HISTORY OF HYPERBARIC OXYGEN THERAPY
Hyperbaric Medicine is currently viewed as being new and controversial.
However, the concept and utilisation of Hyperbaric Oxygenation has in fact, been in existence since 1662.
During the past 30-40 years, Hyperbaric Medicine has gained most of its recognition for the treatment of certain mainstream medical conditions specifically related to the diving industry, including decompression sickness and air embolism.
The origins and development of Hyperbaric Medicine are closely tied to the history of diving medicine. The actual origins of diving are not known, however it was recognised as a distinct occupation as far back as 4500 BC.
The first records of actual diving equipment, used to extend the limits of underwater activity, are attributed to Alexander the Great in 320 BC, when he was reported to have been lowered into the Bosphorus Straits in a glass barrel during the siege of Tyre.
Around the year 1500, Leonardo Da Vinci made sketches of diving vessel chambers, but did not develop them for practical use. In 1620, the Dutch inventor Cornelius Drebbel developed the first true diving bell. This vessel had the ability to be compressed to 1 atmosphere but had no supplementary Oxygen. In 1691, Edmund Halley, after whom the comet is named, improved diving bell chambers by devising a method of replenishing the air supply.
The first attempt to use a hyperbaric chamber in medicine was made by the British physician Henshaw, in 1662. The chamber was fitted with a large pair of organ bellows, with valves paced so that air could either be compressed into the chamber or extracted from it. In the ‘domicilium’ increased pressures were used for the treatment of acute disease, and reduced pressures for the treatment of chronic diseases.
“In times of good health this domicilium is proposed as a good expedient to help digestion, to promote insensible respiration, to facilitate breathing and expectoration and consequently, of excellent use for prevention of most affections of the lungs”
In the Netherlands, the Dutch Academy of Sciences sponsored a prize in 1782 and subsequent years, for the design of an apparatus to study the effects of higher pressures in biology. There were no contenders, nor any recipients of the prize. It is ironic that the recent advances in Hyperbaric Medicine are based heavily on the work of the Dutch, almost two centuries later.
In the 1830’s, France led the new fashion in Hyperbaric Medicine. Hyperbaric chamber exposures of between 2 and 4 atmospheres absolute were stated to increase the circulation to the internal organs, improve the cerebral blood flow, and produce a feeling of well being.
Junod (1834) first made these observations, and they were taken up avidly by his colleagues, Tabarie and Pravaz. In 1837, Pravaz built a large hyperbaric chamber using it to treat a variety of ailments. The chambers were promoted and used specifically for pulmonary diseases, including tuberculosis, laryngitis, tracheitis and pertussis, as well as apparently unrelated diseases such as deafness, cholera, rickets, metrorrhagia and conjunctivitis.
Fontaine (1877) developed the first mobile hyperbaric operating theatre, and by this time hyperbaric chambers were available in all major European cities. Interestingly, there was no general rationale for hyperbaric treatments, and as a result, prescriptions varied from one physician to another. In those days, no methods were available to estimate the partial pressure of Oxygen in blood, which at 2 ATA of air is about double that at sea level. In comparison, if pure Oxygen is breathed at 2 ATA, the partial pressure of Oxygen in the arterial blood is twelve times higher than normal.
During the second half of the nineteenth century, hyperbaric centers were being advertised as comparable to health spas. Junod referred to his treatment as “Le Bain d’air comprime” (the compressed air bath). In 1855 Bertin wrote a book on this topic and constructed his own hyperbaric chamber. The literature on Hyperbaric Medicine up to 1887 was reviewed by Arntzenius and contains a remarkable 300 references.
During the 1850s many hyperbaric chambers were in use throughout Europe. “Pneumatic Institutes” flourished and mobile hyperbaric facilities were introduced. In 1879 a fully equipped mobile hyperbaric operating room was completed, so that surgery could be performed in hospitals, sanatoriums, and even in private homes. It was claimed that patients recovered from anaesthetic more rapidly when in the chamber (an observation of particular note nowadays, when the effect of Hyperbaric Medicine on both gas elimination and high-pressure neurological syndrome are of considerable interest). Cyanosis and asphyxia were reported to be less, or absent. Post-anaesthetic excitement and vomiting were markedly decreased.
