hospital, but for some reason she could not make arrangements then, and the next time I saw her she was in a very anemic condition. She had lost a great deal of blood in the meantime, so that her hemoglobin when she entered was only twenty-five per cent. I had Doctor Dock see her in consultation, and he agreed that it would be folly to attempt any operation with the hemoglobin so low. At his suggestion she was placed on Blaud's pills, increasing the dosage rapidly to twenty-five grains ter in die. There was a marked change in the hemoglobin in a comparatively short time. Within two or three weeks it changed from twenty-five per cent to sixty per cent, and it seemed most favorable for operation. But again family reasons prevented her from having the operation. She began to flow and the hemorrhage was alarming. While the hemoglobin is not as deficient as it was when she entered the hospital, she is more anemic than she was ten days ago. The amount of flow now is only trifling, and we shall proceed with the previous treatment, and within ten days or before I hope to operate upon her.

I will show the inverted uterus to you because I think it can be well demonstrated. We had a good opportunity of seeing how the blood came from a menstruating uterus, although the uterus was turned wrong side out. It oozed from this very red, raw-looking surface, and when a speculum was introduced it filled the lower blade in a very few minutes. Now, in the case of a fibroid where the hemoglobin was only fifty per cent, I referred the patient to the medical side, and she began flowing there after they had improved her blood as in this case. She was packed tightly, but to no effect. At the suggestion of Doctor Arneill, we used gauze soaked in a thirty-five or forty per cent solution of antipyrin. This acted very well and controlled the hemorrhage. We tried the same thing here, but it did not work so well. Naturally, we were trying to control a physiologic process which was under the control of the nervous system. We packed the vagina tightly with gauze soaked in this solution and removed the gauze every day, and we finally got the hemorrhage under control, or at least so that it was not alarming. I suppose, however, we did not shorten the time of the menstrual period very much. There is one thing about packing the uterus in this case. One would think that it was a very favorable place for septic absorption, and the history shows that the tubes and ovaries in these cases are affected very frequently. You will notice the odor after the packing has been in place less than twenty-four hours, but there has been no indication of septic trouble here.

There are three operations for the relief of this condition. The first operation is one advised by Thomas and is simplicity itself, although it was a very dangerous operation in its early days. That was an abdominal section and dilatation of the cervical ring. The reason why you cannot put your finger in there and push it back is on account of this contraction. The fundus is larger than the neck and it will not go through. The ovaries may be within the cup and they may not. Sometimes they are down near the fundus and sometimes they are above.

What Thomas did was to make an abdominal section and dilate until he could push the fundus through the cervix from below. But one would not like to do such an operation on an anemic patient, if he could accomplish the same from below. I am not speaking of this from my own experience, but from my reading. Another operation is through the vagina, and there are two methods. The first is the operation through the anterior culdesac. The uterus is pulled down as far as possible toward the perineum and a horizontal incision made above the cervix through the mucosa. The trouble is that ordinary landmarks are gone and you have to work carefully or you will open the bladder, but if you stick close to the cervical lip you can do no harm. After isolating the cervical lip, put in another tenaculum and pull downward; then cut in the median line, of course cutting through the peritoneum as well as the uterine tissue. This incision must be carried pretty well to the fundus; that reduces the constriction and you can reinvert the uterus. The only difficulty, as I would judge from my reading, is that the peritoneum is apt to slip back, as there is always very redundant uterine tissue there. In this case it may be difficult to accurately approximate the peritoneal edges. One author advises that they be trimmed down so that the two parts of the wall will come together.

The other operation is to go in from behind, into the posterior culdesac, and it seems to me that is a distinct disadvantage because it is farther away and harder to get at.

(The patient was later operated upon by the second method outlined above, and made a good recovery.)

DEMONSTRATION OF A SPECIMEN OF THE QUARTAN MALARIAL PARASITE.

