1710 to 1790: William Cullen writes about asthma

As we enter the 18th century in our history of asthma we can see that the personal opinion of the so called asthma expert started to take a back seat to scientific theory. One of the first to base his asthma writings on studies he performed was William Cullen.

According to Encyclopedia Britanica he was born in 1710 to the lawyer of the Duke of Hamilton.  In 1734 to 1736 he studied medicine at the University of Edinburgh, and it was here that he became interested in chemistry.  In 1736 he started a medical practice in his home town of Hamilton and lectured on science at the University of Glasgow.

William Cullen (1710-1790)

He quickly earned himself a good reputation.  In 1741 he married and had children who would also earn fame.  Throughout most of his adult life he would study natural medicine, and was particularly interested in scientifically classifying diseases. He thus became a nosologist.

He believed that most diseases were fostered by some kind of disorder of the nervous system, and that the muscle was "a continuation of nerve."  This belief affected his description of asthma, it's causes, and the remedies to treat and prevent it. (1)

Still, when it came to asthma, he found the task of classifying it as a disease, and distinguishing it from other forms of dyspnea, to be a major challenge.  The main reason was because most physicians of his day were stuck on the idea that all or most shortness of breath was asthma.

Cullen became one of the first asthma experts to base his beliefs, or at least try to confirm them, based on studying signs and symptoms of that disease while a person was alive, and comparing it with what he saw in autopsy.  This would become a common trend followed into the 19th century.

The fact that he saw defining asthma as a challenge can be observed by the following quote from Cullin's 1794 book, "First lines of the practice of the psych,":

"The term of asthma has been commonly applied...by many writers... to every case of difficult breathing, that is, to every species of dyspnoea.  The methodical nosologist, also, have distinguished  asthma from dyspneoea chiefly, and almost solely, by the former being the same affection with the latter, but in a higher degree.  Niether of these applications of the term seems to have been correct or proper.  I am of opinion, that the term asthma may be most properly applied, and should be confined, to a case of difficult breathing that has peculiar symptoms and depends upon a peculiar proximate cause which I hope to assign with sufficient certainty."  (2)

Thus, he believed the term asthma, prior to his redefining it, offered a great deal of confusion.  And he was right.  He thus became the first to attempt a definition of asthma, an effort that was continued by other asthma experts into the 19th century, and still goes on to this day.

He likewise notes that even while some authors have defined asthma as spasmotic asthma, they have not distinguished the term from other forms of dyspnea. Cullin would propose that the term asthma be used to denote spasmotic asthma alone, and not other conditions that cause shortness of breath. He refers to it as either spasmotic asthma or convulsive asthma, terms that were used interchangeably by 19th century writers.

Thus, in his 1772 book " Nosology: or, a systematic arrangement of diseases, by classes, orders ," he defined asthma as:

Difficult respiration recurring at intervals, with sense of stricture in the breast, respiration performed with a wheezing noise; difficult cough at the beginning of the fit, sometimes none, free towards the end; and often with copious discharge of mucus."  (3)

In, "The first lines of the practice of the psychic," he defines asthma as:

"Spasmotic, constriction of the muscular fibres of the bronchiae: which not only prevents the dilation of the bronchiae neccessary to a free and full inspiration, but gives also a rigidity which prevents a full and free expiration like many other convulsive and spasmotic affections is readily excited by a turgescence of the blood, or other cause, of any unusual fulness and distention of the vessels of the lungs (inflammation?)"  (4)

He defined asthma as containing the following "facts,":

• It's hereditary
• It seldom occurs early in life, and hardly to the time of puberty, or after it
• It effects both sexes, but most frequently the male
• I have not observed it to be more frequent in one temperature or another
• It does not seem to depend upon any general temperment of the whole body, but a particular constitution of the lungs alone (it's not psychosomatic?)
• It frequently attacks... but hardly ever continues to be repeated for some length of time without occasioning an emaciation of the whole body
• Attacks are generally in the night or toward the approach of night (yet occassionally in the day)
• It comes about suddenly
• It may go into remission
• It is there for the person's whole life
• Returns happen with different circumstances with different persons
• Fits are more frequent in the summer
• It may threaten immediate death, seldom occasions it
• Many persons have lived long under this disease
• Seldom entirely cured
• It effects each person differently
• Each patient has unique external triggers  (5)

