perfectly normal. In order to eliminate every disturbing element, the patient was kept under chloroform during the first stage, and delivery was effected rapidly and easily with forceps. After delivery the aneurismal symptoms returned, and were now present, though much modified. The speaker said that he had reported the case, not only because of its unique character, but because there had been so much doubt as to the proper course which ought to be pursued. It really seemed as if the growth of the aneurism had been retarded by utero-gestation.

DR. LEE cited, in the same connection, a case which illustrated the beneficial effects of support applied to an aneurism by an adjacent tumor. Eighteen months before he had seen in consultation a lady who had at the same time an abdominal aneurism, a subperitoneal fibroid and a floating kidney. As the fibroid was rapidly increasing in size, he feared that it would compress the aneurism to such a degree as to cause its rupture. Arrangements were accordingly made to have the patient enter the hospital, where it was designed to attempt the cure of the aneurism by exposing it through an abdominal incision, and introducing a coil of fine wire into the sac with the view of inducing coagulation of the contained blood. But the aneurism became smaller as the uterine tumor enlarged, the pains in the lower limbs diminished, and the lady's general condition was much improved. Dr. Lee attributed the diminution in the size of the aneurism to the increased support afforded by the growing tumor, and probably also to the partial coagulation of the blood within the sac.

DR. GILLETTE agreed with Dr. Lee's explanation, and added that his patient's condition had improved so much during her pregnancy that he was inclined to believe that, if the state had been prolonged a few months more, the aneurism would have been entirely cured.

DR. MURRAY stated that he had seen Dr. Gillette's patient several times, and was sure that there was no syphilitic taint in her case. He had searched various hospital records in order to discover, if possible, whether any case had been reported in which an aneurism had occurred in a syphilitic patient who went to the full term of pregnancy. His search had been unsuccessful.

DR. HANKS asked if any treatment had been directed towards the aneurism. Had iodide of potassium been given?

DR. GILLETTE replied in the negative. There was not the slightest trace of syphilis.

DR. JANVRIN did not see that the original question, regarding the advisability of inducing premature labor, had been answered by any of the former speakers. He believed that it was more unsafe to bring on premature labor than to allow the patient to complete her pregnancy, since there was frequently quite as much straining during a labor occurring at the fourth or fifth month as there was at full term. He was, therefore, in favor of adopting the course which had been pursued in the present instance.

DR. J. H. DEW (present by invitation) cited a case which he had observed in 1869, when he was connected with the Maternity Hospital. A woman, at the end of the first stage of labor, suddenly collapsed and became moribund. Cesarean section was performed at once, and twins were delivered. On opening the abdomen there was a tremendous outgush of blood from the peritoneal cavity. The patient died, and at the autopsy there was

found an aneurism of the splenic artery that had been ruptured by the expulsive efforts.

DR. POLK thought that the case just narrated was the best answer to the question under discussion. He did not believe that there was much danger of an aneurism being ruptured by the pressure of the gravid uterus, since the latter really acted as a support: the real danger lay in the straining efforts which occurred during delivery. Where the sac was large and its walls thin there was great liability of rupture, but in a case such as that of Dr. Gillette where the aneurism was of slow growth, it was fair to assume that there had been no thinning of the walls, especially as there was an absence of any syphilitic history. No absolute rule could be laid down. The speaker could not agree with Dr. Janvrin that there was the same amount of straining at an early stage of pregnancy as at term. Given a syphilitic case, with a strong probability of degeneration of the walls of the sac, he would advise the induction of premature labor.

DR. GILLETTE agreed with the last speaker. It was not the pressure of the gravid uterus that he had feared, but the expulsive efforts of the second stage; hence he had endeavored to make the labor as easy as possible. In certain cases he believed that it was the attendant's duty to produce abortion.

DR. JANVRIN still adhered to the opinion previously expressed, that in the case of a multipara (not a primipara), the straining at three or five months was quite as severe as at full term.

A SUCCESSFUL CASE OF ALEXANDER'S OPERATION.