DOCTOR DOCK: I have a specimen here that I thought would be of interest to all of you. We get very little malaria in this latitude, and a case of quartan malaria is rare anywhere. A few days ago, Doctor Morris, who graduated last June, sent me some specimens of quartan malaria. I have under this microscope a specimen showing the sporulating quartan. This is a very beautiful specimen. It is very hard to catch them in this form. Under another microscope I have a younger form. This shows that the case is a complicated one. The preparation shows the characteristic sunflower or marguerite or rosette of the quartan. It shows eight spores around the central pigment. I have here some photographs showing two pictures of the quartan, and also, for comparison, some of the tertian and malignant forms which will be interesting to compare with the preparation.

SYPHILITIC INTERSTITIAL KERATITIS.

DOCTOR FLEMMING CARROW: This is a case of interstitial keratitis. Most observers claim that interstitial keratitis occurs only as a result of hereditary syphilis, while others claim that we may have cases of this sort without inherited syphilitic taint. Inasmuch as I have seen such cases in animals, it would seem that it does not necessarily occur as a result of syphilis. It is the disease which usually affects dogs as they recover from puppy distemper.

This disease makes its appearance first in one eye, and when that eye is about blind, it makes its appearance in the other. The patients ordinarily make good recovery in about six months. The cornea is infiltrated, is opaque, while on the scleral border there is a salmoncolored patch, which, with the corneal infiltration, distinguishes the disease. There is marked photophobia. In the case before us, where there is undoubtedly syphilitic taint, we have the accompanying Hutchinson teeth. So the case is interesting from the appearance of his teeth. He is taking fifteen grains of potassium iodid and bichlorid of mercury ter in die, and is standing the treatment well, and is gaining in weight. I have never found that patients could get along without mercury in these cases.

ORIGINAL ABSTRACTS.

MEDICINE.

BY JAMES RAE ARNEILL, A. B., M. D., ANN ARBOR, MICHIGAN.

INSTRUCTOR IN CLINICAL MEDICINE IN THE UNIVERSITY OF MICHIGAN.

AND

DAVID MURRAY COWIE, M. D., ANN ARBOR, MICHIGAN.

FIRST ASSISTANT IN MEDICINE IN THE UNIVERSITY OF MICHIGAN.

A NEW METHOD OF COUNTING LEUKOCYTES. TURK (Wiener Klinische Wochenschrift, July 10, 1902). blood counting instrument to come into general use, it must possess three qualities ease of handling, simplicity and speed.

The ordinary method, that of Thoma Zeiss, with a dilution of one to ten and the ordinary counting slide, requires perfect technique. Many of the modifications sacrifice accuracy for convenience.

In normal blood, by the ordinary method, there are sixty to ninety leukocytes per square millimeter field. In leukocytosis there are two hundred to three hundred, while in leukopenia there are twenty to sixty. The sources of error aggregate only ten to twenty-five per cent, but in order to attain even this approximation one must count five per cent of all blood diluted, and more in leukopenia. In leukocytosis and leukemia, one must count as many fields as in normal blood, but the dilution may be made greater.

In using circular fields, the danger is of counting some space twice, of overlooking cells near the periphery, and of not getting the field exactly of the right size. In addition, I r is not a definite number, so that this is a source of error. The ordinary method is accurate if one can have five to seven chambers, and make as many drops. But it is suggested having a counting chamber with more counting space ruled. on. This is not a new idea. Zappert in 1892 and Elzholz in 1894 used large chambers, though not for this purpose. They used them for

