Over the past half century, a substantial literature has been generated in the field known variously as cardiac psychology, behavioral cardiology, and psychocardiology. A PubMed search of the terms “psychosocial factors and cardiovascular disease” currently yields >39,500 citations. Depression, social isolation, anger and hostility, anxiety, type D (distressed) personality, and post–traumatic stress disorder, have all been linked to the onset and outcome of coronary artery disease (CAD), the leading cause of death and disability in Western society.

The type A behavior pattern (TABP) was the first psychosocial risk factor scientifically associated with CAD. The 2 cardinal symptoms of the TABP are free-floating (easily aroused) hostility and time pressure (doing too much in too little time). In their seminal 1959 study, 2 cardiologists, Meyer Friedman and Ray Rosenman, reported that subjects diagnosed type A had an increased risk of myocardial infarction (MI), compared with those assessed type B (largely an absence of type A behaviors). A 22-year follow-up of this cohort, however, determined that subjects with type A actually survived their MIs “better” than those with type B. A large, although inconsistent and frequently controversial, literature accumulated around the TABP over a half century. Currently, there is little research on the overall pattern, the focus having shifted to anger and hostility. Nonetheless, several clinical trials using type A theory have demonstrated reduced cardiac morbidity and mortality. Keeping the controversy alive, a recent Cochrane Review concluded that “an aim to treat type-A behaviours were more effective than other interventions” in clinical trials treating post-MI patients with group psychotherapy.

The life of the eighteenth century English surgeon John Hunter provides a fascinating illustration of the type A paradigm ( Figure 1 ). There is good reason to believe that Hunter suffered from poor self-esteem, the presumed “nucleus” of the TABP. Originally trained as a carpenter, Hunter had little formal education and never received a medical degree. Everard Home, Hunter’s brother-in-law, disciple, and first biographer, described him as insecure: “[Hunter had] diffidence respecting himself …. Giving lectures was … particularly unpleasant … so that the desire of submitting his opinion to the world and learning their general estimation were scarcely sufficient to overcome his natural dislike to speaking in public.” Home noted that Hunter would sometimes revise his lectures for 20 years before “giving them to press,” and before presenting them he would often compose himself with a draught of laudanum (opium). Foot, a contemporaneous surgeon as well as an early biographer, wrote, “… by … lecturing at home [rather than at the hospital [Hunter] … shut out everyone capable of comparing his dogmas to established doctrines.” “[He] … depressed the … merit of others and exalted his own ….”

Interrelationships between type A behavior components and pathophysiological processes. From Friedman M and Ulmer D. Treating Type-A Behavior and Your Heart. New York: Knopf, 1984:70.

Copyright 1984 by Knopf. Reprinted with permission from Knopf. CAD = coronary artery disease.

Hunter was a driven man, and this no doubt contributed to his vast productivity. When driven by insecurity, however, type A theory predicts that the desire for achievement can become insatiable, giving rise to the symptoms of “time urgency” and “free-floating hostility.” Failure to meet temporal expectations would often trigger Hunter’s wrath. “Hunter was a great economist of time …. Any unnecessary discomposure of engagements … greatly annoyed him, and caused him to give vent to his feelings in no unmeasured terms.” Hunter’s brother-in-law characterized his temper as: “very warm and impatient, readily provoked, and when irritated, not easily soothed.”

Hunter’s lifestyle and pace were “hyperaggressive,” another type A characteristic: “Four hours of sleep with an hour after dinner, was all the time he devoted to the refreshment of his body. He had no home amusements … for the relaxation of his mind.”

“He was generally to be found in his dissecting room before six in the morning and worked there until breakfast at nine. Then he saw patients at his house until twelve, after which he went out on his rounds …. He dined at four, slept an hour, and spent the evening working. At twelve the family retired to bed and the butler brought a fresh argand lamp, by the light of which Hunter continued his labors until one or two in the morning, or even later in winter. Of course, all this had the inevitable result: he broke down and had to go to Bath for a long convalescence. But the warning seems only to have made him work harder … and the pace grew faster.”

In addition to Hunter working beyond his body’s capacity, a number of curious incidents also suggest the type A “drive toward self-destruction.” On one occasion he broke his Achilles tendon during strenuous dancing and on 2 others Hunter was nearly killed, once when he was frolicking with a prize bull given to him by the Queen and another playing with 2 leopards that he kept.

