Friday, March 24, 2017

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

Thursday, March 23, 2017

1981: Nursing caps and smoking nurses

Nurses in the 1970s (2)
Not, 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 be 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   

Wednesday, March 22, 2017

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

Tuesday, March 21, 2017

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.

Monday, March 20, 2017

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 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 wagering character (sic)nor 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:
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 that asthma asthma as a nervous disorder is an age old concept that was postulated by various physicians over the years. This "nervous theory of asthma" gained momentum, and therefore became deeply embedded into 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 at the turn of the 20th century, only to begin its comeback in the 1950s after a famous asthma doctor by the name of Franz Alexander listed asthma as one of the seven psychosomatic disorders.

According to dictionary.com, psych is a Greek root for 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. 

Physicians in Germany became infatuated with psychosomatic disorders in the 1920s. This inspired an uptick in the idea that asthma was nervous. Many of these physicians, including Dr. Alexander, migrated to the United States, and this inspired interest in psychosomatic medicine in the United States. (2, page 771)

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. (7, page ?)

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. (5, 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. (5, page 222-223)

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

Friday, March 17, 2017

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.  (6, 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.  (6, 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.   (6, 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. (6, page 284)

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

Thursday, March 16, 2017

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.

Wednesday, March 15, 2017

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

Tuesday, March 14, 2017

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. 

Monday, March 13, 2017

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

Friday, March 10, 2017

1981: Sus-Phrine: The greatest asthma medicine ever

"When we vacationed to California in 1976.
Dr. Gunderson gave us this to take along." Mom wrote
I think that the world's greatest medicine was Sus-Phrine (brand of epinephrine). It was actually a long acting version of epinephrine. It gave you your breath back within five minutes. I was given this medicine many times in the emergency room. It was a lifesaver.

A few years ago, as I began my quest to learn more about this medicine, a doctor told me that he liked it because a person would come in with status asthmaticus (asthma non-responsive to treatment), and he would prescribe a Sus-Phrine shot followed by a shot of a systemic corticosteroid.

The steroid would take 1-2 hours to reduce airway inflammation. In the meantime, the Sus-Phrine started working within minutes, and would last up from 6-10 hours. So, he said, the Sus-Phrine would keep airways open long enough for the steroid to take effect. Patients would have to stay in the hospital at least an hour after the shot so they could be monitored for potential side effects. Then they'd be sent home feeling good.

I would surely be feeling good. I would be wired. Sus-Phrine was essentially adrenaline. It's a medicine that essentially mimics the sympathetic (flight or fight) nervous system (sympathomimetic). It narrowed blood vessels to speed up the flow of blood to increase blood pressure. It increased the rate and speed of your heart. It caused palpitations. It made you excited. It made you jittery. It kept you awake for hours. But you didn't care, because it felt so good to be able to breathe.

Since 1901, epinephrine was available to be used for asthma. It started working in 3-5 minutes, but only lasted a few hours. This meant that repeat shots were often needed. It had to be given into the muscles, and this was most frequently the gluteal muscle (the butt). It also had to be given with a very large needle, which made the butt a good spot for injection. And kids were not keen to seeing a large needle, let alone having to drop their drawer and getting poked in the butt.

An An ampule of Sus-Phrine (1)
Sus-Phrine was first introduced to the market in the 1950s. Apparently, according to Emergency Medicine PharmD, it was the first medicine that didn't have to be given by intramuscular injection with a large needle. It was available in a concentration of 1:1200 (aqueous solution), which (if you are a nurse and I am not) can be delivered with any gauge needle and introduced to the body subcutaneously (meaning into the fat), meaning you could just get the shot in the arm with a small needle.

I only mention this because I started getting this shot in the mid-1970s and early 1980s when I would have been 5-10 range. Even though they would always assure me they had seen many naked butts before, it was always better to pull down my sleeve than to pull down my drawers. I'm sure this is the same for any kid.

