Monday, February 20, 2017

1889: Mackenzie defines hay fever

Morell Mackenzie (1837-1892)
By the 1890s, Hay Fever was a well accepted condition by the medical community, and there were plenty of books written on the subject, including one by Dr. Morrell Mackenizie. He defined hay fever as a medical condition whereby exposure to certain substances causes catarrh and asthma.

He said:
The disease may be defined to be a peculiar affection of the mucous membrane of the eyes, nose, and air-passages, giving rise to catarrh and asthma, almost invariably caused by the action of the pollen of grasses and flowers, and therefore prevalent only when they are in blossom.  
Along with other physicians who wrote on the subject, he observed  hay fever, "like influenza and cholera, did not occur in Europe in the 'good ole times,' or it was entirely overlooked until a comparatively recent period."

More likely, hay fever in Europe was probably confused for some other malady that presents with similar symptoms.

However, he also added that...
...the fact that it has certainly become more common in the last few years would seem to prove either that irritating properties have been newly acquired by certain vegetable bodies, or that the wear and tear of the so called "higher civilization" of modern life has lead to the more frequent development of the nervous temperament, resulting in a particular idiosyncrasy, which renders us vulnerable in a new way.
This was not a new idea, as the modern way of living was blamed as the cause of catarrh going all the way back to 1776 when George Cheyne wrote his book, "The English Malady."

References:
  1. Mackenzie, Morrell, "Hay Fever paroxysmal Sneezing," 1889, London, J. & A. Churchill
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Wednesday, February 15, 2017

1980: My first rescue inhaler

Anyway, this was how I dealt with my asthma until one humid spring day in 1980.  My mom took me to see Dr. Gunderson.  Yes, this was one of those times when I was very short of breath.  I remember sitting on the doctor's bed after as he listened to my lung sounds with his stethoscope.  Then he said, "I have something I think might help you.  I will be right back"

Moments later he returned with a little white inhaler. "This is a medicine called Alupent. Here, I'll show you how to use it."  He took off the little round cap, and, holding the inhaler two finger length from my mouth, said, "Open your mouth.  When I say, go, take in a deep breath and I'll squirt.  Hold your breath for ten seconds.  Ready!  Go!"

I tasted the medicine, but almost immediately forgot about the taste as the medicine worked: my breath came back.  "Ahhhhhh," was all that came from me.  I smiled.  The doctor gave me a second puff, and I felt even better.  I swear to you that that first puff was the only time I ever tasted a bronchodilator.  I have since taken so many of them that I do not taste it.  I am immune to bronchodilator taste.  And I know it has a taste, because my patients remind me of this all the time.

My mom held onto the inhaler at first.  I would say she did this for about a month or so.  The she probably got so tired of me asking her for it, and noting that I was an expert at taking it, she just gave it to me. In retrospect, I am very much aware that she was never told of the risks of taking such an inhaler.  She was not told this because I was there when my doctor gave it to me.  I heard what he told her.  He did not say, "Do not ever let him use this more than every six hours!"  He did not say, "There have been asthma deaths linked to overuse of asthma inhalers."

He said none of that.  He did not scare my mom away from giving me this inhaler.  And for that reason, my mom just gave it to me.  I tried to be good with it at first, but then I became short of breath before the six hours was up, and I sneaked a puff.  Of course at first I felt really guilty, but I learned that this made me feel better without any real side effects.  Before you know it, I was puffing on my inhaler all the time.  I had become, in effect, a bronchodilatoraholic.

I'm sorry if I make my parents look bad here, and that wasn't my intention at all.  The truth is that my parents were normal parents who didn't have asthma themselves so there was no way of them knowing what I was going through.  At the time I think they simply didn't understand the severity of my condition.  There were thousands of parents like mine around the world.  Quite frankly, my doctor was clueless too.  But at least he had the gut to give this little ten-year-old boy an alupent inhaler so he could at least have some relief from time to time.

Monday, February 13, 2017

1980: Asthma terror in the hotel room

In 1979, even though there were some on the market, I did not have access to rescue medicine.I do not know why this was. However, I might presume that it had something to do with the scare that occurred during the 1950s when the inhaler was first introduced to the market. There was a rise in asthma related deaths during the ensuing decade, and the inhaler was blamed. So, perhaps due to that, doctors feared prescribing rescue medicine for kids especially. I would verify this with Dr. Gunderson, my doctor from this era in my life, but he has since passed away.

What I was prescribed was a pink solution. It was in the bathroom medicine cabinet. Once a day, and usually only when I was having trouble breathing, mom gave me a dose with a teaspoon. She probably should have measured it out better, but this was the method her mom used with her for giving medicine, so it's what she did. At least, that's what I would imagine.

I don't know why, but my mom made me responsible for remembering my medicine when we went places. You could judge my mom and say this was stupid. But, as my wife always says: You do the best you can with the wisdom you have today, and as you learn better you do better. My mom, when I asked her about this, has no memory of it. I don't blame her. It makes sense that I'd remember it and not her, as there is one of me and she had many other kids to take care of, including herself and dad.

In my own defense, asthma was treated as an acute disease back then. This means that you didn't take medicine when you felt good; you didn't take medicine every day to prevent asthma symptoms. Mom only spoon fed this medicine to me when I complained of feeling short of breath. So, considering I might go months without needing it, this made it easy for me to forget to take it with me when we went on vacation as a family.

So, I did have a bottle of some pink syrup. When I was short of breath mom took me into the bathroom and gave me this medicine with a teaspoon. What was it? I have not idea. I wonder, however, if it was Alupent solution. Dr. Gunderson must have decided this was the best medicine, the safest medicine, for an asthmatic child. However, I would be more inclined to say it was theophylline solution. It may also have been a steroid. My memory is hazy here, and I have no way of clearing it up, unless someone reading this has some wisdom to share.

