The Dead Ringer: Medicine, Poe, and the fear of premature burial

Christopher Dibble, BS  

University of North Carolina at Chapel Hill, NC, USA

Premature burial was a great cause for concern to both the public and medical profession throughout the 19th century. Writers such as Edgar Allan Poe stoked the fear with gruesome stories of burials and near-death experiences. This fear was not simply a product of literary sensationalism, but was also grounded in legitimate medical uncertainty. Medical training varied greatly in quality, and diagnostic equipment remained unreliable. Furthermore, death from infectious disease was common and burials were often expedited in the face of epidemics. The medical profession took premature burial very seriously. Many articles and books were published on the subject, societies were formed, and meetings were held throughout the world. Creative and often questionably effective ways of preventing premature burial were proposed, including safety coffins, waiting mortuaries, and a number of novel tests for death. As medical knowledge expanded in the early 20th century and more sensitive instruments were invented, the fear of premature burial faded from the public conscience. Yet some of the themes can be seen today in the debate over organ donation and life support.

 

Keywords: Premature burial, E. A. Poe, safety coffin, waiting mortuary, suspended animation

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Fear of premature burial in the 19th century

 “Scarcely, in truth, is a graveyard ever encroached upon, for any purpose, to any great extent, that skeletons are not found in postures which suggest the most fearful of suspicions.”  -Edgar Allan Poe, The Premature Burial, 1844 (Fig. 1). (1)

The fear of premature burial was a powerful force in both the public mind and medical literature of the nineteenth century.  Premature burial has a long historical record, but those living in the nineteenth century witnessed a unique combination of legitimate medical uncertainty and calculated literary sensationalism.  Premature burials likely did happen, largely because the medical profession lacked equipment and expertise to properly distinguish death from near-death  states. 

The etiology of epidemic diseases was unknown before physician John Snow’s epidemiology and physician Robert Koch’s bacteriology. (2) Prevailing theory held that leading killers such as cholera and yellow fever were transmitted by miasmas, or bad air. Thus, physicians often erred on the side of public health when disposing of bodies suspected to have perished from infectious disease. An 1834 article reflecting on the 1793 yellow fever epidemic in Philadelphia describes the sentiment at the time, “We have every reason to believe, that many persons, suffering with disease, were removed from their houses and interred before the vital spark had fled . . . The dying were taken with the dead, to avoid the trouble of a second visit; there was none to call them into account.” (3) Yet medicine was only part of the problem. Nineteenth-century writers, such as Edgar Allan Poe, capitalized on the fear of premature burial to sell their publications.  Novelists made their reputations exploiting the horror of the burial experience and newspapers eagerly recounted details from the most recent incidents. One example comes from a December 1838 article in the Sunday Times titled “Noises From the Tomb,” and describes “A frightful case of premature interment” recently occurring in France. (4)  As public awareness increased and hysteria escalated, the medical profession made a serious commitment to solving the problem of premature burials.  International conferences were held, journals were founded and macabre partnerships between medicine and industry were forged.

Medicine and medical training were in a poor state in the nineteenth century.  Incompetent or fraudulent physicians were the rule rather than the exception of pre-Flexner Report medicine and often no medical intervention was better than any at all. (5) Even in the twenty-first century, with full body scans and brain activity tests, the line between life and death remains murky. (6)  Without modern technology like electroencephalograms or electrocardiograms, nineteenth-century physicians had only their fingers to feel for a pulse and mirrors to check for condensed breath.  Correctly diagnosing death became more specific with the invention of the stethoscope in 1816, and subsequent improved iterations in 1852 and 1873. However, 19th century stethoscopes were significantly less sensitive than their modern counterparts.

Technological limitations were not the only factor contributing to the possibility of premature burial: deciding when life ended often relied upon physicians with little or no formal training. Even when appropriately trained physicians were involved, the medical field had limited understanding of neurological conditions such as epilepsy or coma that could explain apparent death. Thus it was a documented phenomenon that the “apparent dead” would recover as last rights were conducted or even at the funeral. (7)  Combined with physicans’ uncertainties, the frequent need to expedite burials to avoid infectious disease epidemics, and the lingering (and justified) fear of the medical establishment’s legacy of grave robbing, the public’s fear of premature burial was understandable.

