The nineteenth century was struck by a collective panic about being buried alive, leading to a bevy of new laws, regulations, and inventions like the safety coffin. In this episode, we explore how medical science created and fueled this fear by blurring the line between life and death with the invention of new tests for death, developing life-saving technologies like rescue breathing, and even re-animating corpses. And just in case you thought the fear of premature interment was something of the past, we explore how issues raised in this panic still inform medicine today. Learn about all this, a brand new #AdamAnswers, and more in Episode 20 of Bedside Rounds, Buried Alive!

Sources

Pernick, M. Back from the Grave: Recurring Controversies over Defining and Diagnosing Death in History. Death: Beyond Whole-Brain Criteria. Volume 31 of the series Philosophy and Medicine pp 17-74
The Uncertainty of the Signs of Death and the Danger of Precipitate Interments and Dissections, from the Library of Congress: http://www.loc.gov/teachers/classroommaterials/lessons/jefferson/pdf/signs.pdf
NYTimes article: http://query.nytimes.com/mem/archive-free/pdf?res=9F00E4DF1E3EEF33A25752C2A9649C94649FD7CF
Newgate Chronicle:
http://www.exclassics.com/newgate/ng464.htm

Music

All music thanks to Kevin Macleod from Incompetech.com. Tracks in this episode included: Secret of Tiki Island, Rollin at 5, Bushwick Tarantella, Thinking Music, Villanous Treachery, March of the Spoons, Wepa

Transcript

Dumela, this is Adam Rodman, and you’re listening to Bedside Rounds, a tiny podcast about fascinating stories in clinical medicine. This episode is called Buried Alive, and it’s about the curious panic in the 19th century about being buried alive, how it was caused by advances in medical science, especially in blurring the lines between life and death, and how the issue might not be as settled today as we like to pretend that it is.

If you, dear podcast listener, were alive during the 1800s, you would be terrified of being buried alive. And no wonder; even today we still read Edgar Allen Poe’s “The Cask of Amontillado” and “The Fall of the House of Usher. And of course there are more salacious works that time has forgotten, like Jon Snart’s Thesaurus of Horror, which is neither a thesaurus, nor is it that scary by modern standards. It DOES purport to give the true story of a man buried alive in the most morbid fashion possible, and I’m quoting here “the victim’s final struggle, bathed in blood and excrement, BEHOLD a master-piece of horror!!!!” And this is hard to get across through the radio, but there were three exclamation marks there.

And God forbid you opened the newspaper. The New York Times recounted the tale of poor Jenkins, a young man from Asheville in my home state of North Carolina:

[He] had been sick with fever for several weeks and was thought to have died. He became speechless, his flesh was cold and clammy, and he could not be aroused, and there appeared to be no action of the pulse and heart. He was thought to be dead and was prepared for burial, and it was noticed at that time that there was no stiffness in any of the limbs. He was buried the day after his supposed death, and when put in the coffin it was remarked that he was as limber as a live man. There was much talk in the neighborhood about the case, and the opinion was

frequently expressed that Jenkins had been buried alive.

Ten days later the grave was disinterred in order to be taken to the family burial grounds:

The coffin was opened, and to the great astonishment and horror of his relatives, the body was lying face downward, the hair had been pulled from the head in great quantities, and there were scratches of the finger nails on the inside of the lid and sides of the coffin. These facts caused great excitement and all acquainted personally with the facts believe Jenkins was in a trance, or that animation was apparently suspended, and that he was not really dead when buried, and that he returned to consciousness only to find himself buried and beyond help. … The relatives are distressed beyond measure at what they term criminal carelessness in not being absolutely sure Jenkins was dead before he was buried.

I mean, after reading through this stuff for the past few weeks, I understand the fear. But why this period in time? Stress of determining the dead from the living is nothing new, and an awareness of the potential for premature burial has been present throughout recorded history. For most of human history, death was when a person seemed, well, dead. Tests for death were crude, and focused on whether a person had stopped breathing, or had no pulse. Other tests were, well, nonspecific would the right term. The Romans, for example, had the conclomatto, the death mourning ululation, usually done by the deceased’s female relatives. If there was no response, the person could be buried. You can imagine how this could go horribly wrong. And we know that during the Black Death in Europe in the 14th century, when bodies were interred as quickly as possible to stop spread of the disease, the fear of being buried alive was, likely quite rightly, almost as high as the Black Death itself.