There was an alupent inhaler on the market at this time. There was also an epinephrine inhaler called Primetime Mist that was available over the counter, but most doctors advised against prescribing this medicine, especially to kids. On the box of antihistamines was a warning not to let asthmatics use it, so this was not allowed either. So, other than this little pink solution, there weren't many options when I felt short of breath -- such as if I was exposed to my asthma triggers. Here I was a kid, and I had no rescue inhaler. I had not Primetime Mist, and I had no Alupent. I did not even know they existed at this time in my life. If my asthma got bad enough, mom was told to take me to the emergency room for 0.5cc of epinephrine. Mom even had a note from doctor Gunderson for when we went on vacations, such as we did in June of 1996 when we went across country to California.

If my asthma got bad enough, dad would run the hot shower and close the door. He and I would stand in the bathroom until we couldn't stand it any more. We would exit the bathroom. It definitely felt soothing to leave the hot and steamy bathroom into the cool hallway air, but it did not do anything for my breathing. I would be short of breath when I entered the bathroom, and I would be short of breath when I exited the bathroom. This was an old wives tale that steam helped asthmatics. It does help kids with croup, but I didn't have croup. In the old days, these two ailments were often confounded. Steam is good for croup. Steam is bad for asthma. It makes air thicker and harder to inhale. But, you do the best you can with the information you have today, and as you learn better you do better. Back then, doctors didn't know better.

So, I was not aware of any Alupent inhaler. When I started coughing, wheezing, or showing any signs of being short of breath, my mom, or my grandma, or my dad, would resort to the old wive's tale asthma remedies.  I remember my grandma Lila rubbing Vix VapoRub all over my chest. My other grandma (my dad's mom) would run the hot water in the sink of her old Victorian home on 5th avenue in Manistee (she had no shower), and would put a towel over my head. This had the same steamy effect as the method dad used. I think it made grandma feel good that she was doing something. When she removed the towel, I would tell her I felt better, even though I probably didn't.

Well, actually there was a moment of relief as you left the hot steamy air to inhale cool, refreshing air. But this was probably because humid air is heavy and hard to inhale, and the cool air gave me an immediate feeling of relief.  In essence, this therapy was no better than creating pain in one part of your body to make you no longer feel the pain somewhere else.

These were all days when I felt mildly short of breath. You know, you can live that way. It's similar to what you see with many COPD patients today who, as the disease slowly progresses, get gradually more short of breath over time.  It happens so slowly they don't even realize they are short of breath. Then they come to the emergency room, we give them a breathing treatment, and they are amazed at how much better they can breathe. Chances are they didn't even come to the emergency room for their breathing. They had a bad stomach or something, and the ER doctor recognized the classic signs of COPD.

No, I'm not implying I didn't know I was short of breath.  I'm not saying that.  What I am saying is I sort of developed a tolerance to it.  I had asthma attacks since I was two years old, so I had lived with it for so long, knew there was nothing I could do about it, so I developed a coping strategy of grinning and bearing it -- at least until it got severe. But it was not severe in 1976 -- not yet. 

I must have been a little older than six if mom made me responsible for my medicine. Maybe it was 1978 or 1979. Maybe I was ten. But it seems it must have been before 1980. Anyway, sometime around there we went south to a Quinn family reunion. This would be my dad's mothers side of the family. I can't remember where the reunion was, but it was at a campground. Years earlier we camped. This year mom and dad rented a hotel room. Mom hated camping. Camping was bad for my asthma. So we stayed in a hote.

I remember getting there and feeling short of breath. I told mom. She got mad at me when it was learned I forgot my medicine. Again, I don't fault my mom here. Don't write me emails telling me how bad my mom was for making me remember my own medicine. Mom denies this ever happened. However, I am convinced it did. In fact, I know it did.

So, instead of going to a pharmacy and getting me some medicine (or maybe this was not an option then), or instead of taking me to the hospital, mom gave me a cough drop and left us five boys in the hotel while they went out on a date.  Yes, that's a true story.  My older brother Bobby was in charge. No. Wait! I actually think my cousin Molly babysat us. I think that was it. 

I remember my brothers goofed around, and I never left my bed.  Little Tony was a baby and he was sleeping.  And Dan fell asleep right away.  David and Bobby were closer to my age (Bobby a year older and David a year younger) and they had fun.  They kept farting and running around the room. They might even have teased me, as they had no idea why I was being such a baby. In the meantime, I was stressed, sweaty, and panicky.  

Finally my brothers all fell asleep, but I remained awake.  I tried to sleep, but I could not turn the wheels off in my head.  I could not help hoping my mom and dad would walk through the hotel room door.  It seemed like hours, days, even weeks.  In actuality, it was probably only a few hours.  In actuality, it was probably no later than nine-o-clock: late for a kid but not late for adults out having fun with their friends and relatives.

I must have fallen asleep at some point, because all of a sudden I realized my inside cheek is all wrinkly from where the cough drop rested.  I was still positioned high on my pillow, and air I inhaled was hard coming.  I could get half a breath, but it was still very uncomfortable.  I remember I started to cry after my brothers all were sleeping. I was up late when my brothers were breathing hard, and farting in their sleep.  

Anyway, this was a terrible night in a hotel room. I think that by the time mom and dad came home I never said anything. By this time I didn't want to ruin their night. I had made it this far, I can make it the rest of the night. I do not remember what happened after that.More than likely, I just dealt with it

The next day we went swimming in the hotel pool. We did this all day. However, while my brothers had fun swimming, I stayed on the shallow end with my chest above the water. If my chest went under the water, my breathing became too heavy under the pressure of the water. I think at some point I decided to just get out of the water, as the chlorine must have bothered my asthma too. A fun day for everyone else, a not so fun day for the asthmatic who forgot his medicine. 

Saturday, February 11, 2017

My Experience With Theophylline

Here’s some interesting facts about my experience with theophylline. This, I think, is an interesting story, as it shows how far asthma wisdom has improved just during my lifetime. This is where I enter into our asthma history.

