Monday, December 28, 2015

1772: Heberden describe cardiac asthma

William Heberden (1710-1801)
William Heberden, sometimes referred to as "the last great physician," is known to the medical community as the first to describe angina pectoris, or what would later become known as cardiac asthma. (1, page 369)(2)

Heberden was born in London in 1710, only a few short years before William Cullen, one of the first physicians to specialize in asthma.  While Heberden did not specialize in asthma per se, he did share his knowledge about the disease.

He was the son of Richard Heberden, a physician who left behind no track of his medical profession.  Because William Heberden showed promise, he was allowed to start secondary school at an early age.  He started at St. John's College and then moved on to Cambridge.  He earned his medical degree in 1739.

Twentieth century medical historian Fielding Hudson Garrison said:
A Cambridge graduate of superior attainments, Heberden was esteemed as one of the finest Greek and Hebrew scholars of his time, and he resembles the classic writers in his careful portrayals of disease. (1, page 369)
Among his most significant accomplishments was his description of angina pectoris, a condition that would later be classified under the rubric term asthma by Erasmus Darwin in 1818, and then would gradually become better known as cardiac asthma, and ultimately become a disease entity of its own.  

Garrison said:
An actual case of angina pectoris was described in the memoirs of the Earl of Clarendon (1632) in the person of his own father, but it was Heberden's classic account that put the disease upon a scientific basis, and his work was soon confirmed by the observations of Parry (1799) and Edward Jenner. (1, pages 369-370)
In 1632, Richard Heberden wrote:
the pain in his arm seizing upon him, he fell down dead, without the least motion of any limb. (3, page 219
Thirty-six years later, in 1768, his son William Heberden first first described angina pectoris to the Royal College of Chest Physicians. His description was later published in 1772 in his book "Commentaries on the History and Cure of Disease."    (1, page 369)(2)

He referred to the condition under the heading "Pectoris Dolor."  He wrote:
Beside the asthma, hysteric oppressions, the acute darting pains in pleurisies, and the chronical ones in consumptions, the breast is often the seat of pains, which are distressing, sometimes even from their vehemence, often from their duration, as they have continued to tease the patient for six, for eight, for nine, and for fourteen years. There have been several examples of their returning periodically every night, or alternately with a head-ach. They have been called gouty, and rheumatic, and spasmodic. There has appeared no reason to judge that they proceed from any cause of much importance to health (being attended with no fever), or that they lead to any dangerous consequences; and if the patient were not uneasy with what he feels, he needs never to be so on account of any thing which he has to fear. (4, page 302)
So it's clear from this description that he, unlike Darwin a century later, clearly saw angina pectoris as something unique from asthma.  Although, it was similar to asthma in that it it was distressing and that it was intermittent.

Check out his remedy:
If these pains should return at night, and disturb the sleep, small doses of opium have been found serviceable, and may be used alone, or joined with an opening medicine, with a preparation of antimony, or with the fetid gums. (4, page 302)
This is interesting because morphine was often sometimes used as a remedy for asthma.  Even more interesting is that over 240 years later, morphine is still a top line recommendation for the treatment of chest pain.

He also prescribed blisters of the chest, or an issue to the thigh, as external remedies.  Thankfully these remedies have long since been abolished as medical treatments.  (4, page 303)

He also suggested other remedies:
A large cumin plaster has been worn over the seat of the pain with advantage. The volatile or saponaceous liniment, may be rubbed in over the part affected. Bathing in the sea, or in any cold water, may be used at the same time. (4, page 303)
He then, more specifically, described angina pectoris  He wrote:
But there is a disorder of the breast marked with strong and peculiar symptoms, considerable for the kind of danger belonging to it, and not extremely rare, which deserves to be mentioned more at length. The seat of it, and sense of strangling, and anxiety with which it is attended, may make it not improperly be called angina pectoris. (4, page 303)
 He continued:
They who are afflicted with it, are seized while they are walking (more especially if it be up hill, and soon after eating) with a painful and most disagreeable sensation in the breast, which seems as if it would extinguish life, if it were to increase or to continue; but the moment they stand still, all this uneasiness vanishes. In all other respects, the patients are, at the beginning of this disorder, perfectly well, and in particular have no shortness of breath, from which it is totally different. (4, page 303)
The pain is sometimes situated in the upper part, sometimes in the middle, sometimes at the bottom of the os sterni, and often more inclined to the left than to the right side. It likewise very frequently extends from the breast to the middle of the left arm. The pulse is, at least sometimes, not dist rbed by this pain, as I have had opportunities of observing by feeling the pulse during the paroxysm. Males are most liable to this disease, especially such as have past their fiftieth year. (4, pages 303-304) 
After it has continued a year or more, it will not cease so instantaneously upon standing still; and it will come on not only when the persons are walking, but when they are lying down, especially if they lie on the left side, and oblige them to rise up out of their beds. In some inveterate cases it has been brought on by the motion of a horse or a carriage, and even by swallowing, coughing, going to stool, or speaking, or any disturbance of mind. (4, page 304)
He was clearly describing dyspnea with exertion associated with chest pain, or what would become known as cardiac asthma.  Modern physicians refer to it as heart failure, a condition that still is confused with asthma as it presents with similar signs and symptoms.

The end of a fit of angina pectoris, according to Heberden, was similar to that of asthma:
The termination of the angina pectoris is remarkable. For if no accident intervene, but the disease go on to its height, the patients all suddenly fall down, and perish almost immediately. Of which indeed their frequent faintnesses, and sensations as if all the powers of life were failing, afford no obscure intimation. (4, page 305)
He believed the disease was, like asthma, spasmotic in nature:
The angina pectoris, as far as I have been able to investigate, belongs to the class, of spasmodic, not of inflammatory complaints.
He offered the following evidence:
  1. The access and the recess of the fit is sudden
  2. There are long intervals of perfect health
  3. Wine, and. spirituous liquors, and opium, afford considerable relief.
  4. It is increased by disturbance of the mind.
  5. It continues many years without any other injury to the health.
  6. In the beginning it is not brought on by riding on horseback, or in a carriage, as is usual in diseases arising from scirrhus, or inflammation.
  7. During the fit the pulse is not quickened. 
  8. Its attacks are often after the first sleep* which is a circumstance common to many spasmodic disorders (4, page 304-305)\
He noted some cases that presented with unusual circumstances.  For instance, some patients spit up blood, and some note feeling dizzy and drop dead on the spot.  

William Heberden died in 1801 at the age of 91.

References:
  1. Garrison, Fielding Hudson, "An introduction to the history of medicine," 3rd edition, 1821, Philadelphia and London, W.B. Saunders Company
  2. "William Heberden: Study of cardiac disease," Britannica.com, http://www.britannica.com/EBchecked/topic/259009/William-Heberden, accessed 2/12/14
  3. Guthrie, Douglas, "Heberden Society: Dr. William Heberden," Annals of Rheumatic Disease, September, 1951, 10 (3), pages 217-220
  4. Heberden, William, "Commentaries on the History and Cure of Disease," 4th edition, 1816, London, Printed for Payne and Foss - Pall Mall
  5. Brown, Orville Harry, "Asthma, presenting an exposition of nonpassive expiration theory," 1917, St. Louis, C.V. Mosby Company

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