By Dr Milton Maltz MD MPhil, London
Historical Review
“But there is a disorder of the breast marked with strong and peculiar symptoms, considerable for the kind of danger belonging to it, and not extremely rare, which deserves to be mentioned at length. The seat of it, and sense of strangling and anxiety with which it is attended, may make it not improperly be called angina pectoris.
They who are afflicted with it, are seized while they are walking, (more specifically if it be uphill, and soon after eating) with painful and most disagreeable sensation in the breast, which seems as if it would extinguish life, if it were increase or to continue., but the moment they stand still all this uneasiness vanishes.
In al 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. The pain is sometimes situated in the upper part, sometimes in the middle, sometimes at the bottom of the sterni, and often more inclined to the left than to the right side. It likewise very frequently extends from the breast to the middle of the left arm. The pulse is, at least sometimes, not disturbed by this pain, as I have had opportunities of observing by feeling the pulse during the paroxysm. Males are most liable to this disease, especially such as have past their fiftieth year.
After it has continued a year or more, it will not cease so instantaneously upon standing still; and it will come on not only when the person are walking, but when they are lying down, especially if they lie on the left side, and oblige them to rise up our of their beds. In some inveterate cases it has been brought on by the motion of a horse, or carriage, and even by swallowing, coughing, going to stool, or speaking, or any disturbance of mind. Such is the most usual appearance of this disease.”
This classical description of angina pectoris was by William Heberdem in 1768 (figure 1).
Its merit lies in the fact that he was the first to include a description of the “paroxysmal oppression” in the thorax. His account is so perfect that it still hold true today.
A few years later, a postmortem, carried out by John Hunter, revealed “The two coronary arteries, from their origin to many of their ramifications upon the heart, were become one piece of bone.”. Hunter himself suffered from angina and after his death in 1793 the coronary arteries were found to be calcified. The first person to make a diagnosis of coronary thrombosis while the patient was still alive was Adam hammer in 1876. He reasoned correctly that the sudden appearance and rapid progression of the symptoms could only be due to a cutting off of the supply of nourishment to the heart, and that such an obstruction could only be due to a thrombotic occlusion of at least one of the coronary arteries. In his paper he writes “I mentioned my conviction to my colleague at the bedside. He however had a non-plussed expression and burst out”, “I have never heard of such a diagnosis in my life”, and I answered, “Nor I also”. but the postmortem examination proved Adam Hammer correct.
The beginning of the 20th century brought some clarifications, and acceptance of the fact that angina pectoris and coronary thrombosis are due to disease of the coronary arteries. This began specifically with the work of James Bryan Herrick in 1912. The “Journal of the American Medical Association”, published his classical account of this condition in a paper entitled “Clinical Features of Sudden Obstruction of the Coronary Arteries”. Besides giving to the medical world by far the best description of this disease, Herrick showed that sudden obstruction of a coronary artery is not necessarily fatal. In 1918 Herrick and Nuzum made the first direct reference to the occurrence of anginal pain among patients having severe anaemia. With their Luci explanations they showed why the clinical picture could vary greatly from patient to patient this clearing away much of the confusion of the past. The distinction between angina pectoris due to ischemia of the heart muscle (insufficient blood supply) and degrees of occlusion (causing necrosis or death of a small area of heart muscle) had to wait until electrocardiography came into general use.