1959: Nebu-Halent Inhaler

1954 ad for Nebu-Halent Inhaler (You could use bronchodilator of your choice)

The nebuhaler was a product that entered the market in the late 1950s following the release of the first inhalers: Medihaler Epi and Medihaler Iso. 

The new product was a Freon-powdered pocket unit with a reservoir chamber with a self-cleaning, baffling device.  

It was called the Nebu-Haler.  The medicine used was Nebu-Halent, or you could use the medicine of your choice.  

This device made it possible to deliver finer, smaller particle-sized aerosols to the patient.  

It did not gain the popularity of the original Medihalers that entered the market in 1956, although it was another option for asthmatics.  

1954: The DeVilbiss Pocket Nebulizer

During the 1930s the DeVilbiss number 40 nebulizer could by found in the homes of many asthmatics.  It was a nice product that provided quick relief by the use of one or another epinephrine product (such as Asthma Nefrin, a.k.a., epinephrine).  

Chances are if you knew an asthmatic you probably saw one of these at one point or another.  Either one of these or a similar brand of glass nebulizer with rubber bulb syringe.  Either one of these or one or another brand of asthma powder.

Yet there were obvious flaws with the DeVilbiss No 40, such that it was made of glass and was fragile, and the aerosolized particles were too large for getting inhalents to the bronchi and alveoli.

This product was improved upon in the 1950s based on suggestions of doctors (and probably patients too) with the DeVilbiss Number 41 Pocket Nebulizer.  You can see a 1954 advertisement for the product here.  

1940s: The Collision Nebulizer

Photo compliments of E.M. Collision's own book (5, page 4)

While the 1930s gave us the first electric nebulizer, they were large, bulky, and expensive.  Most people who needed aerosolized inhalations simply resorted to other means, such as a glass nebulizer with rubber bulbs like the DeVilbiss number 40, or by igniting asthma powders of various sorts. Some people still resorted to using asthma cigarettes.

It was believed that the aersolized particles produced by most nebulizers or atomizers were large and impacted in the upper airways.  This was proved by experiments performed by Huckel and published in 1925.  He determend that aerosol particle had to be 5 microns or less, and be dense enough, to make it to the bronchi and alveoli to be effective. (1, page 10-11)

Another concern of physicians was that experiments "demonstrated that atomization robs air of oxygen."  This was a major concern especially when a treatment was given with a rubber face mask.  It was for this reason atomization was mostly "limited to hand sprays, and it's employment confined to quite short inhalations of a palliative nature to stop an asthma attack or for the treatment of the upper air passages." These short treatments were generally accomplished with two or three puffs using glass nebulzers.(1, page 6-7)

1, page 23)

So there was an obvious need for an improved product that would solve these problems.  And such a product was invented in the early 1930s  by W.W. Collisoin and introduced to the market in 1932 by a company named Collision.  The product was aptly called the Collision Nebulizer.(2)

It was an interesting product that was connected to the top of an oxygen tank, and this pretty much solved the oxygen dilemma.

Flow was adjusted to meet the demands of the patient, and was generally set between 7-8 liters per minute.  (1, page 5, 14, and 25)  

Flow from the oxygen tank filled a reservoir bag, so flow was monitored by monitoring "movements of a bag."  (1, page 5)

It also had a baffle in it to filter out large particles, and this ensured most of the particles inhaled by the patient were small enough and dense enough to make it into the smaller airways where they could do some good.  In this way, this product distinguished an "atomizer" from a "nebulizer."  Atomizers from this point on were used for perfume, disinfectants and paint products, and nebulizers were used for respiratory medicine. 

Studies at this time also showed that the rate and depth of breathing also effected where the aerosolized particles deposited.  If the patient breathed too fast and too deep most of the particles impacted in the larger airway, so it was determined the patient should breathe calmly.  (5, page 14)

Worded another way, laminar (smooth) air flow was preferable to turbulent airflow. Turbulent air is fast and furious and has an increased risk of causing the aerosolized particles to impact in the larger airways, such as the mouth and throat. A smooth, laminar flow is needed for the medicine to make it to the smaller airways. This is created by slow, or simply normal breathing during a breathing treatment.