DR. POLK said that he desired to report this case (which was the tenth that he had had) because of its successful termination in spite of unfavorable circumstances. The patient was fifty-six years of age, and had a complete procidentia with extensive ulceration of the cervix. By very careful measurement the depth of the uterus was ascertained to be four inches. The operation was performed and the patient kept in bed for four weeks (the usual time), after which she was allowed to walk about, the uterus being supported by cotton tampons. The perineum was then repaired. The patient was now ready to go home, her uterus being in good position, and measuring only two and one-half inches. The speaker mentioned this case because at a former meeting the President had referred to the operation in terms of disfavor.

DR. HANKS asked Dr. Polk if many of these cases of prolapsus would not be improved if they were kept in bed for several weeks, and their uteri retained in position, without their having any operation at all.

DR. POLK replied that such treatment had not produced any effect in his case.

DR. T. A. EMMET said, in reply to a question from the President, that he had seen Dr. Alexander operate upon three cases of retroversion, which had been operated on by Dr. Alexander where the ligaments had been shortened eight months before. The uterus in this instance was indeed in a position of anteversion, yet it sank about as low in the pelvis as it must have done when it was retroverted. Dr. Emmet believed that the same result as to the reduction in size could be obtained by repairing the existing lacerations of the cervix.

THE PRESIDENT said that since reporting the four cases which formed the subject of his paper last spring, he had had two others, in the last of which he failed to find the ligaments, as the woman was very fat. The other case was entirely successful, as Dr. Coe could testify, since the patient had been under his care before and since the operation. She entered the hospital practically an invalid, with a retroverted uterus, and prolapsed ovaries, which caused her intense suffering at each menstrual period. Now the uterus and ovaries were in nearly the normal position, the woman was able to walk about briskly without a cane, and she had begun to earn her own living. The first period after the operation was entirely painless. The President added that two of his six operations had been successful, and one partially successful, while in three cases he had failed to find the ligaments. If he was able to find the ligaments in three cases, why not in the other three? Simply because they were unfavorable cases, and because the operation had that element of uncertainty about it. In spite of the criticisms of Dr. Alexander (which he regarded as rather unfair), he still believed that the operation was limited to those cases in which the round ligaments could certainly be found, that is, to patients with a moderate development of adipose tissue.

DR. POLK said that he had experienced no special difficulty in finding the ligaments. Only in his first case he failed to find the ligament on one side. As Alexander had pointed out, operators were very apt to pull out some fibres of the transversalis muscle instead of the cord. If the ligament was not found at the external ring, the surgeon should always look for it in the inguinal canal. Facility was gained by practice, for, whereas the speaker had occupied forty-five minutes in his first operation, the last was finished in fifteen.

DR. T. A. EMMET asked if there were not some danger of drawing down the peritoneum with the ligament.

DR. POLK had never met with this accident, even in cases of chronic peritonitis or cellulitis.

THE PRESIDENT regarded Dr. Alexander's description of the operation as faulty, because he had followed that surgeon's directions exactly, and had cut down upon the external ring without finding the ligament. It was afterwards found in a flap on one side of the ring. He had twice cut down as far as the peritoneum without unpleasant results, but without finding the ligaments.

DR. POLK could not understand how there was so much difficulty in finding the ligament, because, if the ring was found, the ligament must lie in it.

This the PRESIDENT denied so far as his experience went, for in his last (and unsuccessful) case, both he and Dr. Van de Warker, who witnessed the operation, searched in vain on both sides among the masses of fat over the ring, and between the distinctly exposed pillars of the ring, for any fibres that might fairly be taken for the round ligament.

TRANSACTIONS OF THE OBSTETRICAL SOCIETY OF PHILADELPHIA.

Stated Meeting, Thursday, November 5th, 1885.

The President, B. F. BAER, M.D., in the Chair.

LYMPHATIC LEUKEMIA IN CHILDHOOD.

By JOHN M. KEATING, M.D.-The short paper which, by invitation, I propose to read to you this evening, will, I am sure, prove of interest on account of its clinical variety and the infrequency with which we meet the disease in current literature. To make the subject more interesting and more lucid, at the risk of recalling to your memory matters already familiar, I will premise with a few remarks on the blood in health in children and briefly with its diseases.

