My daughter's asthma attack, and the arrogant doctor

My daughter, Mrs. L, all three years of her, was introduced to the asthma beast this past week.  She required a breathing treatment a few weeks ago and it worked like a charm.  Yet last weekend the asthma beast struck with a vengeance.

She woke up in the night coughing.  I gave her a breathing treatment and it seemed to work.  Yet the next night she was up crying.  I entered her room and she was sitting up in bed.  It didn't take much convincing for her to let me carry her to the living room.

The nebulizer -- the community nebulizer for my family -- was already set up next to the recliner I set in with her.  I grabbed an amp of Albuterol and squirted it in, and revved the machine to life.  You can always tell when a kid benefits from a bronchodilator because she sits through it. 

Yet the treatment did little to relieve her coughing.  I sat up with her for an hour watching some old cartoon I can't even recall what it was.  Quite frankly I don't think she did either.  In fact, we didn't even have the sound on.  The vision of a toon was all that was needed to placate my daughter.

I was emotionally into this, because I could remember vividly sitting up in bed all night long when I was a kid not being able to breathe, and my parents had no clue.  It's not like they didn't care, they just didn't know.  I didn't want my child to have that scar, so I doted her.

The next day, Sunday, my wife or I had to give her a breathing treatment every few hours.  She probably could have used one more frequently.  Yet it was enough for us to realize she needed more than bronchodilators:  she needed systemic steroids.

Her doctor was out of town, so that posed a problem.  If she was in town we would have called her and she would have written a script for prednisone.  She knows me and my wife.  She knows I'm an RT and a lifelong asthmatic.  She knows we have a pharmacy here and everything except steroids to keep an asthmatic full of fresh air.  Yet she was out of town.

Dr. B. is a new doctor and I've worked with her enough to be impressed with her.  Yet she said she wasn't familiar with Mrs. L enough to just prescribe something over the phone.  So she recommended we take her to the ER. 

This posed a dilemma. Surely we had no problem taking her to the ER, but my wife and I both know that a trip to the doctor's office usually results in an assessment and a quit treatment of the cause of the problem.  Then you go home and that's that.  You get better. 

Yet if you go to the ER they have to do a bunch of stuff just to cover the butt of the doctor.  Labs will be drawn, an x-ray will be given, and an IV will be put in.  We mentioned this to Dr. B. and she said she'd call the ER doctor with her recommendation.

Great!  Or so we though.  The ER doctor was pissed that Dr. B called her.  The ER doctor was condescending and arrogant to my wife.  She said something like, "It doesn't matter what your doctor said.  I'm here and I'm assessing your daughter.  I have to do what I think is needed.  Dr. B. is not here."

My wife said she wanted to walk out the door right there.  If her daughter didn't need the steroids right now that's what she would have done.  And this is the hospital I work at.  The nurses tried to take a pulse ox on my daughter's food, and my daughter said, "Go away!  Leave me alone!"

My wife said, "Why don't you guys leave and I'll get a pulse on on her finger."

Yet they insisted on getting a pulse ox on her foot.  Here my daughter, my shy daughter who is deathly afraid of people, has five nurses holding her down to get a pulse ox.  My daughter cried and fought vehemently. Good for her.  I wish she would have fought harder.

The doctor peeked her head in at this time and said, "Well, she's crying.  So she must be breathing fine."  My wife responded, "Wait for her to stop crying and you'll see she's retracting and her fingers are blue."

The doctor left.  The nurses left.  My wife got a pulse ox reading in about 2 seconds once they were out of the room.  My daughters oxygen saturation of 82%.  That's not good.  And this all happened in triage.  When she finally got to her room my wife had to fight off the impulse of the doctor to insist an IV and labs be drawn.  Yet my wife stubbornly resisted.  I am proud of her.  "All she needs is steroids," my wife insisted.

The doctor was pissed.  She listened to Mrs. L. with her stethoscope.  She said, "She's wheezing.  She has inspiratory and expiratory wheezes.  Inspiratory wheezes are the worse kind.  You should have come in sooner.  If you need to give treatments every two hours you need to come to the ER."

My wife rebutted her comment:  "We did come to the ER."  And she probably thought, "You dumbF#$@!"  I know my wife thought that because I know my wife.  Yet I bet that doctor would doubt me. 

The doctor prescribed a steroid drink, and my wife said Mrs. L. won't drink it.  The doctor said, "We'll mix it up in a pop and she won't even know the difference."  My wife said, "She's never had a pop in her life, so she probably won't even know what pop is.  She won't drink that."

So you can see this made for an interesting visit.  Finally my wife said, "She's not going to drink this stuff.  Let's just give her the shot and get it over with."  Five nurses held Mrs. L. down, and she didn't even fight.  Later that night she said to me at home, "Daddy, I got a shot and I didn't even cry."  She smiled.  She smiled because she knew the shot made her better. 