Sus-Phrine (8)
Sus-Phrine became standard for asthmatics who presented to the emergency room during the 1970s to about the mid-1980s. This would have been about the time albuterol entered the mainstream of asthma treatments. It must have been discovered about this time that albuterol was just as effective as epinephrine in opening airways and ending asthma attacks. Giving 2-3 albuterol breathing treatments would also prove to offer the patient fewer side effects as a bonus.

I must have been given Sus-Phrine many times early on in my life. I know this, because, in 1976, my parents decided to take us to California. It was a three day car ride. This would have occurred just after I finished Kindergarten in June. My mom had my doctor write a note to any random doctor who might have to take care of me in case my asthma acted up. The note, written on a prescription pad, said:
Sus-Phrine (8)
"This boy is a known asthmatic undergoing hypersensitization program. If he has severe asthmatic attack without a fever he will respond well to 0.2cc Susphrine sub-q. Stat & observe 20 minutes."
By the late 1980s, and particularly between 1981 and January 1985, I made regular trips to the emergency room. I remember sitting on the hospital bed. I remember my dad saying, "In five minutes you will feel better."

Of course, they always had to give me an Alupent nebulizer treatment first. After a while I knew this wasn't going to work, but they always did it. As I inhaled the mist, I watched as a nurse would prepare the shot. When the treatment neared completion, the shot was given to me on my left or right arm.

Then I watched the clock. It was an oval clock on the wall right in front of me. It was 8 p.m.  I watched the red second hand go round and round as my shoulders dug deep into the mattress I was sitting on. I'd concentrate on my breathing. At first my breath would only go in half way. My chest was tight. I must have been near panic, or I wouldn't have asked mom or dad to take me.

Five minutes would go slow. But, right on cue: at the five minute mark my breath would start coming back. Each subsequent breath would go in deeper and deeper. Then I'd take in a deep breath and it would be easy. Then I'd take several deep breaths just because I could.

I can tell you with complete honesty that there is nothing better than all of a sudden being able to breathe after several hours of struggling to do so. It is just a great feeling. In fact, it usually created a feeling of euphoria. And, quite frankly, in retrospect, I'm not sure if that euphoria was the result of all of a sudden being able to breathe, or a side effect of the medicine. I imagine it was a little of both.

Nearly all of my ER visits were at West Shore Hospital. I remember going to the emergency room at West Shore Hospital in 1991 for an asthma attack. This was the first time I did this since 1985. I requested Sus-Phrine. The nurse never heard of it. The doctor had a vague memory of it, and consulted the pharmacist. The pharmacist and doctor talked about it for a while, and the pharmacist decided he had a cabinet that might have the medicine I requested.

This was the last time I was given the shot. It was discontinued within the next few years. A study published in 1991 in the Journal of the National Medical Association conclude that "Subcutaneous, long-acting epinephrine (Sus-Phrine) provides no additional benefit to a beta-2 agonist (albuterol) by nebulization for children with acute asthma." (6)

To be honest, I have never been given an epinephrine shot since then either, which spotlights the changing times as far as we asthmatics are concerned.

Further reading and references:
  1. Emergency Medicine Pharm D: Throwback Drug Thursday: Sus-Phrine, An Aqueous Formulation of Epinephrine
  2. Naterman HL. Ephinephrine base suspended in water with thioglycolate. J Allergy 1953; 24:60.
  3. Unger AH, Unger L. Prolonged epinephrine action. Ann Allergy 1952; 10:128-130
  4. Ben-Zvi Z, Lam C, Hoffman J, et al. An evaluation of the initial treatment of acute asthma. Pediatrics 1982; 70:348-353.
  5. Ben-Zvi Z, Lam C, Spohn WA, et al. An evaluation of repeated injections of epinephrine for the initial treatment of acute asthma. Am Rev Respir Dis 1983; 127:101-105.
  6. 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.
  7. Jenkens, Charles M, "A Clinical Study of 'Sus-Phrine,' an Aqueous Epinephrine Suspensionfor Sustained Action," Journal of the National Medical Association, March, 1953, 45, pages 120-122
  8. Bezzant, John L., "Epinephrine: Comparison of short vs long acting," http://library.med.utah.edu/kw/derm/pages/ni18_3.htm, accessed 3/10/17
  9. "Sus-Phrine (brand of epinephrine), Physician's Desk Reference," 1991, page 1006
  10. Feldman, B. Robert, "The Complete Book of Children's Alergies: A Guide for Parents," 1986, Times Books
  11. Brenner, Barry E., editor, "Emergency Asthma," 1999, New York, Marcel Dekker, Inc., page 322

