1931: The Emerson Respirator

His father worked as Commissioner of Health in New York during the polio epidemic of 1916, and perhaps as a result of this inventor John Haven Emerson (1906-1997) had a recollection of suffering from the illness as a child.  So he had a vested interest in inventing a mechanical respirator that was more efficient and more comfortable than the Drinker and Shaw Respirator.  He ultimately refined the Drinker and Shaw Respirator and came up with his own product that became the Emerson Respirator.

Like the Dinker and Shaw Respirator, the patient would lie on a table that could be slid in and out of the tank.  The table was often referred to as a cookie tray.  The side of the tank, which was blue, had portal windows so nurses could have access to the patient whenever they needed.  Over the patient's head was a mirror they could see behind then. The bellows were stored under the tank, which was lightweight, and wheels were added to make the devices mobile. (1)

The machine could also produce a large range of tidal volumes by adjusting the pump settings, and it was relatively quiet (a noted improvement over the Drinker Respirator).  In the event of power failure there was a hand crank at the foot end of the device so the doctor or nurse (or later the inhalation therapist) could provide breaths manually. It was also simple to produce, which made it affordable.   It was said to be about half the cost of the Drinker Respirator.   Emerson's design still cost as much as a house, yet it was still somewhat reasonable, or about half the cost of other such respirators at the time. (see chart below) (2)

Emerson introduced his iron lung during a polio epidemic in 1931, and it soon became the most popular respirator in hospitals in Europe and the U.S.  Emerson's respirators continued to be the most used ventilator until  the 1950s and 60s when the Jonas Salk and Albert Sabin polio vaccine became available for kids around the world.  The vaccine was first introduced in 1954, and injected into millions of kids between 1956 and 1960 "with dramatic results." An oral vaccine was later introduced and administered to millions of kids between 1962 and 1964. (3)

There were various versions of the Emerson Lung, and the Drinker and Shaw Respirator, that were available in hospitals around the United States and Europe.  Richard Daggett, in his 2010 book "Not just polio: my life," explains that the machines made a whooshing sound as air entered and exited the patient's lungs. He explained that he was placed in a Drinker Collins Iron Lung in the early 1950s, and he described waking up in the machine: (4, page 30, 31)

There was a mirror over my head and, in the mirror, I could see a row of large black bellows across the room.  They were going up and down.  I didn't know much about respirators, but I figured one of them must be making me breathe.  I tried to figure which one it was by timing my breathing with the motion of each bellows.  None of them seemed to match my breathing pattern. It wasn't until later in the day, when my mirror was adjusted upward, that I realized that those bellows were all attached to the underside of other respirators.  I couldn't see mine because it was beneath me.... I was in a Drinker Collins Iron Lung."  (4, page 29)

Daggett explains that as a child it was difficult to grasp the seriousness of having bulbospinal polio and, ultimately, pneumonia.  He wrote: "I was very naive. I had no understanding of how serious my condition was.  Oh, I knew I was completely paralyzed, but the long-term impact did not sink in.  My greatest concern was that I might miss the first day of school." (4, page 33)

It must have been common for these patients to develop pneumonia, as their would have been constant secretions forming in the upper air passages that needed to be cleared, or they would be inhaled, thus causing respiratory infections such as pneumonia.  Daggett mentions the constant urge to blow his nose, which he often did "without even using a tissue." (4, page 31, 33)

Because their muscles of respiration would have been paralyzed, these patients would have lacked the ability to clear their own secretions. So, despite having the means of breathing for them, some of these patients still drowned in their own secretions. Others developed pneumonia, and this this further complicated treatment. So keeping airways clear of secretions was a constant concern for caregivers. This made it important to have easy access to these patients.

Yet bulky iron lungs made it hard to access patients. Their bed had to be slid out from inside the tank, and artificial breaths performed manually. One person had to turn the patient, while another cleared secretions.

This problem was remedied somewhat with the invention of a suction device in 1937.  Daggett said he had a tracheotomy that gave caregivers an easy means of clearing his airway. This may have been aided by an early suction device. (4, page 30)

Iron lungs were viewed as neat life saving devices. Yet they were also viewed as horrible way to spend the rest of your life. Thankfully, for most of those kids inflicted with polio, the paralyzation was only temporary, with most recovering after spending a week or  two inside a tank. Many, like Dagget, lived to tell their stories.

Iron lungs were replaced during the 1950s by positive pressure breathing machines. This was a necessary change because it made it easier to access patients. This also made it easier to breathe for patients during operations and in emergency situations. Still, during an era when many children were inflicted with a paralyzing disease, the iron lung was a godsend.

