Commentaries on the History and Cure of Diseases

Commentaries on the History and Cure of Diseases is a clinical treatise published posthumously in 1802 by William Heberden, based on a Latin manuscript composed during the final years of his life and translated into English by his son. Heberden had practiced medicine in London for over fifty years. The work covers more than a hundred diseases alphabetically, drawing almost entirely on his own case observations rather than theory or authority. It is best known for introducing the term angina pectoris and providing its first systematic clinical description, but the book’s broader significance lies in Heberden’s insistence on honest reporting of what he did and did not know, his skepticism toward received remedies, and his repeated defense of patient autonomy against medical overreach.

Place in 18th-Century Medicine

The Commentaries sits at the close of an era in which, as Bynum observes of medicine in 1790, organized medicine had little demonstrable effect on the population growth then underway across Europe; medical schools, hospitals, journals, and energetic doctors all existed, but these institutions did not yet translate into life-prolonging therapeutics. (Bynum, 1994) Heberden’s contemporaries built large theoretical systems on this thin empirical base. William Cullen at Edinburgh organized disease into elaborate nosologies based primarily on symptoms rather than anatomical lesions, treating the body as an integrated whole in which individuals, not organs, were the actual loci of disease. (Bynum, 1994) On Bynum’s reading, this holistic, symptom-oriented framework had a structural blind spot: heart disease occupied an insignificant place in Cullen’s thinking because the system was too physiological and too holistic to attend to local organ pathology such as valvular disease or atherosclerosis. (Bynum, 1994)

Heberden’s Commentaries works in the same therapeutic landscape but moves in the opposite methodological direction. Where Cullen built downward from a system, Heberden worked upward from cases. Where Cullen’s nosology treated the heart as an awkward fit, Heberden devoted a careful chapter to a previously unnamed cardiac syndrome. Where Cullen denied that phthisis was contagious and attributed it to inherited diathesis, (Bynum, 1994) Heberden reported what he could see: a hereditary tendency, a vulnerable age window, and dissection findings that complicated the textbook account. The book is not a counter-system; it is the absence of system.

Structure and Method

The Commentaries proceeds alphabetically through diseases, from diet and general principles through specific conditions — angina, arthritis, asthma, diabetes, fever, consumption, smallpox — concluding with a philosophical reflection on the limits of medical knowledge. Each chapter is a compressed report of clinical experience: what Heberden saw in his own patients, how diseases presented and progressed, which remedies helped and which did not, and where honest uncertainty remained.

Heberden’s method was observation with minimal theoretical commitment. He classified diseases by their visible features and natural history rather than by humoral or mechanical theory. When discussing fever, he insisted that different fevers require different treatments and that the physician must adapt to the patient’s age, constitution, and manner of living, as well as the season and the character of the current epidemic. (Heberden, 1802) He distinguished inflammatory fevers requiring bleeding from jail-fever and similar types that seldom needed it but often benefited from clearing the stomach and bowels. (Heberden, 1802) He confessed that a specific remedy for continual fevers remained one of the great gaps in medicine, and that despite much experimentation with antimony preparations, he had never satisfied himself that they did more good than any other equally strong purges and vomits. (Heberden, 1802)

Angina Pectoris

The chapter on pectoris dolor contains the clinical description for which Heberden is most remembered. Patients are seized while walking, especially uphill and soon after eating, with a painful sensation in the breast that seems as if it would extinguish life if it continued, but the moment they stand still all uneasiness vanishes. (Heberden, 1802) Heberden coined the name angina pectoris for this condition, noting that its seat, sense of strangling, and accompanying anxiety justified the term, and observing that the disorder had scarcely had a place or a name in medical books despite not being extremely rare. (Heberden, 1802)

The clinical detail is precise. The pain frequently extends from the breast to the middle of the left arm. The pulse is sometimes not disturbed during the paroxysm. Males past fifty are most liable. (Heberden, 1802) Heberden reported seeing nearly a hundred cases, of which three were women and one a twelve-year-old boy. (Heberden, 1802)

Heberden classified angina pectoris as a spasmodic rather than inflammatory complaint, citing seven criteria: sudden onset and offset, long intervals of health between attacks, relief from wine and opium, worsening with mental disturbance, years of persistence without other apparent injury, no provocation by horseback riding, and undisturbed pulse during attacks. (Heberden, 1802) He described the terminal course: if no accident intervenes, patients all suddenly fall down and perish almost immediately. Autopsy of one case by a skilled anatomist revealed no fault in the heart, valves, arteries, or veins except some small rudiments of ossification in the aorta. (Heberden, 1802) The pathological anatomy was too sparse to settle the question, and Heberden knew it. The spasm classification was wrong — coronary artery disease, not spasm, causes most angina — but the clinical picture he drew remained standard for over a century.

