4000-539 B.C.: First civilizations advance medicine, part 2

So with Urek as the capital of Sumeria, its god, the god of the sky, became the chief among all the gods.  He was Lord of the Heavens, Lord of the Constellations, Lord of the spirits and demons. The great legends and myths of Urek became known to all the people of Sumeria.  They all learned of legends and myths such as how the gods created the world from mud, and how a mighty king of Urek by the name of Galgamesh set off on a great adventure with his friend Enkidu to defeat the monsters and demons that were wreaking havoc on the world.  After the gods killed Enkidu, a saddened Galgamesh set off on a quest to find eternal life.

Galgamesh met a man named Utnapishtim who was granted eternal life by the gods after he survived the Deluge with one of all the animals (a story similar to that of Noah).  Utnapishtim told Galgamesh about a magic herb that would grand eternal life that was at the bottom of the sea.  Galgamesh found the magic herb, but it was stolen by a serpent, who then developed the ability of renewed life by shedding it's skin.

Still, there would have been ongoing disagreements among the rules of the other city-states, and at various times one or another of these city-states ruled over Sumeria, with its god moving to the head of the hierarchy of Sumerian gods.  It's legends were learned by the people.  Yet even as this happened, the legends and gods of the previous ruling city-states continued to be worshiped.

In either case, Sumeria started out as a democracy and ended as a monarchy. One person made himself king, ruler of all Sumeria, and he chose his successor when he died (which probably was his son in most cases).  (Foster, page 46) 

An assembly of elders and warriors of the monarchy were required by the gods to make sure all the people did the work of the gods, and so members of the monarchy had time to sit around and think.  They also had time to collect things other than simply food and things that were essential to life.  They learned they could obtain more "things" by taxing the slaves of the gods, who were more than willing to offer the goods they produced because they believed in the myths created by the kings and the king's people.  

Through taxes the kings collected items of pottery and gold.  They collected wood carvings.  They collected an abundance of food.  They made the god's slaves build for them some of the most impressive structures of all the land, and the people did this because they thought they were doing the work of the gods.  So in this way, Sumerians were among the first to amass a collection of material items, many of which have been discovered by archeologists.  The Sumerians and Babylonians worshiped these items as opposed to the gods, and perhaps it was in this way the Biblical story of the Tower of Babel unfolded. 

The writers of the Hebrew Bible made bold predictions regarding the Babylonians, and to the plight of archaeologists and historians, the boldest of these predictions came true.  As noted by Plinio Prioreschi in is 1998 history of medicne:

"The Mesopotamian civilization differed greatly from its contemporary and neignboring Egyptian civilization.  It has been pointed out that whereas the latter was characterized by confidence in the powers of man and by a frontier spirit full of youthful self-reliant arrogance, the 'mood' of the Mesopotamian civilization is well expressed in a quotation from the Galgamesh Epic: 'mere man -- his days are numbered; whatever he may do, he is but wind.' As if to express the same difference, the Egyptian pyramids still stand to proclaim the power of man, whereas the prophecy of Jeremiah (51:37) that 'Babylon shall become heaps' has come to pass, as all that was built in Mesopotamia has crumbled to dust."(Prioreschi, pages 427-8)

So the melancholy nature of the people of Mesopotamia was well known, and this may have played a role in their ruthless nature.  And perhaps this was the reason the various Sumerian city-states created laws,  or codes, that people were required to follow.  Many of these rules were very strict, such as an eye for an eye, a tooth for a tooth, and a hand for a hand.  It was all an experiment, you must understand, because they had no examples to learn from.  This was completely unlike the members of the Constitutional Convention when they got together in Philadelphia around 4,700 years later, who had many examples to learn from as they were creating the U.S. Constitution. The problems faced by the Sumerians had never been faced before, and the solutions were the first solutions.

Sumerians, Babylonians, and Assyrians created armies and armed them with
knives, swords, spears, and arrows.  This was necessary both to control the
people amid society, but also to protect themselves from enemy nations and,
of course, to fight wars.  (Weaponsandwarfarecom)

Another problem was motivating people to do the work, and to fight wars.  Perhaps the first democracies didn't work because, left alone, people weren't willing to make the sacrifices necessary for the collective. Or perhaps these weren't true democracies, and they weren't formed correctly.  Perhaps a ruler was only chosen during times of strife, and between strife people and city-states were left to do as they pleased, and this was part of the problem, or why problems ensued.

Of course, the founding fathers learned all those years later that democracies never work, because they require every person to stay up on politics, and Lord knows people don't do this.  With most people refusing to vote, or not understanding the need to, or not being interested, one person in power almost always becomes the divine ruler.  This is what happened in ancient Rome, and in ancient Greece, and many times, over and over, throughout history.  Yet the people around Mesopotamia did not know this as they were creating the first governments.

So, perhaps due to the failures of democracies, for whatever reason, monarchies were established.  Perhaps the most powerful king of one of the city-states stood up to the challenge and was accepted as king of the civilization.  It became his job to motivate the people to do the work of the gods, as, after all, they were created by the gods to be servants for those gods.  At least that's what the people were told.  This was the best way, perhaps, for the ruling parties to obtain and maintain order.  This was the best way to make progress.

Picture of Ziggurat in the public domain.

Yet even the king himself was a servant to his god, and this god lived in a temple. Such temples were impressive structures that were built on hills or mounds.  Some of these city-states may have been built around such mounds, although some of the mounds may have been created by human labor. The mighty temples upon them were called Ziggurats. 

Public buildings were built around these temples, and among these buildings were palaces for the ruling class, homes for the priests and even schools and libraries. Wrapped around these mounds were homes made of mud brick and reed sticks that were "closely packed together along narrow, winding streets." (Kingfiisher) 

Surrounding these were many fields where crops were grown (mostly grain) and tamed animals roamed.  Surrounding these were nearby towns, much like today's cities have suburbs. (Foster, 38-39)

The Tower of Babel by Pieter Bruegel the Elder (1563)(from Wikepedia)

The purpose of the Ziggurat was to provide a home for the god or goddess of the city-state to live. These temples were impressive structures, and originally they were made of mud-brick, the same as the individual homes.  When there were floods sometimes the mud would wash away, and the people would  band together to rebuild the temples.  When they did this they made the temples bigger and larger than before, and far more impressive  As greater knowledge and material was obtained, these temples were made of rock, material that did not wash away by the floods.  Many of these structures, although warn by centuries of the rain and sun beating upon them, are still available for modern people to enjoy. Some speculate that the temple built by the people in the city-state of Babylon was the Tower of Babel referred to in the Bible. (Foster, page 39)

To be continued...

