THE CHAIRMAN.-I would like to ask a question as to whether there is any specific cause operative in the production of these cases. Whether syphilitic or gonorrheal infection may have anything to do with it, and also whether inflammation of the mucous membrane of the uterus precedes these causes. Is it, in other words, an acute or chronic inflammation of the mucous membrane that causes it?

DR. HENRY T. BYFORD.-I have nothing to add, except that Dr. C. R. Parke, of Illinois, reported a case to me, in which the discharge of the liquor amnii took place, labor pains came on, and the umbilical cord became prolapsed. He replaced the cord and gave ergot. As labor did not progress, he finally gave morphia and quieted the pains. In three months the woman was delivered of a living child; mother and child did well.

DR. H. P. NEWMAN.-I saw a single case; the discharge, however, was greater than in the cases related, and came on about six weeks previous to the abortion; the membranes were not examined.

DR. W. W. JAGGARD said that he had listened to the reading of Dr. Earle's paper and the discussion with great interest. He could not, however, agree with the author of the paper in considering the pathology of hydrorrhea uteri gravidi as obscure and confused in all its details. Carl Braun (Zeitsch. d. Ges. d. Wiener Aerzte, 1858, No. 17, p. 257) and C. Hennig (Der Katarrh der inneren weiblichen Geschlechtstheile, Leipz., 1862, p. 48) had clearly and distinctly described the pathological anatomy of the condition. Chronic decidual endometritis may terminate in the formation of new connective tissue, or may manifest itself by the production of a yellow, sero-albuminous fluid, variable in quantity, which accumulates between decidua vera and reflexa, or when vera and reflexa are united, between decidua and chorion. Carl Braun accordingly considers the condition to be a serous endometritis. Hennig aptly terms it catarrhal decidual endometritis. Catarrhal decidual endometritis must be distinguished from collections of fluid between the amnion and chorion, the so-called amnio-chorial water. Bischoff has designated the unorganized, albuminous fluid uniting chorion and amnion as the tunica media. The quantity of this fluid may increase abnormally, at the same time that its consistency is diminished. McClintock describes a case, referred to by Spiegelberg, in which the amount of "amnio-chorial water" was so great as to simulate hydramnios. The "amniochorial water" may be discharged without the interruption of pregnancy, but then the discharge of fluid is not repeated as in the intermittent discharges of hydrorrhea uteri gravidi. Labor always follows the rupture of the amniotic sac-a fact which establishes the possibility of a differential diagnosis in the large majority of cases. It is unusual for labor to be prematurely induced by the discharge of the "amnio-chorial water," or collections of catarrhal secretions between chorion and decidua.

A condition strictly analogous to hydrorrhea uteri gravidi is frequently observed in uterine fibroids. The intermittent discharge of a yellowish sero-albuminous fluid from the uterine cavity is a symptom of such frequent occurrence in this condition that attention is directed to it by most systematic writers.

With reference to the etiology of hydrorrhea uteri gravidi, there were several facts of practical import. Any antecedent endometritis-gonorrheal, syphilitic, or of other origin-is an adequate etiological factor. Hydremia appears to favor the development

of the condition. The coincidence of hydremia with catarrhal decidual endometritis would certainly indicate the exhibition of chalybeate tonics in the treatment of the latter affection.

He fully agreed with Dr. Merriman in attaching great importance to the critical examination of the fetal envelopes in order to clear up a doubtful diagnosis.

DR. EDWARD W. SAWYER called attention to the fact that watery discharges from the uterine cavity frequently occurred during the puerperium.

He thought that the condition, technically termed hydrorrhea gravidarum, was due in all cases to the transudation of the amniotic fluid. This was the opinion ably advocated by Charpentier. DR. W. W. JAGGARD thought Dr. Sawyer had not quoted Charpentier correctly. Charpentier mentions Stapfer's recent moncgraph (Thèse de concours, 1880) in flattering terms; enumerates the various hypotheses proposed by a large number of observers, and says the German theory, already referred to, is the most probable.

DR. CHARLES W. EARLE.-I have but very little to say, Mr. Chairman, in closing the discussion. It seems to me, however, that there is one thing, at least, that we should learn from our consideration of this subject this evening. It seems to be impossible for any one to determine the exact source from which a considerable amount of fluid is occasionally discharged from the vagina of a pregnant woman. We do not know whether this fluid comes from the amniotic cavity or external to it; therefore, we should not give ergot or commence the dilatation of the os uteri after a watery discharge, believing that labor must come on, because from the testimony we have received here to-night, and from other evidence, it does seem that even if the liquor amnii is prematurely evacuated in a few cases, pregnancy may go on to full term.

