Foot pump nebulizer still on market today

This is a foot pump nebulizer I found at an online store.
It's still on sale for $10. 

I also moderate Facebook pages. On one page I moderate was a discussion on nebulizers. A fellow asthmatic said she used to have a foot pump nebulizer.

Here is her her comment:

"My very first portable nebuliser was a totally useless foot pump affair! I couldn't do it myself because of the effort it took, and because it was foot pump powered it was impossible to get a constant and steady stream with anyone else doing it, plus they would tire quickly. Ixve no idea how it ever came to be on the market, such was it's uselessness, but it was my father's idea of a cost-cutting purchase without any appreciation of what it needed to be used for. I'm certain it's not what the doctor had in mind when they said we needed to get me a home nebuliser. That was back in the late 1980s, maybe 1988 or so."

I do know that there were foot pump nebulizers back in the 19th century. But this was back when there was no electricity. Between 1900 and 1930 there were squeeze bulb operated nebulizers. These were usually used to deliver a low dose of epinephrine. So, it was surprising to see that these types of nebs were sold in the 1980s.

Interestingly, I did a Google search for "foot pump nebulizer, 1980s" and one popped up in the search. A sketchy site I wouldn't recommend clicking on. But, I wonder if those would be good for 3rd world countries where there's no power and no access to inhalers.

The problem with the rubber squeeze bulb nebulziers is they were hard to operate. You could squeeze and squeeze and you only got a tiny bit of mist. I imagine the foot nebulizers may have been a step up from that. Still, they weren't very helpful.

I know this because I got a rubber bulb to attach to the bottom of my first nebulizer. This was in 1985. Sometimes I would play with this. I'd attach it to the bottom of the cup and squeeze, squeeze, squeeze.

As noted above, just a minor mist was ejected. I couldn't imagine using this to end an asthma attack. It would take forever. But, if it's all you had, then maybe you would make do.

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. 

1930: Pneumostat, the first electric nebulizer

Pneumostat in use (2)

While a variety of steam inhalers were available in 1850, it was learned that the best way of getting medication to the lungs was not by steam but by mist. Between the 1850s and 1930 there were a ton of inhaler and nebulizer devises made, but none were ideal.

The problem with these early mist producing inhalers was that they required manpower to create the flow needed to create the mist. As with other industries, the ability to control electricity changed everything. Marketers soon started playing with the idea of creating an electric nebulizer.  

The first one to enter the market was produced by Weil in Frankfort.
It was a compact unit, meaning it was a combination compressor and nebulizer.  The comperssor created the electricity that created the flow to turn the solution of water and medicine to a mist. 

According to "Hugh Smyth, in his book, "Controlled Pulmonary Drug Delivery," it was a "110-120 volt machine was supplied in UK by Riddle to nebulize bronchovydrin (papaverine and eumydrine)."   (1, page 68)

Pneumostat (2)

Bronchovydrin also had adrenaline (epinephrine) and atropine in it.  It was a solution used to provide quick relief of an asthma attack.  I really had a hard time finding any other information on it, although it was used by lifelong asthmatic Harold Beck.

The electric nebulizer of the 1930s was epensive, so the physician may prefer to have the patient use a nebulizer where the flow is generated by hand power, like it was prior to the electric device.  One option would be the Adrenaline Inhaler or the Devilbiss No. 40 Glass Nebulizer.

Considering the bulkiness and cost of this machine, it was common for a pharmacist to own one, and for patients in need to visit that pharmacist. (3)

References:

1. Smyth, Hugh D.C., "Controlled Pulmonary Drug Delivery," 
2. Sanders, Mark, "Pneumostat," Inhalatorium.com, page 131, http://www.inhalatorium.com/page131.html
3. Nickander, K, Mark Sanders, "The early evolution of nebulizers," MedicaMundi, 2010, 54/3, pages 47-53

Additional reading and viewing:

1. 'Pneumostat' inhaler, London, England, 1934-1935
2. Therapeutic inhaler, London, England, 1935-1942

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. 

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

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

1870: The Eclectic Inhaler

The Eclectic Inhaler (3, page 181)

Along with the Nelson inhaler, there were various other inhalers supplied by the S. Maw and Son allowing people to inhale medicated vapors.  One such inhaler was the Eclectic Inhaler.

It was long recognized by the medical profession that the inhalation of moist air would benefit people with breathing difficulty, but also the inhalation of medication inhaled with the moist air.  The eclectic inhaler was another such inhaler device that allowed for the inhalation of medicated steam.   (1, page 64)

Dr. Morell Mackenzie directed the production of the inhaler and recommended its use in his 1865 book "Use of the laryngoscope in diseases of the nose and throat" and an 1881 book he edited "The Pharmacopoeia of the Hospital for Diseases of the Throat and Chest."

