Tuesday, November 22, 2011

1722: William Cullen writes about asthma

William Cullen (1710-1790)
As we enter the 18th century hypothetical theories of medicine start to take a back seat to scientific evidence.  One of the first to base his asthma writings on studies he performed was Dr. William Cullen.

He was born in 1710 to the lawyer of the Duke of Hamilton.  He started his education in his home town of Hamilton in Scotland, and then went to Glasgow where he studied medicine. After he was only there a short time he was appointed apprentice to Mr. Praisley, a surgeon with an extensive library, a valuable asset for an aspiring physician.  1, page 133)(2)

In 1729 he went to London to further his career, and was appointed surgeon aboard a merchant vessel sailing from London to the West Indies. Upon his return he took a position at a local apothecary. While this was the only such trip he would take, he paid peculiar attention to the "diversity of climate on human constitution, and to observing the diseases peculiar to the West Indies." (1, page 133)(2)

He returned to London and was hired as an assistant to Mr. Murray at an apothecary shop. It was here he studied medicine (materia medica). He continued this work until 1932 when his father and brother died, and he was compelled to moved back to Scotland near the village of Shotts in Lanarkshire (now North Lanarkshire).  (1, page 133)(2)

In Schotts he cared for the invalid child of Captain Cleland, of whom he sailed with a few years earlier. He practiced medicine here for two years, before going to live with a Clergyman in Northumberland where he studied and became adept in literature and philosophy. (1, page 133)(2)

In 1734 he attended medical school in Edinburgh, and then two years later returned to his private practice in Hamilton. Here he stayed for eight years (1736-1744), honing in his medical skills at his own medical practice. He took care of the Duke of Hamilton, and was given credit for curing the Duke of a serious illness.  (1, page 133)(2)

He cared particularly for the poor, offering his services to them without fee.  It was in 1740 that he received his medical degree from Glasgow. He gave lectures on the theory and practice of physick, materia medica, and botany.  Some say he was the first physician at Glasgow.   (1, page 133)(2)

Medical historian Lindsley Bradford said that during his lectures he...
...was independent and spoke so slightly of Boerhaave that he was called a Paracelsus, a van Helmont, a whimsical innovator. And the Lord Provost Drummond even requested him to speak respectfully of the Leyden professor... he was much loved by his students." (1, page 134)(2)
In the meantime, in 1741, he married and had children. He also earned himself a good reputation.

In 1755 he returned to the University at Edinburgh where he was ultimately named sole professor of medicine, a position he held until just before his death in 1790 at the age of 78. He ended up having 11 children, some of whom earned fame of their own. (1, page 134)(2)

Throughout most of his adult life he would study natural medicine, and was particularly interested in scientifically classifying diseases. He thus became a nosologist, and a pretty good one at that.

He was a solidist, in that he was more interested in the living solid parts of the body as opposed to the fluids. In this way he believed most diseases were fostered by some kind of disorder of the nervous system, and that the muscle was "a continuation of nerve."   (1)(2, page 135)(3, page 318)

He essentially believed that life itself was a continuation of the nervous system. This belief would affect his description of diseases, their causes, and the remedies used to treat them.  (1)(2, page 135)(3, page 318)

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. Not only was this a challenge for him, it continues to be a struggle for some physicians in the modern world. 

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 was a common trend among physicians of his era.

The fact that he saw defining asthma as a challenge can be observed by the following quote from Cullen'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.  Neither 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."  (4, pages 387-88)
In this way he was the first to define asthma as a specific disease, as opposed to an umbrella term for any malady that causes dyspnea and wheezes.  In other words, he was perhaps the first to suggest that all that wheezes is not asthma.  From this point on each physician would form their own theories regarding asthma based on their own experiences and observations.  The debate as to how to define asthma would continue well into the 20th century, and we can thank Cullen for beginning it.

Cullen, therefore, became the first to form a specific theory regarding asthma.  He said that while many authors before him said asthma was spasms of the air passages, none distinguished asthma from other forms of dyspnea.  Cullen, therefore, proposed the term "asthma" be used only to denote spasmotic asthma alone, and not the hundreds of other medical conditions that cause dyapnea

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. Cullen would propose that the term asthma be used to denote spasmotic asthma alone, and not other conditions that cause shortness of breath.

