Tuesday, August 19, 2014

1910-1903: Early PEP and Insentive Spirometers

Cohen's Resistance Valve (Figure 38)
Physicians near the middle  of the 19th century were aware of the importance of exercising your respiratory muscles to prevent and treat lung disease.  The concept was first thought of in 1910 as means of preventing and treating consumption (tuberculosis).

From the 1850s onward various devices were created to exercise the lungs by inhaling and or exhaling against resistance.  Some of the more common methods were described by Tissier in his 1903 book "Pneumotherapy: Including Aertherapy and Inhalation methods."

According to Tissier, all of these devices or techniques provide similar results, and none has an advantage over the others.  The ultimate goal being to exercise the lungs on a daily basis with the goal of, over time, increasing respiratory capacity.  

Some examples are:

1  Valsalva Meneuver:  This is a technique we still recommend today when a patient's heart goes into certain funky rhythms to try to get it back to normal. Back then it was used as a therapy to exercise the lungs.


Basically, the patient takes a full inspiration, and then exhales through a closed glottis with all your respiratory muscles, making a full, and forceful expiratory effort. When I explain this to my patients, I basically say to the patient to exhale as though you were trying to take a crap. It's a funky way of explaining it, but it works.

The effect of this technique (and all the devices described here) is to exercise all the respiratory muscles, and it also increased intra-thoracic pressure. By increasing intrathoracic pressure, the circulation is also slowed because the vessels are squeezed and this slows circulation.

Figure 40 -- Howe's Breathing Tube
The increased pressure also recruits alveoli and portions of the lung not used regularly, and this works to improve breathing.  This creates more room for air exchange in the lungs.  We now know this causes a form of PEEP that increases oxygenation.  A similar effect is created when a newborn is grunting or crying.  Thus, Tissier suggests crying exercises respiratory muscles, and parents who don't let their children cry risk having their child's lung muscles not developing properly, and this predisposes them, so he believed, to tuberculosis of the lungs.

Figure 41-- Resistance Spirometer
2.  Ramadge Tube:  The tube was recommended for patients suffering from tuberculosis. Due to his invention he is often described as the Father of Aerotherapy.

Tissier describes the Ramadge Tubes this way: "Ramadge had his patients breathe the emanations from heated tar through long narrow tubes, the diameters varying with the ages of the patients, and attributed all the benefits derived from the inhalation to this respiratory exercise of the lungs. The length of the tube serves the double purpose of protecting the patient's face from the heat of the inhaling apparatus, and of retarding the free egress of air from the lungs, which is an essential feature of a perfect inhaler." I describe the Ramadge Tube in more detail in this post.

Figure 42-- Spirometer used for resistance Exercises
3.  Dobell's Residual Air Pump:  I described this device in my last post. A patient placed the mask on his face and exhaled against pressure. The results are similar to the effects of the valsalva maneuver. However, I think the next device more resembles our modern devices, and appears to be much simpler.

4.  Cohen's Resistance Valves:  Pressure results from "Little cylinders containing ebonite valves controlled by spiral springs (Fig. 38). The tension of the spring is regulated by turning the cap of the cylinder, and a scale on the outside indicates indicates the pressure used. This device allows for resistance against both inspiration and expiration.

5.  Cohen's Simplified Resistance Valve:  It's similar to Cohen's Resistance Valve. It's less expensive, but it's also less accurate. Along with causing resistance, the "inhalant chamber (A) contains a sponge or tuft of absorbent cotton, which may be saturated with some medicinal substance." (See figure 39)

6.  Howe's Breathing Tube It's similar to a Ramadge Tube, which is why the tubes are sometimes referred to as either Howe's or Ramadge's Tube. Since it provided pressure and also allowed for the inhalation of medicine, both the Ramadge and Howe tubes are sometimes referred to as inhalers. (see figure 40)

7.  Resistance Spirometer:  They are used the same way as the Ramadge and Howe Tubes, or any of the above devices and, again, offer no advantage over any of the above. However, the device can be used day to day and allows the patient to monitor his progress by writing down daily the values indicated on the spirometer. There were many similar devices, two of which are indicated in figures 41 and 42.

Further Reading
  1. The first PEP Therapy, Incentive Spirometer
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 227-230.  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.  For a more detailed description of any of the devices mentioned on this blog click on the links provided. Unless otherwise indicated, all material from this post was from Tissier's book. 
  2. Minnesota State Medical Society, "Transaction of the Minnesota State Medical Society," 1886, St. Paul, H. M. Smyth Printing Co.

