1815: Parry supports bronchitic theory of asthma

Caleb Hillier Parry (1755-1822)

Much like the great London physician William Heberden, Dr. Caleb Hillier Parry of Bath was known for taking copious nots. Perhaps he used these notes when describing asthma in his 1815 book "Elements of Pathology," (1, page 372)

He was born in Bath in 1755 and received his general education at the academy of Warrington, and his medical and philosophical education at the schools of Edinburgh and London.  (2, page 372)

William Heberden was the first to describe Angina Pectoris in a speech he gave to the Royal College of Chest Physicians in 1768.  In 1772 his speech was published in The Transactions of the Royal College.  While he described the symptoms of chest pain accurately, Heberden did not know chest pain was caused by a diseased heart.

A few years later, in 1786 a friend of his by the name of Edward Jenner, the same man who earlier had discovered the world's first vaccination, said that angina pectoris was caused by "ossification," or hardening of the coronary arteries, or the arteries that deliver blood to the heart.  In a letter to Dr. Heberden, he said that without the right amount of blood, the heart could not perform its function of pumping blood through the vessels of the body.  (2, page 372)(3, pages 37-38)

Jenner shared his knowledge on the subject with his friend Dr. Parry.  Parry, in turn, communicated what Jenner learned about the subject, plus some insights of his own, with the medical community through his 1797 book "An Inquiry into the Symptoms and Causes  of Syncopy Anginosa, Commonly Called Angina Pectoris."  (2, page 372)(3, page 37)

This work was well received by the medical community. It was through this book that Caleb Parry became the first person to suggest that the way we live, and the foods we put into our bodies, may lead to disease, particularly angina pectoris. He suggested regular exercise and the avoidance of fresh meat.  (2, page 372)(3, page 38)

While "Angina Pectoris" was well received, his most famous work by far was "The Elements of Pathology," which, according to The Gentleman's Magazine:

This exhibits a great system of original and unexampled depth of observation, accuracy of conclusion, and abundance of fact and illustration; it may truly be considered as an almost unparalleled example of great originality and capacity.

It was in this book that he shared, among other things, his knowledge on the subject of asthma.

In patients who are subject to spasmodic asthma, fits of that disorder often begin with a violent coryza, in which the eyes become red and watery, and all the symptoms of a cold in the head are observable. After a few days, or sometimes even only hours, these symptoms suffer some degree of alleviation, and the malady proceeds to the bronchia, occasioning all the well-known signs of spasmodic asthma. What, then, is this state in the bronchia, but an affection of the mucous membrane of those cells, exactly similar to that which had previously existed in the same membrane in the nose? (4, page 196)

It may, however, be said, that asthma is a spasmodic affection, depending on causes acting on the mind, &c. and returning at regular periods. (4, page 197)A

A little over a century later, Orville Brown summed up Parry's view of asthma this way:

Parry suggests that engorgement of the mucous membrane of the bronchi produced such tumidity of it as to mechanically interfere with the passage of the air. (4, page 32)

In other words, like Robert Bree, Parry was a supporter of the bronchitic theory of asthma.  He was a great physician and medical philosopher until he was afflicted by a case of palsy 1816. He died in 1822.

Further Reading:

• 1815: Dr. Parry shares his wisdom of asthma (5/3/16)

References:

1. Garrison, Fielding Hudson, "An introduction to the history of medicine," 3rd edition, 1821, Philadelphia and London, W.B. Saunders Company
2. Urban, Sylvanus, "Dr. Caleb Hillier Parry," The Gentleman's Magazine and Historical Chronical, from January to June, 1822, volume XCII, London, printed by John Nichols, pages 372-373
3. Roberts, Barbara H., "Treating and Beating Heart Disease: A Consumers Guide to Cardiac Medicines," 2009, Jones and Bartlett Publishers, chapter two: "Treating Angina Pectoris," 
4. Parry, Caleb Hillier, "Elements of Pathology and Therapeutics; being the outlines of a work intended to ascertain the nature, causes, and most efficacious modes of prevention and cure, of the greater number of the diseases incidental to the human frame," Volume I: General Pathology, 1715, London, Printed by Richard Cruttwell
5. Brown, Orville Harry, "Asthma, presenting an exposition of nonpassive expiration theory," 1917, St. Louis, C.V. Mosby Company

