient, aged 16 months; irreducible hernia of tumor on its under aspect and was removed along with it. left Fallopian tube and ovary; mother stated that it appeared Recovery. six months previously, after an attack of crying; the entire Tricomi:" Case 1.—Patient, aged 14; right congenital ingui- was The walls of the tube were and mass removed. gelatinous nal ovarian hernia; reducible; operation. Sac contained ovary presented naked-eye appearances of tuberculous salpingitis. and tube. Reduction of hernia. Excision of sac. Recovery. Recovery. Case 2.—Patient, aged 40; left inguinal hernia; partly re- 3 Pollard:83 Patient, aged months; congenital hernia of the ducible. Operation; sac contained healthy left ovary, omen- right ovary, situated over the external abdominal ring; ir- tum, small portion of tube adherent to sac; removal of ad- reducible ; strangulated; laparotomy; sac contained ovary and hesion and reduction. Recovery. fimbriated extremity of the Fallopian tube; sac and contents TscherninG:*8 Patient, aged 6 months; born six weeks be- completely excised. Recovery. fore full term. Since birth a right inguinal swelling; re- Puech:84 Patient, aged 26; left inguinal hernia apparently ducible and held by a truss. Now incarcerated for two days, congenital, containing ovary and tube; irreducible, sensitive with pain and increased temperature. Examination showed an and painful at menstrual epochs, increasing in size each time. olive-sized body in the right labium, not reducible; also a small Quadflieg:85 Patient, aged 41. In fourth month of preg- left reducible hernia; herniotomy; wound healed in eleven nancy. For nine years an irreducible right inguinal hernia. days. Later died of enteritis. Sac contained right ovary and tube. They were reduced and Autopsy: On the right there was no hernia, but a small recovery followed. canal through which the round ligament and the'tube passed. Reymond, E.:80 Patient, aged 38; left inguinal hernia, ex- On the left was a small hernia containing none of the genitalia. isted since two years of age; also acquired umbilical hernia. Microscopic examination of the mass removed at operation Inguinal hernia, irreducible; operation; sac contained portion showed ovary, fimbriated end of tube and some broad liga- of intestine, left fibrocystic ovary and tube, and portion of ment. The hernia was into the canal of Nuck. bladder; return of bladder to abdominal cavity; recovery; Tubby:97 Infant, aged 4 months. Operation disclosed both operation for umbilical hernia; recovery. ovaries and both tubes in a left inguinal hernia. The organs

Downloaded From: http://jama.jamanetwork.com/ by a University of Pennsylvania User on 06/15/2015 were partly covered by the peritoneal sac and were adherent to the Cases Femoral Hernia.—Of these the structures. Left and Analysis of of surrounding Operation. tube ovary three were and two was and five, right left. There incarcera- were removed. Right tube and ovary tube were reduced. tion and with and in Suppuration in the abdominal wall. Death. Autopsy showed strangulation, operation recovery all. The range from 40 to 69 no peritonitis. Organs normal except as stated. ages years. Wbincii, H. C. :"8 Patient, aged 26; acquired left inguinal CASES OF OBTURATOR HERNIA CONTAINING BOTH hernia; menstrual sac con- pain during epochs; operation; OVARY AND TUBE. tained left ovary and tube, firmly adherent to the sac; both were removed. Recovery. Blazina:1"3 Patient, aged 66; died of pneumonia and at Zogbaum:"9 Case 1.—Patient, aged 8 days. Congenital in- autopsy an obturator hernia was discovered. The sac con- guinal hernia. Child died of suffocative catarrh. At autopsy tained the right tube and ovary. J. D. :'"* the sac was opened and found to contain the left tube and ovary. Lickley, Patient, 87; death from hemiplegia. Au- Case 2.