Saturday, August 16, 2014

1800-1900: Evolution of Artificial Respiration

Figure 5
So as far back as Biblical times the idea of using positive pressure breaths was utilized to save lives, as Biblical characters were known to perform mouth to mouth breathing when necessary to "bring a person back to life."  Yet it wasn't until the end of the 18th century that the concept was introduced to the modern world.

By the 1930s various experiments had been performed on the advantages of pressure changes for the benefit of various disease conditions, and it was also at this time the concept of using pressure changes to provide artificial respiration was thought of.

So the evolution of artificial respiration through the 19th century is as follows:

1832:  Dalzeil respirator:  I wrote about this respirator in this post.  (16)

1845:  Oxygen breaths

A man named Erichson invented the first device that provided positive pressure breaths with oxygen through a cannula inserted through a pipe inserted into one of the nostrils.  He recommended ten breaths a minute.
Figure 4

1858:  Bouchut's Intubation Tube:  In this year French physician Eugene Bouchut (1841-1898) became the first to describe insertion of a tube into the airway as opposed to a catheter in a case of dyspnea. The tube he used during seven cases between 1856-1858 (24, page 661-662) was a rounded silver tube narrower at the end to be inserted as you can see in Figure 1, and it was 1.5 to 2 cm long and 7 cm in diameter.  Interestingly, a silk thread was attached to the distal end of the tube that was "brought out to the mouth, and was intended to prevent the tube from going down the trachea or esophagus; and to allow it to be taken out when necessary." He later "insisted on the distinction between his method and catheterism." However, of the seven cases he cited to the French Academy of medicine, only two lived and both required tracheotomy.  Yet he proved the procedure could be done. Various other physicians described success with this or similar procedures between 1858 and 1880 when the Joseph O'Dwyer introduced his tube. (see figure 1)(23, page 5)


1867:  Richardson's Double Acting Rubber Bellows:  Benjamin Ward Richardson created a bellow system similar to Hunter's Bellows (although he may not have known of Hunter's Bellows). The original system took up a lot of room, so he invented the double acting bellows, which "consists of two rubber bulbs terminating in common tube that was called the nostril-tube."  One bellow supplied inspiration, the other expiration.  (See figure 4)

1875:  Blake cures poison victim:  Using a device similar to Richardson's Bellows, Blake connected a reservoir of condensed oxygen to it and treated a case of acute poisoning with success.  Before this time artificial respiration (often referred to as insufflation) was used mainly to treat neonatal asphyxia, but now the focus was also on treating adults.  The nozzle of the device was inserted into the nostril.  

1876:  Woillez Iron Lung (Spirophone):  I wrote about the Spirophone in this post.

O'Dwyer's Intubation Tube for a child 2-3 years old (23)
1880:  The first useful endotracheal tube:  Dr. Joseph O'Dwyer (1841-1898)of New York, and his fellow physicians at the New York Foundling Asylum, observed problems with trachetomy.  He decided another means of breathing for patients was necessary, and he at first trialed flexible catheters into the nasal passages.  Yet this didn't meet his satisfaction so he devised a tube to be placed into the larynx where it would remain.  By trial and error he tinkered with the device until it met his satisfaction.  The device was made with a bivalve tube with a narrow transverse diameter, and about an inch long."  A shoulder on the upper end prevented the tube from slipping down.  By trial and error the tube transformed so the tube was a "plain tube of elliptical form about an inch in length.  He then played with longer tubes until he found the desired length.  The final tube used was made of brass and lined with gold, and was accepted by the medical community.  (See figures 2 and 3.)  A complete set was included in a box, that included sizes for different aged children, an obturator, an introducer, an extractor, and a gag.  The length of the tubes in inches were 1.5, 1 3/4, 2, 2.25 and 2.5.   The obturator of the physicians choice is connected to the end of the introducer, and this is used to insert the tube.  If necessary a small thread could be inserted and tied to a hole on the outer edge of the tube to prevent it from going down the traches, and to facilitate removal.  The kit also came with a scale (see figure  5) which helped the physician determined appropriate depth of the tube according to age.  The scale is used like this: "The smallest tube reaches line 1, and is intended for children about one year and under. The next reaches line 2, and is for children between one and two years. The third size, marked 34 on the scale, should be used between two and four years. The fourth, marked 5-7, is for the next three years, and the largest tube is for children from eight to twelve."  O'Dwyer also designed larger tubes and equipment for adult intubation. (23, page 9-18)
O'Dwyer's introducer connected to obturator (23, page 16)

