William Heberden's classic description of angina pectoris was first presented to the Royal College of Physicians in 1768. It was published in 1772, in the Medical Transactions of the College. Many aspects of his description are true to this day. He describes both typical exertional angina as well as variant angina which eventually affected a patient only when he was in bed and was relieved by sitting up. He also points out the influence of mental stress. Although it is a classic, it is not the first description of angina. A case was described in 1632 in the memoirs of the Earl of Clarendon.
Commentaries on the History and Cure of Diseases
By William Heberden, M.D.
Heberden W. Some account of a disorder of the breast.
Medical Transactions 2, 59-67 (1772) London: Royal College of Physicians.
Besides the asthma, hysteric oppressions the acute darting pains, in pleurisies, and the chronical ones in consumptions, the breast is often the seat of pains, which are distressing, sometimes even from their vehemence, oftener from their duration as they have continued to tease the patient for six for eight, for nine, and for fourteen years. There have been several examples of their returning periodically every night, or alternately with a headache. They have been called gouty, and rheumatic and spasmodic. There has appeared no reason to judge that they proceed from any cause of much importance to health (being attended with no fever,) or that they lead to any dangerous consequences and if the patient were not uneasy with what he feels, he needs never to be so on account of anything which he has to fear.
If these pains should return at night and disturb the sleep, small doses of opium have been found serviceable, and may be used alone, or joined with an opening medicine, with a preparation of antimony, or with the fetid gums. Externally, a small perpetual blister applied to the breast has been successful, and so has an issue made in the thigh. A large cumin plaster has been worn over the seat of the pain with advantage. The volatile, or saponaceous liniment, may be rubbed in over the part affected. Bathing in the sea, or in any cold water, may be used at the same time.
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 more 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 especially if it be up hill, and soon after eating) with a painful and most disagreeable sensation in the breast, which seems as if it would extinguish life, if it were to increase or continue; but 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. The pain is sometimes situated in the upper part, sometimes in the middle, sometimes at the bottom of the os 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 that disease, especially such as have passed 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 persons are walking, but when they are lying down, especially if they lie on their left side, and oblige them to rise up out of their beds. In some inveterate cases it has been brought on by the motion of a horse, or a 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; but some varieties may be met with. Some have been seized while they were standing still or sitting; also upon first waking out of sleep: and the pain sometimes reaches to the right arm, as well as to the left, and even down to the hands, but this is uncommon: in a very few instances the arm has at the same time been numbed and swelled. In one of two persons the pain has lasted some hours, or even days; but this has happened when the complaint has been of long standing, and thoroughly rooted in the constitution: once only the very first attack continued the whole night.
I have seen nearly a hundred people under this disorder, of which number there have been three women, and one boy twelve years old. All the rest were men near, or past the fiftieth year of their age.
Persons who have persevered in walking till the pain has returned four or five times, have then sometimes vomited.
A man in the sixtieth year of his life began to feel, while he was walking, an uneasy sensation in his left arm. He never perceived it while he was traveling in a carriage. After it had continued ten years, it would come upon him two or three times a week at night, while he was in bed, and then he was obliged to sit up for an hour or two before it would abate so much as to suffer him to lie down. In all other respects he was very healthy, and had always been a remarkably strong man. The breast was never affected. This disorder, its seat excepted, perfectly resembled the angina pectoris, gradually increasing in the same manner, and being both excited and relieved by all the same causes. He died suddenly without a groan at the age of seventy-five.
The termination of the angina pectoris is remarkable. For, if no accidents intervene, but the disease go on to its height, the patients all suddenly fall down, and perish almost immediately. Of which indeed their frequent faintnesses, and sensations as if all the powers of life were failing, afford no obscure intimation.
The angina pectoris, as far as I have been able to investigate, belongs to the class of spasmodic, not inflammatory complaints, For,
In the 1st place, the access and the recess of the fit is sudden.
2dly, There are long intervals of perfect health.
3dly, Wine, and spirituous liquors, and opium afford considerable relief.
4thly, It is increased by disturbance of the mind.
5thly, It continues many years without any other injury to the health.
6thly, In the beginning it is not brought on by riding on horseback, or in a carriage, as is usual in diseases arising from scirrhus or inflammation.
7thly, During the fit the pulse is not quickened.
Lastly, Its attacks are often after the first sleep, which is a circumstance common to many spasmodic disorders.
Yet it is not to be denied that I have met with one or two patients, who have told me they now and then spit up matter and blood, and that it seemed to them to come from the seat of the disease. In another, who fell down dead without any notice, there immediately arose such as offensive smell, as made all who were present judged that some foul abscess had just then broken.
On opening the body of one who died suddenly of this disease, a very skillful anatomist could discover no fault in the heart, in the valves, in the arteries, or neighboring veins, excepting some small rudiments of ossification in the aorta. The brain was likewise every where sound. In this person, as it has happened to others who have died by the same disease, the blood continued fluid two or three days after death, not dividing itself into crassamentum and serum, but thick, like cream. Hence when a vein has been opened a little before death, or perhaps soon after, the blood has continued to ooze out as long as the body remained unburied.
With respect to the treatment of this complaint, I have little or nothing to advance: Nor indeed is it to be expected we should have made much progress in the cure of a disease, which has hitherto hardly had a place or a name in medical books. Quiet and warmth, and spirtuous liquors, help restore patients who are nearly exhausted, and to dispel the effects of a fit when it does not soon go off. Opium taken at bed-time will prevent the attacks at night. I knew one who set himself a task of sawing wood for half an hour every day, and was nearly cured. In one also the disorder ceased of itself. Bleeding, vomiting, and purging, appear to me to be improper.
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