- "Dr. Anonymous" Unmasked: Resolution of an Eighteenth Century Mystery in the History of Coronary Artery Disease
Paul Kligfield, MD, and Konrad Filutowski, MD
Over 2 centuries ago, William Heberden of London published the original description of angina pectoris in the second volume of Medical Transactions of the College of Physicians of London (hereafter, Medical Transactions).(1) Entitled "Some Account of the Disorder of the Breast," his paper was based on 20 cases :presented to the College in 1768, published early in 1772, and expanded by an additional 80 cases as a chapter in his Commentaries on the History and Cure of Diseases, which appeared posthumously in 1802.(2)
Heberden's portrait of angina pectoris remains among the most concisely accurate clinical descriptions in the medical literature, and he cautiously avoided unsupported speculation regarding the etiology of this disorder.(1) "What the particular mischief is," he observed, "is not easy to guess, and I have had no opportunity of knowing with certainty." Although Heberden was aware of sudden death in patients with angina, he had never seen an autopsy. "Most of those, with whose cases I have been acquainted," he explained, "were buried, before I had heard that they were dead."
Soon after publication of his paper in Medical Transactions, Heberden received a letter from an anonymous correspondent who outlined in substantial medical detail his own symptoms of angina pectoris.(3) Anticipating imminent sudden death, Heberden's correspondent offered his body for autopsy examination in the hope that it would be of some value in clarifying the cause of the disease. Heberden published the letter along with comments on the case and the autopsy report in the next volume of the journal, but in the printed text the letter was signed simply as "Unknown." The frustrated benevolence of this unknown writer, recently known as "Dr. Anonymous,"(5-7) and the search for his identity are a fascinating chapter in the early history of angina pectoris. We will show that "Dr. Anonymous" was not a doctor and that he no longer remains anonymous.
Heberden's anonymous correspondent: Extracts of the clinical description of angina had been reprinted in considerable detail, in March of 1772, in the 33rd volume of The Critical Review: or, Annals of Literature (here after, The Critical Review), a literary magazine(8) published in London. Heberden's correspondent was prompted to write of his own symptoms by reading this review, not by reading the original paper in Medical Transactions.(3) I am now in the fifty-second year of my age," he wrote in a letter dated April 16, 1772, "of a middling size, a strong constitution, a short neck, and rather inclining to be fat." He observed that Heberden' s recent description appeared "to exactly correspond with what I have experienced of late years."
Heberden's correspondent suffered from angina pectoris associated with palpitations suggestive of ventricular arrhythmia.(4) "The first symptom is a pretty full pain in my left arm a little above the elbow," he observed,(3) "and in perhaps half a minute it spreads across the left side of my breast, and produced either a little faintness, or a thickness in my breathing; at least I imagine so, but the pain generally obliges me to stop." Even more remarkable were associated sensations that "have frequently led me to think that I should meet with a sudden death."
There follows a most vivid description suggesting perception of the enhanced stroke volume that results from postextrasystolic potentiation after single or sequential premature ventricular complexes. "I have often felt," he observed, "what I can best express by calling it an universal pause within me of the operations of nature for perhaps three or four seconds; and when she has resumed her functions, I felt a shock at the heart, like that which one would feel from a small weight being fastened by a string to some part of the body, and falling from a table to within a few inches of the floor."
Believing from this oppressive sensation that death would shortly follow, Heberden's correspondent offered his body for pathologic examination hoping to "shew the cause of it; and, perhaps, tend at the same time to a discovery of the origin of that disorder, which is the subject of this letter, and be productive of means to counteract and remove it." The author's sense of impending doom was realized within 3 weeks of the date of his letter,(3,4) with sudden death following angina that developed during an after-dinner walk. As reported by Heberden, "by a paper found in his will, if he died suddenly, he had desired that I might immediately have notice of it, in order to have the body opened and examined."
The autopsy was performed within 2 days by the most prominent anatomist available. "I used my best endeavors," Heberden reported, "that such a benevolent intention should not be frustrated, by procuring the experienced and accurate anatomist Mr. J. Hunter to open the body." Hunter was assisted in this examination by his pupil Edward Jenner.(9)
Both the letter from Heberden's unknown correspondent and Hunter's postmortem findings were published in the third volume of Medical Transactions.(3) Unfortunately, despite close attention to the postmortem state of the chest, Heberden reported that "no manifest cause of his death could be discovered." Although no structural abnormalities of the heart were noted at the time, Jenner later reported to Caleb Hillier Parry(9) that the coronary arteries in this important case were not carefully examined.