Therapeutic Skepticism

A recurring pattern in the Commentaries is Heberden’s refusal to claim more than his experience warranted. On asthma, he noted that some cases cannot bear country air and are much more tolerable in great towns, while the far greater number are impatient of cities and always easiest in the country. (Heberden, 1802) He reported that asthma almost always manifests upon waking from the first sleep and that lying down particularly aggravates breathing. (Heberden, 1802) But he also recorded a case of severe asthma that improved spontaneously after four years, and acknowledged that such instances make it uncertain whether relief was obtained by the efforts of nature or by the effects of medicine. (Heberden, 1802) This is an early articulation of what would later be called the problem of confounding — the difficulty of distinguishing therapeutic effect from natural resolution.

On diabetes, Heberden argued that it was more likely a symptom of some other disorder than a disease of the urinary organs themselves. (Heberden, 1802) He challenged received wisdom about glycosuria: the urine in diabetes was said to have a honey-like sweetness, but in his judgment, based on his most complete cases, it ought rather to be called insipid. (Heberden, 1802) He observed that diabetes and dropsy may be alternative terminal paths of a broken constitution, suggesting that some trivial circumstance determined the body to take on one disease rather than the other, and that removing either would do little toward saving the patient’s life. (Heberden, 1802)

Patient Autonomy and Clinical Humility

The opening chapter on diet contains some of the most striking passages. Heberden argued that physicians are too strict in dietary rules and that too anxious attention to diet has often hurt the well and added unnecessarily to the distresses of the sick. (Heberden, 1802) He trusted the patient’s own judgment about food choices over the physician’s, stating that he never met a person of common sense whom he did not think much fitter to choose for himself than Heberden was to determine for him. (Heberden, 1802) In scarcely any disease, he insisted, should the patient not be left to choose whether to sit up or keep to bed: the patient’s strength and ease are chiefly to be attended to. (Heberden, 1802)

These are not throwaway remarks. They represent a considered position on the physician’s relationship to the patient — one that placed observation and restraint above theoretical authority, and that recognized the patient as the primary witness to his own condition.

Differential Diagnosis

Heberden was meticulous in distinguishing diseases that resembled each other. He differentiated scarlet fever from measles by the pattern of eruption (diffuse redness versus distinct spots), degree of skin roughness, presence or absence of cough and watery eyes, and the timing of eruption: first or second day in scarlet fever, third day face and fourth or fifth day arms in measles. (Heberden, 1802) He noted that delirium is of much less prognostic importance in scarlet fever than in other fevers, since in other fevers it seldom appears until they have reached a dangerous height, while in scarlet fever it sometimes accompanies the very first day. (Heberden, 1802)

On gout, he described the classic presentation in the great toe, the succession of pains in different parts making up a whole fit, and three etiological categories: hereditary, created by intemperance, or arising from unknown causes even in the sober and abstemious with no family history. (Heberden, 1802) (Heberden, 1802) He reported that gout never begins before puberty, that women are less subject than men though not rarely affected, and that violent repeated fits produce chalkstones that make joints stiff and almost useless. (Heberden, 1802) He recorded Oliver of Bath’s view that irregular gout partakes of the nature both of rheumatism and palsy. (Heberden, 1802)

Disease and Mortality

The chapters on consumption and smallpox show Heberden at his most careful. He reported from the London bills of mortality that consumption was the most destructive of all maladies to adults in London, with one in four of those who grow to manhood carried off by it, but warned that this statistic was inflated because all who decline and waste from obscure diseases were charged to this article. (Heberden, 1802) He stated that consumption was most certainly derived from parents and that the period between puberty and thirty was the time of greatest danger. (Heberden, 1802) He recorded dissecting a consumption patient whose lungs were in a most diseased state, yet during the whole illness there was no spitting of blood, no pain of the breast, nor any difficulty lying on either side — demonstrating that classical symptoms can be absent in confirmed pulmonary disease. (Heberden, 1802)

On smallpox, he reported that inoculation had not always secured patients from having smallpox afterwards when the initial eruption was imperfect, describing a case of full smallpox ten years after inoculation. (Heberden, 1802) He observed that an uninoculated person may safely associate and even lie in the same bed with a variolous patient for the first two or three days of the eruption without danger of infection. (Heberden, 1802) He identified excruciating pain in the loins as an infallible prognostic sign that a bad smallpox would follow. (Heberden, 1802)

