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It is always to be considered so formidable an operation

sional qualities of the surgeon. that danger lies on either side cannot be considered as entirely within the limits of safetyand certainly the lessons of the past show us that danger too often lurks in delay. I believe that these cases should always be given the benefit of conservative surgical advice, the surgeon following the case with the medical practitioner; and if our patient is so situated that we can watch him closely, and note at frequent intervals any change in his condition, it seems to me better, until the risk from waiting becomes plainly the greater, to assume the risk of delay rather than that of operation. The symptoms clearly demanding operation may be either general or local, or both. Even with quite pronounced local symptoms, not excepting diffuse peritonitis, the general condition of the patient may sometimes warrant our waiting, and many cases of general peritonitis recover. On the other hand, very slight abdominal symptoms may be present, and yet the condition of the tongue, pulse, temperature, etc., sharply demand decided action. When there is plainly a tendency to pointing, or palpation reveals the probable presence of pus, nothing is gained by delay.

No special technique for operation can be laid down. The objects in view will be the evacuation of pus, the search for and, if possible, the removal of the irritant, whether a diseased appendix or not, thorough irrigation, disinfection, and proper drainage. How these objects will be attained vary in individual cases. For the incision, probably the right semilunaris offers the most favorable site, unless marked tumefaction or actual pointing direct elsewere.

I have records of eighteen cases to which I have been summoned in consultation, where the seat of disturbance was in the right iliac fossa, and the symptoms pointed strongly to what is laid down in the literature of the day as appendicitis. Twelve of these cases under treatment recovered without operation ; the six which received operative treatment I will briefly refer to. CASE I. Man; 24 years of age; recurrent attacks for several years. Detected Detected pus, and evacuated a circumscribed abscess in cæcal region. The appendix could not, with certainty be found, although something appeared which might have passed for this organ in a necrosed condition. No other cause for the abscess appeared. Recovery.

CASE II. Bank teller; had suffered from probable recurrent peritonitis for some years. At the time of operation peritonitis was diffuse. There had been obstinate constipation for several days. On opening the abdomen, I found appendix in a normal condition. There was what at first appeared to be a slight twist

at one point in the small intestine, but insomuch as it disappeared suddenly during the necessary manipulation for closer examination, no positive demonstration that it was the direct cause of the trouble could be made. The small intestine was thickly covered with small, dark spots, and no other pathological condition appeared. Recovery.

CASE III. Man; aged, 63; presented in the left inguinal region all the symptoms of that which would at once have been termed appendicitis had it occurred on the other side. I had previously examined the patient and quite fully decided upon the presence of an incomplete left-inguinal hernia, although there was some suspicion of a malignant growth. The symptoms being urgent, I operated and found a part of the descending colon strangulated in the inguinal canal with perforation and fecal abscess. There was, also, considerable indurated tissue, which was submitted to microscopic examination, with a report of nonmalignant appearance,

An attempt at closure of the perforation was made, which at first seemed unsuccessful from the appearance of fecal discharge through the drainage-tube, but this finally ceased, and the patient made a complete recovery. Six months later I was called to see the patient, and found him with every symptom of appendicitis (as per books), this time upon the right side. In view of the fact, however, that suspicion of malignant growth had been aroused by the previous conditions, and no especially urgent symptoms occurring, the patient was carefully watched and delay advised; but suddenly symptoms of perforation developed, and laparotomy was performed. The appendix was found perfectly normal, but the ascending colon presented several perforations, and also a strip for five inches along its anterior surface from two-eighths to five-eighths of an inch in width, which was denuded of peritoneum. I approximated the edges of the peritoneum, and closed all the perforations which could be found, but I was by no means certain that all were reached. The patient died in forty-eight hours.

CASE IV. Boy; aged, 12; upon whom I had operated four years previous, evacuating a deeply-seated abscess in the right inguinal region. A fistulous opening remained for two years, occasionally discharging, but finally closing and remaining so for some time, when it again broke out, and I was called. I decided to open the abdomen for the purpose of ascertaining the condition of the appendix, and found it, after a tedious search, adherent, together with the cæcum to the peritoneum close to the mesentery of the colon, nearly on a level with the umbilicus. I did not deem it wise to make sufficient dissection for breaking up these adhesions for fear of infecting the general peritoneum

by opening into the abscess cavity. I therefore tied the appendix off by a double ligature and closed the wound. There was no improvement in the discharge from the fistula, and as soon as the boy recovered from the laparotomy I decided to explore from the side, following in the main the fistulous tract. I did so, and found as the cause of all the disturbance a large brass pin imbedded in the tissues behind the ascending colon. This pin at first appeared to be a shawl-pin with an elongated head, but the head proved to be a stony concretion nearly a half inch in length and one-fourth inch in diameter. The pin undoubtedly came from the intestine, but it is an open question whether it perforated the cæcum or the appendix itself. The patient made a perfect recovery.

Very many post-mortems have showed the appendix in all stages of ulceration even to total obliteration, when there had occurred absolutely no symptoms of disease in its locality.

In at least twenty-five laparotomies for other causes in which I have taken occasion to observe the appendix, I have usually found it normal, but in a few instances, somewhat enlarged, as from inflammation, though seldom adherent.

That he appendix itself so frequently threatens human life, I believe has not been clearly demonstrated, and I predict that the views of modern surgeons will, when the sanguine opinions which are so liable to arise from early successful experiments. have been submitted to the criticisms of expert experince, be decidedly modified.