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Here are some interesting facts about iron lungs from http://americanhistory.si.edu/ :

1. The National Foundation of Infantile Paralysis began mass distribution of tank respirators in 1939
2. In the 1930s, an iron lung cost about $1,500  -- the average price of a home
3. 1n 1959 there were 1,200 people using tank respirators in the U.S., in 2004 there were 39

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References

1. "The Iron Lung and Other Equipment,"  http://americanhistory.si.edu/,  http://americanhistory.si.edu/polio/howpolio/ironlung.htm, accessed February 27, 2012
2. Previtera, Joseph, "Negative Pressure Ventilation: Operating Procedure (Iron Lung)," Tufts Medical Center, Respirator Care Programs, http://160.109.101.132/respcare/npv.htm, and http://160.109.101.132/respcare/ironlung.htm, accessed February 27, 2012
3. "Emerson Infant Respirator," Case Western Reserve University, Ditrick Medical History Center,  http://www.neonatology.org/pdf/EmersonInfantRespirator.pdf, accessed February, 27, 2012
4. Daggett, Richard Lloyd, "Not just polio: my life story," 2010, Bloomington, IN, iUniverse
5. Drinker, Charles, Charles F. McKhann, "The Use of a New Apparatus for the Prolonged Administration of Artificial Respiration: A Fatal Case of Poliomyelitis," Journal of the American Medical Association,  May 18, 1929, reprinted in same publication on March 21, 1986, volume 255, no. 11, pages 1473-1475 
6. Drinker, Phillip A., Charles F. McKhann, "The iron lung: first practical means of respiratory support,"  Journal of the American Medical Association, 1986, March 21, vol. 255, no. 11,, pages 1476-1480

1929: The Drinker Respirator

A clipping from a newspaper article, probably sometime around 1928.
Photo form the University of Virginia Historical Collections. Photo
originally published in "The use of a new aparatus for the prolonged
administration of artificial respiration" by Phillip Drinker and Charles
F. McKhann. (1, Iron Lung)

The first effective ventilator that gave breaths without an operator was the Drinker Respirator by engineer Phillip Drinker (1894-1972).  The product was  introduced to the world in a 1929 article by Dr. Phillip Drinker and Dr. Charles F. McKhann. (1, Iron Lung)(4)

The report highlighted the fact that manual resuscitators (such as the lungmotor or pulmotor) forced too much air into the lungs too fast, and could only be used for so long due to worker fatigue. Plus, they wrote that "respiratory excursion obtainable by manual efforts is most disappointing. In our experience, it is almost impossible to produce and maintain adequate oxygen interchange by manual methods of artificial respiration alone, in cases requiring long term administration." (4, page 1658)

Their solution was the Drinker Respirator.  It was the first mass producible negative pressure ventilator, otherwise known as the iron lung, mechanical respirator, or tank respirator.

Image of the Drinker Iron Lung.  You can see the marine like port
holes on the sides of the tank that could be used to see the patient.
Small holes could be accessed for basic toughing. (5, page 232)

This respirator is often referred to as the Drinker and Shaw respirator because Phillip Drinker worked with his brother Cecil and Dr. Louis Shaw to create and test the device. The Consolidated Gas Company of New York came up with the idea and recruited Harvard Professor Cecil Drinker. He in turn recommended his brother, who was a chemical engineer. Dr. Shaw was a colleague of Phillip. (1, Iron Lung)

The final product was first introduced to physicians at Harvard in 1928. Actually, the original name for this respirator was the Drinker Tankrespirator, but the name iron lung is the name that ultimately stuck. No one knows for sure who came up with the term "iron lung." One article cited an "anonymous journalist."

While it was useful for many types of patients (morphine overdose, carbon monoxide poisoning, electric shock, near drowning, etc) it was originally made for those affected by coal gas poisoning.  (7, page 93) Yet it is is most remembered as being associated with the polio epidemics, used to breathe for the many children most severely stricken with the disease infantile poliomyelitis.

The machine consisted of a metal tank that completely enclosed the patient's body except for the head.  The patient would lie on his back on a bed.  The bed would then be slid into the tube or tank.  The neck would be sealed around rubber collars to provide a seal to prevent air from entering or escaping the tank.

Inside the tank was completely air tight.  Pumps, which were originally two vacuum cleaners with bellows, and a manometer used to operate the device, sat on a table next to the tank, and they were operated by electricity and a large bedside oxygen tank.  The rate could be set by adjusting dials on the gearbox.  While there was no means of measuring tidal volume, breaths could be provided at a constant depth and rate. There are reports that the machine was quite noisy, so one must imagine this only compounded the stress of patient.

