Toilet seat inhaler

As I've written many times I lose inhalers left and right.  My son must have found one and was playing with it when I suddenly heard a slam in the bathroom.

My initial reaction was that he had his hand slammed in the toilet -- again.  Yet upon entering the room he was just standing next to the toilet crying.  I picked him up and end of story.

Three hours later I'm at work and my wife sent me the following picture.  Apparently he was holding the inhaler when the seat slammed.  I just thought I'd share this with my readers. 

360-460 B.C.: What did Hippocrates think about asthma?

Hippocrates

If you peruse ancient writings you'll find many references to asthma, or at least asthma-like symptoms. The ancient Egyptians, Greeks, Chinese and even Japanese all recorded asthma-like events and the remedies to go along with them.  Yet it was Hippocrates,  particularly in his book Corpus Hippocraticum, who made asthma a household name.

By his writings Hippocrates is considered to be the father of medicine.  His father was a physician, and he learned much of his skill, technique and work ethic from his father.  During his career he practiced medicine in Greece and Asia minor, and he spent considerable time teaching at the School of Cos.

According to Plinio Prioreschi in his book, "A History of Medicine:  Vol . II -- Greek Medicine," We don't know his size, stature, or even his personality.  In fact, we don't even know if all the treaties attributed to him in the Corpus were even his ideas.  Likewise, most of the statues of him weren't even created until after his demise.

When Hippocrates walked the grounds of Greece from about 460-360 BC, or the 5th and 4th Centuries BC, many physicians believed disease was caused by the gods and evil spirits, and often treated them with potions or chants meant to rid the body of evil spirits.  Yet Hippocrates and his family of physicians had other ideas. 

Another interesting thing for doctors to do during ancient Greek times was to take bribes to kill their patients. When one person wanted to get rid of a rival, he would bribe a doctor to create a poison to kill that person.  Hippocrates frowned upon this act. 

Hippocrates was born on the island of Kos at around 460 BC, and visited Egypt as a young man to study medicine.  After his studies he believed diseases had a natural cause, and he studied the human body to learn the cause, and he questioned his patients to learn as much about them and their condition as possible.

He became one of the most popular and famous physicians of his day, and is still to this day considered one of the best doctors of all time.  He was very skilled at his craft, was among the first to preach good bedside manner, and he preached that no physician should do harm to his patients.

Plinio writes that there were three schools of physicians competing among themselves (the Cos, Cnidian and Italian), with Hippocrates being a member of the School of Cos.  The Cnidian and the Cos medical schools were near each other and were competing "in knowledge and effectiveness in curing disease."

Prioreschi notes one theory that each school was stuck in it's own paradigm and had different methods of treating illness, and since the Cnidian and Cos were in close proximity (20 miles apart),  the Corpus Hippocraticum was therefore the result of a koinon, or an association between the two schools.  The Corpus Hippocraticum is basically a Treaties whereby the two schools compromised on how to treat medical conditions.

In total, Hippocrates and his family of physicians composed about 60 treaties on various medical conditions, their causes, symptoms and possible remedies.  His medical writings were followed by physicians through Medieval times, and his Hippocratic Oath, although modified, is still used to this day.

While there is no evidence Hippocrates did any of the writing himself, he is given credit. This might be due to his hard work, method of teaching, and skillful medical technique.  Plato (Hippocrates died when Plato was about 55), wrote that Hippocrates was the "famous physician."

Thus, Greek medicine has been dubbed by history as Hippocratic Medicine.  There is also evidence all of the writings are anonymous, and many were written before and even after his life.  Yet most were written during his life, and thus he has received the historical credit, perhaps out of respect to him more so than anything else.  He has thus been dubbed by history as the Father of Medicine.

Some experts believed the Cnidian may have had another belief about illness, yet the Con belief about the four humors is the one that won out by the time the book was written.  Humors is the medical term for bodily fluids.  Hippocrates believed an imbalance of the humors caused disease, and also determined our personality.

Yet what we do know is the idea that all illness caused by an imbalance of the four humors became a paradigm physicians had a hard time getting away from even up to the 1850s when blood letting or bleeding was still practiced by some to balance the humors.

In fact, it is common wisdom that George Washington was believed to have contracted pneumonia at the end of his life, and to balance the humors Washington's doctors bleed him.  Yet while they thought they were helping the first President, we now know this remedy probably helped to speed up his demise.