1888:  Foot operated Bellows

Dr. George Fell invented a system of bellows whereby the operator would use his hands to provide positive pressure breaths.  He would either use a tracheotomy or face mask.  In 1891 this system was revised by Joseph O'Dwyer of New York so that breaths were provided by pressing down on a lever with your foot.  O'Dwyer preferred to connect his bellow system to an endotracheal tube.  O'Dwyer was concerned about over-distention of the lungs due not allowing enough time for expiration, and therefore recommended giving slow breaths, or 10-12 per minute. (21, page 283)

1891:  Concerts of Intubation:  By the late 19th century many of the same concerns physicians have today about intubation were considered.  One such concern being the ulceration of tissue due to pressure of the tube set upon it for a long period of time.  Tubes were generally taken out after six days with success, although in some cases were left in 12 days or longer. Dr. Rank, a German physician, ultimately recommended removal of the tube after 10 days, and if necessary, the physician should consider tracheotomy. Some physicians recommended extubation after the 5th day, which would be in line with modern protocols.  Feeding the patient was also a concern, and was either done with soft foods or liquids, or by nasalgastric tube.  It was recommended that if the tube was accidentally spit up that the nurse take advantage of the moment to try feeding the patient prior to re-introducing the tube (if the tube is still needed). (23, page 29-20)

1898 Matas's Apparatus for Artificial Respiration:  Around this time the need arose for a means to prevent asphyxia when chloroform was used. There was also the concern of preventing pneumothorax during artificial respiration.  Matas deviced the "experimental automatic respiratory apparatus" as you can see in figure 4.  This was never put in use on a real patient, and was mainly used to study the effects of pressure during inspiration and expiration.  You can see some of the major components in the picture: MF = O'Dwyer intubating cannula and stopcock for introducing chloroform; M = Mercurial manometer to measure pressure or vacuum; H is the handle to work the pump and forces air into the lungs.   The operator places a finger over a hole in the O'Dwyer intubation cannula, and when he removes his finger expiration occurs.  (R = Rubber tubing.)  It was quite a contraption for its time. Experiments were performed on dogs and human cadavers, although it was decided it was not fit for use on humans. (See figure 4) (21, page 284)
Figure 4 (21)

1900:  Cuffed Endotracheal Tubes and laryngoscopes

Right around the turn of the century was when the furst cuffed endotracheal tubes (ETT) started showing up.  This was necessary to prevent air from leaking around the tube so that bigger breaths could be given, and it also worked nice to prevent aspiration around the tube. A larygoscope was first described in 1855 using sunlight to see the vocal cords, and by 1913 a battery powered laryngoscope with an external light was invented.  This was refined so it had a handle with a battery and a light bulb at the end of the scope for easy visualization of the vocal cords.   (18)

Related posts:

  • 4000 B.C. - 1800:  Evolution of Artificial Respiration
  • 1800-1900:  The Beginning of Pressure Therapy
  • 1800-1900:  The Beginning of Pressure Therapy (part II)
References:
  1. Szmuk, Peter, eet al, "A brief history of tracheostomy and tracheal intubation, from the Bronze Age to the Space Age," Intensive Care Medicine, 2008, 34, pages 222-228
  2. Price, J.L., "The Evolution of Breathing Machines," (this must have been written in the 1950s or early 1960s because the last reference was to IPPB being used as a respirator) (reference to The Bible, Kings, 4: 34)
  3. Tan, S.Y, et al, "Medicine in Stamps:  Paracelsus (1493-1541): The man who dared," Singapore Medical Journal,  2003, vol. 44 (1), pages 5-7
  4. "Resuscitation and Artificial Respiration," freewebs.com, Scientific Anti-Vivisectionism,  http://www.freewebs.com/scientific_anti_vivisectionism4/resuscitation.htm, accessed March 1, 2012
  5. Price, op cit
  6. Lee, W.L., A.S. Stutsky, "Ventilator-induced lung injury and recommendations for mechanical ventilation of patients with ARDS," Semin. Respit. Critical Care Medicine, 2001, June, 22, 3, pages 269-280
  7. Price, J.L., "The Evolution of Breathing Machines,"  (see also reference #1 and #3 above)
  8. Szmuk, op cit, page 225
  9. Price, op cit
  10. "Resuscitation and Artificial Respiration," freewebs.com, Scientific Anti-Vivisectionism,  http://www.freewebs.com/scientific_anti_vivisectionism4/resuscitation.htm, accessed March 1, 2012 (see also reference 1 above)
  11. Lee, op cit
  12. Price, op cit
  13. Price, op cit
  14. Szmuk, op cit, page 225
  15. Price, op cit
  16. Woollam, C.H.M., "The development of apparatus for intermittent positive pressure respiration," Anaesthesia, 1976, volume 31, pages 537-147
  17. Previtera, Joseph, "Negative Pressure Ventilation: Operating Procedure (Iron Lung)," Tufts Medical Center, Respirator Care Programs, http://160.109.101.132/respcare/npv.htm, and http://160.109.101.132/respcare/ironlung.htm, accessed February 27, 2012
  18. Szmuk, op cit, page 226-7
  19. Fourgeaud, V.J, "Medicine Among the Arabs," (Historical Sketches), Pacific medical and surgical journal, Vol. VII, ed. V.J. Fourgeaud and J.F. Morse, 1864, San Fransisco, Thompson & Company,  pages 193-203  (referenced to page 198-9)
  20. "Biographical Dictionary of the society for the diffusion of useful knowledge," Longman, Brown, Green and Longmans, volume III, 1843, A. Spottingwood, London, page 124-5
  21. Tissler, Paul Louis Alexandre, "Pneumotherapy: Including Aerotherapy and inhalation...," 1903, Philadelphia, Blakiston's sons and Company, page 284,5
  22. Hasan, Ashfaq, "Understanding Mechanical Ventilation: A practical Handbook," 2010, New York, Springer
  23. Ball, James B, "Intubation of the Larynx," 1891, London, H.K. Lewis
  24. Garrison, Fielding Hudson, "An introduction to the history of medicine," 1922, 3rd edition, Philadelphia and London, W.B. Saunders Company

