By Dr. Paul Ehrlich and Henry Ehrlich
We were saddened to read that our co-author Dr. Lawrence Chiaramonte had died due to complications from Covid-19 at the age of 82. He had been in an assisted-living facility, which is an epidemic story ripped from the headlines. Looking at the Dr. Larry posts still featured on this website (where they will remain), we realized that we hadn’t had a post from Larry since 2017, which is probably about the time he entered the facility. It became harder for him to participate the further he got from practice.
Larry’s life was a real Horatio Alger story. His immigrant father was a barber at Yale, and Larry managed to attend both Yale College and Yale Medical School on scholarships. He trained in family practice, pediatrics, and allergy and immunology both at Yale and later at Johns Hopkins. He established a program that produced dozens of allergists in Brooklyn, New York, with a focus on inner-city populations. His work on compliance and use of peak flow meters became part of the national guidelines for the treatment of allergy. He also started the first food allergy center in New York City and has undertaken several surveys with the NPI group regarding Americans’ beliefs about food allergy.
Fortunately, between our book, Asthma Allergies Children: a parent’s guide and this website, Larry managed to leave behind a lively, provocative body of anecdotes and observations drawn from his devotion to the science and practice of allergy. Here we present some of that material from our book, which is still worth buying and reading although much has changed. You would also be well advised to look at Larry’s many posts on this website, which was created in some ways to be an evolving second volume of the book. As we noted when we started it, medicine moves faster than print.
DR. LARRY — STUDENT AND TEACHER
SOUNDS OF SILENCE
More years ago than I would like to admit, I was a supervising resident of a large city hospital that served poor children primarily. I worked with interns, doctors just out of medical school. It was a balancing act: protecting the children from less experienced doctors while giving these interns room to gain experience and learn. We all worked long hours through many sleepless nights.
Sometimes snap judgments had to be made during those long shifts. But I always told my interns, “When in doubt, ask.” “Dr. Kramer” was a shy but better-than-average intern. She called me one morning in tears. “They admitted a 12-year-old asthmatic boy to my service at ten last night. I started treatment and went on to another admission. When I returned to check on him a few minutes ago he was dead.”
That morning I reviewed the chart, and talked to the mother. Many high-risk factors had been missed upon admission during a very busy night. Among them, the boy had a recent hospitalization for asthma, and had been seen in several different emergency rooms over the preceding few days, also for asthma. In addition, use of oral steroids had recently been stopped, and someone forgot to tell Dr. Kramer that the boy had been intubated (had a breathing tube inserted by mouth) for asthma in the past. He was also using his bronchodilator repeatedly without his inhaled steroids, which is a lopsided, medically risky way to treat chronic asthma that is no longer allowed.
Not learning all this was a tragic oversight, although if you ever see a New York City emergency room on a Saturday night, you will find it credible. But Dr. Kramer’s real mistake was one of well-intentioned judgment. The child was lying in a dark open ward, and the doctor didn’t turn on a light so as not to awaken the other children. She didn’t hear any wheezing and took that as a sign that the treatment was working. She learned the hard way that sometimes the absence of wheezing is a bad sign, not a good one.
No one who has ever witnessed the autopsy of an asthma patient can ever forget the sight of the mucous plug that emerges from the lungs, the thing that has made breathing literally impossible. When I was a resident, I watched as a pathologist withdrew a mucous plug almost as hard as concrete from the chest of a young boy. The lining of the airways was stuck to the mucus.
PEARLMAN OF WISDOM
When I was training, I had a mentor named Alan Pearlman who told me, “I never test for allergies.” I thought he was crazy. Well, if he was, then I am almost crazy, because I test less and less. As you develop clinical experience, you find that a good history is much more important than any lab report. Sometimes I will test to confirm what I already suspect. Patients and parents of patients don’t always like this. They will say,“If you don’t test, what am I paying you for?” I tell them, “You are paying me to use all my experience to make you (or your child) better.”
