Sister Gertrude Lawson, graduated in 1887, pictured in the operating theatre in 1907. Sr Lawrence probably did not play an active role in the surgery, at this time the surgeons were assisted by a male attendant. In 1899 Sister Laura Pratt wrote, "There were 3 main operating days, the surgeons being Mr Henry O'Hara, Mr Cook and Mr Buchanan. There was one theatre sister whose duties were to prepare the theatre and attend all operations, buy and keep instruments in repair, prepare all types of sutures. She was on duty 24 hours for emergencies with a trained deputy on call from the ward in her absence. This system was altered about 1909 when each nurse at the end of her second year was given a month in the theatre" David Hume Nelson led a colourful and notable life. Born in Edinburgh, he moved to London around 1835, spent some time in prison for theft, returned to Edinburgh to qualify for his MD in 1848, before being elected physician at the Queen’s Hospital in 1849 and joining the Faculty at The Queen’s College in Birmingham shortly afterwards ( Sanders and Harper, 2014). David Hume Nelson’s qualifications in respiratory medicine are also well founded, having published his dissertation On the principles of health and disease in 1850 and featured in a series of case histories in the Provincial Medical and Surgical Journal (PMSJ, a forerunner to the BMJ) around 1850–1851 ( Anon, 1850a; Anon, 1850b; Anon, 1851). As part of a ‘strictly introductory’ ( Anon, 1850c, p 41) series of clinical lectures serialised in the PMSJ between 1851 and 1853 (also published in book form in 1850), David Nelson also gave three lectures on ‘The morbid condition of the lungs and respiratory tubes’ (Nelson, 1851, 1853a and 1853b). It is notable that inhalation is not mentioned as a form of treatment in any of these lectures, focusing instead on more traditional ‘heroic’ humoral cures such as blood-letting, cupping, leeches and the use of mercury, antimony, and oral expectorants. Following these early publications, David Hume Nelson seems to have turned his attention to other clinical matters, publishing a series of articles in the British Medical Journal between 1860 and 1863 on ‘ferro-albuminous’ treatments and peptic acids, all of which resulted from a ten-year clinical study in Birmingham into Bright’s disease concluding in 1860 ( Nelson, 1860a; Nelson 1860b). Figure 5 : Advertisements for some of the inhalation devices made by S. Maw https://dx.doi.org/10.15180/170807/005 Inhalation therapies in the second half of the nineteenth century typically involved either volatile or combustible materials for smoking or vaporisation ( Sanders, 2007, p 79), including medicines of herbal origin such as stramonium, a direct link to modern antimuscarinic therapies. However, non-volatile, purified small molecular weight drugs began to emerge from the early twentieth century including adrenaline (extracted from adrenal glands; see Burnett, 1903) in 1903, atropine (purified from Hyoscyamus extracts; see Terray, 1909), ephedrine (structurally-related to adrenaline, purified from Ma Huang herb; see ( Chen and Schmid, 1924), and cortisone treatment by the 1950s (see Carryer, 1959). This required an evolution of device technologies to disperse bulk liquids into aerosol droplets that contained the dissolved (or suspended) drug, or to disperse ultra-fine bulk powders of the drug into inhalable aerosols under mechanical or aerodynamic forces. The result of this was the invention and development of the forerunners of modern inhalation devices including jet nebulizers (e.g. the Pneumostat, widely used from the 1930s but still generally housed in surgeries and pharmacies) or hand bulb nebulizers such as the Parke-Davis Glaseptic, and Abbots’ Aerohaler (1948), which is clearly comparable to modern dry powder inhalers, and ultimately the pMDI in the 1950s ( Sanders, 2007, p 79).

