1907: Dr. James Sawyer's Asthma Powder

The following is the recipe for making Dr. James Sawyer's Asthma Powder as per The British Pharmaceutical Codex:

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PULVIS STRAMONII COMPOSITUS.

Compound Stramonium Powder.

Synonym.—Sir James Sawyer's Asthma Powder.

Stramonium Leaves, in powder ... ... 50.00

Lobelia, in powder ... ... ... ... 6.oo

Anise Fruit, in powder 12.00

Tea Leaves, in powder ... ... ... 6.oo

Oil of Eucalyptus 1.oo

Potassium Nitrate, sufficient to produce ... 100.00 

Mix the oil with the vegetable powders, then add the potassium nitrate.

This powder is used to relieve asthma. About half a teaspoonful is pressed by the fingers into the shape of a cone, which is then lighted at the top; the patient inhales the fumes as the powder burns. The powder is used several times daily, as may be necessary, for asthma. Pulvis Lobeliae Compositus is a similar preparation.

Note.—A simpler form of Sir James Sawyer's Asthma Powder consists of 50 of stramonium leaves in powder, mixed with 25 each of potassium nitrate and anise fruit in powder; it may be distinguished as Pulvis Stramonii Nitratus.

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1983: The mist tent and the nice respiratory therapist

It was 1983. I went to the emergency room for bad asthma. I was given the Sus-Phrine shot and rolled up to a room behind the nurses station. My asthma episode was really bad. So, doctor Oliver wanted me right by the nursing station. So, they put me in a room literally right behind the station.

There was a window where I could watch the nurses. I hated it. There was no privacy. I was actually stressed that I wouldn't be able to change without a bunch of female nurses watching me. But, after the first night, after I was feeling better, the doctor said I could have the curtain pulled. This was nice.

I was kind of a claustrophobic kid. When I was in Kintergarden and first grade, I remember we had to wear hats and snow suits. I hated this. I felt like I couldn't breathe when I was all bundled up like that. The teachers hated it that I was not compliant. But, ultimately, what choice did they have but to let me go out without them on.

Okay, the same thing with nasal cannulas. Here I was struggling to breathe for hours before I went to the emergency room, and that last thing I wanted was something over my face. I would get a breathing treatment, I would get the shot, and at some point someone would say, "We better put oxygen on him."

I would pull it off. They would put it on. I would take it off. They would put it on. I would take it back off. I remember this happening often. And, I don't ever remember anyone ever giving me a hard time about it. It probably bothered them, as I imagine I appeared cyanotic at times, but it never bothered me. All I wanted was the shot. I knew the shot would make me feel better. I didn't need something on my face.

So here I am, sitting in this room behind the nurses station. Mom is reading to me. I'm feeling soothed. And the doctor comes in. He says something about a mist tent. I wasn't thrilled about it. And I wasn't upset when it was several hours before a respiratory therapist came in and said, "It will be like being in a tent."

I wasn't thrilled, but I didn't feel like fighting. I knew that reason was because I refused to wear a cannula. And, I suppose, I must have been cyanotic. However, based on the fact the therapist appeared to be dragging his feet with setting it up, I highly doubt I was cyanotic. It was probably just some stupid idea my doctor got. I know how doctors are now that I have been working with them 20 years. Sometimes they just feel as if they have to do something, even if that something is something that's not needed.

Okay, so I ended up in this tent. The TV was on. I could hardly see the TV through the wrinkled plastic that was over my bed. Okay. It was nice and cool in it, however. Mom was sitting next to my bed. She may have read to me. But then my dinner came. I wasn't even in the tent for an hour, and I was allowed out to eat. I never went back in.

Later that night a really nice therapist came into my room. There usually wasn't a therapist on night shift. But tonight there was. She came in around 8 p.m. to give me a breathing treatment. She talked to me for hours. She was so nice. She told me I didn't have to go back into that tent. I was so happy. Before she left, I said, "Make sure you wake me up tonight for my treatments." She said, "I will."

She never did.

Fast forward 25 years. My coworker is Joella. I came into work one day and she said, "A memory occurred to me this morning. I was working in Manistee part time. I was called in to work because they had a 10-year-old asthmatic in a mist tent. A thought occurred to me: It was YOU."

She was right. Her name was Joella. She is now retired and living the good life.

This experience inspired a post at healthcentral.net, along with the following comic.

1900: Park-Davis Glaseptic Nebulizer

The Glaseptic nebulizer was used to aerosolize
Solution to the respiratory tract: nose, mouth
and lungs.  It was a "handy apparatus" and
produced a fine spray by squeezing the rubber
bulb.  The nebulizer and throat piece were made
of glass because some solutions chemically react
with metals.  It was easy to use and portable.(3)

When epinephrine was discovered at the turn of the century, and it was proven to be useful in ending asthma attacks, a device was sought out to deliver the medication directly to the lungs. 

The only logical options at the time were glass nebulizers that worked by squeezing a rubber bulb.  One such product was the Park-Davis Glaseptic Nebulizer made by Parke-Davis & Company in Detroit, Michigan.

Older nebulizers were made of metal, and some medicines reacted with metal.  So the newer nebulizers were made of glass.  On the box is written:  "Ready for instant use, easily kept clean and efficient with either oily or watery liquids. Effective in producing a spray with only small quantities of liquid. No metal to corrode or affect the medicinal properties of solutions".

The product was described by the editors of Therapeutic Notes in 1910 this way: (2, page 215)

The working parts of this apparatus consist of one piece of glass, with one rubber bulb and tube and glass throat piece. The base is of metal, nickel plated. Under light pressure upon the bulb the medicament is drawn by the air current to the top of the inner tube and expelled as a fine spray. Oils of all densities, as well as aqueous, spirituous and ethereal liquids, are nebulized instantly, though there may be only a few drops in the reservoir. The Nebulizer is three and one-half inches high, and is marketed in a neat carton.

1907 Ad for Adrenaline Solution and Glaseptic Nebulizer (1) It provided
another option for physicians and their patients.

Another article in the same magazine notes: (4)

MEDICATED VAPORS—HOW TO EMPLOY THEM.