In essence, as noted by Barry E. Brenner in Emergency Medicine, the Hippocratic writers "separated scientifically proven medicine with superstition and infused scientific spirit and ethical principles into medicine."

So what did Hippocrates know about asthma?   It's important to note here that the definition of asthma to ancient societies may have been completely different than what we think of asthma today. In fact, the actual term "asthma" was derived from the Greek word aazein, which means to exhale with an open mouth or to pant.  Actually, asthma is derived from the Greek word Panos which means panting.

The first reference to asthma was Homer's epic poem the Iliad about 800 BC. Although Homer used it more as a term to describe gasping or air hunger at the end of life, or exhaustion from fighting in a battle (I wrote about Homer in more detail here).

The first appearance of this term as a medical reference was by the Corpus Hippocratacum. Yet whether Hippocrates (or his team) used the term to refer to a symptom (shortness of breath) or as a particular disease is difficult to tell.

Hippocrates didn't have any particular remedies for asthma, as he pretty much thought of all diseases as an imbalance of the four humors: blood, yellow bile, black bile, and phlegm. Any particular diseases were thought to be the result of some poison that caused an excess or depletion in one of the humors.

His remedies were generally basic, and focused on avoidance of things that made a person sick, which included a good diet, exercise, plentiful sleep and cleanliness.  Yet if disease was persistent he relied on such remedies as bleeding, massage, herbs and purging. All of which were meant to maintain a balance of the humors.

Asthma was believed by Hippocrates to be an excess of phlegm. An increase of phlegm in the brain caused epilepsy, and seizures were the result. Many asthma experts of old believed that asthma and epilepsy were related, thus asthma being a seizure of the respiratory muscles.

Pneumonia and catarrh were described in his writings, with catarrh being what we might think of as nasal allergies. Everything else, for the most part, was asthma. Any dyspnea (the feeling of air hunger) was asthma. Anything that caused wheezing or increased sputum was asthma.

Exhaustion after exertion was asthma. Dyspnea due to heart failure was described as asthma. Dyspnea that occurred near the end of life was asthma. Foreign bodies that block the upper airway resulting in dyspnea was asthma. Trouble breathing because the air was humid was asthma. Bronchitis was asthma. Emphysema was asthma. Asthma was asthma.

Hippocrate's Aphorisms noted that asthma was more common in the middle aged and in the fall season. One of the neat things about Hippocrates is that he correctly identified asthma as a disease of bronchospasm, while many asthma experts (as noted here) all the way to the 1980s thought asthma was a psychological (nervous) disorder.

Hippocrates also described asthma as a disease associated with those persons who participated in certain occupations.  Yet that idea was scrapped and until Bernardino Ramazzini scooped it back up in the 17th century.  Occupational asthma was never taken seriously until the turn of the 20th century.

Hippocrates also accurately described asthma as a disease inherited along the family line, and while this was supported by a few experts along the historical line, it wasn't proven until modern times.

So it's quite obvious that many theories have been proposed over the years about asthma, and most of them are poppycock theories. Yet when one idea gains fame, it becomes part of the mainstream.  As is normal with human thought, once an idea is adopted, it becomes part of the paradigm.  Hippocrates idea of asthma as an imbalance of the humors was one such paradigm that gripped the medicine until the 20th century. 

One thing you will realize as you study the history of asthma, or medicine as a whole, is that physicians tend to be dogmatic in their beliefs, even when they are wrong.  It's for this reason that many people still to this day believe that all dyspnea is asthma. 

In 2500 years since Hippocrates walked the earth theories about asthma have spun in several different directions, and every direction was mentioned at one point by the Hippocratic writers.  Hippocrates was such a brilliant and influential physician that he continues to influence medicine to this day, which makes it easy to fathom how he's often considered the father of medicine.

Click here for more asthma history.

10 Reasons chronic lungers should work in a hospital

My dad recommended when I was in high school that I get a job working in a hospital.  He likewise recommended I become a respiratory therapist.  I heeded my dads advice, but didn't go to school to be an RT until I was 25 only because I was afraid I'd fail chemistry.