Yet. Steroids work on asthmatics in my family.  We don't need labs and xrays and IVs and all that unnecessary stuff.  Surely if the steroids didn't work you can look for something else. 

My wife said the nurses were great.  Later I talked to one of these nurses about that doctor, and she said the doctor has to cover her butt.  Yet I said, "A doctor should also respect the wishes of the parent.  A parent knows her child more than a doctor does.  Not to disrespect the wisdom of that doctor, yet she really needs to respect the parents, especially when the parents are a nurse, and an RT who is a lifelong asthmatic.  It's not like there's no experience here.  We're not your typical ignorant parents."

This is exactly the reason I never go to the ER when my asthma acts up.  The last time I was an ER patient they took me off my theophylline and almost killed me.  Eight days later a different doctor put me back on my theophylline and I miraculously got better.  So if you have asthma, and you know what works for you, and the doctor wants to do something totally different, who's right? 

That steroid shot gave my daughter almost instant relief.  She ran around the living room that night the way I'm accustomed to seeing her, all happy and cheerful.  In the end, that's what's most important.  As far as the rotten ER doctor, she was a rental doctor and both my wife and Dr.B. reported her arrogance to the powers that be.

Thank God for asthma hybernation

Thank God for asthma hibernation.  This awkward disease has a way of hiding in the sand for years making it's owner think the beast has left the building.  Then just as you think it's gone WHAM!  it hits you like a mack truck smashing into a possum on an expressway. 

Thank God for asthma hibernation.  It made for five good years.  It made for five hunting camps.  It made for five years of emptying boxes and moving furniture in the basement.  It meant five years of raking leaves.  It means five years of playing catch with my son.  It means five years of rolling in the grass with my younger kids.

Yet asthma hibernation has it's own dark side, and this can be deadly for some.  Because by not showing it's ugly head you might think the asthma beast is gone forever, and you enjoy yourself too much.  You spend time around your allergens.  You tempt the beast this way.  There's this old rule that you never mess with a sleeping giant.

Thank God for the sleeping giant.  Yet while surely you should enjoy the days when it's gone, you should never tempt it.  You shouldn't stand by the fire at hunting camp, inhaling the fumes and scents, even though that's what everyone else does.  You can't because the beast may strike.  The beast did strike.

Thank God for the sleeping giant.  Yet while surely you should clean your basement, you should limit yourself to a few minutes on the job as opposed to working until the job is done.  Because in doing this your allergies struck, and then it hit your lungs.  And then it wiped you out. 

Thank God for asthma hibernation.  Thank God the beast goes away for a while.  Yet we also thank God for the medicine in the cabinet that can make the beast's tail loosen up its squeeze on your air passages. 

Thank God for that five year old thralling pill that finally gave me my breath back last night.  Those three continuous breathing treatments didn't do a thing. The panic was real.  The anxiety was real.  Yet that five year old pill, the one you weaned yourself off of after 30 years of chronic theophylline dependence, was staring at your face.  "Why not?  What do you have to lose?"

It went down.  You laid down to get some rest, hoping, praying you'd fall asleep -- eventually.  You sit high up on the pillow, concentrating on each breath.  The breaths didn't go in all the way.  Dyspnea.  Air hunger.  panic.  Calm.  Calm. You try to convince yourself

Than, 30 minutes later, unexpectedly, it came in all the way.  Did it really happen.  You inhaled again, the asthmatic did.  He inhaled.  It went in again.  A feeling of euphoria ensued like he knew he could never explain to someone who didn't have this disease.  The 5 year old theophylline pill worked.  It worked.  Sleep came.  Rest.  Rest.

The next day you could feel the allergies.  Your eyes are sore and red.  Your chest burns from all the heaving of each breath the night before.  Yet you feel joy knowing the breaths came in.  Air. Fresh air.  What a joy.  Yes.  We asthmatics will never take air for granted, as others do. 

Thank God for air.  Thank god for the ability to breath it.  Happy Thanksgiving.

1722: William Cullen writes about asthma

William Cullen (1710-1790)

As we enter the 18th century hypothetical theories of medicine start to take a back seat to scientific evidence.  One of the first to base his asthma writings on studies he performed was Dr. William Cullen.

