1876: Dr. Beard: Nervous theory of hay fever

Hay-fever sufferers, much like asthmatics, look like normal, healthy people between episodes.  Actually, they might even look normal during episodes. So once the disease was defined by John Bostock in 1819, physicians were quick to conclude that hay-fever, like asthma, was a nervous disorder.  Yes, your hay fever is all in your head.

Well, surely your symptoms weren't all in your head.  The itchy eyes, nose and throat, the watery eyes, the sniffling, sneezing and wheezing are real.  But the cause of your symptoms is indubitably caused by a  a nervous temperament.  Surely you can get the condition without being nervous, but this was more the exception than the rule.

It appears that the champion for the nervous theory of allergies is our good friend, the physician George Miller Beard, the standing head of the United States Hay Fever Association. He explains that: (1, page 77)

"In order to induce an attack, there is necessary first of all a predisposition, frequently hereditary, to special and excessive sensibility of the nerves supplying the affected parts.

"The debilitating influence of heat and the external irritation of a large number of vegetable and other substances are exciting causes merely, widely varying in their effects with different individuals, and of themselves are powerless to induce, or at least to sustain, an attack. As the disease depends mainly on the individual predisposition, no two cases will be precisely alike, but all will differ as individuals differ."

Now, it is important to note here that by implying that hay fever sufferers are "nervous" in no way am I implying that people who have hay fever are goofy in the head, or mad or insane.  This is farthest from the truth.  Dr. Beard explains: (1, page 85)

"Skepticism of this sort comes from an entire misconception of the meaning of the term nervous. Nervousness is assumed to signify debility—of body or of mind, or of both; and to show itself by paleness, emaciation, and incapacity for muscular or cerebral toil. Of all popular delusions, none are more baseless than this. The nervous temperament—even the nervous diathesis, and various manifestations of that diathesis—may coexist with an imposing physique, and with both the appearance and the reality of high health. Physiology and pathology may thus go hand in hand; few people are wholly sick or wholly well; in certain directions we maybe diseased or liable to disease—in all other directions we may be almost absolutely strong."

So the underlying disposition among hay fever sufferers is a nervous temperament, and this predisposes them to the effects of a variety of causes, such as dust, ozone, plants, flowers, grasses, hay, animals, and of course pollen.

Evidence?  Yes, you want evidence.  Dr. Beard provides the following:

1. It's hereditary character:  Because it runs in families makes it nervous.  "From this we justly conclude that the disorder is of a constitutional character, in the sense that a tendency to it is innate in the organization.  Since dust and pollen don't trigger hay fever in most people, they are thus deemed tetriary or secondary causes.  The primary cause must be something inert, like the nerves.  The descendents of those who suffer from it are the ones most likely to also suffer from it.  "Parents who are of the nervous diathesis, and who illustrate this diathesis by sickheadache or hysteria, may have children and grandchildren among whom prevail many nervous symptoms, of which hayfever is but one."(1, page 79-81)
2. It prevails mostly among those who have nervous diathesis:  People most likely to have it have stressful brain jobs, are educated, upper class, and have an "active emotional nature," and it seems to "develop with the progress of civilization...As would logically be expected, it is oftener met with in cities than in the country, is more marked and more frequent at the desk, the pulpit, and the counting-room than in the shop or on the farm."  It is more likely to be prevalent in those who "overwork" the brain (brain or desk job) as compared to overworking the muscles (outdoor job, farming). It is more prevalent in the nervous melancholy person (the thinker) as compared to the relaxed phlegmatic person (the relaxer).  (1, page 81-87)
3. It is peculiar to modern civilization, and most prevails in most climates and countries where other functional nervous diseases prevail:  "We have seen already that hay-fever is a disease of the nineteenth century; it has arisen side by side with neuralgia,with nervous dyspepsia, and allied disorders, of which the eighteenth century knew little or nothing.* There are physicians who can recall the time when neuralgia, now the heir-loom of all well-to:do families, was an unknown word, and when nervous dyspepsia, now so common as to excite no comment, was unheard of."  Hay fever is also seen more in the U.S. and Britain, countries that are more civilized.  Some in Europe call it the English disease, considering it's more prevalent there than in other less civilized countries of Europe. (1, 87-89)
4. The symptoms of the disease, from first to last, through all the stages, are largely of a nervous character, and are made better or worse by mental influences: Consider the following nervous symptoms prevalent in most, but not all, hay fever victims: (1, page 90)
• Lassitude
• Sleeplessness
• Poor appetite
• Depression
5. It sometimes appears to take the place of other diseases, and to be replaced by them:  Physicians have noted that patients with upset stomach, for example, noted their symptoms of that ailment went away as soon as the hay fever struck, and returned when hay fever symptoms disappeared.  Ironically, I have noted this same thing.  I once remember telling my mom I have never been nauseated and short of breath at the same time.  It's an interesting observation and I can see by my own personal experience how it might be thought of.  (1, page 92)
6. It is affected for better or for worse largely by those influences that operate through the nervous system:   The remedies of the symptoms prove the illness is "under the influence of the mind.  Symptoms come on during periods of overwork and emotion, and remedies to relax the patinet seem to make the symptoms go away.  Likewise, "the remedies that thus far have been of the highest service for the relief of the symptoms, as quinine, arsenic, electricity, stramonium, alcohol, opium, ether, are pre-eminently nerve remedies, and in all the diseases for which they are used accomplish their results directly through the nervous system. Hygienically it is found that cold, of any kind or from what ever source—cool land-breezes, cool sea-breezes, the coolness of elevations or high latitudes, or a cellar or dark room —never fails to relieve; and for a large number of nervous states cold is one of the most potent of tonics."  (1, page 92-94)
7. Three factors are needed for hay fever symptoms to be present:  Symptoms are only present when all three of the following are present (removal of any one makes the symptoms go away, or not appear): (1, page 94)
• Predisposition
• Heat
• External irritant (dust, pollen, etc.)
8. Like other functional nervous diseases, hay-fever appears to be excited more by heat following cold than by continuous heat:  Geographic regions where the weather changes around the year, as it does in the tropics, the poles, and northern U.S., have a greater incidence of hay fever sufferers.  Such changes in temperature cause exhaustion, and this stimulates the nervous system.  Geographic regions that are consistently warm have lower rates of hay fever, such as the northern parts of U.S., the tropics and the poles.  So "warm climates are the best resorts for nervous people."  (1, page 95) 