—Patient, 43 days. Congenital inguinal hernia; topsy; obturator hernia was discovered; the sac contained the aged whole irreducible. Patient died of pneumonia. At autopsy the sac was right ovary, 1 cm. of the round ligament and 4.8 cm. of the tube. opened and found to contain the left ovary and orifice of tube. right Zurhelle, E. :iw Patient, aged 44, married 21 years. Nine Rogneh-Gusenthal:105 Patient, aged 66. Incarcerated ob- turator fifth normal births, after last birth she had a left-sided parametric hernia; death day after excision; at autopsy sac was found to contain with exudate. In 1903, operated on by median incision. Left cystic right broad ligament, tube and the uterus drawn over to ovary and removed and a small cyst punctured ovary, being the obturator foramen; the condition had over 26 the in right ovary. Right ovary and tube normal Feb. 19, 1906, existed years; ovary, tube and small of intestine were in a state of operated on for right inguinal hernia of ovary and tube, of 6 portion beginning gan- months' duration. Recovery. grene, therefore could not be reduced (Fig. 2). Schopf:106 of Analysis of cases of inguinal hernia. Patient, aged 68; acquired hernia the left tube and ovary through the obturator canal; irreducible; herni- .31 Not stated . 5 Right otomy; ovary and all but 5 cm. of the tube removed. Death Left .44 - from Double .8 Total .88 collapse. ' In five of these eases not classed as double there was double Analysis of Obturator Cases.-—Eight, 3; left, 1; total, 4. at hernia, hut one side only contained genitalia. In one case both Found autopsy, 2; death after operation, 2. The ovaries and both tubes were in the same hernia. ages range from 66 to 87. Results of operations: CASES OF ISCHIATIC HERNIA CONTAINING BOTH at Found Autopsy. 7 Recoveries.69 OVARY AND TUBE. Not stated . 1 Deaths . 7 Operated on .80 Not stated . 4 Chenieux:107 This was a case of right ischiatie hernia; ex- Total .88 Total .80 tirpation of ovary; ovary and tube in the sac. Routier:108 40; at In 18 of the 80 cases on the ovaries and tubes Patient, aged acquired hernia; operation operated proved to be the cystic ovary which, with the were returned to the abdomen. In 2 cases the ovaries together tube, had passed through the ischiatie notch. Recovery. were removed and the tubes returned to the abdomen. REFERENCES. In 2 cases the hernia recurred and the other ovary was 1. Andrews: "Hernia of the Tube Without the Ovary," The found in the sac. Journal A. M. A., Nov. 25, 1905. 2. Malformation was observed in 7 cases. It was prob- Doling: "De herni\l=ae\uterin\l=ae\atque hane justo tempore subse- quentis partis C\l=ae\sareihistoria," Vitemberg, 1612. in more. affords little 3. ably present Herniotomy oppor- Oelhafen: "De partibus abdomine contentis," Gedani, 1613. for of the 4. Oneidas: "Diss. de hernia uteri," Lugd. Batav., 1680. tunity inspection pelvic organs. 5. Haller. Tubal within the hernial sac occurred in "Disputat. Chir. Select," 1755, vol. iii, p. 41. pregnancy 6. Balin: "L'Art de Guerir les Hernies," 1768. 5 cases. In one case the uterus was in the pel- 7. Hufschmid: Schweizerische Zeitft. f. Heilk., vol. pregnant also ii, 1863, p. while the ovary and tube were in the hernial sac. 48; Arch. f. klin., Chir., vol. viii, p. 637. vis, 8. Hulke, T. W.: Medico-Chir. Trans., vol. xlvii, p. 97. There was in 11 twisted in 1864, strangulation cases, pedicle 9. Schillbach: Jenaische Zeitft. f. Med. u. Naturwisft., 1864, 13, ovary in 6, tuberculosis of the tube in 2 and vol. 1, p. 242. cystic 10. Hamilton and Bellevue in In 8 cases intestine or omentum Terry: Hospital Reports, 1876. sarcomatous ovary 1. 