Poe and premature burial

While physicians certainly shared the blame for the public’s fear of premature burial, this meme was also driven by print.  Newspapers contributed, but above all were literary figures of the time, most prominent among them being Edgar Allan Poe.  Many of Poe’s stories contain strong themes of premature burial, and offer significant insight to the psychology of the fear.  Medical themes are readily apparent, including a fear of being buried alive due to a variety of neurological phenomena, including coma, fainting, and seizure. His 1844 short story The Premature Burial is a good example, with Poe writing, “To be buried while alive is, beyond question, the most terrific of these extremes which has ever fallen to the lot of mere mortality. That it has frequently, very frequently, so fallen will scarcely be denied by those who think. The boundaries which divide Life from Death are at best shadowy and vague. Who shall say where the one ends, and where the other begins? We know that there are diseases in which occur total cessations of all the apparent functions of vitality, and yet in which these cessations are merely suspensions, properly so called.” (8)  Poe’s unnamed narrator describes in Gothic detail his increasing paranoia and excruciating fear of hasty or untimely burial.  The Premature Burial covers the archetypal points of the contemporary fear: the common occurrence of premature burials and falling into a trance while travelling (and thus away from friends that could help prevent the fate), culminating with a burial experience so horrifying that the narrator is finally shocked out of his fear forever.  In typical Poe fashion, the story is presented as a recollection of events that were neither confirmed nor denied until a certain number of magazine copies were sold.

While lacking such dead giveaway titles, many of Poe’s other works prominently feature premature burial.  In The Fall of the House of Usher, the plot revolves around Roderick Usher’s mental breakdown due to guilt that he prematurely buried his sister.  It turns out he is correct, and she breaks free from her tomb, ripping her fingernails and funerary garb in the process, and bursts into his bedroom during a supernatural storm. (9) 

In the lesser known Berenice, the protagonist Egaeus suffers from a psychiatric disorder that causes periods of mental separation from the physical world and the eponymous fiancée suffers from epilepsy or a similar disorder.  He fixates on her teeth, dreaming about inspecting them from all angles, until he is awakened from a reverie by a servant informing him that Berenice’s grave has been defiled. (10)  Egaeus realizes he has a bag of dentistry tools and a full set of human teeth in front of him.  It is suggested that she was prematurely buried, due to her affliction with a type of epilepsy causing her to fall into deep, almost catatonic states. (11)  Cataplexy, or a sudden and transient episode of loss of muscle tone, was a common theme in premature burial horror works and reflected the nineteenth-century belief that people who slept especially deeply or were prone to trances or seizures were at high risk for premature burial.

The theme of premature burial is also touched on in The Facts in the Case of M. Valdemar.  The narrator describes the “true” story of a man who was hypnotized as he died and was thus stuck between life and death. (12)  From a medical standpoint he had no vital signs, yet was not truly dead; a sure candidate for premature burial.  Poe suggests M. Valdemar is in “suspended animation,” a state blamed by many for premature burials.  Suspended animation is also featured in the satirical Some Words with a Mummy, as the narrator discusses the merits of modernity over cigars with an Egyptian who had been in suspended animation for thousands of years. (13)  Famously, The Cask of Amontillado features immurement, or murder by burial, as the slighted Montresor walls his provocateur Fortunato into his family catacomb. (14) Finally, many other lesser-known Poe works feature themes of premature burial, including Morella (1835), Ligeia (1838), and Eleonora (1842).

