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to that of acute haemolytic anaemia. Later, when the blood level became stationary at just over three million red cells and the jaundice became more marked in conjunction with a permanent reticulocytosis with marked increase of fragility, a reversion to the original diagnosis was made. The history of bilious attacks probably indicates the occurrence of previous less severe haemolytic crises. The younger boy presented the features usually said to occur in acute haemolytic anaemia, as first described by Lederer in 1925.1 The typical characteristics were pyrexia, leucocytosis, and reticulocytosis with severe anaemia of sudden origin without any obvious cause. The majority of the published records of' acute haemolytic anaemia describe the anaemia as being hyperchromic in type,2 3 4 although low colour index cases have been described.5 In the present cases the colour index rose following transfusion. In previous reports regarding Lederer's anaemia the fragility has been found to be increased at the time of admission, and has then diminished until normal when cured. The reverse was found in these cases, the cells showing an increasing fragility during the period of observation. The first case, that of the elder boy, may be looked upon as one of acholuric jaundice showing several unusual features. Cases have previously been described with a normal fragility, and Gansslen6 states that 10 per cent. of acholuric jaundice subjects show a normal fragility. Thus the initial normal fragility in the present case is not unique. The absence of any reticulocytosis until after the second transfusion must, however, be rare, as the reticulocyte count is stated always to be raised in the disease.4 7 Barber8 has, however, reported a case with a reticulocyte count of only 0.5 per cent. The low colour index on admission is also uncommon, and suggests some error in technique, since the film showed the cells to be well filled though small in diameter. The rapid improvement following splenectomy is a usual finding, as is the presence of gall-stones at operation. The younger boy would have been regarded as a typical case of Lederer's anaemia if his brother had not been found to have acholuric jaundice. The very mild degree of icterus present in association with such a profound degree of haemolysis is surprising, a fact which has been previously discussed.9 The leucocytosis with primitive cells in the blood film is more suggestive of a Lederer's anaemia, but sometimes occurs in acholuric jaundice.' The very acute onset of anaemia with pyrexia in two brothers at about the same time suggests an infective origin, but as in previous cases careful bacteriological examinatioin of the stools and urine failed to reveal any haemolytic organisms. No septic foci were discovered, and in neither case was there evidence of external or internal bleeding. Splenectomy is obviously indicated for the younger child, who has shown a mild relapse since discharge, and is liable to another acute crisis with a posbbly fatal outcome.

A NOTE ON PRE-OPERATIVE PREPARATION OF CASES WITH GRAVE INTRA-ABDOMINAL HAEMORRHAGES