1840 bronchospasm proved

Charles J.B. Williams proved that asthma was a disease of bronchospasm way back in 1840. You can read about his experiments in the book "The Pathology and Diagnosis of Diseases of the Chest," (4th edition, London, 1840, p. 320).

He's the same doctor who "suggests the word lub dub as conveying a notion of the two sounds" of the heart. Of course the lub being the sound produced by the contraction of the ventricles of the heart, and the dub being the reflux of the blood against the valves of the heart.

I obtained this information from "The Medical Lexicon: A dictionary of Medical Science," which was published in 1866 (page 466).

According to J. Lotval, "Contractility of Lungs and air tubes: experiments performed in 1840 by Charles J.B. Williams, (1994)"the main theory about asthma in the 18th century was that it was a disease of excess mucus, and in the 19th century it was recognized that airflow obstruction may also be due to airway smooth muscle contraction.

The London physician did a series of tests that proved bronchospasm. J.B. Berkhart in his 1878 book, "On Asthma: It's Pathology and Treatment," (page 25-26) wrote that:

"Bronchial contractility was denied as often as asserted, Dr. C.J.B. Williams again took the question up in order to settle the matter in dispute. He, indeed, succeeded in showing, by experiments conducted with all necessary precautions, that mechanical, as well as chemical and electrical stimuli do produce contraction of the air tubes. Thus the theory of bronchial spasm obtained the support of experimental physiology. And even those who until then wavered in their opinions as to the possibility of such a spasm saw now no reason for doubting, but readily accepted that doctrine.

According to Lotvall, Williams also proved that the bronchospasm was "abolished by belladonna and strammonium (anticholinergics)" and the effects of these medicines wore off over time. Also, and interestingly enough, he proved that Morphine "inhibited" bronchospasm.

In fact, in his 1864 book, "On Asthma: It's Pathology and Treatment (page 24)," Dr. Henry Hyde Salter wrote that the experiments of Williams and others like him (Longet and Volkmann verified William's discovery) "might have saved the spasm theory of asthma."

Yet even though it was scientifically proven, there remained those who continued to doubt, and many who refused to remove themselves from the paradigm that asthma was a disease of the humours or caused significantly by sputum or that it was a nervous affection.

We'll investigate the doubters next week.

Sneaking away from the asthma hospital

Unlike most patients of 2-May, patients of 7-Goodman had to have permission to leave the floor -- except at night.  At night we kids had free roam of the entire hospital, and all the tunnels.  You could have a lot of fun with all the available stomping grounds under National Jewish.

The usual culprits were my room mate Eric, a girl named Trisha and whatever friend she decided to drag along, and whatever kid Eric decided to drag along.  After Sean was admitted he and Eric became good friends, and the usually 7-Goodman sneak-a-way team. 

Those who were participating got their pajamas on, curled up in their beds, and turned out the light.  Then the radios were turned on.  Back home I was used to sleeping in the silence, so I hated the radio being on all night.  I actually complained about it during weekly group, and to my counselor, but nothing was ever done.  So I dropped it.  Yet then, by mere chance, I discovered the real reason for the tunes.

With Madonna's Material Girl playing softly, I watched as Eric shifted out of bed and into the next room.  I heard some whispering and then silence.  After a few minutes I hopped out of bed and peered around the corner.  Through the flickering light produced from a small black and white TV I saw the back of a shoe and the watched as Marti replaced the drop ceiling and curled back into his bed.

That was last night.  This night -- coincidentally -- Material Girl was on the radio again as I peered into the next room.  Willie, a portly black kid from Chicago who was wearing all long-johns, was facing opposite me and performing his famous break dance moves.

I learned by now the sneak-aways occurred right around eleven, long enough after the 9:30 p.m. bedtime that most of us would be sleeping -- at least us kids most likely to snitch.  Yet I don't think the sneak-away-kids realized this, yet to snitch would instantly place a kid on the outcast list, and the rest of your stay would be pure hell. 

So they'd wait till the rest of us were sleeping to reduce the snitch risk yet mainly they waited for the 11 pm.m nursing shift change when the nurses were giving report.  Their talking, and the sound of music, muffled out any noise -- ideally it did anyway.  I never slept through the sneak-a-ways because I was a light sleeper, yet I never revealed my position.