We have an interesting pamphlet bearing this title which we shall be pleased to send to any of our readers on request. It deals with our line of Inhalants and also our Glaseptic Nebulizer. The latter is a big advance on other atomizers. As its name implies, every part of it with which the contained liquid comes in contact is of glass and can easily be kept aseptic. There are no loose parts to be lost and no metallic tubes to corrode. As it operates effectively with only a few drops in the reservoir it is a most economical apparatus; moreover, it can be securely sealed by the introduction of a single cork, thus preventing evaporation and spilling of contents, and facilitating transportation in the pocket or instrument bag. It produces an excellent spray, when either an aqueous or oily liquid is used.

The Glaseptic Nebulizer came in boxes as seen here.  It was
manufactured and sold by Park-Davis & Co., Detroit, Michigan

An advertisement on page 212 of the same catalog notes there is only one glass part of the nebulizer, and it's the part the solution goes into. The only other working part is the throat piece, which costs $1.25.

Epinephrine (Adrenaline) came in small glass ampules that were snapped open, and the liquid contents were spilled into the glass reservoir.  Water could be added to the solution for a longer treatment. The patient would place the mouthpiece up to her lips and create a mist by squeezing the bulb.

Other medicines were also recommended for inhalations, such as Acetozone and Chloretone for hay fever.  For hay fever, either of these, or adrenaline, was squirted into the nasal passages for quick relief of symptoms.  (2)

The Glaseptic Nebulizer only cost $1 and was readily available for those who needed it.  Plus it could be used either in the doctor's office or in the comfort of your own home. 

This article and picture are from the Therapeutic Times. The nebulizer produced a fine spray
that was ideal for atomizing soluble medicine to the respiratory tract, particularly the nose and
throat.  It was also an ideal way to apply adrenaline directly to the respiratory tract.  It was simple,
and portable, meaning it could be used in the doctor's office or by asthmatics at their homes.
I am posting it here mainly because I think its a good close up of the nebulizer.
(From Therapeutic Times, volumes 28-32, Park, Davis & Co., 1921)

References:

1. Advertisement from Surgical journal, Volume 14 By International Association of Railway Surgeons, American Association of Railway Surgeons, page 472, railway surgical journal, 1907.  You can find another ad in Pharmaceutical Review, 1907, volume 25, Hoffman, Fredrick, Edward Kremers, editors, advertisement page 78
2. "SUGGESTIONS AS TO THE LOCAL TREATMENT OF HAYFEVER AND ACUTE AND CHRONIC CATARRHS," Therapeutic Notes, Volumes 17 and 18, Park Davis and Company, 1909 and 1910, page 215
3. Leyden, Hans, "Preliminary Remarks in regard to the Percutaneous Method of Applying the "Ehrlich-Hata 606," Therapeutic Notes, Volumes 17 and 18, 1909 and 1910, Park Davis and Company, page 168 (also see advertisement on page 212)
4. "Medicated Vapors and how to employ them," Therapeutic Notes, Volumes 17 and 18, 1909 and 1910, Park Davis and Company, page 5
   
   

1930s: Spiess-Drager (Apneu) Nebulizer and Inhalatoriums

Figure 1 (4, page 4)

The modern nebulizer is based on the work of Professor Spiess, who was working for Drager in Frankfurt, in 1902.

His nebulizer used a flow of oxygen from a compressed nebulizer to atomize solutions placed in a reservoir cup.

The system essentially consisted of the nebulizer, which was connected to a compressed air or oxygen tank.  The flow was set between 5 and 12 liters per minute.  (3, page 7)

The product was connected to a rubber mouthpiece by a rubber hose.  The system used the Venturi principle to atomize the solution to be inhaled.

The inhaler, sometimes referred to as the Spiess-Drager, Apneu, or collision inhaler, was used to study the effects of various inhaled medications.  The medicine most commonly used was Glycerin (a mixture of epinephrine, water, and glycerin) to patients with chronic bronchitis, chronic laryngitis, croup related pneumonia, interstitial pneumonia, and tuberculosis.  (3, page 7)

It was, in effect, the first nebulizer/inhaler device to utilize an oxygen tank, and was the first such device that allowed physicians to give oxygen and nebulized therapy simultaneously.  (4)

W.E. Collision, in his 1935 book "The Inhalation Therapy Technique," described the history of this inhaler. He said:

In 1902 Professor Speiss of Frankfurt introduced his inhaler, which incorporated the use of oxygen and atomized liquids.  His method was extensively used throughout Germany and during the Great War.  This apparatus was introduced into England by Mr. P.S. Douglas-Hamilton and myself in 1924 and was exhibited at the British Medical Association Exhibition (which was held in Bath in the following year), and in subsequent years until 1932, when the Collision inhaler was exhibited for the first time at the Association's Exhibition at the Imperial Institute of London. (4, page 4)

The London Inhalatorium... afforded
a comfortable treatment room
to those being treated."  (2, page 134)

Since most people with lung disorders could not afford to bring this equipment to their homes, this inspired London physicians to open up an inhalatorium in Grosvenor Place.  This created a comfortable, and affordable, setting for patients to inhale medicine with oxygen. (2)

Other medicine inhaled by the device was  epinephrine (adrenaline), menthol, eucalyptus, terpentine and insulin. (2).

The treatment would last about 10-15 minutes.

This spawned an inhalatorium fad of sorts.  Other inhalatoriums opened, and similar collision nebulizers were introduced to the market.  One such copycat was Hirth's Jet Nebulizer.

Asthmatics might also enjoy the pleasures of an inhalatorium.  They may only visit when having trouble breathing, or they might visit 3-4 times a day as a preventative measure.

The Spiess-Drager Inhaler, and the inhalatoriums it spawned, provided a unique opportunity for inhaling medication.  This was a nice set up for the time.