Figure 2 -- Diagram of Eclectic Inhaler (1, page 64)

In the Pharmacopoeia he described the simplicity as to how the product worked (refer to figure 2).

a.  An open vase that contains the boiling water and the medicine.  It is shown in figure 2 A filled to the black line, which is about a pint of water.  Above the black line is a space for moist hot air. (1, pages 65-66)

b.  A lid resembling an inverted tumbler.  When the patient inhales air is drawn in from holes in the lid, over the surface of the hot water, and up an opening to the mouthpiece, as you can see by the course of the arrows.  An opening in the lid allows for the insertion of a thermometer to make sure the water is the desired temperature. (1, pages 65-66)

c.  This is a stand on which the vase rests.  It is made hollow with an opening to allow easy insertion of a heated lamp.  (1, pages 65-66)

Using it was as easy as removing the lid, pouring in boiling water to the black line, adding cold water to make the water an ideal temperature for inhalation, pouring off excess water until it reaches black line again, adding volatile medicine, replacing the lid, placing a heated lamp into an opening under the vase, inhaling the medicated water. (1, page 66)

For treatments lasting longer than six minutes, a spirit lamp may be used in place of the heated lamp.  (1, page 66)

When used properly, a bubbling noise will be heard while inhaling.  The benefits of inhaling the medicated vapor should be soon received.  (1, page 66)

As an additional warning, the authors of the encyclopedia add:

Inhalations should, as a rule, be used before meals, and not more than six inspirations should be taken in a minute. In order to avoid catching cold, the patient should not go out of doors for half an hour after inhaling. (1, page 67)

The product was distributed by S. Maw and Son, the same distributors of the Improved Nelson Inhaler and the Earthenware Inhaler. The company paid for a full page ad in the December 24, 1870, edition of the British Medical Journal in which it advertised all three products. 

Included as part of that ad was a description of the eclectic inhaler, which was described and recommended by Dr. Morell Mackenzie in his 1871 book "Laryngoscope."

BULLOCK AND REYNOLDS' ECLECTIC INHALER AS RECOMMENDED BY DR. MORRELL MACKENZIE Physician for the hospital for Disease of the Throat; and assistant physician to the London Hospital... This apparatus can be used for all medicated vapours, and may be employed from all positions of the patient. It requires no effort on inspiration, insures the thorough medication, of the vapour, and accurately maintains the temperature desired... S. MAW, SON, AND THOMPSON... (2, see ads between pages 673 and 673)

The ad further noted an additional charge for thermometer, heated lamp, and spirit lamp.

There was also a brief review of the Eclectic Inhaler in the July 16, 1870 edition of the British Medical Journal:  

INVENTIONS, &c., IN MEDICINE, SURGERY, DIETETICS, AND THE ALLIED SCIENCES... A NEW INHALER... Messes. Maw & Son have supplied us with a description of Dr. Morrell Mackenzie's new "Eclectic Inhaler." It is believed that this apparatus combines, in a manner hitherto unattained, the qualities necessary for a perfect inhaler. It holds a considerable quantity of water, and has a large chamber for mixed air and medicated vapour; it can be kept at a nearly uniform temperature for a considerable time; it's use requires but little effort on the part of the patient, and it may be employed either in the sitting or incumbent posture... The inhaler will probably be exhibited at the annual meeting of the Association, when members will, no doubt, be able to inspect it. (2, page 67)

It was a good inhaler for its time, and if you were a patient of Dr. Morell Mackenzie, chances are it was the inhaler he recommended to treat your difficult breathing.

References:

1. Mackenzie, Morell, editor, "The Pharmacopoeia of the Hospital for Diseases of the Throat and Chest," 4th edition, 1881, Philadelphia, Plesley Blakiston
2. Hart, Ernest, editor, "Maw's double valved earthenware inhaler," British Medical Journal, The Journal of the British Medical Association, volume II, July-December, 1870, (December 24, page 672 of this publication)
3. Sanders, Mark, "Inhalatorium.com," Eclectic Inhaler, page 181, 

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1869: Lewin's Inhaler

Mathieu's Nephogene (from Lewin) (2)

There were many problems with the Nephogene (nebulizer) created by Mathieu.  The greatest concern was that the spray produced was so forceful most of the mist created pounded into the oral cavity and produced a cough, according to Jacob Cohen in his book "Inhalation: its therapeutics and practice."

This made it certain little of the spray made it to the lungs.  Of course Cohen made sure to mention that this device was not first devised to deliver respiratory medicine, but to spray medicines on any part of the body.  

The person to fine tune the device to make it more appropriate for the inhalation of respiratory medications was Lewin of Berlin.  Cohen described the device as such: (1, page 190)

Lewin, of Berlin, has constructed an apparatus with an ordinary suction pump (syringe) which forces the liquid into a reservoir, the air within which is thus compressed, and in its turn becomes a propelling force, driving the fluid, on the opening of a valve, out of a very fine aperture, whence it impinges on a convex button, and becomes thus broken into spray. This apparatus once set in action will continue to work for a considerable time without further pumping. (1, page 190)

Lewin's glass nebulizer (1)

Yet another problem with inhalers prior to Lewin was that they were all mostly made of medal.  This meant that certain medicines couldn't be used if they interacted with metal. Lewin aimed to correct this problem by using a "strong glass reservoir" instead of metal." It was also graduated with markers so the operator knew how much water to put into it.   (1, pages 194, 195)

