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Having Already Published an Article on Hernia of the Tube Without The HERNIA OF THE OVARY 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 uterus, 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 ovaries. 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 Fallopian tube, 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- enterocele. 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.
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