The Legacy of William Heberden

With his brilliant intellect and an outstanding ability for clinical observation, the illustrious 18th century English physician William Heberden wrote an immortal chapter in the annals of medicine. While his name remains eponymous with one of his relatively minor discoveries, the Heberden nodes of osteoarthritis, Heberden's contributions were more far reaching. He gave the medical world an extraordinarily vivid and accurate description of a condition that he aptly named “angina pectoris.”William Heberden, the elder (1710–1801), was born in Southwark, England, when the century was barely 10 years old; he would live to see the end of it and enrich it with his own immortal legacy. At the age of 7, Heberden enrolled in the local grammar school, where he showed great promise and impressed the faculty. At 14 years, Heberden went to Cambridge and entered St. John's College as a student. After receiving his bachelor's degree and subsequent postgraduate studies, he became a Fellow at the college. At 29, Heberden was awarded his medical degree from the college.For the next 7 years, he continued his practice of medicine and lectured on materia medica in Cambridge, until his return to London, where he had a rich and productive professional career. In 1746, Heberden was admitted as a Fellow of The Royal College of Physicians of London. The immense talent and genius of the newcomer was recognized by The Royal College of Physicians of London. Heberden was invited to deliver the prestigious Gulstonian Lecture in 1749 and was chosen to be the Harveian Orator in 1750. Subsequently, he also delivered the Croonian Lecture in 1760. Heberden was one of the pioneering forces behind the establishment of the Medical Transactions of the Royal College, a forum wherein members could report their observations on patients for discussion.Heberden's reputation as a teacher and scholar won him friends and fans in the highest circles of society. Among his friends was none other than Benjamin Franklin, who was very much impressed with the principle of smallpox inoculation, based on the ancient Oriental practice of variolation. Heberden collaborated with Franklin in the preparation of a written pamphlet on the success of variolation, which contained instructions on how to perform the procedure.Well versed in Latin, Greek, and Hebrew, Heberden was concerned with factual documentation of clinical findings and did not indulge in speculation. He ran a relentless crusade against the poison antidote formulated by Mithridates, the King of Pontus, Asia Minor, in the first century bc. This all-purpose antidote had been part of the pharmacopeia since the time of Mithridates, and after Heberden's persistence, it was eventually removed from the pharmacopeia of the Royal College of Physicians.In 1752, Heberden married Elizabeth Martin. Their first child died in infancy and Elizabeth died tragically in 1754, after giving birth to their second son, Thomas. When Thomas was 6, Heberden found a new wife, Mary Wollaston. They had 5 more sons and 3 daughters, including the famous William Heberden the younger, who would also make his mark in medicine. The Commentaries of Heberden, written in Latin and published by William Heberden the younger in the year following his father's death, included 102 chapters. In an era that preceded the stethoscope and other technical and biochemical innovations, this extraordinary treatise included elegant descriptions of several clinical entities.With regard to his most monumental medical contribution, Heberden broached the issue of chest pain in a report to the Royal College of Physicians in London in 1768, entitled “Some Account of a Disorder of the Breast.” He gave an accurate account of angina pectoris in this report; an older designation of this malady was “Heberden's asthma.” Heberden provided the first succinct and graphic account of angina pectoris, compiling his own experience along with descriptions of “dolor pectoris” he found in the literature. His initial account of his personal experience with 20 patients was published in 1772 in the Transactions of the Royal College, but over the years he had the opportunity to observe 80 additional cases of angina pectoris, documented posthumously in 1802 by his son.Today, more than 2 centuries later, Heberden's classic account of angina pectoris remains remarkably accurate. Heberden noted that people afflicted with this malady were seized with a most disagreeable sensation in the breast while walking, which would seem to take their life away. The moment they stood still, the uneasiness vanished. Heberden noted that a number of his patients were men, almost all more than 50 years old, with a short neck and usually overweight. Heberden also noted that the natural tendency of this malady was to kill its victims suddenly. Based on his observation that the pulse rate was not always affected during one of these acute paroxysms (a finding thought at the time to be an inevitable accompaniment to heart disease), Heberden discounted the heart as the likely source of this discomfort.An unnamed 18th century physician, who read Heberden's report and recognized the dreaded symptoms of angina pectoris in himself, requested that Heberden conduct an autopsy upon his death. It is seriously doubted if this autopsy, which was performed by the celebrated John Hunter and which uncovered little of etiologic importance, included a careful examination of the coronary arteries. Edward Jenner, who assisted Hunter in the postmortem examination, later apparently reported that the coronary vessels were not examined in this case.Heberden's contributions to clinical medicine are exhaustive. He was emphatic that chickenpox was not a milder version of smallpox and that the two were distinct maladies. He recognized the purpura in hypersensitivity vasculitis, described subsequently by Schönlein and Henoch. Heberden was opposed to some of the aggressive therapies advocated during his day, including ferocious bleeding, purging, excessive sweating, excessive bloodletting, and other quack remedies. Although he did not understand the true nature of diabetes, Heberden felt that polyuria in diabetes was unrelated to the kidneys.Heberden described the “digitorum nodi” (Heberden nodes) in osteoarthritis: “What are those little hard knobs, about the size of a small pea, which are frequently seen upon the fingers, particularly a little below the top, near the joint? They have no connexion [sic] with the gout, being found in persons who never had it. …” Heberden noted that these nodes did not appear in the acute “rheumatism” of the young, prior to puberty.Heberden also ventured into such other nonmedical arenas as botany. He declined the offer of appointment as physician to Queen Charlotte, wife of George III. He retired from medical practice in 1782, at the age of 72.His lifelong habit of making copious and detailed notes at the bedside of his patients allowed Heberden to compile a wealth of clinical material. His conclusions stemmed from his own observations and analytical mind rather than unconfirmed reports or dogmatic teachings of celebrated figures. Indeed, William Heberden has been justly regarded as the father of clinical observation in the 18th century, for the extreme versatility of his accomplishments and his far-reaching influence.

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