Thursday, September 18, 2014

950 B.C.: Solomon will heal your asthma

He was the son of David, the slayer of Goliath, and he reigned as King of Israel from 970-931 B.C. He is considered one of 48 Biblical prophets, and that means that he had healing powers. As an educated man, he most surely would have received knowledge of health and healing.  What this healing powers entailed no one knows..  

It is known that this man of great wisdom had healing powers, at least according to the Bible.  One example can be found in Acts of the apostles 5: 12-16:
And by the hands of the apostles were many signs and wonders wrought among the people; (and they were all with one accord in Solomon's porch.  and the rest durst no man join himself to them: but the people magnified them. And believers were the more added to the Lord, multitudes both of men and women.) Insomuch that they brought forth the sick into the streets, and laid them on beds and couches, that at the least the shadow of Peter passing by might overshadow some of them.  There cam also a multitude out of the cities round about unto Jerusalem, bringing sick folks, and them which were vexed with unclean spirits: and they were healed every one.
Perhaps among them were folks with asthma, or allergies, or bronchitis, or heart failure, or kidney failure or some other respiratory disorder. Perhaps it was a person who was near death, dyspeic due to failure of the various organs of the body.  All of these would have been healed through the healing powers of the prophet and King Solomon

Tuesday, September 16, 2014

900-1300: The Soporific Sponge

Physicians at the School of Salerno in the 15th century are believed to be the first to provide anesthetics during surgery.  The method used was to turn a simple sponge into an inhaler, what surgeons referred to as the "soporific sponge," according to historian Garrison Fielding Hudson. (1, page 142)

Hudson explains that "surgical sleeping draughts" are referred to as the "soporiphic sponge" as early as the 11th century in "the beautiful Jenson imprint of the Antidotarium of Nicholas of Salerna that was published in Venice in 1471.  (1, page 142)

This was a sponge that was "steeped in a mixture of opium, hyoscyamus, mulberry juice, lettuce, hemlock, mandragora and ivy, dried, and, when moistened, inhaled by the patient, who was subsequently awakened by applying fennel-juice to the nostrils." (1, page 142)

This "prescription" was believed to be derived from earlier treatments of "anodyne applications" used to treat insomnia at the temples of the Aesclepius by the Ancient Greeks and Romans. Later on Mandragora became "preferable to opium and hemlock." (1, page 142)

Could you imagine the stress that a physician wanted to give you such a medicine in an age when it was still greatly feared to be operated on? This type of fear was noted in a poem in Marlowe's Jew of Malta: (3, page 143)
"I drank of poppy and cold mandrake juice. And being asleep, belike they thought me dead."
So the anesthetic may have been taken internally by some, yet it was due to this fear that the anesthetic was not taken "internally by Salernitan physicians." I think this was a wise decision, and this made the "Soporific Sponge" a wise alternative.

The"Soporific Sponge" is an early, yet primitive, example of one of the first uses of an inhaling device. It is for this reason I mention it here. 
It is also surmised that the Salerno medical community greatly influenced Arabic medicine.  Yet, ultimately, Arabic medicine would grow so that it superseded the old Greek traditions taught at Salerno, and this is believed to be what caused the fall of Salerno from its "high estate."  The School of Salerno met its demise sometime in the middle of the 13th century.(1, page 187)

  1. Garrison, Fielding Hudson, "An introduction to the history of medicine," 1922, Philadelphia, W.B. Saunders Company

Thursday, September 11, 2014

Asthma History: Introduction

According to my mother I was diagnosed with asthma at the age of two, which would be in the year 1972.  Considering she said I was sniffling, sneezing and wheezing even before that, chances are I developed asthma and allergies close to my birth on January 4, 1970.  Despite the claims of my doctors, I never outgrew my asthma.

When I was about ten-years-old, which would be in 1980, my asthma, already bad enough, took a turn for the worse.  While other kids were able to run around and have fun during recess, I was forced to sit on the bench.  While other kids were living normal lives, I was asking the Principal to call my mom because I couldn't breathe.

I remember my mother taking me to many unscheduled visits to Dr. Gunderson, and many more to the emergency room, and most of these for asthma.  Sometime in 1980 Dr. Gunderson introduced me to a small, pocket-sized device that gave me my breath back instantly.  It was an inhaler.  I quickly became great friends with this new object, taking it with me wherever I went.

