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THE USES OF PILOCARPINE.
342 That the x rays are apt to mislead it is only necessary to refer to THE LANCET of June 27th, p. 1804, in which an illustration is given in a paper by Dr. J. F. Halls Dally showing a fairly large clear area to the left of the figure, described by the writer of the paper as representing a I space " existing between the lung and the diaphragm-"a clear transparent interval...... this space corresponds to the lower part of the which the lung does not fill up except on deep pleural cavity " inspiration." Now to the uninitiated it would appear from this description as though a vacant space existed in the thorax, or a vacuum of some kind into which the lung descended on inspiration, whereas, of course, the truth is that every hair’s breadth of "space"in the pleural sac is permanently filled up, and that when a deep inspiration is taken the diaphragm unrolls or peels off the chest wall, permitting the edge of the lung to extend down concurrently. In conclusion, I submit that not only can the careful and constant practice of the various refined methods pertaining to ordinary physical diagnosis enable one to demonstrate all that can be shown by the x rays in cases of early phthisis, but that the results so obtained are earlier in point of time, alone trustworthy in respect of differentiation, and in any stage of the disease, free from the pitfalls of radioscopy. I am, Sirs, yours faithfully, A. G. AULD. Henrietta-street, W , July 25th, 1903.
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after this the habit of perspiration without drugs was quite regained. He became a man of free perspiration. Getting good results from its use always ; every case of pneumonia recovering ; babies, instead of getting ipecacuanha or a mixture containing it when suffering from chill, got pilocarpine, beginning with about 2oth part of a grain and increasing the dose every hour till they began either to perspire or to expectorate and got good results. 3. Dangers -I have never had any bad effects from its In a few cases the profuse salivation produced by use. moderate doses has led me to think that if the patient was not strong enough to sit up and to expectorate for an hour there might be a danger of oedema from this cause. I could also understand that a profuse perspiration might be attended with collapse but I have never noticed anything to make me think that pilocarpine has any intrinsic action in depressing the heart and I have given it in the early stages of pneumonia frequently to a patient-as above stated, an alcoholic-with palpitation and to a patient who had malarious fever, enteric fever, and pneumonia at one and the same time. Can I offer a suggestion concerning its use in Bright’s disease, particularly of the practice of using the weaker diaphoretics and other agents until the patient is getting in extrerrais and more or less waterlogged and then, in the absence of perspiration, giving a full or moderate dose of pilocarpine in perhaps a hot pack. The profuse salivation some. times induced by moderate doses would lead me to think there is greater danger in thus giving, or even incurring, the liability to give pilocarpine in a late stage of illness than in an early stage when time would admit of gradual and careful dosing and the patient was strong enough to expectorate. The dose I have usually given is one-third of a grain hypodermically. Perspiration is generally the quickest effect, appearing in about five minutes ; salivation is generally later, but I have known profuse salivation appear in less than a minute with no bad effects. The patient was strong enough to sit up to expectorate. Not infrequently, again, salivation and expectoration are not affected in the slightest. A safer and quicker plan would appear to be to give pilocarpine in very small doses in Bright’s disease at the onset as the first diaphoretic agent and then if no objectionable effects showed themselves gradually increasing the dose according to the circumstances of the case until the patient perspired freely, a result which in the vast majority of cases would be attained without the trouble of other agentshot packs, &c. I hope these short observations may lead by ventilating the subject to clearer opinions of a drug concerning which most contradictory opinions have been expressed and which outside of its diaphoretic action I have found to be the most varying drug in its effect that I have ever used. I hope also to learn from any of your readers of any dangers, particularly cardiac, arising from the use of this drug, the value of which in pneumonia, particularly in the early stages, has been so frequently witnessed as to recommend its future use.
THE DANGER OF RAILWAY TRIPS TO HIGH ALTITUDES, ESPECIALLY FOR ELDERLY PEOPLE.
To the Editors of THE LAN C E T. SIRS,—In the extremely interesting and instructive article on the above subject by Dr. Theodore Zangger in THE LANCET of June 20th, p. 1730, there is the following statement: "Notwithstanding diligent search I have been unable to discover any previous publication referring to the effects of rapid changes of altitude on elderly people." Very similar observations to those of Dr. Zangger were Tecorded by the late Dr. Alfred L. Loomis in the New York Medical Journal, June 12th, 1886. In a paper which I published in the Lizerpool Medieo-Clairurgicccl Joz6rnaZ, July, 1888, on the Oertel Treatment ofHeart Disease I referred to the observations of Dr. Loomis and since then I have had many opportunities of advising patients of the risks they were to avoid on their visits to Switzerland. However, the great value of Dr. Zangger’s paper is in no way lessened by the fact that he was forestalled by Dr. Loomis.-I am, Sirs, yours faithfully, JAMES BARR. Liverpool, July 26th, 1903.