Friday, August 15, 2014

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. 

Tuesday, August 12, 2014

1870-1900: The Pneumatometer (Part II)

By 1903 there were various pressure devices used to provide positive pressure breaths for therapeutic reasons and for artificial respiration.  The devices were mainly operated by some form of physical labor, such as through pumps and bellows.  I described some of them in my previous post, and here I will list a few more.
Stoerk's Apparatus (Figure 30)(1)

Please note that all of these apparatus's are described in a book called, "Pneumotherapy: Including Aerotherapy and inhalation methods," by Paul Lewis Alexandre Tissier, and edited by Solomon Solis Cohen.

Stoerk's Apparatus:  It allows for inspiration by positive pressure and exhalation through rarified (less oxygen that what's in the air) air.  Rarified air causes a sort of suction or negative pressure that  causes a negative intrathoracic pressure that induces expiration.  

Unlike the other pressure devices, this one didn't require direct or physical depression of bellows or pumps, instead "compression is obtained by a change of level in the water in a system of communicating vessels, brought about by setting up an oscillatory movement which changes their relative positions (Fig. 30).

An oscillating motion is created by swinging it back and forth with your hand.  So the oscillations cause positive pressure (condensation) to cause inspiration, and negative pressure (rarified air, or suction) that causes expiration.  

Dorell's Residual Air Pump (1)
Dobell's Residual Air Pump:  The device was small and compact, and could be carried in your pocket.  (See figure 31)

It's described as "kind of mask which isfitted to the front of the mouth and held in place with a ribbon which passes around behind the ears; the apparatus is provided with valves to embarrass inspiration while expiration remains free. As a result the intrathoracic air is rarefied, and at the end of three to six respirations the residual air is reduced to a minimum and the diaphragm attains its maximum elevation. The patient then inspires in ordinary air, and this inspiration being freer than he is accustomed to, he experiences a sense of increased comfort. The same manoeuver is repeated several times at each sitting. The apparatus is certainly ingenious, but there is no means of determining with accuracy the degree of success attained."

Water Engine Bellows (Figure 32)(1)
Water Engine Bellows:  It's also referred to as The Water-blower or Double Ventilator of Geigel and Mayer.  The container is made of sheet iron and is filled to two thirds of it's capacity with water.  The container is completely enclosed except for four openings at the top.  To of these openings communicate with room air.  One holds a meter to measure volumes.  The fourth opening is where the pressure escapes.  A tube is connected to this opening, and a rubber mask is connected to the opposite end.  

Bellows inside are operated by a crank.  The principle is similar to the way water engine or gasometer is operated. The patient holds the mask over his face, and turns the crank  As the crank is turned pressure escapes through the fourth opening, and this causes inspiration.  (see figure 32)
Dupont's Apparatus (Figure 35)(1)

Dupont's Apparatus:  It's based on the principle of the Bunson water pump or aspirator, is inexpensive, allows for inspiration as deep as you desire, and can be used wherever there is a flow of water  The pressure is regulated by a mercury pressure manometer    

Tissier describes it as the best apparatus for the reasons indicated in the previous paragraph.  Rarification and compression of air is done simply by pumping a pump alongside the apparatus.  Pressure is determined by flow of water or by working a stopcock on the patient tubing  