During the 1920s, researchers learned that theophylline opened airways to make breathing easier. Theophylline is a white crystalline powder first isolated from a tea leaves in 1888. Theo is Latin for tea, and phylline is Greek for plant. During the 1920s was recognized as a bronchodilator and was first prescribed for asthma. During the 1940s an IV version of the medicine was used in hospitals. During the 1950s it was used to treat asthma. However, it wasn't until the late1970s (I was born in 1970) that it was commonly prescribed for the treatment of asthma (back then, asthma was only treated as an acute disease, and you didn't take medicines to prevent symptoms). During the 1970s, slow release theophylline was introduced to the market, beginning with the brand Theo-Dur. So, if you felt fine, you quit taking your medicine. My point here is that I was born at the precipice of good asthma medicine. However, I was also born about 19 years before asthma was treated as a chronic disease, where asthma preventative medicines were taken every day to prevent asthma symptoms. (5, 6)


In 1976, I was introduced to theophylline. I would have been six. It was probably a solution called Sustair. Mom kept it in the bathroom medicine cabinet, and spoon-fed it to me once or twice a day when I complained of shortness of breath. I would go without taking it for long periods of time. Around 1980 I was prescribed a white pill called Theo-Dur. I figured I would probably never get off it. My memory around this time is a little hazy. I asked my mom if the medicine I was taking was theophylline, and she had no memory. There was another medicine, one that tasted terrible, that I took when my asthma was bad. It was also a solution. Considering corticosteroids taste nasty, I'm guessing this other medicine was a steroid. If you have knowledge of medicines a kid might be prescribed for asthma during this era of our history, please let me know. I asked my mom about it, but she doesn't remember. My doctor at this time has since passed away, so I obviously can't ask him. I do know I was started on theophylline at an early date, so I think I'm safe to assume the medicine I took every day back then was theophylline.

I actually wrote a story a while back about forgetting to take it with me on vacation. Keep in mind I was not introduced to the rescue inhaler until I was 10 in 1980. Physicians had to constantly monitor patients on theophylline to monitor theophylline levels. (4) I don't remember getting poked a lot, so, if this was done, it wasn't too often, maybe once a year -- maybe never.


In 1980, I had episodes of severe nausea and headache. I remember these episodes were always blamed on the flu. However, a part of me now wonders if it was due to an unintentional overdose of theophylline. A therapeutic dose is above zero. The safe zone is less than 10. In order to gain a therapeutic benefit, the dose had to be high enough that the benefits often came with side effects such as tremors and stomach problems. Sometimes I wonder about this. The headaches and nausea were so severe that, even at the age of ten, I cried. .A normal theophylline level is zero (it’s not needed). A high theophylline level has been linked with some severe side effects, such as nausea, headache, seizures, and even death.

Initially, a level of 15-20 was considered therapeutic and safe. However, later on, 5-15 (or a level of 10), was considered therapeutic and safe for most asthmatics. (6) I do not know what theophylline level my doctors were searching for.

This was also the year I was introduced to Albuterol. My albuterol history will be told at a later date. I'm sure you'll find that interesting considering I became a prototypical rescue inhaler abuser.


By 1984,  I knew caffeine was a mild bronchodilator. I don’t remember how I learned about it, but I was told from someone that caffeine opened airways. I tried it a few times with negligible results. I figured, and probably rightly so, that my was too severe and required stronger bronchodilators than just coffee.  Years later, I’d learn that theophylline is a member of the xanthine family of medicine, the same family theophylline belongs too.

For the record, coffee was first recommended as a treatment for asthma by Henry Hyde Salter in 1959. But there was no mention of it in later medical textbooks that covered asthma, such as Henry Osler's 1901 edition of "The Principles and Practice of Medicine." (3, 5)


In 1985, my theophylline dose was tweaked. I was admitted to “the Asthma Hospital” in Denver, and doctors there monitored my blood theophylline level for a 24 hour period. I had a port put into a vein in my right hand that allowed nurses to draw my blood every couple of hours. By doing this they observed that my theophylline level dipped around 2 p.m.. So, rather than me taking my dose in the a.m. and p.m., they had me take it at scheduled times, such as 6 a.m., 2 p.m. and 10p.m. This kind of sucked because I had to get up early and stay up late. I also had to remember to take it in the afternoon. But it worked. When I repeated the test a month later, my theophylline levels remained stable throughout the day, resulting in better asthma control. The doctors at this hospital also had me take Azmacort 4 puffs 4 times every day to control my asthma. The combination of these medicines worked great. The problem was being compliant with this regimen, as it was a lot of pill taking and puff inhaling. This was a problem not just for me, but for many other asthmatics at the time. The good news for asthmatics was that, during the 1980s, many other asthma medicines were approved by the FDA that reduced inflammation and kept airways open. This included a safer rescue inhaler called albuterol (Ventolin, Proventil) and inhaled corticosteroids like beclomethasone (Vanceril) and later triamcinolone (Azmacort).

In 1987, it was learned that some antibiotics caused theophylline levels to spike. I was vaguely aware of this, but like the risk of dying due to rescue inhaler abuse or simply due to having asthma, I heeded the warnings little attention. The antibiotic known to discovered to raise theophylline levels was Ciprofloxacin products. A warning was placed on the Theo-Dur package insert, so this is probably how I was alerted to this. I do not think it was my doctor. Why would a doctor warn you of the risks of taking a medicine he would never prescribe for me anyway? The labeling change was not added until 1990. Just a thought here: Maybe I was prescribed one of these medicines, and this explains my nausea-severe headache story above. Probably not, but you never know.