My attention has been called to the phenomenon mentioned by Dr. Sawyer, and if I had not desired to make my paper as brief as possible, I should have spoken of the watery discharges which occasionally take place after labor. I have never seen a case, but it is mentioned in the literature, and it is believed by those who have written upon the subject that the fluid in these cases comes from either the large lymphatic vessels, or perhaps from a continuation of the same disease which produced the discharge before. The doctor is certainly not quite in accord with the majority of authorities when he says that the discharges of pregnancy always come from the cavity of the amnion.

DR. EDWARD W. SAWYER.-No; but the term "hydrorrhea❞ should be reserved for that class of cases.

DR. EARLE.-This is not hydrorrhea, as I understand it. This term should be applied to a discharge of fluid from outside of the amniotic membrane; perhaps not from outside of the chorion, but certainly from outside of the amnion.

DR. E. J. DOERING read a paper entitled:

REPORT OF A CASE OF HYDATIDIFORM PREGNANCY.

After a brief discussion of the etiology and pathology of cystic degeneration of the chorionic villi, Doctor Doering related the history of the following case:

Mrs. W. D. P., a cultured lady, of slender physique, twenty-one

years of age, was attended by me in labor fifteen months ago, and delivered by instruments of a healthy boy weighing ten pounds. Her general health has been good. She has had no miscarriages either previous to or since the birth of her child. Her last period occurred during the latter part of October, 1885. During the month of November the catamenia remained absent, which she attributed to a cold, the idea of pregnancy not occurring to her as she had none of the usual symptoms. During the month of December, and particularly during the week preceding the holidays, she was on her feet constantly, although not feeling well, having sensations of chilliness, followed by a feeling of heat and general depression. On the Sunday before Christmas, a slight and painless flow of blood commenced, believed by her to be the period now four weeks overdue. The flow continued several hours and then ceased. On Christmas day, while seated at the dinner-table, she was suddenly attacked with a profuse hemorrhage, the blood saturating the floor, and continuing until a degree of faintness. was produced, in which condition I found her on my arrival a few minutes afterwards. The hemorrhage, which had been entirely without pain, ceased suddenly. A careful examination confirmed my suspicion of pregnancy, although I was much surprised at the size of the uterus, corresponding to a four and one-half months' pregnancy, the fundus rising nearly midway between the symphysis pubis and the umbilicus. There being no further hemorrhage, no pain and no dilatation of the os, an expectant plan of treatment was pursued by instructing the patient to keep in bed, enjoining absolute rest, and giving her a few doses of morphia. On the following night, another hemorrhage occurred, but of not much consequence, and requiring no interference. Two days later, on the morning of the 28th of December, another hemorrhage took place, more copious than the last one, but still unaccompanied with pain. An examination showed slight dilatation of the os, but not sufficient to permit the recognition of the contents of the uterus. As the patient was beginning to show decided symptoms of anemia, the vagina was tamponed and ergot administered to check the hemorrhage and favor uterine contractions.

Uterine pains soon commenced, accompanied by considerable hemorrhage; the os dilated fully one inch, the presenting part giving the sensation to the finger of a blood-clot. This was soon expelled in detached portions, and on removal from the vagina was readily recognized as a hydatiform mole, having all the characteristic appearance of a grape bunch, composed of a mass of translucent vesicles, about the size of currants, containing a clear, limpid fluid. After inserting two fingers into the uterus and emptying it as thoroughly as possible of all the diseased tissue, the hemorrhage promptly stopped. The entire mass removed equalled about the size of a large orange. Some febrile reaction occurred, but for several days the temperature did not exceed 100° F. and

the pulse 95, the treatment consisting of quinine and ergot internally, and the use of uterine and vaginal injections of carbolized water.

On the beginning of the fourth day, the patient was suddenly seized with a severe chill, followed by the usual symptoms of septic poisoning, high temperature (104° F.), rapid and feeble pulse, superficial respiration, great tympanites, thirst, vomiting, and arreste d lochia, with no pain or tenderness over the abdomen. The outlook was anything but promising, but the prompt administration of large doses of quinine, combined with diaphoretics, turpentine stupes, warm fomentations, and the continued use of antiseptic injections was followed by the most gratifying results, and after four days of great anxiety the patient had recovered sufficiently to be declared out of danger. At the present time, eighteen days since the expulsion of the mole, the patient is up and about the house, with a good appetite, and making preparations to leave in a week or two on a journey to the South.