Yet working in a hospital sure has it's advantages when you're an asthmatic, or if you have any lung disease for that matter.  So, listed here are the advantages of working in a hospital if you have a lung disease:

1.  You become better educated about your disease

2.  You have access to all the best medicine

3.  You work with doctors and nurses who can treat you if you're ill

4.  Nurses can suck the excess wax out of your ear

5.  Observant nurses can observe that your asthma is acting up and that you need help

6.  Air conditioning

7.  Clean and safe work

8.  You can rest often

9.  You get to hang out with other patients with similar diseases

10.  You can take treatments at work

1840 asthma definition: Spasmotic and Paralytic

Adding to what I wrote in my last post, Charles .J.B. Williams, the same man who proved dypsnea due to asthma was a result of bronchospasm, described two forms of asthma:

1. Spasmotic: Isolated attacks of dyspnea that accompany emphysema (air trapping)
2. Paralytic: Dyspnea associated with chronic pituitous catarrh.

If you're like me, you're saying, "What?"

After futher study, I've determined that Spasmotic asthma, according to Williams, was air trapping due to bronchospasm that goes away either on its own or with one or a variety of asthma remedies. It's a barrel chest that goes away.

Paralytic asthma is basically emphysema as we define it today, or the natural course of air trapping that occurs as the lungs break down with age. It's a barrel chest that never goes away.

So what is chronic pituitous catarrh? Well, it really has nothing to do with asthma. I think the best definition comes from Thomas Davies, "Lectures on the Diseases of the Chest, in the course of which the practice of Percussion and Auscultation is fully explained," The London Medical Gazette (Saturday, Nov. 22, 1934):

"The aerian (nasal) mucus membrane is moderately swollen, and frequently somewhat softened, it is rarely extensively redenned, but generally spotted irregularly. You will also find, that in almost all severe cases, the air cells of the lungs are more or less infiltrated with serum."

Basically, it results in very thick sputum in the chest, kind of like what occurs with chronic bronchitis (COPD) and bronchiectasis (CF). This thickened mucus, and emphysema together, can occur with age, yet now we know it's a disease process often associated with smoking. We now refer to it as COPD.

According to the "Textbook of Human Physiology," from 1889 (Philadelphia, pg. 663): Paralytic asthma might actually be "temporary paralysis of the pulmonary nerves, which excite the respiratory center (excito-respiratory). This is essentially a definition that comes from those who believe in the nervous theory of asthma, that asthma (bronchospasm, air trapping, dyspnea) are caused due to something stimulating an abnormal nervous response.

So perhaps they believed paralysis of the pulmonary nerves resulted in emphysema (i.e. air trapping).

Dr. J. Bergson in 1839 believed only in the spasmotic form of asthma and he wrote about it in "Spasmotic Asthma in Adults" in 1850. He believed asthma consisted of constrictions of the bronchi and air vessicles and this was secondary to someting irritating the vagus nerve. Thus, he believed in bronchospasm caused by a nervous response (emotion).

Bergson denied the theory of paralytic asthma. Actually, John Reid did experiments that disproved paralytic asthma and proved that it's only spasmotic. Bergson just applied Reid's theories to the understanding of asthma.

I think this is what Williams was referring to by his definitions. Yet it's significant to note here that none of these definitions are used today. If you Google Chronic Pituitous Catarrh, all the definitions come from old medical journals.

Ear wax and infections

It's seems as though the asthma body leads us from one ailment to another.  If it's not asthma its hay fever.  If it's not hay fever it's a wandering eye.  If it's not burning flat feet it's a headache due to sinus problems.  If it's not that it's an ear ache and a sense of fullness in an ear or two.

That was my most recent problem.  My right ear has felt full the past several months.  I actually saw my doctor a couple weeks ago and that was the only day my ear wasn't bothering me, and for some reason he didn't check my nose and ears.  

Yet yesterday my ear totally plugged off, a headache raged through my head, and the ringing was terribly annoying.  Plus I was working.  Then I decided I couldn't stand it no more so I wandered down to the ER clinic room and asked a PA if she'd do me a favor and check my ears.

I have a history of wax buildup in my ears, and I have a history of ear infections too.  Yes, I know otitis media is a disease that kids get, but I get it too.  I remember as a kid getting ear aches so bad I couldn't stand.  I don't have that problem any more, yet the sense of fullness is equally annoying.

A few years ago an ER doctor found that I had an ear infection and gave me a prescription of antibiotics.  It's nice to have doctor friends this way.  This time, however, the PA said I had an impaction in my.  She asked a nurse to flush my ear pro bono.  Yes, it's nice to work in a hospital sometimes.  