Usually, attacks of hay fever only come about when you are exposed to these causes, animals or vegetable.  In most regards, this therefore makes hay fever more or less a seasonal disease, as most of the predisposed matter are only present at specific seasons of the year, such as the summer or fall, hence the terms "summer catarrh" or "fall catarrh."

Therefore, "as the disease is not due to any single specific cause, animal or vegetable, as has been supposed, no specific will ever be found for it," states Dr. Beard. "As with ordinary asthma, sick-headache, and other neuroses, to which it is in some respects analogous, the attacks may be prevented and relieved, and some remedies will act specifically for individuals; but no one remedy will ever be found to relieve all cases." (1, page 78)

Considering there is no proven cure, the following have been tried with some success (1, page 78):

• Avoidance of exciting causes (heat, light, dust, worry, animal irritants)
• Fortifying the system by tonics before and during the attack, and relieving the symptoms by those sedatives and anodyne, locally or generally administered, which are found by eperience to be bet adapted for each individual cae
• Spending the season of the attack:
• At sea; preferably in high altitudes, here the air is always cool, invigorating, and entirely free from vegetable and animal irritants
• In elevated mountainous regions, where in all latitudes the air is cooler and more invigorating than at low elevations, and some at least of the vegetable irritants are less abundant.
• In high latitudes, at any elevation where the air is sufficiently cool.
• At the sea-shore, or on islands near the coast.
• For those who can not leave their home, keeping quiet in cool, closed, darkened rooms.

When the above remedies don't work, or for those who cannot afford to take such a vacation, the following are remedies that can be tried before and during the attack: (1, page 78)

• Local applications:
• Quinine 
• Arsenic
• Iron
• Electricity
• Atomization:  
• Quinine
• Camphor 
• Palliatives (Remedies that experiment shows to be most useful for each individual.

One may also use just about any remedy that proves to have palliative effects on the symptoms of the disease, notes Beard.

Beard also makes a bold prediction about the future of hay fever:

These facts relating to the transmissibility of hay-fever are the more astonishing when taken in connection with the fact that the disease is so recent. There has scarcely been time as yet for the malady, so to speak, to get intrenched in families, for our grandfathers never heard of this trouble, except, perhaps, as a distant and doubtful wonder, while at the present time it is increasing with such rapidity that in twenty-five years, it is safe to say, there will be thousands of families who have more than one representative in the hayfever army. (1, page 80)

It's interesting anyway.  While Beard and other experts of his era were wrong about hay fever being nervous, Beard was correct when he predicted a steady rise of hay fever sufferers in the future.

Yet, it is true, writes Beard, that "hay fever is, then, a disease of the fashionable and the thoughtful -- the price of wealth and culture, a part of the penalty of a fine organization and an in-door life." (1, page 87)

References:

1. Beard, George Miller, "Hay-fever; or catarrh: it's nature and treatment," 1876, New York, Harper and Brothers

1876: Many names for hay-fever

Prior to John Bostock defining hay fever for the medical community in 1819, hay fever seemed not to exist.  However, from our own history we know it probably did exist and was misdiagnosed as a cold, flu or some other such ailment.  Still, the term hay fever evolved as a term long before 1819, to the point that even Bostock himself labeled "hay fever" as an inapropriate name.  Yet it stuck nonetheless.

In the 1876 edition of his book, Morill Wyman noted that:

...at the time of the publication of the first edition (in 1872) of this Essay, the "June " or " Rose Cold " was the only form of annual catarrh generally known. Since then, the number of sufferers from the autumnal disease has apparently greatly increased, until they seem greatly to outnumber the others. That this apparent increase is in no small degree due to the greater knowledge, may be admitted. Still, there is reason to think that the disease is on the increase, and it may be that the cause of this increase is to be found in the change of condition and habits of the people of the northern section of the United States, and more particularly of New England, which seems to be the home of the disease." (1 page 101)

As the occurrance of the disease rose, various names were used depending on the the season involved and the suspected exciting cause. Edmund Holmes listed several of those names in his 1876 essay, "Summer Catarrh," and they were as follows: (2, page 200)

• Hay-Fever
• Summer-Fever
• Rag-Weed Fever
• Snow-Fever
• Hay- Asthma
• Rye-Asthma
• Pollen-Asthma
• PollenPoisoning
• Pollen-Catarrh
• Bostorck's Catarrh
• Catarrhus iEstivus
• Summer Catarrh
• Summer Catarrh from Idiosyncrasy
• Typical Early Summer Catarrh
• Autumnal Catarrh
• Summer Bronchitis
• Rose-Cold
• Peach Cold
• Harvest Cold
• June Cold
• July Cold.

