|Year : 2013 | Volume
| Issue : 2 | Page : 188-190
Temporal arteritis; Bayard Taylor Horton's headache era
Bhaskara P Shelley
Department of Neurology, Yenepoya Medical College, Mangalore, Karnataka, India
|Date of Web Publication||13-Dec-2013|
Bhaskara P Shelley
Department of Neurology, Yenepoya Medical College, Mangalore - 575 018, Karnataka
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Shelley BP. Temporal arteritis; Bayard Taylor Horton's headache era. Arch Med Health Sci 2013;1:188-90
The earliest recorded description of temporal arteritis dates to the 10 th century when Ali Ibn Isa of Baghdad in his memorandum book described temporal arteritis and made observations on the relationship between inflammatory signs over the temporalis muscles with visual symptoms notably the loss of sight. , Ali ibn Isa (940 to 1010 BC) is acclaimed to be one of most famous ophthalmologists of the 10th century, who had made an influential and landmark contribution as author of 'Notebook of the Oculists' containing information of over one hundred different eye disorders. The 'Notebook of the Oculists' was widely used by European physicians for hundreds of years. Ali ibn Isa is understood in literature to have undertaken the excision and cauterization of inflamed temporal arteries to treat patients who were suffering from heat and inflammation of their temporal muscles, which sometimes ended in loss of vision. There are rather few definite historical documentations of temporal arteritis for several centuries depicted through historical photographs, paintings, and portraits. 
The first clinical description of temporal arteritis was given by Jonathan Hutchinson in 1890 of St. Bartholomew's Hospital at London who described a man named Mr. Rumbold. He was an 80-year-old father of a porter at the London Hospital who had symptomatic and painful red streaks on his head that prevented him from wearing his hat. Hutchinson recognized these as inflamed swollen superficial temporal arteries. He referred to this patient's condition as a form of "thrombotic arteritis of the aged" but did not appear to be clear about its relationship to arteriosclertic disease, which also resulted in thrombosis. 
It was 42 years later in 1932, Bayard Horton, Magath, and Brown at a Mayo Clinic staff meeting reported two patients with a characteristic clinical presentation of temporal arteritis, highlighting especially the prominence of headache, the difficulty in chewing food, and transient diplopia.  They performed the first temporal artery biopsies that showed the well-known pathologic findings.  Horton deserved the credit for recognizing the connection between the constitutional symptoms and the arteritis of the temporal vessels and for introducing temporal artery biopsy as a diagnostic test.
Jennings in 1938 emphasized the blinding ocular complications and the associated musculoskeletal symptoms now known as polymyalgia rheumatic (PMR).  In 1941, Gilmoure suggested the presence of giant cells as characteristic for the disease, which he called "giant cell chronic arteritis" abbreviated as GCA.  During the 1930s, the term "Temporal arteritis" was gradually introduced, whilst the designation "Cranial arteritis" was coined by Kilbourne and Wolff in 1946 to point out that the temporal artery is not the only scalp artery affected in GCA.  From this time on, cases of temporal arteritis/giant cell arteritis (TA/GCA) became increasingly common in the literature.
I would like to reiterate that the pursuit of knowledge that is patient care-driven is knowledge that stays with oneself. The passionate pursuit of excellence and attention to detail, the meticulous and skilled history-taking is the chief ingredient of a dedicated clinician. However, modern doctors are oriented towards technology-driven diagnosis, as they are either ignorant of these details or unwilling to invest time in history-taking. Let me exemplify the art of medicine and scientific temperament of Bayard Horton as he was clinico-pathologically describing the first cases of temporal arteritis. He was described to be a smart man, a keen clinical observer, and a very hard worker  characterized by his meticulous documentation, clinical notes and descriptions, and follow up. His discovery of treatment certainly symbolizes the zeal of medical humanism and passion as a headache researcher. A researcher has to wear his 'working shoes,' wonder with scientific inquiry, and think with an open mind that is coupled with the desire to learn, to investigate, and to explore the unknown for medical discoveries. Horton and colleagues obtained the first biopsy specimens of the temporal arteries in temporal arteritis and were the first to describe the histopathology. Temporal arteritis was thus referred to as Horton's disease.