11. Courty: "Trait\l=e'\des Maladies de l'Uterus." was mentioned in the sac and in 2 the vermiform ap- 12. English: Oesterr. Med. Jahrb., Vienna, 1871, p. 335. The ages range from birth to 52 years. 13. Puech: "Des Ovaires et leur Anomalies." pendix. 14. Langton, G.: St. Barth. Hosp. Reports, London, 1882. 15. Lejars: Gaz. des H\l=o^\p.,1889. CASES OF FEMORAL HERNIA CONTAINING BOTH OVARY 16. Brunner: Beitr. z. kiln. Chir., 1889, vol. iv, p. 32. AND TUBE. 17. Hagner: "A Case of Hernia of Parturient Uterus Through the Linea Alba," The Journal A. M. left crural hernia of the and tube A., vol. xii, p. 302. Broca:1"1 Aged 40; ovary 18. Roux: Congr\l=e`\sFran\l=c;\aisde Chirurgie, Fifth Session, 1891. strangulated. Sac was extirpated with the ovary, but the 19. Schwartz, Ed.: Id., Sixth Session, 1892. tube, beiner healthy, was returned to the abdomen. Recovery. 20. Boeckel, Jules: Gaz. M\l=e'\d., Strasburg, 1892. 21. Brohl: Haller:' This author an enormous crural hernia in Deut. med. Wochft., 1893. reports 22. Rosanoff: Arch. f. kiln. Chir., 1895. in whom hernia was the sac was a woman, the strangulated; 23. Lejars: Rev. de Chir., January and February, 1893. opened; left ovary and a portion of the tube were found. Re- 24. Manega: Riforma Medica, Naples, 1894. duction followed and the patient made good recovery. 25. de Vaucher: These pour le doctorat, 1854, p. 49. Caesar:88 femoral her- 26. Menci\l=e`\re:Rev. mens. des Mal. de l'Enfance, 1897. Hawkins, Patient, aged 65; right 27. Bernier: Centbl. f. 1898. of bowel incarcerated; hernia Gyn., nia; symptoms strangulation; 28. Browne, H. Bernard: Gynecological Trans., vol. xxiii, p. 1898. was divided into two parts, one of which felt like omentum on 29. Martin: See his work, "Krankheiten der Eierst\l=o"\ke und opening sac; while Fallopian tube and broad ligament with a Nebeneierst\l=o"\ke,"for article. 30. Morf, Paul F.: "Hernia of with five or six inches of were the Fallopian Tube Without shriveled ovarium, intestine, Hernia of the 1901. went Ovary," found on dividing the stricture; the bowel readily up, 31. Belbin: Brit. Med. Jour., 1898, vol. i, p. 1398. also the . Recovery. 32. Bilhaut: Ann. de Chir. et d'orthop., Paris, 1904, vol. xvii, Hufschmid:7 A case of irreducible, crural hernia, the size p. 193-197. 33. Black, Carl: Ill. Med. Jour., 1904. of an egg. Sac contained the fimbriae and part of right tube 34. Bloodgood: Johns Hopkins Hosp. Rep., 1898, 1899, vol. vii, and ovary; operation; recovery. p. 318. Parker:103 Patient, aged 69. Right acquired strangulated 35. Boeckel: Rev. Med. et Chir. des Mal. des Femmes, 1882, vol. crural hernia. Sac contained ovary and Fallopian tube; rad- iv, p. 115. ical operation; recovery. 36. Lemhofer: Inaug. Dissert., Leipsic, May, 1895, vol. xvii. 37. Bristow: Trans. Med. Soc. State of New York, 1902, p. 252.

Downloaded From: http://jama.jamanetwork.com/ by a University of Pennsylvania User on 06/15/2015 38. Broca: Bull. Soc. Anat., Jan. 27, 1893 (Case 4). Rev. mens. hut it grew larger and was painful during her menstrual des de vol. L. Mal. l'enfance, 1897, xv, p. 275 (Cases 1, 2, 3); periods. Dr. Carstens examined it and believed it to be a Progres Med., 1904, vol. xix, 3rd series, p. 54. of the cord. It was soft and so he said 39. Bucura: Zentbl. f. Gyn, 1904, No. 46, p. 1410. hydrocele fluctuating, that he a 40. Bullitt: Louisville Month. Jour. Med. and Surg., August, the best thing was to remove it. When opened it 1904, p. 97. very little fluid came out, and with it the tube and ovary, 41. Cahen: M\l=u"\nch.med. Wochschr., 1900, No. 38. and the sac extended into the internal canal. The uterus 42. Charon: Jour. de clin. et de vol. therap. infant, Paris, 1898, was well up and the other side was all He vi, p. 21. pulled right. and the made a 43. Chiarelli: Centbl. f. Gyn., 1883, p. 464. closed the sac in the usual way patient good 44. Coote, Holmes: Lond. Lancet, 1864, vol. i, p. 96. recovery. 