He was born in 1710 to the lawyer of the Duke of Hamilton.  He started his education in his home town of Hamilton in Scotland, and then went to Glasgow where he studied medicine. After he was only there a short time he was appointed apprentice to Mr. Praisley, a surgeon with an extensive library, a valuable asset for an aspiring physician.  1, page 133)(2)

In 1729 he went to London to further his career, and was appointed surgeon aboard a merchant vessel sailing from London to the West Indies. Upon his return he took a position at a local apothecary. While this was the only such trip he would take, he paid peculiar attention to the "diversity of climate on human constitution, and to observing the diseases peculiar to the West Indies." (1, page 133)(2)

He returned to London and was hired as an assistant to Mr. Murray at an apothecary shop. It was here he studied medicine (materia medica). He continued this work until 1932 when his father and brother died, and he was compelled to moved back to Scotland near the village of Shotts in Lanarkshire (now North Lanarkshire).  (1, page 133)(2)

In Schotts he cared for the invalid child of Captain Cleland, of whom he sailed with a few years earlier. He practiced medicine here for two years, before going to live with a Clergyman in Northumberland where he studied and became adept in literature and philosophy. (1, page 133)(2)

In 1734 he attended medical school in Edinburgh, and then two years later returned to his private practice in Hamilton. Here he stayed for eight years (1736-1744), honing in his medical skills at his own medical practice. He took care of the Duke of Hamilton, and was given credit for curing the Duke of a serious illness.  (1, page 133)(2)

He cared particularly for the poor, offering his services to them without fee.  It was in 1740 that he received his medical degree from Glasgow. He gave lectures on the theory and practice of physick, materia medica, and botany.  Some say he was the first physician at Glasgow.   (1, page 133)(2)

Medical historian Lindsley Bradford said that during his lectures he...

...was independent and spoke so slightly of Boerhaave that he was called a Paracelsus, a van Helmont, a whimsical innovator. And the Lord Provost Drummond even requested him to speak respectfully of the Leyden professor... he was much loved by his students." (1, page 134)(2)

In the meantime, in 1741, he married and had children. He also earned himself a good reputation.

In 1755 he returned to the University at Edinburgh where he was ultimately named sole professor of medicine, a position he held until just before his death in 1790 at the age of 78. He ended up having 11 children, some of whom earned fame of their own. (1, page 134)(2)

Throughout most of his adult life he would study natural medicine, and was particularly interested in scientifically classifying diseases. He thus became a nosologist, and a pretty good one at that.

He was a solidist, in that he was more interested in the living solid parts of the body as opposed to the fluids. In this way he believed most diseases were fostered by some kind of disorder of the nervous system, and that the muscle was "a continuation of nerve."   (1)(2, page 135)(3, page 318)

He essentially believed that life itself was a continuation of the nervous system. This belief would affect his description of diseases, their causes, and the remedies used to treat them.  (1)(2, page 135)(3, page 318)

Still, when it came to asthma, he found the task of classifying it as a disease, and distinguishing it from other forms of dyspnea, to be a major challenge. The main reason was because most physicians of his day were stuck on the idea that all or most shortness of breath was asthma. Not only was this a challenge for him, it continues to be a struggle for some physicians in the modern world. 

Cullen became one of the first asthma experts to base his beliefs, or at least try to confirm them, based on studying signs and symptoms of that disease while a person was alive, and comparing it with what he saw in autopsy.  This was a common trend among physicians of his era.

The fact that he saw defining asthma as a challenge can be observed by the following quote from Cullen's 1794 book, "First lines of the practice of the psych,":

"The term of asthma has been commonly applied...by many writers... to every case of difficult breathing, that is, to every species of dyspnoea.  The methodical nosologist, also, have distinguished asthma from dyspneoea chiefly, and almost solely, by the former being the same affection with the latter, but in a higher degree.  Neither of these applications of the term seems to have been correct or proper.  I am of opinion, that the term asthma may be most properly applied, and should be confined, to a case of difficult breathing that has peculiar symptoms and depends upon a peculiar proximate cause which I hope to assign with sufficient certainty."  (4, pages 387-88)

In this way he was the first to define asthma as a specific disease, as opposed to an umbrella term for any malady that causes dyspnea and wheezes.  In other words, he was perhaps the first to suggest that all that wheezes is not asthma.  From this point on each physician would form their own theories regarding asthma based on their own experiences and observations.  The debate as to how to define asthma would continue well into the 20th century, and we can thank Cullen for beginning it.

Cullen, therefore, became the first to form a specific theory regarding asthma.  He said that while many authors before him said asthma was spasms of the air passages, none distinguished asthma from other forms of dyspnea.  Cullen, therefore, proposed the term "asthma" be used only to denote spasmotic asthma alone, and not the hundreds of other medical conditions that cause dyapnea

He likewise notes that even while some authors have defined asthma as spasmotic asthma, they have not distinguished the term from other forms of dyspnea. Cullen would propose that the term asthma be used to denote spasmotic asthma alone, and not other conditions that cause shortness of breath.

In this way, perhaps, William Cullen can be referred to as the father of the spasmotic theory of asthma.  We can also call it the convulsive theory of asthma, or, in the modern world, the bronchospasm theory of asthma. All mean the same thing.