References:  See post "2000 B.C.:  Assyrian physicians will treat your dyspnea"

I

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Bronchodilator Reform: Some things never change

Sometimes wisdom advances ever so slowly, or, in the case of respiratory therapy, not at all.  Consider the following passages from Nathaniel Chapman, the founder of the American Medical Association, from his 1844 book "Lectures on the more important diseases of the thoracic and abdominal viscera,":

Difficult breathing, which constitutes the most prominent feature of this disease, seems to have attracted medical attention from the earliest antiquity. The Greek writers, as we learn from Celsus, distinguished it according to its gradations,—calling it when moderate, dyspnoea—when more severe, asthma—and when of the utmost violence, orthopnoea. In the progress of time, these terms underwent considerable fluctuations in their meaning andapplications, till finally that of asthma was made to embrace every case of embarrassed respiration, whatever might be its nature, or the manner in which it was induced. But this condition presents such infinite varieties in these respects, that a more precise and limited definition was required. Later authorities, therefore, restrict its use to a peculiar form of this affection —recurring in paroxysms, each of which, having a quotidian aggravation, coming ontowards evening or in the night, and subsiding in the morning, usually with more or less expectoration.

I thought this was an interesting observation by a smart physician, especially considering 170 years later we are still treating every case of embarrassed respiration as asthma.  

Medicine slow to accept science

Medicine is the only profession based on science to be slow to accept science.  That's because it's easy for a physician believe in something, or prescribe something, because "it sounds good" as opposed to "it is proven good."

Hippocrates observed this over 2,000 years ago when he said:

Instruction, to be beneficial, should be founded on facts. Arts are deduced from reflection; but any reflections or reasoning, not accompanied by facts, evince that fault somewhere exists. To think merely, and produce nothing, is a proof of error, or of ignorance especially in medicine. Here, opinion alone is criminal, and becomes injurious to the sick. Confidence in self-opinion is delusive, since fact too often proves its falsehood, as impure gold is tried in the furnace. The common remark, that “finis coronat opus (the end crowns the work),” is lost on such persons as I have pointed out, although the true method of attaining the science is daily manifested to all who desire its acquirement.

He then adds:

It may be concluded then, admitting the truth of the preceding remarks, that knowledge and medicine must go hand in hand. The physician who is truly a philosopher is a demigod. Medicine and philosophy are closely allied. That which is taught by the latter, is practised by the former,—contempt of riches, moderation, decency, modesty, honour, justice, affability, cleanliness, gravity, a just appreciation of all the wants of life, courage in adversity—opposition to fraud and superstition, and due consideration of the Divine power. The physician is perpetually exposed to the hazards of incontinence, turpitude, avarice, intemperance, detraction, and insolence. How far these may influence his character, may be estimated by his conduct towards his patients, his friends, and families.

Keep in mind here that philosophy was (is) the quest for wisdom, so physicians were not just educated in medicine, but all wisdom.  They were also knowledgeable in algebra, geometry, chemistry, astronomy, astrology, etc.  They were very well rounded in their education.

Yet  still, through it all, there was a tendency to theorize in medicine.  And even while there was always an attempt to use empirical evidence and science, the medical profession never quite made it all the way there.  Much of what we still do in the hospital is based on speculation.

Examples include oxygenating patient's who complain of symptoms even though their SpO2 is normal, or not oxygenating COPD patients based on the hypoxic drive myth.  Another example is giving Tylenol and Ventolin for the placebo affect.

Reference:

1. Hippocrates, "On decency in manner and dress," epitomised from the original Latin translations by John Redman Coxe, "The writings of Hippocrates and Galen," 1846, Philadelphia, Lindsay and Blakiston

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The birth of medicine

The quest for knowledge is philosophy.  Philosophers ask questions and search for answers.  These answers are called theories.  As better wisdom is obtained, better theories are formed.  Thus, it was out of philosophy that medicine was formed, only gradually becoming a profession of its own.

At the onset of the ancient world, at a time when civilizations were formed around 10,000 B.C., there were obviously men who sat around thinking, and these would have been the first philosophers.  Yet it wasn't until around 800 B.C. when philosophy gained any steam, and this occurred in ancient Greece around 400 B.C.

Greek citizens owned slaves who did all the work, and so they were able to spend their time however they wanted.  Those who were curious about the world became the first philosophers.  It was this circumstance that gave rise to the Age of Philosophers in ancient Greece.

Of this time in our history, medical historian Fielding Hudson Garrison, in his 1922 book "An introduction to the history of medicine," said:

Never before, or since, had so many men of genius appeared in the same narrow limits of space and time. (2, page 86)

Meryon said:

He lived at the most remarkable epoch of intellectual development, having as contemporaries the philosophers Socrates, Plato, and Xenophon; the statesman Pericles; the historians Herodotus and Thucydides; the poets Pindar, AEschylus, Euripides, Sophocles, and Aristophanes; and last, though not least, the sculptor Phidias. (1 page 22)

Medicine existed before the age of philosophers, although this medicine was mainly based on mythology and religion.  Health and disease were believed to be caused by the gods and cured by the gods. If you were sick you'd pray to the gods for forgiveness for your sins, and you'd make sacrifices to the gods hoping that by feeding him he'd become happy with you and bless you with good health.

If that didn't work you'd see a priest/physician for his recommendation.  You would spend a night in a temple to the god Asclepion, the god of health and healing, and while you were sleeping, the god would give you the cure in your dreams.  You'd tell the priest what you dreamed, and he'd interpret them for the remedy.

Hippocrates, and his fellow physicians at the school of Cos, were the first to help transition medicine away from this, and toward a practical science.  This was the beginning of medicine as we know it.

Now, much of the theories written by Hippocrates, and even by physicians as recently as the 1850s, might be considered spurious by the modern reader.  Regardless, it was viewed as quite rational by these older physicians, and the remedies, if nothing else, provided hope when there otherwise was no hope.

