munication between the appendix and cæcum was very narrow, the lumen not exceeding the size of a knitting needle. The abdominal incision was closed in the usual manner. Soon after the operation the patient suffered considerably from nausea and retching, which gave rise to considerable pain in the wound. A slight elevation in the temperature a few days after the operation announced a slight suppuration in the superficial portion of the wound, which, however, soon subsided, and the healing by granulation proceeded in a satisfactory manner. Aside from this disturbance the patient went on to an uninterrupted and permanent recovery. Examination of the appendix after this removal showed that it was somewhat distended in its central part by a few drops of a thick, very offensive, purulent fluid of the consistency of cream, of a brownish color; the odor was not feculent, but rather foetid. No concretion or foreign body was found. The mucous lining of the appendix showed distinct but not very deep ulcers, both involving the entire thickness of the mucous membrane. The ulcer nearest the cæcum was the largest, occupying the whole circumference of the lumen about one-quarter of an inch wide. The second ulcer nearer the apex was not larger in circumference than the size of a split pea. The serous coat near the junction of the cæcum was considerably thickened. Microscopical examination of the fluid showed broken down tissue, pus corpuscles and pigment granules.

GENERAL REMARKS ON EARLY RADICAL OPERATION FOR

APPENDICITIS.

Excision of the appendix in cases as reported above must be considered in the light of a curative and prophylactic operation. It is curative, as by it the cause of the disease tissues is completely removed, and it is prophylactic, as by it the disastrous consequences of a probable later perforation are positively prevented. Extirpation of the appendix at a time before the inflammation process has reached the serous coat is one of the easiest and safest of all intra-abdominal operations. The operation is performed in a healthy aseptic peritoneal cavity, and if the customary antiseptic precautions. are carried out, healing of the visceral and abdominal wounds by primary intention may be confidently expected. The operation eliminates a structure which if not entirely useless. has at most only an unimportant physiological importance. -The Journal.

(To be Continued.)

Jaborandi and Pilocarpine in Bright's Disease.

BY P. R. EGAN, ASSISTANT SURGEON, U. S. A., EAGLE PASS, TEX.

The leaves of Pilocarpus pinnatus have been used to produce sudorific effects for centuries. The alkaloid has been before the profession for the last twelve years. Neverthe

less, the truth of a recent statement will be readily admitted. Willoughby says (The Lancet, May 25, 1889): "There are few drugs of which the physiological action is so direct and palpable, but of which the therapeutic uses are so undetermined."

In the discussion which followed the reading of Dr. C. S. Wood's paper on "Some Points in the Treatment of Chronic Albuminuria, or Bright's Disease" (The Medical Record, March 24, 1888), pilocarpine was mentioned by but one speaker. Dr. Page's faith in the drug was not of a very exalted nature. Pilocarpine,” he added, “has been recommended for the purpose of eliminating this so-called uræmic poison. The chief objections to this remedy are its depressing effect upon the heart, and sometimes it causes such a profuse salivary secretion that the patient almost strangles." So, too, Heither, of Vienna: “He had never seen any good result follow the use of pilocarpine in renal diseases after ascites had once set in. He admitted that it produced its physiological effects of increased perspiration and urination, but believed these to be purely temporary, and to have nɔ beneficial result; whereas the depression consequent upon the use of the drug was not seldom alarming."

Before the New York Academy of Medicine (Birmingham Review Dr. Francis Delafield brought forward a paper on the Treatment of Acute and Subacute Nephritis" (The Medical Record, March 23, 1889). It was discussed by seven representative physicians of that great medical centre. one referred to the use of pilocarpine-in truth, the remedy was almost ignored.

But

On the other hand, the general concensus of recent authorities on materia medica is that expressed by Stille ("National Dispensatory"): "When dropsy arises in connection with desquamative tubular nephritis (especially scarlatinous), or even with interstitial nephritis, the medicine is very efficient; in the former case often leading to a cure, in the latter to a prolongation of life.

From Professor Wagner's clinic at Buda-Pesth comes the following: "When used according to the above-mentioned principles (quod vide), pilocarpine will be found in most cases of Bright's disease, even when hot baths and other diaphoretics prove useless, always to diminish dropsy to such an extent that the patient is more or less protected against dangerous uræmic suffocative attacks. In this way it may be possible to obtain a relative cure; that is, in secondary granular contracted kidney" (British Medical Journal).

In The Lancet for December 22, 1888, J. G. Marshall, B. A., M. B., Cantab, writes: "The value of jaborandi and its derivatives in the treatment of the dropsy of Bright's disease can not be overestimated. By its use I have relieved in several cases some of the most distressing features of this complication, and prolonged or rendered less painful the termination of life in others, but in none has the drug been exhibited with such satisfactory results as in the following case." Mr. Marshall then details the history of a fisherman, aged nineteen, who contracted Bright's disease, for which he was unsuccessfully treated at home and in hospital. When he again saw him "his face was livid, and the swollen condition of the cellular tissue of his neck made it almost as broad as his shoulders. He coughed incessantly; there was copious intra-thoracic effusion, and the subcutaneous tissue all over the chest was doughy' to the touch. His abdomen was as big as a barrel, and there was extensive œdema of the genitals. His legs and thighs were enormously swollen, and water was exuding from them. He was passing a small quantity of urine, which was of a dirty color and loaded with albumen." Mr. Marshall treated him with hypodermic injections of one-fourth of a grain of pilocarpine hydrochlorate.