References:

1. Green, Henry-Lionel and W.R. Lane, Particulate Clouds: Dusts, Smokes, and Mists, Second Edition, Spon Ltd., London, 1964. (linked to from Inhalation.net, "Atomizers for Droplet Aerosol Generation," accessed Oct. 8, 2012)
2. Sanders, Mark, "The London Inhalatorium," Inhalatorium.com, page 134, http://www.inhalatorium.com/page134.html accessed 10/9/12
3. Bisgaard, Hans, Chris O'Callaghan, Gerald C. Smaldone, editors, "Drug Oxygen Delivery," 2001, New York, Marcel Dekker, page 7
4. Collision, W.E., "Inhalation therapy technique," 1935, London, William Heinemann

1991: Study finds albuterol works just as well as epinephrine

In my quest to write a little history of Sus-phrine (epinephrine) I finally found an article I'd been looking for for quite some time. The article was regarding a study comparing the long-acting version of epinephrine with Ventolin (albuterl). It was a breakthrough study. It's basically why we give albuterol breathing treatments for asthma instead of epinephrine injections.

Before I delve into the study, I think a little background is pertinent here. Epinephrine was established as a very effective treatment for asthma during the first few decades of the 19th century. So, if you suffered from severe asthma and went to your doctor with an asthma attack, there's a good chance you were given an epinephrine injection.

Epinephrine was great because it opened airways within only a few short minutes. The down side was that it only lasted 3-4 hours. This often meant that repeated injections were needed to keep airways open long-term. This problem was solved in the 1970's with the introduction of Sus-phrine, which was essentially a long-acting epinephrine: it lasted 6-8 hours.

During the 1970's and 80's if you went to your doctor for severe asthma, you might be given a Sus-phrine shot instead of the traditional epinephrine. My mom kept track of this kind of stuff for me when I was a kid, and I know I was given Sus-hrine in the early 1970's. In 1976, when I was only six-years-old and my family wanted to travel from Michigan to California, my doctor wrote a note saying that if this boy has a severe asthma episode, Sus-phrine works great.

I was initially given these shots in the doctor's office. However, later on I had to go to the hospital. It got to the point that, by 1980, I was literally asking for "the shot." An I got it every time. This came to an end in 1991. This year I went to the emergency room and I asked for "the shot." But, the doctor had never heard of what I was asking for. I said, "It's called Sus-phrine."

After talking with the pharmacist he was able to find one. He gave me the shot. This was the last time I was ever given a Sus-phrine shot. A few months later I had another asthma attack and went to the emergency room. This time I was given a bunch of albuterol breathing treatments. They worked just as well as the shot at opening me up. And, as a bonus, I didn't feel like doing laps when I was done; my heart didn't feel like it was going to explode.

This probably wasn't the only such study, but a 1991 study published in Pediatric Emergency Care tiled, "Effect of injected long-acting epinephrine in addition to aerosolized albuterol in the treatment of acute asthma in children." The study basically showed that Sus-phrine was no better than albuterol at opening airways and ending asthma attacks. 

Considering side effects of albuterol are essentially negligible, and the fact that doctor's generally feel comfortable giving high doses of it in the emergency room when needed, the study was a breakthrough study. It pretty much removed epinephrine as a top-line treatment for severe asthma attacks and moved albuterol up to the top. 

As anyone who works as a respiratory therapist knows, albuterol has remained at the top ever since. In fact, albuterol is considered so safe by the medical community. that it's given indiscriminately to anyone who comes into the emergency room with shortness of breath or wheezes regardless of the cause. If it works, great. If it doesn't work, it was worth a try. 

References and further reading:

1. Kornberg AE, Zuckerman S, Welliver JR, et al. Effect of injected long-acting epinephrine in addition to aerosolized albuterol in the treatment of acute asthma in children. Pediatr Emerg Care 1991; 7:1-3.
2. Asthma History: 1981: Sus-Phrine: The greatest asthma medicine ever

1894: Alabone's compressed air inhaler

In 1894, Edwin W. Alabone became the first to develop an inhaler that used compressed air "pumped up by hand," according to W.E. Collision in his 1934 book "Inhalation Therapy Technique. (1, page 3-4)

Collision said Alabone probably wasn't the first to come up with this idea, and that he probably got it when he was in the United States.  He was, however, the first to introduce this type of inhaler to Britain.  (1, page 3-4)

This was a significant invention, because in 1902 Professor Speiss of Frankfort would use a similar concept in creating a nebulizer that would become very commonly used in inhalatoriums during the 1920 and 1930s.

References:

1. Collision, W.E., "Inhalation therapy technique," 1935, London, William Heinemann

1981: Nursing caps and smoking nurses

Nurses in the 1970s (2)
No, that's not me.
But it's the only picture I could find
depicting nurses in their old uniforms.

The daughter of a patient of mine said she was a nurse in the 1970s. She said she remembers one nurse who would have a baby on either side of her. She said she would sit and chart like that for hours, and chain smoke. She said this was acceptable back then; the dangers of it were rarely if ever, questioned.

This reminded me of when I was admitted to the hospital sometime in 1981. I remember the nurses wore the prototypical white nursing uniform and cap. I remember asking a nurse how she kept the cap on her head, and she said she used a bobby pin. She even went as far as to show me how it was done.

That night I smelled smoke. I also had trouble breathing. In the morning, my breathing was still tight when my doctor came around. I wasn't trying to get the nurses in trouble as I innocently mentioned smelling smoke during the night. My doctor stormed out of my room. I could hear him talking at the nurses' station.

A year later I was admitted to the same room and for the same reason. This time the nurses were not wearing their uniforms. I asked about this, and the reason I got was, "They are now optional, and we decided not to wear them anymore." It was sad, in a way, not to see the uniform, although I understood why they wouldn't want to wear them.

Actually, they were in uniform. They were all wearing scrubs. And I suppose it was better for them, as they had more freedom as to what they could wear, and what colors. It was probably nice not to wear that hat. And, from what I read, they were more difficult to keep on your head than this nurse told me.

It was also during this visit that I remember, on the day I was admitted, hearing my doctor at the nurses' station. He said: 

"I do not want any smoking while this asthmatic boy is admitted. That is an order."

Obviously, I'm paraphrasing. But that was the gist of it.

