Monday, January 11, 2016

1885: Holzapple prescribes oxygen for pneumonia

George E Holzapple believed there were cases of pneumonia where oxygen may become deficient in the blood resulting in a condition called asphyxia.  When this happens the blood essentially becomes more venous, resulting in all the muscles of respiration being called into action, resulting in more breaths that were more frequent and deeper.  He said expiration becomes more marked, and the process ends in expiratory convulsions.  (1, pages 264-265)

He said that physiologists believed these expiratory convulsions were the response sent by the medulla oblongata of the brain as a result of asphyxia. (1, page 265)

He said the vaso-motor center of the brain will also have an effect on the vessels, causing them to become constricted, resulting in "increased arterial tension (high blood pressure) and the filling of systemic veins (bulging veins, edema). (1, page 265)

The heart will beat slower, but with more force, in order to do its job.  To pump blood through narrow vessels it pumps harder, but less frequently.  It ultimately poops out and becomes a weak pump. (1, page 265)

Blood continues to make it's way to the heart, but the heart is unable to pump it through the body.  The heart, therefore, becomes enlarged, or what he refers to as "distended."  He said that as "blood return to the coronary arteries becomes more venous, the contraction of the heart becomes more and more feeble," ultimately beating with less force. (1, page 265)

He said, "The phenomena result from an insufficient supply of oxygen in disease and in health. From the infrequency and feebleness of the heart's action, the blood accumulates in the heart, lungs, and great veins.  The heart is in danger of paralysis, from overdistension all as the result of lack of oxygen." (1, page 265)

Along with causing changes in the force and contractility of the heart, and the rate and depth of breathing, asphyxia also caused a bluish tinge of the skin where oxygen was low, which was referred to as cyanosis.  (1, page 266)

He postulated that since severe pnemonia may result in asphyxia and cyanosis, that perhaps these patients might benefit from intermittent  inhalations of oxygen.

 In the beginning of the winter of 1885, at York Hospital, he was asked to attend to a 16-year-old male who had a severe case of lobar pneumonia with cyanosis. This patient was not administered oxygen and died.

In March of the same year he was asked to attend to a 16-year-old male who also suffered from severe pneumonia, cyanosis and dyspnea (he was breathing at a rate of 75-80 breaths per minute), and who was begging for relief, Dr. Holzapple said he...
...resolved to administer the very element he craved.  In a few minutes after administering oxygen cyanosis became less, the patient expressed himself as somewhat relieved, and in twenty minutes his respirations were reduced from 75 to 60 in a minute. The effects on the respiration and his color were distinctly appreciated by the parents and those around the bedside of the young man.  I repeated the administration a number of times during that day until it was no longer needed. the patient recovered rapidly. (1, page 266)
He later took care of of 15-year-old girl with lobar pneumonia. When she presented with cyanosis and dyspnea on the seventh day, and after she begged for breath, Dr. Holzapple prescribed the administration of oxygen every 3-4 hours. The patient eventually died, but he was convinced the patient lived an extra 48 hours, giving nature a fighting chance, due to the oxygen therapy. (1, page 266)

He said he didn't expect the oxygen to cure patients with pneumonia, he expected that it would, however, "assist nature so that the patient may endure the effects of the disease till nature no more needs our assistance." (1, page 266)

His advice to physicians regarding oxygen was this:
To say that you are not prepared to administer it is no excuse when death is imminent, for every physician is as well prepared as I was, or soon can be at little expense. (1, page 266)
The problem with administering oxygen during this era was the difficulty in delivering it to the patient, as no standardization was in place.  Holzapple describes the method he used as rather "crude."  He said:
I generated oxygen from chlorate of potassium and black oxide of maganese, in large test tubes heated over a spirit lamp, and with rubber tubing I conducted the gas to the bottom of a deep bucket filled with water, which I had placed to the side of the patient's head.  Then with a fan the gas bubbling out of the water was wafted to the patient's face. (1, page 266)
He acknowledged that he was not aware he had become the first to recommend the administration of oxygen to patients with pneumonia.  In the two years following his experiments physicians became aware of the benefits of oxygen for pneumonia.  However, he said:
I am inclined to think, however, that the average county practitioner has very little medical literature that refers to the use of oxygen in pneumonia, which was one reason for writing this article. I advocate the use of oxygen not only in pneumonia, but whenever it is deficient unless for special reasons contra-indicated." (6 ,page 267) 
While Holzapple demonstrated the medical usefulness of oxygen,the apparatus he used was admittedly crude, yet it also did not deliver pure oxygen.  In fact, no device was yet invented that would deliver pure oxygen to the patient.  It would still be several years before adequate technology would be discovered to transport and administer it when needed.

  1. Holzapple, GE, "The uses and effects of oxygen gas and nux vomica in the treatment of pneumonia," New York Medical Journal, September 3, 1887, volume 46, pages 264-267
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