These theories kept medical wisdom alive through ancient Greece, and Rome, and then through the dark ages of medicine when all wisdom was lost.  Yet it would be found, and relearned, and finally was handed down to us.  And, especially since the year 1900, the medical profession has taken a 5,000 year leap through time.

So, while many of my friends say they hate philosophy, they are likewise saying they hate wisdom.  We must understand that it was through philosophy that medicine was born, only to take on an identity of its own over time.

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1743: The first mechanical ventilator

Stephen Hales (1677-1761)
 (1, page 328)

Stephen Hales was among the great men of science who lived during the 17th century. Among other achievements, he was the first to accurately measure blood pressure, and invented an artificial ventilator used to purify air into prisons, ships, and granaries.

He was born in 1677 into the world of Isaac Newton, the man who inspired the scientific revolution.  When Hales was only a boy of ten-years-old, Newton was at the peek of his career, publishing his book Philosophiæ Naturalis Principia Mathematica (Mathematical Principals of Natural Philosophy).  It was in this book Newton published his laws of motion and laws of universal gravitation.  Such wisdom, when he learned about it in school, must have inspired the young Hales. (4, page 66)

A young Hales would also have been influenced by Robert Boyle and John Mayow.  Boyle's was a great chemist (some say alchemist) who was best known for his use of the scientific method and creating Boyle's law, which states the inverse relationship between absolute pressure the volume of gas.  Mayow was such a great mind that, had he not died prematurely at the young age of 35, might have been the first to discover oxygen and carbon dioxide.  (4, page 66-67)

As those great men set a path for men like Hales, he would do the same for those who followed in his tracks, such as Joseph Black, who discovered carbon dioxide, Joseph Priestly, who discovered oxygen, Scheele, who also discovered oxygen, Lavoisier, who also discovered oxygen and gave it a name, and Henry Cavendish, who discovered hydrogen.

Hales entered Corpus Christi College, Cambridge, in 1696, and studied science, botany, and chemistry.  He was ordained in 1703, and he began his work on chemistry at the laboratory at Trinity College.  In 1709 he was appointed as minister to the Parish of Teddington, where he would spend the rest of his life. He was married in 1719, although his wife died in 1721.  lived died at the age of 83 in 1761.  (4, page 65)(5)

His main contributions to science and physiology came in his Statical Essays that were published in two parts Vegetable Statics, published in 1727, and Haemastaticks, published in 1733.  

In Vegetable Statics he discussed plant physiology and chemistry.  Yet his most significant contributions to our history come from his later work Haemastaticks, which is described by britannica.com as the most significant contribution to the physiology of blood circulation since the works of William Harvey. (5)

In this book he described an experiment where he inserted into a blood vessel and allowed blood to rise up the tube.  In this way he became the first person to accurately measure blood pressure. (5)

He also described measuring the capacity of the left ventricle of the heart, the output of the heart per minute, and the speed and resistance to flow of blood in the vessels.  (5)

He became very interested in the spread of disease, and was aware that people in close quarters were more likely to catch diseases.  Of course in his day, once you caught a disease such as tuberculosis, you were at the whim of God, meaning that there was little you could do but pray that you got better.

He knew that people who living in close quarters, in areas that were poorly ventilated, such as in prisons, ships, and granaries, were at an increased risk for becoming infected with diseases because they were all breathing the same stale air. Infections would easily spread from one person to another.  (2, pages 241-243)

So he set out to invent something that could be installed at these places to ventilate air from the outside in order to freshen the air inside.  What he ended up inventing was the first artificial mechanical ventilator which he introduced to the public in 1743.

He published his invention and opinions in his 1758 book "Treaties on Ventilators."

Sir John Simon wrote about "English Sanitary Institutions" in 1897, and explained how Stephen Hale's invention was also beneficial for people who spent time in prisons, military barracks, military hospitals, and aboard ships.  He said:

Dr. Hales's "lungs"... seem to have been often advantageously used in ships, prisons and hospitals (the military was) ordered by the Lords of the Admiralty to adapt his "fire-pipes" to His Majesty's Navy 4 Readers of the present day who may find it hard to imagine the " putrid " quality of the atmospheres which in those days the inmates of prisons and ships and barracks and hospitals had to breathe, can well assist their imagination by referring to the pages of Hales and other contemporary reformers. (3, page 119)

John Pringle (1707-1782)
(1, page 374)

The invention was helped along by John Pringle, who who was a surgeon general of the British Army from 1742-1758, and considered the father of modern military medicine. (1, page 373)

He studied the spread of disease among the military, particularly fevers.  He observed, along with others, that the more people were in a confined space, the greater likelihood the spread of fevers would be.  (2, pages 241-3)

Attributing it to the stale air inhaled, he championed to have Hale's mechanical ventilators installed in hospital wards.  (2, pages 241-3)

He discussed the importance of military sanitation, especially the importance of Hale's mechanical ventilator, in his 1752 book "Observations on the Diseases of the Army." He also wrote about the importance of antiseptics to prevent the spread of disease. (1, page 373)

The problem with the ventilator was electricity hadn't been invented yet, and so the machine had to be man powered.  So, not only was the machine itself expensive, it was expensive to work and maintain. (1, pages 241-3)

So many military hospital wards resorted the difficult task of maintaining wards in well ventilated places such as "barns, churches, or ruinous houses.  Of  course the simplest and least expensive solution was simply to keep patients in the same poorly ventilated wards they were already in.   (1, pages 241-3)

When this was the case, many such institutions worked hard to install as many windows as they could into such places.  When new places were built, as many windows as possible were installed.  Windows, therefore, were the least expensive option to improve ventilation, and by the late 1750s most hospitals had plenty of windows.  (1, pages 241-3)(2, pages 241-243)

Of course, Pringle also said there was an increased effort to try to keep patients separated.  This, along with better ventilation from open windows, seemed to help allay the problem, at least to a certain degree.  (2, pages 241-3)

It got to the point that there are stories of patients who were lying sick in bed looking up through the holes in the ceiling at the stars and moon in the night sky, or feeling the hot sun upon their bodies during the day.  This must have been a nice, refreshing atmosphere to get healthy in.

However, when the weather wasn't so friendly, such a venue must have posed a problem, especially when the rain or snow was falling.