S. Solis Cohen's Double Apparatus:  This is combination gasometer (a container that stores gas)  and water pump and was created by the author of one of our other 19th century respiratory therapy books.  There are various advantages to this device:
  1. It corrects the flaws of the other pressure devices
  2. It is continuous in action and relatively compact
  3. The price is moderate
  4. It can be used by the patient at his or her home
Cohen's Apparatus (1))
The device is described as follows:  

"It is true that the degree of compression of the air is regulated by means of weights placed on the upper portion of the condensed-air cylinder, and that the degree of rarefaction is regulated by means of weights attached to a system of cords and pulleys by which the cylinder containing the rarefied air is raised; but the apparatus is operated and the pressure modification obtained by means of a double-acting bellows—so that air is drawn out from the cylinder which is to contain rarefied air and discharged into the outer atmosphere, while fresh air is forced into the cylinder intended for condensed air. Although one stroke of the footlever accomplishes both condensation and rarefaction, the two systems are independent, and there is no communication between the cylinders except through the air-passages of the patient. This is an extremely ingenious idea, which, in addition to the other good qualities of the apparatus, should insure its success."
The Cohen's Apparatus was invented in 1883, and introduced to the medical community via the New York Medical Journal in the October 18 issue  Since he based his ideas on the other previously mentioned models, that would date all of them to before this time.

I think these are all "ingenious" ideas for helping patients breath easier, considering a lack of electricity.  Still, every one of these devices required labor to get them to work.  Still, they were options for both the physician and the patient

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 296-224.  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.

Thursday, August 07, 2014

4004 B.C.: The beginning of Time?

At some point early on in human existence men and women grew curious about the their surroundings, and they began to ask questions.
In essence, as the Biblical allegory says, they ate from the tree of knowledge.

Thus, as noted by Alexander Wilder in his 1901 "History of Medicine:"
By such eating of the Tree of Knowledge, the eyes become open, and the man is as god. He makes “the divinest conquest of the human intellect." (1, page 2)
When was this tree of knowledge planted, no one knows for sure.  According to the Bible God created Adam and Eve, and they lived in the Garden of Eden, and this was the beginning of time.  According to Patricia D. Netzley, in her 1998 book "The Stone Age," "some editions of the King James bible even offered the date of Creation: as 4004 B.C.  This date was developed by a religious scholar, an Irish archbishop named James Usher, who used time reference in the bible to construct a system of biblical chronology."  (5, page 18)

This actually makes sense, considering a written language was supposedly invented in Mesopotamia around 3200 B.C., and subsequently this language made its way to Egypt.  This means it was at about this time when all the information from the past was written down for the first time, information such as:

  • Myths
  • Legends
  • Religions
  • Laws
  • Recipes for foods
  • Recipes for remedies
Prior to this time this information was relayed by word of mouth, probably by words turned into lyrics and relayed by poems recited or songs sung around the fires late in the evening under the moonless sky, or somewhere on a cold and snowy evening in a cave around a warm fire.  Now that there was an ability to write, this information was recorded.  

Since there was no ability to write prior to about 3200 B.C., each generation had to start from scratch, and so it's probable the information relayed must have been kept very simple. The stories about the past were probably kept very simple, as can be noted by some of the early Biblical stories.  For example, the story of Adam and Eve is very short, probably because it was so long ago.  It only makes sense mankind wouldn't be able to remember stories from more than 800 years before their time, with the most distant passages in the Bible dating to about 4004 B.C. 

Interestingly enough, this date was believed to be accurate, and according to the people who wrote the Bible is was accurate given the limited knowledge of human history at that time.  When people found stone tools of primitive humans, they were classified as things like "petrified thunderbolts, fairy arrows, exhalations of the clouds," writes Netzley.  By the 1600s, however, "scholars suggested that these ancient items might somehow be related to human activity."  (2, page 17-18)

Historians have proven that the stories in he Old Testament really did happen, and provide us with an accurate depiction of human history.  However, there is evidence that human activity persisted long before he beginning of Biblical times.  There is also evidence of knowledge, diseases, remedies, and even doctors prior to 4004 B.C.