Chances are, as we read through the various books and articles on hay fever we'll come across enough unique names to double this list.  It must be considered that this was the beginning of knowledge of a disease that we now simply refer to as allergies. 

References:

1. Wyman, Morill, "Summer Catarrh," 1876 (first edition was published in 1872), New York, Hurd and Houghton
2. Holmes, Edmund W., "Hay Fever," Philadelphia County Medical Society: Proceedeings," volume XVII, session of 1897, Augustus and

1917: Meltzer's pharyngeal Insufflation Apparatus

Along with being the first to link asthma with allergies, Dr. Samuel James Meltzer (1851-1920) invented a mechanical device that could be used to provide artificial respiration.

He was born in Russia, studied medicine in Germany, received his medical degree there in 1882, and emigrated to New York in 1883 where he set up a medical practice. In 1904 he became head of the Rockefeller Institute's Department of Physiology and Pharmacology, and in 1907 he became a full time physiologist. He became the original president of the American Association of Thoracic Surgery in 1918.

So in his quest to improve knowledge of medicine, and to improve the technology for helping people, he was well prepared.

One of the neat things about the formation of the Humane Society in 1774 was that the organization kept data of all the cases it's members participated in. So this data, along with the data of many other societies, was studied by Dr. Meltzer. He likewise had access to medical studies, many performed by others, some performed by himself.

Upon reviewing the data, he set out to invent a device to provide artificial breaths that was both safe and effective.  He referred to his final product in a 1917 article in Medical Record as the Pharyngeal Insufflation Apparatus.  It was a device that was operated by a foot bellows.  When the foot bellows were depressed by the operator, air flowed through a hard, kink free rubber tubing and into the lungs of the victim.  When the operator took his foot off the bellows the patient exhaled by natural recoil of the chest wall.  

It actually was a rather simple device, but operating it took quite a bit of training and practice, mainly due to the fact that much coordination was needed.  Before I explain how the device was operated, first I must explain the parts.  

Fig 2 -- This shows an enlarged pharyngeal tube (Ph .T.) with its various
particulars,and a stomach tube (S.T.) in it

1.  Foot operated bellows:  As noted previously, when depressed by the foot air flows through the tubing.  

2.  Tubing:  It has to be of a hard rubber that was kink free

3.  Oxygen tank:  Now this part is optional.  Oxygen tanks at this time were large and bulky, and were only available in certain locations, mainly hospitals.  The rubber tubing was connected to metal adapters and the oxygen tank was introduced to the system.  As air flowed over this connection, oxygen would be drawn into this flow.  

4.  Reservoir bag:  Next in line was a large rubber bag.  During exhalation air (or oxygen) accumulated in this bag so that as soon as inspiration was triggered the air was ready to give the victim a "full respiratory blast." 

5.  Respiratory Valve:  After the reservoir bag as a valve. A ring on this valve would be moved left to give a breath and right to cause exhalation.  

6.  T-Tube:  This "carries on its rubber end a clamp screw, which, when not screwed down, permits most of the air to escape through the tube, while, on the other hand, by gradually screwing down the clamp upon the rubber tube the amount of air entering the pharyngeal tube will gradually increase." In other words, this clamp was Meltzer's way of studies that showed that bellows force too much air into the lungs too fast, thus causing trauma to the lungs.  The T-Tube allowed the operator to control this pressure, thus, ideally, preventing pulmonary trauma. 

Fig 3 - Showing an earlier arrangement of the
apparatus. B., bellows: T.T. T-Tube inserted
between the bellows and the respiratory valves:
R.V., respiratory valve: Ph. T., pharyngeal
tube: S.T., stomach tube.

7.  Pharyngeal Tube:  This was a tube, usually connected right to the system, that was inserted into the patient's mouth and into the trachea.  It was Meltzer's version of an endotracheal tube (what Meltzer referred to as an intratracheal tube, although he noted the other term was catching favor).  His tube was described by himself like this: 

This tube has a flat surface at its lower side which rests on the tongue and a curved surface on its upper side. At the pharyngeal end of the tube the upper surface is longer than the lower one. The external end of the tube has a protrusion with a neck for connection with the respiratory valve and an opening through which a stomach tube may be pushed down through the esophagus into the stomach. When no tube is in use this opening is closed with a movable plate. (See Fig. 2.)... furthermore, the prolongation of the curved side of the tube raises the soft palate and thus prevents the escape of air through the nose.

If this tube was not available, a trach tube may be used, or a mask.  However, Meltzer noted that a mask should not be used except for in the case of an emergency because it's use increases the risk of driving "infectious materials usually present in the nose and pharynx directly into the lungs and thus produce fatal inflammation of that organ.  By using a pharyngeal tube that risk is reduced to a minimum."

The problem with the tube was that "the introduction of the tube into the trachea requires some dexterity and practice."

8.  Stomach tube:  This fits into the external opening of the pharyngeal tube and is meant to prevent air from entering the stomach and intestines.

9.  Tongue Forceps:  These are used to move the tongue out of the way prior to insertion of the pharyngeal tube

10.  Tape:  This is used to secure the pharyngeal tube to the tongue.  This serves two purposes:  One, to prevent the tongue from blocking the airway; two, to secure the pharyngeal tube and stomach tube into place.