Hunter began to manifest “angina pectoris” when he was approximately 45 years of age, although he did not know its cause. The association of this symptom with CAD was first made by Hunter’s pupil Edward Jenner, who did not reveal the connection out of consideration for his teacher. Jenner waited until after Hunter’s death before publishing his findings. Home noted, “It is a curious circumstance that the first attack of these complaints was produced by an affection of the mind, and every future return of any consequence arose from the same cause … and as his mind was irritated by trifles, these produced the most violent effects on the disease. His coachman being beyond his time, or a servant not attending to his directions brought on the spasms ….”

By age 65, Hunter had become the foremost surgeon in London. His contributions to the field of anatomy were prodigious and included the first explorations of the lymph system and important discoveries about the male and female reproductive systems. Hunter had been appointed Surgeon General to the Army, Inspector General of Hospitals, and Surgeon Extraordinaire to George III, King of England. He owned city and country homes, employed >50 people, and “was almost adored by the rising generation of medical men, who seemed to quote him as the schools at one time did Aristotle.”

Despite all this worldly success, things were not right in many of Hunter’s interpersonal relations, suggesting a deterioration in his personality, a further manifestation of the TABP. For many years, Hunter was estranged from his brother and mentor, renowned physician William, over claims of which of them had discovered the circulation of the placenta. At St. George’s Hospital, beginning in 1788, “there was already a war between Hunter and his colleagues.” He affected to be too proud to explain …. He estranged himself from all intercourse with the corporation of surgeons …. He hated his equals in the profession, and who can esteem him who hates them!”

In a letter to the faculty, Hunter unilaterally declared that he would not share students’ tuition with the other surgeons at St. George’s Hospital: “as the increase of the pupils became very considerable, and the greater number entered with me the only method left was to keep the money I received by the pupils as my own property.” A special court ruled against him.

Around this time, a young Scotsman without a formal education applied to study at St. George’s Hospital and appealed to Hunter for help with his admission. Hunter too had little formal training and had unsuccessfully opposed the “law concerning the [academic] qualifications required for admission.” Hunter took up the cause of this young man, who may well have reminded him of his own youth, against “a regulation which thirty years sooner, would have excluded himself from the hospital.”

Such were the circumstances surrounding the hospital board meeting of October 16, 1793. Early that morning, Hunter met a baronet who had called on him and told her “that he was going to the hospital; that he was fearful some unpleasant rencontre might ensue, and if such should be the case, he knew it must be his death.” The habitually punctual Hunter arrived late. After being contradicted by a colleague, “… not being perfectly the master of the circumstances … [Hunter] withheld his sentiments, in which state of restraint he went into the next room, and turning around … gave a deep groan, and dropt down dead.”

Some time before that fateful board meeting, in an oft quoted statement, Hunter had said that his “life was in the hands of any rogue who chooses to annoy or tease me.” Just 1 year before his demise, Hunter was arguably the first in medicine to describe “an instantaneous death from a violent affection of the mind.” A few years later, Adams noted wryly, “if he had not his own death in view, he has at least described its immediate cause … with the perspicuity which could not have been exceeded if he had attended the examination of his own corpse.”

A recent anecdote sent by a colleague demonstrates that Hunter’s fate is still quite salient. A surgeon was about to begin a case. The operating room staff called to ask for a nurse practitioner (NP) to come and deactivate the patient’s implantable cardioverter-defibrillator. The staff member, however, told the NP the incorrect implantable cardioverter-defibrillator manufacturer. When the NP arrived, she had the wrong programmer and had to go back to retrieve the correct device. By the time she returned, the surgeon was furious that he was made to wait. At the end of the case, the NP was called to turn on the device. The surgeon was again enraged at how long it took her to arrive. Immediately after the operation, he called the cardiology office to register a formal complaint and then proceeded to lodge a complaint with the chief executive officer of the hospital. The surgeon then proceeded to the physician lounge, where he had a witnessed cardiac arrest. All efforts to resuscitate him were unsuccessful, and after 90 minutes he was pronounced dead. He had often been angry and mean to staff.

A 2009 meta-analysis of 25 prospective studies in healthy subjects reported that anger and hostility were associated with an increased risk of cardiac events, and in 19 studies of subjects with established CAD, anger and hostility predicted poor prognosis. Anger can trigger MI and lower the threshold to ventricular fibrillation, with either condition leading to sudden cardiac death. Moreover, anger intensity has recently been linked to increased risk of MI onset. Although this information is far too late to benefit John Hunter and the surgeon in our modern anecdote, the world can certainly learn from their personal stories.