Thursday, April 24, 2014

1717: Floyer establishes spasmotic theory of asthma

In 1698 Sir John Floyer, an asthmatic himself, published his book A Treatise of the Asthma.  In this book he became the first asthma expert to make the case for asthma as a separate disease from other lung disorders. This is significant because prior to this division all that was short of breath was asthma.

He also lived during a time when supernatural remedies were slowly going out of favor, yet some physicians, such as Floyer, didn't like the change.  Floyer preferred to treat asthma as a disease caused by an imbalance of the four humours (black bile, yellow bile, blood and phlegm) as opposed to some physiologic condition of the body.

Despite this, Floyer was wise enough to see that there was more to asthma than his predecessors assumed, and therefore Floyer became a significant figure in the evolution of the asthma definition.  Now surely he slowed progress some by rejecting fellow asthma experts with more scientifically linked ideas (such as Jean Baptiste van Helmont and Thomas Wilson), yet in other ways he did well.

However, to his credit, while he treated asthma by older methods, he was a supporter of the notion of asthma as a disease of contraction of the air passages.  Yet he also believed the diaphragm was a cause of the ailment, "which seemed to him rigid, and spasmotically drawn up by some contractile force within the thorax; and this force he considered to be the air tubes and lungs, contracted by an inflation of the membrane lining the chest and covering the lungs," according to John Charles Thorowgood in his 1894 book about asthma and chronic bronchitis. (2. page 10)

Thorowgood provides some intriguing quotes fromk the second edition of Floyers book A Treaties on Asthma that was published in 1717.  Thorowgood quotes Floyer as writing:
"I have assigned the immediate cause of the asthma to the straitness, compression, or constriction of the bronchia; and in the continued asthma (it's always there, or it's chronic) the causes must be constant, as dropsy, tuberculum, etc. The return of periodic asthma (it comes on only occasionally) depends on the defluxion (discharge, such as from a runny nose due to catahrr or inflammation) of humours on the primae viae (the bowels). Thus, the old notion of the asthma being a defluxion of serous humours is certainly true, because evident to our senses in the evacuation of serosities....  Some,' continues Floyer (p. 43), 'express their feeling, during a fit of asthma, as if the lungs rose, and were drawn upwards to choke them. Contraction of the vesicuise is very probable, because the bronchia are contracted, and the vesiculse have the same muscular fibres to help expiration, by which they may be drawn so up as not to admit the air.' (2, page 11)
Thorowgood also provides a passage from Floyer's book comparing the chest with bellows:
 'We can,' says he, 'move the bellows easily; but suppose a bladder tied within the bellows over the nozzle, so as to receive the air and suffer none to get into the cavity of the bellows, it will follow that in a perfect stoppage of all the entrances of air the bellows could not be opened; and if no more entered than may be contained in the bladder, the bellows would be opened but a little way, and would inspire difficultly. So it appears in the business of the asthma, the inspiration is difficult and laborious, because but little air can be admitted into the contracted bronchia, and the vesicular drawn up. This puts the scapular and intercostal muscles and diaphragm upon a violent endeavour to press in the air and open the lungs, which nisus (physicians trying to understand asthma) authors have mistaken, and supposed the pneumonic (lung) muscles, especially the diaphragm, to be convulsively affected; but it may easily be apprehended that the diaphragm cannot press the viscera (internal organs) downwards to enlarge the breast if the air cannot be admitted into the lungs to follow its depression and fill the cavity of the breast; and this is the true reason why the diaphragm cannot move in the asthmatic fit. The contraction and stiffness of the lungs during asthma causes a catalepsis (stiffness) or rigidity of the diaphragm—the part most unjustly accused of this tyrannic oppression.' (1, page 11-12)
Thorowgood notes that other physicians before Floyer noted the rigidity of the diaphragm and credit it as the "essential cause of asthma."  Floyer, on the other hand, while he notes this rigidity, contributes it to contraction of the air passages of the lungs.  The wheezing heard on expiration, therefore, is caused by the narrowed air passages, which is caused by contraction of the muscular fibres that wrap around them. (1, page 12)

Two other things of interest that Thorowgood mentions about Floyer:

1.  Floyer also refers to asthma that is associated with no other observable signs as hysterical asthma, and he refers to the "hysteric" who wheezes but produces no phlegm is proof that asthma is not caused by phlegm but by contraction of the air passages.  (1, page 12)

2.  Floyer clearly rejects the nervous theory of asthma postulated by Willis and van Helmont.  Thorowgood writes: "(floyer) regarded the contraction as brought about by mechanical pressure rather than by nervous influence seems clear, from his saying that certain writers of his day, Van Helmont and Dr. Willis, were wrong in regarding asthma as a convulsion, to be treated by anti-spasmodics, hot tinctures, gums, volatile salts, and sulphur medicines. The proper method is by evacuants, and remedies calculated to promote secretion and effect the discharge of humours —anti-congestive rather than anti-spasmodic treatment.

It is clear, though, by the writings of Floyer that he was probably the physician who established the spasmotic theory of asthma, which is also called the convulsive theory of asthma, or the bronchospasm theory of asthma.  He believed asthma was caused by contraction of the bronchi as opposed by a nervous disorder.   

