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Beverley Robinson.

A manual on inhalers, inhalations and inhalants; and guide to their discriminating use in the treatment of common catarrhal diseases of the respiratory tract online

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A MANUAL



Inhalers, Inhalations and Inhalants



AND
GUIDE TO
-THEIR DISCRIMINATING USE-
IN THE TREATMENT
OF



COMMON CATARRHAL DISEASES

OF THE

RESPIRATORY TRACT.



BEVERLEY ROBINSON, M. D.,

M
Clinical Professor of Medicine at the Bellevue Hospital
Medical College, New York.



Second Edition.




1888.
GEORGE S. DAVIS,

DETROIT. MICH.



Copyrighted by
GEORGE S. DAVIS.



■Hftnuv tmpitf



BIOLOGY

UBRARY






INTRODUCTION.

I am convinced that a small book on inhalers,
inhalations, and inhalants, is needed by general prac-
titioners of medicine. First, because the text-books
for sale are somewhat out of date. Second, because
those obtainable do not answer actual requirements,
owing to their size and completeness. By this criti-
cism, I mean particularly that many inhalers are
described in detail, which are no longer employed at
all — and, indeed, never were used, except perhaps by
the inventors — and views are related at length, which
were formerly debatable, but now are settled definitely.
I am of the opinion, also, that books of this sort are
useful only when based upon personal experience, and
also provided they express individual convictions, and
not simply the opinions of others.



M51409



CHAPTER I.

MEDICATED SPRAYS.

The kinds of atomizers in ordinary use are
numerous.

Some throw a very coarse spray, like Leffert's
(fig. i), and are mainly useful as instruments for




Fig. i. — Leffert's Nasal Spray Apparatus.

cleansing purposes in diseases of the nose and throat;
others project a medium coarse spray (fig. 2) or a
quite fine spray (fig. 3), and with proper limitations,
are serviceable as a means of local medication.

All hand atomizers are worked by means of either
a single or by two rubber bulbs. Two bulbs produce
a continuous spray, as the middle bulb, or the one
next the bottle of the atomizer, acts as a receiver for



.:;:•>;'; — 6 —

compressed air. A single bulb causes an interrupted
spray,, which is almost continuous whenever the bulb
is pressed repeatedly and rapidly with the hand. If a
continous spray is in use, the end bulb must not be
pressed upon previous to withdrawal of the nozzle,
during the time the middle bulb is emptying itself of




Fig. 2. — Goodyear Flexible Tube Atomizer.

the compressed air. Otherwise the spray will continue
to be formed, and, whenever the nozzle of the atomizer
is removed from the nares, or mouth, will wet and soil
the patient's face and clothing. It can be appreciated
how annoying this occurrence is, both to the patient
and physician, and particularly, if a staining fluid like
nitrate of silver, or iron, is used.

If the bottle of the atomizer contains a non-stain-



— 7 —
ing liquid, the resulting damage, or disagreeable effect,
is not so great.

The advantage of the single bulb lies in the fact
that when the pressure with the hand ceases the effect
passes away within a few seconds, and the spray
stops, and in withdrawing the instrument, there is
little, or no risk of wetting the patient with the atom-
ized fluid.




p IG 3 — Davidson Hard rubber Atomizer,

CONTINUOUS SPRAY (WITH TWO TIPS).

In the Goodyear Atomizer (fig. 2), the tubes
being made of fine metal, may be bent at will, and
the volume of the spray can be regulated by straight-
ening the tube, and then turning the inner tube to
right or left. Do this before using the tube, thus
assuring such a spray as may be desired. The inner
tube may be unscrewed and removed for facility of
cleaning it if it should become clogged. The sim-



plicity of its construction, and its adjustability to

most cases, render this a very desirable instrument.*

The most improved form of atomizing tubes are

those known as Sass' spray tubes (fig. 4). They were




Fig. 4. — Sass' Hard-rubber Spray Tubes.

originally made of glass. They are now made of
metal and hard rubber. The latter tubes are less
liable to break than the former, Neither do they sepa-
rate from each other, since the two tubes, horizontal
and vertical, are not cemented together, but are joined
firmly by solder, or rubber. The tube of Sass, in
order to be effectually used, must be employed



*The description here given is taken from the Goodyear
Company's circular, and only changed so far as to be, in my
opinion, entirely accurate.