To sum up the contributions of Hales I will quote Dr. Garrison:

Stephen Hales (was) an English clergyman of inventive genius, who enriched practical science in many ways, particularly as the originator of artificial ventilation."  (1, page 328) 

References:

1. Garrison, Fielding Hudson, "Introduciton to the history of medicine," 1922, London, W.B. Saunders Company
2. Hudson, George L, "British Military and Naval Medicine, 1600-1830," 2007, Amsterdam, New York, Editions Rodopi B.V.
3. Simon, John, "English Sanitary Institutions," 1897, 2nd edition, London, John Murray
4. Darwin, Francis, edited by Francis Wall Oliver, "Makers of British Botany," 1913, London, Cambridge University Press
5. "Stephen Hales," britannica.com, http://www.britannica.com/EBchecked/topic/252340/Stephen-Hales, accessed 7/11/14

Can evolution exist with Christianity?

Do you believe in evolution?  Do you ever think about it?  I think there is too much evidence to completely deny evolution, and I am a staunch believer that evolution and science and religion can all exist on the same planet.  Even Einstein was an ardent believer in both science and God. 

Pope Francis has a good quote on this topic: "We are not some casual, meaningless product of evolution. Each of us is the result of a thought of God."

You guys can believe whatever you want about evolution, but this is just my view.  This is how I think of it.  I think it's crazy to think that a creation as intelligent as humans, as complicated as we are, could just be created on a whim of nature.  I think nature was created by God, and we evolved from the primitive man God placed on this planet.  We grew.  We evolved into what we are today. 

There is another aspect that I try to swallow, and that is that if man evolved from apes, where are all the half man half apes.  Although, some scientists have discovered bones of humanoids like Lucy around campfires of of Neanderthals, suggesting that man saw its predecessor as competition and force them to become extinct.  You can use your imagination as to how they did this.

Can this type of extinction, of evolution, occur even if there is a God.  Why not?  Copernicus and many during his time had to wait until the end of their lives, or after their lives, to publish their research for fear the Church officials would kill or imprison them.  Ultimately, however, the Church came to understand that religion and science can both exist side by side.  Although some religions, such as the Muslim religion, have a tougher time with this, so it appears (correct me if I'm wrong). 

Thoughts?

Fear and depression may cause ill health

Surely it makes sense that if a perosn is scared to death, or if he is depressed, his immune system will be negatively effected.  We see this many times in the hospital setting, where an elderly person who is infested with disease is silent, which is a sign of depression.

In such a case, hopefully the physician is also trying to relieve the person's depression in order to facilitate healing.  Another option would be faith healing, where a priest comes in to see the patient to provide spiritual healing, which has been proven to promote happiness.  And this goes along with my theory that hope and faith in and of itself can facilitate healing.

On the other hand, as noted, fear and depression may make a person worse.  This was a topic that historian Fielding Hudson Garrison discussed in his 1922 history of medicine:

In surveying these different superstitions, one point becomes of especial moment. It is highly improbable that any of the remedies mentioned actually cured disease, but there is abundant evidence of the most trustworthy kind that there have been sick people who got well with the aid of nothing else. How did they get well? Short of accepting the existence of supernatural forces, we can only fall back upon such vague explanations as "the healing power of nature," the tendency of nature to throw off the materies morbi or to bring unstable chemical states to equilibrium, the latter being the most plausible. But, in many cases of a nervous nature or in neurotic individuals, there is indubitable evidence of the effect of the mind upon the body, and in such cases it is possible that a sensory impression may so influence the vasomotor centers or the internal secretions of the ductless glands as to bring about definite chemical changes in the blood, glands, or other tissues, which, in some cases, might constitute a "cure." We know that the reverse is possible, for example, in such occurrences as the whitening of the hair from intense grief or fear, or the production of convulsions in a suckling infant whose mother has been exposed to anger, fright, or other violent emotions before nursing it. As Loeb strongly puts it, "Since Pawlow and his pupils have succeeded in causing the secretion of saliva in the dog by means of optic and acoustic signals, it no longer seems strange to us that what the philosopher terms an 'idea' is a process which can cause chemical changes in the body."1 Billings compares the sensation obtained by placing the hand on a cold object in a dark room with the way in which the blood "runs cold" when one realizes that this object is a corpse.2 Crile's important studies of surgical shock show the strong analogy existing between the phenomena produced by shock, the extreme passion of fear, and the symptom-complex of Graves' disease, particularly in regard to the pouring out of the thyroid secretions and the destruction of the Purkinje cells in the brain. W. B. Cannon shows that in fear, rage, or anger, the emotions which prepare the animal for fight or flight, the digestive and sexual functions are immediately inhibited, the adrenal secretion is rapidly poured into the blood, mobilizing sugar from the hepatic glycogen up to the point of glycosuria, counteracting the effects of muscular fatigue, and hastening the coagulation time of the blood, thus giving the organism wonderful capacity for offence, defence, flight, and repair of injured tissues. A man in a fighting or frightened mood is a ductless gland phenomenon. The pathological effect of ideas upon the sacral autonomic is seen in the

A little knowledge from our past.

Worshiping myths results from ignorance

I write on this blog often how ignorance impedes progress.  I came upon an excellent discussion of this by the greate historian Fielding Hudson Garrison. Sorry this passage is long, but it's worth the read:

Buckle* maintained that ignorance and low-grade minds are the cause of fanaticism and superstition, and, since his equation is reversible, we may consider this proposition true if we apply it to certain fanatical leaders of mankind, savage or civilized, who, as "moulders of public opinion," have retarded human progress. Chamfort said that there are centuries in which public opinion is the most imbecile of all opinions, but this reproach cannot be entirely saddled upon "the complaining millions of men." History teaches everywhere that permanent ignorance and superstition are the results of the oppression of mankind by fanatical overmen. In medicine, this is sometimes ludicrously true. "There is nothing men will not do," says Holmes, "there is nothing they have not done to recover their health and save their lives. They have submitted to be half-drowned in water, and half-choked with gases, to be buried up to their chins in earth, to be seared with hot irons like galley-slaves, to be crimped with knives like codfish, to have needles thrust into their flesh, and bonfires kindled on their skin, to swallow all sorts of abominations, and to pay for all this, as if to be singed and scalded were a costly privilege, as if blisters were a blessing, and leeches a luxury. What more can be asked to prove their honesty and sincerity?"1 Yet while the lack of public enlightenment in certain periods produced the stationary or discontinuous mind, there are signs that the modern organized advancement of science may bring forth rich fruit for the medicine of the future through the social cooperation of the mass of mankind with the medical profession. As the ancient Greeks hung upon the teachings of Empedocles and Hippocrates, as modern humanity responded beautifully to the ideas of Jenner, Pasteur, and Lister, so there has been at no time a greater interest in the advancement of medicine and public health, as manifested in periodicals and newspapers, than in our own. The awakening of the people to looking after their own interests in regard to the organization and administration of public hygiene is, no doubt, the hope of the preventive medicine of the distant future. Yet, even under the best conditions, it is still possible and probable that many highly intelligent and highly educated persons will continue to hug their whims and superstitions, consult quacks, and be otherwise amenable to psychotherapy, absent treatment and "action at a distance." "To folk-medicine," says Allbutt, "doubt is unknown; it brings the peace of security."