The operation went quick.  It went like this:

11:00 Marti would stand on his bed.  Marti's bed worked best because it was snug up to the wall, and there were no wires or pipes above the drop ceiling.  Jeff would hop out of his bed and onto Marti's, and Marti would hop off.  Jeff was the tallest so he'd stand on the bed and help any participators up.

 Karl was a cool, very intelligent black kid from Atlanta.  He was a 7-Goodman patient the longest when I arrived, and he earned a private room and a TV.  While I never saw him sneak away, he'd bring out his TV just for the light. 

So under the flickering black and white light of the TV I watched -- my head peering around the corner --as Jeff stood on the bed and assisted Eric and then Sean -- the only time I ever saw him without his race cap in those early days, so his hair was astray in his face -- climb up, using the edge of the brick wall for support. 

Obviously you couldn't walk on the drop ceiling, so the kids walked along the tops of the walls.  I heard a story of a kid who fell through about five years earlier, giving away our secret.  Yet that was long ago, and hopefully forgotten. 

11:03 Jeff replaces the drop ceiling and climbs into his bed.  Karl grabs his TV and returns it to his room.  In an hour there would be a light tap over Marti's bed.  Jeff would assist in helping the kids climb down.

The girls would sneak away too, and sometimes they'd meet up with a kid or two from 2-May in some hidden cove under the buildings.  A cigarette would be smoked, and perhaps even a joint of marijuana. Either that or a trip to the store across the street was in order.

After I was admitted to 2-May I learned it was easier to sneak away from that floor.  The kids waited until the nurses were asleep and sneak out the slip of a window and walk along the edge of the building to where there was a hill. They'd jump off and have their way. 

The problem with sneaking away from 2-May is they didn't have access to the 7-Goodman elevator to the basement and the tunnels, so they had to have their fun outside. 

One night I was exceptionally tired and studying for an exam when I turned and saw my friend Gary in the window.  I was startled and let out a scream.  Gary rushed away, just in time so the nurse who came in to check on me didn't see him.  Yet it didnt' matter.  The gig was up.  It took me a long time to live that down.  I never snitched, yet I know Gary was busted when the counselors did a room check.

So needless to say I was on the do-not-trust list.  I did get off it eventually, but not because Gary decided to speak to me again.  The reason was because at an asthma institution patients come, and patients get discharged.  Thankfully for me Gary's stay wasn't long.

Back when I was on 7-Goodman there was one time I almost slipped up.  I was in the front rear seat of the National Jewish van.  The van was packed with kids.  PE instructor Charlene was driving, and PE instructor Jeff was in the passenger seat.  As we the van moved down E. Colfax Avenue the NJH complex was to our right, yet to our left was the old and empty National Asthma Center building.

I said, "It would be cool to walk around that building some night."

Charlene turned and gave me a dark stare, as well did the other kids.  I was wasn't thinking at all about sneaking away to that place, I just love history.  Yet it was this incident that made me aware of another nightly journey was to that old building. 

I can tell this story now because I've heard 7-Goodman and 2-May have since been closed.  I imagine the liability and stress of taking care of teens was part of it.  Yet I imagine improved asthma wisdom was probably the main reason for the closure.

1899: Is asthma simply a "Nerve Storms"

Nerve Storm: Seizure, as in seizure of the entire body (epilepsy), seizure of the muscles of a certain joint (gout) or seizure of the respiratory bronchi (asthma). The seizure is caused by some imbalance either internal (emotion) or external that triggers the abnormal response of the brain.

I've read about asthma being described this way in many older journals, yet Dr. Joe Shoemaker in his 1899 book, "The Monthly Encyclopedia of Practical Medicine" (Philadelphia, Vol. XIII) uses this term.

He further describes asthma as:

• A disease essentially due to some nervous change (this was the accepted dogma of the time)
• Partial hereditary (so we still think this)
• It's occurrence is largely in "neurotic" subjects
• It's occurrence in families subject to migraine (hmmm, where does this come from?)
• Attacks are characteristic of asthma (dyspnea due to bronchospasm)
• Pt inclined to hold to a chair or bed railing firmly to help expiratory muscles of expiration
• And all this is caused by a "nervous storm"
• Triggered by some unknown cause
• The cause of who has such a "nervous change" also remains a mystery
• It's seen in children and some adults
• It's rare
• Sudden in onset
• Occurs between 2-4 a.m. (remember, this is based on his observations)
• Accessory and natural muscles of respiration are contracting vigorously
• Dusky face shows embarrassment to circulation and deficient oxygen in the blood
• Sweating skin shows muscular exertion
• Lungs enlarged during paroxysm
• Yet auscultation shows little to no air entering them
• No normal respiratory murmur, instead expiratory whistle is heard upon austultation
• Sonorous rhonchi often heard (which is what we now call a wheeze)
• Duration of attack is variable, yet is often over by morning
• Duration may last 24 hours or longer
• Attack ends with expulsion of mucus
• No continued cough or expectoration

This is all part of the nervous storm we call asthma. What do you think?