Alfred student nurses always wore arm bands to identify their level of seniority. This specific style was used from 1950-1992. This changing understanding of drug delivery was obviously of particular importance for physicians interested in respiratory illness. Scudamore introduced the findings of his clinical trials of inhalation in respiratory patients as follows: ‘It constitutes a new method of treatment to administer by inhalation those medicinal agents which the science of modern pharmaceutical chemistry has brought to light; and it is my object […] to show that they are capable of exerting a very important and beneficial influence in certain states of pulmonary and bronchial disease’ ( Scudamore, 1830, p 2). Apart from programmatically highlighting the innovative nature of this therapy, Scudamore also points towards a changing understanding of pharmaceutical therapy to a more localised and directed form of drug delivery when he writes that the ‘rationality of applying some remedial agent in a direct manner to the seat of the disease will not be questioned’ (ibid). Similarly, Murray demands application of medicinals ‘locally to the lungs’, claiming ‘if you inhale vapour, which condenses in the cells, at least a small part of it, it bedews and covers the surfaces and ulcerations’ of the lungs, hence acting directly at the source of the irritation ( Murray, 1829, p 173 and p 180). Alongside its appeal as a less physically invasive remedy, the practice of inhalation may therefore also be seen as part of a general trend towards targeted drug delivery and action emerging in mid-century Victorian Britain. Some material may contain terms that reflect authors’ views, or those of the period in which the item was written

or recorded but may not be considered appropriate today. These views are not necessarily the views of Victorian Collections. New nurses in preliminary training school had no arm badge and a red pattee cross on their hats. The 'signed on' first year student exchanged the hat with a red pattee cross for a hat with the hospital badge shown in the picture and wore the arm badge of the white pattee cross on a light blue square; the second year nurse wore a red skeletal cross on a white square and the third year nurse a filled in red cross on a white square. Prior to the 1950s the nurses from 1880 were identified by only two arm patches, a red skeletal cross and a filled in red cross which were on arm bands and were worn above the elbow on the left sleeve. This system meant that all hospital staff could tell at a glance what stage of training the student was at and behave accordingly. By reconstructing the ‘biography’ of the Nelson Inhaler, this article will attempt to sketch a network of medical and commercial interests and expertise in London which aligned in the 1860s to help establish inhalation as a popular, inexpensive and trusted form of medical therapy for respiratory and pulmonary ailments. By looking at what connects physicians, apothecaries, and patients – the medicines and technologies that were prescribed, made, bought, and which caused wellness, side-effects, and even death – we can develop a narrative of illness as it was experienced by practitioners and patients alike. Pharmaceutical therapies – medicinal products procured from physicians, apothecaries, or commercial sources such as druggists – were the most common form of medical care among the working and middle-classes over the last three hundred years or so and any history of medicine using material objects needs to begin with these cures. Lung disease was a key issue in nineteenth-century discourse and here the smallest objects and seemingly simple technologies (pills, medicated steam, inhalation devices) enable powerful and provocative accounts of both the private and socio-historical dimensions of medicine. Through its widespread availability the Dr Nelson Inhaler allows us to develop multiple narratives of medical history and its omnipresence speaks to the question of self-medication and health consumerism in the nineteenth century. Its emergence from the orbit of the RMCS, on the other hand, can also help us to reconstruct a surprisingly thorough framework of what was, essentially, quality control, which was highly unusual for pharmaceutical technologies in the nineteenth century. A rare photo of the Alfred Hospital operating theatre 1907, at that time instruments were boiled in water and soda and most receptacles were enamel ware, rubber gloves were not introduced until 1908. Brown, pressed cardboard laundry case, no handle, catches at both ends, and protective covers on each corner of the base and lid.

HAND MADE WITH LOVE & CARE - This portable soother is one of the best quality British handcrafted Medical Antiques that you can trust to instantly ease your hay fever symptoms, flu, coughs and colds due to its powerful inhalation therapeutic effect This type of inhaler proved so efficient that its design has changed little since Dr Nelson’s Victorian model. Nelson’s inhalers were used well into the 20th Century and even modern steam inhalation devices differ only slightly. Thanks to the ease in using this item it became a popular home medicine in treating respiratory infections without the need for a physician or expensive equipment. Used by singers and performers worldwide to hydrate the vocal folds and provide immediate relief from irritation or inflammation of the throat.Inhalation therapy has been practiced in some form or another for over two thousand years. In ancient times odours, steam and smoke have been inhaled for both medical and non medical purposes. The term ‘inhaler’ first appeared in the late 18th Century, but it was from the 1800s that the ceramic inhaler was popularised in mainstream medicine and importantly, in the home.