Horton's first saw his patient in 1931 who was a 50-year-old woman with symptoms of headache, scalp tenderness, weight loss, fever, and night sweats.  He made meticulous chart notes where he noted bilateral, left more than right, temporal arteries to be tender and enlarged. She was anemic and had an elevated erythrocyte sedimentation rate of 67 mm at the end of first hour documented on 30 th March 1931. On 11 th April 1931, he had an artist make a sketch of the enlarged red and somewhat nodular left temporal artery and being intrigued by the nodular, tender and prominent vessel, he went on further to persuade one of his surgical first assistants to resect this part of the temporal artery. The temporal artery biopsy did show evidence of granulomatous arteritis, and the culture from the artery showed Actinomycosis. Since treatment with potassium iodide did not ameliorate her condition, Mayo pathologist Thomas Magath concluded that the actinomyces was a contaminant. Horton subsequently saw his first patient in December 1932 when he opined that the painful tender areas along the left temporal artery represented periarteritis. After reviewing the first two patients, Horton and colleagues reported these cases on 7 th December 1932 at the weekly Wednesday evening Mayo Clinic staff meeting. They briefly reported on the 52-year-old woman and 68-year-old man who had been admitted to Mayo Clinic in spring 1931. Both had a 4 to 6 week history of fever, weakness, anemia, and painful tender areas on the scalp and along the temporal vessels. With their biopsy evidence of periarteritis of 1-2 cm portion of temporal artery, they reported it as 'an undescribed form of arteritis of the temporal vessels'; a new clinical syndrome of 'temporal arteritis,' which was later officially recognized as disease entity in a JAMA editorial in 1946. In 1938, Jennings was the first to describe vision loss in temporal arteritis, and Horton did not report cases of vision loss until 1943.  His notes in 1954 documented that he had a series of 99 cases of temporal arteritis at the Mayo clinic and had recognized 12 cases of unilateral and 23 cases of bilateral loss of vision.
Horton saw his first patient with jaw claudication and temporal arteritis in 1942. He was not only a focused medical discoverer, but also compassionate as he had requested the Mayo Foundation in 1942 for charity care as his patient could no longer afford medical care. In 1944, Horton was the first to report yet another cardinal feature of jaw claudication in association with temporal arteritis. He observed that this pain occurred only with chewing and promptly disappeared with rest and related the pain to ischemia of the muscles of mastication resulting from thrombosis of the facial arteries. Horton resected the segment of the thrombosed facial artery where the microscopic appearance of the vessel was identical to that, which they have previously described as characteristic of the syndrome, temporal arteritis. Having made the clinical descriptions of temporal arteritis with visual complications and jaw claudication, and the pathologic hallmark as granulomatous arteritis, Horton proceeded with his quest for explicating treatment. In 1942, he gave his first patient with temporal arteritis and jaw claudication Kendall's adrenocortical extract and documented no response as the extract did not have pure cortisone. However, in 1949, Horton used cortisone in his case of temporal arteritis and hypothesized whether cortisone would prevent the serious complication of blindness. Horton in 1955 concluded that cortisone can be used to treat temporal arteritis and decrease the incidence of visual complications. 
