1866: Catologue of stethoscopes

Check out these stethoscopes from the a physician's catalog of S. May and Son from 1866. Keep in mind these are not actual size.:

Reference:

1. S. Maw and Son, Manufacturer of respiratory equipment, "A catalogue of surgeon's instruments, air and water beds, pillows, and cushions, bandages, trusses, elastic stockings, inhalers, galvanic apparatus, and other appliances used by the medical profession," 1866, London, 11 Aldersgate St., Buttler and Tanner, The Selwood Printing Works, page 127-8

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1865: Dr. See supports diaphragmatic theory of asthma

Germain See (1818-1896) was a German physician wrote several articles on asthma and other lungs diseases in the various medical publications of his era, and he is referenced more than once in this asthma history.  It is obvious, that through his writings, he was well acquainted with respiratory disease, including our asthma.

In 1865 he gave his support to the ideas of Alton Wintrich and Heinrich Bamberger that asthma was not caused by spasms of the muscular fibres in the lungs, and instead was caused by spasms of the diaphragm. (1, page 5) (2, page 2) 

In his 1890 book, Ernest Shmiegelow said See reviewed all the theories of the day.  He quotes See:

"Asthma is a neurosis in the medulla oblongata, that is to say in the centre of respiration, caused by an acquired or native elevated reflex irritability in this organ. The cause of the attacks must be sought for in irritations, which originate in pneumogastric nerves or other peripheral nerves. The effect of the reflex exhibits itself in the motory nerves of the inspiratory muscles, specially those of the diaphragm. We have, therefore, before us a permanent neurosis, whose attacks are caused by an irritation especially of the pneumogastric nerves, and which is always concluded by a tetaniform contraction of diaphragm, this theory only (in contrast to the bronchial spasm) can explain the dilatation of the lungs... The principal factor in the asthmatic attacks is therefore not (as in the bronchial spasm) a direct motor effect of the pneumogastric nerve, only the sensitive pneumogastric fibres take a part in this respect as they lead the irritation up to the noeud vital of the spine, whence the irritation spreads through the nervi phrenici to the diaphragm. " (1, page 9-10)

Joseph Berkart, in his 1878 book, said See divided asthma into three elements: (2,page 2)

1. Dyspnoea
2. Bronchial exudation
3. Emphysema of the lungs (2, page 2)

See believed asthma was always accompanied by organic lesions, and diseases such as chronic bronchitis and emphysema, but never caused by them. (2, page 37)

While others, such as George Kidd, believed asthma was a symptom of emphysema or chronic bronchitis, See believed it was, according to Berkart: (2, page 37)

...always a substantive disease, accompanied, but never produced by organic lesions. He recognised, however, only one form of it. In his opinion, asthma was essentially a neurosis of the vagus and its branches, and manifested itself by a tetanus of all the respiratory muscles, and by a bronchial exudation. The presence of these two "elements" combined was alone characteristic of the affection, whereas emphysema of the lungs was only their constant attendant. Emphysema, he maintained, was not an essential, but merely the consequence of the inspiratory traction during, and the bronchial exudation after, the attack.

Berkart said a goal of German experts, such as See, was, to...

"...maintain that, to warrant a diagnosis of pure bronchial asthma, the bronchial mucous membrane should appear healthy, nor should any other cause for the dyspnoea be discoverable. Still, not all supporters of this definition adhere to it throughout. They admit that asthma may be complicated 'with' or 'grafted on' other cardiac and pulmonary affections. But, as these affections are themselves capable of producing asthmatic seizures, the distinction in a given case between this symptom and the supposed complication would be purely arbitrary." (2, page 3)

In other words, according to Berkart, pure bronchial asthma was only diagnosed when there were no other scars found upon the lungs or the heart, at least according to the Germans. (2, page 3)

References:

1. Shmiegelow, Ernst, "Asthma, considered specially in relation to nasal disease," 1890, London, H.K. Lewis
2. Berkart, J.B., "On Asthma: It's pathology and treatment," 1878, London, J. & A. Churchill
3. Brown, Orville Harry, "Asthma, presenting an exposition of nonpassive expiration theory," 1917, St. Louis, C.V. Mosby Company; reference used: ee, Germain: Nouv. Diet, de Med. et de Chir. Practiques, 1865, iii, p. 585, pages 36, 89
4. Gee, Samuel, A lecture on permanent asthma, delivered at the Hotel Dieuj, by Prof. Germain See, translated from the Union Medicale, by H. McS. Gamble, "Gailard's Medical Journal," volume 37, edited by Edward Samuel Galliard, 1884, New York

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1864: Alfred Newton's Dry Powdered Inhaler

People have probably inhaled powders of certain dried and crushed herbs for their perceived benefits since the beginning of time.  Yet the first device for assisting with this process was patented in 1864 by Alfred E. Newman.  His device was the first dry powdered inhaler.