Thus, in his 1772 book " Nosology: or, a systematic arrangement of diseases, by classes, orders ," he defined asthma as:

Difficult respiration recurring at intervals, with sense of stricture in the breast, respiration performed with a wheezing noise; difficult cough at the beginning of the fit, sometimes none, free towards the end; and often with copious discharge of mucus."  (5, page 118)

In, "The first lines of the practice of the psychic," he defines asthma as:

"Spasmotic, constriction of the muscular fibres of the bronchiae: which not only prevents the dilation of the bronchiae neccessary to a free and full inspiration, but gives also a rigidity which prevents a full and free expiration like many other convulsive and spasmotic affections is readily excited by a turgescence (swelling) of the blood, or other cause, of any unusual fulness and distention of the vessels of the lungs (inflammation?)"  (4, page 397)

He defined asthma as a nervous affection as compared to the accumulation of mucus which he regarded as part of dyspnea cararrhalis.  and containing the following "facts,": (4, page 387)

• It's hereditary
• It seldom occurs early in life, and hardly to the time of puberty, or after it
• It effects both sexes, but most frequently the male
• I have not observed it to be more frequent in one temperature or another
• It does not seem to depend upon any general temperament of the whole body, but a particular constitution of the lungs alone 
• It frequently attacks... but hardly ever continues to be repeated for some length of time without occasioning an emaciation of the whole body
• Attacks are generally in the night or toward the approach of night (yet occasionally in the day)
• It comes about suddenly
• It may go into remission
• It is there for the person's whole life
• Returns happen with different circumstances with different persons
• Fits are more frequent in the summer
• It may threaten immediate death, seldom occasions it
• Many persons have lived long under this disease
• Seldom entirely cured
• It effects each person differently
• Each patient has unique external triggers  (4, page 387)
• There is a greater chance of curing the disease in youth than in advanced age (9 page 390)
• It's a chronic disease, which may continue to give very great distress at intervals, for a considerable number of years (9, page 390)

The following were his signs and symptoms of asthma:

• Sudden dyspnea
• Tightness of of stricture across the breast
• A sense of straightness of the lungs impeding inspiration
• Desire to get into an erect position
• Desire for free and cool air
• The difficulty of breathing goes on for some time
• Both inspiration and expiration are performed slowly
• With a wheezing noise
• Speaking is difficult and uneasy (in violent fits)
• Often some propensity to coughing, but it can hardly be executed
• Sometimes the pule increases
• Sometimes fever (usually with increased pulse)
• If urine is voided early it's usually with little colour or odour
• If urine voided late it's usually of a high color and sometimes deposits a sediment
• Sometimes the face is flushed and turgid, more commonly pale and shrunk
• After long continuance, it often ends in a hydrothorax
• Occasionally some aneurism of the heart or great vessels (it thereby proves fatal) (4, pages 387-410 )

Even after some sleep and the breathing becomes easier and easier, the following signs and symptoms may continue for some time:  (4, pages 387-410 )

• Feels some soreness across chest
• Cannot breathe easy in horiontal posture
• Can hardly bare any motion of his body
• In afternoon has uneasy flatuency of his stomach
• Unusual drowsiness
• Difficulty of breathing returns toward evening
• May occur for several nights
• Followed by remission (especially after coughing up copious sputum) (4, pages 387-410 )

These symptoms may continue for many hours, Cullen said, "then a remission takes place by degrees; the breathing becomes less laborious and more full, so that the person can speak and cough with more ease, and, if the cough brings up some mucus, the remission becomes immediately more considerable, and the patient falls into a much wished for sleep." (4, pages 387-410 )

There are two forms of asthma:

1. Humid: With expectoration of mucus.  This is also called humoral asthma.  
2. Dry: Without expectoration of mucus. This is also called spasmotic asthma.

Cullen described things that excited asthma as exciting causes, or things that cause the disease to be "readily excited.  He said these are unique from person to person.  He said when the disease cannot be cured "by our art," it can often be cured by encouraging the patient to escape from the exciting cause.  Some exciting causes were: (4, pages 387-410 )

• External heat (weather or warm chamber)
• Warm bathing
• Summer weather (particularly dog days)
• Changes of weather (especially sudden colder to warmer)
• Full meal
• Air in stomach
• Exercise (or whatever else can hurry the circulation of the bloos)
• Cold
• Excitement of nervous system, as by passions of the minds
• Odors
• Smoke 
• Dust  
• Hysteria 
• Hypochondriasis
• Dyspepsia
• Atonic gout 
• Other conditions that cause dyspnea  (4, pages 387-410 )
• Weather changes (9, page 393)
• Large cities (9, page 393)

Things that are hot or cold excite an attack by the following means: 

An asthmatic fit seems thus to depend upon some fulness of the vessels of the lungs, it is probably that an obstruction of perspiration, and the blood being less determined to the surface of the body may favour an accumulation in the lungs, and thereby be a means of exciting asthma. This seems to be the case of those asthmatics who have fits most frequently in the winter season, and who have commonly more of a catarrhal affection accompanying the asthma; which therefore occurs more frequently in winter, and more manifestly from the application of cold." (4, page 395-396)