This device was nice because it allowed the physician to prescribe a "precise" dose of medicine, and also be assured the medicine would reach the lungs where it's desired and have the greatest effect.  Collision describes his own device this way:

"It presents none of the tiresome features associated with medical apparatus, and is readily understood by patients.  While providing a vapour that meets the requirements of modern medicine, it embodies most simple and easily understood controls, and is comparatively small and compact.  These features have overcome the impracticability of patients taking a proper course of duly prescribed treatment at home, and of having the inhalations available at any time and during the hours of the night." (1, page 21)

There were two phials, one amber and one and one white.  The amber phial was for photosensitive inhalents.  A large teaspoon of each inhalent prescribed was placed in one or the other phial.  For daily curative (preventative) treatments Collision recommended placing camphor, menthol, or creosote in the white phial.  The recommendation was for these treatments to be taken every day as a preventative therapy.  Many asthmatics, however, stopped taking the medicine when they felt good. (1, page 22-3, 32-33)

To end an acute episode of asthma, Collision recommended placing adrenaline in the amber phail.  If the patient had an asthma attack while inhaling from the white phial, a handle can be switched from "white phial" to "amber phial." Or, when necessary, the handle could be switched to "both phials" to take in medicine from both.(1, page 22-3)

Rubber tubing leads to a mask with two one way valves, one opens on inspiration, and the other opens on expiration.  This prevents exhaling into the system, and allows expiration into ambient air.  A small hole allows for some ambient air to be drawn in during inspiration.  (1, page 24)

After each use the oxygen gauge should be checked to assure there's enough oxygen in the tank to support a treatment, if the patient requires one for an asthma attack during the night. 

References:

1. Collision, W.E., "Inhalation therapy technique," 1935, London, William Heinemann
2. Rau, Joseph L, "Conference Proceedings:  Design Principles of Liquid Nebulization Devices Currently In Use," November 2002, Volume 47, Number 11, Page 1257einemann

1932: The first use of the term 'Aerosol'

Many asthmatics participate in what is sometimes referred to as Aerosol Therapy. When you take a breathing treatment you are basically aerosolizing medicine so it can be inhaled.  While aerosols are present through history, the term wasn't used until the 1930s.

It was first used in 1932 by R. Whitlaw and E. Gray Patterson.  The term is derived in the following manner (1, page 173):

• Aer = air
• sol = solution

In subsequent years various generic terms have also been used, which include the following (1, page 173, (2 page 5):

• Mist
• Micromist
• Fog
• Fume
• Spray
• Haze
• Smog

The term aerosol basically refers to "the suspension of a liquid or solid particle in a gaseous medium. The term originated as the gas phase analogue to hydrosols (meaning 'water particle' in Greek) and refers to suspension of particles in a liquid." (2, page 3)  Most "theories describing aerosol behavior assume the particles are spherical." (2, page 6)

Aerosolized particles generally average in size from barely larger than a molecule to as large as 100 micrograms.  Although for the purpose of aerosolized particles to reach the respiratory tract, the following is necessary (3):

1. Greater than 10 um deposits in the nose
2. Greater than 5 um deposits in the mouth
3. 5-10 um deposits in the first six generations of bronchi (large airways)
4. 1-5 um deposits in the last 5-6 generations (small airways)
5. Greater than 3 um have a tendency to impact the conducting airways
6. 0.8-2 um are optimal for alveolar deposition

Bronchospasm, as what occurs in asthma, generally occurs in the smaller airways. For this reason, the ideal particle size is 2-5 um for best airway deposition. This is the particle size that is generally created by most hand held nebulizers. Particle size less than 2 um are too small to be therapeutic.

Particles smaller than 10 micrograms generally hold their contents well, so the medicine is not likely to be lost upon aeroslization.  (2, page 9)  It's for this reason respiratory medicine can be mixed together in the same solution.

References:

1. Korting, Monika Schafer, editor, "Drug Delivery," 2010, Germany, Springer-Verlag Berlin Heidelberg.  The reference used for this information is Aiche, 1990)  Although a more specific reference would be Whitlaw-Gray, R, and Patterson, H.S., in "Smoke: A Study of Aerial Disperse Systems," (Arnold, London, 1932), 192 pages
2. Kulkarni, Pramod, Paul A. Baron, Klaus Willeke, editors, "Aerosol Measurement: Principles, Techniques and Applications," 3rd edition, 2011, Wiley
3. Elliot, Deborah, Patrick Dunne, "A Guide to Aerosolized Drug Delivery," American Association of Respiratory Care, page 9.  I wrote about this at RT Cave as you can see here. 

1930s: Asthma Nefrin and the Devilbiss Nebulizer

One of the cheaper options for asthmatics during the 1930s was to purchase a DeVilbiss Glass Nebulizer No 40 and use it to inhale epinephrine or another solution.  It came with a rubber bulb syringe. 

Epinephrine (Asthma Nephrine was a brand name) was removed from the glass vial by using a bulb syringe dropper.  Two to three drops were placed into the nebulizer, or as instructed by a physician. 