The book "Controlled Pulmonary Drug Delivery" describes the inhaler this way:

In 1864 another step forward with dry powder inhalation took place. Alfred E. Newman applied for a patent in London after correspondence with Dr. James in New York.  The dry powder device resembled a mantle clock with an orifice at one side, inside was a mesh and a crank shaft with feathers to beat the powder creating a dust, which would pass through the mesh towards the mouth.  It was not especially portable, but Newton recognized that the powder needed to be pulverized into a fine dust and that it should be kept dry, two essentials of modern dry powder inhalers. The device was designed for the delivery of potassium chlorate which today is recognized as a lung irritant. (1, page 60)

The authors also note that while dry powder inhalation was "in vogue" during the 1860s, it was generally meant to treat diseases of the throat such as laryngitis.  Still, it was a revolutionary concept and a precursor -- albeit large, bulky, un-portable, and probably -- to modern dry powder inhalers.

The device may also have been used for tuberculosis.  (2).

Quality pictures of the device can be observed by checking out either of the links in the references below.

References:

1. Smyth, Hugh D.C., Anthony J. Hickey, editors, "Controlled Pulmonary Delivery," 2011, New York, Springer, page 60-61
2. Sanders, Mark, "Pioneers of Inhalation: Vapour Trails and Powder Monkey," from Inhalatorium.com: Online Museum of inhaler technology, slide show presentation, accessed on 11/13/12

1865: Bamberger supports diaphragmatic theory of asthma

Heinrich von Bamberger (1822-1888)

Heinrich von Bamberger was an Austrian pathologist who provided evidence, similar to Duchenne before him, that he said supported the diaphragmatic theory of asthma.

Born in Prague in 1822, he earned his medical degree in 1847.  He worked as a pathologist at the University of Wurzburg and, beginning in 1872, at the University of Vienna.  (1)

While he wrote two books that were well received by the medical community, including his 1857 book "A Treaties on the Diseases of the Heart," he also published a book for physicians in 1865 sharing his knowledge of asthma called "Ueber Asthma Nervosum."  (1)

He supported the theories of Alton Wintrich, Guillaume Benjamin Amand Duchenne, and Michael Anton Biermer.  Joseph Berkart, in his 1878 book "Asthma: It's Pathology and Treatment," said:

In a case of fatal dyspnoea he had occasion to observe the tetanus of the diaphragm, and to convince himself by post mortem examination, of the absence also of structural lesions. Although the symptoms of that case by no means resembled those usually assigned to asthma, he, nevertheless, regarded them as characteristic of the disease. Reviewing then the theories held on the nature of the affection, he arrived at the conclusion that the presence of the bronchial muscles did not warrant the assumption of a bronchial spasm. If this existed, he would expect to find the diaphragm ascended, the intercostal spaces drawn in, and a dull resonance on percussion; indeed all the physical signs described by Williams and Bergson in conformity with their theory. But, as yet, he had never met with a case presenting those symptoms. So far as his observations went, he had always found dilatation of the thorax and hyper-resonance on percussion. These signs could be accounted for only by assuming a tonic spasm of the diaphragm and the auxiliary muscles of respiration; and he therefore inclined to the opinion of Wintrich, Duchenne, and Valette. (2, page 36-37)

Berkart said Bamberger further divided asthma:

• Central: Nervous asthma that causes tetanus of the diaphragm (he also beleived that paralysis of diaphragm was a cause of asthma, especially in cases of muscular atrophy observed by Duchenne.) (2, page 37)(3, page 7)
• Peripheral: Asthma that accompanies emphysema, bronchitis, pleuritic effusions and tuberculosis (2, page 37)

Other physicians who supported the diaphragmatic theory of asthma were Lehmann, George H. Kidd, and Germain See.  (2, page 37)

So you can see that the diaphragmatic theory of asthma garnished some very respectable support during this era.