References:
  1. Thorowgood, John C., "Asthma and Chronic Bronchitis: A New Edition of Notes on Asthma and Bronchial Asthma," 1894, London, Bailliere, Tyndall, & Cox.  The quotes from Floyer were referenced by Thorowgood from Floyers book "A Treaties on Asthma," which was published in 1717.  Pages referred to are in the quotes above. 

Tuesday, April 22, 2014

1768: Asthma classified as a disease

Prior to the 19th century the symptom was the disease, and the treatment was some form of supernatural remedy.  And even when an herb was the remedy, the reason it worked was rationalized by superstition.  Of course the other common remedy was a simple prayer, which worked through efforts of the gods or God worshipped. 


For the most part, prior to the transition from superstition to science, diseases were merely symptoms.  For example, if you were short of breath you had asthma unless there was some other rationalization for your dyspnea, such as tuberculosis or influenza or pneumonia.  Asthma, in a sense, was a symptom more so so than a disease.

T.E. Weckowicz and H. Liebel-Weckowicz, in their book "History of Great Ideas in Abnormal Psychology," explain that prior to 18th century (and even during the 18th century for the most part) illness was categorized by the Constitutional models that were devised by Hippocrates and Galen, which emphasized symptoms.  (1, page 168)

During the 18th century a shift was made away from the Constitutional model and toward the disease model of disease.  Weckowicz and Weckowicz propose three theories as to why this may have occurred.  (1, page 68)

1.  They suggest that various epidemics of diseases "suggested the possibility of contageon."  They mention Girolamo Fracastoro of Verona (1484-1553) who "wrote a famous poem about syphilis.  He postulated that diseases were caused by minute germs which passed from one person to another. He recognized that smallpox, measles, bubonic plague, phtisis (tuberculosis) were contagious diseases." (1, page 68)

They also mention Fracastro, the Jesuit Father, Athanasius Kirchner (1602-1680) who "claimed to have found microscopic worms in the blood of patients suffering from infectious diseases."  While the "link between bacteria and infectious disease was not definitely established until the middle of the nineteenth century," the idea was beginning to grow in the minds of the medical profession, or at least the scientific community. (1, page 68)

2.  They suggest that "clinitians tended to isolate the symptoms of disease from the total patient and to treat them as entities in themselves." (1, page 68)

3.  "There was a growing interest in morbid anatomy. The bodies of dead people were dissected, the diseased organs were examined, and the pathology of the organs was linked with the symptoms of the patients." An example here may be the diagnosis of the disease pneumonia by the observation of fluid or puss in the parts of the lungs that they ultimately attributed to the symptoms the person had prior to death, such as dyspnea and coughing up colored secretions. (1, page 68)

Weckowicz and Weckowicz list the significant figures in the birth of nosology, or the classification of diseases, and I will list some of the ones most significant to our asthma and allergy history here.  (1, page 68-9)

1.   Felix Plater:  (1536-1614)  (He considered asthma as a mental disorder.  He observed the asthma attack when nothing else seemed to be wrong)  He classified nervous disorders, dividing them into "idiots, morons, cretons, mutes, and melancholics." (1, page 69)

2.  Thomas Willis:  (1621-1675) (He was the person often given credit as the first to classify asthma as a nervous disorder).  He's also known as among the first two men to classify psychological diseases.  He classified mental patients as "melancholics, maniacs, idiots, and Apoplectics." (1, page 69)

3.  Dr. Thomas Syndenham (1624-1689):  He was among the first to favor the disease model as opposed to the constitutional model of Hippocrates and Galen.  He stressed, in his book Medical observations Concerning History and Cure of Acute Diseases (Sydenham, 1848), that "each disease should be treated by the specific remedy for it." (1, page 68)

He also stressed the importance of nosology (classification of disease), and he suggested such classification should be made similar to the methods used to classify plants and animals. He also classified diseases according to their symptoms. (1, page 68-9)

4.  Theophile Bonet of Geneva:  (1620-1689) "He compiled all the existing knowledge of pathological anatomy in his work Sepulchretum." (1, page 68)

5.  Dr. Carl von Linne (Linneaus):  (1707-1778) He continued work on the classification system started by Sydenham, and he classified plants according to genera, families, and orders.  He also "treated diseases as plant species." (1, page 71)   He published his works on nosology in his 1763 book "Genera Morborum."  

6.  Francois Boissier de Sauvages de Lacroix:  (1706-1767) He classified disease in his book Nosologie Methodique (Systematic Nosology).  In this book "he distinguished twenty-four hundred diseases which he divided into ten classes, each further divided into several orders and genera. (1, page 71)

Lineaus was a medical student when Sauvages first book was published in 1731, and the two met and started corresponding.  This led to a lifelong friendship whereby the two "influenced one another" in forming classification systems.  In 1763 they both published their own treaties on nosology, Linnaeus published Genera Morborum and Sauvages published Methodical Nosology. (3, page 98)

Sauvages also was mentioned by Dr. John Charles Thorowgood in his 1878 book "Asthma and Chronic Bronchitis." Thorowgood notes the following:  (2, page 10)
As knowledge and observation progressed, the intermittent character of the breath difficulty of asthma was duly observed and insisted on; and we find Boissier de Sauvages, in his 'Genera Morborum' (1768), defining asthma as 'difficultas spirandi periodice recurrens, chronica.'(2, page 10)
In this way, Boissier de Sauvages may have actually been the first person to classify asthma as a disease as opposed to just a symptom. 