The directions, per the package insert, for using the inhaler are as follows:

Directions and box for the DeVilbiss Glass Nebulizer Number 40

"This Nebulizer is especially designed for use with 1:1000 Epinephrine solution prescribed in the treatment for asthma.  It produces a vapor free from drops that can be inhaled into the air passages.  Also available for water, oil, or glycerine base solutions where the treatment requires a vapour instead of a spray...

"Grasp the bulb firmly using the fingers against the palm of the hand, rather than two or three fingers against the thumb.  Keeping the mouth wide open, place throat tube (A) just inside the teeth and direct it toward the back of the throat.  Inhale deeply while compressing the bulb.  

"If less volume is required cover the vent hold (B) with a finger or the stopper.  After using nebulzer, always replace both stoppers to prevent any possible entry of dust or dirt."

Asthma-Nefrin

The instructions recommended washing the nebulizer with a water solution with vinegar in it.  This was the same instructions I was given for my plastic nebulizer in 1985, although the new recommendation is just to use soap and water. Although it would never hurt to use vinegar.

Epinephrine solution (Epinephrine Chloride, Asthma Nefrin)  was a nice option until 1972 when the FDA removed the solution from the market due to a scare that the medicine was linked to asthma related deaths. 

However, the FDA also noted that there was no specific evidence linking asthma nefrin with asthma deaths. 



The Devilbiss Nebulizer remained on the market until the 1950s when the modern inhaler was invented. 

1910: Hiram Maxim Pipe of Peace

Sir Hiram Maxum (1840-1916) (2)

Sir Hiram Maxim (1840-1916) became famous for inventing a killing machine, and then he was ridiculed for inventing a life saving machine.  The killing machine was the Maxim gun, the first machine gun, capable of firing 160 times in one minute.  The other was a breathing machine used by people suffering from respiratory diseases, including asthma, catahrr, hay fever, emphysema, etc.

In his 1915 book, "My Life," he tells his own story:

I think it was about the year 1900 that I had a very severe attack of bronchitis. First, we had the family physician; then he called in two experts on throat troubles; but they did me no good. They recommended, however, that I should go to Bournemouth and put myself under the treatment of a noted specialist. It was a failure. I returned to London and consulted the greatest specialist on throat troubles in England, and a few days later he sent me about half a ton of stoneware bottles containing mineral water. I took some of the water and followed the treatment for a time without the least effect. I was then recommended to go to Mont Dore, where they have strong and hot mineral springs and there are many doctors who make a speciality of treating bronchitis. I submitted to a very long system of steaming and boiling and taking the waters with no effect. I next learned that at Royat, not far distant, there was an English physician who was supposed to be the greatest expert on throat troubles in France. After he had been working on me about three weeks he said: "There remains only one thing for you to do, and that is to go to Nice and go through a system of treatment at Vos' Inhalatorium."

The Maxim inhaler and his "calming concoction" Dirogo (5)

I spent the next winter at Nice and was much gratified to find that I was greatly benefited by the treatment. It was very long and very severe. Every day I had to inhale an hour at a time; but the bronchitis had disappeared completely by the beginning of April, when I returned to England. However, with the cold and foggy weather of the next autumn the trouble returned as bad as ever; so again I went to Nice and went under the treatment. While there I heard a great deal of discussion regarding throat troubles—generally in the French language. Mr. Vos became very much interested in my case, perhaps more so on account of the comic sketches that I made for him, some of which greatly amused the Russian Grand Dukes who were his patients. At any rate I made a point of learning all that could be learned about the treatment of bronchitis before I left Nice, and the next season, when the trouble commenced again, I bought some glass tubing and made a few glass inhalers myself. By making a mouthpiece of such a shape that the vapours were introduced directly into the throat instead of medicating the inside of the mouth I found that my simple device was much more effective than the very elaborate machinery of Mr. Vos.

When I became fully satisfied that my apparatus would ward off bronchitis, I gave a few away, and they all did very well indeed. The next move was to get two hundred of them made by a glass-blower, and these I also gave away, with splendid results. This created a demand, and I placed the sale of the instruments with the eminent firm of John Morgan Richards and Sons, of London, since which time hundreds of thousands have been sold and have given entire satisfaction.

A short time ago, while returning from the seaside, I found myself in a first-class compartment with a distinguished-looking gentleman. He asked me if I were not Sir Hiram Maxim, and upon telling him that I was he gave me his own name, which I recognized as being one of the most eminent of the Harley Street physicians.

He said: "I have tried your inhaling apparatus with very good results; it is a splendid thing; I recommend it to all my patients who have throat troubles. You have prevented an immense amount of suffering in the world and you ought to be very proud of it."