One day as I was puffing on my inhaler I wondered what life would be like for asthmatics prior to modern medicine.  As I started to investigate this, I ended up on a journey that took me all the way back to the beginning of human existence 2.5 million years ago, and then all the way back to the current world.

I learned that for most of history (perhaps 99.9 percent of it) the asthmatic had to choice but to suffer through an attack.  Once I realized this I likewise realized how privileged I was to have been born in 1970, as compared with 1870 or, worse, 1870 B.C.

I also quickly learned that, as with the warpath of mankind, the path of disease can be traced back to the beginning of human existence.  In fact, disease may go back farther than war itself, as diseases exists regardless of the desires of mankind.  Although, as we learn from the Biblical Cain, fighting began early enough in a quest for selfish gain.

So while most histories follow the path of war, this history follows the path of health and healing, with an emphasis on asthma.  In order to organize this history I will use the following definitions:
  • Prehistory (prehistoric):  Time prior to the first written language, or recorded history, which is generally considered to be around 2700 B.C. 
  • Ancient:  Time after written language, or time with recorded history.  This period lasted from around 2700 B.C. until the fall of Rome in 476 A.D. 
  • Time:  After the birth of Christ people developed a need to keep track of time, and so the birth of Jesus was chosen as the date to begin time.  The date of his birth was estimated and this was chosen as 1 A.D. When a child is born we usually refer to the first year as zero.  With time the first 100 years is considered the first century, and therefore the years 100-199 were referred to as the 2nd century.  It's for this reason why the years 1900 to 1999 were referred to as the 20th century.  This is just how it is.  
This system was created to help people study history and keep track of dates and time.  Whether accurate or not, this is how history is recorded.  I will use this system to categorize this history of asthma:
  • Beginning to 5000 B.C.: Prehistoric people (prehistory)
  • 5000-2700 B.C.: Ancient Societies (Before History and Time)
  • 2700 B.C.-1 A.D.: Ancient Societies (During History, Before Time)
  • 1 A.D.-276 A.D.:  Ancient Societies (Beginning of Time)
  • 276 -1600 A.D.: Middle Ages (The Dark Ages of Medicine)
  • 1600-1800:  Age of Reason (The Age of Enlightenment)
  • 1800-1900:  The Scientific Revolution (the Age of Progress)
  • 1900-2000: The Age of Results
  • 21st Century:  The presents
  • My asthma story
Each chapter in this history is one blog post, and each will focus on one thought.  In this way I am able to keep each chapter pithy and, therefore, easy to read.  While I have done some of my own research, I try to tell this history through the eyes of those who lived it, or those who spent hours studying it.  This will, I think, give you a more complete picture of the history of asthma.  

However, considering the vastness of our history, and the brief time each person lived among it, this history is but a small glimpse of the past.  Most of our history is told by the select few privileged to be able to read and write, so it is nearly impossible to impress upon what life was like among the common folk.

Still, there was just enough evidence to draw a picture of what life must have been like for those who suffered from asthma over the years.

So what was it like to live with asthma in fill in location and year?  To best answer this question, I make a gallant effort to describe the the various cultures.  This, I think, should should allow us to gain a more complete understanding what it would be like to be sick if you lived among them.  

However, I would like you to consider the following quote from historian Henry E. Sigerist:
"We have no evidence whatsoever of any paleolithic medicine." (1, page 107)
I say this because there will be times throughout this history when we must use our imaginations to gain an understanding of what it was like to live with asthma in fill in the year and place.

So what was life like for asthmatics 2.5 million years ago?  Let's go!

  1. Sigerist, Henry E "History of Medicine," volume I: Primitive and Archaic Medicine, 1951, New York, Oxford University Press

Tuesday, September 09, 2014

1871-1900: Pneumatometers as Spirometers

By the 1870s various engineers were tinkering with the Hutchinson Spirometer with the intent of improving upon it  Yet in 1871 Dr. L. Waldenburg invented a device that some physicians believed was better than the spirometer for diagnosing various airway diseases.

The main problem with spirometry was that volumes varied based on height and age.  This problem appeared to be remedied with the invention of the pneumatometer which measured more the force of a patient's exhalation, and therefore gave a better picture of the patients lung muscle strength.