References:

  • Wilder, Alexander, "History of Medicine, a brief outline of medical history and sects of physicians, from the earliest historic period; with an extended account of the new schools of the healing art in the nineteenth century, adn especially a history of the American eclectic practice of medicine, never before published," 1901, Maine, New England Eclectic Publishing Co.
  • Netzley, Patricia D, "World History Series: The Stone Age," 1998, San Diego, CA, Lucent Books

Tuesday, August 05, 2014

1870-1900: The Pneumatometer

Hawke's Apparatus
Due to the perceived therapeutic benefits of pressure therapy, between 1800 and 1870 various apparatus's were invented to provide "pneumotherapy" for such conditions as asthma, throat edema, emphysema, bronchitis, or dyspnea caused by diphtheria(2, page 45)

If you were a physician at this time you saw before your own eyes the evolution of pressure therapy.  By 1903 pneumotherapy was mentioned in various medical books, although it was still "under-utilized."  Paul Louis Alexandre Tissier's, in his 1903 text, "Pneumotherapy: Including Aerotherapy and Inhalation Methods and Therapy," provides a detailed description of pneumotherapy. (1)

He expains that the machines available provided pressure changes upon the respiratory passages (1): 
  • By inspiration of condensed air (we now call it positive pressure)
  • By expiration into condensed air (what we now call PEEP)
And the following methods decrease pressure in the lungs (1):
  • By expiration into rarified air (what we now call negative pressure)
  • By inspiration of rarified air 
Withington's Apparatus
Tissier describes the following devices.  Most of them were used in the patients home mainly by the patient placing a rubber mask over his face, although some may also be used by physicians as spirometers or to provide artificial respiration.  (1)

1.  Hauke's Apparatus:  After a series of tests by Hawke from Vienna, it was introduced around 1870.  (3)It's basically a tank filled with water to supply pressure or rarified air upon expiration and inspiration as provided by a pump or bellows.  Rubber tubing connects from the tank to a rubber mask that fits over the mouth and nose, held in place by the patient. (1)

Hauke recommended using this to offset the "dyspnea caused by diphtheretic laryngitis in which it was not always successful."  It was also used successfully for pulmonary tuberculosis and emphysema.  The problem with this device is there was no way of measuring breaths given  (1)

2.  Waldenburg's Apparatus:  The flaws with the Hauke design were corrected by Waldenburg of Berlin.  The 1873 model consists of two reservoirs of sheet iron, and an inner and outer cylinder, with the inner cylinder gliding on the outer one.  (1)

A cap on the outer cylinder is 10 cm in height and wider than the outer cylinder.  The inner cylinder is moved up and down by means of weights and pulleys.  "Water is poured into the apparatus so that, when the inner cylinder is forced down into the outer cylinder, the apparatus is filled to the brim, the cylindrical cap at the top of the outer cylinder being destined to receive the water that overflows when the inner cylinder descends."  (1)

Graduated scales allow for measuring volume.  A rubber hose is connected to a spun metal mask cushioned with rubber.  Both positive and pressure breaths can be given with the device, and the breaths can be measured "regularly and accurately."  In fact, the device could also be used as a spirometer to measure lung volumes.  (1)

Figure 25 --Apparatus of Finkler and Kochs
Air could be moistened and warmed by adding a wolffe bottle.  Tissier also notes that the "apparatus has been deemed worthy of detailed description, as it has probably been used more frequently than any other."  (1)

The apparatus was later modified by Cube, Weil, Schnitzler, and other folks you'd be familiar with if you were an RT in this era. (1)

As you can see by figures 21 and 22, some of these wouldn't be applicable for home use, and may even be too bulky and expensive even for hospital use.  

Apparatus of Finkler and Kochs:  "With this apparatus (Fig. 25) condensed air is forced into the lungs during inspiration, expiration being assisted by withdrawal of air from the lung."

Inspiration is basically caused by positive pressure, and expiration occurs by negative pressure or suction.  

The device can also be used as a spirometer to measure forced expiratory capacity, or "the quantity of air that can be expired after the fullest possible inspiration."

Beidert's Instrument:  This is an interesting device that's designed similar to a musical instrument called the harmonica, "to one extremity weights are affixed...  it's walls are made of leather, air tight, and have a necessary strength to maintain their original form against overpressure of air."

The machine is operated this way:  "The machine is placed upright on the margin of a table, so that the tube will be in a groove cut into the wooden base, and the desired quantity of (iron) weights is fastened to the upper cover of the bellows. If the upper end is turned down, the weights will sink and the bellows will fill itself with air. The bellows is then turned back, while the patient compresses the rubber tube with his fingers until he is ready to inhale through the mouthpiece attached; he then gradually inhales the air as the weights compress the bellows. While the patient expires into the free air the bellows is filled again by turning, and the operation continued in this manner indefinitely."

Pressure can also be applied in the following manner:   For expiration into rarefied air, the tube is compressed and the bellows turned weights downward; applying the tube to the mouth, the air passes from the lungs into the partial vacuum produced by the expansion of the bellows. The bellows filled with the expiratory air is emptied by turning, while the patient inspires air at the atmospheric pressure, and the operation is repeated."