It's interesting that this observation was made in 1922 and it still holds true today, 91 years later.  We still have doctors who believe in myths, and as we know, a myth is something that is based on superstitions and feelings as opposed to fact.  A myth is something that has never been proven, such that ventolin treats pneumonia, CHF and pulmonary fibrosis, or that oxygen will knock out a COPD retainers hypoxic drive.  Surely you know such are myths, as they have never bee proven, although they are treated as facts by God knows how many people -- way too many people.

A few good examples can be found in my post: The 15 biggest myths of respiratory therapy. 

*I have no idea who this is.  In many older history books the author generally uses last names without any further knowledge on who the person was.  Although I imagine he was a smart man

From the black art to the first apothecary shop

We must first remember that white magic was considered magic that made people feel better, and black magic was magic that made people feel worse.  Now we must consider that chemistry was originally referred to as the black art.

Chemistry comes from the term "chemi" which comes from Ancient Greek and refers to the Black Land, which was the term for Egypt due to black soot left after the annual flooding of the Nile River (this black soot fertilized the land).  Although some speculate the term "chemistry" came from the term al-kimia which means to cast together.

To be more specific, the Greek historian Plutarch (46-120 A.D.) referred to the land of Egypt as Chamia, and from Chamia, or Chimia, comes the term Chemistry.  It's also sometimes referred to as Chymistry.  Scripture writes of the land of Cham, which is in reference to Egypt, the Black Land, or the birthplace of Chemistry. 

The Greeks learned of the Black Land and of the Black art through people who traveled as traders between the two lands.  The Egyptians are considered by many to be the first to mix various chemicals to come up with substances, many of which we still use today (such as make up, perfumes, soaps, dyes, distillation, leather, glass, alloys and amalgams, and more).

So Chemistry was learned by the Greeks from the Egyptians, and the Romans learned it from the Greeks and the Egyptians.  Physicians would eventually learn of various herbs that would be mixed in such a way by apothecaries who would provide remedies to the physician.  In this way, the chemists, the pharmacist, was a middle man who worked between those who discovered and found the various herbs and the physician.  It wouldn't be until the 5th century A.D. that the Arabs would form the first apothecaries who worked between the physician and the patient.

Chemistry was still a vague skeleton of the Egyptian art all the way to the 19th century, at which time science became more prevalent in the United States and Europe.  Since then the art of Chemistry has grown into the full and flourishing tree -- the full and flourishing complicated tree -- that it is today.  Thus, Chemistry essentially started out as an attempt to blend various roots and herbs into remedies.  And thus we have the birth of the pharmacy profession. 

Check out these tracheostomy tubes from 1866

If you guys thought tracheostomy tubes were a modern tool for physicians, think again.  The following is an advertisement from the a physician's catalog of S. May and Son from 1866:

DOUBLE TRACHEOTOMY CANULAS, of silver, three axes, improved, as Pig. 6.

each 22/-, 23/-, and 1 4 0 The outer canula of this instrument can be introduced quite flat.

£ s. rf.

IMPROVED DOUBLE TRACHEOTOMY CANULAS, of silver, three sizes, improved,

as Fig. 7 24/6, 26/6, and 1 8 0

This instrument allows the patient free motion of the head. 

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 85

The best remedy is hope and faith

I have noted many times on this blog how I think the best cure of disease is faith and hope.  This is especially true when a physician's drugs no longer do any good.  It was especially true prior to the 1900s when modern science gave us medicines that actually help patients.  It was especially true in the days when most medicines made a person feel worse, and sometimes even killed them. 

Fielding Hudson Garrison was a historian who wrote about this in his book "An introduction to the history of medicine" in 1922.  He wrote:

 "The best inspirer of hope is the best physician," an aphorism which contains the germ of the Freudian theory of psycho-analysis—to "minister to the mind diseased" by removing the splinter of worry or misery from the brain, in order to restore the patient to a cheerful state of mental equilibrium... It is also the secret of the influence of religion upon mankind, and here the priest or pastor becomes, in the truest sense, tin Arzt der Seele. In practical medicine, the principle now has a definite footing as psychotherapy... Psychotherapy cannot knit a fractured bone, antagonize the action of poisons, or heal a specific infection, but in many bodily ills, especially of the nervous system, its use is far more efficient and respectable than that of many a drug which is claimed to be a specific in an unimaginable number of disorders. (1, page 33-34)

He also discussed a variety of ancient remedies, which included spells and charms, amulets and talismen, and he speculated that these were pobably the best remedies, as compared to recipes for medicine.  He wrote:

In surveying these different superstitions, one point becomes of especial moment. It is highly improbable that any of the remedies mentioned actually cured disease, but there is abundant evidence of the most trustworthy kind that there have been sick people who got well with the aid of nothing else. How did they get well? Short of accepting the existence of supernatural forces, we can only fall back upon such vague explanations as "the healing power of nature," the tendency of nature to throw off the materies morbi or to bring unstable chemical states to equilibrium, the latter being the most plausible. But, in many cases of a nervous nature or in neurotic individuals, there is indubitable evidence of the effect of the mind upon the body, and in such cases it is possible that a sensory impression may so influence the vasomotor centers or the internal secretions of the ductless glands as to bring about definite chemical changes in the blood, glands, or other tissues, which, in some cases, might constitute a "cure."

Every study on the subject has proven it.  But who needs studies when you have historical observations and common sense.