THE USES OF PILOCARPINE.
To the Editors of THE LANCET. SiRS,-A frequent use of this drug in South Africa for pneumonia amongst the blacks in Rhodesia and nearKimberley I am, Sirs, yours faithfully, for about a year without a single death and with uniformly M.A. Oxon., L.R.C.P., L.R.C.S. Edin. WILLIAM ROPER, results has me form led to different opinions with regard good Bridport, Dorset, July 14th, 1903. to (1) its action, (2) its uses, and (3) its dangers than those learnt from books. Most diverse opinions have been expressed about this drug. Under each of the above headings can I be allowed to give some of my own experiences ? NOTES FROM INDIA. 1. Aetion -In quite a few cases it has no effect whatever (FROM OUR SPECIAL CORRESPONDENT.) except in inducing perspiration. In the majority of cases it seems to have some other effects, of which purging, vomiting, and salivation are perhaps the most frequent. It would appear that, without trying it, there is no telling Sanitary Reports for Bengal and Assam.-The New Title of t7ae Indian Army Nursing Servi(J6.-The Plague what its action will be besides that of perspiration. I Epidemic. recollect clearly the action of moderate doses of pilocarpine, Nitrate induced THE sanitary reports for Assam and Bengal for 1902 have nitrate and muriate, in my own case. perspiration, vomiting, purging, and very slight bronchial just been published. Last year was very unhealthy in Bengal. expectoration ; muriate induced perspiration only. Neither A curious feature is the high infantile mortality which has been shown during recent years and which in the city had the slightest effect on the saliva. 2. Z7.—In South Africa a white man, an alcoholic with of Calcutta is simply appalling. In 62 per cent. of the town palpitation of the heart, nephritis, and habit of perspiration areas of Bengal the total deaths exceeded the births. The lost, came to me for treatment. I injected hypodermically death-rate from fever in some places is enormous. A district one-third of a grain of pilocarpine nitrate. I have never I death-rate from fever exceeding 35 per 1000 has been kn 3wn this fail to induce perapiration and although I have reported on 14 occasions during the past four years and on always stopped to give the antidote (atropine) this has three occasions has exceeded 40 per 1000 and the Bengal never been necessary. The patient afterwards took the same Government has directed that an inquiry should be conducted dose, one-third of a grain, by the mouth with no effect, by a specially qualified officer. The ratio of deaths to attacks but on hypodermic injection of a similar dose perspiration from plague fell to 84 6 but this is in excess of what is conmuch more profuse than on the first occasion took place and sidered the normal ratio. Calcutta, however, gives a still
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ON
after this the habit of perspiration without drugs was quite regained. He became a man of free perspiration. Getting good results from its use always ; every case of pneumonia recovering ; babies, instead of getting ipecacuanha or a mixture containing it when suffering from chill, got pilocarpine, beginning with about 2oth part of a grain and increasing the dose every hour till they began either to perspire or to expectorate and got good results. 3. Dangers -I have never had any bad effects from its In a few cases the profuse salivation produced by use. moderate doses has led me to think that if the patient was not strong enough to sit up and to expectorate for an hour there might be a danger of oedema from this cause. I could also understand that a profuse perspiration might be attended with collapse but I have never noticed anything to make me think that pilocarpine has any intrinsic action in depressing the heart and I have given it in the early stages of pneumonia frequently to a patient-as above stated, an alcoholic-with palpitation and to a patient who had malarious fever, enteric fever, and pneumonia at one and the same time. Can I offer a suggestion concerning its use in Bright’s disease, particularly of the practice of using the weaker diaphoretics and other agents until the patient is getting in extrerrais and more or less waterlogged and then, in the absence of perspiration, giving a full or moderate dose of pilocarpine in perhaps a hot pack. The profuse salivation some. times induced by moderate doses would lead me to think there is greater danger in thus giving, or even incurring, the liability to give pilocarpine in a late stage of illness than in an early stage when time would admit of gradual and careful dosing and the patient was strong enough to expectorate. The dose I have usually given is one-third of a grain hypodermically. Perspiration is generally the quickest effect, appearing in about five minutes ; salivation is generally later, but I have known profuse salivation appear in less than a minute with no bad effects. The patient was strong enough to sit up to expectorate. Not infrequently, again, salivation and expectoration are not affected in the slightest. A safer and quicker plan would appear to be to give pilocarpine in very small doses in Bright’s disease at the onset as the first diaphoretic agent and then if no objectionable effects showed themselves gradually increasing the dose according to the circumstances of the case until the patient perspired freely, a result which in the vast majority of cases would be attained without the trouble of other agentshot packs, &c. I hope these short observations may lead by ventilating the subject to clearer opinions of a drug concerning which most contradictory opinions have been expressed and which outside of its diaphoretic action I have found to be the most varying drug in its effect that I have ever used. I hope also to learn from any of your readers of any dangers, particularly cardiac, arising from the use of this drug, the value of which in pneumonia, particularly in the early stages, has been so frequently witnessed as to recommend its future use.