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1802: Heberden first physician to recognize hay fever

For most of history people were clueless about colds and allergies.  The symptoms associated with them -- itchy and watery eyes, stuffy and runny nose, scratchy throat, coughing, sniffling and sneezing -- were probably brushed off as minor ailments.  Most people did not seek help, as doing so would be a sign of weakness. Instead, they went about their business the best they could.

While there were occasional vague and allusory descriptions of these common ailments, there were more serious diseases called plagues that earned the attention of most medical writers.

The term "plague" became a generic term used through most of history to describe diseases that were both lethal and destructive.  (1, page 17)

It was not until sometime during the 17th century that the term "fever" began to replace the term plague in describing diseases.  A good example of this came in the year 1666 when Thomas Sydenham published his book "The Method of Treating Fevers." He described diseases such as scarlet fever, perpetual fever, malaria fever, hospital fever, and typhoid fever. (1, page 17)

Still, it wasn't until the mid 18th century, and mainly during the 19th century, when the causative agents of specific symptoms were identified, that the term "fever" was used with increased frequency.  Examples would include rose fever and hay fever, with hay fever gaining the most recognition.  These terms crept into medical nomenclature as physicians linked sniffles and sneezes with rose and hay season. (1, page 17)

A generic terms that was more generally accepted by medical authorities was "catarrh."  This term comes from the Greek term katarrho, which means to flow. It generally referred to the flow of humors, or secretions, due to congestion of the vessels (swelling and inflammation) of certain parts of the body, such as the eyes, nose and throat.

Generally speaking, the symptoms that resulted were generally brushed off as the common cold.  For instance, William Heberden, in his 1802 book "Commentaries on the History and Cure of Disease," described catarrh this way:

If such a catarrh lasts only a few days, it is called a cold in the head; but in many it becomes a chronical disorder, and has lasted with no long intervals for several months, for four years, or every night for ten years; or has returned periodically twice a month for several years, or once in three weeks. (2, page 113)

The problem with the term catarrh, and the probably reason it was eventually phased out of the materia medica for the most part, was because nearly every disease causes some form of catarrh.  It was such a generic term that it lost its relevance. By Heberden's time the phase out had already begun, although the complete extrication of the term would take another 100 plus years.

Another term often used was Coryza, although it was not mentioned by Heberden.  It was a more specific term used to describe catarrh of the nose and throat, and was frequently used to describe the common cold. It was yet another generic term to describe a cold, although it was later used to describe a symptom of hay fever.  The word comes from the Greek term koruza which means "running of the nose."

As part of his chapter on catarrh, of which he also referred to as "defluxion," he described what may people think is the first description of hay fever by a medical writer.

I have known it (catarrh's) return in four or five persons annually in the months of April, May, June, or July, and last a month with great violence. In one a catarrh constantly visited him every summer; and in another this was the only part of the year in which it ceased to be troublesome. (2, page 113) (3, page 14) (4, page 14)

While he did not use the term hay fever, or hay asthma, or rose cold, or any of the other terms to describe the condition that had gained the fancy of the public, it's quite obvious this is was he was describing here.

References:

1. Ergonul, Onder, Chris A. Whitehouse, editors, "Crimeon-Congo Hemorrhagic Fever: A Global Perspective," 2007, Netherlands, Springer
2. Heberden, William, "Commentaries on the History and Cure of Disease," 4th edition, 1816, London, Printed for Payne and Foss - Pall Mall
3. Smith, William Abbotts, "On Hay-Fever, Hay-Asthma, or Summer Catarrh," 1867, London, Henry Renshaw
4. Mackenzie, Morell, "Hay fever and paroxysmal sneezing," 5th ed., 1889, London, J&A Churchill

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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

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