But what makes the nineteenth century panic so interesting — and so relevant to the 21st century — is that WE caused it. Prior to the Enlightenment, doctors were not really involved in death. Medieval and early-modern doctors followed the Hippocratic prohibition of medical treatment for the dying; once they determined a patient was dying, they would leave the in the case of their family. The onus of determining death, then, was on them. When early modern physicians rediscovered the classics, they began observing and experimenting. And when they turned to the ultimate mystery — the transition between life and death — they were disturbed by what they found. Initially, the death exam by physicians was much like it had been for over a millenia — feeling for a pulse, watching for chest rise, or placing a mirror beneath the nares, but it quickly became apparent that these weren’t very good. In 1740, the acclaimed anatomist Jacque Benigne Winslow collected a series of cases into a book called “The Uncertainty of the Signs of Death and the Danger of Precipitate Interments and Dissections,” which was widely translated and distributed.

I’m on record as being a fan of pre-twentieth century medical literature, which has the distinct advantage of not being incredibly boring. So I’ll just read some of the chapter headings of the English translation:

“ A woman comes to Life the next Day after her internment by means of one of her domesticks, who attempted to steal a ring from her finger.

“A child taken alive out of its mother’s belly after it had been interred with her”

“A lady comes to life in the vault where she was buried, and eats her fingers”

“A person recovered to life and having been sixteen hours in the water, and another who had been underwater no less than seven weeks”

And my favorite, because I can totally imagine this scenario:

“A woman, supposed to be dead, revived by a candle accidentally setting fire to the bed on which she was laid out.”

Winslow was pretty pessimistic about physicians’ abilities: he concludes that “putrefaction is the only infallible sign of death”.

Winslow just had to look around in 18th century Paris to see the disturbing medical advances. The first was the invention of artificial respiration, the first reports of which were published the same year as Winslow’s treatise, in 1740. Artificial respiration, or rescue breathing, is the classic life guard move — breathing into someone’s mouth. By the late 18th century “humane societies” had been started in most European cities to teach artificial respiration for drowning and suffocation victims, and they apparently had quite the impact. The London society claimed to have saved almost 2,000 people in less than 20 years. As the lives of those saved ticked up, Winslow updated his book with stories of people saved from drowning hours later with artificial respiration.

But the real shock to diagnosing death came with the invention of electricity and electroresuscitation. Sorry, that was a terrible pun. So by the 1780s, Luigi Galvani had scandalized audiences across Europe with dramatic presentations of dancing animal limbs and disembodied beating frog hearts. But it was his nephew Giovanni Aldini who took the process of “galvanization” to its logical conclusion by reanimating a corpse. In London in 1803, a man named George Forster was convicted of drowning his wife and young child, and sentenced to hang. Fortunately for us, the subsequent events were chronicled by a local paper:

He died very easy; and, after hanging the usual time, his body was cut down and conveyed to a house not far distant, where it was subjected to the galvanic process by Professor Aldini who showed the eminent and superior powers of galvanism to be far beyond any other stimulant in nature. On the first application of the process to the face, the jaws of the deceased criminal began to quiver, and the adjoining muscles were horribly contorted, and one eye was actually opened. In the subsequent part of the process the right hand was raised and clenched, and the legs and thighs were set in motion. Mr Pass, the beadle of the Surgeons’ Company was so alarmed that he died of fright soon after his return home.

Some of the uninformed bystanders thought that the wretched man was on the eve of being restored to life. [The experiment’s] object was to show the excitability of the human frame when this animal electricity was duly applied. In cases of drowning or suffocation it promised to be of the utmost use, by reviving the action of the lungs, and thereby rekindling the expiring spark of vitality.

This event still has impact today, if only because Aldini’s experiment was the inspiration for Mary Shelley’s Frankenstein, a story about another physician using electricity to bring a corpse back to life.

While artificial respiration and electroresuscitation showed that the dead could be revived, during this same period, physicians began to realize that many diseases that had previously been diagnosed death were in fact treatable. By the end of the 19th century, the list included coma, cataplexy, hypothermia, stroke, high fever, head injury, and opiate intoxication, among others.

Doctors coped with the changing landscape in one of two ways. Maybe “suspended animation” truly was possible, that traditional signs of life like breathing and pulse weren’t truly indicators of life, and that life could be stopped and then restarted. This view was very popular, especially with the public, and helped feed the panic about being buried alive. But another school, which would eventually win out and which we still roughly follow to this day, argued that in all of these cases where people were brought back to life, patients were not dead at all — rather, the methods used to diagnose death were not sufficiently sensitive. What was needed, they argued, was better tests to diagnose death — and physicians to administer them.

