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small size ofgroup A, 8~'men, raised the possibility of selection, but concern on this score was largely ~llayed by the fact that, before the investigation, only 4 of 23 persons with clinical coronary disease were aware that ~f@ #,~.~, ~bI~ @~rs~nalky an~Ib~ioar ipa~t,~m does indeed precipitate coronary artery disease then appro.ach by researcher..s as 9f.the .comple.xity of the - More than twenty .years "ago FR-IED~L~N and " ROSENMAN~ reported that a certain, type of personality~ in employed, middle-agdd U.S. citizens, . was associated with an indreased risk of clinically apparent coronary heart disease. They had studied three groups ofmen. In group A the behaviour pattern was primarily characterised by intense ambition, competitive drive, constant preoccupation'with occupational deadlines, and a sense ofurgency. These men were contrasted with a second group, B, who had a converse behaviour pattern....Group .C consisted of totally blind, ttfie/nployed men who had Iittle ambition or drive but who were .~h~6fiic~lly'.insecure and anxious. Some ve~ preventive conclusions "were reached. Clinical coronary artery disc'~/se was seven times more frequent, and arcus senilis Over three times more frequent, in group A than in group~ B or C. Data on cigarette smoking, exerc!se, x.vorking hours, alcohol ingestion, and heredity were studied but none of these seemed to account for the extraordinary difference between group A and groups B and C. Group A individuals had a higher cholesterol th~n the others ~gthout convincing evidence of dietary or other relevant differences. Thehypoth~is was that their behavinur [~attem (designated q'pe A) was of itself" largely responsible for their higher serum cholesterol and alto, dlrcctly or indirectly, for their increased su~eptibility to clinical coronary artery disease. The different components ofhuman reaction, and, on the other, the quantification 0fan adversg influence on_the_ heart, blood vessels, and health. Lastly, any hypothesis based on:such analyses requires testing by controlled - interference or perturbation. Such testing has also to proceed to clinical trial if any conclusions arc to be subsequently translated into treatment. Type A bchaviour is~a state of m~ntai arousal associated with a positive, compctitive~ ambitious, time-conscious, driving existence. It is not to be confused with Merely working hard, nor is it necessarily associated with a tangible successful outcome--rather, a mismatch bctwee.n, striving intent and accm~plished rcsults~ The essence OfLVpC A could conceivably be as fundamental as genetic ".det~rmlnatio .n, but it might e~ually include orbe solely ~ due to the repeated conditioning of a particular life- style and euvironmcnr. Its presence" is relative and at present the degree can be ascqrtaincd onlyby interview or questionnaire. How far such ~lata quantitatively represent a personal response characteristic is uncertain, and cbnservative psychometricians would settle for "present" or "absent". More accurate" definition and measurememt is desirable, in various ~ differ',mt sociaL, occupational, racial, and national groups. A better explanat.;on of numerical quantilication is atso necessary. Very few doctors~ and fewer laypeople, have a realistic perspective ofwh~t a risk Factor implies for an h:divldual. In the case of a single risk~ such as Tt05280025

.high blood-pressure, high cholesterol, or smokin~ the" s~atistics seldom have much impact on the.patient be:c.ae:se .of the loag ~rG~s~d]Le.' !Indeed the risk may . . well/~e psychologically small when it is made clear that, • "}" :i¢V, da wit.h a stror~g statist~'~al assodatie~, ontya points ofview. F=stly, ~e ~a~itude of the t~e A risk ~h~ ~en ~sessed as to ~h~t of .... ~T~. Beha¢iour m~ifi~gion is a sen~tive ~aer. We may not ~sh to mend our ways. We may live and work in an environment that has en~uraged and rewarded the type A attitude. Our immediate world may or may not ~sk ~o. ehan;g¢'. A substantial loss. of~pe A beha~our c~d ~a~.