By 1988, I knew what happened when I forgot to take my theophylline.  In my defence, I was a college student at the time and was really busy learning. I simply forgot to take it for a couple days. My asthma became increasingly worse during the day, and my inhaler failed to remedy the situation. My chest became tight, and felt like someone was inside it with a feather tickling my airways.  I started coughing, and it was a painful cough productive of white secretions. It was a familiar feeling. I felt it before, many times. Over time, I learned it was because my theophylline level was too low. The remedy was to take theophylline. I trudged to my dorm room. By the time I got home my asthma attack was in severe mode. I took my theophylline dose, and sat all frogged up on the edge of a chair. I watched the clock. I knew I would start feeling better in about 20 minutes. It was a long, grueling 20 minutes. It’s a neat, euphoric feeling when one moment you can’t even take in half a breath, and then all of a sudden each breath gets deeper and deeper. You also don’t want to experience this. As a side note here, my room mate Frank came into the dorm room during this time and saw me in my panic stricken state. I was embarrassed. He was concerned. I said, “I will be fine. Just give me a half hour.” Of course, I said this in short, choppy sentences. What happened? A normal theophylline level is zero. My airways are chronically inflamed. Theophylline helps reduce this inflammation to make airways less twitchy and keep them open. The exact mechanisms are complicated and not well understood. However, once you start taking it, your body becomes dependent on it. When I missed a more than one doses, my theophylline level fell and this inflammation got worse. It irritated nerve cells in the area to cause that itching feeling. It irritated goblet cells to increase mucus production causing that painful cough.


In 1991, I started taking Salmeterol (Serevent). This is basically a long-acting albuterol. You were only supposed to take two puffs twice daily. I don’t know if it worked or not. I don’t know if I was even compliant with it (and probably wasn’t). What I do remember is one night my asthma was really bad, and I kept waking up and leaning to my right to grab my albuterol inhaler. I took many, many, many puffs on my inhaler that night. When I woke up, I realized that I didn’t puff on my serevent that night: I was puffing on my Serevent. This was when I realized that the fears about this great medicine are unwarranted. I realized Serevent does not kill asthmatics. If people die of asthma and a serevent inhaler was found clutched in their grasps, it was because they over relied on this medicine rather than seeking help. Of course, in the world we live in, the medicine usually gets the blame when bad things happen. Anyway, as you read on you will see why I put this in this post. My doctors tried to get me to take this medicine over the next ten years, although, especially considering I was using (and abusing) albuterol, Serevent made me too jittery. I hated this side effect, so I refused to take it.


By 1993, I was placed on the highest theophylline dose ever. The asthma hospital helped me obtain good control of my asthma. However, by 1993 it was uncontrolled once again. My doctor at that time (Dr. Oliver) increased my dose to 600 mg twice per day. It worked great to control my asthma. The problem with this is the there are side effects of theophylline, and they are similar to when you drink too much coffee. It increases mental acuity. It keeps you awake. It relaxes your esophageal sphincter and causes reflux of stomach acid, or what is now referred to as GERD. I became nauseated. My stomach was bloated. I felt horrible. I saw a surgeon. He performed a procedure called an EGD, or esophagogastroduodenoscopy. You could also call it an upper gastrointestinal endoscopy test. It confirmed I had an ulcer. There’s no way of knowing for certain the cause of an ulcer, but considering the high dose of theophylline I was on, it seemed the likely culprit. Of course, it could also have been a side effect from a steroid burst, or stress, or a bacteria.


In 1997, my new doctor (Dr. B.) was concerned about my high dose of theophylline. He was an Internist. He also said that he had never heard of such a high theophylline dose as mine. However, he checked my theophylline level and it was less than 10. He said he didn’t want to try to wean me off of theophylline due to the risks, and also due to my fear as to what would happen to me if I quit taking it (see above). Regardless, my Internist was surprised such a high dose didn’t kill me.


In 1997, Dr. B intentionally took me off my theophylline. Ironically, the day after I met Dr. B. I had a severe asthma attack. In a feeble attempt to self-help myself, I took extra theophylline. This was stupid. I was admitted to the hospital. A blood draw confirmed for the doctor my theophylline level was high. So, he cut me off my theophylline. This was equally stupid. Never take someone who is chronically addicted to theophylline off it. My asthma got worse. Seven days later I was still on high doses of corticosteroids and my asthma was still terrible. It was the weekend. My regular doctor got the day off. So, a  new doctor came to see me (Dr. M). She prescribed a dose of aminophylline. It’s basically theophylline given by IV. Within hours I was breathing easy. That doctor may have saved my life. Prior to being admitted I was still prescribed 4 puffs of Azmacort 4 times a day. However, a new medicine called Flovent had been introduced to the market. It contained fluticasone, an inhaled corticosteroid that only needed to be taken twice per day. This was my new prescription. It made compliance easier. It was also thought to be a better steroid. I don’t know that it was really better, however, other than it made compliance easier. He also prescribed Serevent. I tried to be compliant with these two inhalers. But, once again, the Serevent made me too jittery, so I quit taking it.


In 2001, I started taking Advair. It was (is) a combination of long acting bronchodilator called salmeterol. I was aware of it for a few years. However, I feared the fact that Serevent was in it. I figured it would just make me too jittery. However, I had a friend named Shauna who also had severe asthma, and her asthma (she said) greatly improved once she started taking Advair. So, I decided to try it. It worked great. My asthma greatly improved. In fact, once day, I went to Detroit to visit my brother Tony. I was with my girlfriend (and current wife). I panicked. My wife and I scrambled to find a pharmacy to get theophylline. Thankfully, I was using Rite Aid, and there was one near my brother’s home. I had my theophylline filled. A few months later, we visited her friends Carrie and Chris at their apartment. I once again forgot to bring my theophylline. However, I did not get it refilled. I had no trouble with my asthma that night. This was when I realized that Advair was doing a great job of reducing airway inflammation and keeping my airways open. I wondered, “Will I be able to finally get off theophylline?”


2003, the decline of theophylline as a top-line asthma medicine. During my annual checkup with Dr. B. he said, “Ten years earlier nearly every one of my asthmatic and COPD patients were on theophylline. Today, hardly any are.” There was a brief discussion about this, and we both decided to continue my current regimen. I had been on it so long, and it worked, so why change it. However, this got me to thinking. It was about this time I started discussing a slow wean with Dr. B. I tried several times, but there was that constant fear in the back of my mind. I failed to wean myself off it.