11.  Paddle Wooden Board:  This is strapped using belts and meant to compress the stomach.  The idea here is to help prevent the entrance of air into the stomach and intestines. 

12.  Handy Small Bag:  All the parts of the apparatus, along with the tongue forceps, scissors and tape, "ought to be kept connected and kept in readiness in a handy small bag."  This will assure that they are readily available when they are needed.  

Once he had put together the device of his liking, he put it to the test on animals and dead human beings.  Of interest is that he admits that when he started testing the device he was not aware that previous studies showed that the use of bellows increased the risk of harm being done to the lungs, and air getting into the stomach, "which does more harm than good."

Fig 4 - Showing the apparatus in position. except the bellows
and the oxygen tank. You can also see in this picture the correct
application of the paddle wooden board.  Here you can see that
it is fastened around the belly by the use belts.

Although by performing his tests he came to this realization on his own, and, based on his findings, made several changes to the design of his apparatus.  One such change was the addition of the t-tube, which allows for pressure to be gradually increased so as not to over distend the lungs.  It was also based on his studies that he came up with the idea of the stomach tube and the paddle wooden board.

Meltzer describes his plan for using his apparatus on a victim in need:  You can decide for yourself if he makes it look easy or complicated: 

When coming to a victim who requires immediate artificial respiration the order of the procedure should be as follows: First the application of the abdominal board—in order to prevent the entrance of the insufflated air into the stomach and the intestines. Second, to pull out the tongue as far as possible by means of the forceps. Third, to insert the pharyngeal tube of the readily connected apparatus as deep into the pharynx as possible with the fiat side of the tube on the tongue. The tongue should now be tied to the tube by means of tape— not too tight... The working of the bellows with one foot, and the moving of the ring of the respiratory valve with the thumb of the right hand should be started immediately on tying The tongue to the pharyngeal tube. At the beginning of the procedure the T-tube should be kept open; it should soon be gradually screwed down until the thorax shows a distinct raising when turning the ring to the right and falling, when turning to the left. The heaving of the chest need not be too strong.The degree of the heaving can be readily controlled by means of the screw, which should be turned down gradually, and which will then be capable of accomplishing all the care which may be obtained from the use of a mercurial valve. Moving of the ring thirteen to fifteen times per minute will give a satisfactory respiration; or the operator may time the moving of the thumb by therhythm of his own respirations. In case of need one individual who had some training may accomplish all three procedures and start the artificial respiration in less than one minute after finding the victim.

He notes that it may take some practice to get the timing to get the rhythm down of moving the ring and pressing the bellows.  He recommends going with the rhythm of your own breathing.

Samuel James Meltzer (1851-1920)

He also recommends that any potential rescuer should be trained in the methods of manual respiration, and of the two most common methods at this time -- the Schaefer and the Sylvester-- he recommends the Schaefer method.  To learn more about the manual methods of respiration, click here.

Meltzer also notes that if the operator is concerned with the circulation of the heart, the Schaefer method may be performed by a second rescuer.  If there is no second rescuer, Schaefer suggests an idea that that once occurred to Schafer:

"If he were now confronted with the task of resuscitation he would kneel astride over the subject and perform the simple motions of horseback riding without employing his hands and arms at all." This simple manner of employing the prone method could be readily combined with the use of the author's pharyngeal insufflation apparatus, and the operator who is performing the Schafer method could at the same time manipulate with one hand the respiratory valve and with the other hand regulate, when necessary, the T-tube. But the operator must learn tomove the ring of the valve to the left (expiration) synchronously with throwing his body downward upon the individual and to move his thumb tothe right (inspiration) simultaneously with the raising of his body from the individual.

The most interesting aspect of this apparatus was that it was not patented, so the "cost is probably less than one-fifth of the patented apparatuses."

References:

1. Meltzer, S. J., "History and analysis of the methods of resuscitation," Medical Record: A Weekly Journal of Medicine and Surgery, July 7, 1917, Volume 92, Number 1; Thomas L. Stedman, editor, Medical Record, Volume 92, July 17, 1917 - December 29, 1917, New York, William Wood and Compay

1912-2001: Dr. Martin Wright

If you were a respiratory therapist during the 1960s, 70, 80s and even the 1990s, you probably heard of the name: Wright. You may not know a first name, or even the person, but you were familiar with his products: the Wright Respirometer and the Wright Peak Flow Meter.

And even while his products have made their way to the dark side of shelves in the back of supply rooms, or simply faded into oblivion, his product line has been refined and re-introduced into the market by other names, or padded into other products, with their users having little knowledge of where they came from, nor who introduced them to the marketplace for us to use.  

His name is Basil Martin Wright.  He was a bio-engineer who had a flare for inventing things that measured inspiratory and expiratory flow.  The need for such devices developed during the 1950s when improved anesthetics and pain relievers allowed physicians to perform routine surgeries, particularly abdominal surgeries.  

Wright Respirometer

The need developed for a machine that would breathe for patients.  This was one of the main reasons for the invention of the positive pressure ventilators as you can see here.  On these old ventilators there needed to be some mechanism for measuring the volumes of inspiration and expiration, or tidal volumes, of patients.  This is where the Wright Spirometer comes into play.  