AN ECONOMIC CHOICE, NOT A MEDICAL ONE
Once an HMO offered me the chance to become a consultant, and asked for a proposal for guidelines on how many lung-function tests they should pay for per year for asthmatics. This was a false proposition because the effectiveness of treatment varies from patient to patient. It was obvious what they wanted: someone who would set aggressive guidelines, i.e., a low number, that would minimize their costs.
Also in the competition for this contract was a former student of mine who low-balled his proposal—deliberately setting a low number—and won the contract. Medicine is a business as well as a healing art, especially in this day and age. Some of us are more business oriented than others.
DR. LARRY—STICKLER FOR TRUTH
FOOD ALLERGY: PERCEPTION AND REALITY
During my experience running a food allergy center, we encountered patients with food allergy complaints who did not have provable food reactions. They attributed vague and variable symptoms that occurred hours or even days after ingesting multiple foods to allergies, whereas real food allergies are manifest very shortly after eating a single food. The urge to blame life’s problems on diet is powerful, and challenging it with medical science is really a challenge to a belief system. This is a great dilemma for the honest clinician. If the patient and the family are not adequately supported by, say a dietician and family therapist as well as an allergist while the food investigation proceeds, they may find their way to the nearest alternative practitioner, where food reactions that do not really exist will be treated with methods that do not work.
SCIENCE OR NO SCIENCE?
For over twenty years I have been involved in fending off disinformation about food allergy. For the record, food allergy is an immune response to certain foods. It is not a catchall for vague complaints about mood or energy levels or behavior. Nor is it the cause of a perceived increase in ADHD, autism, or even asthma, which is the current line of discussion.
It’s hard enough to get good medical science into common use. When it’s arrayed against the false medicine that people want to believe, it’s much more difficult. Whenever this happens, I think of the words of that eminent Italian American philosopher Yogi Berra: “It’s déjà vu all over again.” The situation is complicated by the fact that there are elements of each that are implicated in all the others. For example, sleep disturbance from allergy and asthma presents itself in the inattentiveness and bad behavior that are sometimes treated as ADHD. Autistic children may be intolerant of certain foods, but food intolerance is not allergy. Many people who traffic in disinformation are quite well meaning, and desperate to find hope in an apparently hopeless cause. But others, like the Russians who coined the word disinformation in 1955, have an agenda, like selling false cures, or even books. Real food allergy manifests itself very shortly after ingesting the offending foods in a limited number of distinct ways.
PSEUDO FOOD ALLERGY
Food and the rituals of mealtime are an important glue that holds families and households together, which is healthy when families are healthy but can be part of a family problem if the family is troubled. When I see a patient who claims to be allergic to twenty foods or more, and their symptoms are vague and variable and don’t appear for more than twelve hours after eating, I start to ask if there’s anything unusual going on at home because I suspect that the “allergies” are part of some other problem.
Sometimes the extent to which people will go to deal with their imagined allergies is astonishing. Years ago, I was skin testing a young woman named Alice in connection to her very real asthma. I noticed some strange lumps around her joints and asked her to see a rheumatologist. He examined her and informed me that she had scurvy—a disease resulting from vitamin C deficiency that used to afflict sailors on long sea voyages hundreds of years ago—something that present-day doctors almost never see. The Royal Navy figured out that scurvy could be prevented by consumption of fresh limes—hence the word “limey,” the word by which the English are known to this day.
Alice managed to contract scurvy because of the “anti-allergic” diet she contrived for herself for her self-diagnosed allergies. She thought that she was allergic to corn and corn products like corn syrup among many other foods. Try reading labels and see how many things have corn products in them. But her diet must also have excluded fresh uncooked fruit and vegetables of all kinds, since most of them contain traces of vitamin C.
I sent her to Johns Hopkins for food challenge studies in which potential problem foods are given in a controlled setting so that a bad reaction can be treated. I was just learning how to do them at that time. Her tests were negative but she wouldn’t accept the results. She left the hospital rather than try eating corn in a protected environment. What was wrong with her?
