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

How and why do "new" diseases come into existence? It is interesting to speculate whether a newly described disease, symptom complex, or clinical syndrome is, in fact, new at all, or whether it existed previously but was simply unrecognized or unreported. It is generally accepted that British physician William Heberden (1710-1801) published the first report of angina pectoris in 1772; this article, based on a presentation he had made to the Royal College of Physicians of London four years earlier, contains a classic description of exertional chest discomfort, later shown to be most often associated with coronary artery disease.

Canadian physician Leon Michaels, in a book filled with data to support his argument, makes a compelling case that angina pectoris was virtually nonexistent before the mid-eighteenth century. Although he does not claim that it was a totally new disease, he reviews documentary evidence that supports his contention that angina was at least so rare that one physician never saw enough patients with the complaint to recognize it as something unique or worth writing about.

Within a few generations angina went from being unknown to a common clinical problem—one that now affects millions of persons in developed and developing countries around the globe. In his well-researched monograph, Michaels argues that specific social and economic factors determined where and when angina was first observed and how often. He draws from a wide range of sources to support his hypothesis that what was truly new in Georgian England was what we now term "cardiac risk factors." Moreover, these culturally driven risk factors (such as smoking, high cholesterol, and physical inactivity) affected a population that included more older persons than previously. This created a new social and medical context suitable for angina to appear or, at least, to be noticed by a few physicians.

Michaels includes a detailed discussion of specific agricultural and social changes that occurred in Georgian England—and later diffused to North America and continental Europe. He shows that there were significant changes in diet, lifestyle, and habits (especially among the middle and upper classes) in England that resulted from the agricultural revolution. Many persons consumed more and fattier meat, more eggs, and milk with a higher fat content. Although these dietary changes were very important, other forces were also at work: Michaels discusses the role that genetic factors, tobacco, hypertension, obesity, stress, age, and limited physical activity likely played in the appearance and growing incidence of angina.

Michaels makes a compelling case for risk-factor modification. He draws effectively on historical trends and the social and economic factors that shaped those trends to support his argument that risk factors are the key to preventing coronary heart disease today—just as they were responsible for its appearance in Georgian England. It is disturbing that powerful economic forces, coupled with individual human dynamics, continue to fuel an epidemic of coronary heart disease—despite the lessons of history and epidemiology.

During the past generation there has been growing acceptance of the critical roles that cardiac risk factors play in the genesis of coronary heart disease. The United States in particular has mounted a major public health campaign designed to educate individuals about the cardiac implications of choices they make with respect to such things as smoking and diet. Cigarette package warnings and detailed dietary labeling are two visible signs of the public concern. But billions of dollars are at stake, and the public is marinated in marketing campaigns that encourage smoking and eating foods that are unhealthy.

The book's fourteen chapters are complemented by eleven illustrations, twelve figures, and fifty-six tables (filled with technical data and statistical information). There...