References:

1. Garrison, Fielding Hudson, "An introduction to the history of medicine," 1922, 3rd edition, Philadelphia and London, W.B. Saunders Company

1866 Stethoscopes

Check out these stethoscopes from the a physician's catalog of S. May and Son from 1866:

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

Oxygen tanks are not really tanks. Huh?

Did you know that oxygen tanks aren't really tanks?  It's true.  The technical term for a gas stored in such a fashion is not tanks, but bottled gas.

A tank refers to a container that stores gases at ambient temperatures and has an open top.  Oxygen tanks do not have an open top.  Oxygen is stored in pressurized containers, or bottles. The containers must be sealed, and therefore cannot be open at the top.

Yet for whatever reason the word "tank" was used initially instead of pressurized bottles, and so the term stuck.  While the term pressurized bottles is used in Europe, here in the U.S. we refer to oxygen containers as oxygen tanks or cylinders.

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1983: Alupent available over the counter

In March of 1983 a thin, high shouldered 13-year-old boy named Rick Frea (me) walked into the Revco Pharmacy in Shoreline, Michigan, found his way to the cold and allergy section, and plucked a little gold, green and white box off the shelf.  He checked the label, which said:  Alupent Inhalation Aerosol with mouthpiece (metaproterenol sulphate).  His blue lips spread into a huge smile, "Could it be this easy?" he thought.

He walked stiffly and anxiously to check out, afraid the clerk would say something, especially considering he just bought one from the pharmacist six days ago.  But that one was empty, of no use to him, and now he needed a new one.  He felt guilty about squirting it empty so quick, and now that it was over the counter he wouldn't have to guilt his way past the pesky pharmacist.

As he stepped out into the cool March air a sense of relief brushed through him.  His lungs felt stiff and heavy, although he learned to fake that he could breathe normal.  But I can't take a puff here, he thought.  Don't want that pesky pharmacist to have any chance to see me.  

He briskly walked across the parking lot, across U.S. 31, and into the wooded pines onto a trail that went up a hill and out of distance of the cars and the K-mart, Revco and Eberhardt shoppers across  the street, and there was no way that pesky pharmacist would see him (as though the pharmacist had nothing better to do).  He stopped, ripped open the box, cast it aside, and held the full inhaler in his grasp.  He took off the little white round cap, and inserted the mouthpiece into his mouth.

A week later he repeated these actions, and walked through the Revco with an equal amount of guilt and anxiety.  Only the next time he used his own money, considering he was afraid to ask his mother for fear that she would question his over use.

Three months later the product wasn't on the shelves.  He asked the clerk, and she said, while chomping on her gum, "Yeah, well, ah, that's the medicine they decided couldn't be on the shelves anymore.  You'll have to talk to the pharmacist."  No way am I going to do that, he thought, and he left the store disappointed.

Instead, he huffed and puffed his way back home and stressed about telling his mom she needed to spend money on a new inhaler.  Now he was back to where he was in February.  He didn't tell his mom how bad he was breathing, and so she took her time coming home that evening.  Rick anxiously watched for her from the living room window.

Soon it was dark, and lights approached the driveway.  It was her.  "Mom, you have my inhaler?"  She said, "I forgot it. I just got you one last week, though.  What happened to that one?"  So then Rick confessed how miserable he felt, and so his mother went back to the pharmacy she just left. Now Rick felt guilty to go along with anxious and short of breath. He was to the point of panic, yet he managed to stay calm, somehow, someway.  It's what he always did.

So such was the dilemma of being a thirteen year old hardluck asthmatic in 1983.  Someone felt his pain by allowing for the inhaler to be purchased over the counter, yet someone else didn't care about Rick, and took the inhaler back off the shelves.  Yet the sun  rose again the next day, and his breathing continued, at least enough to keep him at home and alive.

The ironic thing was, his doctor knew about his overuse, and even gave him permission.  Rick  specifically brought it up once:  "Um," he said while sitting on the edge of the doctor bed, fingers pressed into the paper covering, "Is it... do you think, um, that it's okay that I'm using my inhaler a lot?  I mean, um, er, sometimes I feel guilty about this."

The doctor new him for a year now, and even came to the office special on his nights off to see the boy.  A couple times he even gave an injection of Susphrine to the boy in his office, which always brought about instant relief.  So he new how bad his asthma was; that it was worse than your typical case.  The doctor was silent a moment, as though searching for the right words. "Don't feel guilty about it.  It's something you need," Dr. Oliver said, speaking slowly. "The alternative is you'll damage your heart if you can't breathe.  I think you need it.  You need to breathe."

Thinking about this conversation all these years later has Rick still wondering why his doctor never gave Rick a warning about using his inhaler too much.  Yet these were different times.  There were no great asthma medicines, and asthma wisdom was different back when Dr. Oliver went to medical school.  He did what was best for the times.  Yet, as we know, when we learn better we do better.

The boy didn't feel comfortable with his doctor's answer, though.  He could tell the doctor didn't feel comfortable with what he said either.  Yet, again in retrospect, Rick knows words can sometimes be hard to find.  The doctor must have known if it weren't for that little inhaler there would be no life in Rick's life.  Rick wasn't able to do much as it was, but if he didn't have that inhaler, he wouldn't be able to even sit in his favorite chair watching his favorite show without suffering.  He'd simply stay in his bedroom, with the window open, gasping for air.

Surely, you're thinking, he could go to the emergency room, but that only gave relief for a while.  Supposedly he could live in a bubble.  He could be on systemic steroids, but there were risks to those medicines too, far greater risks than Alupent.  So the doctor gave Rick what he wanted, what he needed, and continued to renew his Alupent prescription.  Yet his doctor worried a great deal about young Rick Frea, and it's for that reason he met him and his mom so many times after hours at his office.

For the record, this boy was on all the best asthma medicine.  He had an inhaler called Vanceril (Beclomethasone) that he took two puffs of every eight hours.  He had a dry powdered capsule that he inhaled by using the spinhaler twice a day.  But even with all that medicine, he continued to suffer from asthma.  He had what he would define twenty-five years later as hardluck asthma.

So by July of 1983 Alupent was no longer available over the counter.  Rick's mom said she read that seven kids died from overusing it, so the FDA took it off the market, although this was merely heresy.  Regardless, he would no longer be able to bypass the doctor and pharmacist.  Yet it really didn't matter for this asthmatic, because he never stopped seeing his doctor, and he was on all the best asthma medicines.  He may not have been a gallant asthmatic (another term Rick later defined), but considering his age and all the medicines he was ordered to take, he did fairly well.