A patient could live inside one of these tanks for days or weeks without harm.  The patient, since his head was outside the tank, could "adapt themselves quickly to their new method of breathing and learn to eat, drink and sleep without having the attendant stop the machine." (6, page 95)

To examine, treat, and bathe the patient the bed would have to be slid out of the tube.  If necessary, manual methods of ventilation could be used while these procedures were being performed.  (5, page 232)

Image of the Drinker Respirator.  You can see that the pumps
and manometer were on a separate table to the left.  To access the
patient, the bed was slid out as shown. While outside the tank
the patient could be kept alive with manual methods of respiraiton
if necessary. As you can see, maintaining the tanks and
caring for the patient was a cumbersome task.   (5, page 231)

For less invasive procedures, such as taking temperatures, blood pressures, auscultation, checking IV lines, and basic touching of the patient, there were "small holes (pipe taps) on the sides of the tank.  For the basic observation of the patient there were "marine like port holes' also on the sides of the tank.  (5, page 234)

Here you can see the rubber collar that secures
tightly around the patients neck so that the
head could rest outside the tank on the
adjustable support.  (5, page 233)

Over time the iron lung was improved in order to make the machines more accessible to patient care, and to make the machines easier to operate and move from one room to another.  For example, by the 1950s the pumps and bellows would set under the tank to make the unit more compact, and wheels were added to the legs.  Of course another reason this was probably done was to keep up with the competition.  

The Drinker Respirator was ideal because it allowed physicians an opportunity to keep their patients alive long enough to treat them, thus allowing their bodies a chance to recover.  While the machines were ideal for victims of all ages, they were most remembered as being used for the many children stricken with the most severe forms of infantile poliomyelitis, which causes respiratory paralysis. Without the ventilator these kids would often succumb to fatigue, respiratory failure, and ultimately death.

While the devices may have been cumbersome, uncomfortable and noisy:

"The response of these patients to the respirator was very gratifying," according to a 1931 article in the Western Journal of Medicine.  "Usually before their condition became alarming they were told that if they became too fatigued they could have the help of the respirator, and in several instances patients asked to be placed in the machines for a trial.  A few of the children were very apprehensive and had to be given opiates over a short period when first placed on the respirator.  None of these patients had any difficulty in adapting themselves to the rhythm of the machine."  (2, page 5)

Many children with poliomyelitis recovered after a week or two in the iron lung, and went on to live normal lives. .  

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The Technical Exposition:  Opportunity to try the Dinker Respirator:  Warren E. Collins Inc. will exhibit the Dinker Respirator, for prolonged administration of artificial respiration in cases of infantile and diptheretic paralysis, gas and drug poisoning, electric shock, alcoholic, coma, etc.  Doctors are invited to make a personal trial of the Respirator to see how it feels. New improvements on the Roth-Barach oxygen tent and the Benedict-Roth Metabolism Apparatus will also be of interest, and demonstrations will be gladly given without obligation.  See these in Booth 110, near the main entrance.  (3, page 1617)

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References:

1. "Iron Lung: 1929 Dinker Respirator," University of Virginia Historical Collections at the Claude Moore Health Sciences Library,"  http://historical.hsl.virginia.edu/ironlung/pg4.cfm, accessed February 26, 2012
2. Shaw, E.B.,  H. E. Thelander, and M. A. Limper, "Respiratory Failure in PolioMyelitus -- it's treatment and the Dinker Respirator," Western Journal of Medicine, 1931 July; 35(1), pages 5–7
3. "The technical exposition," Journal of the American Medical Association,  1931, vol. 96, no. 19, page 1617, http://jama.ama-assn.org/content/96/19/1615.full.pdf
4. Drinker, Charles, Charles F. McKhann, "The Use of a New Apparatus for the Prolonged Administration of Artificial Respiration: A Fatal Case of Poliomyelitis," Journal of the American Medical Association,  May 18, 1929, reprinted in same publication on March 21, 1986, volume 255, no. 11, pages 1473-1475; 
5. Drinker, Phillip, Louis Shaw, "An apparatus for the prolonged administration of artificial respiration,"  Journal of Clinical Investigation, June 29, 1929, 7 (2), pages 229-247
6. "Philip Drinker '15 given medal of invention," The Princeton Alumni Weekly, October 23, 1931, volume 32, page 95
7. "Obituaries: Phillip Drinker 1894-1972," Anal of Occupational Hygiene, 1973, 16 (1), pages 93-94
8. truy this one or this one or htis one. or htis one 'list of landmark articles,            check out this presentation