This was a portable device that could be used to provide pressure changes to be used therapeutically to treat various diseases, such as emphysema, croup, bronchitis, and asthma.  The first such device was introduced by Hawke in 1870 called the Hawke Apparatus.  This device was nice because "air in the receiver can be condensed (increase in pressure) or rarified (decrease in pressure), and used in either of these conditions for respiration." (1)

Hawke believed his apparatus would be especially useful in croup and emphysema.  He believed that since emphysema resulted in air being trapped into the lungs, that expiring against rarified air (which was basically suction) this would help empty this air from the lungs. In croup he believed condensed (positive pressure, pressure support) should be inspired. He later recommended inspiration of compressed air for consumption.(1)

After Hawke wrote about his apparatus he received "favorable results," although this type of device wasn't truly accepted by the medical community until Waldenburg improved upon it with his own device, called the Waldenburg Apparatus.  And the neat thing about Waldenburg's apparatus is it had a graduated scale so you could measure the degree of pressure changes.  This was nice for two reasons:
  1. You could measure the amount of pressure used to benefit the patient, which allowed similar settings to be used at future visits or uses, and allowed physicians a guide to setting up future patients.
  2. You could use it as a spirometer to measure the force of a patients exhalation, and to measure vital capacity.
It was likewise different from the spirometer -- even better -- because "spirometry deals with the vital capacity of the chest, which depends chiefly upon the circumference and height of the thorax, whilst in pneumatometry the height of the thorax has no influence." (3)

"U-shaped tube, open to the atmosphere and suitably mounted, is filled with mercury in both branches to the same level, which is marked zero. One branch is connected with a rubber tube and mouthpiece (or mask or nosepiece) used by the person under observation, whose expiratory and inspiratory force is measured by the ascent or descent of the mercury in the other branch, as shown upon a millimetric scale (Fig. 1)." (2, page 25)

So, "When the patient expires through the tube, the column of mercury sinks in the proximal limb of the manometer and rises in the distal, while with inspiration these movements are of course reversed, and in either case the amount of displacement is to be read off on the scale." (3, page 146)

Likewise, "Since the level of the mercury when at rest corresponds in both limbs to the zero of the scale, the reading obtained must, of course, be doubled to represent the true difference in the level of the two columns." (4, page 146)

Keeping in mind expiratory pressure is normally greater than inspiratory presssure, Waldenburg (and later other physicians) determined the following normal values for forced inspiratory and expiratory pressures for males and females (3 and 4):
  • Male inspiratory pressure:  70-100
  • Male epiratory pressure:  90-130
  • Female inspiratory pressure: 50-80
  • Female expiratory pressure: 70-80
The diagnostic purposes are as follows (3):

1.  Expiratory pressure is increased in relation to inspiratory in:
  • Phthisis (even at a very early stage), 
  • Stenosis of the air passages
  • Pulmonary congestion
  • Pneumonia
  • Pleurisy
  • Any abdominal affections as impede respiration by pressing the diaphragm upwards.
2.  Expiratory pressure is diminished until it becomes equal to or below the inspiratory in:
  •  pulmonary emphysema.
Other than for diagnostic purposes, this test can indicate: (2)
  1. The power of the respiratory muscles
  2. The mobility of the thorax and expansion of the lungs
  3. Elasticity of the parenchyma of the lungs. 
So, by performing tests on both the Hawke and Waldenburg apparatus's, physicians discerned the following facts: (1)
  1. Emphysema results in imperfect expiration, while inspiration is normal or increased (the natural result of increased use of inspiratory muscles)
  2. Catarrh of small bronchi results in imperfect expiration, and normal inspiration
  3. Phthisis (tuberculosis, consumption) results in a decreased inspiration, and later expiration is imperfect.  
  4. Stenosis of respiratory ducts results in imperfect inspiration, but expiration is normal
  5. Inflammation of lung tissue and pleura results in similar effect as phthisis
There were a variety of similar products on the market, although Waldenbur's continued to be the preferred pneumatometer for both as a pressure apparatus and spirometer, at least through the turn of the 20th century, according to most sources I used as references.  
    1. 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
    2. 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. Tissier page 72
    3. Brunton, Lauder T, The Practitioner: A Journal of Therapeutics and Public Health, Vol. XVII, July to December, 1876, London, MacMillan, "Pneumotachometry," page 216
    4. Brown, John James Graham, "Medical Diagnosis," 2nd edition, 1884, New York and London, Birmingham and Co., "Pneumotameter," pages 25-26
    5. Effects on the heart are questionable, although most studies conclude the pneumatometer  benefits asthma, bronchitis, emphysema, phthisis

    Thursday, September 04, 2014

    2.5 million years ago: The dawn of empathy

    The first humans walked the earth as early as 45,000 years ago.  Chances are these early people suffered from diseases such as asthma, and so this is where our history must begin. These are the people who ate the apples from the tree of knowledge, and who learned to have empathy for their fellow beings.  They therefore learned to not only feed and nurture themselves, but other people and animals as well.