It is unclear how much Poe was influenced by historical reports of premature burial and how much of the horror was his original idea.  The Premature Burial plays exquisitely on popular fear, yet as a man of the times it is likely that Poe’s environment imparted some personal fear of premature burial.  Regardless, he was not alone in incorporating themes of premature burial into his works to heighten the horror.  And it was not just pulp fiction that contributed to and profited from the public fear of burial: newspapers sold many copies describing first or secondhand accounts of premature burials, with headlines such as “Died in His Coffin” and “Case of Burial Alive.” (15)

Medicine and premature burial

While the press and the Gothic genre could be accused of sensationalism, historical records from the medical profession indicate that premature burial was a legitimate problem.  An 1877 case report in the British Medical Journal described an unfortunate woman’s experience in Naples, “a case not likely to inspire confidence in the minds of those who look forward with horror to the possibility of being buried alive.” The prosecutor presented evidence that “A woman was interred with all the usual formalities, it being believed that she was dead, while she was only in a trance.  Some days afterwards, when the grave in which she had been placed was opened for the reception of another body, it was found that the clothes which covered the unfortunate woman were torn to pieces, and that she had even broken her limbs in attempting to extricate herself from the living tomb.” (16) The judge found the doctor who had signed the death certificate and the mayor who had authorized the interment guilty for involuntary manslaughter and sentenced each to three months imprisonment

While a significant element of the medical profession remained skeptical about the possibility of premature burial (an editorial in the British Medical Journal termed it “hysterical nonsense”), for many nineteenth-century physicians the issue was how often premature burials occurred, not whether or not they occurred. (17)  The Doctor Regent of the Faculty of Medicine in Paris, wrote in 1819 that, “One third, or perhaps half of those, who die in their beds, are not actually dead, when they are buried.” (18)  He went on to clarify that not all of the prematurely buried would have recovered, but that sometimes death took longer than the medical profession believed.  Later in the century, an influential book Premature Burial, and How it May be Prevented by William Tebb, the co-Founder of the London Association for the Prevention of Premature Burial, estimated that in 1895, “Two thousand seven hundred persons at least, in England and Wales, are yearly consigned to a living death, the most horrible conceivable.” (19)  Nearly one hundred pages from the book meticulously describe confirmed cases of premature burial, with chapter titles such as “A Remarkable Case of Stupor”, “A Physician’s Personal Experience”, “The Death Trance”, and “Fatal Mistakes.” (20)

Tebb was a controversial figure. Although he did not have a medical degree, many physicians were members of his organization, and an army Colonel M.D. co-authored subsequent versions of Premature Burial.  His effectiveness stemmed from his meticulousness, skill in public relations, and an unquestionable enthusiasm for the issue. Critics labeled his organization as alarmist, and not fact-based. (21) Yet Tebb was adept at marshalling his own experts and perhaps more importantly, disseminating his message throughout society, rather than limiting himself to medical journals.

Many in the medical profession agreed that premature burial was a serious problem and thus great attention was given to its prevention.  In 1897, an international conference was held in Italy, with the New York Times writing, “Prominent physicians and laymen are at present busily engaged in preparing an exhaustive report, with exhibits, on the subject of apparent death and premature burial . . . there will be an international competition and a prize will be awarded for the best work on the solution of a problem in which not only professional, but, more or less, every mortal is interested.” (22) The result of so much scrutiny from different disciplines and nationalities led to the development of different schools of thought on preventing premature burial.

One solution was to err on the side of caution in declaring death.  In Tebb’s Premature Burial and How It May Be Prevented, he supported the suggestions of a leading Prussian physician, who noted, “One cannot be too careful in deciding as to life and death, therefore I always advise a delay of the funeral as long as possible, so as to make all certain as to death.” (23)  Specific suggestions are then offered, including “The dead should not be buried before the fourth day; we even have examples to prove that.  Eight days or a fortnight is too soon, as there have been revivals as late as that.  I say everyone should respect those who only seem to be dead.  They should be treated gently, and kept in a warm bed for thirty-six hours.”  The physician goes on to describe the horror of premature burial, and Poe may as well be the narrator, “No wonder those who are buried alive, and who undergo indescribable torture, condemn those who have been dearest to them in life.  They will have to undergo slow suffocation, in furious despair, while scratching their flesh to pieces, biting their tongues, and smashing their heads against the narrow houses that confine them, and calling to their best friends, and cursing them as murderers.”  (24)