Frenkel's Apparatus
It appears like it would be a lot of work, but if it makes a person feel better, then it might be worth the effort.  

Frenkel's Apparatus:  If you think the figure to the right looks like an accordion, you would be... wrong.  You sit with the apparatus on your lab, and between your palms.  You place the mask over your mouth and nose. 

The air is rarified when you pull the accordion out, and when the device is compressed the air is condensed.  So pulling the "accordion" out will cause expiration, and pushing it in will cause inspiration.  

In compliance with all pressure devices since the Hauke Apparatus, "on the margin of the apparatus is a centimetric measure to measure how many centimeters the wooden disks are separated or brought together." It is by this means that volumes can be measured.  
Figures 21 and 22

So it appears to have been a very interesting device, and perhaps the simplest and easiest to use.  It could easily be used at home by the patient whenever needed.  The device can also be used at a doctor's office or hospital for artificial respiration in the case of asphyxia or poisoning, and could be used as a spirometer.  

Next week I will describe a few more of these devices.  

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 296-224.  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. 
  2. Minnesota State Medical Society, "Transaction of the Minnesota State Medical Society," 1886, St. Paul, H. M. Smyth Printing Co. 
  3. Rose, A., "Treatment of Disease of Respiration and Circulation by the Pneumatic Method," New York, The Medical Record: A Weekly Journal of Medicine and Surgery, Edited by George F. Shrady, M.D., Volume 10, Jan. 2, 1875 to Dec. 25, 1875, New York, William Good and Co., page 577
  4. Foster, Frank, editor, "Practical Therapeutics," Volume I, 1897, New York, Appleton and Co., page 19

2640 B.C.-1820 A.D.:First descriptions of hay fever

Like asthma, allergies were probably prevalent early in human history.  Yet the symptoms of a runny nose, sniffly, sneezes and wheezes, along with red and watery eyes, were probably confused with other maladies, such as asthma or influenza. So there were only random mentions of the malady before it was formally defined by the medical community in 1819.  

About 2,640 years before the birth of Christ, King Menses of Egypt was reported to have died after being stung by a wasp. As far as historians are aware, this is the first account of an allergic reaction.  So it's evident allergies go all the way back to the ancient world.   


Right around this time a Middle Eastern Physician named El-Razi observed redness and swelling of the nasal passages in some of his patients.  He described what we might consider allergic rhinitis or hay fever.  Yet those terms weren't used until the 19th and 20th centuries.

Arnoldo Cantani, in his book, "Pediatric Allergy, Asthma and Immunology," describes how Caesar Augustus suffered from asthma and seasonal rhinitis (allergies/ hay fever).  Caesar is also believed to have suffered from asthma. (1)

Roman Emperor Claudius (10-13 B.C to 54 A.D) is believed to have suffered from allergy symptoms, and his son Brittanicus (41?-55 A.D.) is believed to have suffered from an allergy to horses. Historical reports have it that when exposed to horses his eyes would swell up and he'd develop a rash.

Princes Nero and Brittanicus
Brittanicus was heir apparent to the throne.  Yet due to his allergies he was limited in what he could do.  And when his mother died, Claudius remarried to Agrippina the Younger.  She had a son named Nero, and Claudius adapted him.  Nero almost immediately won the favor of the public, and Nero ultimately eclipsed his younger brother and was named Emperor in 54 A.D.

Nero would ultimately become famous for throwing Christians to the Lions.  Yet within only a few months of his reign, he is believed to have poisoned his weaker, older brother Brittanicus to death.

Paul M. Ehrlich and Elizabeth Shimer Bowers, in their 2008 book "Living with Allergies," note that it was an Ancient Roman Physician who was the first to describe allergies.  The authors quote Lucretius, who lived from 99-55 B.C., as saying, "What is good for some may be fierce poisons for others." (2, page 4)

Physicians around 850 A.D. observed many of their patients developed sneezing, nasal stuffiness and runny noses when the roses were blooming.  Upon further examination they observed redness and swelling in the nasal passages that resulted in the runny nose, and they referred to this condition as rose fever.

The medical term catarrh was first used to describe the miserable condition that result in a runny nose around 1350 and 1400 A.D, according to dictionary.com.  The term catarrh comes from the Greek word katarrous which means "literally down-flowing."  So the term catarrh refers to the redness and swelling of the nasal passages that results in nasal drainage regardless of the cause.  It was a term commonly used by physicians through the 19th century.

King Richard III
Ehrlich and Bowers mention how legend has it that King Richard III (1452-1485) knew he had an allergy to strawberries and he used this knowledge to kill Lord Hastings.  The King purposely ate some strawberries and blamed his allergic reaction on a curse from Lord Hastings.  Lord Hasting's was beheaded as punishment, and his head was served on a platter.