1769: John Millar writes about asthma

John Millar (1733-1805) was a Scottish Physicians.  He cared for patients of all ages, although he tended to favor caring for women and children. So when an epidemic of asthma ravaged through the border counties of England and Scotland after great quantity of rain fell in 1755, Dr. Millar was among the first physicians called. (1, pages 11-14)(4, page 96)

He arrived on a blustery day, and was called to the home of a Baker.  A short, stout man wearing a white apron that was covered with white powder met the doctor as his buggy was parked by the entry of the Bakery.  The doctor could smell the sweet aroma of bread, and his stomach grumbled.  He climbed down from the buggy, reached back in for his bag, and followed the baker into his shop, up a narrow and steep set of winding stairs, to a small, hot, room, where a girl was sitting on the edge of a bed, leaning with her face on the edge of a window that faced the street.  He could hear a loud wheeze each time she took in a breath.  He could see by the vigorous shaking of her body that she was working arduously to suck in every breath.

He did not request for the girl to move, and instead squeezed his way around the bed and sat next to her, setting his bag along side him on the back of the bed.  He put his arm around the girls shoulder and hugged her.  "I'm going to help you feel better," he whispered.

He felt her head, and observed it was hot and clammy.  He also observed that she had picked away all the paint on the ledge of the window.  He touched her stomach, and his hand rode in and out as it undulated with each breath.  He said, "Does your stomach hurt? Are you sore down here?"

The girl did not respond, except by her tears and distressing look on her reddish face.  Her mother, however did respond.  She said, "She complained of a sore stomach, and she felt nauseated and vomited.  And she has been very nervous the past few days, refusing to go to school and to do her chores." Her husband, the baker, put his arm around her shoulder and held her tight. "We were so mad at her.  Now we wish we hadn't been."

"You didn't know," the doctor said.  "I believe her stomach indigestion, the fact that he suffers from a nervous affection, perhaps as from a hysteric or hypochondirac disease, and I presume it is asthma."

The doctor reached into his bag and pulled out a bottle and a spoon. He opened it and gave it to the girl.  He would give it to many sick girls and boys that day.  The last stop was at the house of a lawyer, whose girl was in the early stages of the disease.  She seemed to get immediately better when given the remedy.

The lawyer's wife asked him if he wanted to stay in the guest room, and he admitted he was tired.  Before he slept, he opened his bag and pulled from it a journal.  He wrote about every patient, and what he gave.

The next morning he went from business to business, home to home, to see other children, and a few adults, who were afflicted with this asthma.  At night he found a place to sleep, usually by the mother of the last child he saw that day, although on the last night before he planned to return home he slept in the Mayor's guest house.

It had been two weeks since he began treating sick children, and he had traveled from town to town, and had been treated well everywhere he traveled. Many children were cured by his remedies, although, a few times, he held a child during the last moments of life.

After a large meal cooked by the mayor's wife, he returned to the guest house for the night and pulled his journal from his bag.  He sat at a desk and wrote as much as he could remember about the past two week's events.  He wrote:
"Peruvian bark given early, seldom failed to perform a cure... the asthma was more or less frequent according to the state of the weather, that it prevailed most in spring and autumn, and especially in moist seasons. (1, pages 9-11)
He wrote that pure (spasmodic) asthma is most prevalent are places that have increased moisture, and have a tendency to be cold and damp, with the asthma presenting mostly in the spring and autumn. The remedy for this type of asthma is Peruvian bark. Without treatment death may ensue, or "remissions become less and less distinct." (1, pages 11-14)

While Millar described this epidemic as asthma, it was actually croup or some other related disease.  About 50 years later, after he had invented the stethoscope for listening to lung sounds, French physician Rene Laennec determined that the same disease was actually suffocative catarrh.  (4, page 96)

In the meantime, after caring for hundreds of children with what he considered to be asthma, Dr. Millar took his notes and decided to write a book to educate other physicians about this disease.  In 1769 his book was published as "Observations on the asthma and on the hooping cough."

