made, and the practitioner is then in possession of all that is necessary for a complete examination of the blood in a case of severe anæmia. The detailed examination can be made at home in a leisurely manner. The blood in the narrow tube is already diluted to 1 in 100, and the red cells can be counted at once. The hæmoglobin is estimated by pouring the contents of the wider tube into the compartment of the Von Fleischl hæmometer, and filling up the remaining space with distilled water, the depth of colour being then judged of in the usual way. The films should be stained with eosine and hæmotoxyline, and the search for nucleated red cells must be careful and prolonged. This is so important that I shall mention here two cases which came under my care in which the diagnosis was at first doubtful. In both there was a considerable anæmia, with some poikilocytosis and a moderately high colour index. It was all important to discover whether megaloblasts were present or not. On carefully going over four or five slides, I failed to find any nucleated red cells in either case. I then searched every film with the help of the mechanical stage. This more rigidly accurate scrutiny detected nine megaloblasts on one slide and thirteen on another. The diagnosis of pernicious anæmia was then made in both instances, and has since been confirmed by the later history of the cases. I noted at the time that the nuclei of the megaloblasts in some of the films were but faintly stained, and thus they very easily escaped detection. It is absolutely necessary to be quite sure that the hæmatoxyline used is of good quality, and to take care that it is allowed to act for a little longer time than usual, so as to slightly over-stain the specimen (as judged by the depth of colour of the nuclei of the leucocytes). And I would insist upon the use of the mechanical stage, combined with slight over-staining, before any confident statement is made as to the presence or absence of megaloblasts. Otherwise serious error may ensue. We may now consider briefly those rare cases of secondary anæmia in which megaloblasts are found in combination, it may be, with a high colour index. Ehrlich himself admits that in certain anæmias due to worm-infections (with parasites such as bothriocephalus and ankylostomum, for instance) the blood may exactly resemble that of pernicious anæmia. Yet good observers have recently found that the anæmia of ankylostomiasis and of other worminfections is usually of the chlorotic type, having a low colour index, and not showing megaloblasts.* Probably, therefore, in the great majority of cases of this kind there would be no difficulty in diagnosis. Moreover, in the few recorded cases where the blood was truly megaloblastic, the colour index was only moderately raised, not in any way recalling the high figures common in pernicious anæmia. In a few cancer cases the blood may conform to the type found in pernicious anæmia. Such a case is reported in an interesting paper by Dr. T. Houston, in the course of which he describes a case of mammary cancer in which there were megaloblasts in the blood and the colour index was high.† condition was accounted for by the post mortem examination, which showed that the bone-marrow was extensively invaded by nodules of secondary cancerous growth. This It must not be forgotten that in the vast majority of cases of malignant disease, even when accompanied by very severe anæmia, the blood changes are of a type exactly opposite to that obtaining in pernicious anæmia. This should be borne in mind in order that cases such as the one mentioned above may be seen in true perspective. It has been suggested that a high colour index is so reliable as a test for true pernicious anæmia that, as a rule, it is quite unnecessary, and, indeed, superfluous, to hunt laboriously for megaloblasts. I cannot agree that this is so. Recently, in a case of Raynaud's disease in the Salop Infirmary which was under the care of Dr. E. Cureton, I found that the colour index was very high, yet there were no megaloblasts or megalocytes, nor was there any poikilocytosis. The blood condition was so remarkable in this case that I avail myself of Dr. Cureton's kind permission to refer * Drs. A, E. Boycott and J. S. Haldane Journal of Hygiene, Vol. III., No. 1, p. 95. + British Medical Journal, Nov. 13th, 1903. to it, and shall give in full the result of an examination of the blood which I made one or two days after gangrene of the right foot had commenced in the great toe. The Blood in a case of Raynaud's Disease with Com- From a study of the above record, it is clear that, relying upon the very high colour index alone, this case might be set down as one of pernicious anæmia. But, save in that one particular, the blood in Raynaud's disease is entirely different in every respect. The total absence of megaloblasts and of poikilocytosis, and the presence of a very considerable eosinophilia, place the blood condition as a whole in strong contrast with that characteristic of pernicious anæmia. REPORTS OF CASES. A CASE OF RECOVERY AFTER OPERATION FOR RUPTURE OF AN OVARIAN DERMOID. By WILLIAM BILLINGTON, M.B., M.S. Lond., F.R.C.S., Surgeon to Out-patients, Queen's Hospital, Birmingham. L. L., a girl aged twenty-one years, was admitted into the Queen's Hospital on the evening of April 26, 1903, with all the symptoms of acute general peritonitis. The history was as follows: Until three weeks before admission she had been perfectly well, and had never had any abdominal pain. Three weeks ago she began to suffer from dull, aching pain across the lower part of the abdomen, with occasional sharp twitches, not specially localised to either side. For the first week the pain was constant, but during the last two weeks it had been intermittent. The pain was not severe enough to prevent the patient from going about her work as a domestic servant. The night before admission, about 10 p.m., she was suddenly seized with severe pain in the lower part of the abdomen, and vomited several times. The pain persisted during the night and the following day, but became more localised to the right iliac fossa. The bowels had been regular up to the time of onset the night before admission. Menstruation commenced at fourteen years of age, and was regular until a year ago. During the last year she had sometimes missed a month, and on one occasion two months. The flow was apparently normal and painless. When seen on the evening of admission patient was evidently very ill. Her face was flushed, lips dry, tongue furred, temperature 104.4 degrees, and the pulse, 140, small, and running. She complained of a great deal of abdominal pain, and on examination the abdomen was distended and rigid below the umbilicus and tender all over. The tenderness was most marked over the right iliac fossa, and here a hard, rounded tumour the size of an orange could readily be felt. The lump was rather nearer the middle line than the ant. iliac spine. The condition was thought to be one of acute appendicitis, with spreading peritonitis, and immediate operation decided upon. An incision about three inches long was made parellel with Poupart's ligament, over the swelling. On opening the peritoneum a quantity of thin sero-pus escaped, and the intestinal coils were found injected and moderately distended. The appendix was readily found, and was quite healthy. Lying in the iliac fossa, close to the pelvic brim, a movable tense lump was found. The surface of the lump was studded over with small nodular swellings. At this stage the first incision was extended inwards to the outer edge of the rectus muscle, the deep epigastric artery being clamped and divided. The lump could then be lifted out of the abdomen. serting a trocar canula, some oily fluid escaped, and its nature became evident. A thick pedicle was made, ligatured in stages, and the dermoid, together with the Fallopian tube, removed. On in On passing the hand behind the uterus, Douglas's pouch was found to be filled by a second dermoid growing from the left ovary. This was adherent, but on gently separating the adhesions the fingers passed through an opening into the interior of the cyst, and some of the contents escaped. With a little trouble this second dermoid was freed, brought out through the original wound, its pedicle ligatured, and the cyst removed. The pouch of Douglas and the lower half of the belly were carefully cleansed as far as possible with gauze swabs, and all fluid mopped up. No irrigation was employed. A rubber tube, surrounded by gauze, was placed in Douglas's pouch, and brought out through the abdominal wound. The |