In this way, perhaps, William Cullen can be referred to as the father of the spasmotic theory of asthma.  We can also call it the convulsive theory of asthma, or, in the modern world, the bronchospasm theory of asthma. All mean the same thing.

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."  (5, page 118)
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 (swelling) of the blood, or other cause, of any unusual fulness and distention of the vessels of the lungs (inflammation?)"  (4, page 397)
He defined asthma as a nervous affection as compared to the accumulation of mucus which he regarded as part of dyspnea cararrhalis.  and containing the following "facts,": (4, page 387)
  • 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 temperament of the whole body, but a particular constitution of the lungs alone 
  • 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 occasionally 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  (4, page 387)
  • There is a greater chance of curing the disease in youth than in advanced age (9 page 390)
  • It's a chronic disease, which may continue to give very great distress at intervals, for a considerable number of years (9, page 390)
The following were his 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 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) (4, pages 387-410 )
Even after some sleep and the breathing becomes easier and easier, the following signs and symptoms may continue for some time:  (4, pages 387-410 )
  • 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) (4, pages 387-410 )
These symptoms may continue for many hours, Cullen said, "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." (4, pages 387-410 )

There are two forms of asthma:
  1. Humid: With expectoration of mucus.  This is also called humoral asthma.  
  2. Dry: Without expectoration of mucus. This is also called spasmotic asthma.
Cullen described things that excited asthma as exciting causes, or things that cause the disease to be "readily excited.  He said these are unique from person to person.  He said when the disease cannot be cured "by our art," it can often be cured by encouraging the patient to escape from the exciting cause.  Some exciting causes were: (4, pages 387-410 )
  • 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  
  • Hysteria 
  • Hypochondriasis
  • Dyspepsia
  • Atonic gout 
  • Other conditions that cause dyspnea  (4, pages 387-410 )
  • Weather changes (9, page 393)
  • Large cities (9, page 393)
Things that are hot or cold excite an attack by the following means: 
An asthmatic fit seems thus to depend upon some fulness of the vessels of the lungs, it is probably that an obstruction of perspiration, and the blood being less determined to the surface of the body may favour an accumulation in the lungs, and thereby be a means of exciting asthma. This seems to be the case of those asthmatics who have fits most frequently in the winter season, and who have commonly more of a catarrhal affection accompanying the asthma; which therefore occurs more frequently in winter, and more manifestly from the application of cold." (4, page 395-396)
On the other hand, things like smoke or dust or hysteria, hypochondria, dyspepsia and atonc gout "excite the powers of the nervous system."  (4, page 397)

Regardless of the exciting cause, the "proximate cause of this disease is... spasmotic, constriction of the muscular fibres of the bronchiae: which not only prevents the dilation of the bronchaie necessary to a free and full inspiration, but gives also a rigidity which prevents a free and full expiration.  This preternatural constriction, 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." (4, page 397-398)

Regarding the prognosis of asthma, he says the following:
The asthma, though often threatening immediate death, seldom occasions it; and many persons have lived long under this disease. In many cases, however, it does prove fatal; sometimes very quickly, and perhaps always at length. In some young persons it has ended soon, by occasioning C c 4 a a phthisis pulmonalis. After a long continuance, it often ends in a hydrothorax; and commonly, by occasioning some aneurism of the heart or great vessels, it thereby proves fatal. (4, page 399-400)
As far as remedies, he says the following:
As it is seldom that an asthma has been entrely cured, I therefore cannot propose any method of cure which experience has approved as generally successful. But the disease admits of alleviation in several respects from the use of remedies; and my business now shall be chiefly to offer some remarks upon the choice and use of the remedies which have been commonly employed in cases of asthma. (4, page 400)
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.  Of this group there are 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 because 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. 
3.  Other asthma dyspneas and orthopnea symptomatic of cardiac and pulmonary difficulties and obstructions (he's probably referring to conditions we'd refer to as bronchitis, pneumonia, or heart failure)