    Now we don't know if asthma existed back then, but let's assume it did.  Better yet, I'm certain asthma-like symptoms were probably felt by people when they were sick with infections, or perhaps as their heart and kidneys failed.  So let's assume a person 45,000 years ago was short of breath and gasping for air.  Observing his misery, another person would come to his aid, offering any help he could.

    Now let us take this a step further.  While a human is a human is a human, there were human-like people who roamed the earth long before us.  Whether or not we evolved from them is up to you to decide, but there is a ton of evidence that they existed.  There is evidence they were able to adjust to various situations, and to make their own tools.  There is also evidence that as their brains grew, they developed the ability to ponder about the world around them, and to, well, love and have empathy.

    Scientists have placed the first humanoids (something that resembles a human) as first appearing on earth as early as 7 million years ago, with the first human-like humanoids walking the earth 2-3 million years ago. The first human-like humanoids were called Home or Homo Habilis, meaning "handy or skillful," writes Patricia Netzley in her 1998 book "The Stone Age."   These humanoids were the first to adapt to their surroundings by inventing and using stone tools.  These tools were used for "scraping or sawing wood... cutting meat... cutting grass stems or reeds," writes Netzley. (1, page 9, 12)

    They were the first to joint together at a "home base," where they shared food.  Food sharing, it must be understood, is among the first signs of empathy for people other than yourself.  It must have been a major challenge to not eat the food you hunted for yourself, and carry it to the base camp for someone else to eat.  Helping others by feeding them must have been the earliest form of healthcare or medicine. (1, page 41)

    About 1.8 million years ago was a more human-like humanoid called home erectus, which means "upright man."  He walked the earth until about 300,000 years ago.  This was the first humanoid to experience a population crisis, and this meant that there were too many people in a given area for the available food.  This provided an incentive for them to migrate to where food was available.  This meant they were forced to adapt; to discover new lands, to find new food sources, to invent new tools, and invent new methods of living.  All of this would have been necessary in order to adapt to their new surroundings. (1, page 43-47)

    The changing climate also forced them to migrate to places where it was cold, and they therefore were the first to discover the importance of fire sometime around 400,000 years ago.  At first they took advantage of natural fires that occurred due to lightning or lava, although eventually they learned to control fire themselves, and ultimately make it by themselves. (2, page 27)

    While sitting around the fire home erectus had time to experiment, and he learned that meat could be cooked, and that this made food more tender and easy to chew.  They also experimented by cooking various plants, and learned that plants that were stiff or horrible tasting made for good food when cooked.  (2, page 27)So with less need for strong facial muscles to chew raw meat, some speculate fire may have contributed to the thinning out of the face and jaw (those who believe in the theory of evolution believe this anyway).

    The first home sapiens, or "wise humans," first started walking the earth around 500,000 years ago.  Among the most well known of the home sapiens were the Neanderthals (Neandertals) who lived in small groups of about 25, mainly in caves, although they did have the ability to make crude shelters of materials they gathered from the woods. They had mastered the use of fire, and perhaps it was because of the fire that encouraged small groups of men and women to band together as small families or tribes, replete with men, women and children who worked together for a common cause (or so we can speculate). (1, page 52-60)

    People who mastered the skill necessary to make and control fire were among the most important members of the family or tribe.  The knowledge they obtained often meant the difference between keeping warm or freezing; life or death.  The fires allowed them time to socialize, and to fall in love with other members of the family or tribe.  This is evidenced by the fact they buried their dead in decorated grave sites, and provided the dead with gifts to take with them to the next world. (2, page 27)

    Neanderthal men, and the women who were without child, searched for food during the day, and they brought this food back to he cave to share with the women, children, and the sick.  Yes, there is evidence Neanderthals took care of the sick.  (1, page 52-60)  One burial site was discovered of a man with no right arm, and there is evidence he managed with one arm for many years before he died, probably aided by his fellow men and women. (3, page 37)

    Some speculate that the fact Neanderthals took care of the sick and performed burial rituals, and celebrated the life of the dead following these rituals, is evidence they had traditions.  The fact they had traditions is evidence, some suggest, that they had language.  This would have allowed one generation to communicate with the next, perhaps by easy to remember lyrics, or perhaps they just grunted (we just don't know). (1, page 61-63)