It was bath time. A nurse came in to give me a sponge bath. I insisted on not doing this. But she insisted on doing it. We ended up compromising. There was a tub in a room across the hall. I insisted the door be shut. She insisted it is open. We compromised, and the door was shut but not locked. I cleaned up quick because I knew nurses by then.

So I got clean. I did not have an asthma attack during this visit. And I ultimately went home after a few days. Anyway, it's neat to have this memory of being a patient at this transitional time in the history of nursing.

References:

1. Getty Images: Neat old videos of nurses wearing their uniforms
2. workessentials.com: History of Nursing Uniforms Through Time   

1885: Recommendations for inhaling medicine

There were so many different inhalers and nebulizers made and sold during the course of the 19th century that I could write about them adnauseum. If you want to see a larger sample you should check out a really neat site by Mark Sanders, who has amassed a copious supply of antique inhalers and nebulizers, and displays then on his website: Inhalatorium.com.

There were many devices, and every one was the best one available to the people who invented and sold it. And each one had different medicines recommended for it's use, such as some were specifically made for anesthetics, some for ether, some for opium, some for any other assortment of medicines.  

Various medicines inserted into the various nebulizers and inhalers were:

• Iodine
• Creasote
• Carbolic acid
• Camphor
• Ether
• Chloroform
• Nitrate of amyl
• Nascent chloride of ammonium
• Opium
• Strammnium
• Atropine.

Depending on the device, the medicine could be inhaled by steam or mist, with the ideal method being by mist, because a mist can deliver both volatile and non volatile medicines to the airways of patients.

So how often should nebulizer therapy be prescribed?  How long should the treatments be?  At what temperature should the water be heated to?  What kind of breaths should the patient take?  These questions were answered differently by different physicians, and may vary depending on the instrument used, and the medicine used. 

It also depended on the malady the physician was trying to treat.  Is the patient having trouble breathing currently?  In such a case he may not mind sitting around for hours sucking in the mist of a device that requires frequent squeezing of a bulb or bellows.  

Although if the patient is has a chronic disease, and is taking the medicine as preventative therapy, the treatments may be schedules on a regular basis and taken for a recommended frequency.  Again, it may depend on the patient, physician, and ailment.  

Jacob Solis Cohen's recommendation is that the treatments should be taken at regular intervals, for a few minutes (how long can you sit around squeezing a bulb), and should be done before meals "because, as a rule, they are less apt to the empty than the full stomach; while, moreover, if they are to be of service, they often stimulate the appetite, or at least promote the desire for food."

He recommends the patient stay in the house at least thirty minutes after a treatment, "especially if warm vapors have been inhaled; as sudden exposure of the warmed-up respiratory tract to the change of temperature between in-doors and out-of-doors, may, under unfavorable conditions, be followed by injurious consequences."

He also describes the appropriate method of breathing:

"The proper method of inhaling gases and vapors from an inhaler must be acquired by the patient, otherwise the vapor will merely be drawn into themouth and reach the pharynx, and if it mixes at all with the air in the lungs, will do so by diffusion; but with a little effort the manner of effecting penetration into the lungs can be readily acquired." (1, pages 15-16)

He also recommended, if steam was the method of medicine delivery, that the water be heated to between 110 and 135 degrees Fahrenheit to create an inhaling temperature of 84 to 93.  He recommends the temperature not be higher unless the goal is to produce expectoration. (1, pages 17-18)

As with today's medical industry in regards to the inhalation of respiratory medications, there was speculation mingled with science.  Yet it would probably be a true statement if I said the patient, regardless of the doctors recommendations, came up with his own answers to the above questions.  When he found something to work, he repeated it as he so choose to get the desired results.  That's just how we asthmatics are.

References:

1. Cohen, Jacob Solis, "Inhalation in the treatment of disease: it's therapeutics and practice," 1876, Philadelphia, Lindsay and Blakiston

1983: Mom's voice and the nice respiratory therapist

The highlight of any of my stays in the hospital was when my mom came to visit. Usually she would come early in the morning and stay until after the notice rang over head, "Visiting hours are over." During the day mom would read to me. One time, as there was nothing else to read, she read a story from reader's digest. The story was too complex for me to understand (or maybe I was too hyped up from all the medicines I was on to treat my asthma) and had trouble paying attention to the story. However, I loved to hear my mom's voice. Hearing mom's voice was therapeutic. It was almost as therapeutic as Sus-Phrine. There is just something soothing about hearing your mom's voice as she is reading a story. It is so relaxing. I loved it when she did it, and wish she would have more often. However, in our busy household, about the only times I remember her reading to me was in the doctor's waiting room or when I was in a hospital be. That's fine. I will take those memories wherever I can get them.

So mom left one day when i was eleven. A respiratory therapist name Star came into my room. She was a young therapist. She was really nice. I liked her probably because she would actually pay attention to me. She would sit on the edge of the bed and watch TV with me. One time I was flipping through the stations and came to a channel with some naked Aborigines. I started to turn the channel, but Star told me to keep it on this station. I wasn't interested in learning about them, but she was. I was too busy laughing. She kind of scolded me for laughing at them. I didn't do it intentionally, i was just giddy. It was probably from all the medicines I was strung on.

The next day mom brought my brothers to visit me. Mom had to take them home. When mom left I went to look out the window. This was when Star entered my room. She gave me my treatment, and then said "Let's play some cards." Of course, there was a deck of cards that mom brought me on my table. I don't remember what game we played, but she stayed in my room for quite some time. It was nice to have the company. I was so happy to have a therapist who paid attention to me like this. But, there was a page overhead, and she had to rush out of the room. Still, it was nice that she helped me pass the time.

Sixteen year's later, when I was hired at Memorial Medical Center in Ludington as a respiratory therapy, Star became my co-worker. Star would later tell me I was a very excitable kid.

1889: The Carbolic Smoke Ball

A part of an 1892 advertisement for the Carbolic Smoke Ball

The years 1889 to 1891 brought an influenza pandemic to London that wasn't necessarily life threatening, although it caused a significant amount of suffering.    (3, page 73)

The cause of influenza was a mystery at this time, and this sort of fed into the fear of it.  There were also few (if any) laws regulating medicine in those days, so this allowed anyone to enter the market, even if there was no proof his product was effective.