7.  William Cullen:  (1710-1790)  I'm actually adding him to this list on my own because he was also among the first nosologists.  He was a physician from Edinburgh, and he was among the first to base his theories of asthma on studies he performed.

He believed most diseases, asthma included, were caused by some disorder of the nervous system.  He found it difficult to classify asthma as a disease mainly because most other physicians of his day believed all or most cases of dyspnea were asthma.

He was among the first physicians to study signs and symptoms of diseases while a person was awake, and compare this with findings on autopsy.

According to Thorowgood, Culen defined asthma in his 1772 book "Synopsis Nosologiae Methodicae" as follows: (2, page 13)
 'spirandi difficultas, cum angustise in pectore sensu, per intervalla subiens.' (2, page 13)
He believed spasmotic asthma was caused by constriction of the muscles that wrap around the smaller bronchiole tubes.  This theory, which was also supported by John Floyer, received a lot of attention among the medical community through the 19th century, said Thorowgood.  (2, page 13)

There were many ardent supporters of this theory during the course of the 19th century, and I will list them and discuss their contributions to asthma in a later post.

Thorowgood also said that Cullen further classified asthma into the following three groups: (2, page 13)
  1. Idiopathic Asthma:  There are 8 varieties of this
  2. Symptomatic Asthma: There are 2 varieties of this
    1. Gouty Asthma (asthma arthriticum)
    2. Syphilitic Asthma (Asthma Venereum)
  3. Other:  This "consists of a long list of asthmas, dyspnoeas, and orthopnoeas symptomatic of cardiac and pulmonary difficulties and obstructions  (2, page 13)
Conclusion:  So these are some of the earliest nosologists responsible for the early categorization. The systems created by Sydenham, Linneaus and Sauvages made nosology popular, and during the 1760s through the 1780s there were an abundance of treaties dedicated to nosology, with Cullins work being among them.  (3, page 98)

So, throughout the 18th century physicians were on a quest to match the symptoms that occured in life with what they saw on autopsy.  The more they did this the more diseases they discovered, and this resulted in an effort to classify these diseases in order to organize them.

The next rush among the medical community would be to further understand the various diseases.  Yet they would soon find out that asthma left no scars, and therefore was not so easy to define.  The debate as to what causes asthma would be fought long and hard by many physicians during the 19th century.

References:
  1. Weckowicz, T.E. and H. Liebel-Weckowicz, "History of Great Ideas in Abnormal Psychology,"1990, New York, Elsevier Science Publishing Company, Inc. 
  2. Thorowgood, John C., "Asthma and Chronic Bronchitis: A New Edition of Notes on Asthma and Bronchial Asthma," 1894, London, Bailliere, Tyndall, & Cox
  3. Flangsmyr, Tore, J.L. Heilbron, Tobin E. Rider, editors, "The Quantifying Spirit in the Eighteenth Century," Berkley, Los Angeles, Oxford, University of California Press
  4. Butlin, H. Trentham, President of the Laryngological Society of London, "Proceedings of the Laryngological Society of London elected at the annual meeting January 13th, 1897," 1897, London, Printed by Adlard and Son

Thursday, April 17, 2014

1850s: Why do young people outgrow asthma?

For many centuries it was believed that most cases of asthma were present in children, and that as one ages the asthma has a high tendency of disappearing.  The first person, to my knowledge anyway, to come up with a theory as to why this was believed, was Dr. Henry Hyde Salter. 

Dr. Salter believed that asthma was a nervous disorder, and that some exciting cause excited the nervous system and this ultimately caused spasms of the bronchial muscles that constricts the air passages.  When this occurs blood in the pulmonary vessels is unable to move through the blocked portions of the lungs, and becomes congested. 

When asthma is pure (free from any organic changes), it is intermittent, meaning that the attacks come upon the patient and then go away for a long period of time before one occurs again.  The period of time between may be random (cannot be predicted) or periodic (can be predicted). 

Salter believed asthma was more likely to be pure the younger the person is when he acquires it, so that asthmatics under the age of 15 have a great chance of outgrowing it, those between 20 and 40 a fair chance, and over 40 a rare chance. 

"Now, why is this?" Salter asks.  "Why, caeterus paribus, (everything else being equal) should age have such a determining influence on the tendency of asthma?

He answers his own question:

1.  The young are more capable of repair:  "Partly for the reasons that I have mentioned—that in the young the powers of repair are great, in those advanced in life feeble; that in the young the pulmonary congestion that always accompanies asthma completely vanishes in the intervals of the attacks, the capillaries recover their tone, and the nutritional balance of the lungs is regained; whereas in the old the engorged capillaries are slower in recovering themselves, and the pulmonary congestion hangs about the patient some time after the asthmatic spasm has disappeared, manifesting itself by a profuse mucous exudation, and a certain thickness of breathing and incapacity for exertion. If the attacks are frequent this pulmonary congestion never entirely vanishes, and thus is produced a kind of spurious chronic bronchitis, with a tendency to aggravation by each attack, which is one of the worst and commonest complications of the asthma of the old."