Technical and medical remedies

A more formalized approach to the “wait and watch” philosophy was the invention of “Waiting Mortuary” (Fig. 2).  Conceived of in 1787 by the Frenchman François Thiérry, these institutes were known as “hospitals for the dead” in which the recently deceased would be watched day and night for signs of revival or putrefaction. (25) Food, drink, and even cigars were on hand for any awakenings.  This phenomenon was no joke: a dozen of these institutes were constructed at great cost between 1790 and 1830. (26)  Germany (Prussia/German Confederation/German Empire) was the leader in constructing these Waiting Mortuaries, followed by France.  Some Waiting Mortuaries were constructed with public money, others operated by subscription (27). Given the low frequency of success, the cost, and sanitation issues, waiting mortuaries fell out of favor as a less centralized method came into use: the safety coffin.


Figure 2 Plans for a Waiting Mortuary.  (A) exterior. (B) Interior. Note private and group “attendance rooms.” (C) Private room. Strings are tied to the corpses’ fingers and are connected to a bell, which they will ring upon movement. (21)

While designs varied, the basic concept of a safety coffin was to provide some means of escape for the wrongly buried. Physicians, inventors and businessmen patented over thirty designs in Germany between 1855 and 1899 and twenty-two in America between 1868 and 1925 (Fig. 3). (28)  Safety coffins ranged from simple designs – ropes tied to a corpse’s hands that ran to an above-ground bell – to extremely complex – vibration sensors attached to mechanical contraptions that would light a candle, ring a bell, and open a periscope, with some models even featuring a telephone with a direct line to the cemetery-keeper. (29)  And these were just for below ground burials. Vault options bore resemblance to ancient Egyptian customs, with all of the aforementioned plus liquor cabinets and meals for the recently recovered deceased.

Figure 3 Inventors respond to premature burial. (A) Patented Safety coffin, 1868. (B) Another coffin patent, 1904. (C) Early 20th century burial vault. Note exit mechanism is on the inside. (25)

The most successful of the safety coffin inventors was Count Michel de Karnice-Karnicki. The Count was a Russian nobleman who claimed to have had a revelation after witnessing the premature burial of a young girl. (30)  After several years of work and fundraising, the Count presented his design to an audience of leading physicians and politicians at the Sorbonne in 1897. (31)  The demonstration was a success and secured important medical society endorsements.  One of his principle improvements from standard safety coffins was that putrefying gases were prevented from communicating to the outside world by an adjustable hatch, a feature the Count understandably added after a visit to one of the German waiting mortuaries.  By the time of his death, the Count’s device had become one of the most trusted methods for preventing premature burial. (32) Due to cost, they were largely a middle or upper class phenomenon, although drawing the interest of all of society.  Interest in safety coffins peaked in the late nineteenth and early twentieth centuries, although certain elements of their design continue even today. 

While safety coffins could help in the event of a premature burial, they did nothing to address the underlying problem: imperfect methods for determining death.  One answer to this quandary, exemplified by the waiting mortuaries, was to define putrefaction as the only true sign of death; however, this approach suffered from a lack of sensitivity, leading to needless storage of corpses and increased risk of contagion.  Many other approaches for detecting “false death” were tried, including putting pungent chemicals in the nose, cutting off fingers, rubbing the groin with prickly bushes, placing stinging insects in the ear, playing bugles next to the ear, and rectal challenge with a hot poker. (33)  An alternative approach derived from growing confidence in power of medical science to restore life.  Many techniques were put forward, including rhythmic tongue pulling, tobacco smoke enemas, and chest compressions. (34) While tongue pulling was never fully accepted by the medical community, tobacco smoke enemas were one of the most popular ways to resuscitate the “apparent dead” (Fig. 4).