Heberden's unknown correspondent provides the earliest description of angina pectoris associated with significant cardiac arrhythmia Despite efforts to uncover the identity of this astute observer who anticipated his own sudden death from ischemic heart disease and also made a benevolent effort to contribute to our understanding of its cause, the name of Heberden' s corresponent, whose published letter was signed simply "Unknown," has remained a mystery.
Heberden and "Dr. Anonymous": Was "Unknown" a practicing clinician? For the past half century Heberden's correspondent has been occasionally referred to as a physician, frequently by the romantic pseudonym of "Dr. Anonymous." Attribution of his remarkable insight into disease processes to medical qualification can be traced to Segall in 1945(5). On the basis of a review of the Hunter case manuscripts in the Royal College of Surgeons, Keele subsequently proposed that Heberden's anonymous correspondent was Dr. Haygarth of Chester, and this identification was continued by Leibowitz(7) in his comprehensive review of the history of coronary disease. Recent accounts of these eighteenth century events have further popularized the description of the unknown victim of angina pectoris as "Dr. Anonymous."(4)
Heberden' s correspondent was certainly familiar with medical terminology. "My pulsations," he wrote,(3) "at a medium are about 80 in a minute; the extremes, when in a perfect state of health, beyond which I scarcely ever know them, 72 and 90." In addition to sophistication regarding diagnostic signs, familiarity with pathologic processes can also be inferred from his letter to Heberden. "I had no traces of having the least disorder within me of any kind," he continued, "either from spitting blood, or any corrupted matter, nor ever entertained the last thought of any abscess being formed. I have never troubled myself much about the cause of it, but attribute it to an obstruction in the circulation, or a species of rheumatism."
Although this description suggests that its writer was indeed conversant with medical language and concepts, it should be emphasized that his awareness of Heberden's description came not from its primary source, but from extracts published in a literary periodical available to the lay public. Heberden makes no comment regarding the occupation of his correspondent. No deaths in 1772 among members of the Royal College of Physicians can be found in Munk' s The Roll of the Royal College of Physicians of London,(10) although the possibility that he was indeed a nonmember physician cannot be excluded from the written record. As an alternate possibility, the medical insight expressed in the letter is not beyond the understanding of a literate layman.
Dr. Haygarth of Chester: It is absolutely clear, however, that Heberden's correspondent could not have been Dr. John Haygarth of Chester, who lived from 1740 to 1827 and was 32 years old when Heberden's paper was published. Review of the Clift transcripts of the Hunter manuscripts in the Royal College by one of us (KF) failed to document any relevant mention of Haygarth. Further, since Chester lies approximately 180 miles northwest of London, it is highly unlikely that an autopsy could have been performed in London within 2 days of death.
It is also unlikely that a patient known to Haygarth was Heberden's unknown correspondent. Of note, Haygarth was well acquainted with Heberden's clinical description of angina. On November 11, 1773, he read a paper before the College of Physicians entitled "A Case of the Angina Pectoris, with an Attempt to Investigate the Cause of the Disease by Dissection, and a Hint Suggested Concerning the Method of Cure," which was subsequently published in Medical Transactions(12). In this report Haygarth recounted the clinical history of a patient seen in February 1773, a 48-year-old man who was "rather corpulent, short-necked, of a sedentary life, and much employed in writing." The patient's symptoms were suggestive of angina and he was later found, at autopsy, to have a purulent mediastinitis.
The most relevant inference from this report is Haygarth' s apparent unfamiliarity with the case of Heberden's correspondent in 1773. Although Haygarth reports that "within the space of two years I have seen two other cases with similar symptoms, both of which proved suddenly fatal," neither of these was apparently examined after death, and an autopsy by Hunter could not have been forgotten. Referring to his single case of mediastinitis, Haygarth observed that "no practical inference can be deduced from a solitary example; but it will I trust be sufficient to excite those, who have future opportunities of inquiry."(12) Further evidence refutes any connection of Heberden's correspondent with Dr. Haygarth or, indeed, with the town of Chester. In the 1772 bill of mortality from Chester, tabulated and reported by Haygarth,(13) no deaths consistent with sudden death in a middle-aged man with angina are noted.
A profile of Heberden's unknown correspondent: What then can be said of Heberden's unknown correspondent? Based on the primary sources in the third volume of Medical Transactions alone,(3) a profile can be assembled that provides essential criteria for the identification of "Unknown." At the time the letter was transmitted to Heberden, the corpulent male writer was living in London and was 52 years old, which suggests a year of birth about 1720. It is also clear from Heberden's comments that the death of "Unknown" occurred within 3 weeks after the letter was sent on April 16, 1772, or by Thursday, May 7, of that year. Autopsy was performed by John Hunter within 48 hours of death, with burial likely shortly afterward.