References: 

1. "Bamberger, Heinrich von, "The Encyclopedia Americana," 1920, compliments of wikisource, http://en.wikisource.org/wiki/The_Encyclopedia_Americana_(1920)/Bamberger,_Heinrich_von, accessed on 3/6/14
2. Berkart, J.B., "On Asthma: It's pathology and treatment," 1878, London, J. & A. Churchill; Berkart references the following: Ueber Asthma nervosum: Wiirzb. Mediz. Zeitsch., Bd. vi, 1868, p. 102-116.
3. Thorowgood, John Charles, "Notes on Asthma," 1878, 3rd edition, London, J and A Churchill

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1865: Clarks spray Producer

Figure 1

The Bergson tubes became "widely known among English practitioners," and they were used in a variety of products. One physician by the name of Dr. Andrew Clark of London used the tubes to create an inhaler of his own.  (1, page 465)

George Beaston said that Clark wanted to "have an instrument that would give a continuous spray, and with this view he had a pair of Bergson's tubes fitted into the cork of a graduated glass bottle, and had attached to them a double hand bellows with suitable valvular arrangements which allowed of a constant spray being kept up for an indefinite time. This instrument was made for him by Krohne & Sesemann (London surgical equipment producer) in the spring of 1865, and has since been known as Clark's spray producer. It is seen in Fig. 1, and it will be at once recognised as merely an improved edition of Bergson's original idea." (1, page 465-466)

You can see it was a little more compact than the original Bergson Inhaler, although still required some work to obtain a mist -- the squeezing of the bulb. There were various inhalers or nebulizers similar to this design, and you can see them by clicking on the link below.  

References:

1. Beatson, George, "Practical Papers on the Materials of the Antiseptic Method of Treatment," Vol. III, "On Spray Producers," Coats, Joseph, editor, "History of the Origin and Progress of Spray Producers  ", Glasgow Medical Journal, edited for the West of Scotland Medical Association, July to December 1880, Vol. XIV, Alex and Macdougall, pages 461-484

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1865?: Dr. Nelson's inhaler

Nelson Inhaler with glass mouthpiece

By the mid 19th century various methods were invented for the inhalation of medications through steam.  One such device was the Nelson inhaler, which ultimately became one of the most popular inhalation devices.

Spencer Thomson described the inhaler in his 1866 book "A dictionary of domestic medicine and household surgery."  He said:

Dr. Nelson's improved earthenware inhaler, an apparatus for the inhalation of  ether, chloroform, henbane, creosote, vinegar, etc., in affections of the throat and bronchial tubes, asthma, consumption, etc. (6, page lii)

John M. Scudder described it in his 1867 book "On the use of medicated inhalations, in the treatment of diseases of the respiratory organs."  He said:

"The most efficient apparatus for the inhalation either for simple steam or of medicated vapors... It is constructed of earthenware, and, in addition to its complete adaption to the purpose for which it is intended, possesses the triple recommendation of cleanliness, portability, and cheapness." (1, page 22)

The inhaler was manufactured by Maw & Son of Aldersgate St., which was later changed to Maw, Son, and Thompson.  Dr. Nelson's name with directions were on the side of the inhaler.  The inhaler was commonly sold and used for many years, and sold by various manufacturers who made slight adjustments to the design.  (2, page 258)

The Nelson inhaler was called "New and Improved," perhaps because of the unique design and that it was small and relatively portable compared to other inhalers, or tea pots.

Here is a news clip from the February 11, 1865, edition of the Medical Times and Gazette:  (3, page 160)

NEW INVENTIONS

NELSON’S INHALER

We have tried "Dr. Nelson's New Improved Earthenware Inhaler," and believe it to be a cheap and convenient instrument.  It serves both for simple hot water or for hot water medicated with the extracts of soothing plants such as are suitable for acute catarrh and quinsey, as well as for various medicinal substances which are tried in the advanced stages of phthisis, in spaspotic asthma, etc.  The instrument is easily cleaned, and cannot be misused.

Here is a description of the new inhaler from the February 11, 1865, edition of the Lancet. (5)

Diagram of Dr. Nelson's inhaler (5)

NEW INVENTIONS

IN AID OF THE

PRACTICE OF MEDICINE AND SURGERY

DR. NELSON'S IMPROVED EARTHENWARE

INHALER

The utility of topical medication of the air-passages by the inhalation of the vapour of water impregnated with various substances extensively recognised by the profession. The absence of any simple and efficient apparatus for the purpose is often the only reason why the great relief which such applications are capable of affording is withheld from the patient. Medical men will find in the little inhaler of Dr. Nelson, made by S. Maw and Son, a very handy, cheap, simple, and effective apparatus. It answers very well all the purposes for which it is intended, and no hospital or infirmary ought to be without it. Its construction will be seen from the annexed woodcut. The hollow tube at B; and, having replaced the latter, inhale the vapour through the mouth-piece at A, the exhaled breath passing freely through the tube at C. For the inhalation of the vapour of hot water only, or the infusion of stramonium, hops, or other medicinal plants, the sponge in the tube need not be displaced." We recommend it for general adoption
Here is an advertisement from the British Medical Journal, December 17, 1870: (4)

