Monday, September 26, 2016

1850: Todd says asthma disease of mind

Robert Bentley Todd (1809-1860)
He was born in Ireland in 1809, and he became known as the intoxicated physician.

He was known to roll in on his carriage "to visit patients equally intoxicated by the quantities of alcohol he had prescribed for them," said F.F. Cartwright in 1974.  (1, page 893)

Cartwright said he was known to prescribe a pint and a half a day of alcohol, his famous remedy. (1, page 893)

Cartwright said that such an exorbitant prescription for alcohol was not out of the norm for this period of time.  So we must not use this bit of wisdom in judging the famous doctor. (1, pages 893-894)

He qualified in Dublin in 1831, and then joined the Aldersgate School in London in that same year as lecturer of anatomy and physiology.  In 1836 he moved to Westminster and became elected to the Chair of Physiology and Morbid Anatomy. He was only 27-years-old at the time. (1, page 894)

Cartwright said that lectures at medical schools were a rare treat prior to Dr. Todd, although his lectures became so popular with the students that other schools adapted the practice.  Cartwright quotes his obituary, which stated:
Physiology was ill defined in those days; it was meant the study of the healthy body as opposed to morbid anatomy, the study of the deceased body.  Todd described himself as an anatomical physician.  What he meant was that the science of medicine depended upon the study of anatomy just as did the science of surgery. Naked-eye anatomy was not sufficient; with his great friend, William Bowman, Todd was largely responsible for popularizing the microscope as an essential instrument in diagnosis. He insisted the accurate diagnosis must always precede treatment, a desideratum by no means universally accepted at that time. (1, pages 894-895)
His research with the microscope lead him to some significant discoveries, such as cirrhosis of the liver, which became known as Todd's Disease.  Such discoveries ultimately lead him to publishing some significant medical books, such as "Cyclopedia of Anatomy and Physiology of Man" in 1843.

In the year 1851 he hired Dr. Henry Hyde Salter to be his assistant, even assisting him write the final two volumes of his "Cyclopaedia of Anatomy and Physiology." (4, page 887)

Dr. Salter ultimately became the preeminent expert on asthma.  Dr. Salter believed there was too much evidence to refute the argument that asthma was spasmotic, although Dr. Todd Thought otherwise.  In his book "On Asthma: Its Pathology and Treatment," which was originally published in 1860, Dr. Salter described Dr. Todd's theory regarding asthma, and gives his reasoning why, to him, it was poppycock. (3, page 26-27)