On the other hand, things like smoke or dust or hysteria, hypochondria, dyspepsia and atonc gout "excite the powers of the nervous system."  (4, page 397)

Regardless of the exciting cause, the "proximate cause of this disease is... spasmotic, constriction of the muscular fibres of the bronchiae: which not only prevents the dilation of the bronchaie necessary to a free and full inspiration, but gives also a rigidity which prevents a free and full expiration.  This preternatural constriction, like many other convulsive and spasmotic affections, is readily excited by a turgescence of the blood, or other cause of any unusual fulness and distention of the vessels of the lungs." (4, page 397-398)

Regarding the prognosis of asthma, he says the following:

The asthma, though often threatening immediate death, seldom occasions it; and many persons have lived long under this disease. In many cases, however, it does prove fatal; sometimes very quickly, and perhaps always at length. In some young persons it has ended soon, by occasioning C c 4 a a phthisis pulmonalis. After a long continuance, it often ends in a hydrothorax; and commonly, by occasioning some aneurism of the heart or great vessels, it thereby proves fatal. (4, page 399-400)

As far as remedies, he says the following:

As it is seldom that an asthma has been entrely cured, I therefore cannot propose any method of cure which experience has approved as generally successful. But the disease admits of alleviation in several respects from the use of remedies; and my business now shall be chiefly to offer some remarks upon the choice and use of the remedies which have been commonly employed in cases of asthma. (4, page 400)

The remedy generally depends on the cause of the symptoms.  From here he classifies asthma into three groups:

1.  Idiopathic:  Without manifest cause, or being accompanied with other disease

2.  Symptomatic:  From erruption or other acrid effusion being repelled.  Of this group there are two varieties:

• Gouty (asthma arthriticum): I believe here he's referring to asthma that results from swelling of the air passages. He calls it gouty because it mimics the inflammation from gout or arthritis.
• Syphilitic (asthma venereum): Again, this is possibly referring to inflammation in asthma being similar to that of syphilis. 

3.  Other asthma dyspneas and orthopnea symptomatic of cardiac and pulmonary difficulties and obstructions (he's probably referring to conditions we'd refer to as bronchitis, pneumonia, or heart failure)

Thus, if asthma arrises from "difficult transmission of the blood through the vessels of the lungs (swollen broncheolar muscles), threatening suffocation," the best remedies are noted below: (4, page 400)

• Blood letting (less and less necessary as disease progresses, although it was a common 18th century remedy for swelling, or congestion (turgescence) of blood in the tissues) (4, page 401-403)
• Emollients (relieving the bowels helps to ease breathing, as an empty stomach is beneficial) (4, page 404)
• Moderately laxitive glysters (have been found to give considerable relief) (4, page 404)
• Gentle vomits by emetics (flatuency of stomach are frequent attendants, and very troublesome for asthmatics, used to prevent and treat asthma)  (more useful in winter than summer) (4, page 404)
• Issues (useful in obviating plethora, although this rarely occurs with asthma) (4, page 405)
• Acids and neutral salts to treat asthma fits excited by turgescence of blood (also recommended by Floyer "On the Asthma.") (4, page 405)
• Ether (an antispasmotic found to give the best relief.  It's also safe, but not long lasting) (4, page 407)
• Opium (Works best for spasmotic or dry asthma; Best antispasmotic has been found effectual and safe; may use large doses if needed) (4, page 407)(9, page 393)
• Simply avoiding the occassional or exciting cause (4, page 408)
• Breathing the air low to the ground, as compared to mountain air (4, page 408)
• Good diet, or a spare, light and cool diet is proper(4, pages 408-409) (9, page 393)
• Avoiding a large meal (4, page 409)
• Avoiding food that is of slow and difficult solution in the stomach (slow to digest)
• Eating animal food of the lighter kind, and in moderate quantity (4, page 409)
• Avoid vegetables that are flatulent (4, page 409)
• Drinking water and cool water liquors is generally safe (4, page 409)
• Gentle exercise (riding horseback, going in a carriage, sailing, (4, page 410)
• Coffee (9, page 392)
• Emetics (works well for humid asthma) (9, page 392)
• Smoking or chewing tobacco (9, page 392)
• Various other remedies (recipes provided in his book)  (9, page 392-393)
• Inhaling the vapour of Ether (9, page 393)
• Inhale hydrocarbolic air, or air with increased oxygen, for humid asthma (9, page 393)
• Inhale hydrogen if dry asthma (9, page 393)
• Ipecacuanha in small doses for dry asthma; may give 3-10 grains every other day (great remedy) (3, page 393)
• Blistering between shoulders necessary for asthma arthriticum (not for pure asthma)

The following he proved to not work:

