of dense fibrous tissue which was very vascular. The vessels, for the most part, had well formed walls and they were very much congested and some contained thrombi. There was very little areolar tissue in the pedicle. Here and there were a few hemorrhages and areas of round cell infiltration indicating the presence of an inflammatory process."

The second case upon which Dr. Markoe operated was that of a patient who applied at the Hospital September 11, 1911, for care during confinement. She was somewhat sallow in appearance but presented no evidences of other abnormalities and was therefore not admitted at the time. She again applied on November 3, 1911, and being in labor was allowed to enter the Hospital. An examination of the abdomen at this time revealed just above the fundus of the uterus between the ensiform cartilage and umbilicus, a movable tumor which changed its position with respiration. This tumor was not particularly tender and could easily be moved about from one side to the other by the hand of the examiner. The patient's labor pains were ineffectual, so that after a reasonable time, forceps were applied and an easy delivery accomplished. A first degree laceration of the perineum was then repaired and her recovery was uneventful, except for one rise of temperature to 102 degrees which was due to constipation.

Her blood count during convalesence showed red cells between 3,000,000 and 4,000,000; hemoglobin, between 70% and 80%; leucocytes between 7,000 and 11,000. On account of this slight anemia and her cachectic appearance, she was sent to the roof-garden of the Hospital where she remained in the fresh air, was given a generous diet and general tonics and her condition improved so rapidly that on the 20th of November, seventeen days after confinement, it was decided to remove the tumor already mentioned. Examination at this time revealed another mass the size of an orange which seemed to be located in the left broad ligament; this was tender but not movable. Accordingly, under ether anaesthesia, a median incision, ten cms. in length from the symphysis upward, was made, and on opening the peritoneum there appeared in the wound a tumor the size of an orange, evidently a growth from the omentum. To this was attached the vermiform appendix by many firm adhesions. The omentum was also adherent to the abdominal wall by moderately strong adhesions which were cut and tied, care being taken not to interfere with the circulation of the omentum. At the same time, the appendix was detached from the cecum by the purse string method leaving it attached to the omental tumor, both being removed together. The pelvis was then explored and a normally involuted uterus found, which was pushed over towards the right side by another tumor the size of a small grape fruit, lying anterior to the broad ligament and behind the bladder. This mass was firmly adherent and plainly a part of the omentum. With great care it was freed and on removal proved to be a second omental cyst. Before closing the abdomen and inspection showed that

both ovaries were normal and not involved in the adhesions. The abdomen was then closed in layers without drainage and a dry dressing applied. The subsequent progress of the case was uneventful. The wound healed primarily; the temperature twice reached 101 degrees, but rapidly went to normal and remained so until the patient's discharge from the Hospital.

The following is a report of the tumors by the Pathologist, Dr. J. R. Losee.

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"The larger tumor, a cyst, was spherical, ten cm. in diameter and was covered by peritoneum and omental fat. Its cavity was filled with a

clear serous fluid and subdivided by septa of connective tissue. The wall was semi-transparent and of irregular thickness.

Histological examination of its wall showed that it was composed for the most part of a dense fibrous tissue structure, certain areas of which had undergone calcareous degeneration. There were a few groups of round cells throughout. There was no endothelial or epithelial lining.

The smaller cyst was ovoid, being seven cm. long by five and a half cm. wide. It had the same general and special characteristics as the larger one, except that it had attached to it by bands of fatty areolar tissue, the vermiform appendix and its meso-appendix."

The third case was a private patient of Doctor McPherson's and gave the following history: A.R.; G.H. No. 3007; admitted to the Private Patient's Department of the Lying-In Hospital September 12, 1911; age twenty-seven; para ii. She stated that she had had a tumor in the inguinal region since birth which she thought had enlarged somewhat in the last year but was not certain on this point. Her family and personal histories were not abnormal, with the exception of the ordinary diseases of childhood and there was nothing in regard to her history or habits which bore any relation to the case. Physical examination showed a woman well developed and well nourished with nothing of importance noted except a tumor the size of a grape fruit in the right groin. This was firm, slightly fluctuating and gave no evidence of impulse on coughing. It could not be reduced and was somewhat tender, probably owing to the pressure of the patient's corset. Bimanual examination showed the pelvic organs to be in normal condition with the exception of a retroversion of the uterus, and no connection between the tumor and the pelvic adnexa could be made out. The case was thought to be one of inguinal hernia, with the possibility of the sac containing an ovary and tube, but on cutting down over the mass it was discovered to be cystic, filled with fluid and found to be an omental cyst which had prolapsed through the inguinal canal, and which was attached by a long pedicle. In as much as an operation on the uterus was contemplated, a second incision in the median line was made and this pedicle which sprang from the great omentum above was tied off and the cyst was easily removed by way of the inguinal incision. The abdominal wound was closed in the usual way and the hernia then repaired in the ordinary Bassini manner.