The following are the signs and symptoms of asthma:

• Sudden dyspnea
• Tightness of of stricture across the breast
• A sense of straightness of the lungs impeding inspiration
• Desire to get into an erect position
• Desire for free and cool air
• The difficulty of breathing goes on for some time
• Both inspiration and expiration are performed slowly
• With a wheezing noise
• Speaking is difficult and uneasy (in violent fits)
• Often some propensity to coughing, but it can hardly be executed
• Sometimes the pule is increases
• Sometimes fever (usually with increased pulse)
• If urine is voided early it's usually with little colour or odour
• If urine voided late it's usually of a high color and sometimes deposits a sediment
• Sometimes the face is flushed and turgid, more commonly pale and shrunk
• After long continuance, it often ends in a hydrothorax
• Occasionally some aneurism of the heart or great vessels (it thereby proves fatal) (6)

Even after some sleep and the breathing becomes easier and easier, the following signs and symptoms may continue for some time:

• Feels some soreness across chest
• Cannot breathe easy in horiontal posture
• Can hardly bare any motion of his body
• In afternoon has uneasy flatuency of his stomach
• Unusual drowsiness
• Difficulty of breathing returns toward evening
• May occur for several nights
• Followed by remission (especially after coughing up copious sputum) (7)

These symptoms may continue for many hours, "then a remission takes place by degrees; the breathing becomes less laborious and more full, so that the person can speak and cough with more ease, and, if the cough brings up some mucus, the remission becomes immediately more considerable, and the patient falls into a much wished for sleep."  (8)

Causes are generally unique from person to person.  The following are what Cullen would describe as asthma triggers, or things that cause the disease to be "readily excited"****:

• External heat (weather or warm chamber)
• Warm bathing
• Summer weather (particularly dog days)
• Changes of weather (especially sudden colder to warmer)
• Full meal
• Air in stomach
• Exercise (or whatever else can hurry the circulation of the bloos)
• Cold
• Excitement of nervous system, as by passions of the minds
• Odors
• Smoke
• Dust  (10)

He wrote that while the disease cannot be cured "by our art" the patient "can escape the disease by escaping the occasional or exciting causes, which I have endeavered to point out above.

He observed the disease is seldom cured and therefore he "cannot profile any method of cure which experience has approved as generally successful."  However, he does propose some remedies that his observations have shown to be successful during an accute attack or to prevent such an attack.

The remedy generally depends on the cause of the symptoms.  From here he classifies asthma into three groups**:

1.  Idiopathic:  Without manifest cause, or being accompanied with other disease

2.  Symptomatic:  From erruption or other acrid effusion being repelled

Two varieties:

• Gouty (asthma arthriticum): I believe here he's referring to asthma that results from swelling of the air passages. He calls it gouty becasue it mimics the inflammation from gout or arthritis.
• Syphilitic (asthma venereum): Again, this is possibly referring to inflammation in asthma being similar to that of syphilis. (11)

3.  Other asthma dyspneas and orthopnea symptomatic of cardiac and pulmonary difficulties and obstructions (what we might now refer to as heart disease, heart failure, heart attacks, etc.) or what we might refer to as cardiac asthma)

Thus, if asthma arrises from "difficult transmission of the blood through the vessels of the lungs (swollen broncheolar muscles), threatening suffocation," the best remedies are noted below:

• Blood letting (less and less necessary as disease progresses)
• Emollients (empty stomach is beneficial)
• Moderately laxitive glysters (have been found to give considerable relief)
• Gentle vomits by emetics (flatuency of stomach are frequent attendants, and very troublesome for asthmatics, used to prevent and treat asthma)  (more useful in winter than summer****)
• Acids and neutral salts to treat asthma fits excited by turgescence of blood (also recommended by Floyer "On the Asthma."
• Ether (an antispasmotic found to give relief but not long lasting)
• Opium (Best antispasmotic has been found effectual and safe)
• Good diet
• Gentle exercise (riding horseback, going in a carriage, sailing, 
• Flowers of zinc**