2.  The young are less likely to develop chronic bronchitis:  "Another complication of asthma—dilated right heart —is much more apt to occur in the old than in the young, and for the very reason that the dyspnoea in the old is so apt, by the generation of this spurious bronchitis of which I have been speaking, to pass from the occasional and intermittent form characteristic of pure asthma, and become continuous and permanent . As far as I have seen, the right side of the heart never becomes dilated by asthma, however severe the dyspnoea may be during the attacks, if the intervals between them are considerable, and the recovery in those intervals complete. It is a continued and not an occasional and transient arrest of the pulmonary circulation that dilates the right side of the heart. It is from this fact that we see dilatation of the right side of the heart, venous stasis, and general dropsy so much more common as a result of chronic bronchitis than of asthma."

3.  The young have more room for hope:  "But this greater disposition in asthma to produce organic change in the old than in the young is not the only circumstance which imparts to age its determining influence on the tendency of the disease. In asthma, as in all other constitutional disorders, we have in the young much more room for hope from those changes in the type and build of the constitution which in them are so marked and striking; whereas in the old the constitution is set and fixed, and we have but little to hope on this score. Indeed, the existence of a constitutional peculiarity in a child is of itself almost a presumption that he will one day lose it; while in an old person it furnishes a presumption equally strong that it is fixed and indelible.

4.  Young lungs have more time to recover between fits:  "Again, in an old person the probability is that the asthma has existed longer than in a young one, and, as I shall show presently, the chances of recovery from asthma (as is the case in almost all diseases) are in inverse proportion to the length of time that the disease has existed."

5.  The young are more likely to have pure nervous asthma:  "But there is a special reason, depending on the nervous nature of asthma, that makes us sanguine of recovery in the case of the young, and which explains at the same time the greater frequency of pure nervous examples of the disease in the young than in the old. What, for want of a better name, we must call "nervous irritability" is much more marked in the young than in the old. It appears continuously to diminish from birth forward. Sources of irritation that in the young are adequate to the production of the most violent nervous phenomena, in mature life are powerless to produce such effects. The cutting of a tooth, for example, will send an infant into epileptic convulsions: one never hears of a fit from the second dentition. A young child will grind its teeth, or even be violently convulsed, from the presence of ascarides in its rectum; but one never sees such results from worms in the adult. And thus the diminution of nervous irritability, as childhood passes into youth and manhood, may make an attack of asthma less and less prone to occur on the supervention of its exciting causes, and less intensely spasmodic when it does occur. I believe, indeed, that this diminution of nervous irritability is the true explanation of that gradual recovery of young asthmatics which is so common, so almost universal."

6.  Youth asthma is not causes by organic changes:  Lastly, age influences unfavorably the tendency of asthma, not only because it is more apt in advanced life to engender organic disease, but because it is also more apt to have organic disease as its cause. The causation of asthma in youth and age is indeed very different. In age there is commonly some appreciable organic basis for it; in youth much more rarely.

So there you have it: six reasons why the youth are more likely to outgrow their asthma. 


References:
  • Salter, Henry Hyde, "On Asthma: It's Pathology and Treatment," 1882, New York, William Wood and Company, pages 135-142  (original publication of chapters in magazines during the 1850s. The articles were compiled and published as a book, the first edition of which was in 1860 in London)

Tuesday, April 15, 2014

1970-1985: No antihistamines for asthmatic boys

As I look back on my asthma past, which I've done a lot lately considering I'm writing a history of asthma, the thing that irritates me the most is that I wasn't allowed to take anything for my allergies.  I had severe allergies, and I was forced to sufferer through every one of them.

The reason this irritates me so much is there were antihistamines available since the 1950s, and there were even antihistamines in the bathroom cabinet at our house, yet I wasn't allowed to take them.  Now I don't know if it was my mom's fault or my doctors, but the reason my mom gave me was because the box states not to use if you have asthma as it "may cause wheezing."

I have severe allergies.  I'm allergic to a variety of molds, dust, fungus, and you name it.  Today I know that when my allergy symptoms are controlled, so controlled is my asthma.  The thing it when you're an adult it's easier to stay away from your allergens.  It's still no fun to avoid them, yet it's possible  

Kids, on the other hand, are under constant pressure of their siblings and friends to play on the ground, the dirt, the woods, etc.  Kids are closer to the ground, where allergens hang out.  Kids roll on the carpet.  Kids play in the basement.  Kids play in old, dusty, worn out forts.  Kids play hide and seek in bushes.  Kids are all over.  It's just what kids do.  

So you can see how it would be hard for a kid to avoid allergens.  As a kid who tried to be as normal as possible, I usually did whatever my brothers and friends wanted to do.  I paid little attention to my allergies, and I usually suffered as a result (although this changed as I got older).  And, when the sniffling and sneezing came about, I was forced to suffer.  When I got older I'd sometimes request a medicine for it.  Yet I was allowed none of it.  I was forced to suffer (My parents had empathy, they just weren't allowed to use antihistamines for me).  

I remember more than once playing with my brothers, and all of a sudden my eye would be swollen shut.  My mom would have me sit in my room, or on the couch, for hours with a hot, washcloth over my eye.  I remember this would happen often while on vacation. If my asthma acted up, that was an added dilemma.  Yet my allergies were something that there was nothing I was allowed except avoidance and warm wash cloths, and sitting like a moron on the couch while everyone else was having fun.  At school I got picked on.

