TALES OF ANGINA
The oppressive chest pains induced by exertion, known as angina pectoris, have plagued sufferers for centuries. Even the hearts of ancient Egyptian mummies have revealed calcified coronary arteries, an anatomical change that restricts blood flow to the heart muscle that is the usual cause of angina. A full description of anginal pain, recognizing it as a distinct entity to be distinguished from other chest complaints, was first made by William Heberden in an address to the Royal College of Physicians in 1768. The address was published four years later in the Medical Transactions of the Royal Society of Physicians and in the periodical, Critical Review or Annals of Literature, a popular magazine aimed at an educated readership that frequently published medical news.
Heberden describes angina in the following words: “Those who are afflicted with it are seized, while they are walking, and more
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| Article by Heberden in Medical Transactions. (Hathi Trust) |
particularly when they walk soon after eating, with a painful and most disagreeable sensation in the breast, which seems as if it would take their life away if it were to increase or continue: the moment they stand still, all this uneasiness vanishes. In all other respects the patients are at the beginning of this disorder perfectly well, and in particular, have no shortness of breath, from which it is totally different.” Heberden adds that he and another physician, whom he discussed the matter with, both noticed a high frequency of sudden deaths within a short time after the onset. Heberden speculated on some sort of “strong spasm” beneath the sternum as the cause of pain, not mentioning heart disease.
William Heberden was one of the most sought-after physicians in London. Born in 1710 to an innkeeper, his early schooling was at a grammar school that emphasized the Classics. He entered St. John’s College at Cambridge at the age of
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| William Heberden (Wikipedia) |
fourteen, obtained a Bachelor of Arts degree four years later, followed by further study and a medical degree after another eleven years. He taught physic and materia medica for several years at Cambridge and later opened a practice in London. He was a careful observer, taking extensive clinical notes that coalesced eventually into a book: Commentaries on the History and Cure of Disease. His description of digitorum nodi (Heberden’s nodes) appears there. He was a founder of the journal, Medical Transactions, published by the Royal College of Physicians.
He was conservative regarding the multiplicity of medicines at the time, naming only Peruvian bark for ague, mercury for syphilis, sulfur for the itch (probably scabies), and opium as specific remedies. His broad education and gentle manner attracted many friends and patients, especially from the sphere of literature, such as Samuel Johnson, who dubbed him “ultimus Romanorum,” the last of our learned physicians. He was a friend of Benjamin Franklin, who persuaded him to write a pamphlet on the prevention of smallpox by variolation (inoculation of smallpox virus, a technique used prior to vaccination with cowpox-derived virus), which Franklin published in America on his own press in 1759. The pamphlet was distributed free of charge, the cost being absorbed by Franklin and Heberden.
One of Heberden’s patients suffering from angina had willed his body to be dissected when he died. Heberden asked the famous surgeon and anatomist, John Hunter, to perform the autopsy. Helping
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| Edward Jenner (Wikipedia) |
him was Edward Jenner, his 23-year-old pupil in surgery. They found no particular cause of death. Fourteen years later, Jenner, now in practice in the town of Berkeley, autopsied a patient of his with angina pectoris who had died suddenly. While making a transverse section of the heart, Jenner’s knife encountered something hard and gritty. As he wrote to a colleague, Caleb Perry, he looked up at the old and crumbling ceiling, “…conceiving that some plaster had fallen down. But on a further scrutiny, the real cause appeared: the coronaries were become bony canals.” Jenner, sensing that the “bony canals” impaired cardiac circulation and might cause anginal pains, was anxious to publish his finding but hesitated. He had kept in close touch with John Hunter and knew that Hunter himself was having anginal pains. He worried that publication of the idea would have distressed his old mentor and friend.
Knowing Heberden was Hunter’s physician, Jenner wrote to him. He observed that patients with angina had a substantial layer of fat around the heart, and, “as these vessels lie quite concealed in that
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| John Hunter, by John Jackson (Wikipedia) |
substance, is it possible this appearance has been overlooked?” He felt certain that the coronary arteries of Heberden’s previous case had not been examined and he feared that if Hunter learned of his theory of hardened arteries, “it may deprive him of the hope of a recovery.” Heberden agreed that it was best not to publish the findings as Hunter’s anginal attacks sometimes came when he was agitated.
Sadly, a few years later, in 1793, after a dispute at a hospital board meeting, Hunter suddenly collapsed and died. At autopsy, his coronary arteries were “in the state of bony tubes, which were with difficulty divided by the knife,” consistent with Jenner’s speculations.
Edward Jenner later achieved fame with the discovery of the immunizing effect of cowpox against smallpox. He had suppressed his seminal discovery of the hardened arteries in anginal patients out of concern for a friend, a generous act. Heberden and Jenner had opened the way to the study of coronary circulation and its relation to angina pectoris and myocardial infarction. Effective therapies were not to emerge, however, for many years.
SOURCES:
Acierno, Louis J, The History of Cardiology. Parthenon Publishing Group, 1994.
Fisk, Dorothy, Dr. Jenner of Berkeley. Heinemann, 1959.
Finger, Stanley, Doctor Franklin’s Medicine. University of Pennsylvania Press, 2006.
Hart, F D, “William Heberden, Edward Jenner, John Hunter, and angina pectoris.” J Medical Biography, 1995; 3(1): 56-8.
Heberden, W, “Some Account of a Disorder of the Breast.” Medical transactions / Royal College of Physicians. 1772; v. 2: 59-67.
Heberden, W, Commentaries on the History and Cure of Diseases. London, 1802.
Beasley, A W, “A Story of Heartache: The Understanding of angina pectoris in the Pre-surgical Period.” J Royal Coll Physicians Edinb 2011; 41: 361-5.
