Friday, March 10, 2017

1769: John Millar writes about asthma

John Millar (1733-1805) was a Scottish Physicians.  He cared for patients of all ages, although he tended to favor caring for women and children. So when an epidemic of asthma ravaged through the border counties of England and Scotland after great quantity of rain fell in 1755, Dr. Millar was among the first physicians called. (1, pages 11-14)(4, page 96)

He arrived on a blustery day, and was called to the home of a Baker.  A short, stout man wearing a white apron that was covered with white powder met the doctor as his buggy was parked by the entry of the Bakery.  The doctor could smell the sweet aroma of bread, and his stomach grumbled.  He climbed down from the buggy, reached back in for his bag, and followed the baker into his shop, up a narrow and steep set of winding stairs, to a small, hot, room, where a girl was sitting on the edge of a bed, leaning with her face on the edge of a window that faced the street.  He could hear a loud wheeze each time she took in a breath.  He could see by the vigorous shaking of her body that she was working arduously to suck in every breath.

He did not request for the girl to move, and instead squeezed his way around the bed and sat next to her, setting his bag along side him on the back of the bed.  He put his arm around the girls shoulder and hugged her.  "I'm going to help you feel better," he whispered.

He felt her head, and observed it was hot and clammy.  He also observed that she had picked away all the paint on the ledge of the window.  He touched her stomach, and his hand rode in and out as it undulated with each breath.  He said, "Does your stomach hurt? Are you sore down here?"

The girl did not respond, except by her tears and distressing look on her reddish face.  Her mother, however did respond.  She said, "She complained of a sore stomach, and she felt nauseated and vomited.  And she has been very nervous the past few days, refusing to go to school and to do her chores." Her husband, the baker, put his arm around her shoulder and held her tight. "We were so mad at her.  Now we wish we hadn't been."

"You didn't know," the doctor said.  "I believe her stomach indigestion, the fact that he suffers from a nervous affection, perhaps as from a hysteric or hypochondirac disease, and I presume it is asthma."

The doctor reached into his bag and pulled out a bottle and a spoon. He opened it and gave it to the girl.  He would give it to many sick girls and boys that day.  The last stop was at the house of a lawyer, whose girl was in the early stages of the disease.  She seemed to get immediately better when given the remedy.

The lawyer's wife asked him if he wanted to stay in the guest room, and he admitted he was tired.  Before he slept, he opened his bag and pulled from it a journal.  He wrote about every patient, and what he gave.

The next morning he went from business to business, home to home, to see other children, and a few adults, who were afflicted with this asthma.  At night he found a place to sleep, usually by the mother of the last child he saw that day, although on the last night before he planned to return home he slept in the Mayor's guest house.

It had been two weeks since he began treating sick children, and he had traveled from town to town, and had been treated well everywhere he traveled. Many children were cured by his remedies, although, a few times, he held a child during the last moments of life.

After a large meal cooked by the mayor's wife, he returned to the guest house for the night and pulled his journal from his bag.  He sat at a desk and wrote as much as he could remember about the past two week's events.  He wrote:
"Peruvian bark given early, seldom failed to perform a cure... the asthma was more or less frequent according to the state of the weather, that it prevailed most in spring and autumn, and especially in moist seasons. (1, pages 9-11)
He wrote that pure (spasmodic) asthma is most prevalent are places that have increased moisture, and have a tendency to be cold and damp, with the asthma presenting mostly in the spring and autumn. The remedy for this type of asthma is Peruvian bark. Without treatment death may ensue, or "remissions become less and less distinct." (1, pages 11-14)

While Millar described this epidemic as asthma, it was actually croup or some other related disease.  About 50 years later, after he had invented the stethoscope for listening to lung sounds, French physician Rene Laennec determined that the same disease was actually suffocative catarrh.  (4, page 96)

In the meantime, after caring for hundreds of children with what he considered to be asthma, Dr. Millar took his notes and decided to write a book to educate other physicians about this disease.  In 1769 his book was published as "Observations on the asthma and on the hooping cough."