Although this is not how Wright came to invent his devices.  In 1949 he joined the Medical Research Council's for pneumoconiosis, a lung disease caused by inhaling mineral dust.  He realized the unit "lacked the mechanisms of monitoring and studying lung capacity of patients.  So it was for this council that, in 1959, he invented the Wright Peak Flow Meter, the first device for measuring peak expiratory flow (PEF).  This made studies of lung function possible and lead to a greater understanding of lung disease." (1, page 11)

Case for Wrights Spirometer

Such devices also allow the physician to assess the progress of the patient over time.  As the patient gets better, the PEF will get higher, and if the patient gets sicker the PEF may become lower.  The first peak flow meters were large and cumbersome, but in 1974 Wright invented a simpler, cheaper, portable device that could easily be used by the patient at home as a tool to monitor the progress of his disease.  I wrote about the history of the peak flow meter in this post  (1, page 11)

Today peak flow meters are made by a variety of manufacturers, are for single patient use, and are easy to use.  Most asthma experts recommend all asthmatics have one at home, and they blow into it every day at the same time, and to write down their highest number.  This number is referred to as the patient's personal best.  Then the patient makes some simple calculations, and as the PEF starts to drop to a certain point, a plan can be devises what to do and whether the doctor should be called, or whether to simply get to the emergency room, or call 911.  I wrote about the peak flow meter in this post.  

Basil Martin Wright 

In 1957 he started working for the National Institute for Medical Research in London, focusing on creating a similar device to allow anesthesiologists to monitor the tital volumes of patients under the power of anesthetics and pain relievers.  This was important because such medicine has the power to knock out the respiratory drive, and measuring tidal volumes is a great way to measure loss of drive to breath.  

The devices were used to help the anesthesiologist know if prolonged assistance with breathing was indicated, or if the patient required assistance with breathing by use of a mechanical ventilator.  The device was ultimately used by respiratory therapists to monitor the tidal volumes on patients with neuromuscular disorders, or to monitor the progress or regression of patients on mechanical ventilation.  We used to use the Wrights Respirometer daily as part of our weaning screen.  Today the measurements are made by the microprocessor on the ventilator.  

References:

1. World Almanac Library, "Cutting Edge Medicine:  Machines in Medicine," 2007, Arcturus Publishing Limited, page 11

1910-1920: The oxygen revolution

Joseph Barcroft (1872-1947)
In 1886 he received his M.D. from Cambridge,
and began his study of hemoglobin.
He exposed himself to different environments
to determine their effects on the human body.
.

Three significant events occurred at the dawn of the 20th century that resulted in increased interest in supplemental oxygen therapy. The first was the invention of a means of measuring oxygen saturation. The second was an experiment that Dr. Joseph Barcroft performed on himself. The third were experiments by WWI physicians to find a treatment for pulmonary edema caused by gas poisoning.

The ability to draw arterial blood was a significant discovery. It was hurter in 1912 who introduced the method. (2, page 693)

Yet even more significant was the machine blood could be inserted into that would determine the how saturated hemoglobin molecules in the blood were with oxygen molecules. This is referred to as oxygen saturation. Once inserted into the machine, the saturation was reported as a percentage.

John Scott Haldane (1850-1936)
He graduated from Edinburgh University in 1884,
and worked with his uncle at Oxford,
where he became interested in air,
its composition, and effects on humans.

Adolf Fick of Germany and Paul Bert of France described oxygen tensions as units of partial pressure, and it was these units that made it possible to describe the difference between arterial and venous blood. Since the partial pressure of oxygen in arterial blood is higher than the partial pressure of oxygen in venous blood. Or at least this is the case in a healthy individual. (1, page 4) (2) (6)

Donald Dexter Van Slyke (1883-1971) and John Scott Haldane (1892-1964) of Scotland developed effective means of measuring these differences. (1, page 94) (2) (6)

Further studies by various experts determined the normal levels and critical levels of oxygenation. It was determined that a normal arterial saturation of hemoglobin is between 95 and 98 percent, and a normal venous saturation is between 70 and 75 percent. These new values allowed physicians to monitor a patient's oxygenation status, and the effectiveness of oxygenation therapy. (2)(3, page 369)

Among the first to prove the significance of this discovery was Sir Joseph Barcroft, who lived for six days in an atmosphere that had 18 percent oxygen in the air, as opposed to the normal 21 percent that's in roomair. Alvin L. Barach, a pioneer in oxygen therapy, liked to use Barcroft's experiment as an example to prove the significance of oxygenation.

Barach explained:

"On the last day, the oxygen saturation of his arterial blood was 88 per cent., and after the performance of work 83.8 per cent. He lay in the chamber racked with headache, with occasional vomiting, and at times able to see clearly only as an effort of concentration. He became faint on exertion. His pulse, normally 56, had risen to 86. These effects were apparently due purely to oxygen want. The degree of anoxemia that produced them has frequently been found in pneumonia and heart disease by the investigators mentioned above. In many instances, the saturation of the arterial blood falls to far lower levels. It would, therefore, seem likely that lack of oxygen in the degree often found in disease would produce bodily discomfort, disturbances in function and damage to living structure." (3, page 369)

The effects on Barcroft were similar to the effects of pneumonia and heart failure for some patients. Studies showed that the oxygen saturation could range from 75-95 percent in cases of cardiac insufficiency, and 60-95 percent in cases of pneumonia. (2, page 693)

So it became apparent these diseases, as they progress, decrease the amount of oxygen that gets to the blood and to hemoglobin.  