Benadryl was a medicine in the bathroom medicine cabinet also that was marketed as a cure for allergies.  It was available as a prescription since 1946.  But I wasn't allowed to use it.  Perhaps the reason for this goes back to 1949, 21 years before I was born, when the Food and Drug Administration (FDA) cleared Neohetamine as the first antihistamine for sale over the counter without a prescription.  This medicine and a variety of others, including Benadryl, were advertised in magazines all over the U.S. as a remedy for allergies and colds that could be purchased without a prescription.  (1, page 227)

By 1950 there were over 21 over the counter antihistamine products, "packaged under one hundred different trade names in tablets, nasal sprays, eye drops, and creams."  (1, page 216-17) and they were advertised heavily, in what was called by many the "Cold War," according to historian Gregg Mittman.  Consumers started purchasing various antihistamine products believing that they were buying a cure for allergies and colds.  Mittman says that sales of antihistamines boomed.  

People were taking the medicine without reservation, and they were giving it to their kids.  Yet it didn't take long before parents realized antihistamines didn't cure hay fever, and had little effect on colds.  In fact, some were even noticing side effects, especially in children.  In the process of drying out the nasal passages and stopping the nasal drip, the medicine caused dehydration of the respiratory tract, especially if used in excess.  This caused wheezing, and possibly other asthma symptoms.

Mittman explains that "The initial attack on OTC antihistamine drugs came not from consumers or the FDA but from the AMA (American Medical Association)."  So while some were claiming antihistamines were the new miracle drug for colds, "Austin Smith, editor of the Journal of the AMA, declared that 'no one yet knows what harmful effects (antihistamines) may produce on the body in general, or on specific tissues, when taken over prolonged periods of time." (1, page 227)

Various groups started calling for the FDA to force manufacturers of the medicine to list potential side effects.  Mittan quotes the New England Journal of Medicine:  "This is the most striking example to date of the advertising methods of manufacturers and promoters who are steadily going over the heads of the medical profession in attempts essentially to force physicians through their trumped-up public demand to accept remedies before their usefulness has been adequately substantiated and ill effects determined." (2)

Mittman adds:  "While the FTC (Federal Trade Commission) deliberated over whether drug companies had violated federal trade laws, physicians stepped up their attack by alerting the public to the inherent dangers of antihistamines, particularly for children."  Voila.  That's what I was getting at.  I was a child, a direct recipient of this scare. As far as I know the scare may have saved lives, but it forced me to suffer (note: I may have suffered even with antihistamines, although, considering they help me today, I'm going to assume they'd help me back then).  (1, page 230)

Herman Bundesen, president of the Chicago Board of Health, warned that some children had died after "indiscriminate antihistamines use."  Likewise, "Children taking antihistamines for allergy or colds, advised Bundesen, needed to be placed under a physician's care.  Bundesen also advised caution and restraint in embracing antihistamines as the magical cure for children's allergies.  As much as parents might wish it, antihistamines did not eliminate the need for shots, special diets, or environmental control of the home.  The therapeutic effectiveness of antihistamines varied, Bundesen insisted, according to place -- in this case, the body of an individual child" (3)

A June 1950 compromise by the FTC allowed advertisers to continue advertising the products, although they could no longer say that they would "cure, prevent, abort, eliminate, stop, or shorten the duration of the common cold."  In other words, nothing changed.  There was nothing in the FTC decision regarding safety of the medicine. Advertisers, according to Mittman, were allowed to continue as they were already doing. (1, page 230)

The AMA was unhappy by the ruling.  However, an editor in Collier's was "cynical" the way I'm cynical regarding the medical industry (at times). The editorial suggested the AMA was merely hoping "to give the prescribing physician a monopoly on the first promising remedy that ever came along."

I think the same can be said of Ventolin of 2012.  Could you imagine how much business doctors would lose if Ventolin was available over the counter. Asthmatics with little money wouldn't be forced to pay for a doctor to get their hands on one, and they wouldn't have to pay $75 a pop, because the price would undoubtedly go down.  Patients, and parents, could decide how to treat asthma, as opposed to physicians.

I'm not petitioning for OTC Ventolin, I'm just making an example here.  Although, I think instead of scaring parents and doctors away from antihistamine use, the OTC should have provided doctors and parents with a warning such as:  "Use this medicine with caution for young asthmatics.  Consider the benefits with the risks, which are.... if you absolutely need to use this medicine, stop using it if your child appears to have an asthmatic attack as a result of taking the medicine."

Such a warning would have prevented abstaining use for asthmatic/ allergic children such as myself, patients who truly needed the medicine.

So in the 1950s and 1960s there was an ongoing battle:  doctors wanted allergy sufferers to see a doctor, and FTC and FDA wanted patients to be able to treat their own allergies, much like they treat their own colds.  (1, page 231)

To add to the scare, it must be added here that by that Mittman notes that by the mid 1950s it was observed that antihistamines did not do anything to stop an asthma attack, that was a job for bronchodilators.  (1, page 231) This must have been an added disincentive for doctors to prescribe antihistamines for young asthmatics.

Adults could do whatever was needed to get the medicine that allowed them to function in life.  Yet a child, as I was in the 1970s, had to rely on his physician and parents to not only observe the allergy and cold symptoms, but to do something about it.  I was basically at the whim of the warning on the box that warned against using on children and especially children with asthma. As a result I had to suffer despite the remedy in the medicine cabinet.