Dr. Salter said:
In an interesting clinical lecture, published in the Medical Gazette for December, 1850, Dr. Todd advances the opinion that asthma depends upon a poisoning of the nerves of respiration, or those portions of the nervous centres with which they are connected, by a particular materies morbi, by which their function is so perverted, that a spurious and morbid sense of want of breath is engendered; that this central or subjective breathlessness is the first step in the morbid phenomena; that it need have no real objective cause in the lungs themselves; that bronchial spasm is an accompaniment, not a cause, of the dyspnoea of asthma; and that you may have asthma without any bronchial contraction whatever.
Dr. Todd's argument is this—In many points asthma resembles gout; gout is humoral; therefore asthma is humoral. Again—you may have asthma with puerile breathing; with puerile breathing the bronchi cannot be contracted; therefore asthma may co-exist with uncontracted bronchial tubes.
But let me give in his own words the views of one whose opinions always carry with them so much weight.
"Like asthma," says Dr. Todd, "gout comes on quite suddenly; there is no warning. A man may go to bed quite or nearly well, and may wake up early in the morning with a fit of the gout in his great toe. There is another disease, epilepsy, in which we have exactly the same phenomenon. A patient, with or without warning, falls down foaming, livid, and convulsed; the paroxysm goes off and leaves him in his ordinary good health, and he may go on for years and not have another. Again—we know a fit of the gout leaves no organic lesion if it occurs once or twice, but, if it is often repeated, it leaves permanent injury in the joints it attacks. The same of asthma; the organic changes are all secondary, and a few attacks leave no traces behind them.
"The theory at present most in favour with regard to gout is, that it is a disease of assimilation, and that this defective or vitiated assimilation gives rise to some materies morbi. When this matter is eliminated from the system the attack passes off; when it accumulates the attack comes on. In asthma defective assimilative power is a frequent coincident. Gout, too, and rheumatism, and all humoral diseases, resemble asthma in being inherited.
"When the materies morbi of asthma has been generated, its effect is to irritate the nervous system, not generally, but certain parts of it, those parts being the nerves concerned in the function of respiration, viz., the pneumogastric, and the nerves that supply the respiratory muscles, either at their peripheral extremities or at their central termination in the medulla oblongata and spinal cord; extreme difficulty of breathing is the result, and, as a consequence of this, ultimate disease of the lungs.
"Many pathologists ascribe all the phenomena of asthma to spasm of the circular muscular fibres of the bronchi. The first link in the chain of effects of the immediate exciting cause of asthma would be, according to them, spasm of the bronchial tubes, then dyspnoea. Undoubtedly, a state of spasm of the bronchial tubes would produce a great deal of dyspnoea; but what I want to point out to you is, that this state of spasm of the bronchial tubes ought rather to be regarded as one of the accompaniments, one of the phenomena, of asthma, than as its cause. The feeling of breathlessness, or, in other words, a peculiar state of certain nerves, or of a certain nervous centre, the centre of respiration, is the first link in this chain of asthmatic phenomena. The spasm of the bronchi follows sooner or later upon this, and often it follows so quickly upon it as to appear to come simultaneously with it. Does it ever precede it? I doubt this.
"Undoubtedly you may have severe asthma without severe spasm of the bronchial tubes. I remember a well-marked instance of this in a gentleman whom I attended for a chronic disease—cancer, as I thought, of the liver. For nearly a week before his death he suffered from the most frightfully distressing asthma, which nothing could control, and which lasted without interruption till he died. I examined his chest repeatedly at all parts, and could hear nothing but the most perfect, loud, and puerile breathing, which is quite inconsistent with a state of spasm.
"Again, a section of the vagi nerves of animals produces phenomena exactly like those of asthma. Whatever be the cause of the dyspnoea in these cases, it is clear it cannot be bronchial spasm, as the muscles of the bronchi would be paralyzed after a section of their nerves."
With regard to the first part of Dr. Todd's theory, founded on the supposed analogy of asthma to gout—that you have in asthma a specific materies morbi—I do not think that the existence of points of analogy in the clinical history of the two diseases in any way implies identity of pathology. To how many diseases are headache, shivering, Joss of appetite, thirst, an accelerated pulse, and loaded tongue common, between the pathology of which there is no affinity whatever? With regard to the second part of his theory—the coexistence of asthma with uncontracted bronchial tubes—I believe that the case that he quotes is one of that subjective dyspnoea, not asthma at all, to which I have already referred. In the anhelitus consequent upon the division of the vagi, I can see nothing resembling asthma. Altogether, I cannot but think that the arguments brought forward by Dr. Todd are inadequate to meet the mass of evidence that can be adduced in proof of the necessity of bronchial spasm and the non-necessity of humoral disturbance in asthma. (3, page 26-67)
Dr. Todd made some significant contributions to medical profession, yet his theory regarding asthma was not one of them.  Still, we don't hold this against him, because it shows, once again, the variety of theories about this disease even into the middle of the 19th century.

He lived only 50 years, yet he accomplished an "enormous amount of constructive work," said Cartwright. (1, pages 893-894)

  1. Cartwright, F. F., "Section of the History of Medicine: Robert Bentley Todd's Contributions to Medicine," Proceedings of the Royal Society of Medicine, September 6, 1974, 67 (9), 893-897
  2. Brown, Orville Harry, "Asthma, presenting an exposition of nonpassive expiration theory," 1917, St. Louis, C.V. Mosby Company, page 33
  3. Salter, Henry Hyde, "On Asthma: It's Pathology and Treatment" 1864, London, Blanchard and Lea, pages 24-25
  4. Sakula, Alex, "Henry Hyde Salter (1823-71): a biographical sketch," Thorax, 1985, 40, pages 887-888 (Henry Hyde Salter)

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