Walking back to the RT cave I could hear sounds I didn't even know existed, and that I didn't hear on the way to the ER clinic.  It was so nice to have my hearing back.

All she did really was flush my ears out with warm water.  She put the warm water into a syringe and squirted it into my ear.  It felt funny but good.  The excess water dripped into a basin.  It's probably a remedy you could do yourself at home.  

Yet I suppose so long as I have access to such good friends at work why would I need to do such a thing myself. Yes, working in a hospital is nice.  

My review of Dulera, Symbicort

I will never shut the door on future experiments with newer asthma medicines based on past experience.  I once rejected Serevent, yet Advair ultimately rid me of my infestation of hardluck asthma.  Yet my recent trial with Dulera didn't go so well, and I ended it.

The problem I encountered was not with the steroid but with the long acting beta adrenergic Foracort.  While it was nice that Foracort was quicker acting as a rescue medicine, it made my heart pound like Alupent used to make my heart pound back in the 1980s.

There were some nights back in the 1980s where I'd use my Alupent before bed and my heart would pound so hard I was afraid I wouldn't wake in the morning.  When I started using the Albuterol inhaler in 1985 and Albuterol nebulizer solution in 1991 this feeling ended.

Yet Formoterol brought it back.  There were a few nights, and mornings, after taking Dulera that my heart pounded.  I never once had that feeling with Advair.  So I decided I could no longer take it.  

I like to think Dulera and Symbicort are basically the same medicine because the LABA is the same in each one (Foracort).  

I also would like to add here that other than the occasional heart pounding the Foracort caused, I felt really safe using any of these LABAs. I have taken extra puffs from time to time with good results as far as my asthma is concerned.  It's a great medicine and it's safe.

I like to think the black box warnings are wrong and basically scare people away from using good medicines.  So long as you use them as prescribed, and so long as you treat your asthma appropriately and don't think your Advair or Symbicort or Dulera will cure your exacerbation, I think you'll be okay.

The first time I tried Advair I basically had to wean myself onto it, and that may be what I have to do with Dulera. Only Advair works so well for me I don't see any point in doing that at this time. However, if you have hardluck asthma and are looking for a good asthma medicine, I highly recommend you try one of the above named medicines.  

Don't give up if you don't get immediate results or if the side effects hit you. Try one and if it doesn't work try another.  Wean yourself onto them slowly while you wean yourself off extra puffs of your ventolin.  You may find that after using a combination inhaler for a few weeks that your ventolin usage declines, and your side effects go away.

That's my advice.  What's yours????

Let'

1840: Is asthma just emphysema?

Even though it had been proven by Dr. Charles J.B. Williams in his 1840 experiments, Dr. George Budd continued to deny that bronchospasm had anything to do with asthma.

Yet there may have been some bias here. He had done experiments on his own, and even made "Remarks on Emhysema of the Lungs" in 1839.

As Dr. J. B. Berkart notes in his book, "On Asthma: It's Pathology and Treatment," Budd repeated Williams experiments and failed to repeat the results. Budd "therefore, rejected the theory of a bronchial spasm, and even doubted whether the circular fibres were muscular, as alleged."

The thing about reading about this in their original works and by the original authors, is that when I was reading about the description of emphysema I was confused. After a while I realized that my problem was because I was going by today's definition of emphysema and not the 19th century definition.

Today we define emphysema as loss of lung tissue that causes air to be trapped in the lungs, and this results in a barrel chest appearance. In the 19th century emphysema was simply air trapping.

Berkhart (page 26) describes how one doctor (Dr. Longet?):

"not only confirmed in the main the results obtained by Williams, but added that in his experiments irritation of teh pneumogastric nerve always produced spasmodic contraction of the brnchi, whereas section of the nerve led to emphysema... since section of the vagus causes emphysema, i.e., distension of the air vesicles, there must be muscular fibres which, if liable to paralysis, are liable also to spasm."

So you see, emphysema is air trapping. It's air being trapped in the lungs due to narrowing of the bronchioles (air passages in the lungs).

What both Williams and Budd may have failed to observe was that they were both onto something. Emphysema (air trapping) is secondary to bronchospasm. Yet it may have taken a few more years to juxtapose these ideas.

The long walk of death

I don't know if this is a figment of my imagination or not, yet I have a memory from my stay at National Jewish where all of us kids were in the gym at the Kunsberg School and our assignment was to run around the gym until we couldn't breathe.