DR. CHARLES WARRINGTON EARLE.-I have seen two cases of this kind, and while I have been surprised a great many times in my practice, I was never more so than upon one of these occasions. I had been in practice about two years, when I was called to attend a lady in confinement near my residence. I found the os uteri well dilated, with the membranes intact and well down in the vagina, when all at once there came a gush of something, and a large quantity of these grape-like bodies made their appearance. I immediately gave ergot and cleared out the uterine cavity, and took the first opportunity to repair to my study to seek an explanation of this, at that time, to me a strange phenomenon. The case was eventually made the subject of a little article which appeared about that time in the Chicago Medical Examiner.

The lady was anemic, and made a slow but perfect recovery. She has enjoyed good health since, but has never again become pregnant.

DR. HENRY T. BYFORD.-I had an opportunity to see this specimen, and it was very much like a bunch of grapes in shape, although Barnes, I believe, claims there is no such resemblance. But he bases his views upon the fact that the vesicles are developed from each other instead of from a common stem.

In regard to the treatment, I think it would now be considered best to scoop out the uterus to prevent septicemia, and so it would be, if that could be easily done. From inquiry of Dr. Doering, I understand the opening in the cervix was rather small, the body anteverted, and it would have been necessary to use an instrument in removing the mole. I have seen severe inflammation, in the broad ligaments, result from curetting the uterus after abortions, with the dull curette. Therefore, I think it is a point of interest well illustrated in this case, that it is not in every instance the proper thing to do; especially when so much has been passed that there is pretty firm tonic contraction of the uterus.

DR. H. P. NEWMAN.-I understood Dr. Doering to say he used ergot. This might explain the fact of finding the cervix closed. DR. DOERING.-I would like to ask Dr. Earle whether he discovered any trace of the fetus.

DR. EARLE.-I did not in my case, but there is a specimen in the museum of the College of Physicians and Surgeons in which the fetus is one and one-half inches long.

DR. CHARLES CALDWELL.-I met with one case in my practice last fall. October 10th, I was called early in the morning, the messenger informing me his wife was having a miscarriage. I found my patient flowing quite profusely. She supposed herself five months pregnant, as she had not menstruated since May.

The last week in July, she flowed slightly for two days. The 12th of August, the flow commenced again, and was so profuse that she went to bed and called a physician, who diagnosed her case threatened abortion, and treated her accordingly, keeping her in bed two weeks. From that time until the hydatiform mole was expelled, the flow never stopped completely, for a single day, but she passed no pieces of the mole. The os was soft and easily dilated. I introduced two fingers into the uterine cavity and removed its entire contents. The mass was too large to be removed intact, and the os was not sufficiently dilated. As I removed each piece the uterus contracted well and firmly, diminishing the size of its cavity rapidly, so I was sure when it was empty.

The lochial discharge kept up for three days. She remained in bed one day, but the next morning prepared her husband's breakfast, and has attended to her household duties since. There were no symptoms of septicemia following. The broken mass would have filled a two-quart measure. Some of the cysts were as large as a bean. I gave Professor Jaggard a specimen to show his class. No fetus could be found in the mass. Small doses of ergot were given for a few days. Menstruation was established in December, and the patient is now strong and healthy.

The inaugural thesis of DR. F. E. WAXHAM, M.D. (Chicago Medical College, 1878), entitled:

INTUBATION OF THE LARYNX, WITH HISTORY OF CASES, was read by the Secretary, Edward W. Sawyer, M.D.

Dr. Waxham described Dr. O'Dwyer's method of intubation of the larynx, narrated the histories of seventeen cases, in which the method had been employed, and drew the following conclusions: "Intubation of the larynx possesses many advantages over tracheotomy:

"1. No opposition is met with on the part of parents and friends; quite a contrast to the difficulty with which we usually meet in obtaining the consent to tracheotomy.

"2. It relieves the urgent dyspnea as promptly and effectually as tracheotomy, and if the child dies there is no regret that the operation was performed, and no discredit is attached to the physician.

"3. There is less irritation from the laryngeal tube than from the tracheal canula. As the tube is considerably smaller than the trachea, it does not press upon it firmly at any portion excepting at the chink of the glottis.

"4. Expectoration occurs more readily than through the tracheal tube.