My introduction to Albuterol

It's neat what memories a quick perusal of your medical records jogs.  For some reason I thought Ventolin was introduced to the market in the early 1990s, yet upon reading my National Jewish medical records I see the Albuterol inhaler was ordered for me to use as needed.  That was back in January of 1985. 

When I was on 7-Goodman we didn't get to carry our own meds, so when we went places, or if we had physical education, the PE instructor carried the only inhaler.  We kids would huddle around when he was giving out puffs like flies around maneur.

He would pass it from kid to kid until we all had our pre-exercise puffs.  We didn't even use spacers.  We were, however, taught to hold the inhaler two finger lengths from your mouth and inhale that way.  In fact, that's still how I use my inhaler to this day.

I don't remember one time anyone at National Jewish mentioning a spacer.  I don't think they even existed.  I had been informed about them prior to National Jewish, but there wasn't one on the market.  What I was taught to use was a toilet paper roll. 

Before I was at National Jewish the rescue medicine I used was Alupent.  Once at NJH it was Albuterol. To be honest, I have no idea why this was.  I know that Albuterol is supposed to have much fewer side effects, yet if that was the reason we used it, then why was I prescribed Alupent when I took nebulizer treatments?

You could also think it could be cost, yet, again, if cost was the reason, then why was I prescribed Alupent for my breathing treatments.  In fact, even when I was discharged from NJH/NAC I was still using alupent nebs and Albuterol inhaler.  That's how it was until 1991 when I learned about the Albuterol solution.  Is it possible Albuterol simply wasn't available as a solution in 1985? 

Either way, that's how it was.  And each time we had an event we'd all use the same inhaler.  We just passed it from one kid to the next until we were all finished puffing up.  Most of the time we used it this way before exercising, yet some of the times we used it this way when we were on excursions outside the hospital. 

For example, after we'd be roaming the mall for a few hours one of us asthmatics would say, "I'm a little short of breath.  Can we use the Albuterol now?"  If Jeff thought it was time for a scheduled dose, or if one of us really needed it, he would pass it around again.  That's just how we did it.

Another memory jogged here is that when we went on excursions outside the hospital we'd always have to lug an oxygen tank with us.  On my first trip to the mall I was told the newest patient had to pull it around.  Thankfully January was a busy month for admissions, because I only had to do it once.  Although I did volunteer to lug it around once or twice.

We had to lug the oxygen around just in case one of us had a bad attack, although I don't ever recall it ever having to be used.  I never heard a story about it ever being used before I was admitted either.

Another thing we did back then was we all used the same vials of medicine solution for our breathing treatments.  We used a syringe to draw up the medicine, yet I'm sure this caused some contamination.  In fact, when I became an RT in 1995 we still used this method.  I think it was sometime in the 2000s that Albuterol and Alupent came premixed with normal saline in those nice little plastic amps.

Doctor anxiety

I've been seen by so many doctors in my life I can't even begin to count how many there's been.  And now, even while I work with my doctor, I still get doctor anxiety.  You'd think I'd be used to doctors by now, yet you'd be wrong.

As I sat on the crunchy paper on the exam table many things wafted through my mind that I wanted to talk to my doctor about, and then I'd talk myself out of it.  By the time he walked into the room all I said was, "Hey, how's it going?"

The doctor sat in his chair clicking on his little computer, spending most of his time trying to find out what medicines I was on.  Although had he asked I would have just told him.  Then he had me lie down and patted my abdomen, listened to my heart, and that was it.  Before I knew it he was walking out the door.

He stopped in the doorway and asked me if I thought Singulari did any good.  "My other patient's don't report any benefit from it," he said.  "You should experiment going off it and see if you notice a difference."