— 9



by means of compressed air from a suitable air-
receiver which contains air under a pressure of at
least 20 to 30 pounds to the square inch (fig. 5). It




Fig. 5.— Compressed-air Spray Apparatus.

is manifest that no such pressure can, be kept up for
any length of time with the ordinary hand bulb, as the
fatigue of working it would soon become too consid-
erable for anyone of moderate strength. Further, it
is probable that the bulbs, or bulb, would soon give
way, or lose their elasticity, and thus become inoper-
ative.

Many of the hand-ball atomizers, as well as the
spray-producers of Sass, work upon the same prin-
ciple. The cold medicated fluid is contained in a
small bottle of suitable shape and size. Into this



bottle, and to within a few lines of its bottom, passes
the lower portion of the vertical spray-tube. Ordinar-
ily — although this is not an absolute requirement for
use — this spray-tube is held tightly at the neck of the
bottle by a perforated stopper in rubber or cork,
through which it passes. A small triangular wedge is
cut on the margin of the stopper and through its en-
tire length, so as to allow the air-pressure to exert it-
self upon the surface of the fluid in the bottle.

To the proximal extremity of the upper tube of
the atomizer, the rubber tubing, connected with the
rubber bulb, or bulbs, is attached. When pressure is
made with the single bulb, the air from it is driven
with more or less force directly along the horizontal
tube of the spray tube. Of course when two bulbs
are used the air passes first into the middle bulb and
then from it through the horizontal tube, and escapes
at its distal extremity. The current of air thus pro-
duced draws up, on account of the vacuum formed in
the lower tube, the liquid in the bottle, which is trans-
formed into spray very near the two spray-tubes at
their farthest end, where they incline to each other at
right angles.

In many hand-ball atomizers the pressure of the
air from the bulb acts directly upon the surface of the
liquid contained in the bottle of the spray-producer
through a hole or tube, merely passing through the
stopper. The liquid in the bottle is thus forced up
through a somewhat fine tube which enters it, as



in the other form described, and owing to progres-
sive narrowing of this tube, when the liquid approxi-
mates its outer extremity, or tip, it takes the form of
spray. The walls of the tip itself have everywhere a
thickness of several lines, and its shape is ordinarily
oval. Sometimes the tip, instead of being fixed upon
the tube, which goes to and passes through the stopper
and into the liquid, is movable, and is either slipped
or screwed on the extremity of this tube. In that case
several tips of different shapes and curves are usually
sold with the same atomizer.

In the instrument just described, the inner tube
terminates by a small orifice, when it reaches the mov-
able tip, but not yet small enough to produce a spray,
so that when the movable tip is taken off and the bulb
worked with the hand, the liquid flows from it in a
very small stream, and a spray is produced only when
the movable tip is replaced. A precaution, in regard
to the use of movable tips in the throat, is worth men-
tioning. Never make use of a movable tip, in spray-
ing either the larynx or the naso-pharynx, which slips
on the main tube of the atomizer, as it is liable to fall
off and lodge in the throat, thus causing distressing
and dangerous asphyxia.

Movable tips of any kind are rendered unnecessary
by the use of Goodyear 's atomizer, as in this one the
main tube can be bent in any required direction, with-
out obstructing the inner tube, or interfering at all
with the formation of a spray. The objections to this



form of atomizer are two. i. If the tip or tube be-
comes occluded it is cleared with more difficulty than
those atomizers in which the tip is movable, and the
inner tube at its distal extremity is of somewhat larger
calibre.* 2. By reason of the relatively soft quality
of the rubber of which the outer layer of the spray
tube is made, it is not so durable, when bent frequently,
as the more solid spray-producer made of hard rub-
ber. Still, despite these objections, I have found
it to be a serviceable instrument and therefore
recommend it. Usually, when its terminal extremity
has become obstructed, I have been able to loosen
any impacted substance, if it be soluble, by soak-
ing the end in warm water for a few moments; after-
wards the force exercised by the bulb is sufficient to
free it completely. A slender wire is, also, often
serviceable for the same purpose, when the other
method fails. A hard rubber atomizer made by
Riker (fig. 6) is provided with a tongue depressor of
the same material attached to the tube. This addi-
tion is very practical as it enables the physician or pa-
tient to use it with great advantage in holding the
tongue down and out of the way of the spray. In re-
gard to the utility of cold tnedicated sprays\ and the
instruments, of course, which produce them, opinions



* This objection cannot be made to their atomisers at
present, as the tips are movable.

fBy cold sprays I mean in this place and elsewhere,
those having a temperature of about 80° F.



