Monday, May 14, 2012

x 1887-1973: Frances M. Rackemann redefines asthma

Frances Rackemann
The year 1901 was the dawn of modern asthma wisdom and treatment. This was a year that saw the introduction of epinephrine and ephedrine. It was also the year that a young man named Francis Milton Rackemann graduated from Harvard College at the age of 14.  He would grow to become the greatest asthma and allergy expert of the 20th century.

In a memorial tribute to his friend, Dr. Walter S. Burrage explained that Dr. Rackeman was born in 1887, and then, after graduating from college, a series of coincidences lead to him becoming an allergist.

First, he followed his cousin to Harvard where he was completing his registration to medical school on the last day. After his cousin was done, the Registrar turned to Rackemann and said, "How about registering yourself? Just mail us a copy of your college diploma and turn up tomorrow at nine o'clock for the first class." Rackemann did both, and four years later he graduated cum laude.

Second, in 1914 and 1915 he worked with Warfield T. Longscope doing research on anaphylaxis. The two would write a series of papers about allergies. This experience catapulted Rackeman's career as an allergist, and he would go on to write over 175 papers on allergies. (7)

There were two popular views on asthma at this time. One was that asthma was a nervous condition, and treating it was as simple as soothing the mind of the patient. The second was that asthma was an allergic condition and that curing it was as simple as finding the right protein to inject into the patient.

Rackeman would write several papers refining the definition of asthma.  The most significant was a report on a study of 150 asthma patients in 1918:  "A Clinical Study of One Hundred and Fifty Cases of Bronchial Asthma."  Another was a paper he wrote in 1969 called, "Nervous Factors in Asthma."

Rackeman believed asthma was a symptom more so than a disease. He also believed that not all asthma could be defined as allergic, and therefore, in his 1918 paper, he categorized most asthma cases as either extrinsic or intrinsic.

Extrinsic asthma is when an asthmatic has a hypersensitivity to a protein in foreign objects, or things that are outside the human body.  Their bodies develop proteins (later identified as IgE antibodies) to these substances, and repeated exposure to these foreign proteins would cause the allergic/ asthma responses.   It's associated with hay fever (allergic rhinitis) and atopic dermatitis (eczema). (3)

He described extrinsic asthma as being more often associated with childhood-onset asthma, and generally presents prior to the age of 12. It effects more boys than girls. Today, it's often referred to as allergic or atopic asthma, and has a greater tendency to be hereditary.

The diagnosis of extrinsic asthma may be made by allergy skin testing. For the treatment of extrinsic asthma he recommended allergy shots to make the patient less sensitive to the proteins in that substance. For example, for a pollen allergy, "treatment with an extract of the specific pollen will relieve the hay fever and the asthma often entirely."

Although, he did mention that desensitization, or immunotherapy as it's often called, does not work for all patients. For example, he suggested that, for those asthmatics allergic to horses, injecting these patients with the proteins of horses does not always prevent the allergic response of those patients to horses.  (3)

Instinsic asthma would cover all those cases of asthma not attributable to allergies, such as asthma caused by sinus infections, chronic sinusitis, nasal polyps, teeth infections, gum infections, throat infections (croup), acute bronchitis, colds, kidney failure (kidney asthma), heart failure (cardiac asthma), gastrointestinal irritation, etc.  It usually effects adults more so than children, and is more likely to be chronic than extrinsic asthma. 

For the treatment of instrinsic asthma the remedy would be fixing the causative agent.  For example, if acute bronchitis is the cause, then the remedy would be to resolve the bronchitis.

However, he wrote that "the treatment of instinsic asthma is far from satisfactory.  Local treatment of the nose, throat and teeth has been long considered important.  The removal of nasal polypi, the drainage of sinuses and the extraction of teeth will all relieve the asthma.  This relief, however, rarely amounts to a cure and even if very marked is rarely permanent.  The fact that many patients have spontaneous intervals of freedom from asthma which last for moths or years, makes the results of any treatment difficult of interpretation."

He also discussed the idea of vaccines to prevent bronchial infections, yet, he wrote, "from these cases must be left for some future time."

Rackeman explained that while asthma may be distinguished by extrinsic and intrinsic, the general symptoms of the disease are very similar.  It's not possible to distinguish between extrinsic and intrinsic by performing a pulmonary function test (PFT), however PFT testing will help a doctor diagnose asthma.  (3)

In 1927 he wrote the chapter on asthma and allergies for the first edition of Cecil's A Textbook of Medicine, a medical textbook still used to this day.  He explained the most up to date wisdom of these diseases at this time, and listed several allergens such as dust, fumes, foods and animal dander.