The patient made an entirely uneventful recovery and when seen three months later was perfectly well.

The report of the pathologist on this case (number III) reads: "Section of wall of cyst shows it to be composed principally of connective tissue with an occasional fibre and a few fat cells. There is nothing distinctive about the arrangement; round cell infiltration indicates that the tissue was in a condition of acute inflammation."

Wakefield claims that nearly all omental cysts are derived from the lymph vessels and should be classified as lymphangiomata because the lymphatic origin of these tumors is consistent with what might be expected of tumors proliferating from structures possessing the anatomical and histological characteristics and the physiological function of this tissue.

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Jacobi states in his article on Cysts of the Omentum" that he believed most, if not all of them, have their origin in the lymph vessels. Hasbrouck believes most of them to be endotheliomata and many others consider cystic tumors of the omentum as congenital in origin.

There seems to be nothing in the characteristics of the cysts presented which would lend any evidence as to their origin from lymph

vessels. On the contrary, they are cysts of the omentum whose walls have undergone calcareous degeneration and are probably congenital or hemorrhagic in origin.

REFRENCES.

Dowd, Chas. N., Annals of Surgery, Nov., 1911.

Hasbrouck, Washington Medical Annals, November, 1907.
Wakefield, Surgery, Gynecology and Obstetrics, August, 1907.

Jacobi, Transactions of the Association of American Physicians, 1901.

REPORT OF A CASE OF GENERAL HEMANGIOMATOSIS OF THE PLACENTA.

By J. R. LOSEE, M.D., Pathologist.

In the course of routine examination of placentae in the Pathological Laboratory of this Hospital a rather rare feature was observed in the following case.

The patient from whom this placenta was obtained was a multipara, thirty years of age, and a native of Turkey. The family and personal histories were in no way abnormal but she stated that her previous labors had always been difficult. On this occasion she was in labor but a short time and was delivered spontaneously at term of an infant which presented by the breech. The puerperium was uneventful and she was

discharged on the twelfth day in good condition.

Macroscopically the placenta was round, about fifteen centimeters in diameter and lobulated. On section it presented several minute calcareous areas but there were no other evidences of pathological lesions. The cord had a central insertion, contained very little Wharton's jelly and was sixty centimeters long.

Microscopical examination of sections taken from several different areas throughout the placenta showed that the villi appeared to be uniformly filled with a mass of blood, which at first seemed to be free hemorrhage but on closer observation this was only partially true and the blood was contained in vessels of various sizes with very thin walls and lined by a single layer of endothelial cells, typical of capillary structure. There was present therefore, a general hemangiomatous condition of the villi. There was also a moderate amount of calcareous degeneration. The child had congenital ichthyosis and received suitable treatment for the same under which it seemed to improve for a few days but afterwards refused to nurse, lost weight, and died eleven days after delivery. No autopsy was permitted.

A review of the literature on tumors of the placenta shows that comparatively few cases of angiomata have been reported. Reis (Amer

ican Journal of Obsteterics, August, 1904) refers to a case of angioma of the placenta which was that of a distinct circumscribed tumor and microscopical examination presented the structure partially of an angioma and partially of an endothelioma.

Brindeau (Rev. Mens. de Gynecologie, d'Obstetrique et de Pediatrie, November, 1908) reported three cases of angiomata of the placenta all of which were definite tumors appearing on the fetal surface of the pla

centa, covered by amnion, and varying in size from a hen's egg to a grape fruit.

Theuveny (Rev. Mens. de Gynecologie, d'Obstetrique et de Pediatrie, January, 1910) reported a case similar to the preceding ones.

The cases thus far reported are those of a definite circumscribed tumor easily enucleated from the adjacent placental tissue which is normal and has the same structure as an angioma of the skin or subcutaneous tissue. On the contrary the case presented is not that of a well-defined tumor but a general hemangiomatous condition of the villi