Instead of doing that, instead of scaring physicians from prescribing a medicine that might have taken the edge off the suffering of a boy with allergies and asthma, they should have warned physicians to weigh the possible advantages with possible side effects.  Physicians should have been warned to trial patients on the antihistamines, although monitor them closely.

Parents should not have been scared into not giving antihistamines to the one person in the household who would truly benefit from them.  Because, I can honestly say, while antihistamines don't take away all the symptoms of allergies, they sure do help.  Today I use Claratin every day, and it's a wonderful medicine.  Claritin is nice not only because it relieves and prevents allergy symptoms, it doesn't make you drowsy like Benadryl.

I also have to add here that when I was a patient at National Jewish Hospital/ National Asthma Center in Denver in 1985, my doctors there prescribed a daily dose of Drixoral.  Yet when I returned home my mom told me I didn't need it so she quit buying it for me. The irony is I probably needed the Drixorol more at home where the entire house was full of allergens, as compared to at the hospital where the only allergens was pollen and whatever other pollution was in the outside air (and only when I was outside, considering most windows were sealed).

So I suppose there was ignorance on both sides of the isle here.  Still, it frustrates me as I look back.  It frustrates me as I see myself suffering, and out of ignorance I wasn't treated. Although, as the old saying goes, do the best you can with the knowledge you know today, and as you learn better you do better.

My parents were also told to get rid of the dog.  My parents were also told to get rid of the plants.  My parents were told lots of things, and they didn't do much.  They did do some.  They replaced the wood heating vents in my room with steam heating vents.  Yet they still burned wood in the basement, and stored wood down there, because it was a cheaper way to heat the house.  Lord knows wood holds mold, and wood smoke triggers asthma by itself.

I empathize with my parents not doing much, however, because they were simply trying to live within their means  Plus neither of the had asthma or allergies, so even while they witnessed my suffering, they may not have fully understood it

I think of those years every time a young asthmatic passes through the ER when I'm working.  I treat patients with a heavy heart when they are in the ER because they can't afford Advair, which costs $220 a pop , or even Ventolin, which costs $73 a pop.  Lacking health insurance, lacking a good paying job, many of these asthmatic/ allergy sufferers have no option but to go to the ER when their asthma acts up.  They have to treat exacerbations as opposed to preventing symptoms. (Prices are in 2012 values)

References:
  1. Mittman, Gregg, "Breathing Space," 2007, New Haven and London, Yale University Press
  2. Mittman, op cit, page 229, quoted from: "MDs Hit Unlimited Antihistamine Use," Drug Trade News, 9 January, 1950, page 35
  3. Mittman, op cit, page 230, quoted from:  Herman Bundesen, "Dangers for Youngsters in Antihistamines," Ladies' Home Journal, June 1950, pages 192, 194

Thursday, April 10, 2014

1850s: Salter's prognosis for asthmatics

What is the prognosis for your asthma? What are the chances you will outgrow your asthma?  With everything else being coeteris paribus (equal), the answer to this question may depend on the following:

1.  Age of the patient:  Patients who develop asthma under the age of 40 are more likely to outgrow their asthma than those over the age of 40.  Barring organic injury, asthmatics under the age of 15 are most likely to "gradually 'grow out'" of their asthma.  Those over 40 have a "fair chance" of outgrowing it.  (1, page 168-9)

2.  Absence of organic disease:  You are most likely to outgrow your asthma if you do not have any pulmonary or circulatory organic changes, such as chronic bronchitis or heart failure. "If the heart and lungs are completely free of organic disease, recovery is possible." If an organic disease exists that causes bronchospasm or is the cause of the asthma, "recovery is impossible" (which is more likely to be the case in asthmatics over the age of 40).  If the "cause is incurable," so to "is its consequence." (1, page 170)

3.  Length of attacks:  Repeated attacks cause damage to the lungs by causing "permanent pulmonary congestion. At each attack the shutting off of air by the narrowed bronchules suspends the normal respiratory changes of the blood in the capillaries. This produces arrest in and ultimately engorgement of the whole pulmonary circulation, capillary and venous. Now this pulmonary congestion... becomes formidible and intractible in proportion to the length of time it has existed. If the atatck is short, and the speedy relaxation of the bronchial tubes quickly readmits a free supply of air, the vessels are at once relieved, the blood passes on, and the transcient congestion leaves no trace behind it." If the attacks last several days or weeks, "the capillaries and venules, long distended, never comletely recover themselves, their tone is lost, and pulmonary congestion, manifested by chronic dyspnoea and expiration, is permanent." The chronic pulmonary congestion occludes the bronchial tubes with mucus and becomes a permanent source of bronchial irritation (it becomes a permanent exciting cause of asthma). (1, page 170)

4.  Frequency of attacks:  "If the intervals are so short that the lungs have not time completely to recover from one attack before the occurance of another, the omen is very bad, because the mischief of each attack being engrafted on some portion of that of its predicessor, the organic derangement is accumulative, and the case one of progressive disorganization."

5.  Completeness of recovery:  If the patient recovers completely between attacks, then you can rest assured there is no permanent permanent organic changes to the pulmonary circulation. If dyspnea persists between attacks, you can rest assured that probably has been some organic changes.

6.  Persistence of exporation:  If the patient is chronically coughing and spitting up secretions from the lungs, this is a bad sign.  It generally means the patient probably has humoral asthma, which by all means is probably chronic bronchitis more so than asthma.  It is definitely chronic in nature and this type of asthma will not go away. 