How might this profile be used to search for the identity of Heberden's correspondent? As a gentleman interested in the eclectic The Critical Review,(5) "Unknown" was likely sufficiently accomplished that historic records of his birth, activities, and death should exist somewhere in England. Discovery of the appropriately timed death of a suitably aged, portly subscriber of The Critical Review from London would suggest a possible identity for Heberden's correspondent. Short of such evidence, a separate correlation of available mortality lists with ages and burial statistics might generate a short list of candidates for recognition. But this search would be long, complex, and potentially unrevealing, and moreover, any suggested identities would remain speculative without contemporary verification.
Bibliophilic serendipity and identification of "Unknown": The matter of the identity of "Unknown" stood for some time, until a serendipitous clue provided new direction. On an antiquarian medical bookhunting trip to London, one of us (PK) found a series of volumes of Medical Transactions, including a first edition of the 1785 letter to Heberden, on a dealer's shelf. When this copy of the letter was later examined in detail, it was found that under the printed closing salutation of Heberden's "Unknown" was neatly written, in an eighteenth century hand, "- Mallet/formerly of Exeter" (Figure 2). Could this Mallet be Heberden's correspondent? Was he a physician, and thus the legendary "Dr. Anonymous," or rather a lay reader of the periodical literature?
It is not clear to whom this copy of Medical Transactions belonged, and thus unfortunately there is no explanation of the relation of the annotator to the events in question or reason for the handwritten annotation that identifies "Unknown" as Mallet in this volume. William Heberden and John Hunter were obviously aware of the identity of "Unknown" and were both alive in 1785, but the handwriting in Figure 2 is not suggestive of either. It is reasonable to suppose that John Haygarth might have learned the identity of "Unknown" from Heberden after presentation of his paper on angina at the College of Physicians,(12) but this is also true of a large number of other eighteenth century readers of the journal.
The initials T. H. appear in ink on the front free end paper of this volume, and also in each of the other volumes of Medical Transactions through the sixth volume, which was published in 1820. These initials may refer to a member of the College of Physicians at the time, who likely would have been a subscriber to its proceedings and familiar with the cases that were discussed. However, according to Munk's The Roll of the Royal College of Physicians of London, only 3 fellows with the initials T H. were elected to the College in the eighteenth century, the youngest of whom, Thomas Healde, died in 1789.(10) Neither of the 2 fellows with these initials elected to the College during the early nineteenth century received their medical degree before 1803,(14) and thus neither could have had first-hand knowledge of Heberden's correspondent or direct contact with Heberden, who died in 1801, or with Hunter, who died in 1793. Since the initials are not clearly in the same hand as the annotation, T. H. may have bought or even inherited these volumes at a later date.
To investigate and to clarify the possible identification of a "Mallet, formerly of Exeter" as Heberden' s correspondent, one of us (KF) examined London newspapers published in May of 1772 for an obituary or for other evidence conforming to the documented profile of "Unknown." A record of recent deaths appears in a column on the front page of the The London Evening Post15 for Thursday, May 7-Saturday, May 9, 1772. In the middle of the list of dates of death and names of the deceased is found "Tuesday, [which would have been May 5, 1772] at Islington, Mr. John Mallet, formerly of Exeter, merchant." The death of this John Mallet is similarly recorded in a number of additional contemporary newspapers, with the surname occasionally spelled Mallett; the dates of death and burial are in perfect conformation with the profile required of Heberden' s anonymous correspondent. Boyd' s index reveals that in 1772, "Jn. Mallet" was buried in Bunhill, a cemetery in central London, and the Bunhill Fields burial grounds index records that on May 7, 1772, Mr. John Mallett of Aldisgate was buried in a grave at a charge of 13 shillings, sixpence.(16) These dates are in complete agreement with the sudden death of "Unknown" within 3 weeks of his letter to Heberden and with the autopsy by Hunter within 2 days of death.