DR. NELSON'S IMPROVED
EARTHENWARE INHALER

Will be found a most efficient Apparatus for the inhalation of Vapour of Hot Water, either alone or impregnated with Ether, Choriform, Henbane, Creosote, Vinegar, etc., in affections of the Throat, and Bronchial Tubes, Asthma, Consumption, etc. 

Price to the trade, 3s 6d each; Retail, 5s 6d.

DESCRIPTIVE HANDBILLS ON APPLICATION

S. MAW, SON, AND THOMPSON

10,11 & 12, ALDERSGATE STREET, LONDON, E.E.

While it's no longer recommended by the medical community, the various versions of the Nelson Inhaler can still be found online.

References:

1. Scudder, John M, "On the use of medicated inhalations, in the treatment of diseases of the respiratory organs," 2nd edition, 1867, Cincinnati, Moorz, Wilstach & Baldwin
2. Bennion, Elisabeth, "Antique Medical Instruments," 1980, California, University of California Press
3. "Medical News: New Inventions: Nelson Inhaler," Medical Times and Gazette: A Journal of Medical Science, Literature, Criticism, and News," February 11, 1865, 2nd edition, London, John Churchill and Sons, page 160
4. Hard, 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)
5. "New inventions in aid of the practice of medicine and surgery:  Dr. Nelson's Improved Earthenware Inhaler," Lancet: The Journal of British and Foreign medicine,"  1865, Volume I, Boston, Boston Medical Library, published by George Fall, ata the office of the "The Lancet" 423 Strand, page 152.  The diagram is also from page 152 of this resource.  
6. Thomson, Spencer, "A dictionary of domestic medicine and household surgery."1866, London, Charles Griffin and Company

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1865: Mackenzie specializes in diseases of throat and chest

Morell Mackenzie (1837-1892)

Dr. Morell Mackenzie was one of the preeminent experts on diseases of the throat during the second half of the 19th century. He would either write or edit various books on diseases of the throat and chest and the best remedies to treat them.

He was born in Leytonstone, Essex, in 1837, and was educated at London Hospital Medical College and in Paris and Vienna.  (4)

He became one of the first experts on the laryngoscope that was invented by Manuel Garcia of Paris.  By using this device he was able to see with the aide of this scope the effects of various diseases on the larynx, pharynx, bronchi, and bronchioles.

In 1862 he opened one of the first hospitals dedicated specifically to diseases of the throat and chest called "Free Dispensary for Diseases of the Throat and Loss of Voice at 5 King Street (later renamed Kingly Street).  (1)

He went on to become assistant physician at the London Hospital, and then full physician.  He was also appointed lecturer on diseases of the throat, an appointment he held for the rest of his life. (4)

The building on Golden Square
as it appeared in 2008,
owned by Clear Media Group

The Dispensary was an instant success, and by 1865 had moved to larger premises (32 Golden Square), to a building that had previously housed the London Homeopathic Hospital from 1851-1856.  The name of the Dispensary was then changed to "The Hospital for Diseases of the Throat."  (1)

This was the first hospital that specialized in diseases of the throat in the United Kingdom, and it was in this year, in 1865, that the hospital took in its first inpatients. (1)

As the number of patients being admitted to the hospital with consumption was steadily increasing, in 1877 the name of the hospital was once again changed to Hospital for Diseases of the Throat and Chest." (1)

Another picture of
the former hospital.

The hospital initially provided free treatment, although eventually a system was established allowing patients to contribute payments based on the their incomes.  (1)

In 1865, Dr. Mackenzie published what he learned about diseases of the throat and chest, and their treatments, in his book "The Use of the Laryngoscope in Diseases of the Throat."  It was in this book that he discussed how directed the invention of the Eclectic Inhaler for the direct application of moist, medicated steam to the throat.

