Engel and the Concept of Disease

Modern medicine has been dominated by the biomedical model of disease, which tends to attribute to each disease a single biologic cause. George L. Engel described in 1959 an alternative perspective that recognizes that the determinants of health and disease are multifactorial with manifestations on social, psychologic, and biologic levels, best conceptualized in terms of a hierarchy of natural systems, a biopsychosocial model. The physician attempts to recognize disease and restore health to the patient at all levels. The interview and examination of the patient are an effort to identify not a single biologic defect-causing disease but "the conditions necessary and sufficient to bring about a particular constellation of signs and symptoms" (Engel 1960).

Born in 1913 in New York City, Engel graduated from Dartmouth College in 1934 and Johns Hopkins University School of Medicine in 1938. An important influence was an uncle, Emanuel Libman, a physician–scientist of international distinction, in whose house Engel lived. Libman asked the only question of James B. Herrick after listening to the uneventful address of Herrick's classic paper "Clinical Features of Sudden Obstruction of the Coronary Arteries" in 1912 (see "Herrick and Heart Disease" at the beginning of Section II). As an undergraduate, Engel began his research career at the Marine Biological Laboratory in Woods Hole, Massachusetts, where he spent two summers and wrote his first two papers. The summer after his freshman year in medical school Engel spent with his twin brother in physiologic research at the All-Union Institute of Experimental Medicine in Leningrad, the home of Pavlov's laboratories. The next summer Engel worked for Harrison Martland, a prominent pathologist in New Jersey, and participated in over 300 autopsies. Through an elective clerkship at Boston City Hospital during medical school, Engel came under the important influence of Soma Weiss.

The first 2½ years after graduation, Engel spent as a rotating intern at Mt. Sinai Hospital in New York City, by the end of which he had presented three papers to the New York Neurological Society and had six papers in press. The next year he spent as a fellow at Peter Bent Brigham Hospital, where he resumed work with Soma Weiss and began teaching clinical methods to medical students, which he would continue throughout his career. Engel also began work with John Romano, a psychiatrist, who was soon appointed Professor of Psychiatry at the University of Cincinnati College of Medicine, where in 1942, at age 29, Engel accepted a joint appointment in medicine and psychiatry. At Cincinnati General Hospital he worked with Eugene Ferris in medicine for 4 years, perhaps his most formative period. In 1946 he accompanied Romano to the University of Rochester as Assistant Professor of Psychiatry and Medicine with the challenge as an internist to develop teaching and research in psychosomatic medicine. Out of this emerged a broad-based program in psychosocial medicine, including a postresidency fellowship to educate nonpsychiatric physicians in the psychosocial dimensions of their disciplines. Engel became an emeritus professor in 1983 and a George L. Engel Professorship of Psychosocial Medicine was endowed in his name.

Engel has drawn attention to an important factor in sudden death, psychic stress. He attempted to "identify and classify the kinds of life circumstances and psychological reactions with which sudden death is alleged to be associated and to establish the prevalence of each association." He read newspapers to find reports of cases of sudden death, writing:

Over a six-year period we succeeded in collecting 170 such items, mostly from the Rochester press but also from newspapers here and abroad, wherever the author happened to be, as well as from interested colleagues who sent clippings. Only reports with clear reference to a precipitating life situation were used, and all instances in which suicide was even a remotely possible explanation were scrupulously excluded. Most deaths occurred within an hour of the event reported although all the victims were considered still to be reacting emotionally to the event at the moment of their demise. (Engel, 1971)

Engel found startling cases of sudden death preceded by emotional upset. The following he included as a case of "sudden death during acute grief":

A dramatic example is the death of the 27-year-old army captain who had commanded the ceremonial troops at the funeral of President Kennedy. He died ten days after the President of a "cardiac irregularity and acute congestion," according to the newspaper report of the medical findings. (Engel, 1971)

Engel classified the life settings during which sudden death may occur into the following eight categories, with the percentage distribution:

1. Personal danger or threat of injury (27%)
2. Collapse or death of close person, on impact (21%)
3. Acute grief, within 16 days (20%)
4. Threat of loss of close person (9%)
5. After danger is over (7%)
6. Loss of status or self-esteem (6%)
7. Reunion, triumph, happy ending (6%)
8. During mourning or anniversary (3%)

Engel emphasized that psychic stress may interact with other factors to induce sudden death, perhaps by initiating the chain of events leading to death. He believed that psychic stress should not be ignored as a possible contributing factor to death and disease and that precautions should be taken in care of the vulnerable patient in environments of stress, such as in the ambulance, emergency room, and intensive care unit.

References

1. Ader R, Schmale AH. George Libman Engel: on the occasion of his retirement. Psychosom Med. 1980;42:79–101. [PubMed: 6997915]
2. Engel GL. A unified concept of health and disease. Perspect Biol Med. 1960;3:459–85. [PubMed: 13820307]
3. Engel GL. Sudden and rapid death during psychological stress. Folklore or folk wisdom? Ann Intern Med. 1971;74:771–82. [PubMed: 5559442]
4. Engel GL. Psychologic factors in instantaneous cardiac death. N Engl J Med. 1976;294:664–65. [PubMed: 1246260]
5. Engel GL. The need for a new medical model: a challenge for biomedicine. Science 1977;589–608. [PubMed: 847460]