Virchow and his followers believe in the mucoid degeneration theory. while Storck, Merkle, Marchand, Findley and others believe in the cystic degeneration theory.

We have here tried to demonstrate the nature of the contents of the cysts by testing for mucin which is soluble in water, a normal salt solution, and an alkaline solution and may be precipitated from these by acetic acid; to prove these tests a part of the vitreous humor of the beef's eye which contains mucus was dissolved in the above named solutions and precipitated by adding acetic acid as may be seen in the three test tubes marked "series one." We then made the same tests with 3 per cent formalin added to determine the effects of the formalin on the reaction, since this was the solution in which the specimen was preserved. The result was the same; see the three test tubes in "series two."

Next the tests were applied to the cyst contents dissolved in the three test fluids with negative results, as demonstrated by "series three," which would seem to prove that the cysts contained no mucin, the chief constituent of mucus.

Marchand has demonstrated that necrosis of the stroma occurs when the syncytium is destroyed regardless of the foetal blood supply, and concludes that the syncytium governs the maternal blood supply to the stroma, also that an adequate maternal circulation is essential to the integrity of the stroma.

This view is supported by the facts in partial moles in which the maternal circulation is less embarrassed the degeneration of the connective tissue is not so marked and that the epithelium of the villi first shows signs of degeneration which renders it incapable of exercising proper influence over the blood supply to the stroma.

Findley thinks the presence of serum in the cysts is due to a disturbance of the reciprocal relation between the maternal and foetal circulations.

From this we would apparently be justified in attributing the degeneration of the connective tissue of the villi to an impaired maternal blood supply, but the relation of the blood supply to the degeneration of the epithelium of the villi is yet to be determined, and since these changes precede those in the stroma it is evident that further investigation is necessary.

Malignant Degeneration.-From the histological view-point, the principal difference between the benign and malignant mole or chorioepithelioma seems to be an increased proliforation of the epithelial elements and penetration of the uterine tissues by the villi to a greater degree in the malignant mole, though just where the benign ends and the malignant begins it seems at present impossible to state.

Symptoms.-The characteristic symptoms of this condition are, discharge of cysts, sero-sanguinous discharge from the uterus and rapid enlargement of the uterus. Associated with these symptoms there are usually nausea, vomiting and pain in the abdomen, back and pelvis. Discharge of the cysts is most characteristic but rare; enlargement of the uterus is probably the most constant sign, though it is not always

sufficiently marked to warrant a diagnosis, especially if the exact period of pregnancy is not known; the sero-sanguinous discharge or hemorrhage is often the first symptom to attract the patient's attention. This is said to be more profuse at night, which was true of the case here reported, as were the colicky pains associated with the discharge.

Nausea and vomiting are usually present and the vomiting is more often uncontrollable than in normal pregnancy.

Pain in the abdomen, back and pelvis usually develops after the hemorrhage has been present for some time and may not be complained of until the cervix is dilating and the bleeding is profuse.

Diagnosis. The diagnosis is usually difficult and sometimes impossible; of course the discharge of vesicles from the uterus or palpation of the same per vaginum would indicate the nature of the lesion at once, but this does not often present, nor do the other symptoms always manifest themselves in a typical manner and when associated with symptoms not peculiar to this condition as they often are, the difficulties are much increased.

Differential Diagnosis.-Among conditions from which hydatiform mole must be distinguished are, multiple pregnancy, hydramniose, threatened abortion or miscarriage, simple and persistent vomiting of pregnancy and placenta previa, all of which at some period of development present one or more of the signs or symptoms associated with hydatiform mole.

Course. In the course of the disease the ovum is usually discharged between the third and sixth months of pregnancy, though gestation may continue to term should the degeneration be confined to a sufficiently limited area; on the other hand, the chorion may become adherent to the uterine wall and prolong gestation to the tenth or twelfth month when on expulsion there may be fatal hemorrhage owing to the obstruction of the uterine sinuses by the unduly proliforated villi which prevents their being closed by the retraction of the uterus; again, the villi may pass through the peritoneal coat and cause fatal hemorrhage into the abdominal cavity. It is also stated that portions of the chorion may remain within the uterus and be expelled at irregular intervals or result in general septicaemia.

Prognosis. Regarding the prognosis of hydatiform mole, the mortality has been variously estimated at from 13 to 25 per cent.

Among the causes of death are, malignant degeneration, hemorrhage, septic peritonitis, general sepsis, uraemia, endocarditis, nephritis and meningitis.

Malignant degeneration, fatal hemorrhage and rupture of the uterus have been known to occur before the expulsion of the mole, though such occurrence is rare. However, the remote sequellae are what give us most anxiety, i. e., malignant degeneration and recurrence; malignant degeneration follows in about 10 per cent of cases and has been known to present from nine days to four and a half years after the discharge of the mole.

Because of this tendency to malignant change every case of hydati

form mole should be carefully watched for the following three years at least.

Treatment. In the treatment of hydatiform mole, prophylactic measures, of course, cannot be adopted, since we do not know its cause. When the condition is recognized, immediate removal would seem. the only rational course, since the tendency to malignant degeneration is so marked and the interests of the child are not endangered, for in those cases in which the degeneration is so limited as to make the birth of a living child possible, the diagnosis could not be made before the termination of pregnancy.

In some instances expulsion of the mole has been brought about inadvertently by the introduction of vaginal tampons and the administration of ergot, hoping thus to control hemorrhage. Should the mole be expelled spontaneously, the uterine cavity should be explored with the finger to insure the complete removal of all placental tissue.

In case of operative procedure, Findley advises that all the tissue be removed with the finger and placental forceps if possible, resorting to the curette only when necessary to control hemorrhage or to separate particles which cannot be removed in the above manner. By adoption of these measures the danger of perforating the uterine wall is minimized.

REPORT OF Case.

The following case came under observation some fifteen months since:

Mrs. T.; 23 years of age; primipara; menstruation normal. There has been a slight leucorrhea since the patient can remember, and she suffers some pain when much on the feet during the courses.

Previous health generally good. Some two years since, patient fell over a box, the corner of which came in contact with the abdomen midway between the umbilicus and the symphysis pubis; with this she was confined to her bed for two weeks, and following it there was more or less pain at irregular intervals for several months, when it ceased, and has not troubled since.

After missing two periods, patient began to vomit; this gradually increased in severity until at the end of thirty days she could retain none of the solid and but a part of the liquid food taken. She first came under observation at this time and was found to be considerably emaciated, quite weak and all but sleepless; the pulse, temperature and respiration were normal; it semed at this time a pronounced case of simple vomiting of pregnancy or the first stage of pernicious vomiting. In the course of a week or ten days there appeared an intermittent Doody discharge from the uterus, accompanied by colicky pains, which simulated a threatened miscarriage, and for which it was mistaken. Bimanual examination caused considerable pain at all times; the cervix was at first closed, but later admitted the tip of the index finger; the size of the uterus corresponded very well with the supposed term of pregnancy, and it was not displaced.

Treatment was directed toward the relief of the vomiting and the supposed threatened miscarriage until it became evident that the uterus

must be emptied if the life of the patient was to be saved. After consultation, this was done, and this specimen of hydatiform mole obtained.

After a somewhat protracted convalescence, she recovered and remained well with the exception of an attack of whooping cough during the past winter.

LITERATURE.

"The Practice of Obstetrics by American Authors," Jewett. "Text-Book of Obstetrics," Williams.

"Text-Book of Obstetrics," Hirst.

"Diagnosis of Diseases of Women," Findley.

"Reprint" from the American Journal of Medical Sciences, March,