PARALDEHYDE IN ASTHMA.

363 the line of treatment which relieved the nasal In the 31 cases already referred to about half were subject to asthmatic symptoms, either some feeling of tightness or oppression of the chest, some wheezing at times, or definite attacks of asthma. I can only find one who though much relieved of his nasal symptoms got no relief from his asthma which indeed steadily got worse. On the other hand, some though relieved were by no means relieved to’ the same extent as in respect of the nasal symptoms. I suspect, if we could only know it, that we relieve the asthmatic symptoms in so far as these depend upon reflex excitation from the nose, but it is impossible to say how far this is so in any particular case. As I have already said, it may be so in the early period of the The general conclusion which I have case and not so later. formed on this matter is that in children and young subjects affected with paroxysmal sneezing there is a much better chance of relieving or curing the associated asthmatic symptoms than in older subjects ; that the shorter the period during which the asthmatic symptoms have been present and the less pronounced they are the more likely we are to relieve or cure them by the same treatment which relieves or cures the nasal symptoms. Still our prognosis with regard to asthma in these cases should always be guarded.

more or

less

by

symptoms.

Upper Wimpole-street,

W.

PARALDEHYDE IN ASTHMA. BY ALEXANDER MACGREGOR, M.D. ABERD., M.R.C.P. LOND., PHYSICIAN TO THE NORTH LONDON HOSPITAL FOR CONSUMPTION AND DISEASES OF THE CHEST AND PHYSICIAN TO THE WESTMINSTER GENERAL DISPENSARY.

As far as I have been able to find out, Dr. Mackie1 of Elgin the first to suggest the use of, and to use, paraldehyde for the relief of asthma.’’The fact that paraldehyde is a sedative largely eliminated by the breath" led him to try its effect in the spasm of idiopathic asthma. He administered it in a number of cases with uniformly successful results and found that it speedily relieved the spasm and induced sleep. My attention was drawn anew to this a few months ago and since then I have given the drug in a fairly large number of cases of idiopathic asthma and other forms of spasmodic dyspncea and my experience confirms that of Dr. Mackie. No drug in my hands has given such satisfactory results. In the treatment of hospital out-patients suffering from asthma morphine hypodermically is out of the question and it is not usually advisable to prescribe chloral in such cases. Paraldehyde is absolutely safe. It not only relieves the spasm but it induces tranquil refreshing sleep without any objectionable after-effects. Besides, no evil results follow a prolonged use of paraldehyde ; it does not give rise to a habit, and on this account it is a much more desirable drug than morphine or chloral. That it has hitherto not been much used in the treatment of asthma one may safely conclude from the fact that neither in Allbutt’s"System of Medicine " nor in " Twentieth Century Practice of Medicine " is it mentioned among the drugs given as useful in the treatment of the disease. I venture therefore to think that the following short notes of a few of the cases in which I have used it may prove interesting and worth recording. CASE 1.-The patient was a woman, aged 24 years, who had suffered from asthma for four years. The nightly attacks of dyspncea had always been very severe and protracted. Chloral gave no relief. She had derived most benefit from a mixture containing iodide of potassium, tincture of lobelia, and solution of hydrochlorate of morphia ; but this combination and many other remedies gave relief only for a short time and her condition became serious. She was losing flesh, cyanosis was constant, and she was weaker. On Sept. 30th, 1898, she was gradually growing ordered half a drachm of paraldehyde every night at bedtime. When seen a week afterwards she said that since taking the paraldehyde her nights had been very good, that she had had only one attack, and it was a very short one. The dose was doubled and then the attacks ceased. On Jan. 6th, 1899, the note in the case-book says: "She continued to take the paraldehyde up to Nov. 18th and has was

1

Brit. Med.

Jour., vol. i.

p.

65, 1893.

taken none since. Her nights are invariably good. Now and then she has a slight wheezing attack which lasts only for a few minutes. She has put on flesh and her colour is quite rosy." CASE 2.-The patient was a woman, aged 37 years, who had been ill for three months ; there was a family history of phthisis. At first the attacks of asthmatic dyspnoea came on chiefly after meals and for a time they were relieved by iodide of potassium and tincture of lobelia. In this case and in several others an occasional dose of a carminative mixture seemed greatly to increase the effect of the other remedies. Very soon the latter had little or no effect, she became much worse and the dyspnoea and laboured breathing prevented sleep. Half a drachm of paraldehyde, repeated in an hour, gave tranquil, refreshing sleep. She continued to take paraldehyde for several weeks and the last note of her case says : ’’ Her nights are good and she reports herself to be ever so much better." CASE 3.-The patient was a woman, aged 36 years, who had suffered from bronchitis off and on for nearly three years. An uncle was asthmatic. She had had a severe attack of influenza in January, 1898. She was first seen on Nov. 15th and she stated that for three months she had suffered from attacks of dyspnoea coming on suddenly during the night, usually about 1 A.M.; she awoke struggling for breath, the attack, with much wheezing and laboured breathing, lasting often for 12 hours or longer. She had had a very bad attack the night before her visit and she was still decidedly cyanotic, but on examination no adventitious sounds were heard in the lungs and the heart was normal. A mixture containing iodide of potassium was ordered to be taken during the day and paraldehyde at bedtime. When next seen, on Nov. 22nd, her report was : "II feel much better, I sleep all night and wake feeling so refreshed." On Nov. 29th the report states that a severe attack occurred on the night of the 26th, the usual dose of paraldehyde induced sleep only for a very short time, and although sleep for the rest of the night followed a second dose the asthma recurred when she awoke and continued till the following evening. She was last seen on Jan. 3rd, and she then stated that she was quite well, that she had not taken paraldehyde for a week, and that she There had not been an attack now slept well all night. since the one mentioned above.