Various studies, including the Barcroft study, proved that a low level of oxygen stimulates the central nervous system to stimulate various changes within the body in an attempt to return oxygenation back to normal: heart rate increases, respiratory rate increases in rate but decreases in depth, patient may become delirious and may have hallucinations  If not treated, death may result.  (2, page 694)

So these studies proved to the medical community the significance of observing the signs and symptoms of poor oxygenation and speedily treating them with oxygen. (2, page 694)

Oxygen was not meant to cure, but to treat the symptom of low oxygenation long enough to allow the physician to remedy the underlying condition, which may include: (2, page 694)

• Pneumonia
• Acute Cardiac Failure
• Severe Hemorrhage
• Epidemic Encephalitis
• Ascent to high altitudes
• Complications of chronic cardiac insufficiency
• Pulmonary Edema
• Acute Bronchitis
• Carbon Monoxide Poisoning
• Nitrous Oxide Poisoning
• Other anesthesia

Further studies also allowed physicians the opportunity to determine that a therapeutic percent of oxygen for most diseases was between 40 and 60 percent, and it's for this reason the oxygen chamber, oxygen catheter, and nasal cannula generally are not effective for oxygenating patients with severe oxygen deprivation. (2, page 696)

Studies likewise showed greater than 70 percent could cause pneumonia, and did so in rabbits. (3, page 373)

It was probably based on these and similar studies that John Haldane, another pioneer of oxygen therapy, would recommend 41% oxygen administration continuously for patients suffering from anoxemia (Haldane would coin a new term to describe this: hypoxemia). (6) (7) (8)

In fact, it is said Haldane once mused:

Intermittent oxygen therapy is like bringing a drowning man to the surface of the water—occasionally. (7) (8)

Yet even while he and other physicians proved the usefulness of continuous oxygen therapy during WWI, it would take a few more years for it to catch on. (6)

Oxygen mask designed by Haldane in 1917

A third significant event was the gas poisonings that occurred during WWI. Phosgene was used by the enemy on the war front because, when it combines with water in the lungs, it creates hydrochloric acid, which damages lung tissue. If inhaled in high enough doses it may cause pulmonary edema within 6-10 hours, leading to acute respiratory distress syndrome (ARDS).  As the illness progresses, the lungs lose their ability to pass oxygen to pulmonary capillaries, therefore causing anoxemia or hypoxemia. (6)

While oxygen was not thought to cure these patients, it was believed that it would treat the symptoms caused by anoxemia, particularly cyanosis and dyspnea.

Sometimes patients who presented with pulmonary edema due to gas poisoning were treated in oxygen chambers, which could be supplied with 40-60 percent oxygen. These chambers were found to be effective in treating cases of chronic gas poisoning. Some patients would spend up to 16 hours a day inside one with good results. (3, page 360)

However, this therapy wasn't practical for common use.

Another means of providing these patients oxygen was to use a tube or funnel to aim the oxygen at their faces, although studies showed this provided no more than a 2 percent increase in oxygenation of inspired air.

So this opened the door for an improved oxygenation apparatus that was easily portable by medics, comfortable to wear, could be used long term for chronic cases, and provided a therapeutic dose of oxygen. John Haldane invented such a device, and it was called the "Haldane Apparatus." (3, page 370)

Alvin Barach said Haldane's apparatus provided oxygen blended into the air the patient inspired, and by doing this the amount of oxygen making it to the alveoli was greatly increased. By this means, the patient was supplied with a therapeutic level of oxygen. (3, page 370)

Barach described the device as consisting of an oxygen tank, a reducing valve, and a face mask. He said:  (3, page 370)

"The mask was connected with a connecting bag which received oxygen from the tank, and with the outside air, from which the patient breathed. Oxygen was added to the inspired air in amounts of from one to four liters per minute. This was largely used in acute cases with generally good results." (3, page 370)

The problem with the Haldane apparatus was the only patients who tolerated it were those who were comatose. It worked great for these patients. Yet for others, for those who were awake and alert, it was not comfortable. Patient's complained that having the mask over their faces created a feeling of claustrophobia, and the mask was also hot and stuffy. This was especially a problem on hot days. Some patients simply didn't tolerate the mask, and some even ripped it off, refusing to wear it. (3, page 370)

Another problem, a pretty severe one actually, was it was impossible for clinicians to see through the opaque rubber masks. Clinicians learned to be vigilant, although this sometimes didn't prevent them from getting busy and not recognizing a patient was vomiting or expectorating foaming pulmonary edema. When not recognized, secretions occluded airways resulting in worsening anoxemia.

This concern opened the door for a more comfortable and safer oxygenation device.

One such device was the nasal cannula or prongs devised by Captain Adrian Stokes, M.D., in 1917. Stokes created the device while triaging patients on the war front who were suffocating due to pulmonary edema, and to which the tight fitting rubber mask of Dr. Haldane was not feasible. The metal cannula provided less oxygen than Haldane's device, although it helped medics keep pulmonary fluid from re-entering and blocking the airway. (1, page 38) (3, page 370)  (5, page 8) (6)

Stoke's cannula was a device similar in design to what we use today, although it was supplied by rubber tubing and the prongs were made of metal, and therefore was not very comfortable. However, patients tolerated it much better than the rubber mask, and of course it was safer. (1, page 38) (3, page 370)  (5, page 8) (6)

A similar device was the rubber nasal catheter, which was initially invented by Arbuthnot Lane in 1907, although re-introduced by Stokes in 1917. The catheter was introduced into the United States in 1931 by Waters and Wineland.  (1, page 17) (5, pages 8-9) (7, page 20)

The soft, rubber catheter (later made of pliable plastic) was a 12 inch long tube that was blindly inserted into one of the nostrils and then secured to the forehead. The patient would then open his mouth, depress his tongue to the bottom of his mouth, and the physician or nurse would check to see that the catheter was in place at the back of the airway. (4)

The end that remained outside the patient had a fitting to which oxygen supply tubing was connected.  On the distal side of the catheter, the side inside the patient's airway, were a series of small holes to allow oxygen to enter the patient's airway.  (4)

Catheters were designed for adults and pediatrics, the flow was set at 1- 5 lpm, and the the delivered oxygen was 22-35%.  The catheters would stay in the nose for a day or two.  If it was needed longer a new catheter had to be inserted. (4)

Most experts recommended changing the catheter every 24 hours to prevent tissue breakdown, and most hospital protocols eventually called for changing it every eight hours.