Because his asthma was different than that described by ancient physicians, and even by other physicians of his era, he believed the ancients must have been wrong in their definition of asthma.  He wrote:
THE accounts which have been given of the Asthma by medical writers, seem only applicable to very advanced stages of it, or to other disorders, accompanied with a symptomatical difficulty of breathing; but perhaps without some previous knowledge of the original disease in its simplest form, more complicated cases can neither be clearly explained nor properly treated. The Author of the following Observations, having often seen it in children, unattended with any other complaint, hath given a description of it, as it really appeared, though very different from that which is to be found in books. (1, page i, ii) 
He said Hippocrates was the...
...first who to posterity a genuine history of diseases, and a rational method of treating them, founded upon faithful and accurate observations; but the simple and natural mode of medicine was soon vitiated by the introduction of false and absurd systems of philosophy. While such absurd theories were taught in the schools of medicine, the practice deduced from them was no less ridiculous; and as one or other of these opinions prevailed, the attention of the physician was employed in searching after medicines possessed of occult powers..."
Dr. Millar believed that it wasn't until the writings of Dr. William Harvey in 1628, who demonstrated "the circulation of the blood," that a rational practice of physic (medicine) was re-established. He said it was only after Harvey's discovery that a true understanding of the human body and its diseases could be learned. (1, pages 1-3)

The "theory and practice of physic" was only then begun.  It was Harvey's observation that resulted in "a careful attention to the rise and progress of disease, and to the effects of the medicines applied to them, (and this) is the only proper way to complete their history, and to establish a certain method of cure."  (1, pages 1-3)

He said that...
...Physicians fully convinced of this, and that no single person is sufficient for so great an undertaking, have long since established societies for collecting and publishing medical observations, which have contributed greatly to the improvement of the art." (1, page 3)
This was similarly noted by historian Fielding Hudson Garrison, who explained that there was an explosion of medical knowledge during the course of the 18th century, particularly regarding human anatomy, internal diseases, clinical medicine, and internal medicine.  Various physicians studied the human body, learning about the various diseases and the remedies that treat them.  (2, page 300, 330) 

Thanks to the discovery by Harvey regarding circulation of the blood, medicine as we know it today was born.  It was this discovery, and the eventual acceptance of it, that inspired physicians to race to learn as much about the human body as possible, and the ailments that plague it, and the remedies that fix it.  The result of all this research, and the discoveries that followed, squashed many of the old theories that enveloped the medical profession.*

Asthma was among the diseases studied and expounded upon, with physicians slowly coming to the realization, as noted by both Millar and his contemporaries, that asthma was more than a general symptom. 