CASE 4.-The patient was a man, aged 44 years, who had suffered from asthma for nearly two years before coming under observation. At first the spasmodic attacks occurred about 2 A.M., but lately they had come on frequently during the day. The lungs were emphysematous and he also had got a mitral systolic bruit. At first he was given paraldehyde and nothing else. More sleep was the result but it was somewhat restless, and he often awoke wheezing, coughing, and retching. He was then ordered a mixture containing iodide of potassium and tincture of lobelia to be taken during the day and the paraldehyde at bedtime. Under this he improved immensely, and a note made after adopting this treatment says that the nights are good and breathing easy during the day. Has been at work for a week." CASE 5.-The patient was a woman who had suffered from I asthma for four years. Her father had been asthmatic for 20 years and six of his eight children suffered from the same disease. The nocturnal paroxysms were very severe and in addition to the usual characteristic symptoms there was a patch of catarrhal pneumonia at the base of the left lung. She was ordered an expectorant mixture with iodide of potassium during the day and paraldehyde at night. On each of the first two nights almost immediately after taking the paraldeyde she fainted but slept quietly all night. After that the drug did not cause even a feeling of faintness but gave the patient quiet nights and there was no recurrence of the asthmatic attacks. CASE 6.-The patient was a woman, aged 47 years, stout, flabby, and very neurotic; she was first seen on Nov. 5th, 1897, when she stated that she had suffered, off and on, for several years and had been gradually getting much worse. Her father was asthmatic and so was a sister who, she said, died in an attack for which she was given morphia hypodermically. At her first visit this patient was cyanotic, her breathing was noisy and laboured, and the usual pulmonary signs were present in a marked degree. For a time she was much relieved by iodide of potassium and tincture of lobelia. After an absence of several months she returned for advice on Sept. 30th, 1898. She was then having at least one severe attack of asthma each week and frequent violent fits of sneezing. She was ordered half a drachm of paraldehyde

364 each night. For three nights she slept well, but after thatj the drug caused excitement. The dose was doubled, she .then slept very well and the breathing was much improved. The sneezing fits ceased after she began to take thei

paraldehyde. CASE 7.-The patient was a man, aged 36 years, whoI had been ill for 11 months. Asthmatic symptoms came on. after an attack of influenza. He complained of shortness of, breath, cough, loss of flesh, and night sweats. He said that he "could get no sleep because of the cough and the struggle! for breath." He was given iodide of potassium during the day and a drachm of paraldehyde at bedtime. A week afterwards he reported himself to be much better and said that he now slept comfortably all night. The note in the casebook a month after he began the treatment says, " He sleeps well and is putting on flesh ; he has gained 6 lb." CASE 8.-The patient was a man aged 34 years who hadI been ill for two years. He complained of a very bad cough, profuse expectoration, and loss of flesh. He also stated that frequently during the night he had to spring out of bed because of a sudden sense of suffocation which ended in a severe and prolonged fit of coughing. He was ordered the same treatment as in the last case but only four doses of paraldehyde were given. When seen a week afterwards he reported that ..during the first two nights his sleep had been unbroken, that the next two nights it had been very good, and that although without paraldehyde for the three following nights he had had no attack and was able to lie quietly in bed all night. CASE 9.-The patient was a woman, aged 30 years. She was neurotic and had been ill for three months. She was first seen on Dec. 6th, 1898. An aunt had suffered from asthma for 18 years. This patient complained of a painful sense of tightness in the chest, shortness of breath, and a troublesome cough, and she was subject to severe attacks of spasmodic dyspnoea during the night. The same treatment was ordered in this case. Immediately after taking the first dose of paraldehyde she fainted and had to be lifted into bed. She said that " the medicine was so strong that it took her breath away," but the result was that she slept all night. She did not continue the paraldehyde, but with iodide of potassium, &c., she improved and on Jan. 3rd, 1899, the report said that she was ever so much better and sleeping well. CASE 10.-The patient was a woman, aged 34 years, who had suffered from asthma more or less for 14 years. She had had three attacks of rheumatic fever. The heart was normal. At her first visit she was very cyanotic, the shortness of breath was distressing, and the breathing was noisy and laboured. The symptoms were greatly aggravated at night and made sleep practically impossible. An expectorant mixture during the day and paraldehyde at night gave marked relief ; she was able to sleep comfortably, and the breathing soon became easier. She continued to take paraldehyde for some weeks and always with benefit; the cough disappeared, and after a time she was able to dispense with both the expectorant and the paraldehyde. CASE ll.-The patient was a woman, aged 43 years. She had suffered from asthma and bronchitis for five years. In her case the symptoms were severe, the cough was troublesome, and she got very little sleep because of the attacks of spasmodic dyspnoea which were frequent and painfully distressing. In addition to an expectorant mixture she was given a drachm of paraldehyde at bedtime. The latter medicine, to use her own words, gave her beautiful nights and she always felt so refreshed after the sleep. The mere obtaining of sleep is of great importance for the asthmatic patient, the strength is saved and what is lost during the day may be more or less regained. The prevention of the spasm is even a greater boon, seeing that each attack increases and prolongs the accompanying bronchitis. Iodide of potassium and tincture of lobelia as a rule do much to relieve the bronchitis and to lessen the spasm, but their effect is immensely increased by securing sleep and the prevention of the nocturnal spasms by means of paraldehyde. The drug occasionally causes sickness and for this reason it proved of no use in a severe case of long standing bronchitis and emphysema. Its disagreeable pungent taste makes it objectionable to children and nervous patients, but it is well clisguised in cinnamon water and tincture of orange-peel. It acts as a rule so rapidly that the dose ought to be taken after the patient has gone to bed. In the to case of more than one of my patients it seemed act immediately and for this reason one nervous man suffering from simple insomnia refused to continue ,