John Mallet of London, formerly of Exeter: Exeter lies about 175 miles southwest of London, in Devonshire. The christening of a Jn. Mallet, "son of Francis & Susan Mallet" is recorded on April 17, 1718, in the Shebbeare Parish register.(17) If this were indeed the same John Mallet of Exeter who was to become Heberden's correspondent in 1772, he would have written the letter of April 16 on a day that might have been an anniversary of his birth, but he then would have been about 54 years old rather than in his 52nd year as claimed by "Unknown" shortly before his death. Such an error might be understandable in this period, even without allowing for the confusion imposed by the apparent loss of nearly a fortnight of 1752 during the transition from the Julian to the Gregorian calendar in England. Even if the child christened in Shebbeare Parish were another of the same name, early records of John Mallet in Exeter can be linked to later evidence of the London merchant, "formerly of Exeter." The public records office in Exeter contains evidence of Mallet as a member of the Exeter Association in 1745 and also as a tax collector for St. Olave' s Parish in 1746, but by 1765, Mallet is described in an assignment of lease filed in Exeter as a merchant in London serving as administrator of the estate of a deceased friend.(18)
By 1770, John Mallet had become an English merchant worthy of notice, although his particular type of trade is unclear. In Baldwin's Complete Guide for that year,(19) which contains among other things "the names and places of abode of the most eminent merchants and traders in and about London," he is recorded as living at Number 9, Westmoreland Buildings, Aldersgate Street, which is a short walk from St. Paul's Cathedral. It was at this time of Mallet's listing among the successful merchants of London that Heberden's correspondent began to experience angina pectoris with effort and to fear the possibility of sudden death.(3) As recorded in the public records office in London,(20) an earlier will of 1768 was revised by Mallet in August 1771 to incorporate his wish "to be burried privately and with as little expense as is consistent with decency." This wish was honored in Bunhill Fields as his fears were realized less than a year later.
We suggest that during this final year of John Mallet's life, he read of Heberden's description of angina pectoris that was abstracted in the The Critical Review. Suspecting his own sudden death and aware of the lack of autopsy correlation to provide evidence of the cause of the disease, this successful London merchant offered his body for dissection in a medically literate letter to Heberden as a benevolent gift to science. The autopsy was conducted by John Hunter, and within 2 days of his sudden death on May 5, 1772, Heberden' s previously unknown correspondent, John Mallet, formerly of Exeter, was buried in Bunhill Fields. There never was a "Dr. Anonymous."
Sources
1. Heberden W. Some account of a disorder of the breast. Med Trans Coll Phys Lond 1772; 2:59-67.
2. Heberden W. Commentaries on the History and Cure of Diseases. London: Payne, 1802.
3. Heberden W. A letter to Dr. Heberden, concerning the angina pectoris, and an account of the dissection of one, who had been troubled by this disorder. Med Trans Coll Phys Lond 1785;3:1-11.
4. Kligfield P. The frustrated benevolence of Dr. Anonymous. Am J Cardiol 1981; 47:185-187.
5. Segall HN. The first clinico-pathological case history of angina pectoris: self- diagnosis by an anonymous physician; autopsy by John Hunter; reported by William Heberden in 1772. Bull Hist Med 1945;18:102-108.
6. Keele KD. John Hunter's contribution to cardio-vascular pathology. Ann R Coll Surg Engl 1966;39:248-259.
7. Leibowitz JO. The History of Coronary Heart Disease. London: Wellcome Institute of the History of Medicine, 1970:87-90.
8. The Critical Review: or, Annals of Literature, by a Society of Gentlemen. 1772; 33:203-204.
9. Parry CH. An Inquiry Into the Symptoms and Causes of the Syncope Anginosa, Commonly Called Angina Pectoris. Bath: R. Cruttwell, 1799:3-4.
10. Munk W. The Roll of the Royal College of Physicians of London, 2nd ed. vol. 2.1701-1800. London: Royal College of Physicians of London, 1878.
11. Weaver GH. John Haygarth: clinician, investigator, apostle of sanitation, 1740-1827. Bull Soc Med Hist Chicago 1930;4:156-200.
12. Haygarth J. A case of the angina pectoris, with an attempt to investigate the cause of the disease by dissection, and a hint suggested concerning the method of cure. Med Trans Coll Phys Land 1785;3:37-46.
13. Haygarth J. Observations on the bill of mortality, in Chester, for the year 1772. Phil Trans 1774;64:67-78.
14. Munk W. The Roll of the Royal College of Physicians of London, 2nd ed. vol 3.1801-1825. London: Royal College of Physicians of London, 1878.
15. The London Evening-Post. Number 6918, Thursday, May 7 to Saturday, May 9, 1772:1 (Burney Collection, Volume 586 B, British Library).
16. Register of Burials at Bunhill Fields Burial Grounds. Public Records Office, London. RG 4/4290, Volume 12A (1771-1780):21.
17. Shebbeare Parish Register 1576-1837:37 (Society of Genealogists, London).
18. Assignment of Lease, 4 March 1765 (Public Records Office, Exeter).
19. Baldwin's New Complete Guide to all Persons who have any Trade or Concern with the City of London, and Parts Adjacent, 12th ed. London: Baldwin, etc, 1770:116.
20. Will of John Mallett (1771). Taverner Wills, Public Records Office, London, I 0/2587.
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1720 - 1772 (~ 51 years)
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Will
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