There is a uniformity of composition of healthy blood which is curious. This is brought about by that equilibrium which is so striking in textures regulated by the production and waste.

The blood corpuscles which we are called upon to study are, 1st, the red, of which there are floating in the plasma about 5,000,000 to the cubic millimetre. These are about of an inch in diameter. 2d, the white, of a diameter of 5 of an inch, having the proportion of 1 to every 300 or 500 red. 3d, the nucleated red found in the fetus and infant, and disappearing about the third or fourth year of life. These may contain one or more nuclei in some instances, protruding from the cell. They measure from 1

to o of an inch. 4th, the hematoblasts of Hogem-"small discoid colorless corpuscles, normal constituents of healthy blood; in drawn blood they aggregate in clumps known as Schultze's granule masses." As to the origin of the red corpuscles I will quote: "They are developed from colorless corpuscles, the lymph cells or leucocytes. The nucleated corpuscles of the embryo also aid in the development. These nucleated cells disappear early in childhood and are then found only in the red marrow." It is Osler's opinion that "they apparently originate from colorless marrow cells which gradually become more homogeneous, and hemoglobin develops in the protoplasm, the nucleus degenerates and disappears, when the cell has the appearance of an ordinary red disc.' Possibly these nucleated cells may give birth to red cells by the process of budding. The relations of the cytogenetic organs to blood formation has always been somewhat debatable ground; the present state of our knowledge may be formulated about as follows: "The spleen certainly takes part in the development of colorless corpuscles, but its participation in red blood formation is more doubtful; though the opinion prevails widely that the spleen is one of the important organs in the formation of

red corpuscles, the evidence for this belief is of an exceedingly scanty nature.

"The lymphatic glands and adenoid tissues in other regions are the seat of constant production of colorless corpuscles, but of their relation to the red corpuscles there is the same lack of information as with the spleen."

Neumann and Bizzozero pointed out the fact that the red marrow appears to be the seat of blood formation. In the adult it is the only region in which embryonic or nucleated red cells are found. In the young, the marrow fills the long bones.

It is Osler's opinion, and I have quoted from his recent admirable articles on this subject, that the evidences of the development of red corpuscles in the marrow rests upon the constant presence of nucleated cells infiltrated with hemoglobin and of their fission. In excessive hemorrhage, natural or induced, it appears to undergo active proliferation, and it is an interesting fact to notice the marvellous rapidity with which the red corpuscles are reproduced after a hemorrhage. The amount of hemoglobin in healthy blood, according to Preyer, is 13.45 grams to 100. This relation is important for us to have in mind, as it proves an index to treatment. The color-test being used, I feel certain that before long it will be a matter of more than ordinary interest to the general practitioner when the means of applying the colortest shall be generally adapted, as has been done already, to daily practice.

In the new-born the blood is said to amount to one-tenth part by weight of the body; in the adult, one-twelfth to one-fourteenth. I may also note that it has been shown by Neumann that the liver in the embryo may be the seat of the formation of corpuscles, though in the adult it is the seat of their destruction.

Let us now take up the subject of anemia in children. Were I to attempt to do justice to this condition, it would take far more time than your patience would allow. We will omit that caused by hemorrhage, by toxic agents, by mineral poisons, by miasm, by syphilis, in which we have an increase in the watery elements and a diminution in the albuminous, and consider that dependent upon disorder of the blood-making organs themselves, and here we meet with a most difficult problem. By the bloodmaking organs we understand the spleen, the lymphatic tissues, and the bone marrow, remembering, of course, that some of these tissues have also to do with blood destruction. We, however, definitely know that an increase in the cytogenetic tissues is associated with disturbances in blood-formation. The organs undergo a hyperplasia, particularly of their fibrous constituents, and the marrow of bone changes from normal appearance to one like spleen pulp. The blood of all patients suffering from anemia presents a reduction in the number of red corpuscles. This is true, no matter whether the seat of the trouble is located in the spleen, the marrow of bone, or in the general lymph glands; the white