Well, the fact that her problems coincided with her breakup with a long-term boyfriend might have had something to do with it. And the fact that she was referred to me by her beautiful sister, who had always overshadowed her and was getting married, probably didn’t help. I could treat her for her asthma, but not her “food allergies.” And certainly not for her own veryreal problems.
THE DOCTOR’S WIFE
Sometimes I think the main reason my wife married an allergist was because of her own lifelong allergy problems, which, thanks be to God, and to good medical care, are now under control. I think of her as an attractive woman with four brothers and three sisters. One day I was looking at childhood pictures of her family. “Honey, I see your sisters. Where are your pictures? Do you have any baby pictures? Preferably naked.” “You dirty old man,” she said, then added, “There are no pictures of me as a baby because my eczema was so bad that my parents hardly took any.”
PINING FOR PIGNOLI
My wife had a deadly allergy to pignoli—pine nuts—which are staples of Italian cuisine. We never had pine nuts in our home. Our kids were raised not knowing the joys of pesto, a sauce made largely of basil and pine nuts. I felt like a rabbi raising his children without bagels.
Once when the children were substantially grown up, my wife went out of state to see her sick sister, leaving me to play Mr. Mom with our three children. We were sitting in an Italian restaurant when the waiter mentioned a pesto special. They asked what it was. I explained it, and they all tried it. It was as if an Italian had discovered America all over again. The rest of the meal consisted of gorging themselves on this delicacy and revelations from my children about what it was like to have an allergic mother and a father who was an allergist. It was obvious to me that much had been left unsaid about life in general as our family steered our way around Mom’s allergies over the years. Buon Appetito.
DR. LARRY–CARING DOCTOR AND MEDICAL DETECTIVE
I had a patient who was repeatedly hospitalized from the age of 2 weeks to the age of 2 months. I couldn’t figure out why she kept having relapses. The mother repeatedly denied having any pets. She also said her house was in good shape. Finally, I took a nurse with me to make a house visit. Not only were there a St. Bernard and a cat in the house, but the ceilings were discolored from leakage around the windows. I told her she had to get rid of the pets and have the windows and siding replaced. The next day I got a call from her saying that a pulmonologist—lung specialist—she knew said he could cure the child with no major change in the home. Three weeks later the child was dead.
A FINE MESS
Mrs. Smith was the mother of a 14-year-old son, Jack. When she made an appointment for an initial visit with him, I asked, as I always do, that she bring all her boy’s medicines with her. She entered carrying a purse the size of a bowling bag and hauled out: albuterol, Ventolin, Proventil, Maxair, Singulair, Accolate, Flovent, Pulmicort, Serevent, Foradil, Aerobid, Theo-Dur, and Uniphyl. In addition she had the newer preparations of Advair and Symbicort. These combination products contain an anti-inflammatory and bronchodilator.
I looked at the pile on my desk. I looked at her and asked, “Mrs. Smith, do you like to cook?” She was startled by my question. “Yes, why do you ask?” I said, “Have you ever come across a recipe that called for oregano, basil, nutmeg, cinnamon, cloves, asafetida, cayenne, jalapeños, parsley, sage, rosemary, and thyme?”
“No. Those are all strong herbs and spices. It would be a mess.”
“Precisely,” I said, “and that’s what you’ve got here. A mess.”
The first thing I did was to arrange the medications into separate
piles on my desk in front of Mrs. Smith:
“Pile A. These are the fast-acting bronchodilators: albuterol,Ventolin, Proventil, Maxair. In fact, the first three are really the same medication.
“Pile B. These are longer-acting bronchodilators and have a slower onset of action, but last longer: Serevent, Foradil.
“Pile C. Singulair and Accolate: These are not steroids, but counter the swelling and tissue damage to the airway lining by blocking the leukotrienes released from the mast cell along with histamine.
“Pile D. Theo-Dur and Uniphyl: These are a form of theophylline that we do not use much any more because of its narrow range of safety and effectiveness.
“Pile E. Inhaled steroids: Flovent, Pulmicort, and Aerobid. These are the best weapons we have to counter the swelling and tissue damage to the airway lining. They get a bad reputation because of the word ‘steroid.’ The more we use them, the more we find them to be effective and safe. But your son shouldn’t be using them all at the same time.
