By George Engel, M.D.
A NEWLY APPOINTED PRESIDENT of CBS inc. died suddenly at the age of 51 the night after his father’s death. A prominent British tycoon prematurely forced into retirement after a bitter dispute with his company died at the airport as he was leaving the country for a “well-earned res.”
The notion that sudden death can be traced to such trauma has a long and persistent history. As far back as written records exist, people are described as dying suddenly while in the throes of fear, rage, grief, humiliation or joy. In the first century A.D. the roman emperor nerve reportedly died of “a violent excess of anger.” Against a senator who had offended him. Pope innocent IV is said to have succumbed suddenly because of the “morbid effects of grief upon his system” from the disastrous overthrow of is army by the Sicilian king Manfred.
With the coming of the germ theory of disease in the late 19th century, the notion that emotional trauma could cause sudden death fell into disrepute. Yet, scientific interest did not cease altogether. For instance, noted Harvard physiologist Walter Cannon wrote a paper in 1942 discussing possible physiological mechanisms in “voodoo death.” In the late 1960s, clinician began to report patients with heart disease who died suddenly after being “at the end of their rope.” My own interest in the sudden death syndrome gained impetus from the unexpected death of my identical-twin brother from a heart attack in 1963. Exactly 11 months later less one day-the last day of mourning according to the Jewish faith-I, too, suffered a heart attack. This occurred during the emotional strain of anticipating the first anniversary of my twin’s death.
Soon afterward, I began collecting newspaper clippings on sudden death. With the aid of colleagues and medical examiners around the world, I compiled 275 cases in which death generally occurred within minutes or hours of a major event in the person’s life. For the most part, the victims were not considered ill at the time; or, if they were ill, not in imminent danger of dying. When we analyzed the circumstances surrounding these deaths, four categories emerged. The most common (135 deaths) involved an exceptionally traumatic disruption of a close human relationship or the anniversary of the loss of a loved one. Fifty-seven of these deaths were immediately preceded by the collapse or death often abrupt- of a loved one. Some survivors were reported to have cried out that they could not go on without the deceased. Many were in the midst of some frantic activity-attempting to revive the loved one or get help-when they, too, succumbed.
Two examples: a 38 year-old father collapsed and died when he failed in his efforts to revive his two-year-old daughter, who had fallen into a wading pool. A 49-year-old man died two hours after hearing that his 22-year-old daughter had been killed and his two grand children seriously injured in a traffic accident. Fifty of the 135 cases died within the first two weeks of a loss, usually of a spouse. One report involved a sequence of three deaths over four days: an 83-year-old man was hospitalized for a heart attack. During his illness, his wife died suddenly. His 61-year-old son (her stepson) came from Florida to New York to see his father and to attend his stepmother’s funeral. He collapsed and died at his father’s home. The old man, bereft of both wife and son, died the next day.
The second most common circumstance preceding death-cited in 103 cases-was a situation of personal danger with threat of injury or loss of life, including fights, struggles or attacks. An elderly man, for example, locked accidentally in a public lavatory, died while struggling to free himself. In another case, two close friends had argued violently. No blows were struck, but one man collapsed and died. The second, who had a history of heart disease, became acutely short of breath and died soon afterward.
Twenty five people died shortly after the danger had passed-e.g.. after being in automobile accidents without suffering injury. In still another case, a 50-year-old man who had survived a major earthquake died sitting at his desk during a minor tremor a few months later. The third category-sudden death in the wake of disappointment, failure, defeat, loss of status or self-esteem-accounted for 21 news items. A 59-year-old college president, obliged to relinquish his post under pressure from his board of prominent citizens died while involved in criminal proceedings or facing charges themselves.
While death under circumstances such as grief, fright or failure may not be particularly astonishing, 16 people in the fourth and final category died at times of triumph, after achieving some long-sought goal, or after joyous reunions and “happy endings.” A 55-year-old man died as he met his 88-year-old father after a 20-year separation. The father then dropped dead. A 75-year-old woman died suddenly after a happy week of renewing ties with her family, which she had left behind 60 years earlier. A 75-year-old man who hit the twin double for $1683 on a $2 bet died as he was about to cash in his winning ticket.
One common denominator emerges from the repos on sudden death. For the most part, the victims are confronted with events impossible to ignore, either because of their unexpected or dramatic quality or because of their intensity or irreversibility. Implicit, also is the idea that the person involved no longer has, or no longer believes that he has, mastery or control over the situation or himself; or he fears that he may lose what control he has. Some people actually seem to conclude that it is no longer worthwhile to try to change the situation. Instead, they seem to expect death, and wait for it quite calmly.
This paralysis at a perceived impasse is dramatically illustrated by the 45-year old man who found himself in an unbearable situation in the town where he lived. Just as he was ready to take up residence in another town, difficulties developed there as well. In an anguished quandary, he nonetheless boarded the train with a friend for the new locale. He got out at a situation stop halfway to his destination. Feeling that he could neither go on nor return, the friend reported, he died of a coronary on the spot. Sudden death in situations of psychological stress is by no means confined to humans. Trapper and zoo keepers know that animals may die after fights or when escape becomes impossible, or when they are transferred to an unfamiliar locale or exposed to abrupt stimulation. In the laboratory, lethal cardiac irregularities may develop when animals are placed in situations with which they cannot contend.
Such physiological changes may involve two basic emergency systems used by both animals and humans to cope with danger. The first, the so-called flight-fight mechanism, mobilizes the body’s resources for massive and quick motor activity. The other, a conservation-withdrawal mechanism, prepares the when there is nothing the animal can do to cope with a threatening environment. The two are usually finely balanced in a reciprocal relationship, but sometimes the give and take between the systems breaks down under extreme or conflicting stimulation-for example, when overriding psychological uncertainty exists. And rapid shifts from one response to the other may seriously affect functioning of the heart and circulation.
Laboratory animals die suddenly under psychological circumstances similar to those that often accompany such deaths in humans. Further, the immediate cause of death this often derangement of cardiac rhythm-which considerable evidence suggests is the most frequent cause in humans. Certain hormonal substances secreted in excess during stress are known to predispose the heart to just such lethal arrhythmia’s. In the laboratory, animals can be saved from heart attacks with drugs that block nerve pathways to the heart and stabilize heart rhythm.
Future animal experiments may one day illuminate the sequence of events linking stress with death-and perhaps suggest ways of reversing the process. For now, physicians would be well advised, when dealing with patients having heart disease or chronic illness, to try to anticipate events that might trigger sudden emotional reactions in these patients. They might consider use of an anti-arrhythmic drug before such a potentially traumatic event and , if there is a death in the family, they should be alerted to the fact that some tranquilizers increase arrhythmia in some people. Perhaps routine annual checkups could be scheduled before, not after, such significant events as retirement or the anniversary of a loved one’s death. Mean-while, more exhaustive case studies of sudden death may yield useful information for physicians and those in the most danger.