This feature is part of a year-long series of excerpts and special commentaries celebrating AFP's 50th year of publication. Excerpts from the two 1950 volumes of GP, AFP's predecessor, appear along with highlights of 50 years of family medicine.
This feature contains excerpts from the article “What to Know About Asthma,” by Francis M. Rackemann, M.D., published in the August 1950 issue of GP, and commentary by Grace Brooke Huffman, M.D., associate editor of AFP.
“Asthma” means a wheeze, and wheezy breathing depends upon the fact that the flow of air in and out of the larger air tubes is obstructed. The obstruction may depend upon a spasm . . . or it may depend upon a swelling of the bronchial mucous membrane . . . [or it] can depend upon the presence of mucus or exudate of various kinds in the lumen of the larger bronchi.
When such an allergic individual has asthma the cause of his trouble ought not to be too hard to find, and the finding depends upon just one thing—the taking of a careful history. When, and on what date did it begin? How old was he at the time? What happened? Why did the asthma begin? Was there an infection? Some new change in the old environment? A new dog or cat? Where did he live? How long had he been there? What sort of place was it? A farm? A house in the suburbs? A tenement? How long did the first asthma last? When did it subside? Did the family move at that time? Did the patient go off to college, and so escape from the dust which was causing trouble at home? Did he ever go to a hospital and if so, how did he do in the clean hospital environment? One must record the history with care. The dates on which changes in asthma occurred must be noted so that these dates can be compared later with the dates on which changes in house, or room, or bed were made.
The Doctor's House Visit
So far the emphasis has been on bedrooms and bedding—on those dusts to which the patient is exposed at night. There are other cases in which the sensitiveness was to the ozite pad under the rug, or to the fancy stair carpet, but these cases are not common. Sensitiveness to animals, particularly to cats, and often to dogs, is more common. Kapok, called “silk floss,” is a common offender. Its fibers become moldy very easily, and the mold breaks the fiber into a fine dust. When one sees a dilapidated pillow on the parlor sofa, one can suspect kapok. When the pillow is kneaded a little, the thumb and forefinger will come right together if it's kapok. If the pillow is held in the light and tapped gently, one can observe that a cloud of fine dust will appear. Kapok is bad stuff. There are many patients who have been quite relieved of their asthma when kapok was found and removed.
From this discussion of household dusts, it is clear that a personal visit by the doctor to the house of the patient will often lead to important discoveries. . . . House visits may be worthwhile, but with a good history, the diagnosis of the probable cause of any simple, allergic asthma should be easy—by the history alone.
If the attack is mild, and the patient is still at home, it may be that a “shot” of epinephrine is all that will be needed. . . . Perhaps, however, epinephrine has been used before, and now the patient is “adrenalin-fast” so that recent doses have made him worse instead of better. If so, the next step is aminophylline 0.25 grams to be injected intravenously, but to be injected very slowly, taking at least three minutes by the watch, for the injection to be given.
Ephedrine is much like adrenalin, but is less potent. . . . The patient takes up to four, or sometimes up to six, pills a day, as he finds necessary.
The nebulizers charged with strong (1 to 100) epinephrine solution are also useful remedies, which most patients suffering from asthma find sooner or later. The sprays are good for asthma of mild to moderate severity, and there are hundreds of patients who carry the machine with them at all times. The same nebulizer can be activated by the pressure of oxygen from a tank, or of air from an ordinary bicycle pump.
Whenever asthma is really bad, the patient ought to be in the hospital. . . . In the hospital, a good nurse and the kindly attention of the doctor will do much to restore confidence. In not a few cases, wheezing which was very severe at home became quite easy to manage as soon as the patient appreciated the security, the safety and the quiet of the hospital. The factor which seems of real practical importance is noted in our hospital as “T.L.C.” “Tender, Loving Care” is an important part of the treatment of asthma, at least in the first stages. The transfer to the hospital is, in itself, an important treatment.
Finally, it is important to keep the patient in the hospital long enough to re-establish his fairly good condition. . . . His treatment should include a period of rest and rehabilitation before he is discharged.
By [depletion] I mean that the patient has lost strength and resistance in a physical sense, or he has lost strength and courage in an emotional sense. In most of the cases he is “depleted” both in his soma and in his psyche. When the poor man was told to go and buy himself a good dinner, his whole outlook on life was greatly improved, and his asthma improved. . . . Another woman . . . wanted a divorce . . . and when at last the legal process was completed she, too, improved greatly.
ACTH and Cortisone
The new ACTH and Cortisone are quite as effective in asthma as they are in arthritis. The present reports deal with only a few cases, but all of them are optimistic and describe the extraordinary improvement which develops as soon as these new steroid hormones were administered. . . . Their arrival in our armamentarium is comparable to the arrival of the atomic bomb in the mechanism of war. Perhaps it is just as well that the drugs are almost impossible to obtain, except by those research institutes which are thoroughly equipped and qualified to study their effects from every possible angle.—FRANCIS M. RACKEMANN, M.D.
Feeling nostalgia after reading an article entitled “What to Know About Asthma” is a surprising sensation. Although we can be deeply grateful for research that has given us the means to treat asthmatic patients with leukotriene receptor antagonists,1 inhaled steroids and inhaled long-acting beta-2 agonists,2 there is still a sense that something has been lost from an era when the doctor made house calls (and even examined pillows!) and when a hospital was a place of refuge, safety, quiet and rest.
A quick MEDLINE search revealed that articles concerning the relationship between stress and asthma are still being published,3,4 but these studies are much less common than studies about the newest treatments available for asthma. The advent of our more powerful, longer lasting and more efficacious treatments for this chronic illness seem to come at the expense of a loosening of the physician-patient bond, at least as it is portrayed in this excerpt. We may not believe that “transfer to the hospital is, in itself, an important treatment,” but are we physicians even now in danger of deciding that the physician-patient relationship has no therapeutic value? Will we decide that “Tender, Loving Care” is unimportant as long as we provide the latest treatment for our patients? New treatments, cybermedicine and the like clearly have the ability to allow us to save lives that would otherwise be lost: picture the physician in a remote outpost who is able to consult in real-time via wireless technology with a world-renowned specialist.
Technology will change dramatically the way we interact with our patients, and may even change what we mean by “home visits.”5 We must determine what value we place on maintaining the deep understanding of our patients' lives and families that has long been a hallmark of family medicine. Fifty years from now, we need to ensure that technological advances will still allow room for the “kindly attention of the doctor.”—GRACE BROOKE HUFFMAN, M.D.