— 13 —
differ. My own belief is that as a cleansing instrument
for diseases of the anterior and middle nasal passages,
no one is more generally useful than Leffert's (fig. i).




Fig. 6. — Riker's Hard-Rubber Atomizer.

Whenever these parts are partially, or completely
coated with mucus, or pus in a fluid, semi-solid, or
dried, inspissated state, the more or less frequent and
prolonged use of a coarse spray is our best means of
ridding them of these secretions.



— 14 —

The fountain syringe and Davidson's syringe are
both objectionable:

i. They may occasion median otitis by reason of
an excessive flow of fluid, which fills the nose, and
under pressure may pass into the eustachian orifices.

2. The stream of watery fluid which is made in
their use is more irritating to the pituitary membrane
than a coarse spray.

3. The fluid does not reach the upper portion of
the nasal fossae, and naso-pharynx, as a rule, and hence
does not loosen and detach morbid secretions from
these regions so thoroughly.

On the other hand, in instances of old fetid and
atrophic coryza, the time required for the effective
use of a coarse spray is often so considerable, that we
are glad to recur to the use of instruments which
furnish a large amount of cleansing fluid in a short
time. In ridding the naso-pharynx, therefore, of
secretions similar in character to those mentioned in
the anterior and middle nasal passages, a moderately
coarse spray may be used at times advantageously,
but when the mucus is very hard and adherent, it is
preferable to employ the posterior nasal syringe
(fig. 7), as we cannot then use the spray long enough,
on account of intolerance of the patient's throat, to
render it entirely satisfactory. In the larynx, the Sass
apparatus, downward spray in all cases where mucus
and pus are visible in this organ, is the best cleansing
means. Rarely, however, are we forced to combat in



— *5 —
the larynx the formation of hard crusts like those
which are so often present in advanced chronic dis-
ease of the nasal passages, are naso-pharynx.



Fig. 7. — Posterior Nasal Syringe.



— 16 —

There are no serious objections to the use of cold
sprays or liquid in the manner described, whenever
the indications for cleansing the mucous membrane of
the nose or throat are evident. When, however, the
nasal passages are not obstructed in any notable de-
gree by mucus or pus; when a mere effort of moderate
blowing will rid the nose of its contents very com-
pletely, I object to the use of cold medicated sprays,
except in rare instances.

I do not believe any but the fine sprays, and pre-
ferably those made by Sass's tubes, are followed by
appreciable beneficial results. In instances of sub-
acute inflammation, either idiopathic or grafted on a
chronic condition, similar in type, I have frequently
known benefit to be derived from the use of these
sprays, at first repeated several times a day, and later
on once a day, or every other day. I do not, how-
ever, approve of their too long continuance, espe-
cially if frequently repeated, as a curative means of
treating catarrhal inflammations of the anterior, or
middle nasal passages. I believe that they often tend,
to produce occlusion of these passages. The turbi-
nated bodies become chronically irritated, are puffed
up and swollen, and whenever the nasal passages are
somewhat narrow, more or less permanent occlusion
is then produced. Indeed, I am now of the opinion
that many reflex neuroses of nasal origin owe their
development, or accentuation, to the injudicious and



— ly —

prolonged use of various medicated sprays.* When-
ever the nasal fossae are particularly capacious and
open, as is true if there be beginning atrophy of the
soft parts, sprays, even though employed quite awhile
on each occasion and repeated many times each day,
are not injurious, simply because the turbinated bodies
do not, or cannot, swell as much as in the hypertrophic
form of nasal catarrh. Moreover, even supposing they
do swell to the same degree in both forms of disease,
they cannot produce occlusion of the nasal passages
to the same annoying and injurious extent. Medi-
cated cold sprays when used in the summer months
through the nose are often useful, or seemingly so,
even in cases in which during the fall and winter
months, they have proved decidedly detrimental. I
attribute this fact: i. To the temperature of the sur-
rounding atmosphere, which approximates very nearly
that of the spray employed. 2. To the presence in
the air of sulphurized, or balsamic vapors — as is true
whenever the patient is sojourning at sulphur springs,
or in the pine woods. During the inclement period
of the year in our climate, if one ventures into the
open air he is, of course, exposed to the action of a
cold and humid atmosphere. This air if breathed, as
it often is, a considerable portion of each day, is
particularly injurious to the mucous membrane



*I have recognized this fact several times even in the
treatment of hay-asthma by cocaine spray.