Twenty-five years later, with his asthma controlled thanks to better asthma medicines, he was asked to write a weekly column for the Health Central Network about living with asthma.  After defining the eleven types of asthmatics, he wrote a column about how Alupent used to be available over the counter.  His editor read it and said, "Can you prove it was available over the counter?"  Rick surfed the Internet and found nothing on the subject.  The column was scrapped.

On January 4, 2012, while his two older children were at school, and his wife relaxing at home, he took his one year old son and three year old daughter to the library.  After story and craft, while the kids were playing with Mrs. Sue's toys, Rick searched for a book that might interest him.  By mere luck he found a book called "Breathing Space: How allergies Shape Our Lives and Landscapes," by Gregg Mittman.

He quickly perused the book and, by mere chance, came upon "Chapter 6: An Inhaler in Every Pocket."  This was a well written chapter on the history of inhalers, and considering Rick was writing his own version of this history for his blog, Hardluck Asthma, he was especially interested.  What really sparked his interest was what Mittman wrote on page 243:

From 1973 to 1985, an estimated 6 billion doses of metraproterenol sulfate (that's Alupent) had been consumed by asthmatic Americans...

Let's stop there a moment.  Considering back in 1983 Rick went through an inhaler on average of one week, and there are about 200 puffs in each inhaler, that means that Rick alone was responsible for over 10,000 of those 6 billion doses.  Wow!

Although, it should be noted, that sometimes Rick was able to make it two weeks, and occasionally a month, with one inhaler.  So even if he was able to have a few good months in the mix, at a minimum he inhaled over 5,000 puffs that year.  That is a stunning amount of puffs.

Now, back to Mittman:

...while revenues from the sale of 20 million inhalers helped sustain the U.S. economy as well as Boehringer Ingelheim.  In the 1970s, growing public skepticism about the health care industry and rising inflation in health care costs spurred the FDA to take action.  It began a systematic review of prescription drugs that might merit OTC (over the counter) status for metaproterenol sulfate inhalers -- specifically Alupent and Metaprel, made by Dorsey Laboratories.  Basing its decision on available evidence, the FDA argued that Alupent and Metaprel were as safe as and 'more effective than currently available OTC epinephrine (inhalers)' such as Primitine Mist.

The first time Alupent was squirted into my mouth was by my doctor in 1980.  At first Rick used it exactly as prescribed, which was no more often than every 4-6 hours.  But after a while he realized his breathing was heavy between puffs, and the idea of taking an extra puffs rolled over in his mind.  Finally he just did it.  Nothing bad happened.  So then he did it again.

Before long he was a bronchodilatoraholic (yet another term Rick later coined), using his inhaler much more often than the manufacturer and physician recommendation.  There were nights his heart was beating so loud in his chest he got on his hands and knees and prayed that he'd wake up in the morning, and every morning his prayer came true.  It's based on this side effect that the Rick Frea of 2012 thought the idea to pull Alupent back off the shelves was probably a good idea.  Mittman continues:

In March 1983, boehringer Ingelheim launched an intensive television advertising campaign notifying asthma patients that "prescription strength" Alupent was not available without the need to see a doctor."

Yay!!   Here is where the young Rick Frea jumped for joy.  Yet the joy was short lived.

The AAAI (American Academy of Allergy and Immunology), the American College of Allergy, and other medical organizations and clinicians were up in arms.  England's bronchodilator scare of the 1960s came to the forefront of doctor's minds, but an awareness of lost market share in allergic bodies no doubt did as well.  James Mann, an FDA physician, told the New York Times that such critics were simply opposed to 'the whole concept of over-the-counter marketing' with its emphasis on self-medication by patients."  But when the threat of a congressional inquiry by the House Subcommitte for Oversights and Investigations appeared, the FDA rescinded its ruling.  In less than three months, Alupent and Metaprel were removed from the cough and cold sections of drugstore shelves and were back on the pharmacist's shelf as prescription-only drugs."

So what happened in 1960 that scared the medical profession so much?   Well, you have to realize that the first rescue inhaler to be introduced to the market occurred in 1956 with the release of Medihaler Epi (epinephrine) and Medihaler Iso (Isopreterenol).  They were both available over the counter, and you'd guess correctly if you said asthmatics flocked to their local pharmacies in search of one of these inhalers, and quickly fell in love with them.  For the first time ever they had access to convenient quick relief, and they could keep it in their pockets.  It became known as the rescue inhaler, quick relief inhaler, pressurized inhaler, puffer, and metered dose inhaler (because it had a controlled dose).

As noted by Mittman:

During the 1960s, their rate of growth far exceeded that of antihistamines in the allergy drug trade.  With over $37 million in sales in 1970, prescribed bronchodilators had surpassed the earnings of antihistamines by over $1 million.  Asthma, once a small, specialized niche market for the drug industry, was starting to look like a field for lucrative growth and market expansion."

So this was good, right?  It was especially good for asthmatics, right?  Well, what happened next made people leery of the OTC rescue inhaler market.  Mittman writes:

By the late 1960s, medical opinion considered the use of bronchodilator inhalers as the most likely explanation for the marked increase in asthma deaths... pressurized inhalers first became available in England in 1960.  Over the next five years, their sales increased four-fold.  Inhalers such as medihaler-Iso were those most commonly found in the medicine cabinets of patients who died.  Of the patients who died, 86 percent had inhaled bronchodilators within the last month of their life.  

So, was the increase in asthma related deaths the result of the inhalers, or just a sign of the increase in the number of people being diagnosed with asthma?  Were overuse of inhalers killing people?  Or, was it because asthmatics were staying home and depending on their inhalers when they should have gone to get help?  Was it just due to lack of education?  Mittman notes this, and says:

Correlation, however, does not prove causation.  Researchers cited many reasons why inhaler use might be a factor in the rise in asthma deaths.  One explanation suggested that the deaths simply reflected cases of patients with severe asthma who had relied on self-medication with OTC bronchodilators rather than seeking medical attention.  Other hypotheses focused on the side effects of chemicals in the freon-propelled, metered dose inhalers.  Once in the circulatory system, isoproterenol might readily induce abnormal heart rhythyms in an organ already sensitized by low levels of arterial oxygen or by the flourinated hydrocarbons used as propellants.  Alternately, excessive use of bronchodilators might cause a rebound effect by exacerbating rather than reducing the constriction of the airways.  Whatever reason, Britain's Committee on Safety of Drugs believed the evidence warranted a ban on direct sales to the public of bronchodilator inhalers.  And asthma deaths promptly declined.  