A scared and suffering populace was more than eager to do anything to prevent and treat the disease.  This created a perfect market for the Carbolic Smoke Ball.

For much of the 19th century there were a variety of recipes for producing powders to be inhaled for a variety of ailments of the respiratory tract and face.  Physicians recommending these powders knew they had to be "pulverized and "kept dry" at all times.

Physicians also recognized that inhaling the powders made patients cough, and this often resulted in coughing up the medicine, and trouble breathing.  So there were continued attempts to perfect the delivery system for such powders.  One such attempt was made by Dr. Fredrick Roe in the late 19th century, and in 1899 he patented his attempt as the Carbolic Smoke Ball.  (1)

Carbolic Smoke Ball Ltd. was manufacturer and vendor of the product (3), and it was marketed in London as a remedy for influenza, and thus the aim was to capitalize on the influenza scare.  It was a "hollow ball of rubber, with a nozzle at the top."  The nozzle was inserted into one of your nostrils, and the ball was squeezed to produce a fine cloud of pulverized powder.  The patient would inhale the powder into his respiratory tract.  (3, page 73)

The product was marketed with the claim that anyone who used it at least "three times daily for two weeks" and contacted influenza to contact the company for an award, a sum of 100 pound sterling.  Although claims against the company (like this one and this one and this one) ultimately resulted in the withdrawal of the offer.  (2)

The following advertisement was in various newspapers in November of 1891:

"100£ reward will be paid by the Carbolic Smoke Ball Company to any person who contracts the increasing epidemic influenza, colds, or any disease caused by taking cold, after having used the ball three times daily for two weeks according to the printed directions supplied with each ball. 1,000?. is deposited with the Alliance Bank, Regent Street, •shewing our sincerity in the matter. 

"During the last epidemic of influenza, many thousand carbolic smoke balls were sold as preventives against this disease, and in no ascertained case was the disease contracted by those using the carbolic smoke ball.

"One carbolic smoke ball will last a family several months, making it the cheapest remedy in the world at the price, 10s. post free. The ball can be refilled at a cost of 5a. Address, Carbolic Smoke Ball Company, 27 Princes Street, Hanover Square, London."

One lawsuit claimed the following (4, page 257):

The defendants advertised that they would pay 100£. to any person who contracted influenza after using their carbolic smoke ball for a specified period in accordance with directions supplied.  The plaintiff bought and used a smoke ball for the period and in accordance with the direction, and afterwards contracted influenza: that the advertisement, coupled with the performance of the condition by the plaintiff, constituted a contract on the part of the defendants to pay the plaintiff 100£; that such contract was not of a wagering character (sic), nor a policy of insurance within (sic); and that the plaintiff as entitled to recover the 100£.

In this case, judgment was given to the plaintiff, and the defendant (the Carbolic Smoke Ball Co.) appealed. The appeal noted that there is no evidence the lady contracted influenza, no evidence she was the actual purchaser, and no evidence she used the product as recommended.  The appeal stated she could have claimed she developed influenza "twenty years after using the smoke ball.  The advertisement must be treated as a mere expression of intention, not as a promise." (4, page 257)

The medicine inside ball was not known, however, according to the 1898 book "The Medical World," the ball contained "310 grams of a gray powder, which upon snuffing up the nose caused violent sneezing, and their is an odor of smoke due to a tarry body. Upon an examination made in our laboratory by H.W. Snow, it was found to consist of (finely powdered) glycyyrhiza and flour and one of the veratrums, probably white hellebore. The smoky body is some tar product, not easy to say just which." (5, page 38)

"The Medical World" states the product, which sells for $2.50, may provide temporary relief of the listed ailments, but not permanent relief.  The book recommends the following technique for using the product:

Directions —Hold the ball about one-eighth inch below the silk floss, with the thumb and forefinger of the left hand, about one and one half inches below the nose, and directly in front of the mouth. Snap rapidly on side of the ball, but only on the place softened and marked, during each inhalation, with the middle finger of right hand, which will cause the smoke to arise. (5, page 38)

After its initial release, the product was marketed for an array of ailments, not limited to hay fever, colds, catarrh, asthma, bronchitis, sore throat, hoarseness, snoring, sore eyes, croup, diphtheria, whooping cough, headache and loss of voice.  The product hung around well into the 20th century.

Further offerings:

1. 1892 Advertisement for the Carolic Smoke Ball in The Sunday Magazine
2. 1892 Advertisement for the Carbolic Smoke Ball in The Strand Magazine

References:

1. Sanders, Mark, "Pioneers of Inhalation," Inalatorium.com, slideshow presentation, accessed on 11/13/12
2.  Bisgaard, Hans, Chris O'Callaghan, Hans Bisgaard, Chris O'Callaghan, Gerald C. Smaldone, editors, "Drug Delivery to the Lungs," 2001, New York, Marcel Dekker, pages 15-18
3. Pathak, Akhileshwar, "Legal Aspects of Business," 2007, New Delhi, Tata McGraw-Hill
4. Witt, John George, Frederick Hoare Colt, editors, "The Law Journal Reports," 1893, London, F.E. Streetens, pages 256-266, "In the Court of Appeal: Carvill v. The Carbolic Smoke Ball Co." This is a specific review of one of the lawsuits against the company.
5. Taylor, C.F., editor, "The Medical World," volume 16, 1898, Philadelphia, 

1951: Alexander defines asthma as one of seven psychosomatic disorders

The idea of asthma as a nervous disorder is an age old concept that was postulated by various physicians over the years. This "nervous theory of asthma," or asthma nervosa, as it was so often called, gained momentum among leading physicians. This idea became deeply embedded in the minds of asthma physicians in the 1850s when a famous asthma doctor by the name of Dr. Henry Hyde Salter wrote on the subject.

The idea seemed to wane somewhat in favor of other theories at the turn of the 20th century, only to gradually begin its comeback in the 1930s after a famous German psychoanalyst by the name of Franz Alexander began talking about asthma as a psychosomatic disorder.