In a fortnight he was relieved of his dropsy, and passing his usual quantity of urine, which still contained some albumen. Mr. Marshall adds: "I think the almost miraculous improvement which followed the use of the pilocarpine is worthy of recording, and (when one considers the usual helplessness of a condition such as I have described in a patient of this age, and from such a cause) that jaborandi and its alkaloids must occupy the first place among therapeutic agents in the treatment of cases of this kind."

Although we may not agree with the statement of a recent authority that in puerper il eclampsia “nephritis is usually, if not always, present" (B. Holmes: Medical News, September 14, 1889), still it is sufficiently akin to acute and

subacute Bright's disease to merit our consideration. Here, too, the same ambiguity prevails. The London Obstetrical Society cordially indorsed the opinion of Dr. John Phillips, that although good effects were produced in twenty-eight cases, yet in nine such dangerous symptoms manifested themselves that he was bound to warn others against its use, especially when coma was pronounced " (The Lancet, October 13, 1888).

On the other hand, The Lancet for 1885 and 1886 contains an account by Dr. Horrocks, of Guy's Hospital, of two very severe cases treated successfully by the injection of onethird of a grain of pilocarpine, repeated to obtain its physiological effects. Cessation of convulsions almost immediately followed the use of the injection; the os rapidly dilated, and the children were quickly expelled, but did not survive. The maternal mortality is generally thirty per cent. A recent writer, however, gives twenty-three cases and no death ( The Medical Record, September 7, 1889). The Lancet for 1886 also contains an account of five cases equally happily treated by Dr. Murphy, with similar injections of pilocarpine. One case so treated by him had thirty-three convulsions in the seventh month of pregnancy, but was afterward successfully delivered at term of a living child.

The writer desires to add two cases to the contribution of Mr. Marshall-one almost similar to his, but in which the result obtained by the use of jaborandi was better; the other a well marked case of acute Bright's disease, with total loss of vision, which was restored in one hour and a half by the use of pilocarpine. Jaborandi and pilocarpine would seem to be especially indicated in all forms of Bright's disease. Its sudorific effect promptly eliminates the poison pent up in the system. Its well-known power of relaxing nervous tension in status epilepticus and kindred conditions (S. B. Lyon, Journal of Nervous and Mental Diseases, April, 1889; Willoughby, ut supra) is of the greatest service when eclampsia is threatened, or convulsions have already taken place. a five years' experience (1882 to 1887) with jaborandi and pilocarpine in large doses, we have never seen, among nondebilitated subjects, any worse results than emesis, which at one time or another has attended almost every drug we have In Case I., instead of increasing the oedema of the lungs as it is said to do, it relieved it after other remedies had failed. colored, aged twenty-four. Was

CASE I.-J. R.

In

seen on April 27, 1885, when he gave the following account of himself: About three months ago he began to swell in his legs and abdomen. Found that he could not easily button his "pants." Says he has never had any venereal disease, but has been a hard drinker. That two nights since, while camping in the valley, with insufficient covering, he suffered very much from cold. That he then began to cough, and rapidly to swell up.

Has anasarca of legs and body as high as his neck. His genitals and abdomen are very much swollen. A percussion wave can not be obtained, but there is dullness on the flanks, changing with change of position. His heart is normal, but beats rapidly-one hundred and twenty per minute. Over his lungs are heard sibilant râles, and fine crepitation, but no dullness. He coughs almost constantly, and ejects mouthfuls of serous fluid. Says he has passed scarcely any urine during the list two days. A sample obtained is very dark colored, and became almost solid on heating. Under the microscope it was found to contain blood-corpuscles and granular casts. There were no nervous symptoms. Suffers from constipation. He was given pulvis purgans, acetate of potash in infusion of buchu and digitalis, and Stokes' mixture for cough. He passed about twenty ounces of urine each day, until May 1. The albumen was slightly diminished, but otherwise there was no change. was then given, morning and evening, ext. jaborandi, fl. 3 j.; aq. menth. pip. 3 j. Sig: To be taken at a dose; repeat in one hour if sweating is not produced. This dose produced its physiological effect without causing emesis. vis purgans and Stokes' mixture also continued.

Next day there was a slight improvement.

He

Pul

On May 5th the following note was entered: Much better. Only few crepitant râles over lower part of chest. Edema only noticeable over sternum. Passep thirty-four ounces of urine of light color; sp. gr., 1.015. No albumen or casts. On the following day it was noted-swelling gone from over chest. His recovery was uninterrupted. Ten days later he was given Bisham's mixture alone, and in the first days of July he resumed his ordinary occupation. Seven months afterward, when last seen by me, he was found to be slim, wiry, and in excellent health. There never had been any return of his oedema, and albumen had not been detected after May 5th.

CASE II.-M. G, aged twenty-eight. —, aged twenty-eight. Was seen De