• Purging (seldom found to relieve vessels of thorax,and does not relieve congestion of the lungs) (4, page 403)(9, page 390)
• Blistering between shoulders or on breast (rarely found it useful in pure asthma) (4 page 404)
• Fetid gums (an antispasmotic proved not to work and be sometimes hurtful) (4, page 407
• Musk (antispasmotic not properly tried) (4, page 407)
• Liquors (few asthmatics can bear strong, warm, tepid drinks because it weakens nerves of stomach) (4 page 409-410)
• Tea  
• Emetics ("The effects of full vomiting cannot be durable, nor its operation be conveniently repeated, so full vomiting cannot always be employed to prevent the recurrences of the... spasm") (6, page 469)
• Infusion of tobacco as an emetic (It's too dangerous (9, page 392)

In an era when physicians were using scientific methods to learn more about human anatomy, and the changes that occur in the body the result in the symptoms observed, it was only a matter of time before one of these physicians used science to better define asthma.  The man who did this was William Cullen.  

Click here for more asthma history.

References:

1. "William Cullen," britannica.com,"  http://www.britannica.com/EBchecked/topic/146062/William-Cullen, accessed 11/12/13
2. Bradford, Thomas Lindsley, writer, Robert Ray Roth, editor, “Quiz questions on the history of medicine from the lectures of Thomas Lindley Bradford M.D.,” 1898, Philadelphia, Hohn Joseph McVey
3. Garrison, "An introduction to the history of medicine," 1921, 3rd edition, Philadelphia and London, W.B. Saunders Company
4. Cullen, William, "First Lines of the Practice of the Phsych," 1784, Edinburgh, Vol. 3, 4th ed., 387-88
5. Cullen, William, "Nosology: or, a systematic arrangement of diseases, by classes, orders," London, 1800, page 118
6. **Jackson, Mark, "Asthma, Illness and Identity," The Lancet, Volume 372, Issue 9643, Pages 1030 - 1031, 20 September 2008
7. Cullen, William, "A treaties of the Materia Medica," Vol. II, Edinburgh, 1789, page 469 
8. Cullen, William, "Professor Cullen's Treaties of the Materia Medica", edited by Benjamin Smith, 1812, Vol II, Philadelphia, page 175 

9. Cullen,William,"The Edinburgh practice of physic, surgery, and midwifery" Vol. II, London, 1803

References:

1. "William Cullen," britannica.com,"  http://www.britannica.com/EBchecked/topic/146062/William-Cullen, accessed 11/12/13
2. Cullen, William, "First Lines of the Practice of the Phsych," 1784, Edinburgh, Vol. 3, 4th ed., 387-88
3. Cullen, William, "Nosology: or, a systematic arrangement of diseases, by classes, orders," London, 1800, page 118
4. Cullen, "First lines...," op cit, page 397
5. ****Cullen, William, "The first lines of the practice of psychic," Vol. III, Edinburgh and London, 1784, pages 387
6. Cullen, op cit, "First lines...," pages 387-410 (Cullen offers a great synopsis of his theory on asthma)
7. Cullen, op cit, "First lines...," pages 387-410 (Cullen offers a great synopsis of his theory on asthma)
8. Cullen, op cit, "First lines...," pages 387-410 (Cullen offers a great synopsis of his theory on asthma)
9. Cullen, op cit, "First lines...," pages 387-410 (Cullen offers a great synopsis of his theory on asthma)
10. Cullen, op cit, "First lines...," pages 387-410 (Cullen offers a great synopsis of his theory on asthma)
11. **Jackson, Mark, "Asthma, Illness and Identity," The Lancet, Volume 372, Issue 9643, Pages 1030 - 1031, 20 September 2008
12. Cullen, op cit, "First lines...," pages 387-410 (Cullen offers a great synopsis of his theory on asthma)
13. Cullen, William, "A treaties of the Materia Medica," Vol. II, Edinburgh, 1789, page 469 
14. Cullen, William, "Professor Cullen's Treaties of the Materia Medica", edited by Benjamin Smith, 1812, Vol II, Philadelphia, page 175 (same explanation found in reference #13 above)
15. Cullen, William, "Professor Cullen's Treaties of the Materia Medica", edited by Benjamin Smith, 1812, Vol II, Philadelphia, page 175
16. Garrison, "An introduction to the history of medicine," 1921, 3rd edition, Philadelphia and London, W.B. Saunders Company

Other readings:

• Cullen,William,"The Edinburgh practice of physic, surgery, and midwifery" Vol. II, London, 1803

I think I can... I know I can...

Like the little Engine that could...

1. I think I can be patient today
2. I think I can go a week without complaining
3. I think I can lose 15 pounds by January
4. I think I can be a better husband
5. I think I can be a better dad
6. I think I can be a better coworker
7. I think I can be a better respiratory therapist
8. I think I can spend more time with my 13-year-old
9. I think I can be a more active American
10. I think I know what I'm talking about

Like the little Engine that could...