“Pile F. Advair is a combination of Flovent and Serevent. Symbicort has as a bronchodilator Foradil and as an anti-swelling agent Pulmicort. Both do pretty much the same job. Symbicort works fast; Advair comes as a powder and may be easier to take. Both are more convenient than taking their components separately. Is he using them all?”
Mrs. Smith looked at me, a bit embarrassed. “I’m not sure that he is.”
Why was I not surprised? Nor was I surprised that her son didn’t seem to be getting any better.
XOLAIR SAVES THE BRIDE
I was called to the emergency room to consult on a young woman with asthma. After the crisis was over, I noticed her ring finger was held in a way I have noticed is characteristic of newly engaged women as they get accustomed to displaying a shining rock. I asked her if she knew what she is allergic to, and she replied, “I have been tested three times and each time I got a severe reaction to the tests. I would like to get better before the wedding.”
I thought, since I can’t do skin tests I’ll try blood tests instead. Not only were the blood tests positive to certain allergens, but her total allergic antibody level was very high. I said, “With your history and IgE level, regular injections might be too risky; I would like to try Xolair.” She said, “OK Doc, just make me better before the wedding.” Then she added, “I’m marrying a marine.” Not as a threat, I believe. With Xolair she was better in two months, and I was invited to a wedding at Camp Lejeune.
DR. LARRY THE SCIENTIST
WHEN THE BOMB DROPS
During the Cold War, I was a student allergist working on a study of ragweed allergy injections with a group of scientists at Johns Hopkins. We needed to know the ragweed pollen count. At that time, allergists counted ragweed by the gravity method. A microscope slide was placed outside and the number of pollen grains falling in 24 hours was counted. A scientist pointed out the number of grains on the slide did not accurately reflect what was in the air because of wind currents. I was dispatched after security clearance to an atomic research center. They were growing ragweed in a circular patch and studying how the pollen spread out as a model of what would happen to the radioactive particles coming from an atomic bomb blast. Being physicists, they had designed a better counter than the allergist’s gravity slide, one that spun around in circles to cancel the effects of wind currents. This rotoslide pollen counter is now standard.
NOWHERE TO HIDE
When I was in training to be an allergist at a New York hospital, an industrialist who had allergies gave us the money to build an allergen-free room. He had used the new “clean room technology” in his business and was convinced he could treat allergy by putting asthmatics in this room. At best we got only mixed results. The asthmatics would live in this room for a few days. Allergens such as molds, mites, and foods were present even though the air was constantly filtered.
KNOW YOUR PATIENT’S ENVIRONMENT
Almost thirty years ago we were treating asthmatic children from the poor areas of Brooklyn. The children had a resistant form of asthma compared to the middle-class children I was treating in Queens. Why?
The standard answer from allergists who only worked in upscale areas was that these poor patients and parents were too dumb or too lazy to follow instructions. Our controlled study proved otherwise. When we asked them to do something within their resources, it was done as well if not better than in middle-class homes.
In another controlled study, we tested for allergens in the group from middle-class, single-family homes and the clinic group from high-rise apartments. We added nontraditional allergens—cockroach, mice, and rats. The clinic group from Brooklyn was positive to these “inner-city allergens” and their asthma seemed to improve more rapidly when we began treating for these allergens. In the mid-1970s we published these findings but they seemed to have little impact; Brooklyn as a research venue carried little weight in those days. In the 1990s a study at Johns Hopkins in Baltimore on poor, inner-city children failed to show that allergy immunotherapy worked. We and others pointed out that the injections did not contain cockroach antigen. When the study was repeated on
children from the Bronx with cockroach antigen, they were shown to be effective.
We have many reasons to mourn Larry’s passing, but reviewing his work for purposes of compiling this tribute gave us another one. He had a profound knowledge of the immune system. We would have loved to pick his brains about the nature of the disease that took him away. What would he have made of the so-called cytokine storm? He always had more ideas than we knew what to do with. We miss him.