This is the way that one of the greatest physicians in the world looked at the subject, but some of my friends not altogether unconnected with the gun business have told me that I have ruined my reputation absolutely by making a medical inhaler, and a scientific friend has written me deploring the fact that one so eminent in science as myself should descend to "prostituting my talents on quack nostrums." However, this little inhaler enables me to live all winter in England and large numbers are now being sold all over the world. So I think I shall be able to withstand the disgrace of having brought out such an invention.

From the foregoing it will be seen that it is a very creditable thing to invent a killing machine, and nothing less than a disgrace to invent an apparatus to prevent human suffering.

It is a curious and interesting fact that one of the gentlemen who has ridiculed me the most recommends these inhalers to his friends and always takes one with him when travelling.

While at Nice I learned that the inhalants could be taken very much stronger if a small quantity of cocaine were used, but as cocaine was regarded as a poison, it was not expedient to use it. I spent my boyhood in the State of Maine, where there is a little plant which, although it is used for flavouring confectionery, really benumbs the mouth and throat just as cocaine does, only in a less degree. By mixing a small quantity of the oil of this plant with pine essence, the vapours may be inhaled very strong without producing coughing, and this little discovery is one of the things that has made the inhalers such a remarkable success.

I suppose I shall have to stand the disgrace which is said to be sufficiently great to wipe out all the credit that I might have had for inventing killing machines. (1)

Sir Hiram Maxim's Pipe of Peace and Maxim Inhaler (3)

He patented his inhaler in 1909 and it "resembled a glass retort and delivered menthol and evergreen essence." (4, page 67)

The medicine was prepared by John Morgan Richards and Sons Ltd., in London. (6) The medicine was referred to as Drigo, and a few drops of it were dipped into warm water in the inhaler reservoir.

Maxum also wrote a book about asthma, and how you can treat your disease in the comfort of your own home without any medicine. In his book he also introduced the world to his new invention, the Pipe of Peace. It was marketed for "relief of all affections of the nose, throat, bronchial tubes, and lungs," according to a 1910 advertisement in the Tribune Almanac and Political Register. (2)

The ad states that "nothing can be more economical or effectual than the Maxum System of Treatment -- Direct Inhalation -- which conveys the vapour direct to the spot where it is needed. It is, in fact, natures cure carried by a clever device to the very part affected, thereby enabling all sufferers to obtain immediate relief."

The ad states the book should be in the hands of all who suffer from respiratory ailments. It recommends you send a letter to the address provided to enter for a chance to receive one of 10,000 free copies of the book. To view the ad you can click here. A picture of the doctor is included in the ad, probably to ad credibility to the product.

According to The Science Museum, a few hundred thousand were sold in the first decade after it was invented. (5) This inhaler is also considered the first combination inhaler.*

*A combination inhaler is any inhaler that allows you to take a combination of medicines, or more than one medicine, at the same time. Modern examples of combination inhalers are Advair, Symbicort, Dulera and Breo, each allowing the patient to inhale a long acting beta adrenergic and an inhaled steroid at the same time. There will be more on this as we enter the end of the 19th century in this history.

References:

1. Maxum, Sir Hiram, "My Life," 1915, New York, McBride, Nast and Company, pages 313-315.  
2. This information is from an ad for the Hhiram Maxum Pipe of Peace from the Tribune Almanac and Political Register, 1910, page 774, edited by Horace Greely, Tribune Association.  The photo of Maxum is compliments of the ad, and even more so compliments of Google Books for providing access to this and other material to which the copy write has expired.  
3. The picture was taken from a really nice website about the life of Sir Hiram Maxum, Browninmgcom, "http://browningmgs.com/Maxim/Maxim-Vickers.htm, accessded 10/10/12
4. Smyth, Hugh D.C. Smyth, Anthony J. Hickey, "Controlled Drug Delivery," 2011, London, Springer, page 67
5. "Sir Hiram Maxim's 'Pipe of Peace' bronchial inhaler, 1909-1910," Science Museum/Science & Society Picture Library, image number 10324710, http://www.sciencemuseum.org.uk/images/I057/10324710.aspx, accessed 10/10/12
6. "Sir Hiram Maxim's 'Pipe of Peace' bronchial inhaler, 1909-1910," Science Museum/Science & Society Picture Library, Inventory number1981-982 , http://www.sciencemuseum.org.uk/images/I057/10324710.aspx, accessed 10/10/12, the inhaler is currently on display in: Making the Modern World.  

For further reading on Sir Hiram Maxim refer to:

1. Brown, Malcolme, "100 Years of Maxim's 'Killing Machines,'" The New York Times, November 26, 1985
2. Science Museum and Society Picture Library,

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:

---

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.

---

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

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

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

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, 

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