1. I know I can be a good dad
2. I know I can be a good husband
3. I know I be a good teacher
4. I know I can spend more time reading
5. I know I can get myself in better shape

This post was written as part of NHBPM – 30 health posts in 30 days: http://bit.ly/vU0g9J

1138 -1204 A.D.: Maimonides writes asthma book

Maimonides (1138-1204 A.D.)

While few may know this, the Muslums may be credited as saving ancient Greek and Roman medical theories for modern times.  This is because while the Western world was engulfed in the dark ages, the Eastern world was full of rising societies.

Europeans were so busy feuding amongst themselves and destroying towns and libraries, the Muslims were growing a society in Arabia and Spain.  In essence, through their travels, the Muslums brought Greek and Roman medical wisdom to Spain.

Maimonides was not a Muslim but a Jew who lived from about 1138 to 1204 AD.  He was among the most famous writers, physicians and philosophers of his day.  He was born in Muslim controlled Spain and learned from his father, who was a Jewish teacher and Rabbi.

Fred Rosner, in his book "The medical legacy of Moses Maimonides" explained that Maimonide's father, Maimon, instilled in him an interest in the sciences and philosophy.  He was blessed with a mixture of Ancient Greek, Roman, Medieval Arab and Hebrew wisdom of all ages. (1)

Despite all his writings, he left very little along the lines of opinions about everyday life, so we know little about his life and personality.  (2)

He was born during the the time of the crusades where Christians traveled to the Holy land to free the city of Jerusalem from the Muslims, who captured the Holy lands from the Bryzantines in 638 A.D.  In order to avoid religious persecution in Spain, Maimonide's family fled Spain and ended up in Fez, Morocco.

While in Morocco, Maimonide's became an avid reader of many of the medical writings obtained from the ancient Greek and Romans, particularly those of Hippocrates and Galen. 

He later wrote that Galen observed Hippocrates to be wrong in many areas of his writings.  But instead of saying, "Hippocrates was wrong," he would cover for Hippocrates, even to the point of changing Hippocrate's meaning, or crediting the error to other writers and not Hippocrates himself.

The family ended up in Egypt, and this is where Maimonide's skill as a physician took off.  The author's of Emergency Medicine  write that "he became appointed as the physician to the great Saladin and then became physician to the Saladin's son, Prince Al Afdal Nur ad Din ali, when the Prince assumed the throne at age 40 in 1193." (3)

Maimonide's wrote a lot during his lifetime, and most of his books were written to someone who requested some type of medical advice.  For example, in the last 14 years of his life he was asked by the Prince to provide some advice on how to live with his asthma.  Maimonide wrote to him that asthma was usually started with a cold and advanced to shortness of breath.

Maimonides ended up writing his "Treaties on Asthma," where he recommended against trying any magical cures for any ailments, and any such remedies should treat the cause as opposed to just the symptoms.  Treatment should also be based on age of the patient and the season, as the disease might be seasonal.

He wrote that ultimately during the course of (an asthma attack) the patient later gasped for air and coughed up a wad of phlegm.

Rosner explained that Maimonides might have been the first to describe psychosomatic medicine when he wrote how a patient who is "mentally agitated" causes his physical well-being to suffer and eventually he becomes physically ill. (4)

Rosner wrote that Maimonaides also adds that "gaiety and joy gladden the heart, and stimulate the blood and mental activity.  Excessive indulgence in the pursuit of pleasure, however, is injurious to one's health.  The avoidance of illness induced by such excesses is by conducting oneself according to ethical and moral principles."

He likewise noted that asthma usually starts as a cold during the rainy season.  However, modern historians aren't sure if Maimonide's description is asthma or some other similar malady.

He's also perhaps the first to describe how city air pollution may be the cause of asthma.  He writes:

"Town air is stagnant, turbid, and thick; it is the natural result of its big buildings, narrow streets, and garbage... Air winds carry stealthily inside the houses and many become ill with asthma without noticing it.  Concern for clean air is a foremost rule in preserving the health of one's body and soul."

He recommended many herbs to be inhaled and was the first to recommend chicken noodle soup as a remedy for breathing trouble.

Aside from chicken soup, his remedies included:

• Clean air
• Healthy eating (he recommends eating certain foods and avoiding others)
• Healthy drinking
• Controlling emotion (was this an early reference to psychosomatic asthma?)
• Exercise
• Rest
• Sleep
• Wakefulness
• Excretion
• Retention of wastes
• Bathing
• Massaging
• Avoid gas producing foods (causes bloating)
• Chicken soup (acute asthma only and only if patient is afebrile)
• Moderate exercise prior to eating
• No exercise right after a meal
• Dry months
• Small quantities of wine
• Enemas to cleanse the bowels (induce bowel movement and to drain thick juices)
• Emetic (severe cases only)
• Aromic herbs (to fortify the brain and dry out any humidity therin)
• Emetics to cleanse the stomach (cause vomiting)
• Sleeping after bathing is good, yet bath water should be warm and contain salt
• Various compound remedies (5)
• Travel to dry regions 
• Moderation of sexual activity (6)