So you can see that while it was more convenient for the patient, there was some risk to the patient too.  It also provided some inconvenience for those taking care of patients requiring it.

While nasal catheters were simple to insert and manage, and while they were generally well accepted by patients, they did not provide enough oxygen in patients presenting with acute pulmonary edema or worsening pneumonia to eliminate cyanosis.  (3, page 370)

The nasal catheter was the most commonly used device for supplying supplemental oxygen prior to the invention of the modern nasal cannula in the 1960s.

Figure 2 --Apparatus for giving oxygen.(3, page 374)

Another option was a device similar to the one in figure 2.  The apparatus works this way: 

"The patient breathes through the rubber mouthpiece M (or a mask could be used) through the can of soda-lime C into a rebreathing bag B. The carbon dioxide exhaled is removed by the soda-lime, and oxygen is admitted from the tank O at a sufficient rate to keep B inflated.In this way the patient rebreathes pure oxygenfrom the apparatus,but since his nose is left open he dilutes this with a certain proportion of atmospheric air. In practice this results in the inhalation of from 40 to 60 per cent, oxygen." (3, page 374)

Yet another option was the oxygen tent. These were clear canopies that were made to cover the entire bed. A machine at the bedside provided an environment inside the tent of about 30 percent oxygen. These were effective as far as oxygenating some patients, although the original oxygen tents were hot and stuffy, and this particularly posed a problem on hot days.

Patients would generally go inside one long enough to catch their breath, and then they'd return to breathing room air. (1, page 94)

Barach recommended to physicians that the best means of measuring oxygenation status was by monitoring the heart rate, respiratory rate, and especially the level of cyanosis (bluish skin color). This was much more logical than an invasive blood draw. (3, page 370)

Caregivers would ultimately learn to monitor these signs, along with level of consciousness, before, during and after therapy.  This, they found, was the best means of monitoring the effectiveness of oxygenation therapy, and whether or not it was still needed.  (2)

What equipment to use to supply oxygen depended on what equipment was available, the physician taking care of the patient, and the independent oxygenation requirements of patient.

How long oxygen therapy was used primarily depended on the patient and how quickly, or slowly, the underlying condition resolved. (2)

Still, by 1922, when Barach wrote many of his papers, he explained that...

"the use of oxygen in medical therapy occupies at present an uncertain role." 

Despite Barach's doubts, the 1920s was an oxygen revolution of sorts.

Barach would go on to study the effects of oxygen therapy on a variety of respiratory diseases, including pneumonia and cor pulmonale. He would also study the effects of oxygen therapy on respiratory failure. For his work, he is often considered the father of modern oxygen therapy.

References:

1. Glover, Dennis, "History of Respiratory therapy," 2010, Indiana, page 94.
2. Barach, Alvin L., "The Therapeutic Use of Oxygen," The Journal of the American Medical Association, Vol 79, No. 9, Chicago, October 26, 1922, page 693-699
3. Barach, Alvin L, Margaret Woodwell, "Studies in oxygen therapy with determinations of blood gases," Archives of Internal Medicine, Vol. 28, 1921, Chicago, American Medical Association, pages 367-393
4. Hess, Dean,  Neil MacIntyre, Shelley Misha,"Respiratory Care:  Principles and Practice," page 281
5. Wyka, Kenneth A.,  Paul Joseph Mathews, William F. Clark, editors, "Fundamentals of Respiratory Care," 2002
6. Grainge, CP, "Breath of Life: the evolution of oxygen therapy," Journal of the Royal Society of Medicine, October, 2004, 97 (10), pages 489-493
7. Heffner, JE, "The story of oxygen," Respiratory Care, January, 2013, volume 58, number 1, pages 18-30
8. Sekhar, KC., "John Haldane: The Father of Oxygen Therapy," Indian Journal of Anesthesia, May-June, 2014, 58 (3), pages 350-352

1910: Early PEP and Insentive Spirometers

Cohen's Resistance Valve (Figure 38)

Physicians near the middle  of the 19th century were aware of the importance of exercising your respiratory muscles to prevent and treat lung disease.  By 1910 the concept of taking deep breaths was used as a means of preventing and treating consumption.

From the 1850s onward various devices were created to exercise the lungs by inhaling and or exhaling against resistance. Some of the more common methods were described by Tissier in his 1903 book "Pneumotherapy: Including Aertherapy and Inhalation methods."

According to Tissier, all of these devices or techniques provide similar results, and none has an advantage over the others.  The ultimate goal being to exercise the lungs on a daily basis with the goal of, over time, increasing respiratory capacity.  

Some examples are:

1  Valsalva Meneuver:  This is a technique we still recommend today when a patient's heart goes into certain funky rhythms to try to get it back to normal. Back then it was used as a therapy to exercise the lungs.