In 2007, I was finally weaned of theophylline. I honestly did not think it would ever happen. However, back in 1988 I was introduced to email and thought it was a stupid idea that would never fly. That same year my journalism teacher said, “I don’t ever envision a world without newspapers.  As it turned out, email was a huge success, newspapers are slowly becoming extinct, and theophylline is no longer a top-line asthma medicine. I had been on Advair for six years. I once again discussed with Dr. B. about a theophylline wean. He said to go really slow. So, this is what I did. It took me a whole year. I reduced it by half a pill a month. For many years afterwards, I kept the bottle of theophylline in my medicine cabinet. It was there as a reminder of how I was once addicted, and thought I would never get off theophylline. It’s a sign of how far asthma medicine has come in my lifetime.


It was also this same year I had a gastrointestinal bleed. I became nauseated and lightheaded one Monday afternoon. I was admitted to the hospital. My hemoglobin was 8 (normal is 13.5-17.5) I had another upper GI scope. It turned out I had another ulcer. I was taking a lot of Aspirins for headaches. I was off theophylline, so I couldn’t blame it. I was on Advair, but I can’t imagine an ulcer would be a side effect of such a low dose inhaled. Still, my doctor put me on Prilosec and said I will never be able to stop taking it. Actually, I am going to blame my theophylline and steroid history for messing up the lining of my stomach. I am because I can.


In 2010, I became addicted to coffee. Is this any surprise. Here I was chronically addicted to another member of the xanthine family. My body must have missed it. So, when I started to drink coffee for the first time in my life, I quickly became addicted. I did not know until recently that caffeine was metabolized into theophylline (actually, I probably did know this and just forgot). Still, it’s should be no surprise that I merely exchanged one member of the xanthine family for another, only a much lower dose. Hence, I still have GERD and the occasional trouble with my stomach. Interestingly, Prilosec has now been linked with dementia, so I suppose I have that to look forward to too, if I so happen to have the genes that lend to that sort of thing.


Here’s an interesting note. As a side here, I want to explain why it is I can now take Advair with no problems, when Serevent once caused me to feel jittery. Studies have shown that when you inhale a respiratory medicine with a propellant, it is distributed better in the airways, possibly resulting in better asthma control. So, it’s possible that just the change in the way Advair is delivered results in fewer side effects. Advair is a dry powdered inhaler. This is the only reason I can think of why I tolerate Advair so well, and that medicines like Serevent inhaler cause the jitters. Another interesting thought is Symbicort, Dulera, and Breo also cause the jitters. I cannot explain why Breo does this, other than it is one strong dose once a day. Serevent, Symbicort, and Dulera are all inhalers, at least when I used them.

Anyway, it’s interesting. Asthma is a heterogenous disease, meaning we are all different. This would explain why my asthma history, and what works for me, is different than what works for other asthmatics. Again, I think this little bit of history is a testament to how far asthma wisdom has advanced in my lifetime. As you follow my story, I will give many other examples.

Further reading and references:

Friday, February 10, 2017

1870-1900: Pneumatic Chambers

(1, page 91)
By 1903 the pneumatic chamber was a viable method of treating patients with various lung ailments.  The therapy was generally referred to as a "compressed air bath," and was provided by means of a compressed air chamber, or pneumatic chamber.

By this time such chambers were refined so that they contained carpet, windows, electric hydraulic compressors, and even humidity.  Some of the devices that were available in 1903 were described by Paul Tissier in is 1903 book "Pneumotherapy: Including Aerotherapy and Inhalation Methods."  Some are as follows:

1.  Tabarie Sphere's:  This was a sphere made of cast iron with two pipes, one to provide pressure from a hydraulic compressor run by steam, and the other to allow for ventilation. Carpet covered the floor mainly to cover the first pipe.  There was an antechamber to allow the physician to enter and exit without disturbing the pressure, and to provide books, newspapers, and drinks to the patients.  It's basically this device that was later copied by others who refined the pneumatic chambers.  I wrote about the Tabarie Sphere in this post.  

Figure 13 and 14
2.  Lange's Pneumatic Chamber: According to Tissier, "Lange's pneumatic chamber differs in shape, and in certain devices for ventilation and the regulation of the temperature, from Tabarie's apparatus. It is cylindrical, constructed of wrought-iron, and accommodates only four persons. The temperature of the compressed air within the chamber is lowered either by means of a stream of cold water directed against the force-pump and the supply-pipes, or by filling the cup-shaped space at the top of the chamber with cold water and allowing it to flow down along the sides, where it is taken up by sheets of linen and cools the air by evaporation. In winter the chamber is kept at a comfortable temperature by heating in the ordinary way the room where it is set up. The chamber is also provided with a device for regulating the flow of the incoming air so that it enters in a steady stream instead of in a succession of puffs corresponding with the strokes of the force-pump. The pressure is secured, as in Tabarie's system, by regulating the inflow and outflow of the air." (1, page 91)

3.  Aerotherapeutic Installation at Jewish Hospital at Berlin:  Here the air is pumped through a large pipe that was connected to a filter to filter out bacteria and dust.  The air then passes through a wooden box where it is warmed by heated steam.  The pipes containing heated air are wrapped in a cloth to prevent condensation.  The air can also be cooled if so desired.  A pipe around the floor of the chamber provides pressure from a compressor in the engine room (see figure 13).
Another pipe allows for ventilation.  To see the device check out figure 14.  (1, page 95)

4.  Dr. Dupont's Pneumatic Chamber:  This was a later design described by Tissier as having both the ability to provide electric lighting at night and telephone service.  They were large enough to hold two or three patients.  It was located at the  Etablissement AeVotheVapique of Dr. Dupont in Paris.  Tissier provides a neat picture of it here on page 93.  