THE DANGER OF RAILWAY TRIPS TO HIGH ALTITUDES, ESPECIALLY FOR ELDERLY PEOPLE.
To the Editors of THE LAN C E T. SIRS,—In the extremely interesting and instructive article on the above subject by Dr. Theodore Zangger in THE LANCET of June 20th, p. 1730, there is the following statement: "Notwithstanding diligent search I have been unable to discover any previous publication referring to the effects of rapid changes of altitude on elderly people." Very similar observations to those of Dr. Zangger were Tecorded by the late Dr. Alfred L. Loomis in the New York Medical Journal, June 12th, 1886. In a paper which I published in the Lizerpool Medieo-Clairurgicccl Joz6rnaZ, July, 1888, on the Oertel Treatment ofHeart Disease I referred to the observations of Dr. Loomis and since then I have had many opportunities of advising patients of the risks they were to avoid on their visits to Switzerland. However, the great value of Dr. Zangger’s paper is in no way lessened by the fact that he was forestalled by Dr. Loomis.-I am, Sirs, yours faithfully, JAMES BARR. Liverpool, July 26th, 1903.
THE USES OF PILOCARPINE.
To the Editors of THE LANCET. SiRS,-A frequent use of this drug in South Africa for pneumonia amongst the blacks in Rhodesia and nearKimberley I am, Sirs, yours faithfully, for about a year without a single death and with uniformly M.A. Oxon., L.R.C.P., L.R.C.S. Edin. WILLIAM ROPER, results has me form led to different opinions with regard good Bridport, Dorset, July 14th, 1903. to (1) its action, (2) its uses, and (3) its dangers than those learnt from books. Most diverse opinions have been expressed about this drug. Under each of the above headings can I be allowed to give some of my own experiences ? NOTES FROM INDIA. 1. Aetion -In quite a few cases it has no effect whatever (FROM OUR SPECIAL CORRESPONDENT.) except in inducing perspiration. In the majority of cases it seems to have some other effects, of which purging, vomiting, and salivation are perhaps the most frequent. It would appear that, without trying it, there is no telling Sanitary Reports for Bengal and Assam.-The New Title of t7ae Indian Army Nursing Servi(J6.-The Plague what its action will be besides that of perspiration. I Epidemic. recollect clearly the action of moderate doses of pilocarpine, Nitrate induced THE sanitary reports for Assam and Bengal for 1902 have nitrate and muriate, in my own case. perspiration, vomiting, purging, and very slight bronchial just been published. Last year was very unhealthy in Bengal. expectoration ; muriate induced perspiration only. Neither A curious feature is the high infantile mortality which has been shown during recent years and which in the city had the slightest effect on the saliva. 2. Z7.—In South Africa a white man, an alcoholic with of Calcutta is simply appalling. In 62 per cent. of the town palpitation of the heart, nephritis, and habit of perspiration areas of Bengal the total deaths exceeded the births. The lost, came to me for treatment. I injected hypodermically death-rate from fever in some places is enormous. A district one-third of a grain of pilocarpine nitrate. I have never I death-rate from fever exceeding 35 per 1000 has been kn 3wn this fail to induce perapiration and although I have reported on 14 occasions during the past four years and on always stopped to give the antidote (atropine) this has three occasions has exceeded 40 per 1000 and the Bengal never been necessary. The patient afterwards took the same Government has directed that an inquiry should be conducted dose, one-third of a grain, by the mouth with no effect, by a specially qualified officer. The ratio of deaths to attacks but on hypodermic injection of a similar dose perspiration from plague fell to 84 6 but this is in excess of what is conmuch more profuse than on the first occasion took place and sidered the normal ratio. Calcutta, however, gives a still
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