Millar said asthma was among the diseases that was slow to be accurately defined.  He wrote:
Sir John Floyer, who was himself afflicted with this disease, describes the chronic asthma, and gives a just detail of its symptoms: but as he was first seized with it when a child, he gives no account of its beginning, nor of the method of treating that early period of it, in which, perhaps, alone a perfect and complete cure is to be obtained? .
What he is trying to say here is that Floyer only recognized adult asthma as opposed to infant and childhood asthma.  Millar continued:
Most other authors who have wrote on this subject, treat, under that denomination, of the Peripneumony, peripheral vomica, Pulmonum, Flatus,. Hypochondriac and. Hysterick Diseases, and, indeed, of almost every other disorder, accompanied with difficult respiration, excepting the least complicated state of that which they undertake to describe.
Here he is trying to say that most authors described asthma as the symptoms of shortness of breath, which is probably secondary to some other malady, as opposed to asthma in its pure form.  He said:
This will not appear surprising when we consider that an asthma, or difficulty of- breathing, is a leading symptom, in all the diseases already mentioned, as well as in many others; and, as it is painful and alarming, the patient, tho' a symptom only, deems it a primary disease, wishes ardently to be freed from it, and represents it principally to the attention of the physician.
On the other hand, as the least complicated species of asthma generally attacks children, or very young subjects, it is frequently confounded with the epilepsy, worms, teething, and other disorders incident to the early period of life, in which the physician can avail himself but little of the information of his patient, and is often misled by that which he obtains from others. Hence the accounts of it which we meet with in medical books, tho they may correspond to certain stages of it, or to the appearances of other diseases, in which a difficulty of breathing is a leading symptom, yet they convey no explicit idea of the origin and progress of the asthma in its simple uncomplicated state. (1, pages 4-5)
Basically he's saying here that there's more to asthma than what has been written about it by previous writers.  Millar breaks asthma down into the following categories.
  1. Acute:  "Terminates in a few days in death, a perfect recovery..." (1, page 92)
  2. Chronic:  It's "often a consequence of (acute asthma), and frequently continues for many years, and often during life." (1, page 92)  
The subheadings that follow here are my own, although I think this would be how Millar defines asthma the disease, as opposed to asthma the symptom of some other disease: 
  1. Pure Asthma: "difficulty of breathing alone, which proceeds from some defect in the bronchial vessels."  (1, page 92)
  2. Secondary Asthma:  Asthma occasioned by " an inflammation, or any obstruction of the lung, a pleurisy, perepneumony, hydrops pectoris, ascites, or any other ailment whither it appears as a concomitant or consequence of these.  
Over a hundred years later, when writing a book on asthma, Dr. Francis Ramadge would use Dr. Millar as a perfect example of how much was written, or assumed, about asthma without doing much investigating into the matter.  

Ramadge quoted Dr. Millar as saying:
The only dissection I ever made in the disease was of a child... (3, page 97)
Perhaps Millar was noting awareness of his limitations when, in the introduction of his book, he acknowledged that what he observed, and later concluded, about asthma was merely the beginning; that there was much more work to be completed regarding the definition of our term asthma.  He said:
Conscious of the difficulty of such an attempt, he does not suppose that he hath completed the history of the disease, but hath endeavoured to collect such observations, as may facilitate the further investigation of it; to point out the particular signs that distinguish it from other disorders in which respiration is only accidentally affected; and he proposes a method of cure which hath often been successfully applied, (1, page ii)

And he was right.  A wise asthma doctor indeed was he, or so we suppose, for the era for which he lived.

*For a list of all the diseases learned about check out reference Fielding Hudson Garrison's book, page 300-302.  He also lists the authors of various "histories of medicine" that were written during the 18th century.  See reference #2 below, or click here

References:
  1. Millar, John, "Observations on the asthma and on the hooping cough," 1769, London
  2. Garrison, Fielding Hudson, "An introduction to the history of medicine," 1913, 1st edition, Philadelphia and London, W.B. Saunders and Company
  3. Ramadge, Francis Hopkins, "Asthma, its species and complications, or researches into pathology or disordered respiration; with remarks on the remedial treatment applicable to each variety; being a practical and theoretical review of this malady, considered in its simple form, and in connection with disease of the heart, catarrh, indigestion, etc." 1835, London,  Longman, Rees, Orme, Brown, Green, and Longman
  4. Andral, M, notes, Renae Laennec, author, "A Treaties on the Diseases of the Chest and on Mediate Auscultation, Regius Professor of Medicine in the College of France, Clinical Professor to the Faculty of Medicine of Paris, &c, &c, &c., Translated from the Third French Edition with Copious Notes, a Sketch of the Author's Life, and an Extensive Bibliography, of the Different Diseases by John Forbes, Member of the Royal College of Physicians, Physician to the Chichester Infirmary, and Physician in Ordinary to his Royal Highness the Duke of Cambridge, to which are added the Notes of Professor Andral, Contained in the Fourth and Latest Edition, Translated and Accompanied with Observations on Cerebral Auscultation, by John D. Fisher, Fellow of the Massachusetts Medical Society," 1838, New York, Samuel S. and William Wood
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Wednesday, March 8, 2017

1871-1900: Pneumatometers (especially Walldenburg's) better than 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)

(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 or vacuum) 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)

Paul Tissier described the device as a "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.  
    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