It was covered by a "strong metal cap with three openings: one for the introduction of the liquid and the subsequent attachment of the condensing syringe; one affords exit to the capillary extremity of a slender tube which reaches to the bottom of the glass; and the third is covered by a spring safety-valve, through which the compressed air may escape after a certain pressure has been produced."  (see figure 19) (1, pages 194, 195)

To work it a "finger is placed upon the capillary extremity of the exit-tube until the air in the reservoir has been sufficiently compressed by a few strokes of the piston, when the finger is removed, and the fluid rushes out with great force and breaks upon a gilded metallic convex button secured in a glass drum, perforated to admit the stream, and attached by a support to the side of the instrument. The drum is not furnished with a waste-pipe, but is so inclined that the excess of fluid will flow over its edge into any convenient receptacle." (1, pages 194, 195)

So there were various advancements made by Lewin both to his nebulizer and to that of Mathieu's.  Yet his most significant contribution was the use of material that wouldn't react with the medicine that might be used in it.

Yet tthere were still flaws with it. It was made of glass.  It was bulky.  It was expensive.

Either way, these nebulizers provided another option for physicians and patient. They were also another step in the evolution of nebulizer therapy.  (1, pages 194, 195)

References:

1. Cohen, Jacob Solis, "Inhalation in the treatment of disease: it's therapeutics and practice," 1876, Philadelphia, Lindsay and Blakiston, part II, "Inhalation of nebulized fluids, or sprays:  nebulized medicaments and the apparatus for their production," pages 184-212

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1867: The four best nebulizers

By 1867 there was quite a selection of nebulizers to choose from. Dr. John Stutter described four of the most significant ones in his 1867 book "On the use of medicated inhalations in the treatment of respiratory organ."  

The four nebulizers were as follows:  (see 1, pages 26-36):

Elsberg's Nebulizer

1.  Elsberg's Nebulizer:  "The simplest instrument is that known as "Elsberg's Nebulizer," Stutter said, which consists of two hard rubber tubes pointed at the extremities, the openings being small, and so hinged that they can be placed at right angles, the openings being immediately opposite, as in Fig. 3. One arm of the apparatus being placed in the medicated fluid, blowing through the other causes the fluid to rise in the tube, and it is carried off" in a fine spray. Rimmel's Rafraichisseur, which is the same in principle, has been employed for some years for distributing perfumes, and may be purchased quite cheap. The principal objection to this method is, that it requires a second party, and the breath cannot but prove offensive to many patients."

Sales-Giron's Nebulizer

2.  Sales-Giron Nebulizer:  "The second form of apparatus consists of a cylinder in which works an air tight piston, like the barrel of a syringe," said Stutter.  "Fluid being placed in it, is forced through minute openings in the nozzle, as a delicate spray.  Fig. 4, represents the instrument of M. Sales Giron, which I have used in my practice with excellent results. When inhalations are much used, I have no doubt they will be manufactured by our hard rubber manufacturers, at a price to bring them within the reach of all"  This nebulizer required lots of work to get a mist, and sometimes may have required two people if the person needing the medicine was too sick.  For this reason it probably wasn't very marketable.  This nebulizer was often listed as the first nebulizer, and for that reason I wrote about it in greater detail here.

3.   Dr. Mackenzie's Nebulizer:  "The apparatus (called the eclectic inhaler) of Dr. Mackenzie," said Dr. Stutter, "is a very good one. The piston is drawn back by a wheel and rack at its upper part, and is forced down by a circular spring which surrounds the cylinder. The apparatus is filled with liquid by a funnel in its top, and all the spray, except that which is inhaled, passes back into the apparatus. He claims the following advantages for  it:  1. Its simplicity, requiring only a few turns of a handle to set it in operation. 2. The extremely fine state of subdivision which it effects. 3. The uniform pressure exerted. 4. The fact that the Waste liquid returns into the apparatus. 5. The ease with which it can be taken to pieces and cleaned."  (no picture available in Dr. Stutter's book, although I wrote about the inhaler here.  I will write about Dr. Mackenzie in an upcoming post.)

Dr. Seigle's Inhaler

4.  Dr. Seigle's Inhaler:  "The third form of apparatus is that of Dr. Seigle, and is preferable to the others, for its simplicity and because it is automatic. The best reason for preferring it, however, is, that its price is such as to bring it within the means of any patient, as it is furnished through the druggists for $5,00, and its construction is so simple, that it is readily operated by any one."  The inhaler (or nebulizer) was designed so that steam delivered the medicine to the patient, so that no assistance, nor cranking, was needed.  I describe this inhaler in more detail here.

So while there were many varieties of mist inhalers, these were your basic nebulizers of this era, at least according to Dr. Stutter.  This was basically what you had to deal with until the 1930s when electricity became available. It was either one of these or inhaling smoke, which was another common remedy for difficult breathing.

References:

1. Scudder, John Milton, " On the use of medicated Inhalations in the treatment of diseases of the respiratory organs," 1867, Cincinnati, 2nd edition, Moor, Wilstach, and Baldwin
2. Wyka, Kenneth A., Paul Joseph Mathews, William F. Clark, "Foundations of Respiratory Care,"

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