HYDATIFORM DEGENERATION IN UTERINE PREGNANCY. 227 



degeneration so often follows one or two normal births or abortions, it would be 

 impossible to find an adequate explanation for the release of the defective ova so 

 often after and not before these events. 



I am reminded also in this connection of a case the detailed history of which 

 is fully known. It is that of a robust young woman who successively gave birth 

 to two moles and then to a normal full-term child and secundines. In this case 

 curettage was done in connection with each mole. Apparently the new endome- 

 trium, which had formed after the second abortion and curettage, permitted 

 normal implantation and normal development to progress to term. To ignore the 

 condition of the endometrium in this case and attribute the development of hydati- 

 form degeneration to the successive releases of abnormal ova would seem to dis- 

 regard important facts especially so since no one has established the occurrence 

 of abnormal ova within the Graafian follicle, a possibility which I do not wish to 

 deny, although Donskoj's report of a case of hereditary mole must surely be taken 

 cum grano salis. 



That an abnormal nidus may be responsible for the advent of hydatiform 

 degeneration would seem to be indicated also by the fact that the process usually 

 was better developed and more general in the tubal than in the uterine cases. That 

 both endometrium and decidua show astonishing differences in structure under 

 pathologic conditions is well known. The entire tubal mucosa, on the other hand, 

 even when normal, forms an abnormal nidus which would affect all portions of early 

 chorionic vesicles somewhat alike, and since, as found by Mall, inflammatory con- 

 ditions in the tubes predispose to tubal implantation, the higher incidence of hydati- 

 form degeneration in the tubes is easily explained. Nor does the existence of partial 

 hydatiform degeneration argue against such an explanation. 



Although Kehrer reported not a single fatality in 50 cases of hydatiform mole, 

 Hirtzman (according to von Winckel) gave the fatality as 13 per cent, Borland and 

 Gerson as 18, and Williamson as 20 to 30 per cent. Von Winckel (1904) regarded 

 these percentages as entirely too high, however, although Oster (1904) reported 2 

 cases of malignancy out of 15 cases in which the late results were ascertain- 

 able. This is an incidence of 13.3 per cent. Since none of 15 patients who had 

 suffered from hydatiform mole had a recurrence, Oster concluded that the cause 

 of hydatiform degeneration is a fortuitous one. Schickele (1906) stated that only 

 3 cases of hydatiform mole with coincident chorio-epithelioma were found in the 

 literature; and Nattan-Larrier and Brindeau (1908) seem to avoid the implied 

 difficulty by premising the existence of a histological as contrasted with a clinical 

 malignancy, a distinction which recalls the conclusion of Schickele that it does not 

 follow that not all hydatiform moles are malignant merely because not all of them 

 cause the death of the patient. Kroemer (1907) found that chorio-epithelioma 

 developed in 5 out of 15 cases of hydatiform moles, or in 33.3 per cent, but only 

 twice in 3,841 "normal implantations." Daels (1908) says La Torre claimed a 

 malignancy of 64 per cent, de Senarcleus one of 28.7 per cent, or 14 out of 49 cases. 

 L. Fraenkel (1910 a ) emphasized that the estimates of the number of cases in which 

 hydatiform degeneration is followed by malignant disease vary greatly, while 