"I already did that," I said.  "When you're paying a dollar a pill you want to make sure it's worthwhile.  Yet I'll try it again sometime."

"Yeah," he said, "but after the allergy season is over."

"Sure thing."

The he asked me if I ever thought about trying Symbicort.  As I was walking out of the office he tossed a Dulera inhaler at me and said, "Try this, it's similar to Symbicort."

"I never heard of this one," I said.  Yet that was the anxiety talking.  I did hear about it.  Yet here I was leaving the doctor's office yet again not having discussed anything I wanted to discuss.

However, I wanted to talk to him about possibly adding another inhaled corticosteroid on top of the Advair to see if it gives me any benefit, yet I think the Dulera would be the next rational trial before taking that step anyway.

What is it about doctors and anxiety anyway?  They're humans.  And, worse, I work with my doctor every day, so why would I be uncomfortable with him as my doctor.

The answer, I think, is that guys like me don't like talking about themselves.  I hate being the center of attention.  So it only makes sense I'd hate a doctor asking me about... me.  Thoughts.

I'm trying Dulera

Dulera was approved in June 2010

My doctor recommended for kicks and grins I try Symbicort instead of Advair. Yet after searching his cupboard realized he didn't have any free samples left, so he grabbed a Dulera and tossed it at me. "Try this," he said. "It's basically the same as Symbicort."

Dulera was approved by the FDA as another option in the line of Advair and Symbicort. The LABA in it is the same as what's in Symbacort, and the inhaled corticosteroid is the same as Azmanex twisthaler, which was approved by the FDA in 2005.

I have read in a few places that the particle size of fluticasone (the inhaled steroid in Advair) is larger due to the fact it's a dry powder inhaler. The particle size of Dulera are smaller and may reach deeper into the lungs to provide a more even dispersion of the medicine.

However, I have not been able to set my eyes on any studies other than the initial studies completed by the company that prove that using Dulera is better than not using any asthma controller medications. I would like to see some studies proving that Dulera is better than Advair or Symbicort.

Formoterol, the LABA in Dulera and Symbicort, is faster acting than Salmeterol, the LABA in Advair. Other than that I'm not sure of any proven benefits of one of these combination inhalers over the others.

However, unlike Advair, Dulera is a metered dose inhaler, and therefore to get the maximum effect a spacer device must be used. That should make it a little more inconvenient because I think spacers are more of a bother than they're worth. Yet we'll see how that goes.

So if any of my readers has access to any further Dulera studies let me know. Other than that, I'll report back in a month when my sample of Dulera is used up, if the side effects of formoterol don't get to me first.

1818 doctor claims asthma is cardiac asthma

Writing as early as 1818 Professor Louis Rostan wrote that he did not believe in nervous asthma. In fact, he went as far to conclude in his writings that asthma was not even so much asthma but was nothing more than cardiac asthma.

J.B. Berkart, in his book "On Asthma: It's pathology and Treatment," 1878, mentioned on page 22 that Rostan had always found some pathological explanation for dypsnea, such as the heart, and therefore had "no reason to assign this to a derangement of the nervous system."

Likewise, Berkart writes on page 32 that Rostan believed "emphysema was a disease of gradual and insidious development, it therefore seemed to them highly probable that the asthmatic paroxysm were merely its precursory symptom." 

He thus believed asthma was a symptoms of emphysema.  Ironically, he got it backward.  Asthma sometimes results in emphysema (air trapping).  And asthma and emphysema have nothing to do with cardiac asthma, even though the two are still often confused even to this day..

In the "Medical and Surgical Journal," published in 1859 and edited by W.W. Morton (page 517), it was likewise noted by the chapter author (Prof. Trouseau) that Rostan did not believe in nervous asthma, and what he "regarded it (asthma) as being symptomatic of affections of the heart."

The authors also note that when Rostan was a physician who studied old men, and based on his studies determined there was no difference between asthma and dyspnea. The author (Trouseau) disagreed.

Rostan's theory arose from the fact he studied older men and women with dyspnea, and determined the cause was not asthma but heart failure (cardiac asthma). So most of Rostan's cases probably weren't even asthma to start with. Thus you can see why he might come up with the theory that all dyspnea and asthma were one and the same.

Berkhart writes that he is wrong and vague in his descriptions of asthma. Yet while Berkhart says this, he was not much closer to the true definition of asthma as the man he was critiquing.  Yet he didn't know this.