In January of 1887, Prince Frederick III of the German Empire and the Kingdom of Prussia, developed hoarseness that progressively worsened.  Initially German physicians thought this was due to the prince speaking too much, but then it was decided he had a case of catarrh, or the common cold.  (3, page 1)

However,  none of the usual catarrhal symptoms made their appearance, and the usual inhalations to treat catarrh were ineffective.  Because of this, Surgeon General Dr. Wegner and Adolf Bardeleben performed a laryngoscopy on March 6, 1887, where they were able to see a growth between the vocal cords.    (3, page 1)

At first it was thought to be a harmless growth, such as a polyp.  Various treatments were made to remedy the situation, but none of them worked.  At one point the growth had been removed, and then grew back larger than it was before the operation.  It was at this time, in May, 1887, that his physicians decided he had cancer of the throat.  (3, pages 4-6)

In order that he would receive the best treatment, his leading physician requested he be seen by Dr. Mackenzie, who was the leading expert on diseases of the throat at the time.  (1)(2)(3, page 1, 8)

Basing his decision on a biopsy report by German pathologist Rudolf Virchow that showed throat lesions in the prince's throat were not cancerous, and his own examination of the patient's throat, Dr. Mackenzie decided the prince did not have throat cancer after all. This decision was made despite evidence the prince still had throat hoarseness. (1)(2) (3, page 34)

Dr. Mackenzie recommended to the prince's physicians that, instead of rushing the prince to surgery, that it be delayed until further testing was performed. All of the prince's physicians, respecting Dr. Mackenzie's expert consultation, decided to heed his recommendation and delay further treatment.   (3, page 10)

At first this seemed like a good idea, as the treatment offered by Dr. Mackenzie seemed to benefit the prince, who continued to hold the doctor in high regard. In September 1887,  Dr. Morell Mackenzie was held in such high regard at this time that he was knighted by Queen Victoria* for his service to medicine and to prince Frederick.  (4)(2)

A few months later, in November of 1888, as the prince's condition continued to deteriorate, it became quite clear that Dr. Mackenzie was wrong, that the prince actually did have throat cancer. (2)

That same month, after a thorough assessment of the patient, his physicians, which included Dr. Mackenzie, offered the prince the risky option of having surgery to remove the cancerous tumor, and he declined.  He opted, instead, to have a tracheotomy inserted when it might become necessary. (3, page 44)

Emperor Frederick III (1831-1888)
Reign (March 9-June 15, 1888)

In March, 1888, Frederick III became emperor of the German Empire and the Kingdom of Prussia.

By this time it was determined the only operative help was to perform a palliative tracheotomy. (1)(2)(3, page 43-44)

Emperor Frederick III died on June 15, after only 99 days as emperor. He was 56 years old.

A controversy ensued where Dr. Morel Mackenzie was blamed for the emperor's death. He was adamantly criticized by German physicians, and even accused of malpractice.

Mackenzie responded by publishing his side of the story in his 1888 book  "The Fatal Illness of Frederick the Noble."

After a review of the case, it was determined that Dr. Mackenzie should have treated the growth as if it were cancerous "if only from fear that it might become malignant," said Dr. Bardeleben.  (3, page 15)

Dr. Bardeleben explained that if the tumor returned after its removal, a tracheotomy should have been performed to allow "radical extirpation of the disease." (3, page 15)

As a result of this review, and as a consequence of his 1888 publication, Dr. Mackenzie was censured by the Royal College of Surgeons. (1) (2)

Despite the controversy, the remainder of his life went on without consequence.

After suffering from bronchitis for a few days, Dr. Mackenzie developed pneumonia and died rather unexpectedly on February 3, 1892, at the age of 54. The hospital he helped to create, however, would continue to serve patients with diseases of the ear, nose, throat, and lungs until 1985, when the premises of Golden Square were closed.  (1) (4)

*Queen Victoria of the United Kingdom was Frederick's mother-in-law. He was married to Princess Victoria, the oldest daughter of the Queen.

References:

1. Lost Hospitals of London: "Royal National Ear, Nose and Throat Hospital," http://ezitis.myzen.co.uk/rntnehgolden.html, accessed 9/5/14
2. "Sir Morel Mackenzie," britannica.com, http://www.britannica.com/EBchecked/topic/354858/Sir-Morell-Mackenzie, accessed 9/5/14
3. Bardeleben, Adolf, "The illness of the emperor Frederick the third," 1888, Berlin, G. Schenck, Royal Publisher
4. Obituary: Sir Morell Mackenzie, New York Times, February 4, 1892, http://query.nytimes.com/mem/archive-free/pdf?res=9505EFDD1E39E033A25757C0A9649C94639ED7CF, accessed 9/5/14

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