Because his asthma was different than that described by ancient physicians, and even by other physicians of his era, he believed the ancients must have been wrong in their definition of asthma.  He wrote:
THE accounts which have been given of the Asthma by medical writers, seem only applicable to very advanced stages of it, or to other disorders, accompanied with a symptomatical difficulty of breathing; but perhaps without some previous knowledge of the original disease in its simplest form, more complicated cases can neither be clearly explained nor properly treated. The Author of the following Observations, having often seen it in children, unattended with any other complaint, hath given a description of it, as it really appeared, though very different from that which is to be found in books. (1, page i, ii) 
He said Hippocrates was the...
...first who to posterity a genuine history of diseases, and a rational method of treating them, founded upon faithful and accurate observations; but the simple and natural mode of medicine was soon vitiated by the introduction of false and absurd systems of philosophy. While such absurd theories were taught in the schools of medicine, the practice deduced from them was no less ridiculous; and as one or other of these opinions prevailed, the attention of the physician was employed in searching after medicines possessed of occult powers..."
Dr. Millar believed that it wasn't until the writings of Dr. William Harvey in 1628, who demonstrated "the circulation of the blood," that a rational practice of physic (medicine) was re-established. He said it was only after Harvey's discovery that a true understanding of the human body and its diseases could be learned. (1, pages 1-3)

The "theory and practice of physic" was only then begun.  It was Harvey's observation that resulted in "a careful attention to the rise and progress of disease, and to the effects of the medicines applied to them, (and this) is the only proper way to complete their history, and to establish a certain method of cure."  (1, pages 1-3)

He said that...
...Physicians fully convinced of this, and that no single person is sufficient for so great an undertaking, have long since established societies for collecting and publishing medical observations, which have contributed greatly to the improvement of the art." (1, page 3)
This was similarly noted by historian Fielding Hudson Garrison, who explained that there was an explosion of medical knowledge during the course of the 18th century, particularly regarding human anatomy, internal diseases, clinical medicine, and internal medicine.  Various physicians studied the human body, learning about the various diseases and the remedies that treat them.  (2, page 300, 330) 

Thanks to the discovery by Harvey regarding circulation of the blood, medicine as we know it today was born.  It was this discovery, and the eventual acceptance of it, that inspired physicians to race to learn as much about the human body as possible, and the ailments that plague it, and the remedies that fix it.  The result of all this research, and the discoveries that followed, squashed many of the old theories that enveloped the medical profession.*

Asthma was among the diseases studied and expounded upon, with physicians slowly coming to the realization, as noted by both Millar and his contemporaries, that asthma was more than a general symptom. 