According to dictionary.com, psych is a Greek root for the mind and somatic means of the body or physical. Psychosomatic medicine, therefore, is the study of physical conditions that are thought to be caused by strong emotions of the mind, such as anxiety, stress, and depression.

In 1920, Hans Alexander (originally from Hungary) became the first student at the Berlin Psychoanalytic Institute, an organization whose goals were to train psychoanalysts, offer psychoanalytical treatment for those suffering from neurosis (manic depressive illness), and to conduct research on the subject. Their ultimate goal was to continue the great works of Dr. Sigmund Freud (1856-1939). (1, Alexander.)

As a quick side note, Sigmund Freud started the study of psychoanalysis around the turn of the 20th century. This involved a patient lying on a couch and talking freely about whatever comes to mind, while the therapist analyzes what the patient says. Freud was infatuated with sexual desires, and he believed males had an inert sexual desire for their mothers. Perhaps out of this is where Alexander derived some of his ideas about asthma.

Alexander and his psychoanalyst colleagues became infatuated with psychosomatic disorders. Among their works was to inspire an uptick in the idea that asthma was a nervous condition. It was here that the idea of asthma as a "suppressed cry for the mother" was born. 

This research was lead by Alexander, who "advanced the hypothesis that bronchial asthma might result, in part, from a threat of detachment from the mother." (1, Alexander)

Dr. Alexander, along with many of his colleagues, migrated to the United States. (1, Alexander) (3, page 771) He moved to Chicago where he set up a psychoanalytic workshop similar to what he left behind in Germany. His work here would inspired interest in psychosomatic medicine in the United States, including the of asthma as a psychological disorder. (1, Alexander.) 

By the 1930s and 40s, the idea that asthma was an allergic disorder was another theory that heavily influenced physicians at this time. While most physicians believed asthma was triggered by emotions, the majority of their efforts in the clinical setting were aimed at gaining control of allergies. (8, page ?)

The psychosomatic theory, combined with the allergic theory, was what ultimately lead the idea of parentectomy during the 1940s. This was an idea of abducting asthmatic children from their homes (with the permission of their doctors and parents) and placing them in asthma institutions, such as the one in Denver, Colorado. 

In 1950, Alexander would list what he considered to be the seven psychosomatic disorders: (2, page 771)

1. Psychosocial dwarfism (sometimes known as Grave's disease, hyperthyroidism)
2. Ulcerative colitis
3. Hypertension (high blood pressure)
4. Peptic ulcer
5. Dermatitis
6. Eczema
7. Asthma

Alexander essentially believed that, along with actual organic (of the body) processes, these disorders may also be caused, or exacerbated, by strong emotions such as anxiety and stress. (8, page 222-223)

He essentially noted that few people with these seven disorders (or very few asthmatics) received "psychoanalytic therapy." Because of this fact, he was unable to describe the benefits of this type of therapy on any of these disorders, including asthma. (6, page 222-223)

This psychosomatic view of asthma became well accepted among the medical profession. And, as we have observed throughout this history, once something becomes embedded in the mind's of physicians, it's difficult to extricate it out of their heads. It's just the way people are. It's just the way the medical profession is.

In 1968, Alexander linked the seven disorders with a personality conflict. For instance, asthma was a constant yearning for the mother or the fear of losing the mother. Wheezing was a sign that this person was having this conflict. The treatment was 

I think that Gregory K. Fritz describes it best. He said: 

I was a general psychiatry resident in 1974 and new to the psychiatric consultation service at a large public hospital. As I was preparing to do one of my first consultations, my attending, in an effort to be helpful, said, "You're in luck: An asthmatic patient. Asthma is a psychosomatic illness." He went on to describe the intrapsychic conflict that was said to be the psychological cause of asthma (a hostile/ dependent relationship between mother and child; the wheeze was a suppressed cry for nurturance.) I remember being both relieved and skeptical that such rote theory would make my job as a psychiatric consultant so simple."  (7, page xix)

Dr. Fritz said he went on to spent the next 30 years as an adolescent psychiatrist at various children's hospitals and as a researcher for pediatric illness. He explained how the next 30 years saw major advances in the relationship between the mind and the body. This would include asthma.

References:

1. Alexander,  Ilonka Venier, ""The Life And Times Of Hans Alexander: From Budapest To Alexander,"2015, Karnac, Great Britain
2. "Psychosomatic." Dictionary.com. http://www.dictionary.com/browse/somatic. accessed 3/19/17
3. Craighead, Edward W., Charles B. Nemeroff, editors, "The Concise Corsini Encyclopedia of Psychology and Behavioral Science," 3rd edition, 2004, Wiley, page 771
4. "Franz Alexander. Britannica.com, https://www.britannica.com/biography/Franz-Alexander#ref838920, accessed 3/19/17
5. Alexander, Franz, "Psychosomatic Medicine: It's Principles and Applications," 1951, Pediatrics, volume 8, issue 6, 
6. "Book Review. Psychosomatic Medicine: It's Principles and Applications," California Medicine, 1951, March, 74 (3): pages 222-223
7. Shaw, Richard J., David R. DeMaso, editors, "Textbook of Pediatric Psychosomatic Medicine," 2010, American Psychiatric Publishing, page xix
8. Jackson, Mark, "Health and Modern Home," 2007, Routledge

1898: Matas's Apparatus for Artificial Respiration

Figure 4 (21)

Just prior to the turn of the 19th century arose the need for a means to prevent asphyxia when chloroform was used for surgeries. There was also the concern of preventing pneumothorax during artificial respiration.  (1, page 284)

It should be noted here that anytime positive pressure breaths are given to patients there is always the risk of applying too much pressure and blowing out a lung, thus causing a collapsed lung, more technically referred to as a pneumothorax. This is often referred to as barotrauma.

This was a major concern for the makers of ventilators all the way to the current century. Safety measures on modern ventilators work to prevent barotrauma. Yet back when these devices weren't so common, coming up with safety measures must have been a major concern. Much experimentation had to take place before any apparatus was put into use on any patient.