MICROSCOPICAL TECHNOLOGY.

BY S. R. F. LANTZIUS-BENINGA, M.D., BOSTON, MASS.

In the following I will briefly describe the principal methods which, during the last year, I have used in the pathological laboratory (B. U. S. M.) to mount microscopical specimens of pathological and normal tissues.

Sections were made from fresh, hardened, and hardened and inbedded tissues. As hardening medium alcohol was preferred; Müller's fluid, bichromate of potash, bichromate of ammonium, chromic and picric acids, corrosive sublimate and Flemming's solution only on special occasions. After hardening, the specimens were generally inbedded in celloidin and then mounted on cork. In any case—whether the tissues were fresh, hardened, or hardened and imbedded — they were cut with the freezing microtome with the exception of some of those which were included in celloidin. With a sharp knife, and due care, their sections can be made even of very large size; and I have found it of great advantage to get sections always as large as possible, as I

have in that way obtained many valuable specimens, as sections of nerves, arteries, glands, etc., while examining the tissue for an entirely different purpose. Sections to be mounted are then stained with the exception of those in celloidin. This takes many stains, and it is, therefore, best to remove it before staining. This can be done by immersing the sections in a mixture of alcohol and ether in equal parts, or, if this is not possible, because the sections are too thin, or consist of several pieces which must retain a certain relative position, they can be put on slides, spread out and then washed with the alcohol-ether mixture till almost all the celloidin is dissolved. Then they are allowed to dry, and the remaining celloidin will glue them securely to the sides, so that the staining can be done without disturbing their position. If oil of cloves is used to clear them up, the amount of coloring matter taken up by the small quantity of the remaining celloidin is not sufficient to interfere with the clearness and beauty of the specimen. Most of it, probably, is removed with the dissolved celloidin when the oil is taken off by means of filter paper.

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For clearing up stained sections I always used oil of cloves, if there were no special indication against it. That it dissolves the celloidin is thought by many microscopists sufficient reason to abstain from its use, and to take some other oil. I regard it rather as an advantage. Besides, it is, aniline oil excepted, vastly superior to all other oils used for clearing sections. have tried oil of bergamot, of santal, of thyme, of peppermint, of origanum, of turpentine, and others, but none of them gave satisfactory results. Kerosene oil is about as good as any of them, and a good deal cheaper. Aniline oil clears up beautifully, and can be used directly after the staining process is finished, as it mixes with water; but it has to be removed entirely before the sections are mounted, or it will, in course of time, stain the whole specimen- the section as well as the Canada balsam-brown, and spoil it; and to remove it another oil is necessary. For including specimens to be kept permanently Canada balsam was used, and in some special cases glycerine.

The principal stains used were hæmatoxylon and aniline dyes. The hæmatoxylon stain I prepared in the usual manner by mixing a saturated alcoholic solution of it with a watery solution of alum (about 18 or 28). This mixture has very little staining power when fresh, but grows stronger with age, and ought not to be used till it has ripened a few weeks. I used it undiluted, leaving the sections in it for a few seconds to several minutes ; they can then be mounted directly after washing out the superfluous stain with water. They are then purple. It is much better, however, to leave them in water for several hours; the

color then will become blue and darker, and only the nuclei retain the stain. To prevent precipitation of the hæmatoxylon the sections ought to be washed two or three times with fresh water directly after they are taken out of the staining fluid. This can be used again, but ought to be filtered every time before and after use. As contrast stains, were used orange G in saturated watery solution, eosine in alcoholic solution, and picric acid in saturated alcoholic solution. Orange G gave a pretty stain, but was not reliable. Eosine in alcoholic solution can be improved greatly by addition of a few drops of ammonia, which makes the hæmatoxylon stain darker blue, and so heightens the contrast. Picric acid in alcoholic solution turns the blue or purple color of the hæmatoxylon to brown or black, and is especially adapted to bring out the cell nuclei distinctly. If ammonia (mixed with alcohol) be used after the picric acid the brown color of the nuclei changes to a very dark green, or to the original blue, while everything else remains yellow. Very clear pictures are obtained in this way. Picric acid is especially good to partly decolorize sections overstained with hematoxylon, as it does not cause shrinking. It may be used after the eosine, and then removed by washing with ammoniacal alcohol extremely fine stain is obtained in that way. About other combinations of different stains with hematoxylon I shall speak later.

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Carmine, as lithium-carmine, borax-carmine, picro-carmine, etc., I have not used much, as the staining with these colors is too complicated, and needs constant attention. Another objection to their use is, that frequently hydrochloric acid is required to remove the superfluous color, and frequently spoils the sections by curling them up. A saturated solution of carmine in equal parts of acetic acid and glycerine, filtered repeatedly till it is perfectly clear, I have used especially to examine and mount specimens containing fat. The sections cut fresh, or after hardening in a medium which does not dissolve the fat, with the freezing microtome are put into the staining fluid, and may remain there any length of time; then they are transferred into glycerine. This, in course of time, takes the stain out of everything but the nuclei, and the sections can be mounted in glycerine. The nuclei are red or brown, and the fat-drops appear in their natural state, very clear and distinct. Specimens are mounted very easily in this way, and keep any length of time. I prefer this method of examining specimens for fat decidedly to the hardening in Flemming's solution, which contains osmic acid, as with this the process of repairing the slides is very complicated; specimens mounted even with the greatest care will not keep long, and last, not least, as the fumes of the osmic acid

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