It is not very surprising that, pounding away as they do, day and night, the muscles of the heart need a rich supply of blood. One might be tempted to think that with blood sloshing around in the heart all the time, nothing much more was needed, but nothing could be farther from the truth: special arteries, the coronary arteries, supply the musculature of the heart; indeed, about 5 percent of the heart’s output of arterial blood is appropriated to its own nourishment. The coronaries are thus the most important arteries in the body and coronary heart disease (CHD) is proportionately important as a cause of distress, ill health, or death—nowadays affecting people in their mid-thirties and early forties as well as in later life. The menace of CHD is fully recognized and fearfully acknowledged in the form of the many jujus by means of which people try to propitiate the angry god; among their number Friedman and Rosenman report: take no animal fats / soft water / sugar; jog / jog not; so perhaps we should not be surprised to learn that abstention from sexual intercourse is included in this collection, for it is part of the Puritan ethic that any activity so pleasurable must be harmful.
The authors’ own message is a much simpler one: CHD is of behavioral origin and in particular is associated with the behavior pattern they classify as Type A:
In the absence of Type A Behavior Pattern, coronary heart disease almost never occurs before seventy years of age, regardless of the fatty foods eaten, the cigarettes smoked, or the lack of exercise. But when this behavior pattern is present, coronary heart disease can easily erupt in one’s thirties or forties. We are convinced that the spread of Type A behavior explains why death by heart disease, once confined mainly to the elderly, is increasingly common among younger people. [Page ix]
Many newspapers and periodicals offer occasional quiz features in which readers are invited to score their answers to a list of impertinent and sometimes offensive questions. By comparing their marks with a table of norms decided upon by a panel of experts—perhaps a fashionable hairdresser, baseball pitcher, Pulitzer prize winner, and psychiatrist—a reader can decide whether he is a truly great or a merely ordinary husband/lover/cook/ judge of claret/etc., or whether he is just a regular guy. For some time to come such quizzes are likely to turn on whether a reader is of Type A or Type B.
We probably first recognize Type A behavior in prep school when a master asks round a class a question to which one boy knows the answer—a boy who waves his arm to and fro in a real agony of superior knowledge, saying, “Oh, please sir, ask me sir, ask me.” Type A behavior, we are told, refers to a complex of personality traits including:
…excessive competitive drive, aggressiveness, impatience, and a harrying sense of time urgency. Individuals displaying this pattern seem to be engaged in a chronic, ceaseless, and often fruitless struggle—with themselves, with others, with circumstances, with time, sometimes with life itself. They also frequently exhibit a free-floating but well-rationalized form of hostility, and almost always a deep-seated insecurity. [Page 4]
The point about the sense of time urgency is well taken: Type As are always listening for radio time signals and adjusting and readjusting their watches. They also habitually take on more work than they can comfortably do (in the time), and time is always an enemy…for “At my back I always hear/Time’s winged chariot drawing near….” Although Type As are competitive, they seldom compete where they don’t excel; the struggle to excel may be deeply exhausting and the failure deeply distressing.
These are all bad traits, no doubt, and bad for reasons other than predisposing their subjects to CHD, but let it not be forgotten that Type As are without doubt the great doers of the world—the people who, because they have organized their lives in such a way as to make use of every moment of them, always seem to be able to do much more than anybody else; even if they live shorter lives, they live much more life while they are living it. An excess of hubris is at once their greatest asset and their greatest defect. If you hesitate over a word, pretending to stammer, or leave a sentence unfinished or stumble over a familiar quotation, someone of Type A is sure to supply the word, to complete the sentence, or put you right. How many readers, I wonder, are naggingly anxious to assure me that in the couplet from Andrew Marvell quoted above the word “drawing” should be “hurrying.” Keep President A waiting five or ten minutes for an appointment and he will inform you, or if reasonably civil merely imply, that he could have earned fifty or maybe a hundred dollars in the time you have squandered—his time, of course.
Because they encircle the heart like a crown—corona in Latin—instead of lying deep in muscle, the coronary arteries are stretched, twisted, turned, jolted with every beat of the heart, not occasionally but over a hundred thousand times a day. “No flexible tube of any synthetic we know of could withstand this sort of beating for more than a few years, much less a lifetime” (page 10).
A good deal of the first part of the book by Drs. Friedman and Rosenman is occupied by a description of the anatomy and vascular hydraulics of the heart—a section the reader is told he could skip but advised not to—good advice, too. In this section and elsewhere the writing varies between good and very good from the standpoint of clarity and cogency, but inevitably there are a few lapses: commenting on the fact that the left coronary artery could not at once take over the functions of a blocked right coronary artery or vice versa the authors say:
Nature for some inexplicable (but probably very wise) reason has thought it best that very few large interconnecting or “bypass” channels should link the right and left coronary circulations. It has permitted, however, some tiny connections to exist between the peripheral or terminal ramifications of these two major coronary arterial systems. Moreover, given enough time and demand, these relatively minute connections can grow larger, and carry more blood from one coronary arterial circulation to another. Hundreds of thousands of Americans whose left or right coronary artery has been severely narrowed or even totally occluded continue to survive and even flourish, probably because of the development and growth of these initially minute connections into moderate-sized vessels. [Pages 11-12]
Such interesting information deserves a less out-of-date explanatory idiom.