And develop tests they did. The most influential was the stethoscope, invented by Rene Laennec in 1819, which would allow doctors to hear even the faintest heart and breath sounds. Laennec, of course, was the subject of the ninth episode of this podcast, which I strongly encourage you to listen to. But physicians were nothing if not creative when tackling the problem of diagnosing death: thermometers for body temperature, the ophthalmoscope for looking at the pupils, injection of noxious chemicals like fluorescein, which would turn the eyeballs of the living bright green, and some particularly horrific procedures like burning the skin with boiling water, stabbing a long needle with a flag on top into the heart, or my personal favorite, Dr. Josat’s nipple pincher.

Tests were followed by new laws. As Napoleon conquered Europe, he imposed a 24 hour waiting period between the diagnosis of death and interment, which was extended all the way to three days in some areas. Public mortuaries were built on the edge of cities, where bodies could be observed for signs of life without risking infection. Munich had 10, lovely marble structures set up like a wheel. Open caskets, bedecked with flowers, were in each spoke, call-bells in their hands. An observer with the latest resuscitation gadgets was watching 24-7. The Society for the Prevention of Premature Burial was founded in London and began to lobby for death certifications by physicians prior to burial and adoption of standardized sets of death tests. While their exploits were more successful in continental Europe than England or America, today they’re mostly remembered for their advocacy for safety coffins, the most famous of which was invented by the Russian Count Michel de Karnice-Karnicki. The unfortunate soul buried alive could pull a string, which would then open an air duct, turn on a light, set off an alarm, and shoot a flag high up above the grave. Alas, there are no confirmed cases of anyone being saved by safety coffins.

With these new laws and increased faith in medical practitioners, the fear of being buried alive had mostly abated by the dawn of the 20th century. But if anything, the divide between life and death was growing hazier by the decade. First, “artificial respiration” became mechanical respiration. In the 1920s, with hundreds of thousands being laid low by the polio epidemic, physicians at Harvard developed the iron lung, in which a patient with respiratory failure could be ventilated for a prolonged period. Shortly thereafter, Aldini’s dream of electroresuscitation was realized, though instead of reanimating execution victims, this new form restarted the heart in patients who suffered electrocution in industrial accidents. Defibrillation changed the diagnosis of “sudden cardiac death” into a survivable disease. By 1940, these innovations allowed for the development of the intensive care unit.

Just like physicians of the early modern era, doctors in these intensive care units quickly realized they had a new dilemma in defining death. Many victims of head trauma from automobile accidents could be kept alive, more or less indefinitely, on a respirator, but they showed no signs of neurological activity, and EEGs or “brain scans” showed no electrical activity. The French called this syndrome coma depasse, and just like the buried alive panic, it was mostly ignored by the public and treated as a medicolegal curiosity. That is, until the night of December 2, 1967.

Denise Darvall was a 25 year-old woman who had been visiting friends and buying cake in Cape Town, South Africa with her mother. While driving home, she was run off the road by a drunk driver. Her mother was killed instantly, and Denise sustained a skull fracture and serious head injuries. She was taken to Groote Schuur Hospital, where she was placed on a respirator in the ICU. Very quickly it was determined that her brain was irreparably damaged, though her other organs were healthy. After getting consent from her father, the surgeon Chirstiaan Barnard removed her heart and transplanted it into a man with heart failure — the first heart transplant in history.

Overnight, media across the entire world took notice. Newsweek got right to the point — the story about the transplantation ran with the headline “When are you really dead?” The parallels with the buried alive panic were obvious. First was the fear itself — rather than being interred alive in the cold ground, it was that doctors would, either through malice or ignorance, take the organs of a living person. That Newsweek article captured this zeitgeist by quoting an anonymous public health official who said, “I have a horrible vision of ghouls hovering over an accident victim with long knives unsheathed, waiting to take out his organs.” Purposefully mindful of the panic a century earlier, physicians got work quickly. Within a year, a group of physicians had developed the Harvard Criteria, which provided a framework for diagnosing brain death. New baskets of tests were developed to diagnose loss of brainstem function. A mere 14 years later, the Uniform Determination of Death Act was passed in the United States, designed to prevent patients from being removed from a ventilator or having their organs harvested until they were truly brain dead.

And just like with being buried alive, the controversies around determining brain death were quieted and died, right?

Ha! If you are a faithful listener of this podcast — and I know you are! — you know one reason I love medical history is that everything old is new again — we’re dealing with the same messy medical issues today as our predecessors. The 21st century has brought new tests, like functional MRI scans. Neuroscience has progressed considerably since the original definitions of brain death. New treatments like tPA and clot retrieval in stroke patients have changed the prognosis for brains that might previously have been called brain dead. Is this fertile ground for a new “buried alive” panic?