— iS —

of the respiratory tract. The result is that very many
people suffer from recurrent attacks of acute catarrhal
inflammation of this region, or from chronic catarrhal
inflammation upon which an acute attack, more or
less severe, is being almost continuously grafted.
The individuals to whom I refer, and of whom there
are such great numbers in New York at least, are
hypersensitive so far as their respiratory mucous
membrane is concerned. They cannot withstand the
slightest draught of air. Even a moderate change of
temperature or atmospheric moisture will occasionally
give them an attack of sneezing or coughing. Their
passage from a warm to a cold room, or vice versa,
going to the theatre, or into a crowded ball-room,
sitting at dinner near a door partly open, being at a
concert for an hour or more with a window sash
drawn down at the far removed end of the room; all
of these slight causes, and many others, i. e., such as
fatigue, excess in eating or drinking, emotional strain,
are, each and all, sufficient at times to become efficient
factors in the production of coryza, pharyngitis,
laryngitis, or bronchitis. If such an individual come
to us for treatment, as of course he often will, what
shall we do for him ? Shall we further increase the
injurious influences to which he is, more or less, of
necessity exposed, by telling him to make use daily of
a cold, watery fluid introduced into his nose, mouth,
larynx, or bronchi, under the form of a fine spray ?
If we do, I am convinced that in a certain propor-



— ly —
tion of cases of nasal inflammation we unquestion-
ably do our patients harm, and particularly is this true
if the local treatment be persisted in for any consider-
able length of time. The harm done in these cases is
without doubt occasioned by the imbibition of the
turbinated bodies with cold watery fluids, even though
of proper density, which at once irritates and causes
them to swell. This injurious result is more likely to
follow the use of cold sprays than of those suitably
warmed. Yet if, in cold weather, we warm the fluids,
the pituitary membrane is rendered even more sensi-
tive than before to changes of temperature, and if it
be afterwards exposed to contact with the outer air,
occlusion more or less permanent from local irritation
or contact is sure to be produced. The only way to
obviate this undesirable consequence in part is to in-
terdict the patient from leaving his room during one
hour after the use of the warm spray through the nasal
passages. Even though this precaution be observed,
in order to re-establish by degrees the ordinary state
of local circulation, the bad effects of such treatment
are so obvious as to be convincing, at least from a
clinical standpoint.

In catarrhal diseases of the naso-pharynx the use
of sprays, moderately coarse, or fine, are scarcely ever
injurious. Indeed, in the great majority of cases in
which this space is affected by acute or sub-acute in-
flammation, they are not merely grateful to the patient,
but in a less or greater degree, beneficial. I have



little doubt that in acute and sub-acute inflammation a
properly formulated and moderately fine spray, ap^
plied one or more times in twenty-four hours, moder-
ates irritation, reduces the quantity of the secretions
formed, changes their physiological character for the
better, and tends to diminish the thickening, or infil-
tration of soft tissues, which has taken place in a more
or less rapid manner. Unless, however, these applica-
tions be followed by the use of a stronger topical
application under the form of powder or liquid, made
by means of the brush, sponge, or insufflator, the pa-
tient does not, except in very acute cases, get all the
local treatment which his case requires. In chronic
inflammatory diseases of this region, except as a
cleansing means, sprays, as ordinarily employed, are
of questionable utility. One may persist day after
day, week after week, and month after month, in the
use of weak sprays, and if these be the sole curative
measures employed, patients do not notably improve,
as a rule, under the unfavorable surrounding circum-
stances. I mean by this, that they do not improve if
the outer air be cold, damp, rainy, blustering, or contains
much irritative dust. I eliminate from present con-
sideration, daily employment, habits, and ambient con-
ditions other than those mentioned, because these are
not different with the majority of individuals during
any considerable time.