~tioa in sta~ug ia job f~uct~on,, in t~e regard Ofcdl~es and possibly in personal income. None of these prospects is very enticing. But, for a ~risk indNid~aI, the long-term view ma~offer little - gk~]l,, ~n~ ~1~:~ ,i~mi~y doctor m~y ~4~etb: make an - absen~eof~peAbehaviour ' unusual effort. ' " '" "~. .- .. :-'-may partly explain the sumi~al or some people who " To what degree can behaviou~l mddific~id~:~l~::~ . ' ;have~multiplidtygfsonvenfion~l risks. , . - " ~ehe~Ithandlifeexpectationoftheindividfial?Itisall " . :; :.'.. ~:(~..~t Will notbe ~y t6~n ohiSh~o~glationsbetween...' too easy to ass~e that there is a slmple)in~, ~n~ that ":~,~., . . . "" typeA, the established risk fa~td[~ and sudden death, modification bfthe one will alter the oiher:Gi~e~ the' " mybcardial infar~tion~"and hhginh; "but there are no ".. need for scientific demonstration~ the most rewarding " ~und~ental .r~mns to. •prevent a. reasonably good statistical circumstances are those in which the highest - . ~ci~ntific j,ob~. There are ~any patterm of mental • incidence oftest points occurs in the shortest pefi~ of . ?" " ,..'fst~td'whieh ~.~been thdu'ght to'predispose to a~te " time. Thus, hypertensive smokers With unfavofi~able , , ~.- :.. ..... ea~.as~=lar..~s~as~.~do~0od~ ret,~ement, lob 1Lprd profiles should be a first fo~s. In ~ese ' ,- l~ a~. d~,ox~e: ar~. ~a~l ~:~[ ~u.rc~s.. for .cir~mst~nces: remoulding era patient's li.fe-st~l~ m~: :. ".-" ~' ~md~;i'd%~g~ff[s."~t ~thre'~ai[~'~0re serious . prove an eth~¢a[ly defensible a~ivity. 10 "t~e'.A - .. ? " " - dl~t~ltie.s~If ~e gype A h~ot~e~is isis:correCt,, then individuals wit~ risk factors of a lower oMer of . -. . obviously .the •links .between'behaviour and the .... magnitude, the prospe~ of a~usfful result is sm~ll: , ~ pat~ophysldloi~ical processes .~afising disease must be ~-. further explored. It is in this area of analysis that the real troubles begin. There is a possibility that a genetic • -. - trait mightbe expressed-in dual fashion--for example~ - there might be a factor ~ common to behaviour determination and arterial wall degeneration. Alt~rriatively, adverse biochemical changes might arise only during a phase oftype A behaviour. FRIEDMAN et al.~ alluded to this possibility in a report on accountants who had higher serum cholesterol when they were • particularly oppressed by deadlines. In either case we are thrown back to the basic mechanisms of atherosclerosis, thrombosis, and adrenergie drive, all • of which have proved difficult enough without the • ~.: added ~:orfiplicatlon 'o~" beha~;ioiar studies. At a less' fun.dgm~ntal level, w'e ~y get some'information from those individuals who are obliged to undeigd several coronary arteriograms; "a ~elected group, admitredly, but one in which a higher proportion of type A • characteristics may be .expected.• In such research, impro .red angiographic techn, iques giving better small • vessel definition a.re importa~.t, for the future. • Optimistically we must suppose that pi'actical medicine will be the hotter for such knowledge. Through the eyes of'the iudividual the key question is wh.ether the.qt~ality or length ell.ire can be improved by interven.tion~ whether with advice or with drugs. th-ere is scant chance of collecting enough "ev~nts~" in a manageable number ofpe0ple. At present there seems no good reason to edvise lower-risklndi,/iduais to mend their ways. Indeed, devil's advocates have been heard to argue that, in some quarters, a small infusionoftype A would be beneficial all round. To Sleep, Perchance to Breathe... ABNORMALITIES in breathing during slee'p have attracted increased attention with the identification, firstly, ofsleep apnoea syndromes,~ in which breathing stop~ for over 10 seconds an average of more than ten times per hour of night-tlme sleep;~ and, secondly, of the much more commo'n disturbances of breathing ,oattern and arterial oxygenation during slsep in patients with chronic lung disease.~-~ Two types of sleep apnoea are distingulshed-central apnoea, where chest wall movement and diaphragmatic contractions cease when airflow stops at the nose mad mouth; and obstructive apnoea, where t~ansient u'pper-alrway obstruction is revealed by persistent chest wall Tt05280026