R. Matas devised 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.  (1, page 284)

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.   (1, page 284)

The operator placed a finger over a hole in the O'Dwyer intubation cannula, and when he removed his finger expiration occured.  (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. (1, page 284)

References:

1. Tissler, Paul Louis Alexandre, "Pneumotherapy: Including Aerotherapy and inhalation...," 1903, Philadelphia, Blakiston's sons and Company, page 284,5

1981: My first bad hospital experience

Most of my hospital experiences were good. This was probably because I went to the hospital not being able to breathe, and I left feeling great. So, it would only make sense I had a positive image of them. However, one experience was horrible. I remember being nauseated. I remember having hallucinations.

I remember struggling so hard to breathe. I remember waiting in the emergency room waiting area at the hospital. I remember there was a window with a clerk. I remember mom talking to the clerk. I remember a door behind the clerk that probably went to the emergency room. I remember seeing a few doctors, nurses, or other staff opening the door, saying something to the clerk, and then closing the door again.

But then you'd sit down. Usually you got to go to the emergency room quite fast when you couldn't breathe. But this time the wait was forever. I couldn't breathe. I was so nauseated. I remember being so uncomfortable that I kept moving from one chair or couch to the next. I remember rubbing my tummy. Man, I was sick.

But the clerk didn't care. She ignored me. She made no effort to get the doctor. I was so angry by this. I just wanted to see a doctor. I wanted a shot. I wanted to lie in a bed. I wanted something to make the nausea go away. And mom felt bad for me. I know she talked to the clerk more than once. I don't know what the clerk said to mom. I would imagine there was a code or something going on, and that was more important than an asthmatic kid. But none of that mattered to the ten-year-old asthmatic.

The next thing I remember is I'm riding in a hospital bed. I watch as the ceiling moves by. I'm feeling pretty good. I'm feeling sleepy. I finally get to a room. I remember shifting from the ER bed to my own bed. I remember rolling over and mom covering me up. Mom stayed with me. I felt good that she was next to me. I slept good.

Someone woke me up. I had to get onto another bed. I was very sleepy. I have a vague memory of changing rooms. I got off the transport bed onto a new bed. I got into the bed. Mom covered me up. She sat in a chair next to the bed. I felt comfort knowing she was there. I rolled over and fell asleep.

Someone woke me up. The same thing happened again. I just wanted to sleep. In retrospect, I must have been given something for nausea. It worked so good. It made me very groggy. Or, maybe they gave me a sedative like xanax. Whatever it was, it made me not have a care in the world.

The next day I woke up with the curtain pulled to my right. The nurses came in many times to take care of the person in the other bed. A nurse in a white nursing cap came in to care for me. At some point that day dad came to visit. Dad was mad that I was in a room with an old man. At some point the curtain was pulled. I have a memory of a man who was near death with his mouth agape. As far as I knew he was already dead.

Dad came to the rescue. He made the nurses move me. They moved me to a room across the hall. Dad was also irritated that they kept having to move me. Now I was in a room with a kid my age. He had had an appendectomy. He was not much company as he was in so much pain, but at least he was a kid.

And, as a bonus, dad said he had a surprise for me. He said he had paid the $5 so I could have a TV. It was on the wall in front of the bed. I got to watch whatever I wanted. It was nice to have my own TV. That made my first bad hospital experience an okay one.

1896: The Pulmonary Inspirator

The germ theory caused much speculation among the medical community. Physicians speculated as to which diseases were caused by infecting agents. Some physicians went as far as to speculate all diseases were caused by infecting agents. So it wasn't out of the ordinary to assume that catarrh, asthma, bronchitis, and even emphysema might also be caused by germs. In this case, the best remedy would be the inhalation of antiseptics.

These physicians were the ideal audience for a product called Pulmonary Inspirator. This is the product featured in an advertisement in The Medical Progress dated July, 1896.  The product is an inhaler specifically designed for the inhalation of antiseptics.

I'm sure the product could also have been used for other solutions too, and I'm sure it must have been experimented with.  Likewise, as with other inhalers of this time, the product was probably clumsy, bulky, fragile and expensive.

Medicine must have been inserted into the container with water. Heat would have warmed the water, and the patient would have inhaled the fine medicated steam. The product was patented and sold under a physician's prescription only.

References:

1. "Suggestions on the management of nervous trouble," The Medical Progress: A monthly history and medical progress,John S. Moreman, M.D., editor, July 12, 1896, volume 12, new series number 79, old series number 126, page 240

1980: My first asthma hospital experience

I do not remember my first hospital visit. In my mind's eye it was in 1980, although it's highly likely it was 1981. I was to the emergency room many times. But I think most of my experiences to this point just involved going to the doctor's office. Based on things my mom wrote in the picture books she made for me, I had been given Sus-Phrine more than once. 

I have no memory of being admitted to the hospital until I was prescribed Alupent in 1980. I mean, it's possible I was to the emergency room, it's possible I was admitted before then, but I can't say for sure. Either way, it was at West Shore Hospital. I usually ran out of my inhaler first. Then I'd try to deal with it on my own too long. Then I'd get the nerve to wake mom. Then either mom or dad would take me to the emergency room. 

I remember the nurses wore their white uniforms and white nursing cap. I remember being admitted to a pediatric unit behind the nurses station. I remember there were a bunch of beds, and some of them had other kids in them. Each bed had a TV. They were all black and white TVs. You had to pay $5 a night for access to the TV, so I did not get to watch TV. 

Anyway, I remember dad being with me. I don't remember how I got up there. I would imagine I was on the ER bed, but I suppose I could have walked. More than likely, I did not walk. Anyway, I had to take my clothes off and put a gown on. I remember the nurse saying I had to do this, and then I looked up and saw that the nurse and a bunch of other nurses were watching me. 

Dad said, "They've all seen under wear before, John." I knew this, but still, it was embarrassing. I ended up changing. I got in bed. Dad had to leave. I remember it being dark. I remember there being just enough light where I could see paintings of animals on the wall. I remember vividly a giraffe. It could have been something else. 

A part of my memory wants to say that Bugs Bunny characters were on the wall. Either way, there was something to look at. I needed something because, after getting a Sus-Phrine shot in the ER, I was pretty wired. I was not going to sleep. This was pretty standard after my ER visits.