I almost want to say this really happened.  I don't remember how long I was there before we did this, although I almost want to think we did this more than once.  Was it done once a month?  I don't know.  I have no way of finding out.

I remember having a discussion with our PE instructor, or whomever was in charge of us during this test.  Yet I remember this person telling us that this was a test to see how well our current medicine regime was working.  We'd premedicate if that was indicated, and then we'd start running.

Some of us dropped right away.  The first time I did this I made it one or two laps and I was out.  Of course I could be wrong about this too, yet I also remember sitting on the bench and the PE instructor not allowing me to go up to 7-Goodman to get a treatment.  He also wouldn't give me a puff of the Albuterol inhaler either.

I remember someone getting me a glass of warm water.  That's what we were supposed to do during an attack.  And I remember other kids having asthma attacks, and some of them just kept running.  They kept running and running.  Yet it's all a blur.  It's a blur because all I could think of was my breathing.  I was in a panic.  I had to go upstairs.

It must have been just after I was approved to participate in PE, maybe within the first month of my stay.  So either it was late January or early February.  I remember I got so bad I was panicky and the PE instructor told one of my peers to show me up to 7-Goodman.  I knew the way, but we weren't allowed to go on our own during an attack.  That was rule #1.

So I finally made it to 7-Goodman thanks to my good friend Sari (last name long forgotten), and the nurse, whomever it was, refused to give me a breathing treatment.  She said my wheeze was in my throat.  My wheeze was often in my throat, and I was still short of breath.  Yet she refused to give me a treatment on the grounds my wheeze was in my throat.

You see, whether you got a treatment was often at the discretion of the nurse on duty, or if we were off campus the PE instructor with the Albuterol inhaler.  If you were having an attack you had no control.  You had to do whatever that person wanted.  But this time I was panicky. 

She kept telling me to sit and to relax and to concentrate on my breathing.  And I got ticked at her and told her to shut up and give me my treatment.  I just want to breathe.  Yet she refused.  Finally some other nurse got tired of seeing me suffer and she intervened and I finally got my treatment. 

The mean nurse kept telling me to concentrate on my breathing, yet I couldn't even get a tenth of my breath in.  I literally thought I was going to die that day.  I had many attacks in my life, and yet that day, at the asthma hospital that was supposed to help me, I thought I was going to die.

Yet I survived. 

A month later the same thing happened, only this time my asthma was more stable.  This time I lasted two laps instead of one.  And this time the PE instructor let me upstairs right away with Sari leading me.  And this time I got a treatment right away.

Yes, that's right.  When an asthmatic says he needs a treatment he needs one.  That should have been rule #1. Yet  don't remember ever having to go through that again.  And even after I was discharged from NJH in July, and after I started school at home the next fall, I was excused from participating in gym class.

Yet I never had to endure that short walk of death ever again. I imagine after failing it twice -- literally -- the asthma experts at NJH learned that running was not for this hardluck asthmatic.  I don't know if it was a scheduled run by my doctor or what.  That part of my medical records was destroyed. All I have is the shortened version.

This memory kind of reminds me of Stephen Kings The Long Walk.  It's a story where these kids enter a run and if you slow down you get a warning.  If you get three warnings you are shot in the head.  Only one winner. 

Well, the winter of 1985 at National Jewish I was among the first out.  I wish there was someone I could talk to to learn more about this memory.  It doesn't matter so much anymore, I'm just curious.

Study justifies weight gain

I was just talking with my wife the other night about how ever since I've been taking Dulera all I want to do is eat.  She said I was full of crap.  Yet a new study I just learned about today may prove me right.  Only it may not have been so much the Dulera but allergies that caused me to gain weight.

Researchers at Yale university studied the effects of antihistamines and determined that people who took them were heavier than those who didn't take them.  Of course the researchers were quick to note the study does not confirm whether obesity lends people to worse allergies or if antihistamines actually cause weight gain.

Yet it's still interesting.  I'm also not implying I'm obese, yet I often find myself gaining weight this time of year.  I used to attribute it to lack of exercise because I tend to spend a little more time sitting outside drinking beer and cooking delicious foods on the grill as opposed to exercising.  This study might provide me with an even better excuse.

However, as I look back on my childhood, when I was thin as a stick, I still had horrid allergies and no weight gain.  Yet my metabolism was better then to, so that might explain why there was no weight gain at that time.  Yet I'm speculating.

It's interesting.  And yes it's just one study.