Liebig's Pneumatic Chamber; here is one of three chambers
5.  Leibig's Pneumatic Chamber At the Dianabad in Reichenhall was built a pneumatic chamber which basically had three chambers, with each chamber holding up to three persons.  It should be obvious by looking at figure 15 from Tissier's book, the chamber has five chairs, so perhaps this is a later design.  One antechamber connects all three rooms, and allows the physician to enter and exit without disturbing the pressure.  The antechamber also acts as a large pressure regulator, preventing the patients from feeling the sudden effects of pressure changes in the chambers.  A ventilation pipe through an opening in the ceiling is supposedly designed in such a way as to provide "perfect ventilation."  It is operated by steam from an engine, which communicates with the chamber through a pipe.  The temperature in the chambers can be controlled, and a different pressure can be obtained in each of the chambers.  

There are a variety of other chambers described, although it appears that for the most part a particular doctor constructed a chamber design for a specific medical institution.  Some patients would have to travel a long way to seek treatment, and even then there was no evidence it did any good.  I suppose in a way it would be similar to patients with certain cancers or chronic pain traveling from all over the United States to seek the treatment of experts at the Mayo Clinic.  

I will mention one more chamber here.
Hauke's Pneumatic Tub

6.  Hawke's Pneumatic Tub:   Well, it was small chamber as compared to the ones mentioned above, and far less expensive, and probably even portable.  It was build in such a way that it could provide compression and rarification of air by turning a crank, and was an alternative to the chambers mentioned above, and to the portable pressure apparatus's I describe in this post.  


Hauke originally recommended using a cuirass that created rarified air, but he ultimately decided the tub provided a better effect. The patient sat in the tub, and a rubber hood was set over the head, slid over the shoulders like a shirt, so that only the face was exposed.  The atmospheric pressure around the body is compressed and then rarified so as to create inspiration and expiration with greater ease than a patient's normal efforts.  (1, page 231)

Tissier describes the device like this (1, page 231):
"(The device is) so constructed that the patient introduces the entire body with the exception of the head, and therefore breathes air under ordinary pressure. The cabinet communicates with two reservoirs, one containing condensed, the other rarefied air. During inspiration the air in the cabinet is rarefied, and expansion of the chest is facilitated. During expiration the air in the cabinet is condensed, the result of which is to aid thoracic retraction and render it more vigorous. By this means the two phases of respiration are influenced, and in an absolutely mechanical manner. The procedure may be truly said to be a method of artificial respiration. Hauke recommends his apparatus especially for children, who generally refuse to breathe into the so-called portable appliances, and, in fact, experience great difficulty in doing so. He has used it successfully in a variety of cases. Kaulich has also obtained good results."
Tissier makes note here of the next phase of pressure therapy: the invention of portable pressure apparatus's, which were generally referred to as pneumatometers.  Hawke became the first to invent such a device, and it was introduced to the market in 1870 and I describe it in detail in this post.   
Figure 3 -- William and Ketchum's Pneumatic Cabinet (6)
7.  William and Ketchum's Pneumatic Cabinet:  There were similar devices, such as William and Ketchum's Pneumatic Cabinet, such as the one you can see in the advertisement in Figure 3.

By the 1900s the chambers were refined so that electricity was used to run the hydraulic compressor, windows provided the ability to see outside, temperature could be controlled, and humidification added.   

Most of the chambers contained an antechamber that allowed the physician to leave and enter the chamber without disturbing the pressure.  This also allowed the opportunity to bring entertainment to the patients, such as "books, newspapers, drinks, and the like, without interrupting inturrupting his treatment." (1, page 88-89)

And also keep in mind there were many of the above such chambers, tubs and cabinets at various medical institutions.  Which one you would use would recommend on your ailment, symptoms, physician, and location.  


References:
  1. Tissier,Paul Lewis Alexandre, edited by Solomon Solis Cohen, "Pneumotherapy: Including Aerotherapy and inhalation methods," volume X, 1903, Philadelphia, P. Blakiston's Sons and Co., pages 88-98, or as noted above.  If the profession of respiratory therapy existed in their era, we would be reading their books.  However, as it was, their books were written for the medical profession. All of the material from this post is from Tissier's book unless otherwise noted in the above paragraphs. 
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Wednesday, February 8, 2017

1876: Colorado cures hay fever

Dr. George Beard lists the above approximate altitudes above sea level for
various areas of Colorado, stating that such high altitudes benefit people
suffering from hay fever and asthma. 
In the mid 19th century it was discovered, perhaps by mere accident, that higher altitudes present themselves to easier breathing. I already covered how tuberculosis patients benefited from sanatoriums set up in Denver, Colorado, and how later these TB sanatoriums were converted to asthma hospitals.  Yet did you know that hay fever sufferers also found relief in the centennial state.  

Vacationing to the State of Colorado was actually recommended as a remedy for hay fever in an 1876 book "Hay-fever; or, Summer Catarrh," by George Beard, president of the American Hay Fever Association.  He wrote that:
In 1873 a pamphlet was issued under the indorsement of the Medical Association of Denver, Colorado, giving details of over one hundred cases of ordinary asthma and hay-fever that had been cured, or more or less benefited, by residence in or near that region. The Committee of Asthmatics, who represented the Asthma Association, state in their report that probably not one half or one quarter of those in Colorado responded to the call for information. They state, furthermore, that the amount of sunshine there is remarkable; from July, 1872, to December 29, 1873, there were but three days (excepting perhaps in June, 1873) when the sun was not seen.
Dr. Henry K. Steele, President of the Medical Association, in a brief report, states that "in the opinion of the above medical association the climate of Colorado, in and about the range of the Rocky Mountains, has a wonderful curative power over asthma; that nearly all such patients coming into this climate are relieved—at least so long as they remain here; and that all, if not entirely relieved, are sooner or later benefited, with the exception of those cases dependent on or complicated with organic disease of the heart or lungs.
 Dr. O. M. Bryan, of Colorado, writes: "I have known a few cases temporarily relieved by visiting Colorado. Persons suffering from hay-asthma are generally relieved soon after crossing the Missouri River. My opinion is that ninetynine cases out of every one hundred would be relieved, or cured for the time being, by visiting the Rocky Mountains. (1, page 151-153)
It's just interesting to note the various studies and reports confirming the benefits of breathing the cool, sunny air of Colorado, or similar places.