The Conclusion

The final chapter is the most philosophically revealing. Heberden confessed that after fifty years of practice, his knowledge of diseases and remedies was slight and imperfect. He attributed this partly to his own limitations but also to the very great difficulty of making improvements in the medical art. (Heberden, 1802) He argued that living bodies possess many additional powers whose operations can never be accounted for by the laws of lifeless matter, and that the art of healing had scarcely had any guide but the slow one of experience, having made no illustrious advances by the help of reason. (Heberden, 1802) He expressed hope that Providence would one day send a genius capable of contemplating the animated world with the sagacity shown by Newton in the inanimate, and of discovering that great principle of life upon which its existence depends. (Heberden, 1802)

This is a vitalist position, though Heberden would not have used the term. He was not asserting a metaphysical doctrine of vital force so much as acknowledging that the gap between chemistry and physiology remained too wide for rational therapeutics. The honest response, in his view, was patience and careful observation rather than premature system-building.

Method as Counter-System

Set against Cullen’s First Lines of the Practice of Physic and the Brunonian and Rushian systems that dominated late-eighteenth-century thought, the Commentaries reads as a sustained argument for a different relationship between observation and theory. Heberden’s chapter on fever insists that different fevers require different treatments and that the physician must adapt to the patient’s age, constitution, and manner of living, as well as the season and the character of the current epidemic. (Heberden, 1802) His chapter on diet rejects the strict dietary rules of his contemporaries on the grounds that anxious attention to diet has often hurt the well and added unnecessarily to the distresses of the sick. (Heberden, 1802) His chapter on diabetes refuses to identify it as a disease of the urinary organs, treating it instead as a symptom of some other disorder, (Heberden, 1802) and refuses to repeat the standard description of glycosuria as honey-sweet, calling the urine in his complete cases “insipid.” (Heberden, 1802)

These are not merely individual contrarian judgments. Taken together they describe a method that refuses to subordinate the case to the system. The closing chapter’s commitment to the slow guide of experience (Heberden, 1802) is not a rhetorical flourish; it is the operating principle of the entire book. Where Cullen’s nosology classified consumption broadly enough to include almost any wasting disease with a pulmonary component and attributed it to inherited diathesis, (Bynum, 1994) Heberden warned that the London bills of mortality inflated the count by charging all wasting deaths from obscure disease to “consumption,” (Heberden, 1802) and reported a dissection in which classical symptoms were absent despite extensively diseased lungs. (Heberden, 1802) The discipline is consistent. A category that overreaches gets narrowed; a textbook symptom that fails in a real case gets the case, not the textbook.

Reception and Posthumous Reading

The book’s significance has been registered most clearly through the chapter that named angina pectoris. The condition Heberden described in 1772 (and developed in the Commentaries) was rare enough in earlier medical writing to lack a settled name, yet within a generation of his published lecture it had a recognized clinical profile. John Hunter, whom Sigerist counts among the most important surgeons of the eighteenth century, suffered from angina pectoris for several years before his death in 1793, a fact recorded in the standard histories without further explanation, suggesting how quickly the term and the syndrome had entered general medical vocabulary. (Henry E. Sigerist, 1933)

Heberden’s broader method has been more difficult to place. The Commentaries fits awkwardly into the general accounts of late-eighteenth-century medicine. Bynum’s survey emphasizes the dominance of system-builders (Cullen, Brown, Rush, the Edinburgh nosologists, the Paris clinical school) whose ambitions were architectonic, (Bynum, 1994) (Bynum, 1994) and the Commentaries sits to one side of that story, neither a system of its own nor a precursor of the lesion-based pathology that would soon supplant the nosologists. The book’s afterlife is preserved less in interpretation than in citation: the angina chapter became standard, the diabetes chapter retained value into the nineteenth century, and the philosophical conclusion has been quoted by historians as a representative voice of late-Enlightenment medical humility.

See Also

• William Heberden
• Angina Pectoris
• Clinical Observation
• Therapeutic Nihilism
• Prognosis
• Diagnosis
• Epidemic Disease
• Smallpox
• Cowpox
• Isaac Newton

Sources

Primary and secondary evidence for this page comes from:

• Heberden, W. (1802). Commentaries on the History and Cure of Diseases. London: T. Payne. [Source ID: heberden-commentaries-1802] — Primary source; the bulk of claims derive from this text.
• Bynum, W.F. (1994). Science and the Practice of Medicine in the Nineteenth Century. Cambridge University Press. [Source ID: bynum-science-practice-medicine-1994] — Contextualizes the late-eighteenth-century systems against which Heberden worked.
• Sigerist, H.E. (1933). The Great Doctors: A Biographical History of Medicine. New York: W.W. Norton. [Source ID: sigerist-greatdoctors-1933] — John Hunter’s angina pectoris.