I do not have any memory of being short of breath after I was admitted for asthma. I was short of breath when I arrived in the ER, but once admitted I was fine. I would imagine I was only admitted because I had made several visits to the ER. I would imagine that the only reason I was admitted was so they could get me away from whatever was triggering my asthma, monitor me, and give me a high dose of systemic corticosteroids and then wean me off. A typical stay for me was six or seven days. 

I remember being in this room more than once. I remember one day another boy had a TV. I remember his mom telling me I could watch. I could not get out of my bed, but she had him turn his TV in such a way so that I could see it. Now that I think of it, this was my memory of Bug's Bunny. I think I remember watching Loonie Tunes. I couldn't make out the TV real well, but it was good enough to act as entertainment. 

This was about the extent of my early asthma hospital admissions. 

1873: The Trendelenburg position is born

Figure 1 --FredrichTrendelenburg (1844-1924) (3)

Probably just about every person in the medical profession is familiar with the trendelenburg position.  It's where you set the patient flat on his back (prone position) and lower the head of the bed so that his hips are higher than the head (see figure 2).

This is done for therapeutic reasons.  Respiratory therapists do it to aid in the drainage of secretions during chest physiotherapy.  Chest physiotherapy is where the therapist cups his hands and bangs on the patients chest to a rapid rhythm. Vibrations supposedly help knock sections from the lungs.

By placing the patient in trendelenburg, this allows the now loose secretions to flow to the upper airway, where they can be coughed up or suctioned out.  Patients who require such therapy are any patients with thick, tenacious secretions, such as bronchiectasis or cystic fibrosis.  Sometimes it's done for COPD patients too, and maybe even some asthmatic patients.

Another use for trendelenburg is to help drain blood to the brain to increase blood pressure.  It seems that one of the first reactions when it's determined a person's blood pressure is critically low is to have the patient lie back and set the bed in trendelenburg.  Yet one might wonder: does this really work to lower blood pressure?

Figure 2 --Trendelenburg position for surgery (2)

The Trendelenburg position was first used in the mid 19th century by German physician and surgeon Fredrich Trendelenburg, according to AMargo A. Halm in her 2012 article in American Journal of Critical Care, "Trendelenburg Position: 'Put to Bed' or Angled Toward Use in Your Unit."  (1, page 449)

Halm explains that Trendelenburg used the "technique known in the Middle Ages as the "head-down position."  In his surgical text of 1873, Trendelenburg recognized that raising the patient's hips caused the bulk of abdominal viscera to slide toward the diaphragm, providing a less cluttered operative field for lower abdominal and pelvic procedures." (1, page 449)

It wasn't until the early 20th century that the position was used by physiologist Walter Cannot to "displace blood from the lower extremities to enhance venous return in the treatment of hemorrhagic shock. This action was thought to cause an 'autotranfusion' to the central circulation, increasing right and left ventricular preloads, stroke volume, and cardiac output (CO)."  It would, thus, increase a patients blood pressure.  (1, page 449)

Use of Trendelenburg for raising blood pressure was questioned during the 1950s, but it became widespread anyway as a "mainstay of resuscitation."  Recently there have been studies that show the position does increase blood pressure, although the effect is only short term.  (1, page 449)

Figure 3 -- Old depiction of trendelenburg (2)

Halm notes that most studies conclude that "Trendelenburg position does not lead to beneficial changes in blood pressure or CO/CI (cardiac output, cardiac index, which are more technical terms for blood pressure).  As a result, this position is probably not useful in rescue efforts.  The associated hemodynamic effects are small and unsustained and thus are unlikely to have a clinically significant impact on hypotensive patients."

The study results, Halm writes, conclude that it's better to use other methods of increasing blood pressure, such as:

• Fluid boluses
• Pharmacological therapies
• Other devices targeted to the cause of hypotension

Yet like any other procedure used by the medical profession, physicians aren't going to stop using something they've been doing for a long time.  Regardless of the evidence, physicians are going to continue doing what they were taught, especially when it's as easy as pushing a button, and especially if it makes them feel they are doing something productive.

Yet Halm notes that this might not be such a good idea, because trendelenburg position can be "associated with harmful cardiopulmonary, neurological, and vascular effects, especially in the presence of disease." (1, page 451)

Side effects of trendelenburg include:

• Anxiety
• Restlessness
• Onset of pounding headache
• Progressive dyspnea
• Loss of cooperation
• Hostile patient
• Struggling efforts to sit upright

Although, it would seem that many of these side effects would result in a ticked off patient, something that would almost assuredly increase blood pressure.  I once had a doctor order BiPAP for a patient just because he thought it would tick the patient off, thereby raising his blood pressure. It didn't work, but it must have made him feel important. I'm being facetious here, but sometimes that's just how it is in the medical profession.

Halm notes that "the position should be used with caution even when immediate/transient benefits are desired."  And I would have to add that the ethics of doing something that has no proven long term effect may work to the disadvantage of therapy.

Usually, however, for the patients I've seen put in trendelenburg, they are usually so sick they don't care; they just want the nurses and doctors to do what they think is necessary to get them feeling better.

I personally think the only time the position would be harmful is when you have a patient in respiratory distress with a low blood pressure.  The temporary rise of blood pressure may come at the expense of making breathing exceedingly more difficult and uncomfortable. But that's just a side thought.

All this said, I have never had a patient complain about being in this position, and usually there sick enough, or medicated enough, not to care.  So chances are pretty good, if you end up in a hospital with a low blood pressure, you'll be asked to lie back, and your bed will be put in trendelenburg.

References:

1.  Halm, Margo A., RN, "Trendelenbug Position: 'Put to Bed' or Angled Toward Use in Your Unit," American Journal of Critical Care, November, 2012, Volume 21, No. 6, page 449-452, www.ajconline.org
2. "Trendelenburg Position," Wikepedia.com, https://en.wikipedia.org/wiki/Trendelenburg_position, accessed 2/24/2016
3. "Fredrich Trendelenburg," Wikepedia.com https://en.wikipedia.org/wiki/Friedrich_Trendelenburg, accessed 2/24/16