enumeration of the eosinophiles and for differential counts of the leukocytes in fresh blood. There is no reason why these chambers should not be used for ordinary counts, though they are not used so much as is warranted by their exactness and simplicity. The Zappert chamber is now the simplest. For technical reasons the ordinary Thoma Zeiss slide is ruled, so that the lines extend one millimeter or more beyond the limits of the square, so that a cross is formed with a one millimeter square in the center. Zappert has, in addition to this, a square nine times as large, so that there are four additional accurately ruled squares for leukocyte count, with spaces one-twentieth to one-fortieth millimeter wide and one millimeter long. The four corner squares are not divided, so that in these counting would be very difficult. Elzholz made further division of the peripheral squares, adding a vertical line division of Zappert's chamber, thereby dividing the corner squares into spaces one-twentieth and four-twentieths millimeters wide and one millimeter long. With this one can count nine square millimeters, though the corner squares are somewhat more difficult than the central ones. But there is a source of error in that the space next to the central square on the right is likely to be counted with the central square. Even one on his guard is likely to make this error, or lose count in trying to avoid it. On account of not always being sure of accuracy when accuracy is necessary, Türk devised the following modification: By starting the ruling one-twentieth millimeter from the outside line he avoids the lack of clear division between peripheral and central square. Also, to know when he reaches this edge, he has an extra line between the outer parallel lines.

This chamber is useful for few or many leukocytes; the entire nine square millimeters can be used, all on the same slide, though this is not necessary for ordinary accuracy. The nine squares are used only in leukopenia, or when the dilution is large or the mixture imperfect. For greater accuracy, one can count separately the smaller squares into which the eight squares outside the central square are ruled. The possible objection that the many lines might give confusion does not hold, as each of the nine squares differs in appearance from all contiguous squares, the difference being visible at a glance. The advantages are speed, accuracy and ease of counting. Source of error is one per cent. to five per cent, three hundred fifty to five hundred cells in seven thousand to eight thousand. One can count three hundred to six hundred cells in fifteen minutes, about three times as many as by using the old method. PRENTISS B. CLEAVES.

RING BODIES IN ANEMIC BLOOD.

CABOT (Journal of Medical Research, Volume IV, Number I) reports a new phenomenon which occurs in pernicious anemia blood and in the blood of individuals with lead poisoning, when stained by Wright's method. This staining method brings out with readiness all varieties of basophilia, both granular and diffuse. It can be employed

to bring out all the anomalies of staining reaction characteristics of the severe anemias.

The bodies referred to above are a new set of reactions which have hitherto been undescribed. They appear as granulations arranged in the form of a ring, generally within but sometimes without the red blood cell. They vary in size from a ring corresponding to the circumference of the nucleus of a normoblast to a ring that has almost the circumference of a red blood corpuscle. Sometimes the rings are twisted and resemble the figure eight. They are generally stained red, although occasionally they are blue.

The author is unable to interpret the meaning of these bodies. He thinks that they are not accidental bodies and that they have some connection with the severe anemia; that they are associated with cellular regeneration and not with cellular degeneration.

D. M. C.

TUBERCULOUS TUMOR, INVOLVING ILEUM AND

CECUM.

ENGLAND (Montreal Medical Journal, September, 1902) reports a somewhat uncommon case of tuberculous tumor of the ileum and cecum. The patient was a woman thirty-five years old who had complained for some months of symptoms of indigestion, such as flatulence, sour eructations, irregular bowels, pain in the epigastrium, vomiting of large amounts of fermented food and mucus and loss of flesh. The abdomen became distended very much at times. In May, 1900, she accidentally felt a lump in the right iliac region the size of a turkey's egg. "There is no distinct history of any symptoms simulating an attack of acute appendicitis."

"The abdomen was opened June 22, 1901, and the growth removed. The following pathologic report is given:

"The specimen comprises eighteen inches of ileum and four of large intestine. Exactly at the junction of the two there is an irregular mass about the bulk of a tennis ball. The mesenteric glands immediately tributary to the part are enlarged to the size of hazelnuts and matted together. The short, nearly three inch, appendix is three times its normal size, being much thickened and largely involved in the mass. "Some nine inches up the small intestine there are four or five small gray nodules, found in its wall, being arranged in the direction of the circumference of the bowel.

"The ileocecal opening is found to be very much contracted, it only admitting a small-sized lead pencil.

"Incision into the lumen of the bowel showed the mass to be densely fibrous with areas of necrosis scattered throughout, and a microscopic examination confirmed the diagnosis of tuberculosis.

"There were abundant giant cells with caseation and fibrous proliferation.

"The mucous membrane was not ulcerated.