8.  Direction disease is taking:  Are attacks becoming less intense or more severe? Are they more frequent or less frequent? Are they severe and more frequent, or milder and more distant? Since the loss of asthma is generally gradual, less frequent and milder attacks is a good indicator the asthma may someday disappear.

9.  Ability to detect exciting cause:  Asthma is easier to treat and cure when the exciting cause is known.  If the exciting cause is living in the country, then the remedy may be simply moving to the city.  If the cause is eating a large meal, the remedy and cure will be eating light meals.  If the exciting cause cannot be detected, or if there are many exciting causes, the "omen is bad."

Salter concludes by noting the following:  "If, then, an asthmatic were to present himself to me and seek my opinion as to his prospects... (after) carefully scrutinized the condition of his chest, put to him the following questions:
  • What is your age? (if not already ascertained)
  • How long do your attacks last?
  • How often do they occur? 
  • Do you lose all traces of shortness or difficulty of breathing between the attacks; or is the breathing always a little difficult?
  • Do you habitually cough and spit?
  • Does the disease appear gaining on you, or the reverse?
  • Is the exciting cause of the attacks clear; and can you undertake that it shall not recur? (1, page 172)
References:
  • Salter, Henry Hyde, "On Asthma: It's Pathology and Treatment," 1882, New York, William Wood and Company, pages 168-172  (original publication of chapters in magazines during the 1850s. The articles were compiled and published as a book, the first edition of which was in 1860 in London)

Tuesday, April 08, 2014

1930: Pneumostat, the first electric nebulizer

Pneumostat in use (2)
While a variety of steam inhalers were available in 1850, it was learned that the best way of getting medication to the lungs was not by steam but by mist.  Between the 1850s and 1930 there were a ton of inhaler and nebulizer devises made, but none were ideal.

The problem with these early mist producing inhalers is they required manpower to create the flow needed to create the mist.  As with other industries, the ability to control electricity changed everything.  Marketers soon started playing with the idea of creating an electric nebulizer.  

The first one to enter the market was produced by Weil in Frankfort.
It as a compact unit, meaning it was a combination compressor and nebulizer.  The comperssor created the electricity that created the flow to turn the solution of water and medicine to a mist. 

According to "Controlled Pulmonary Drug Delivery, it was a "110-120 volt machine was supplied in UK by Riddle to nebulize bronchovydrin (papaverine and eumydrine)."   (1, page 68)

Pneumostat (2)
Bronchovydrin also had adrenaline (epinephrine) and atropine in it.  It was a solution used to provide quick relief of an asthma attack.  I really had a hard time finding any other information on it, although it was used by lifelong asthmatic Harold Beck.

The electric nebulizer of the 1930s was epensive, so the physician may prefer to have the patient use a nebulizer where the flow is generated by hand power, like it was prior to the electric device.  One option would be the Adrenaline Inhaler or the Devilbiss No. 40 Glass Nebulizer.

Considering the bulkiness and cost of this machine, it was common for a pharmacist to own one, and for patients in need to visit that pharmacist. (3)

References:
  1. Smyth, Hugh D.C., "Controlled Pulmonary Drug Delivery," 
  2. Sanders, Mark, "Pneumostat," Inhalatorium.com, page 131, http://www.inhalatorium.com/page131.html
  3. Nickander, K, Mark Sanders, "The early evolution of nebulizers," MedicaMundi, 2010, 54/3, pages 47-53

Thursday, April 03, 2014

1850s: The stomach causes asthma

Due to the relationship between the stomach and lungs, "in no direction is asthma more accessible than through the stomach," or so surmised the infamous asthma expert Dr. Henry Hyde Salter.  And, therefore, one of the best ways of preventing asthma attacks is by eating small, healthy meals.  

The reason for this is "due to the close relationship between the stomach and lungs," writes Salter.  What you put into your stomach can and will trigger your asthma, and therefore, to prevent an attack, you must consider a proper eating regimen, and this is among the first things Dr. Salter would consider when taking you in as an asthma patient.  The remedy that worked was a remedy, and the preventative treatment was to eat less food on Sundays.  

For instance, Dr. Salter was requested at the home of a boy who presented with a case of asthma.  Upon questioning the boy and his family, Dr. Salter realized that the attacks occurred every Monday.  Then, upon further questioning, it was learned that Sundays was a day when the family participated in a great feast.  So it was wise of Dr. Salter to surmise the asthma was brought on through due to a full stomach.

So there are various ways asthma can be caused through the stomach. (1, page 135)

1.  Dyspepsia:  (Upset stomach; indigestion)  Asthmatics are generally dyspeptics. Rarely do you find an asthmatics with a perfectly strong, sound stomach.  "The stomach and lung symptoms are part of one morbid condition; the whole thing is deranged pneumogastric innervation, and the asthma of the pulmonary portion of it." (1, page 135)
  • Their stomachs are irritable, 
  • Their digestion capricious and irregular
  • Dietary restricted
2.  Errors in diet:  "To prevent asthma the most scrupulous care is necessary in all that relates to food," with any of the following bringing on an attack:
  • A debauch (self indulgence)
  • A late dinner
  • A heavy supper*
3.  After meals:  Asthma has a tendency to follow shortly after meals, and when an attack is on the asthmatic will feel obliged to starve as long as the attack is upon him.  Since the asthmatic will continue to have an appetite for food, this starvation only adds to the suffering.  (1, page 137)

4.  Gastric symptoms: 
  •  Flatulence
  •  Hiccough,
  •  Etc.  
By the observation that any of the above may cause asthma that Salter came up with his theory that "the taking of food (either by its mere presence in the stomach, or by the process or results of digestion) acts as an irritant to the morbidity irritable pulmonary nervous system. The affair is excito-motory; the food is the immediate or remote irritant, the nervous circuit involved is the pneumogastric, and perhaps in part the sympathetic; and, in obedience to the common law of reflex action, the potency of the stimulus is increased, or, in other words, the reflex nervous irritability is exalted, by the condition of sleep."