In these cases strong astringent or alterative
applications, preferably of fluids, combined or not



with a proportion of glycerine, must be made once,
twice, three times a week, or every day for a time as
the condition may clearly indicate. If this be done
and all theory be set aside for the while, such patients
as a rule improve and ultimately recover — this latter
result depending much upon the skill and knowledge
of the practitioner and the fidelity of the patient to
prescribed local treatment.

The general treatment of course is assumed to be
precisely what it wouid be if the patient were treated
solely by sprays.

Why, it may be asked, cannot strong sprays be
used with as much, or more, good effect in chronic
catarrhal disease of the naso-pharynx as when local
treatment is carried on by means of strong applica-
tions made with the sponge, cotton, or the brush ?
For two reasons; first, because such applications are
very painful; second, because their action is not suffi-
ciently limited and they come into contact with adja-
cent parts, whose condition, or structure, is opposed
to this ill-advised treatment, and hence a manifest
revolt of function is the consequence, as shown by dis-
tressing, and often lasting, symptoms thus produced.

Some such sufferers were victims of the specialists,
only a few years since, who pretended to cure chronic
follicular diseases of the naso-pharynx by means of
concentrated nitrate of silver and other caustic sprays
repeated many times at short intervals. In the fauces
and pharynx, while moderately coarse sprays are fre-



quently serviceable and grateful in removing morbid
secretions, fine sprays suitably medicated have rather
more curative effect than they have in the naso-
pharynx. Indeed, for acute, or sub-acute inflamma-
tions of these regions which have existed but a short
time, I should not like to be left without this means
of local medication. Some patients, particularly small
children, and nervous, debilitated women, cannot
gargle at all; few persons, men or women, can gargle
effectually. It requires instruction to know how to
do it; it requires habit to be able to accomplish it.
Troltsch has shown this, and Roosa has further in-
sisted upon it. In chronic pharyngitis, accompanied
by more or less inflammation and thickening of the
palate, fauces and tonsils, cure takes place, as a rule,
not on account of the repeated use of the spray, but
mainly on accouut of the astringent and alterative appli-
cations made with the sponge, or brush after morbid
secretions are removed by means of the spray.

I do not wish, however, to be quite as formal
in my small estimate of the utility of spray appli-
cations, as I am in regard to this treatment of
chronic diseases of the nose, or even the naso-
pharynx. Indeed, I am confident that in many neuro-
pathic disorders of the pharyngeal wall due to inflam-
matory infiltration, and in many cases of similar
infiltration unaccompanied by marked hyperesthesia,
undoubted and lasting benefit has been attained by
treatment solely with sprays.



— 23 —

In the treatment of diseases of the larynx, I am
of the opinion that sprays are frequently very useful
in allaying cough, and irritation, diminishing sputa
and abolishing the objective signs of inflammation,
i. e., redness and thickening.

Attention, however, should here be directed to
some important considerations.

The spray must be a very fine spray in order to be
deeply inhaled. It must be projected against the
pharyngeal wall with a certain force, or directly down-
wards beyond the base of the tongue, so as to reach
directly the interior of the larynx and medicate it

properly.

The ordinary hand-ball atomizer is of very little,
or no practical use. The spray thus produced, does not
usually penetrate the larynx, but simply lodges in the
back of the throat and every few minutes is spit up.
Occasionally, some of the fluid gets into the
larynx and trachea, it is true, while the patient is mak-
ing efforts to inhale it, but instead of proving bene-
ficial it occasions immediate distressing cough, some-
times followed by retching. These symptoms are
evidently brought on by the coarse quality of the spray,
for which there is usually great laryngeal intolerance.
In the treatment of diseases of the trachea and
bronchi, as in that of the larynx, if sprays be employ-
ed, spray tubes made after the manner of those of
Sa'ss, and connected by means of rubber tubing with a
cylinder of compressed air, are alone practically use-



— 24 —

ful. I do not, however, commend the use, even of


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Online LibraryBeverley RobinsonA manual on inhalers, inhalations and inhalants; and guide to their discriminating use in the treatment of common catarrhal diseases of the respiratory tract → online text (page 1 of 4)