may appear mainly in the perineum at the site of one or the other ischiorectal fossa. This is more common and constitutes the well-known perineal hematoma. It is not unusual for these types to be more or less fused, as in the case about to be described, the condition existing in which is admirably presented in the colored plate accompanying this article. The hematoma in this instance was a combination of the vaginal, labial and perineal types -a vagino-vulvo-perineal hematoma. The history of the case is as follows:

Mrs. P., aged 28 years, the wife of a physician, presented an excellent family history on both sides. The patient had had all the diseases of childhood, and had always been somewhat delicate, although appearing very well nourished. When nine years of age she had an attack of inflammatory rheumatism which left a heartlesion in the form of a mitral regurgitation. Her menstrual history began at the age of fifteen, and the periods were always attended with pains on the first day of the flow and the preceding day. On these two days the patient was compelled to confine herself to bed. In May, 1903, she was delivered of a premature five months' fetus which had been dead for two weeks or more. There were no complications at the time of this delivery nor were there any unpleasant sequelæ. The following August another impregnation occurred. For the first two months of the gestation the patient suffered severely from nausea and gastric distress. During this time she also passed through a severe attack of urticaria. Fetal movements were detected during the fourth month of the pregnancy but at no time during the gestation were they as vigorous as they should normally have been. Some edema of the legs was detected during the fifth month. An examination of the urine at this time showed a specific gravity of 1.020 and an absence of albumin. A trace of albumin was detected in the sixth month, but this disappeared under the administration of Basham's mixture. In the seventh month the fetal movements became very indistinct, and at the same time considerable edema appeared in the ankles and lower portions of the legs. Albumin was present in the urine, the specific gravity of which remained at 1.020. The patient now complained of some abdominal distress and shortness of breath. These symptoms were relieved by the application of a firm abdominal binder. Constipation, which had always been a prominent feature of the case, now became quite marked, and this was associated with a mild degree of general pruritus, anorexia, and malaise. Tonics and

laxatives were exhibited without much effect, and the question of inducing labor was seriously considered. The uterus showed a considerable degree of irritability, and occasionally the patient would experience paroxysms of sharp, painful contractions which were localized to the lower segment of the abdomen. On the third of April the patient fell into labor, the first pains appearing at eleven o'clock in the evening. These gradually increased in intensity, although at no time, her attending physician reports, were they of any degree of severity. The parturient tract distended readily, and a stillborn male child of eight month's development was expelled at 1:15 o'clock on the afternoon of the fourth of April. The placenta and membranes came away normally, and a dose of ergot was administered. The pulse at this time recorded 80 beats to the minute, and was of good volume. There were no symptoms of internal hemorrhage or collapse. The after-pains were not marked. At 4 o'clock in the morning of the fifth of April the patient began to bleed freely from the uterus. Stypticin and ergot were exhibited with good effect. At this time a dark spot was noticed on the right labium majus, which slowly increased in size. This was associated with severe pain in the right ovarian region and abdominal distention which soon assumed the proportions of a marked tympanites. The general surface of the body now became moist, and the skin acquired a pasty appearance. The pulse at this time was 100, the temperature 98.4°, the respirations 24. Stimulants including whiskey, digitalin 1/100 gr., and strychnin 1/30 gr. were administered together with normal saline solution by the bowel and by hypodermoclysis. By evening of this day, at which time the writer first saw the patient, the tympanites had become extreme and was associated with nausea and eructations of gas. The application of a thick coating of antiphlogistine over the entire abdominal surface afforded great relief from the pain and distension. An enema of the milk of asafetida given at this time was fruitful in producing the expulsion of great amounts of flatus. Calomel gr. 1/20 with champagne relieved the nausea. Under this treatment there was a general amelioration of the symptoms. The pain in the abdomen and labium left entirely, the temperature fell to 97.6°, and the pulse to go. The abdominal distension disappeared altogether, and the bowels opened spontaneously, the evacuations being semi-solid and of a dark-gray color. Concentrated nourishment was given at frequent intervals. By the morning of the sixth of April the dark swelling on the labium had

extended into the vagina and back on the external perineal surface as far as the rectum, which became patulous. The tumor was tense to the feel but palpation did not elicit tenderness. At noon of this day the patient experienced a sinking spell, preceded by a sensation of tingling in the right hand and arm. Her speech became thick and then there was inability to speak at all. Oxygen by inhalation produced reaction, but it was noticed that the movements of the entire right side were limited. The mind was clear, and there was no sign of facial paralysis, nor did the tongue deviate to the side of the mouth. The pulse that evening registered 80 beats, the temperature was 98° F., and the respirations were 26. The patient, however, appeared very weak. Adrenalin, 15 drops by the mouth, was added to the treatment at this time, and the oxygen and normal saline solution continued. The right side was now lifeless. After a restless night the patient entered the morning of the seventh of April in an exceedingly weakened condition. The temperature was kept up by the application of external heat. At noon unconsciousness supervened and death ensued at six o'clock in the evening, seventy-six hours after the delivery of the child.