The remedy:  Basically, a diet should have consist of three qualities: it should be small in quantity, highly nourishing, and of easy digestion. 
  • Eat a healthy diet
  • Don't eat too late in the day, or too soon before sleep*
  • Do not eat food that is indigestible (should be plain and well cooked)
  • Foods should vary; do not give same foods over and over again
  • Foods should be nutritious (due to less food eaten in a day by asthmatis)
  • Avoid meat pies, beef steak, kidney pudding 
  • Avoid drinks containing carbolic acid (Bottled Scout, Scotch ale, etc.)
  • Avoid strong coffee with sugar (undigestible)
  • Avoid any unwholsome foods (as in all of the above)
  • Avoid eating too much (because it's indigestible, not because a full stomach presses up on diaphragm)
  • It is better to eat a large meal at breakfast, as opposed to a large meal at dinner time (this may be due to the fact the stomach has better digesting power in the morning.  As the day progresses, the digesting power becomes "exhausted by succeeding meals) (1, page 141)
  • Nights rest (restores digesting power of stomach)
The most important thing to remember regarding diet is this:  *let no food betaken after such time in the day as will allow digestion being completed and the stomach empty before going to bed

The following is Salter's recommended asthma diet:
For breakfast, a small basin, or breakfast-cup, of bread-and-milk, and besides this, an egg (two for a strong man with a good appetite), or a mutton-chop, or some cold chicken or game. As a drink, if any is required besides the bread-and-milk, I think tea is better.than coffee, cocoa better than tea, and milk-and-water better than either. For dinner (not before two or after four o'clock), let mutton be the staple meat, beef or lamb but rarely, pork or veal never. A little succulent vegetable and potato should be taken; and a little farinaceous pudding, or stewed fruit, or the fruit of a tart, should conclude the dinner. Only one helping of either meat or pudding. I believe, unless there is some special reason to the contrary, that water is the be3t accompaniment to an asthmatic's dinner. No cheese, no dessert. A great sufferer from hay asthma tells me that a little boiled fish and brandy-and-water have the least tendency to bring on his asthma of anything he can take; he can take this when a dinner of butchers' meat would be certain to be followed by difficult breathing. With regard to the brandy-and-water I will not speak positively of its advantages in hay asthma, but in ordinary asthma I do not like stimulus of any kind. With regard to the fish there can be no doubt that it is less of a diet, yields more readily and rapidly to digestion, than butchers' meat, and is, therefore, less provocative of any evil depending on prolonged and laborious digestive effort.' And here let me observe that butchers' meat is of all foods (with the exception of those particular articles of diet which are specially offensive to asthma, and to which I shall refer presently) that which is most apt to aggravate asthmatic dyspnoea, and it is because dinner is a meat meal that it is necessary to take it so early. From any occasional late meal that convenience, or circumstances, may force upon the asthmatic, butchers' meat should always be excluded.
Basically, based on this theory, Salter would question his patient as to his diet.  If you have an asthmatic, for instance, who eats butchers meat every day at 1 p.m. and who later has an asthma attack, then the solution may be eliminating the butchers meat.  If someone eats too late in the day, perhaps the solution is to eat earlier, eat less, or stay up later.

Now keep in mind here this is just a recommendation.  Salter was of the belief that what works for one asthmatic may not work for another, and that is why he was usually up to the idea of the patient experimenting to find what remedy -- or diet -- works best for him.

*A heavy supper causes a full and bloated stomach.  This will cause the stomach to press up against the diaphragm creating less room for the lungs to expand.  Some believe this causes asthma.  Salter believes this theory to be false, that a full stomach causes asthma because "the bulk of the food diminished digesting power by over-distending the stomach and so paralyzing its movements, and by being altogether in excess of the secreting powers of the gastric mucous membrane."  This in turn renders the food indigestible. If the mechanical theory were true the asthma would come on in direct proportion to the stomachs bulk, which is not true.  When eating healthy foods, such as arrow root, one can eat all he wants and this will not bring on a fit of asthma.  He may drink water all he wants, and this will not cause asthma. Another proof of Salter's theory is that asthma does not come on immediately after eating when the stomach is most full, but an hour or two later. Relief by an emetic is not mechanical, as it relieves asthma the moment nausea is felt, not upon vomiting. An emetic works even when the stomach is empty.(1, page 141)

References:
  • Salter, Henry Hyde, "On Asthma: It's Pathology and Treatment," 1882, New York, William Wood and Company, pages 168-9  (original publication of chapters in magazines during the 1850s. The articles were compiled and published as a book, the first edition of which was in 1860 in London)