1772: Heberden writes about asthma

Dr. William Heberden had already become a well respected physician by the time he moved to London in 1759.  Under his care was a large number of Londoners, and he would take care of them for the next thirty years.  They loved him not just because he was perceived as a brilliant physician, but because he was very gentle and kind.

He was one of many brilliant physicians that walked the streets of London during the era, including Dr. Samuel Johnson, who had a terrible case of emphysema, and Dr. Samuel Baillie, who would become an expert on diseases of the lungs, particularly emphysema.

On this particular hot and sunny say he sat in his study with the window open, a ray of sunshine providing plenty of light, and a cool, refreshing breeze gently blowing the curtains.  Gathered before him were the copious notes he compiled about asthma when he was a student, and by the patients he had taken care of with the disease, and the autopsies he had performed on those patients with asthma he was unable to save despite his gallant efforts to do so.

He dipped his quill pen in ink and set the pen to paper.  On a separate piece of paper he had already written the questions he wanted to answer.  The following are the questions he sought to answer, followed by the answers he provided in his book.

1.  Who develops asthma?  The first fit of the asthma has been experienced at all times, from the earliest infancy to extreme old age, and in every intermediate stage of life.

2.  What causes asthma?  Pleurisies, peripneumonies, and frequent catarrhs, often. end in this distemper. A mal-conformation of the breast, and a cough returning every winter, and becoming worse and worse,. bring on an incurable asthma.

3.  How does asthma come on?   In some it comes on suddenly, without any manifest previous illness.

4.  Is it continued or intermittent? Very violent fits of it will allow long intervals of apparently perfect freedom from any difficulty of breathing. There have been instances of its returning every other day, or every week, or once a month, or three or four times in a year about the same seasons, or every spring and autumn, or very commonly every winter, or once in two years. I knew one who was visited with the asthma once . in seven years, six or seven times; but it more frequently returns after no certain period. I have met with those who, after having struggled with this distemper for several years, have had an entire respite for near thirty years. Such long intervals of ease are indeed very rare: it more usually returns every year, becoming continually worse and worse. One person at very distant and uncertain periods became violently asthmatic for a single day, during the whole of which he was in constant danger of suffocation, but afterwards, for a considerable time, would be entirely free from it.

5.  What situations, other than those already mentioned, bring on a fit of asthma? n some it never fails to be brought on in certain situations, or houses, and is not felt in others; though at so small a distance that it is difficult to satisfy ourselves in fixing upon the circumstance which could make the difference.

6.  How long can someone live with it?  There have been those who have lived with an asthma for fifty years; and others have died of it in a few months.

7.  Can it be cured?  Some few constitutions have of themselves either outgrown, or, assisted by some judicious methods of cure, have entirely conquered the asthma. A most dangerous asthma went oft" so perfectly, that after two years the patient was able to attend to business; and in another it ceased after four years. In one it came on during childhood, and often returned with such vehemence, that it was expected to be fatal; but in old age it became much gentler, and for four years ceased to be at all troublesome.

8.  Does asthma occur with any other symptoms besides dyspnea?  It is usually, but not universally, attended with a cough, which makes no small part of the patient's sufferings.

9.  When is it most likely to occur?  Wherever there is any degree of asthma, it rarely fails of showing itself just upon waking out of the first sleep.

10.  Can it be mortal?  Yes.

11.  What are signs that it may take the life of the victim? Though it be right to keep the body open in this distemper, yet a spontaneous diarrhoea is very undesirable; it not only hinders the use of many anti-asthmatic remedies, which are most of them aperient, but it shows an alarming weakness, and is often a sign of the last stage of this illness, and a forerunner of death, especially if joined with a quick pulse.

12.  How long do most fits of asthma last?  The violent fits will sometimes last for several hours, and sometimes only a very few minutes. A vehement asthma, which continued for many months, became of itself gentler, and after four years was almost gone. Similar instances will sometimes occur, which render it uncertain whether relief be obtained by the efforts of nature, or by the effects of medicine

13.  What medicines are useful? In some a difficulty of breathing has returned periodically, like a tertian fever, and has yielded to the Peruvian bark... Emetics not unfrequently procure easy breathing; but cathartics are so very seldom useful, as scarcely to deserve being ever tried. A large spoonful of mustard-seed taken every morning has been successful in keeping the fits off; and so crude quicksilver, and cinnabar, are said to have been; and yet a course of mercurial ointment has several times brought on a difficulty of breathing. Spirituous liquors, strong coffee, the smoking of tobacco, garlic, squills, and solutions of the fetid gums, afford some present ease in a fit; and so will the opening of a vein, and the taking away a little blood: but it may be doubted whether bleeding be ever useful in any other states of an asthma, besides that of the patient's being in danger of instant suffocation: it is undoubtedly often mischievous by unnecessarily wasting the strength, and hastening the dropsy, in which an asthma usually ends. Opium is a powerful remedy in some asthmas, when all other means have failed: is it not useful in all?