An autopsy, confined to the abdomen and pelvis, was made by Professor Harris A. Slocum of the Philadelphia Polyclinic, 48 hours after death. He was assisted by the writer. The peritoneal cavity was found to be free from blood, nor was there a hematomatous formation in either broad ligament nor any involvement of the bladder. There was marked discoloration of the right oviduct, and also of the basal peritoneum of that side. The right ovary was large, the left ovary normal in size. Small fibroid nodules existed in the fundus and anterior uterine wall. Examination of the hematomatous mass internally showed that the boggy tumor began at the upper right side of the vagina and extended outward and downward to lose itself below in the pelvic structures. Examined from without the clot was found to extend from the pubic ramus back to the coccyx and out toward the obturator foramen. The mass was apparently thoroughly encapsulated and tightly adherent to the walls of the sac. It was in size 7 by 31⁄2 by 1 inch. The uterus was opened and found to be normal in every respect. The placental site was at the fundus anteriorly and to the right.

It would be interesting to ascertain whether or not in these rare cases of puerperal hematoma there always preexists, as in the present instance, a chronic valvular lesion or some chronic renal affection. As is well known both of these conditions pre

dispose to a varicose condition of the vessels of the lower portion of the body, and this, in association with the physiologic thinning of the venous walls in gestation, would strongly predispose to rupture and hematomatous formation. A common cause of death in puerperal hematoma is cerebral embolism. This was the primary cause of the fatal termination in the case reported in this paper. The total amount of blood lost was not sufficient to cause death. Whether the embolus comes from the hematoma or from the placental site is another question extremely difficult of solution.

PUERPERAL HEMATOMA IN A MARE.

In connection with the foregoing case the following remarkable occurrence of a similar condition in a pregnant mare will be worthy of record. In August, 1902, the Second City Troop of Philadelphia was ordered out for service in the coal regions during the famous anthracite strike of that year. Among the horses taken out at that time was a mare, which, unknown to the Quartermaster of the troop, had been covered late in the spring. The troop was stationed for forty-three days on Columbia Park Hill just above the city of Shenandoah, Pennsylvania, which was then. the center of riotous activity. The trooper to whom the mare had been allotted had noted that the animal was increasing in size, but the possible existence of gestation had not occurred to him.

One afternoon after an eight-mile hurried ride to and from Mahanoy City to thwart an attempt to destroy a coal-train, the mare collapsed a couple of hundred yards out of camp. With considerable difficulty she was rolled upon a strip of canvas and carried into the horse-fly. She showed by her actions that she was suffering severely, but the veterinary, who had been summoned from town, was unable to state what the condition was. Toward evening a considerable bloody discharge occurred from the vagina, and a pouching of the rectal mucosa was noted. This bulky mass was dark blue in color and protruded for several inches through the greatly distended anus. Relief could not be afforded the animal, and in the early morning hours death ensued.

The body was carted down to the veterinary's shop in the outskirts of Shenandoah, where it was quartered and a thorough investigation made as to its condition. The mare was found to be pregnant about four and a half months with an intrauterine gestation. The Fallopian tubes and broad ligaments were normal in

every respect. Beneath the peritoneum and spreading to involve the right hip-joint and the tissues around the anus was a tremendous blood-clot coming from a rupture of a large branch of the right iliac vein. This rupture had doubtless occurred in a thinned-out vein during the strain of the rapid trip to and from Mahanoy City.

While absolutely ignorant of veterinary pathology, I would venture to say that the condition occurring in this mare must have been one of extreme rarity. The similarity between it and that found in the patient recently seen is at least remarkable. 130 SOUTH SEVENTEENTH STREET.

CYSTIC DEGENERATION OF THE OVARY. AN ANATOMICAL AND CLINICAL STUDY OF 180 CASES.'

BY

PALMER FINDLEY, M.D.,
Chicago, Ill.

SYNONYMS: Microcystic degeneration; cystic ovaritis; follicular degeneration of the ovary; hydrops folliculi ovarii; follicular ovaritis.

The first recorded observations on the anatomy of follicular degeneration of the ovary were made by Rokitansky in 1855. Shortly after this time the clinical significance of the lesion was pointed out by Hegar, Battey, Tait and Cruveilhier. By these observers the lesion was given a most serious aspect. Not only did they hold the condition responsible for many local disorders, but an astonishing array of general nervous phenomena were ascribed to it. Supported by such authorities, it is no wonder that the profession became overzealous in its efforts to remedy the condition. Ovaries were sacrificed unwantonly whenever large follicles were found, not only because of local discomfort but more often because of alleged nervous phenomena, such as hysteria, headache and insanity, which were thought to be excited by follicular cysts in the ovary. In this harvest time of the ovariotomist conservative men in gynecology questioned the rationale of the procedure. Olshausen, Pozzi, Martin and many others denounced the sacrifice of such ovaries for general nervous disorders as unwarranted by the comparatively insignificant lesions 'Chicago Gynecological Society, March 23, 1904.