The following he proved to not work:

• Purging (seldom found to relieve vessels of thorax)
• Blistering between shoulders or on breast (rarely found it useful)
• Fetid gums (an antispasmotic proved not to work and be sometimes hurtful)
• Musk (antispasmotic not properly tried)
• Liquors (few asthmatics can bear strong, warm, tepid drinks because it weakens nerves of stomach)
• Tea  
• Coffee  (12)
• Emetics***** ("The effects of full vomiting cannot be durable, nor its operation be conveniently repeated, so full vomiting cannot always be employed to prevent the recurrences of the... spasm") (13)

Of interesting to note is Cullen's opinion about opium. Cullen noted that opium had been described by other writers as a remedy for tetanus and epilepsy to relax the body and cure the ailment.  He believed it was useful because it relieved these spasmotic affections.

Since he believed asthma was also spasmotic, he believed opium would remedy asthma as well.  However, he notes that it should only be prescribed for asthma that is truly spasmotic in nature.  In this way, he is implying that anyone giving opium have a true understanding of his own (Cullen's) definition of asthma, and not definitions that preceded him.

He also believed that when opium hasn't worked he believed the reason is because the dyspnea was probably not caused by spasmotic asthma but some other cause. (14)

However, if asthma is of the pure spasmotic form opium may be used opium may be used "both to prevent and to moderate fits with great advantage.  However, with other forms of asthma "where the disease depends upon turgescence of the blood in the lungs, opium can hardly be used with safety."

He adds that, "even when the disease is of the catarrhal kind (nasal inflammation), if it be fit to use opium to relieve the catarrh, it may be likewise employed to relieve the asthma depending upon it.  But I must conclude by remarking, that in both the spasmotic and catarrh asthma, I have frequently employed opium in moderating the disease; but have never found it to prove an entire cure of it."

Yet he concluded asthma in the "pure spasmotic form" worked quite well according to his studies. (15)

Click here for more asthma history.

References:

1. Encyclopedia.com, "William Cullen,"  http://www.britannica.com/EBchecked/topic/146062/William-Cullen
2. Cullen, William, "First Lines of the Practice of the Phsych," 1784, Edinburgh, Vol. 3, 4th ed., 387-88
3. Cullen, William, "Nosology: or, a systematic arrangement of diseases, by classes, orders," London, 1800, page 118
4. Cullen, "First lines...," op cit, page 397
5. ****Cullen, William, "The first lines of the practice of psychic," Vol. III, Edinburgh and London, 1784, pages 387
6. Cullen, op cit, "First lines...," pages 387-410 (Cullen offers a great synopsis of his theory on asthma)
7. Cullen, op cit, "First lines...," pages 387-410 (Cullen offers a great synopsis of his theory on asthma)
8. Cullen, op cit, "First lines...," pages 387-410 (Cullen offers a great synopsis of his theory on asthma)
9. Cullen, op cit, "First lines...," pages 387-410 (Cullen offers a great synopsis of his theory on asthma)
10. Cullen, op cit, "First lines...," pages 387-410 (Cullen offers a great synopsis of his theory on asthma)
11. **Jackson, Mark, "Asthma, Illness and Identity," The Lancet, Volume 372, Issue 9643, Pages 1030 - 1031, 20 September 2008
12. Cullen, op cit, "First lines...," pages 387-410 (Cullen offers a great synopsis of his theory on asthma)
13. Cullen, William, "A treaties of the Materia Medica," Vol. II, Edinburgh, 1789, page 469 
14. Cullen, William, "Professor Cullen's Treaties of the Materia Medica", edited by Benjamin Smith, 1812, Vol II, Philadelphia, page 175 (same explanation found in reference #13 above)
15. Cullen, William, "Professor Cullen's Treaties of the Materia Medica", edited by Benjamin Smith, 1812, Vol II, Philadelphia, page 175

Other readings:

• Cullen,William,"The Edinburgh practice of physic, surgery, and midwifery" Vol. II, London, 1803