Basically, the patient takes a full inspiration, and then exhales through a closed glottis with all your respiratory muscles, making a full, and forceful expiratory effort. When I explain this to my patients, I basically say to the patient to exhale as though you were trying to take a crap. It's a funky way of explaining it, but it works.

The effect of this technique (and all the devices described here) is to exercise all the respiratory muscles, and it also increased intra-thoracic pressure. By increasing intrathoracic pressure, the circulation is also slowed because the vessels are squeezed and this slows circulation.

Figure 40 -- Howe's Breathing Tube

The increased pressure also recruits alveoli and portions of the lung not used regularly, and this works to improve breathing.  This creates more room for air exchange in the lungs.  We now know this causes a form of PEEP that increases oxygenation.  A similar effect is created when a newborn is grunting or crying.  Thus, Tissier suggests crying exercises respiratory muscles, and parents who don't let their children cry risk having their child's lung muscles not developing properly, and this predisposes them, so he believed, to tuberculosis of the lungs.

Figure 41-- Resistance Spirometer

2.  Ramadge Tube:  The tube was recommended for patients suffering from tuberculosis. Due to his invention he is often described as the Father of Aerotherapy.

Tissier describes the Ramadge Tubes this way: "Ramadge had his patients breathe the emanations from heated tar through long narrow tubes, the diameters varying with the ages of the patients, and attributed all the benefits derived from the inhalation to this respiratory exercise of the lungs. The length of the tube serves the double purpose of protecting the patient's face from the heat of the inhaling apparatus, and of retarding the free egress of air from the lungs, which is an essential feature of a perfect inhaler." I describe the Ramadge Tube in more detail in this post.

Figure 42-- Spirometer used for resistance Exercises

3.  Dobell's Residual Air Pump:  I described this device in my last post. A patient placed the mask on his face and exhaled against pressure. The results are similar to the effects of the valsalva maneuver. However, I think the next device more resembles our modern devices, and appears to be much simpler.

4.  Cohen's Resistance Valves:  Pressure results from "Little cylinders containing ebonite valves controlled by spiral springs (Fig. 38). The tension of the spring is regulated by turning the cap of the cylinder, and a scale on the outside indicates indicates the pressure used. This device allows for resistance against both inspiration and expiration.

5.  Cohen's Simplified Resistance Valve:  It's similar to Cohen's Resistance Valve. It's less expensive, but it's also less accurate. Along with causing resistance, the "inhalant chamber (A) contains a sponge or tuft of absorbent cotton, which may be saturated with some medicinal substance." (See figure 39)

6.  Howe's Breathing Tube:  It's similar to a Ramadge Tube, which is why the tubes are sometimes referred to as either Howe's or Ramadge's Tube. Since it provided pressure and also allowed for the inhalation of medicine, both the Ramadge and Howe tubes are sometimes referred to as inhalers. (see figure 40)

7.  Resistance Spirometer:  They are used the same way as the Ramadge and Howe Tubes, or any of the above devices and, again, offer no advantage over any of the above. However, the device can be used day to day and allows the patient to monitor his progress by writing down daily the values indicated on the spirometer. There were many similar devices, two of which are indicated in figures 41 and 42.

Further Reading

1. The first PEP Therapy, Incentive Spirometer

References:  

1. Tissier,Paul Lewis Alexandre, edited by Solomon Solis Cohen, "Pneumotherapy: Including Aerotherapy and inhalation methods," volume X, 1903, Philadelphia, P. Blakiston's Sons and Co., pages 227-230.  If the profession of respiratory therapy existed in their era, we would be reading their books.  However, as it was, their books were written for the medical profession.  For a more detailed description of any of the devices mentioned on this blog click on the links provided. Unless otherwise indicated, all material from this post was from Tissier's book. 
2. Minnesota State Medical Society, "Transaction of the Minnesota State Medical Society," 1886, St. Paul, H. M. Smyth Printing Co.

1908: The Bratt's Resuscitator

The Bratt's Resuscitator was among the equipment available during the first 20 or so years of the 20th century to assist with artificial resuscitation.  The device would have been purchased by various gas, mining and electric companies to be used when a person was exposed to gases or was electrocuted.  The devices were also found useful for other purposes, such as attempts to revive victims of drowning. 

The pictures below were provided in a 1908 edition of the The Canadian Mining Journal.  The top two pictures show a rescue station at a mining company.  The following is the description of the mining station:

Among the equipment of the station is a "Dr. Bratt" resusitator. This is a device for inducing artificial respiration and administering oxygen. It consists of a flash of oxygen connected by the tube with a mask for the mouth and nostrils. By moving a handle to and fro the lungs of an unconscious person may be inflated and deflated as in natural breathing. The deviceis of special value for reviving men who have been "gassed," particularly those suffering from the carbon monoxide poisoning" 

The photo in the lower left shows the apparatus by itself.  The photo in the lower right shows it in use.  A Draeger apparatus (the pulmotor) was noted as among the equipment available at the station. Another part of this rescue station was set up as an emergency station, replete with beds, blankets, etc. (1 page 594-596)  

References:

1. Gray, F. W., "The mining operations of the Dominion Coal Company," The Canadian Mining Journal, November 15, 1908, Volume XXIX, Number 22, Toronto; Published in the "Index: Canadian Mining Journal, volume 29, January 1, 1908, to December 31, 1908, The Mines Publishing Company Limited, Toronto, Ontario. Click the links for a better view of pictures.