Friedman and Rosenman interpret the formation of the coronary arterial plaques that narrow the arterial freeway as the outcome of a reparative process: tiny wounds of the arterial wall, perhaps caused by the rough usage the coronary artery is subjected to, are healed over by cells derived from endothelium (the innermost lining of all blood vessels) and these little lesions—added to, perhaps, by the proliferation of cells belonging to other layers of the arterial wall—become a focus for the deposition of fatty matter and cholesterol. Well over 50 percent of American men over the age of twenty-one years, we are told, harbor one or more of these plaques. Considering plaques in this light as an organ of repair, we can understand that even a large plaque does not in itself threaten life. However, if through impairment of its own blood supply it should come to be replaced by “necrotic debris” or calcified tissue (coronary “bone”) then the stage is set for tragedy; for a crack in the plaque itself may now precipitate a clotting process which seriously interferes with the blood supply to the heart and thus causes coronary heart disease—a grave complication of coronary arterial disease.
The authors quote with grim concurrence Sir William Osler’s ironic description of how its victims are so often the most worthy and exemplary citizens—early up and late to bed, always striving hard for success in business or professional life, ready at last to take their well-earned ease when their coronary circulations fail. The authors naturally applaud Sir William Osler’s critical acumen, for his judgment coincides with their own, but this is where the real difficulty begins, for clinical judgment—no matter how experienced or intuitively perceptive the people who exercise it—is simply not enough.
I wonder how many habitual smokers would have given up smoking on the grounds that two very eminent physicians had said that they were absolutely convinced by many years of clinical practice that smoking was an important cause of cancer of the lung. Not many, I should guess. The case against smoking was in fact based upon a number of very considerable epidemiological exercises, notably by Bradford Hill and Richard Doll, some of them of the kind known as “prospective,” that is to say carried out by tracing the medical history through life of people of ascertained smoking habits. By this means, combined with some retrospective evidence and laboratory research, they built up the kind of case against smoking which is neglected only by those who seem intent upon demonstrating the efficacy of natural selection.
The point is that to provide a really compelling case in favor of a theory of this kind, and by implication to dismiss or depreciate the importance of other theories competing to explain the same evidence, is a major undertaking in statistical epidemiology which a busy practicing clinician, no matter how able, is simply not in a position to enter into. The authors might of course take the view that they are not writing a technical scientific text and are no more deeply under an obligation to expound evidence they have assembled from laboratory research on this topic than they are to go deeply into the structural and ultrastructural evidence which led them to their conception of the natural history of the plaque-formation in arteries. This would not be a good defense however because even if their theory of plaque formation were mistaken it would not make very much difference to the causal correlation they are seeking to establish between cardiovascular disease and Type A behavior. This is the really important part of their argument, and it is just here that I feel the case is relatively weak.
Nevertheless, what the authors have indeed done deserves great credit: they have built up very persuasively a strong prima facie case for undertaking just the kind of full-scale investigation that has deprived so many of us of the solace of tobacco. Perhaps in ten years’ time we shall be able to let someone of Type A—if his behavior is indeed incriminated—know to what extent his chances of survival might be improved by a major reform of his temperament and style of life. Ironically enough, I don’t see anybody having enough sustained energy, enthusiasm, and drive for a great epidemiological undertaking of this kind except a consortium of cardiologists, epidemiologists, and psychologists of Type A.
The authors make amends for epidemiological shortcomings by many chapters of first-rate scientific/medical writing on heart diseases. Chapters are devoted to angina pectoris, myocardial infarction, congestive heart failure, and matters to do with diet and exercise. This is very good writing of its kind: learned, urbane, highly informative, and not in the least condescending. There is a discordant note though: I have a strong clinical impression that the use of the word media as if it were a singular noun instead of the plural of medium (p. 35) is an important cause of coronary heart disease among pedants.
Of cholesterol the authors say that the most common and certainly the most medically neglected cause of an abnormally high serum cholesterol in man is “the particular complex of emotional stresses we have designated as Type A behavioral pattern.” It is probably “the major process at work in the majority of Americans whose serum cholesterol is…above…275 mg/100 ml” (p. 48). They note that the feeding of extra cholesterol to experimental animals which have received deliberate arterial wounds produces a virtual replica of the human arterial plaque; but as extra-dietary cholesterol alone can also do it, they infer that coronary arteries suffer a sufficient number of micro-injuries in ordinary life to provide the beginnings of future plaques—evidence that has direct bearing on their interpretation of the natural history of plaque formation in human coronary arteries.
If the behavioral characteristics the authors describe as “Type A” turn out to be as deeply pathogenic as they suspect, then their account of it—in which many of their readers will easily recognize themselves—will acquire a classical status and will be quoted in future publications with just the respectful approval that they themselves now feel for Sir William Osler.
I do think though that in one respect their otherwise penetrating and understanding account falls short of winning complete sympathy: they seem not fully to realize how very often the competitiveness they deplore is competition not so much against fellow man as against the exigences and vicissitudes of a harsh and hostile world. Perhaps the newly appointed chairman’s compulsively Type A behavior is not an attempt to prove to the board that he is a better chairman than the one he succeeded, but is due rather to his own modest misgivings about his suitability or capability for a job of which more and more is demanded of its holder. Perhaps the social setup as a whole is as inimical as Time or fellow man. The authors will carry their entire profession with them in insisting upon the importance of studying each patient in his entirety as an individual and not just studying parts of him and trying to piece them together, and the same might be said about studying human social and cultural ecology in its entirety so that we can discern where the real blame lies and how much of the pathogenesis of CHD is avoidable or remediable. If they did this they would win over every humanist too.
April 4, 1974