Well, that’s it for the show. I like to keep it light and breezy, you know. But wait! It’s time for #AdamAnswers, where we answer whatever questions you have about medicine, no matter how silly or trivial. This week, we have a question from Dr. Aamir Abbas, who wants to know who from among a cadre of medical specialties would best survive on a desert island. I should also take this moment to point out that Dr. Abbas is in fact a surgeon, so I’m probably not going to have to go out on a limb to figure out who he’s rooting for. But even though I’m an internist, I will attempt to answer this question fairly.

Fun fact before we begin, the desert in desert island does not mean the Kalahari, but is an antiquated synonym of “deserted”. So more Lost than Lawrence of Arabia. So I searched long and hard for some data to answer this question, and as far as I could tell, there just aren’t serious scholars doing serious work on the theme of getting stuck on a desert island. So we’re going to have to venture into expert opinion territory.

Let’s start with factors that predict survival in an emergency situation. First would be cooperation. I could not find any studies about cooperation by medical speciality; however, there is a wealth of literature on cooperation by gender. I’m quoting from a meta-analysis here entitled “Sex differences in cooperation: a meta-analytic review of social dilemmas,” which I think counts, because survival on an island certainly is a social dilemma. They actually found NO difference in cooperation between men and women overall — however, they did find that male-male interactions were significantly more cooperative, and that females were more cooperative in mixed gender groups. Since all genders are going to be represented on our theoretical island, we need to find the specialty that has the most gender parity. That throws out gynecology and peds on the female side, and, well, honestly most other specialties on the male side, since men still dominate medicine (not for incoming doctors, but for doctors already practicing). Med-peds, geriatrics, and child psychiatry are the most even, so we will give them a point.

Next is resourcefulness. Again, I have no way to measure this, but I suppose intelligence would be a nice proxy. That being said, all I have is MCAT and Step scores, and I’m not naive enough to believe that any standardized test is a proxy for intelligence, let alone the ability to survive on a desert island. With that caveat, the specialized surgeons win this one hands down — thoracic surgery, plastic surgery, orthopedic surgery, and ENT all have MCAT scores ranging from 32-33, several points above the other specialties.

The final category that I’ll go on is strength and raw power. I would love to run a field day for the hospital like they did in elementary school and rank every single medical specialist in the hospital, but alas, I don’t think an IRB would go for that, and more importantly, everyone at work would kill me. All that I have is an article from the BMJ Christmas edition — and I’m on record as how much I love this — called Orthopaedic surgeons: as strong as an ox and almost twice as clever? Multicentre prospective comparative study.

The conclusion of this article speaks for itself: Male orthopaedic surgeons have greater intelligence and grip strength than their male anaesthetic colleagues, who should find new ways to make fun of their orthopaedic friends

Seems like a pretty strong trial, so I’ll have to give that point to orthopedics! Okay Dr. Abbas, I feel I’m ready to ready to offer up the Bedside Rounds Expert Opinion. I have reviewed the available evidence on the topic of which medical specialty would survive on a desert island, including randomized controlled trials, meta-analyses, and cross-sectional studies, and have concluded that orthopods would be the survivor in this Lord of the Flies situation, with an evidence strength of “C” on the SORT criteria. And you just think of that the next time you read expert opinion. You’re welcome, Dr. Abbas.

I also want to point out that there’s a great reddit thread on this topic entitled “All the specialties are on a deserted island; who stays alive?” The link is on the website; you should check it out. They’re about as scientific than me, but a lot more funny.

That’s it for the show! Thanks for listening! I’d like to take a moment and recognize that this was my 20th episode. You, my crazy listeners, have somehow been listening to me jabber for almost five hours. That’s five hours of your life that you decided to spend with me. Sufficed to say, I’m touch. So thanks! Let me know what you think, or ask me a #AdamAnswers; I’m on Twitter @AdamRodmanMD. I’m also on facebook at /BedsideRounds. All of our episodes can be found at www.bedside-rounds.org, on iTunes, Stitcher, or wherever fine podcasts are found. If you like the show, like us on iTunes — or even better, tell a friend!

All my sources are found on the website, but I’m most indebted to the work of Martin Pernick from University of Michigan, who wrote an excellent article called Back from the Grave: Recurring Controversies over Defining and Diagnosing Death in History.

And of course, as always while I am actually a doctor and I don’t just play one on the internet, this podcast is intended to be purely for entertainment and informational purposes, and should not be construed as medical advice. If you have any medical concerns, please see your primary care provider.

Bedside Rounds

Because medicine is awesome

Because medicine is awesome

Episode 20: Buried Alive

Sources

Music

Transcript