Reference:
  1.  Beard, George M, "Hay-fever; or, Summer Catarrh," 1876, New York, Harper and Brothers, Publishers, pages 151-153
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Monday, February 6, 2017

1875: Bleeding STILL recommended to cure your asthma

No one knows for sure why this was ever practiced, yet for thousands of years in the annals of human medical history, diseases were treated by a remedy called bleeding, or venesection.  This involved intentionally slitting a vein with a sharp object to induce bleeding.  It was the ideal remedy when all else failed, even for asthma or difficult breathing.

Hippocrates generally recommended subtle remedies for asthma, although when all else failed, bleeding remained an option.  So assuming Hippocrates picked up his medical wisdom from the stone tablets at the Aesclepeon of Cos, the practice must have been known to the priests of Ancient Greece since the early days.  And considering the Greeks gained much of their medical wisdom from the ancient Egyptians, it probably goes back much further.

Historian Edward Withington, in his 1894 book "Medical History from its earliest times" proposed an interesting theory regarding bleeding.  He postulated the idea that it may have been picked up by primitive humans, the same humans who would eventually settle in Mesopotamia and Egypt.  He wrote:
Ever since vital activity has existed on the earth, it has, in all probability, been liable to those perturbations which we call disease; wounds and injuries must have occurred wherever there were weapons to inflict them, and fragments of diseased fossil bone are to be found in our museums. We may well suppose that the earliest efforts of intelligent beings were directed towards the avoidance or cure of these disorders, and the older writers amused themselves by searching for instances of medical or surgical practice which they thought might be derived from animals. Thus the most ancient and widely spread of surgical operations, that of bleeding, is said to have been taught mankind by the hippopotamus. "That intelligent animal," says Pliny, "finding himself plethoric, goes out on the banks of the Nile, and there searches about for a sharp-pointed reed, which he runs into a vein in his leg, and having thus got rid of a sufficient amount of blood, closes the wound with clay."  Similarly the use of emetics is said to have been learnt from the dog, that of hellebore from the goat, while the assertion that stags healed their wounds by means of the herb dittany is supported by many authorities, including Aristotle himself. Nor are these stories to be entirely rejected, for have we not lately been told that Count Mattei* discovered the basis of his alleged remedies by observing the plants eaten by a mangy dog in the Apennines? (2, page 7)
Of course Withington was just speculating, yet his theory is interesting.  If nothing else, his theory shows just how far back the practice of bleeding goes back.

Primitive people had no concept of anatomy or diseases, so they probably bleed as a means of purging evil spirits or demons from sick people.  It may also have been a means of pleasing the gods through sacrifice.

S.D. Gross, in his 1875 article "The lost art of medicine," said there was a variety of methods of blood letting, which included, but were not limited to: (1, page 430)
  1. Venesection:  Slitting open a vein 
  2. Cupping:  Placing cups on he skin that cause blistering and bleeding
  3. Leeches:  The leeches to the work of sucking out blood
  4. Scarification
  5. Puncture
  6. Arteriotomy:  Due to difficulty, few practice it.
Gross estimated that the diseases hat benefited the most from bleeding were those of inflammation.  For example, he noted that "Hippocrates and his immediate followers bled largely in pneumonia and pleurisy; and Sydenham, Rush, Louis, Drake, and many others often took immense quantities of blood in the treatment of these maladies."  (1, page 430)

He wrote:
In chronic inflammation, blood-letting is often an indispensable remedy. Even the most ultra advocate of the stimulant method of treatment will hesitate to employ it when destructive action is gradually but surely undermining structure and function. The abstraction of five eight, or even ten 'ounces of blood in chronic pneumonia and pleurisy, especially when associated with severe pain and obstructed respiration, often acts like a charm, relieving suffering and promoting the beneficial action of other measures. (1, page 430)
He continued:
To draw blood to the greatest possible advantage, the quantity should be measured, not by ounces, but by the impression it makes upon the system, as denoted by the pallor of the countenance, the reduction of the heart's action, the softened state of the pulse and skin, the abatement of pain and of other symptoms, as headache, thirst, and restlessness, so universally present in all severe inflammatory attacks. To insure this result in the mor. speedy and decided manner, the blood should be drawn from a large orifice in a large vein at the rate of two and a half to three ounces in the minute, while the patient is in the erect or semi-erect posture. If the body be recumbent during the operation, a much larger quantity of blood will be required to be drawn to produce the desired effect than whet the reverse is the case. While, therefore, the bleeding should be spoliative, care should be taken not to waste the fluid unnecessarily.
 To prevent undue reaction after the operation, the bleeding should not be carried to complete syncope, but merely to an approach to this condition, the effect of the operation being carefully watched by a reference to the countenance and the pulse, lest it should exceed the proper limits, and thus do harm instead of good. Violent reaction, however, in any case, after the abstraction of blood, may generally be effectually prevented by a full dose of some diaphoretic anodyne, as ten grains of Dover's powder with one-fourth of a grain of morphia, given immediately after the operation.  (1, page 430)
He further explains he mode at which bleeding helps with inflammation:
In the first place, the abstraction acts spoliatively, diminishing, as the name implies, the quantity of blood, both in the part and system. Secondly, it weakens the power of the heart, and thereby prevents it from sending the blood with the same force and velocity into the suffering structures. Thirdly, it unlocks all the emunctories, and thus promotes secretion. Fourthly, it disgorges the vessels at the seat of the disease, restores the circulation, and places the absorbent vessels in a better condition for the removal of effused matter. And, last, but not least, it favours the action of other remedies, as purgatives, diaphoretics, diuretics, and anodynes.
So experts had bleeding down to a science, so to speak.

Now, say you were short of breath in ancient Greece, desperate for a solution, and your priest/ physician is pent on cutting your skin to make you bleed. This may not have sounded so irrational to you, as your priest/ physician was equally ignorant of anatomy and disease as you were.  By now there was the belief that such a practice would somehow help to balance the humors of your body to heal your ailing lungs.