He advises against the following common "excessive" remedies from other physicians because they "involve strenuous physical and emotional exercise.":

• Sexual intercourse
• Blood letting
• Hot baths
• Urine stimulation (such as diuretics)
• Purgation (never on healthy people because it doesn't preserve health)
• Sleeping immediately after meals is harmful
• Washing with cold water after meals is harmful
• Excessive bathing during acute attacks (due to wet climate created)
• Opiates (except in severe cases (7)

Possible triggers:

• Wet seasons
• Excessive drinking
• Pollution (8)

Maimonides makes a point to emphasize what Hippocrates noted years earlier, which is to put your life in the hands of someone who bases his wisdom and remedies on scientific training as opposed to someone who treats based on superstition or faith. Worded another way:  Science is better than quackery.

 Likewise, in many instances it may be better to do nothing than to risk greater harm to the patient.

References:

1. Rosner, Fred, "The medical legacy of Moses Maimonides," Chapter 2, "A Treaties on Asthma,"   page 13
2. Yellin, David, "Maimonides," Israël Abrahams, Jewish Publication Society of America, Philadelphia, 1903, page 3
3. Brenner, Barry E, editor, "Emergency Asthma," 1998, New York, page 13
4. Rosner, op cit
5. Rosner, op cit
6. "Asthma History -- Through the Ages," Medical News Today
7. Roster, op cit
8. Roster, op cit

What is the blog "Hardluck Asthma" all about?

Your humble question:  If you were in an elevator and someone asked you about your blog, what would you tell them? 

My humble answer:  On my Hardluck Asthma blog I write about what it's like to live with asthma.  What are the day to day challenges of being an asthmatic?  I also write a lot about the history of asthma.  I try no write from a unique perspective of the disease as to not make my blog a repeat of other asthma blogs, although I sometimes fail at that.  I have three other blogs, and this one is my ME blog.  This is where I get to write about me, my asthma, and how it effects me personally.  I also spend some time writing my asthma story, or what it was like living with asthma when I was a kid.  I had it bad, so bad in fact that I once made over 17 visits to an ER one year, and once spent six months in a hospital.  I like to write about that and a whole lot more asthma stuff.

This post was written as part of NHBPM – 30 health posts in 30 days: http://bit.ly/vU0g9J

Heed the warnings on asthma medicine

Task for the day:  Open a book.  Point to a page.  Free write for 10-15 minutes on that word or passage.  Post without editing if you can.  

My response:  I'm looking at a page in "Asthma:  The Biography," by Mark Jackson.  This is a remarkably thorough read about the history of asthma.  The page I'm looking at discusses fatal asthma.  

In the 19th century many doctors wrote that they rarely ever observed any one dying of true asthma.  It was a disease that caused some suffering for a few days, yet usually let up eventually.  My asthma is like this.  I have an attack, it can be terrible, yet in a few days I know I'll get better whether or not I take medicine for it.  The difference between now and the 19th century is today we have medicine to relieve our suffering.  No one should have to suffer from a bad asthma attack anymore.

Yet no one died from asthma back then.  That changed in the 20th century.  It changed when epinepherine was used to treat asthma in 1900.  Asthma deaths spiked again after the rescue inhaler was invented in 1952, and the first long acting rescue medicine was invented in the 1970s.  

The first impression of asthma doctors was to blame the same medicine that helped asthmatics.  They believed the medicine was killing asthmatics.  The main cause of death was considered to be due to the cardiac effect of the medicine.  This usually resulted when patients would abuse the medicine.

I think this may have contributed to some deaths, yet I think these scientists got it all wrong.  I think the reason asthma deaths started to rise in 1900 is because more people were diagnosed that weren't previously diagnosed.  I think one of the reasons is that you had medicines to help asthmatics if they were diagnosed.

Even recently Advair is blamed for killing some asthmatics.  Yet I don't think that medicine would kill a fly.  The medicine in Advair is no different that ventolin, it's just the longer acting version of ventolin.  I've used an entire inhaler of Ventolin plus taken extra hits on my Advair and still survived.  

I think the reason Advair gets blamed for asthma deaths is because the EMTs arrived at the person's home and saw the Advair clutched in the hands of the asthmatic. So the Advair was given the blame for the death.  Yet the true reason was because instead of calling for help the asthmatic relied on the medicine.  The medicine wasn't working, but by the time the patient realized this it was too late.

So I believe the reason for the rise, at times, in asthma deaths is due to lack of education.  It has little to nothing to do with the medicine.  And I think that black box warnings on such inhalers, or taking them off the market, does more harm than good.  It prevents asthmatics from getting the medicine they need to help them.

So thus is my unedited rant.  

This post was written as part of NHBPM – 30 health posts in 30 days: http://bit.ly/vU0g9J