He also mentioned that most asthma cases were associated with increased eosinophils in the blood and sputum, including Charcot/ Leyden Crystals. (4, page 21)

He also supported the 19th century theory that asthma was a nervous condition. However, while he supported the nervous theory, he did not support the age old idea that a nervous condition, such as anxiety or stress, explained all cases of asthma.

He described this in his 1969 paper, "Nervous Factors in Asthma." He explained that to diagnose all asthma as nervous would result in missing the real cause, which may be an allergy to a cat or a pillow or ragweed pollen.

He explained that some cases of asthma are mainly nervous, and most of the time this involves intrinsic asthmatics.  He also explained how desensitization shots or skin testing may have no other effect that to "impress the patient and show that something is real and being done." (8)

Rackeman believed that the best treatment could be provided when the physician worked with the patient.  For 33 years he set up his general practice at his home, and often his family members had to shuffle through patients to get to their bedrooms.  He would also often visit his patients at their homes, and at times walk away "bandishing a guilty feather pillow." (7)

He was likewise friendly with his students.  He is believed to have provided the first exposure to allergy testing and desensitization to medical students.

In over 175 writings on allergies, he listed a variety of proteins that might cause asthma (6):
  • Ragweed
  • Horse hair
  • The spit protein of wheat
  • Egg white
  • Goose feathers
  • One meat, as beef
  • One fish, as codfish
  • Dust  (4, page 21)
  • Fumes
  • Animal dander
  • Molds (5)
Other than removal from or fixing the causative agent, Rackemann recommended the following as treatments for asthma (note that the treatment for asthma improved throughout Rackemann's career) (4):
  • 0.25 ml Adrenaline chloride repeated every half hour as needed (almost always works for all cases of asthma)
  • Smoking strammonium leaves
  • Cocaine nasal spray
  • Morphine (rarely works)
  • 20-25 mg of ephedrine three times a day as an alternative to adrenaline
  • Potassium iodide
  • Ipacec
  • Moving to a dry climate
  • No eating during an attack
  • Aminophylline in cases where adrenaline doesn't work (after it was proven to be an effective bronchodilator in 1922, it became more prominent intravenously after studies proved it to be effective in 1937.  I have an upcoming post about theophylline)
  • Diuretics for pulmonary edema (although we now know pulmonary edema is associated with cardiac asthma and not true asthma)
Burrage explained that Rackemann provided some of the first exposure to allergy skin testing that students had ever had. Other than Dr. Robert Cooke, Rackeman made more contributions to the understanding of allergy than any other physician. His name was well known within the medical communities in the United States as well as several other countries. (7)

He was a community organizer.  In 1923 he became founder of American Society for the Asthma and Allied Conditions and founder of the Allergy clinic at Massachusettes General Hospital, the first of its kind in the U.S.  He was the first president of the American Association of Allergy in 1934.  Ultimately these two organization merged to become The American Academy of Allergy.

Based on respect for Rackemann and his belief that asthma was an allergic condition and a nervous condition, most emphasis on asthma research was focused on these areas.  While he was on the right track and had noble intentions, this may have slowed the progress of asthma wisdom in other areas.

Yet, it was, Dr. Rackemann's interest asthma drove others to study it more intensely in the years between WWI and WWII. This resulted in a continued growth in asthma and allergy wisdom. Asthmatics should remember him as the most well known and respected asthma expert of the first half of the 20th century. He passed away in 1973 at the age of 85.

His dictum was "there is always something that can be done to help the asthmatic." (7) It was this way of thinking that lead to his many observations about allergy and asthma that lead to improved care for the asthmatic patient.

References:
  1. McFadden, E. R. Jr. "A Century of Asthma," American Journal of Respiratory and Critical Medicine, Vol 170, pages 215-221.  
  2. Adkinson, N. Franklin JR, "Is Asthma Always An Allergic Disease?", 1946, http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2376710/pdf/tacca00085-0288.pdf
  3. Rackermann, Frances M., "A Clinical Study of One Hundred and Fifty Cases of Bronchial Asthma," Archives of Internal Medicine (The American Medical Association), Oct., 1918, Vol. 22, No. 4, page 517-552
  4. Brenner, Barry E., ed., "Emergency Asthma," 1999, New York
  5. Rackerman, Francess M., "Molds as a cause of hay fever and asthma," 1937, http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2242158/pdf/tacca00017-0255.pdf
  6. Rackerman, Frances M., "Asthma, Hay Fever and Allied Conditions," The Medical Clinics of North America, Jan. 1920, Philadelphia and London, pages 1065-
  7. Burrage, Walter S, "Francis Minot Rackermann, M.D.," Trans. Am. clin. Climatol. Assoc., 1974, 85;xliv
  8. Rackemann, Frances M., "Nervous Factors in Asthma," 1969

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