14.  What brings on a fit of asthma? Motion brings it on, and in some there is not the least sign of such a disorder, but when they move, except just at waking out of a sound sleep. The lying down in bed is particularly apt to make the breathing very laborious, and it will often be an hour or more before the lungs can tolerably do their duty in this posture; and they are relieved by by sitting up, and bending the body forward. A very rare case has happened, where lying down has proved a relief.

15.  What air acts as a remedy?  Several asthmas cannot bear the country air, and are much more tolerable in great towns; but the far greater number are impatient of cities, and are always easiest in the country. Cold fresh air is a general relief; but I have known more than one asthma, the fits of which were moderated by sitting before as great a fire as could be borne. Sometimes any change of air is beneficial. More than once an asthma has been more tolerable in England than in warmer countries; but the contrary to this is most generally experienced. So summer is to not a few the time of their breathing with most difficulty; though winter be most generally the dangerous season. A long voyage between the East Indies and England has not relieved an asthma.

16.  Does eating worsen asthma?  In most persons, the breath is shorter and more difficult after a meal; but in a few it has been easier.

17.   How do other diseases affect asthma? A copious spitting, and a sudden oedematous swelling of the lower parts of the body, have apparently saved asthmatic persons from impending death, A violent catarrh, as from a cold, and in old persons a spitting of blood, an imflammation of the leg and a consequent ulcer, a palsy, a pain in the stomach and limbs, cutaneous eruptions, and a fit of the gout, have all seemed to divert the mischief from the lungs; and, though themselves diseases, have yet proved remedies to the asthma. But yet a fit of the gout has partaken of that uncertainty so remarkable remarkable in the effects of many circumstances upon asthmatic patients; for if it have cured some, it has brought the asthma on others, or at least has not hindered a fit of it from succeeding immediately to a fit of the gout. Issues may sometimes be serviceable, but are too often useless.

18.  Is asthma nervous? If we further consider the long intervals of breathing with perfect freedom, which this distemper frequently allows, and likewise the nature of many of its remedies, and that it will be caused by sleep, grief, anger, terror, joy, or a fit of laughter, it must seem probable, that, besides various other causes of an asthma, it is in many instances owing to some disturbance of those functions which are attributed to the nerves.

19.  What are some other observations about asthma that might make one inclined to think it is nervous in origin?  The lungs of a very asthmatic man appeared perfectly sound, and so did the heart and diaphragm: there was neither water nor pus in the thorax, nor was any thing praeternatural discovered, except some exostoses of the vertebrae of the thorax.

20. What other observations are there?

• A woman had laboured with an asthma gradually increasing for eight months. She used to sit with her body bending forwards, or a little inclining to the left side, never to the right. The pulse was extremely irregular. Her legs swelled (the left more than the right), and, being punctured, a great deal of water had flowed from them. A little before her death, a fetid saliva flowed plentifully out of her mouth. She was opened, and no water was found in the abdomen or thorax. The lungs were sound, and free from adhesions. In the aorta, auricles, and ventricles, were were found rough polypose concretions, and the valves between the left auricle and left ventricle were contracted into irregular hard tuberosities.
• Upon opening the thorax of an asthmatic man, the lungs continued to be inflated: their surface was full of air bubbles inclosed in a very thin membrane; when one of these was opened, none of the others subsided. There was no other appearance of distemper about the thorax or lungs.

Bottom Line:  Essentially, Heberden believed asthma was nervous because it left behind no scars in the lungs.  Later physicians would criticize Heberden's description of convulsive asthma as being nothing more than angina pectoris, or what would become known as cardiac asthma or heart failure.

The above writings about asthma would be published in his 1772 book "Commentaries on the History and Cure of Disease."

References:

1. Guthrie, Douglas, "Heberden Society: Dr. William Heberden," Annals of Rheumatic Disease, September, 1951, 10 (3), pages 217-220
2. Garrison, Fielding Hudson, "An introduction to the history of medicine," 3rd edition, 1821, Philadelphia and London, W.B. Saunders Company
3. Heberden, William, "Commentaries on the History and Cure of Disease," 4th edition, 1816, London, Printed for Payne and Foss - Pall Mall