45. Damianos: Deutsch. Ztschr. f. Chir., Leipsic, vol, lxxx, Nos. 3 and 4. 46. Duplay and Wiart: Bull. Soc. Anat., June, 1897. 47. Fleischmann: "Liechen\l=o"\ffnungen," Erlangen, 1815. A PATHOLOGIC STUDY OF SEVEN CASES OF 48. Gaugele: Deut. Zeitft. f. Chir., 1904, vol. lxxiii, p. 216. 49. Genth: Verhandl. d Gesell. f. Geb., Berlin, 1855, No. 8, p. 97. PARALYSIS WITHOUT GROSS ANATOMIC 50. Schweigii, Martin: "Syllepsilogica histor. medica: Hoc est conceptionis muliebris consideration," Dresden and Leipsic, 1731 CHANGE. 51. Guersant: Bull. Soc. Chir., Paris, 1851-1852, vol. ii, p. 127. JOHN H. W. RHEIN, M.D. 52. Guinard and Dudefoy: Bull. Soc. Anat., 1893. 53. Habs: M\l=u"\nch. med. Gesell., No. 3, 1901. (Continued from page 1706.) 54. Halley: Kansas City Med. Rec., 1884, vol. i, p. 260. 55. Hawkins: See Barnes' Amer. Jour. Obstet., 1883, vol. xvi, p. 4. Notwithstanding all these studies the cause of uremic 56. Heegaard: Bibliotek. f. L\l=a"\ger,1904, Nos. 5-8, p. 534 (Case 1); has not been One is "Uber Ovarial hernien," Arch. f. klin. chir., 1904-1905, p. 487. hemiplegia satisfactorily explained. 57. Schnitzier: Wien. klin. Rundschau, 1903, No. 42, p. 793. forced to the conclusion that it may be due not to any 58. Hoist and Tiling: St. Petersb. med. Wochft., 1885, No. 36, one cause in all cases, but to one of a number of causes; p. 301. in some to in others to 59. Hulke: London Lancet, 1883, June 23, p. 1088. cases, perhaps, autointoxication; 60. Jordan: M\l=u"\nch. med. Wochft., 1897, vol. xliv, p. 7. edema or arteriosclerosis; and in still others to the pres- 61. K\l=o"\ssmann:See Martin's "Krankheiten der Eierstocke und ence of microscopic areas of necrosis which have been Nebeneierst\l=o"\cke," 1899, vol. ii, p. 162. in 62. Krieger's Handb. d. Chir., vol. iii, p. 342. described this paper. 63. Larimore: Med. Rec., August 4, 1900, p. 192. Some confusion seems to exist as to what con- 64. Launay and Wiart: Bull. Soc. Fifth really Anat., Paris, 1897, uremic It is a mistake to series, vol. xi, p. 78. stitutes hemiplegia. diagnose 65. Le Nouene, Leopold: Gaz. de Gyn., 1903, vol. xviii, p. 337. all cases of one-sided paralysis occurring in a subject 66. Lentz: Gaz. Med., Strasgburg, 1881, No. 9, p. 97. who suffers from chronic disease, uremic 67. Lockwood: Brit. Med. Jour., 1896, June 3, p. 1442. kidney paraly- a of 68. Lomer: Centbl. f. Gyn., 1884, vol. viii, p. 217. sis. Strictly speaking, diagnosis uremic paralysis 69. McCosh: Trans. Amer. Surg. Assoc., 1895, vol. xiii, p. 481. should be restricted to those cases which 70. Mace and Moncany: Annales de Med. et Chir. develop during Infant, Paris, transient or a which to 1905, vol. ix, pp. 501-503. uremia, palsy, palsy may persist 71. Malherbe: M\l=u"\nch.med. Wochft., 1897, vol. 1, No. 44, p. 9. the end in fatal cases. There is no way, however, that I 72. Manley: Ann. Gyn. and Pediatry, 1893, vol. vi, p. 606. know of, which it can be foretold whether the 73. Mariani: Il sez. prak. fasc., vol. No. 17, 1901. by paraly- policlinico vii, or due to 74. Martin: Rev. Med. de la Suisse Romande, Dec. 20, 1903. sis is of syphilitic origin, is arteriosclerosis, 75. May, Brit. Med. Jour., 1898, vol. i, p. 1389. autointoxication, or to cerebral edema. 