The Eighteenth-Century Origins of Angina Pectoris: Predisposing Causes, Recognition and Aftermath (review)

"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 more at length and of which I do not recollect any mention among medical authors" (William Heberden, "Some account of a disorder of the breast," Medical Transactions of the Royal College of Physicians of London, 1772, 2, 59-67). So begins the English physician William Heberden's (1710-1801) description of what appeared in the mid-eighteenth century to be a fairly unknown malady. Even if physicians knew of the symptoms of this disease (what Heberden would subsequently dub angina pectoris), the instances of it were isolated in the extreme. Before Heberden presented his findings of this "peculiar disease" to the Royal College of Physicians in 1768, only a handful of written accounts existed in the whole of the 2000-year Hippocratic tradition. But by the late eighteenth century, physicians such as Heberden had begun to catalog instances of the disease that they encountered in their practices (in Heberden's case, as early as 1748). However, English clinical practitioners were not the only individuals to take notice, as accounts of the disease can be found in such publications as Giovanni Battista Morgagni's De sedibus et causis morborum (1761), which recorded nearly 500 case descriptions of the disease (see p. 13). At any rate, it seems probable that angina pectoris did not exist undetected for centuries, but rather owed its emergence to a particular set of circumstances in the eighteenth century. Clearly, by twenty-first-century standards, angina pectoris is all too familiar in the minds of both doctor and patient, which begs the question: To what can we attribute the cause(s) of the increased incidence of angina pectoris during the mid-eighteenth century?

In this very interesting book, Leon Michaels engages that very question and sets about the historical task of piecing together eighteenth-century dietary and demographic trends in relation to angina pectoris. The book thus becomes less of a biographical rendering of Heberden than a case study that examines the impact of certain cultural and social developments on eighteenth-century English health. While acknowledging the difficulty of determining the historical effects of factors like diet, tobacco, and stress, Michaels weighs the contribution of such material causes to the emergence of angina pectoris. He juxtaposes historical phenomena (social and cultural) with present-day knowledge of the risk factors correlated with coronary heart disease. It becomes his task to show how the increasing numbers of cases of angina pectoris in eighteenth-century England relate to an ever-rising level of exposure to the modern risk factors of fat, salt, lack of exercise, sugar, stress, and caffeine.

In initiating this enterprise, Michaels wholeheartedly assumes the mantle of the historian. In addition to the published commentaries extant in books and learned journals from the period, where the symptoms of the disease are described in some detail, he also consulted the London Bills of Mortality from 1603 to 1816. The bills, though less detailed than the learned sources, do not contain any record of a heart ailment until 1794. This heart condition, which is curiously referred to as "heart palpitations" appears with increasing frequency in the bills until 1816. It is perhaps impossible to determine that such a condition was either angina pectoris or myocardial infarction, but the sources do indicate that "general heart conditions" were no longer an uncommon occurrence. It is at this point that Michaels work takes on a materialist bent.

Accepting the conventional risk factors for coronary heart disease, Michaels shows how radical dietary changes in the upper and middle classes, occasioned by the Agricultural Revolution, correspond with the increased incidence of angina pectoris in the medical records. Using modern criteria to evaluate phenomena of the past is a dangerous practice for a historian, but...