In 1656 a French doctor named Pierre Borel suspected one of his patients developed a rash when this patient ate eggs.  So one day he attempted to test his theory by placing some egg particles on the patient's skin.  When blisters developed on the patient's skin the physician knew he had made the correct diagnosis.

Dr. Morell Mackenzie writes that In 1565 Dr. Botallus (the man who's name is applied to the foramen ovale in the heart) recognized that many of his patients developed sniffling, sneezing and facial irritation when they smelled roses.  The condition was thus dubbed rose cold or rose fever.  (3, page 18) (6, page 93)(8)

Mackenzie notes that "This observer, therefore, came very near the mark to the real cause of the disease, to which he applied the term coryza a rosarum odore.'

Jan Baptise van Helmont (1579-1644), who helped define asthma, also noted the symptoms of hay fever.  (3, page 18)  Vanhelmont noted that in some of his patients "sweet smelling causing headache, and in some cases difficulty breathing." (6, page 93)

In 1673 I.N Binningerus wrote that he was informed several times by professor James A. Brun of the University of Bastle that is wife, Ursula Falcisin, "suffered from coryza for several weeks every year during the rose season."  (6, page 93)

In 1691 I. Constant Rebecque described how "for thirteen years he had been afflicted with coryza during the rose season...  At first he attributed his sufferings to heat, but in the year 1685, when the summer was exceptionally hot and there were hardly any roses on account of caterpillars, he was struck by the fact his annual disorder did not trouble him.  The symptoms came on at once, however, after inadvertently plucking a rose toward the end of the season.  He concludes that something flows from roses which stings the nose" (7, page 93)

Seventeenth century physician John Floyer noted, in 1698, that asthma symptoms lasted longer and were more "acute" in summer than in the winter.  (3, page 18)  Eighteenth century physician William Cullen may have been referring to hay fever when he wrote that "in some persons asthmatic fits are more frequent in summer, and more particularly during the dog-days, than at other colder seasons of the year," wrote Charle's Blackley in 1873 (I'll write more about him later). (4)

William Heberden (1710-1801) wrote on the subject of catarrh: "I have known it (catarrh) to return in four or five persons annually in the months of April, May, June and July, and last a month with great violence." Heberden's book was published posthumously in 1802 and edited by his son.  (5, page 14)

Mackenzie explains that Heberden made a connection between "rose catarrh of the seventeenth century and the hay fever of the nineteenth, for though this physician does not seem to have been at all aware that the complaint had any connection with flowering plants, he mentions casually that five of his patients suffered from catarrh for a month every summer, while another was similarly affected during the whole of that season."

Various other physicians made references to hay fever or rose fever, such as by C.L. Parry in London in 1801 and 1809.  Or by Elliotson in 1821 who "tells of a patient who had had hay-fever since 1789, and another who was sixty-six years of age and who had had the disease since his seventh year, i.e. since 1755, and of a third who had been afflicted for many years. (3, page 18-19)

Finally, in 1819, the condition would be recognized by the medical community.  By that time the term hay-fever had been around for many years, although there is no evidence as to who created the term, where, and when is a mystery.

References:
  1. Cantani, "Pediatric Allergy, Asthma and Immunology," 2000, New York, page 724
  2. Ehrlich, Paul M., Elizabeth Shimer Bowers, "Living with Allergies," 2008
  3. Hollopeter, William Clarence, "Hay-fever and its successful treatment," 1898, Philadelphia, P. Blakiston's Son & Co.
  4. Blackely, Charles Harrison, "Hay-fever: its causes, treatment, and effective prevention," 1873, 1880 2nd edition, London, Bailliere
  5. Smith, William Abbotts, "On Hay-Fever, Hay-Asthma, or Summer Catarrh," 1867, London, Henry Renshaw
  6. Mackenzie, Morell Sir, "Hay fever and paroxysmal sneezing," 5th edition, 1889, London, J&A Churchill, also see Morell Mackenzie, "On Hay Fever and Rose Fever," The Medical Record, New York, August, 1884, vol. 26. no. 9, page 225
  7. Mackenzie, Morell, ibid, Sir Mackenzie notes here that "This observer, therefore, came very near the mark to the real cause of the disease, to which he applied the term coryza a rosarum odore.'
  8. Koessler, Karl K., "The Specific Treatment of hay fever (pollen disease)," page 665, of "Forchheimer's Therapeusis of Internal diseases," Frederick Forchheimer, edited by Frank Billings and Ernest E. Irons, Volume V, 1920, New York and London, D. Appleton and Company