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: (4, page 400)
  • Blood letting (less and less necessary as disease progresses, although it was a common 18th century remedy for swelling, or congestion (turgescence) of blood in the tissues) (4, page 401-403)
  • Emollients (relieving the bowels helps to ease breathing, as an empty stomach is beneficial) (4, page 404)
  • Moderately laxitive glysters (have been found to give considerable relief) (4, page 404)
  • 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) (4, page 404)
  • Issues (useful in obviating plethora, although this rarely occurs with asthma) (4, page 405)
  • Acids and neutral salts to treat asthma fits excited by turgescence of blood (also recommended by Floyer "On the Asthma.") (4, page 405)
  • Ether (an antispasmotic found to give the best relief.  It's also safe, but not long lasting) (4, page 407)
  • Opium (Works best for spasmotic or dry asthma; Best antispasmotic has been found effectual and safe; may use large doses if needed) (4, page 407)(9, page 393)
  • Simply avoiding the occassional or exciting cause (4, page 408)
  • Breathing the air low to the ground, as compared to mountain air (4, page 408)
  • Good diet, or a spare, light and cool diet is proper(4, pages 408-409) (9, page 393)
  • Avoiding a large meal (4, page 409)
  • Avoiding food that is of slow and difficult solution in the stomach (slow to digest)
  • Eating animal food of the lighter kind, and in moderate quantity (4, page 409)
  • Avoid vegetables that are flatulent (4, page 409)
  • Drinking water and cool water liquors is generally safe (4, page 409)
  • Gentle exercise (riding horseback, going in a carriage, sailing, (4, page 410)
  • Coffee (9, page 392)
  • Emetics (works well for humid asthma) (9, page 392)
  • Smoking or chewing tobacco (9, page 392)
  • Various other remedies (recipes provided in his book)  (9, page 392-393)
  • Inhaling the vapour of Ether (9, page 393)
  • Inhale hydrocarbolic air, or air with increased oxygen, for humid asthma (9, page 393)
  • Inhale hydrogen if dry asthma (9, page 393)
  • Ipecacuanha in small doses for dry asthma; may give 3-10 grains every other day (great remedy) (3, page 393)
  • Blistering between shoulders necessary for asthma arthriticum (not for pure asthma)
The following he proved to not work:
  • Purging (seldom found to relieve vessels of thorax,and does not relieve congestion of the lungs) (4, page 403)(9, page 390)
  • Blistering between shoulders or on breast (rarely found it useful in pure asthma) (4 page 404)
  • Fetid gums (an antispasmotic proved not to work and be sometimes hurtful) (4, page 407
  • Musk (antispasmotic not properly tried) (4, page 407)
  • Liquors (few asthmatics can bear strong, warm, tepid drinks because it weakens nerves of stomach) (4 page 409-410)
  • Tea  
  • 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") (6, page 469)
  • Infusion of tobacco as an emetic (It's too dangerous (9, page 392)
In an era when physicians were using scientific methods to learn more about human anatomy, and the changes that occur in the body the result in the symptoms observed, it was only a matter of time before one of these physicians used science to better define asthma.  The man who did this was William Cullen.  

Click here for more asthma history.

References:
  1. "William Cullen," britannica.com,"  http://www.britannica.com/EBchecked/topic/146062/William-Cullen, accessed 11/12/13
  2. Bradford, Thomas Lindsley, writer, Robert Ray Roth, editor, “Quiz questions on the history of medicine from the lectures of Thomas Lindley Bradford M.D.,” 1898, Philadelphia, Hohn Joseph McVey
  3. Garrison, "An introduction to the history of medicine," 1921, 3rd edition, Philadelphia and London, W.B. Saunders Company
  4. Cullen, William, "First Lines of the Practice of the Phsych," 1784, Edinburgh, Vol. 3, 4th ed., 387-88
  5. Cullen, William, "Nosology: or, a systematic arrangement of diseases, by classes, orders," London, 1800, page 118
  6. **Jackson, Mark, "Asthma, Illness and Identity," The Lancet, Volume 372, Issue 9643, Pages 1030 - 1031, 20 September 2008
  7. Cullen, William, "A treaties of the Materia Medica," Vol. II, Edinburgh, 1789, page 469 
  8. Cullen, William, "Professor Cullen's Treaties of the Materia Medica", edited by Benjamin Smith, 1812, Vol II, Philadelphia, page 175 
  9. Cullen,William,"The Edinburgh practice of physic, surgery, and midwifery" Vol. II, London, 1803



References:
  1. "William Cullen," britannica.com,"  http://www.britannica.com/EBchecked/topic/146062/William-Cullen, accessed 11/12/13
  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
  16. Garrison, "An introduction to the history of medicine," 1921, 3rd edition, Philadelphia and London, W.B. Saunders Company
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