The practice was heavily used among all the healers of the world -- from the primitive medicine man, to the ancient priest and priest/ physician, to the medieval physicians, surgeons and barbers -- until it was given a black eye of sorts in the minds of commoners due to certain abuses.

According to historian Fielding Hudson Garrison, the remedy perhaps was used to extremes in France around the time of Napolean, after his war surgeon, Francois Joseph Victor Broussais, recommended all sickness be treated by covering the body with leeches.  Yet when Pierre-Charles-Alexandre Louis realized leeching was useless during a diptheria epidemic, the remedy of Broussais faded away.  Louis later became the first to prove that bleeding had no effect for pneumonia, and this stopped bleeding for pneumonia, at the very least. (3, pages 340-342)

Gross suspected the end of the practice may have been a result of lost faith among the public and medical professions due to overuse.  He wrote: 
The indiscriminate employment of the lancet in former days did much to bring blood-letting into discredit, not only with the better thinking class of physicians, but the public at large. 'We cure the sick,' says Gui Patin, a professor in the Royal College of France,' when over eighty years old, by blood-letting, and also infants of not more than two or three months, with as much success and as little inconvenience.' (Benjamin) Rush, the great champion of this operation on this side of the Atlantic, bled indiscriminately and remorselessly at all periods of life, the young, the middle-aged, and the old; in all kinds of diseases, in the eruptive fevers, in fever and ague, in puerperal fever, in inflammations, in injuries, in hemorrhages, and even in anaemia, often taking immense quantities of blood, and repeating the operation six, eight, or even a dozen times in the same patient. In short, he and his followers used to bleed in every possible disorder until, in many cases, no more blood would flow, because there was none left That such a practice would at length work out its own destruction is what might reasonably have been expected. It rang its own knell. (1, page 429)
He continued:
I have said that general bleeding can be successfully practised only at the beginning of an inflammatory attack, a fact which, I repeat it, is not to be lost sight of in weighing the propriety of such a procedure. Let it be borne in mind also that bleeding is not to be practised indiscriminately, but judiciously, and with proper regard to the condition of the system. Our fathers grievously erred, because they bled in every stage of disease, and in all states of the system, the plethoric and the anaemic, the strong and the weak. Of course there were exceptions, but as a rule this was the practice; the harm, hence, as a natural consequence of the abuse, the abandonment of the treatment. (1, page 431) 
By the middle of the 19th century old medical theories were replaced by scientific method, and bleeding was basically phased out, going the same way as dilapidated medical theories.  However, there remained a few physicians (as there always are) who refuse to let go of old fallacies, ones who wish to continue using old ideas and remedies regardless of lack of evidence to their usefulness.  One of these physicians was S.D. Gross, who recommended bleeding even into the 1870s.

In an article fittingly titled "The lost art of medicine," Gross explains not only that bleeding should still be recommended for asthma, he recommends that it be performed with a lancet.  Man, could you imagine going to your doctor because you couldn't breath, and have him have you sit on the examining table as he whipped out a lancet from his closet?  He's sharpen it and say, "Well, I don't want to do this anymore than you, but it has to be done if you want to get better."

Of bleeding for asthma, Gross wrote the following:
For bleeding should not be restricted to the treatment of inflammatory disease... In asthma, bleeding is frequently of inestimable value, in relieving engorgement and spasm of the lungs, the causes of the terrible dyspnoea so often present in the more aggravated forms of the disease. I recall to mind the case of a lady who was the subject of asthma from the age of fourteen up to that of eighty six, when she died of pneumonia, whom I repeatedly bled with the greatest advantage in attacks of this kind, which nothing else could relieve. In another case, that of a tall slender gentleman of this city, nearly eighty years of age, in which a severe attack of asthma was complicated with great congestion and slight inflammation of the lungs, the abstraction of less than ten ounces of blood by the lancet led to a speedy convalescence and a complete cure. I verily believe that if this gentleman had not been bled he would have died.
Gross was confident that bleeding would be recaptured as an art of the medical profession.  He wrote:
I well remember the time when the use of cold water was interdicted as highly improper, especially in the treatment of the so-called eruptive fevers, and when ventilation of a sick man's chamber was considered as fraught with danger.  Bleeding will again come into fashion; history constantly repeats itself, and knowledge runs in a circle. No sensible man can fail to read the signs of the times; but it will not be indiscriminate bleeding, but bleeding performed for a reason, early, and, if need be, freely, to save tissue and promote resolution; in the robust and plethoric, in the young and middle aged, not in the weak, the anaemic, the intemperate, the broken-down, and the decrepit. Practitioners, during the last third of a century, have laboured under a delusion and a dream, from which they are gradually emerging to a sense of their duty; and, although I am not a prophet or the son of a prophet, I venture to predict that the day is near at hand, if, indeed, it has not already arrived, when this important element of treatment, so long and so shamefully neglected, will again become a recognised therapeutic agent, and will thus be instrumental in saving many lives, many an eye, many a lung, many a joint, and many a limb.
So if you were an otherwise healthy individual, Gross firmly believed bleeding should not only be recommended for diseases such as asthma, but that he benefits, as he has witnessed, would offer "great, if not permanent, relief."

Gross was not the only physician to continue to find a medical use for bleeding.  Even the great William Henry Osler noted in his 1894 book, "The Principles and Practice of Medicine," that bleeding was useful for certain medical conditions.  Surely the practice ultimately fell out of favor, although it would be another several years before bleeding truly was "a lost art."

Count Cesare Mattei (1809-1896)

References:
  1. Gross, S.D., "The lost art of medicine," The London Medical Record a review of the progress of medicine, surgery, obstetrics, and the allied sciences, volume III, 1875, London, Smith, Elder and Company,  page 432
  2. Withington, Edward, "Medical History from its earliest times," 1894, London, ,Aberdeen University Press, page 407
  3. Garrison, Fielding Hudson, "An introduction to the history of medicine," 1913, 1st edition, Philadelphia and London, W.B. Saunders and Company, pages 340-342
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