Bayard Taylor Horton (1895-1980) received his M.D. degree in 1922 from the University of Virginia and then completed an internship at the University of Virginia Hospital. In 1925, Horton began his fellowship in medicine at the Mayo Graduate School of Medicine. He became a member of the Mayo staff in 1929. In 1940, he was appointed as the head of the Section of Clinical Investigation. He retired from the Mayo Clinic staff in 1958 and moved to Sun City, Arizona, where he was instrumental in the development of the Medical Research Section at the Boswell Memorial Hospital. His international reputation, however, was established with his lucid description of two headache disorders: Histaminic cephalgia (Horton's headache), now termed "cluster headache," and temporal arteritis, now termed "giant cell arteritis." Horton's contributions also included investigating new medications such as dihydroergotamine and the early recognition of medication-induced headache. Horton's description of a patient with histaminic cephalgia warrants review in that it superbly captures the salient features of cluster headache.  He contributed numerous articles to many leading medical journals and delivered addresses before many of the principal medical societies in United States. During the years from 1937 to 1957, he examined 1,402 patients who had contacted him for reason of headache. Horton was a member of the International Cluster Headache Research Group from its inception in 1979 until his death. In 1944, Bayard T. Horton, MD of the Mayo Clinic wrote about his 17 years of clinical usage of histamine in a wide variety of settings. In 1974, he was awarded the Distinguished Clinician Award from the American Association for the Study of Headache.
This piece from the archives of medical history on Bayard Taylor Horton (1895-1980) illustrates his research philosophy of wonder, curiosity, inquiry, scientific temperament, and a 'tireless worker' who certainly did wear his 'working shoes' to leave his footprints in the sands of time for his invaluable contributions to Neurology and headache research. ,, It is phenomenal to realize the zest of Bayard Horton for clinical research on temporal arteritis from 1931 to his final discovery of the therapeutic benefits of cortisone in 1955. Horton is indeed a pioneer in modern headache medicine and research, and with the 'Horton's headache era,' there was an explosion of interest in the world headache community.
| References|| |
|1.||Wilkinson IM, Russel RW. Arteries of the head and neck in giant cell arteritis. Arch Neurol 1972;27:378-91. |
|2.||Hamilton CR, Shelley WM, Tumulty PA. Giant cell arteritis: Including temporal arteritis and polymyalgia rheumatica. Medicine 1971;50:1-27. |
|3.||Hunder GG. The early history of giant cell arteritis and polymylagia rheumatic: First descriptions to 1970. Mayo Clin Proc 2006;81:1071-83. |
|4.||Hutchinson J. Disease of the arteries: On a peculiar form of thrombotic arteritis of the aged which is sometimes productive of gangrene. Arch Surg 1890;1:323-9. |
|5.||Horton BT, Magath TB, Brown GE. An undescribed form of arteritis of the temporal vessels. Mayo Clin Proc 1932;7:700-1. |
|6.||Huston KA, Hunder GG, Lie JT, Kennedy RH, Elveback LR. Temporal arteritis: A 25-year epidemiologic clinical and pathologic study. Ann Intern Med 1978;88:162-7. |
|7.||Jennings GH. Arteritis of the temporal arteries. Lancet 1938;1:424-8. |
|8.||Gilmour JR. Giant cell chronic arteritis. J Pathol Bacteriol 1941;53:263-77. |
|9.||Kilbourne ED, Wolff HG. Cranial arteritis: A critical evaluation of the syndrome oftemporal arteritis with report of a case. Ann Intern Med 1946;24:1-10. |
|10.||Boes CJ. Bayard Horton's clinicopathological description of giant cell (temporal) arteritis. Cephalalgia 2007;27:68-75. |
|11.||Johnson RH, Harley RD, Horton BT. Arteritis of the temporal vessels associated with loss of vision. Am J Ophthalmol 1943;26:147-51. |
|12.||Horton BT. The use of histamine in the treatment of specific types of headaches. JAMA 1941;116:377-83. |
|13.||Horton BT. Headache and intermittent claudication of the jaw in temporal arteritis. Headache 1962;2:29-40. |
|14.||Horton BT. Headahe; clinical varieties and therapeutic suggestions. Med Clin North Am 1949;33:973-1005. |
|15.||Horton BT. Temporal arteritis; report on 39 cases. Proc Annu Meet Cent Soc Clin Res US 1949;19:78. |
| Authors|| |
Bhaskara P. Shelley