The chamber was recommended to facilitate the reduction of hernia, and for patients with asthma, emphysema, chronic bronchitis and anemia. Twenty-seven operations were performed within a 3-month period in this chamber. Success was so great that a large hyperbaric surgical amphitheatre which would hold 300 people was planned, but never actually came into being. Fontein had an accident whilst at the Pneumatic Institute which resulted in his death, the first physician martyr to Hyperbaric Medicine.
Williams, in the British Medical Journal of 1885, made a comment, which would be thought by many to be applicable today:
“The use of atmospheric air under different degrees of atmospheric pressure, in the treatment of disease, is one of the most important advances in modern medicine and when we consider the simplicity of the agent, the exact methods by which it may be applied, and the precision with which it can be regulated to the requirements of each individual, we are astonished that in England this method of treatment has been so little used”
The first hyperbaric chamber on the North American continent was constructed in 1860 in Oshawa, Ontario, Canada. The first such chamber in the United States was built by Corning a year later in New York to treat ‘nervous and related disorders’. The Chamber that received the most publicity, and was the most actively used, was that of a Dr Cunningham in Kansas City during the 1920’s.
Cunningham first used his chamber to treat the victims of the Spanish influenza epidemic that swept across the USA during the closing days of the First World War. Cunningham had observed that mortality from this disease was higher in areas of higher elevation, and he reasoned that a barometric factor was therefore involved. He claimed to have achieved remarkable improvement in patients who were cyanotic and comatose. One night however, a mechanical failure resulted in a complete loss of compression and all his patients died. This tragedy was a sobering lesson but ultimately did not deter Dr Cunningham. His enthusiasm for hyperbaric air continued, and he started to treat diseases such as syphilis, hypertension, diabetes mellitus, and cancer. His reasoning was based on the assumption that anaerobic infections play a role in the etiology of all such diseases.
In Cleveland, in 1928 Cunningham constructed the largest chamber ever built – five stories high and 64 feet in diameter. Each floor had 12 bedrooms with all the amenities of a good hotel. At that time it was the only functioning hyperbaric chamber in the world. As the publicity surrounding his treatments grew, Dr Cunningham was repeatedly requested by the Bureau of Investigations of the American Medical Association (AMA) to document his claims regarding the effectiveness of Hyperbaric Therapy.
Apart from a short article in 1927, Cunningham made no efforts to describe or discuss his technique in medical literature. He was eventually censured by the AMA in 1928 in a report that stated: “Under the circumstances, it is not to be wondered that the Medical Profession looks askance at the ‘tank treatment’ and intimates that it seems tinctured much more strongly with economics than with scientific medicine. It is the mark of the scientist that he is ready to make available the evidence on which his claims are based.”
Dr Cunninghmam was given repeated opportunities to present such evidence but never did so. The Cunningham chamber was dismantled for scrap in 1937, which brought to a temporary end the era of Hyperbaric Oxygen Therapy for medical disorders.
Drager, who in 1917 devised a system for treating diving accidents, first realized the potential benefits of using Oxygen under pressure for the treatment of decompression sickness. For some unknown reason, however, Drager’s system never went into production. It was not until 1937 – the very year that Cunningham’s “air chamber” hotel was demolished – that Bhnke and Shaw actually used hyperbaric Oxygen for the treatment of decompression sickness.
The popularity of Hyperbaric Medicine in the 1930s has now been replaced with an extremely hard-line attitude by mainstream medicine. Hyperbaric Medicine in the year 2000 requires solid substantiated medical fact rather than just promoting ‘benefits’ associated with treatment.
The most recent and most significant documented advances with Hyperbaric Medicine, have emerged with the utilization of high tech investigation including isotopic tracers with Magnetic Resonance Imaging (MRI) and Single Photon Emission Computed Tomography (SPECT).
** MRI and SPECT performed as a pre and post hyperbaric evaluation have provided valuable insights into the mechanisms and actions of Hyperbaric Medicine through Oxygenation. Conditions that have previously been considered to have a poor prognosis, including brain injuries, stroke and neurological based conditions, have been greatly improved with Hyperbaric Medicine.