Yet in the United States the medicine remained on the shelves, and sales spiked from "3.3 million in 1964 to 5.1 million in 1968."  And with what happened in Britain on their minds, physicians observed "disturbing reports of abuse." by patients "addicted" to their rescue inhalers, many of whom died with the inhaler clutched in their grasp.

Mittman continues:

The abuse of bronchodilators prompted American physicians to urge caution in treating asthma through drugs alone.  In 1969, the Allergy committee of the American College of Chest Physicians voted to urge the FDA to limit availability of OTC bronchodilator drugs.  Possible harmful effects also led to greater caution among physicians in prescribing metered-dose inhalers.  (By 1970) refill prescriptions of Riker's medihaler-Iso plummeted by more than 40 percent."

So now, instead of using a medicine that would help them, many asthmatics resorted to the old technique of suffering through an asthma attack instead of using their readily available rescue inhaler.  Scientists still do not know why the spike in deaths in the 1960s, yet the rescue inhaler is still believed by many to be the cause.  

While an epinephrine inhaler marketed as Primatene Mist was displayed next to the Alupent inhaler in March of 1983, Rick bought only one of them once.  He didn't think the inhaler did any good.  He puffed through that inhaler in only a few days.  Unlike what his doctor said about Primatene Mist, he didn't notice any side effects from using it this much.  As a matter of fact, Alupent had more side effects, he thought, than the OTC epinephrine inhaler.  By 1983 Isoproterenol was no longer available as an inhaler, so Rick never had the option to try it, which may have been a good thing, as Iso was believed to be much more potent than Epi.

The Alupent inhaler was much better, he decided, and, according to his doctor, much safer.  And this kind of frustrated Rick, because if it was safer, then why was it taken off the shelves in July 1983? It made no sense.  Yet he was unaware of the 1960 scare and, in a pre-Internet world, had no real means of learning about it.  Yet it was through a book written by Gregg Mittman in 2007 that he learned the answers so many years later.

After the July 1983 decision by the FDA asthmatics could still use rescue medicine, yet at least their pharmacist and doctor would know about it.  To get the medicine, the pharmacist would question the asthmatic, and this happened to me quite a bit.  It's always annoying when a pharmacist does this, yet the professional is just doing his or her job.

To continue getting it the doctor would have to write the prescription, as doctor Oliver so duly did for Rick Frea. In 1985 Rick was introduced to another rescue inhaler called Albuterol (Ventolin), and this one is even safer than Alupent.  So this opens the door for another debate: should Ventolin be available over the counter?

For more respiratory therapy history, click on over to my Hardluck Asthma blog.

References:

1. Mittman, Gregg, "Breathing Space: How Allergies Shape OUr Lives and landscapes," 2007, New Haven and London, Yale University Press, pages 206-250.  Mittman's book is a must buy, as he provides an easy to read history of allergies and asthma.  I endorse this book.

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19th century nebulizers

Dictionary.com provides us with the definition of nebulize:  "to reduce to fine spray; atomize."  And thus a nebulizer, then, would be any mechanical device that can "atomize" a solution and reduce it to a fine spray."  Quite often we refer to this spray as a mist.  So a nebulizer is any device that can create a mist. 

Turning a solution into a mist is a good means of getting medicine down into the lungs, where it's needed and can be of use.  Nebulizers were basically believed to break a solution into atoms, and thus the first nebulizers were often referred to as atomizers.  The process of creating a mist was thus termed atomization.   

Some of the first nebulizers were described by John M. Scutter in his 1867 book "On the use of medicated inhalations in the treatment of diseases of the respiratory organs.  The book was one of the first specifically dedicated to inhalation therapies, including devices to deliver it and the medications.  If the respiratory therapy profession existed back then, it would have been a must read. 

Nebulizers basically work based on the Bernoulli Principle.  The idea comes from the observation that when water hits a rock it creates a mist that can be inhaled.  Daniel Bernoulli published a book in 1738 where he described that a similar effect could be created by forcing water through a narrow tube. The faster water flows through a tube, the less the lateral pressure will be.  Thus, in nebulizer air is forced through a narrow tube, and fluid is entrained into the narrow opening.  The fluid is basically sucked in due to the negative sidewall pressure, and turned into a mist to be inhaled. (2, page 61)

So anyway, the following are the first nebulizers according to Scutter.  I will allow him to do the describing. (see pages 26-36):

Elsberg's Nebulizer

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

Sales-Giron's Nebulizer

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

3.   Dr. Mackenzie's Nebulizer:  "The apparatus of Dr. Mackenzie is a very good one. The piston is drawn back by a wheel and rack at its upper part, and is forced down by a circular spring which surrounds the cylinder. The apparatus is filled with liquid by a funnel in its top, and all the spray, except that which is inhaled, passes back into the apparatus. He claims the following advantages for  it:  1. Its simplicity, requiring only a few turns of a handle to set it in operation. 2. The extremely fine state of subdivision which it effects. 3. The uniform pressure exerted. 4. The fact that the Waste liquid returns into the apparatus. 5. The ease with which it can be taken to pieces and cleaned."

Dr. Seigle's Inhaler

4.  Dr. Seigle's Inhaler:  "The third form of apparatus is that of Dr. Seigle, and is preferable to the others, for its simplicity and because it is automatic. The best reason for preferring it, however, is, that its price is such as to bring it within the means of any patient, as it is furnished through the druggists for$5,00, and its construction is so simple, that it is readily operated by any one."  The inhaler (or nebulizer) is designed so that steam provides the flow that makes the bournoulli principle work, and in this way the operator doesn't need assistance to create a mist.  The device simply sits on a table and the patient can enjoy the mist, and hopefully relief in breathing.  I will describe this inhaler in greater detail in a later post. 

So these are your basic nebulizers of the 19th century.  It's basically what you had to deal with until the 1930s when electricity became available. 

References:

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