76. H.: vol. Morgan, J. Lond. Lancet, 1897, 1, p. 1340. In a of uremic we must 77. Muniagurria, C.: Semana Med., 1902, p. 396. making diagnosis paralysis 78. de Nazaris: Rev. Med. Chir. des Mal. des Femmes, 1895, search for the signs of intoxication of renal origin, such vol. xvii, p. 541. as edema, edema; symp- 79. Owen: Lond. 1896, vol. 1, 765. general pulmonary premonitory Lancet, such as the 80. Panas: Gaz. de Hop., 1868, p. 135. toms, vertigo and gastric disturbances; pres- 81. Parker, Rushton: Brit. Med. Jour., 1893, vol. 1, p. 68. ence of albumin and casts in the urine, and other well- 82. Pinkerton: Brit. Med. Jour., 1899, vol. ii, p. 853. known of uremia. The in old peo- 83. Pollard: Lond. Lancet 1889, vol. ii, p. 165. symptoms diagnosis 84. Puech: Ann de Gyn., 1879, vol. 1, pp. 415, 421; also Ann. de ple is more difficult on account of the resemblance to Gyn., 1878, vol. ii, p. 336. symptoms following hemorrhage and softening of the 85. Quadflieg: M\l=u"\nch. med. Wochft., No. 20, p. 790. 1901, affections which are common in the The 86. Reymond, E.: Bull. Soc. Anat., Paris, 1894, Nov., Dec., p. 842. brain, aged. 87. Rheinstaedter: Centbl. f. Gyn., 1878, vol. ii, p. 545. and character of the 88. variability transitory paralysis Rigby: Lancet, 1905, August 5, p. 360. should make one think of uremia as its cause. 89. Rizzoli: Mem. Chir. et Obstet., Paris, 1872. always 90. De Ruyter: See Moser's "Zur Kenntnis der Ovarial-hernien," Inaug. Diss., 1898, p. 17. CASE REPORTS. 91. Schmidt, Heinrich: Inaug. Diss., Wurzburg, 1896. 92. Steinel, Nicolaus: "Ueber Ovarial Hern.," Inaug. Thesis, In none of the following cases was any gross lesion of M\l=u"\nch,1896. the brain or cord demonstrable at the 93. Sutton, Bland: Med. Press and Circular, 1896, Dec. 2, 582. autopsy. Case 1.—W. 68, a minstrel was ad- 94. Tait, Lawson: Brit. Gyn. Jour., 1885-1886, vol. 1, p. 328. N., aged by occupation, mitted to the in the service of K. 95. Tricomi: Riforma Med., 1894, Nos. 42, 43, p. 507. hospital, Dr. Charles Mills, 96. Tscherning: Med. Selskabs Forhandlinger Hospitalstid, 1898. September, 1905. Except for the fact that his father died as 97. Tubby: Brit. Med. Jour., Oct. 9, 1897, p. 968. a result of an attack of apoplexy, the family and previous his- 98. Wrinch, H. C.: Canada Lancet, 1899-1900, vols. xxxii, and tories were entirely negative. He dated his condition on ad- p. 665. xxxiii, from an accident which occurred two years 99. Zogbaum: Inaug. Diss., Jena, 1844, p. 20. mission, before, 100. Zurhelle: "Zur Kasuistik der Hernia Ovarica inguinalis," though it is doubtful that this had much bearing on his con- Ztbllt. f. Gyn., Bonn, May 12, 1906, vol. xxx, No. 19, p. 541. dition when admitted. While trying to board a car he was 101. Broca: Bull. Soc. Anat., Jan. 17, 1893. knocked down, striking his right hip on the car step. He was 102. Parker: N. Y. Med. Times, January, p. 109. 1855, unable to or to walk, and his urine was invol- 103. Blazina: Prag. Viertljahrssch. f. Prakt. Hlk. 1848, vol. i,p. 126. get up passed 104. Lickley, J. D.: Glasgow Med. Jour., 1892, March. untarily. 105. Rogner-Gusenthal: Wien. Med. Presse, 1893, No. 26, p. 1010, Examination.—On examination, after his admission, it was illustration. found that both were weak, the left decidedly so. The 106. Schopf: Wien. klin. Wochft., 1903, No. 8, p. 207. grips was was able to move both 107. Chenieux: Bull. de Chir., May 21, 1895. gait tottering, although he legs well. 108. Routier: Le Mercredi Med., 1890, vol. i, p. 248. The tongue was protruded in the median line. There was no external and no DISCUSSION. paralysis of the ocular muscles, apparently paralysis of the cranial nerves. The pupils were moderately Dr. J. H. declared that this is a Carstens, Detroit, very rare dilated, and his mentality seemed good. The station was fairly condition. He saw 16 old had recently one case. A girl years good with the eyes closed. Both knee-jerks were quick and a swelling in the left side which she had had for a long time, slightly spastic. On stroking the plantar surface of the feet

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