The Dr Nelson Inhaler emerged into a medical market with a clear demand for reliable therapies for the various respiratory diseases blighting the towns and cities of industrial Europe. Rapid urban development had led not only to the spread of waterborne diseases like typhoid and cholera, but also to a peak in ailments like asthma and consumption, with fogs, smoke, and other pollutants a cause of almost constant suffering throughout the 1800s. In the Medical Times and Gazette the London Fog that killed 273 people as a result of bronchial complaints in 1873 was reported as ‘one of the most disastrous this generation has known. To persons with cardiac and respiratory disease it has in numerous instances proved fatal’ ( Anon, 1873, p 697). Indeed it is telling that Maw’s – one of the largest suppliers of medical and surgical instruments in Britain – displayed various patented inhalers at the International Exhibition of 1862 ( Illustrated Catalogue, 2014, p 125), a reflection of the close and difficult relationship between Victorian industrialisation and medical innovation. Between 1861 and 1865 Dr Nelson’s invented his ‘new and improved’ ceramic inhaler. This double-valved device was designed for steam inhalations - inhaling vapours to clear the body of respiratory ailments. It works by filling the inhaler with an infusion and boiling liquid then inhaling the steam deep into the lungs. The cork stopper is inserted in the wide opening at the top of the inhaler, whilst the hollow glass tube acts as mouthpiece used to inhale the steam.Fabric arm badge patches of differing styles and smaller hat badge sewn on blue and white hounds tooth fabric used for the dresses worn by students. Unveiled at the conclusion of a meeting of the Royal Medical and Chirurgical Society in 1861, [ 1] ‘Dr Nelson’s Improved Inhaler’ was one of the most important milestones in the genesis of reliable treatment of respiratory ailments in the modern era. Affordable and suitable for self-medication, the Dr Nelson’s Inhaler offered simple and reliable relief for patients with respiratory and pulmonary ailments. Conspicuous for its modesty and simplicity, it was one of the most widely produced, reproduced, and used inhalation devices in the final third of the nineteenth century. By reconstructing the ‘biography’ of the Nelson Inhaler, this article will attempt to sketch a network of medical and commercial interests and expertise in London which aligned in the 1860s to help establish inhalation as a popular, inexpensive, and trusted form of medical therapy for pulmonary ailments. This article will look at what connects physicians, apothecaries, and patients in the era: the medicines and technologies that were prescribed, made, bought, and which caused wellness, side-effects, and even death. This approach allows us to develop a narrative of respiratory illness as it was experienced by practitioners and patients alike. Keywords

The notice on the wall reads: "The floor being reserved for the hospital staff. Visitors are requested to take seats in the gallery." Or even What are the Top 10 affordable (best budget, best cheap, or even best expensive!!!) Dr Nelson Steamer Boots available? Etc. By 1865 Dr Nelson’s device was being advertised widely in journals such as The Lancet (1865a, p 152), The Medical Times and Gazette (1865b, p 160) and later in the British Medical Journal (1870, p 674). Now christened ‘Dr Nelson’s Inhaler’, this new inhalation device was produced and marketed by S. Maw & Son from their London base in Aldersgate Street near the present-day Barbican ( Maw’s, 1866, p 82; Maw’s, 1870, p 66). Maw’s was a well-established surgical instrument provider, but they also sold less specialist medical products for the domestic market such as plasters, syringes and bandages. Following in the footsteps of pioneers like Mudge and Ramadge, the company had already begun advertising various inhalers in the early 1840s and later sold devices such as ‘Startin’s Pneumatic Inhaler’ for the new chloroform and ether anaesthesia, making the company an ideal partner for inventors of new respiratory devices ( Illustrated Catalogue, 2014, Vol. 2, p 125).Literature, case histories, and personal accounts give little indication of how long each period of use would have lasted. However, Horace Dobell recommends that the water should not exceed 170 degrees when inhalation begins ( Dobell, 1872, p 203), and William Abbotts Smith generally recommends three vapour inhalations per day, with each session lasting between 15 and 20 minutes ( 1869, pp 60–61, p 72). Other inhalers include detailed instructions according to which patients were initially recommended to undertake one daily session of five minutes’ duration, rising to as many as ten daily sessions lasting up to fifteen minutes as the patient grew accustomed to the therapy (see Siegle, 1865, p 30). Repetitions of this duration will not have required much replenishment of hot water during each individual sitting with the Dr Nelson’s Inhaler. Figure 2 : The original presentation of Dr Nelson's Inhaler in The Lancet in 1865 https://dx.doi.org/10.15180/170807/004