    What we do know is Neanderthals thrived in Europe through hot and cold temperatures.  Their short, stocky frames required about twice as much food as we eat, and to do this they "lived around the edges of forests where they hunted large animals like red deer, horse and wild cattle. The forests gave them firewood, and materials to construct shelters and spears," according to science and nature. (3)

    Then "About 45,000 years ago, the climate of Europe went through a burst of very sudden switches between warm and cold conditions that would have transformed the Neanderthals' environment. The forests on which they depended began to recede, giving way to open plains.  On these plains, Professor Shea believes, the Neanderthal thrusting spear and ambush strategy wouldn't have worked. So Neanderthals retreated with the forests, their population falling as their hunting grounds shrank," according to science and nature.  (3)

    When humans migrated to Europe around 30,000 years ago, their "better brains and more sophisticated tools" were no match for the Neanderthals, who shortly thereafter became extinct. Human  tools and methods of adjusting made them better able to hunt amid and survive amid the the landscape created by mother nature.(3)

    Now, where did these humans come from.  Those of us who are Christians believe they were placed on this earth by God.  Others believe they evolved from the Neanderthals or some other humanoid species.  Others believe in some combination of these two theories.  Believe it or not, there are many Christians who believe there is far too much evidence to prove evolution, and therefore believe there is room for both Christianity and evolution.  So, then, if this is the case, then God created the earth and the humanoids long before the Biblical date for the creation of time, which is pegged by some to be around 4004 B.C. (I will delve into this date more later).

    I'll let you believe as you wish.  All we are concerned about here is what would asthma be like if we lived among these people?  We have no idea.  There is no written record, and there is no evidence of asthma left behind.  Asthma doesn't make its way to bones, which is mainly all we have left of these prehistoric people.  As a matter of fact, asthma leaves no visible scars, not even among the living. So what was it like to live with asthma 2.5 million years ago?  What was it like to live with asthma among the Neanderthals?  All we can do is speculate.

    The truth is: we don't even know when asthma began to appear as a disease. What we can, I think, speculate accurately, is that people probably did get short of breath, or winded, since the beginning of time.  I can imagine that early humans had bodies that wore out early on in life.  Their kidneys started to shut down, and their hearts started to fail, and this would have caused you typical signs of respiratory distress; they would gasp for air, what the ancient Greeks would call asthma (more on the ancient Greeks later also).

    It's also highly probable that many of the bacteria and viruses that plague humanity to this day irritated humanoids and early humans who walked the planet.  These germs entered the air passages, or were ingested by dirty hands, and made their way to places in the body they don't belong.  Prehistoric immune systems worked overtime to expectorate these germs, and this resulted in inflammation, including inflammation of the respiratory tract.  This would cause a runny and stuffy nose, itchy and watery eyes, scratchy throat, and even shortness of breath.

    So in a world where humanoids and humans became increasingly empathetic toward their fellow men and women, in a world where they grew dependent on one another, in a world where they grew attached to one another, in a world where they fell in love with one another, they would most assuredly have felt sad when a parent, brother, sister, or friend, became ill in this way.  They would want to help out.  They would hunt and bring back food and water.  They would speculate as to the cause, and provide what they thought was the remedy.  Sometimes what they did would work, and the remedy would be remembered.  More often, however, the remedy would fail, and sadness would ensue.

    So we can see here that as far back as 2.5 million years ago such people had the ability adapt to their surroundings, and they had the ability to make stone tools and use them to hunt and prepare food. Human-like people as early as the lower paleolithic (2.5 million to 126,000 years ago) had the ability to adapt to their surroundings, and to ponder about the world around them.

    1. Netzley, Patricia D, "World History Series: The Stone Age," 1998, San Diego, CA, Lucent Books
    2. Roberts, J.M., "The illustrated History of the World: Prehistory and the first civilizations: volume I," 1999, New York, Oxford University Press
    3. "Neanderthal: Their bodies were well equopped to cope with the ice age, so why did the Neanderthals die out when it ended,", Science and Nature,, accessed 4/4/13
    4. Garrison, Fielding Hudson, "An Introduction to the history of medicine," 1922

    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
    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)
    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,", Scientific Anti-Vivisectionism,, 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,", Scientific Anti-Vivisectionism,, 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,, and, 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