Trouseau's view was that asthma was a "malady" separate from cardiac asthma, in that sometimes it causes dyspnea, yet also it can cause episodes of gout "or gout in a more diffused form, in attacks of gravel, or rheumatism."

He further notes that if all dyspnea were asthma, then all that is short of breath would be asthma. Or, if all that is dyspnea is asthma, then all diseases of the heart would be asthma, all diseases of the great vessels would be asthma, all cases of dyspnea caused by edema of the glottis would be asthma (I believe he's referring to epiglotitis), and all dyspnea caused by croup would also be asthma.

In retrospect, Trouseau makes a good point here, although he's not exactly correct on his definition of asthma as we define it today.

He also notes that even mild heart disease might cause dyspnea with exertion, such as walking, and this might happen with regularity. While asthma may cause dyspnea, it does not happen with regularity, and generally occurs due to something other than exertion. Sometimes the cause is emotion, and sometimes something else altogether.

He also relates asthma to a fever, where it usually comes on slowly, whereby cardiac asthma occurs suddenly. He figured this out in 1818, and today some nurses and doctors still call upon my services to give bronchodilator breathing treatments for all that is dyspnea. It's interesting anyway to consider this. Still, Trouseau still considered both fever and asthma nervous in origin.

Then the nervous asthmatic and the person with a fever is left with perfect health until the next episode. Heart disease comes on abruptly, and never completely leaves the person in a state of perfect health between episodes as does asthma. It is always threatening to cause dyspnea.

The patient with cardiac asthma will always fear dyspnea with every exertion, while this is not the case with asthma. The asthmatic will, between events, follow his normal course of life.

However, he further notes, this does not rule out that someone with heart disease cannot have asthma and vice versal.

While we know Rostan was correct in his assertion asthma was not nervous, he was incorrect in his assertion that asthma was cardiac related. However, while he may not have came up with the diagnosis of cardiac asthma, he came up with the term.

Which is funny, because here we are in 2011 and most doctors still treat cardiac asthma as though it were real asthma.

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Can I excel despite asthma?

I've done this with quite a bit of success on my other blogs, so I thought I'd try it here at Hardluck Asthma. I like to check my statcounter to see what searches are leading readers here. Assuming the queries were not answered, I provide here my humble responses.

1. Can I smoke even though I have asthma? Yes you can, yet why would you want to. Smoking is linked to worsening asthma, and can even cause severe asthma. If you smoke and have asthma, here's 20 incentives to quit.

2. I have asthma and I can't smell:  Seventy five percent of asthmatics are believed to have allergies, and about 75 percent of asthmatics also have a history of rhinitis and sinusitis. All of these cause inflammation of the nasal passages which in turn can effect your sense of smell. I've had this problem in the past, and still do at times. The best treatment is to work with your doctor to find a good medicine regime to help you out.

3. Can I excel despite asthma?  Yes you sure can. Asthma wisdom and medicine has improved so much in the past 20 years to the point where most asthmatics should be able to live a normal active life. You'll have to work with your doctor though, and continue reading about asthma and how to control it. For good tips on how to control your asthma click here.

4. What's the 18th century name for asthma? Actually, in the 18th century asthma was called asthma. Nasal inflammation was called catarrh. Allergies were described yet not yet identified. Chronic bronchitis, cystic fibrosis, allergies, and many other causes of wheezes and shortness of breath were often all associated with asthma. There were often various classifications of asthma, yet these classifications were usually different from doctor to doctor.  For the most part, 18th century doctors described any condition that caused dyspnea or a wheeze as asthma.  For more click here.

5. Have you achieved excellence despite asthma? I have five blogs, a great job, a wonderful wife, great kids, and an overall wonderful life. To learn how asthma has benefited my life, click here and here

6. Is asthma a nervous condition? No. It was believed to be in the 19th century, yet by 1950 that theory was proven wrong. Stress and Depression may be linked to asthma, and may trigger asthma, but asthma is a real physical condition, not a mental disorder. Click here for more.

7. What are asthma organs? Asthma is more than just a lung disease. I write about this here.

8. Can a barrel chest go away with asthma? Yes it can. It's caused because air gets trapped in your lungs. Once you gain control of your asthma it will go away. I know because mine went away.

So there you have it. If you have any further questions you are free to email me absolutely any time. Thanks.