Millar said asthma was among the diseases that was slow to be accurately defined.  He wrote:
Sir John Floyer, who was himself afflicted with this disease, describes the chronic asthma, and gives a just detail of its symptoms: but as he was first seized with it when a child, he gives no account of its beginning, nor of the method of treating that early period of it, in which, perhaps, alone a perfect and complete cure is to be obtained? .
What he is trying to say here is that Floyer only recognized adult asthma as opposed to infant and childhood asthma.  Millar continued:
Most other authors who have wrote on this subject, treat, under that denomination, of the Peripneumony, peripheral vomica, Pulmonum, Flatus,. Hypochondriac and. Hysterick Diseases, and, indeed, of almost every other disorder, accompanied with difficult respiration, excepting the least complicated state of that which they undertake to describe.
Here he is trying to say that most authors described asthma as the symptoms of shortness of breath, which is probably secondary to some other malady, as opposed to asthma in its pure form.  He said:
This will not appear surprising when we consider that an asthma, or difficulty of- breathing, is a leading symptom, in all the diseases already mentioned, as well as in many others; and, as it is painful and alarming, the patient, tho' a symptom only, deems it a primary disease, wishes ardently to be freed from it, and represents it principally to the attention of the physician.
On the other hand, as the least complicated species of asthma generally attacks children, or very young subjects, it is frequently confounded with the epilepsy, worms, teething, and other disorders incident to the early period of life, in which the physician can avail himself but little of the information of his patient, and is often misled by that which he obtains from others. Hence the accounts of it which we meet with in medical books, tho they may correspond to certain stages of it, or to the appearances of other diseases, in which a difficulty of breathing is a leading symptom, yet they convey no explicit idea of the origin and progress of the asthma in its simple uncomplicated state. (1, pages 4-5)
Basically he's saying here that there's more to asthma than what has been written about it by previous writers.  Millar breaks asthma down into the following categories.
  1. Acute:  "Terminates in a few days in death, a perfect recovery..." (1, page 92)
  2. Chronic:  It's "often a consequence of (acute asthma), and frequently continues for many years, and often during life." (1, page 92)  
The subheadings that follow here are my own, although I think this would be how Millar defines asthma the disease, as opposed to asthma the symptom of some other disease: 
  1. Pure Asthma: "difficulty of breathing alone, which proceeds from some defect in the bronchial vessels."  (1, page 92)
  2. Secondary Asthma:  Asthma occasioned by " an inflammation, or any obstruction of the lung, a pleurisy, perepneumony, hydrops pectoris, ascites, or any other ailment whither it appears as a concomitant or consequence of these.  
Over a hundred years later, when writing a book on asthma, Dr. Francis Ramadge would use Dr. Millar as a perfect example of how much was written, or assumed, about asthma without doing much investigating into the matter.  

Ramadge quoted Dr. Millar as saying:
The only dissection I ever made in the disease was of a child... (3, page 97)
Perhaps Millar was noting awareness of his limitations when, in the introduction of his book, he acknowledged that what he observed, and later concluded, about asthma was merely the beginning; that there was much more work to be completed regarding the definition of our term asthma.  He said:
Conscious of the difficulty of such an attempt, he does not suppose that he hath completed the history of the disease, but hath endeavoured to collect such observations, as may facilitate the further investigation of it; to point out the particular signs that distinguish it from other disorders in which respiration is only accidentally affected; and he proposes a method of cure which hath often been successfully applied, (1, page ii)

And he was right.  A wise asthma doctor indeed was he, or so we suppose, for the era for which he lived.

*For a list of all the diseases learned about check out reference Fielding Hudson Garrison's book, page 300-302.  He also lists the authors of various "histories of medicine" that were written during the 18th century.  See reference #2 below, or click here

  1. Millar, John, "Observations on the asthma and on the hooping cough," 1769, London
  2. Garrison, Fielding Hudson, "An introduction to the history of medicine," 1913, 1st edition, Philadelphia and London, W.B. Saunders and Company
  3. Ramadge, Francis Hopkins, "Asthma, its species and complications, or researches into pathology or disordered respiration; with remarks on the remedial treatment applicable to each variety; being a practical and theoretical review of this malady, considered in its simple form, and in connection with disease of the heart, catarrh, indigestion, etc." 1835, London,  Longman, Rees, Orme, Brown, Green, and Longman
  4. Andral, M, notes, Renae Laennec, author, "A Treaties on the Diseases of the Chest and on Mediate Auscultation, Regius Professor of Medicine in the College of France, Clinical Professor to the Faculty of Medicine of Paris, &c, &c, &c., Translated from the Third French Edition with Copious Notes, a Sketch of the Author's Life, and an Extensive Bibliography, of the Different Diseases by John Forbes, Member of the Royal College of Physicians, Physician to the Chichester Infirmary, and Physician in Ordinary to his Royal Highness the Duke of Cambridge, to which are added the Notes of Professor Andral, Contained in the Fourth and Latest Edition, Translated and Accompanied with Observations on Cerebral Auscultation, by John D. Fisher, Fellow of the Massachusetts Medical Society," 1838, New York, Samuel S. and William Wood
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