taking it. In adults I find it best to begin with a dose of 60 minims, and as Dr. John Gordonpointed out, as a result of his experimental use of the drug, the same dose has equally good hypnotic effect when it hes been taken for months. Although Dr. Gordon does not mention asthma among the diseases in which he found paraldehyde useful as a hypnotic one of the results of his investigations might suggest its use in this disease. He found that it produced tranquil sleep with diminished respirations and in his paper on the subject he says, "This slowing of the respirations in many pulmonary diseases is of distinct advantage." He further says, "It is possible that, since a large amount of the drug is excreted by the lungs, its vapour may exercise a

narcotic influence on the terminations of the sensory nerves of the lung tissue while it is being expired." One can,, therefore, easily understand how, by its double action of inducing sleep and preventing pulmonary spasm paraldehyde has such a powerful effect for good in asthma.

ON THE TREATMENT OF "UNAVOIDABLE HÆMORRHAGE" BY REMOVAL OF THE UTERUS. BY LAWSON

TAIT, F.R.C.S. ENG. & EDIN.,

CONSULTING SURGEON TO THE BIRMINGHAM AND MIDLAND HOSPITAL FOR

WOMEN,

AND

TO

THE

LIVERPOOL, NOTTINGHAM, AND

SOUTHAMPTON HOSPITALS FOR WOMEN.

I HAVE spent much of my leisure during the last few weeks in looking up the authorities on ’’ placenta prsevia’ for some assured statement concerning its mortality. There is nothing more definite than is to be found in Simpson : " All obstetric authors seem to agree on this point, that there is no one complication in midwifery attended with more anxiety to the practitioner and few, if any, with more real danger to the patient than cases of unavoidable haemorrhage from presentation of the placenta." He proceeds to give figures which go to show that the fatality is close on 40 per cent., but I gather from the smothered confessions of other writers and the open admission of my friends who have had large obstetric experience that it really is much higher ; and in spite of the sound principles laid down for its treatment and the improvements therein made by Simpson himself it is probable that more than half the cases die. I have all my life avoided in every possible way contact with obstetric practice, and for 30 years have had no personal association with it save in occasional consultations. Amongst these have to be included 13 (now 14) cases of unavoidable haemorrhage and of this the mothers have died in seven cases and, I think, only three of the children were born alive. It will therefore not be a matter of surprise if I say that I entirely agree with the sentence which I have quoted from Simpson’s 11 obstetric Works." I feel pretty sure that the full mortality of the condition is not yet known, so many patients die from the secondary complications due to the damage of the misplaced placental sinuses; and as these cases are generally not fatal till many days after delivery they are not returned as cases of "placenta pra;via" but as peritonitis, I gather from conversation that only immediate deaths &c. This are as a rule entered under the real and primary cause. is of itself a point of interest about the condition, but not one which concerns me much, though evidently the higher the total mortality is found to be, primary and secondary, the stronger will be my subsequent argument from this point of view. Another aspect from which "unavoidable haemorrhage" is extremely interesting is that it is one of the few points in the practice of surgery where our conduct may be influenced by ecclesiastical authority. The Church of Rome rules that in such a case the living birth of the child is all important and when the interests of mother and child conflict those of the former must yield. In one case to which I was called by the late Dr. Wynne Thomas this decision, arrived at by the mother and the father of the child, as advised by their spiritual directors, seemed to us to cost’the mother her life though it did save the child. Under such circumstances that part of the treatment directed against the immediate risk from (haemorrhage has its influence for good directly

March 2 9th, 1889.

Contributions to the

Study of Paraldehyde, Brit. Med. Jour,