Physicians were not the only ones concerned with premature burials; legislative bodies tackled the problem as well.  In New York State in 1899, Senator Reddington introduced a bill for prevention of premature burial. It read, “No body shall be received unless a statement on the part of an attending physician or coroner, whether he has found the following signs of death or not, is with it: First- Permanent cessation of respiration and circulation.  Second- Purple discoloration of the dependent parts of the body.  Third- Appearance of blistering around a part of the skin touched with a red hot iron.  Fourth- The characteristic stiffness known as rigor mortis.  Fifth- signs of decomposition.” (35) This bill essentially followed precautions advocated by William Tebb and other anti-premature burialists over the last century.  Often legislative action was at the behest of well-organized interest groups such as Tebb’s Association for the Prevention of Premature Burial.  While these organizations are a thing of the past, the fear of premature burial is alive and well in society today.


Figure 4 Methods for reviving the “apparent dead.” (A) Rhythmic contractions of the tongue to resuscitate a drowning victim. (B) Administration of a tobacco smoke enema. (34) 

Premature burial today

Premature burial in the nineteenth century was a major medical and social issue.  The medical profession grappled with ways to prevent its occurrence, inventors made fortunes patenting technological fixes to the problem, and writers popularized their works by playing on the public’s fear.

Yet fear of premature burial is not completely a thing of the past. William Tebb and the Society Against Premature Burial would certainly approve of a review in the August 1996 edition of the Journal of the American Academy of Pediatrics featuring a device for “risk-free burial.”  It reads, “In Italy, Tuscan watchmaker Fabrizio Caselli introduced a special coffin for people who fear they will be buried prematurely.  The $4,500 casket is equipped with a two-way microphone-speaker, a flashlight, a small oxygen tank, a heart stimulator, and a beeper to alert an above-ground monitoring station.” (36)

Poe would have plenty of fodder for modern medical horror today.  ICU physicians deal with M. Valdemars on a daily basis, and Egaeus, the protagonist from Berenice, might think tooth harvesting a minor horror compared to modern-day organ procurement.  There are certainly similarities between the prose in The Premature Burial and accounts of people awakening from comas or states of unconsciousness.  Modern life support and medically induced comas result in states that could be likened to suspended animation, trances, and cataplexy.  We like to think that modern technology prevents mistakes that may have happened in the nineteenth century, but is likely that history will judge twenty-first-century medical beliefs not much differently than some judge nineteenth-century physicians today.  Sensitivity and specificity of detecting death have improved, but the lines remain blurred in situations like brain death or comas.  When these patients are disconnected from life support, is this a form of premature burial?  Without doubt, if premature burials happen today, they are extremely rare. Yet, as anti-premature burial activists argued several centuries ago, the line between life and death is imprecise, and perhaps still beyond exact definition by our technology.

 Chris Dibble is a 4th year MD-PhD student at the University of North Carolina at Chapel Hill. He can be reached for comment at cdibble@med.unc.edu

References. 

1. Poe, Edgar Allan. The Premature Burial. Broadway Journal. 1845; 1:369-373.

2. John Snow showed in 1854 that a London cholera outbreak was spread through water, and Robert Koch published 3 postulates about the role of microbiological agents in causing disease in 1890.

3. Burying Alive. The Casket. 1834; 9:379.

4. Noises from the Tomb. The Sunday Times. 1838 Dec 30;16.

5. Published in 1910 by Abraham Flexner and the Carnegie Foundation, the Flexner Report called on American medical schools to enact higher standards.

6. see: Lock, Margaret. Twice Dead: Organ Transplants and the Reinvention of Death. Berkeley (CA): University of California press; 2002.

7. Behlmer, George. Grave Doubts: Victorian Medicine, Moral Panic, and the Signs of Death. Journal of British Studies. 2003; 42:206-235.

8. Poe, Edgar Allan. The Premature Burial. p. 370.

9. Poe, Edgar Allan. The Fall of the House of Usher. Tales of the Grotesque and Arabesque­. 1840; 1:75-103.

10. Poe, Edgar Allan. Berenice. Southern Literary Messenger. 1835; 1:333-336.

11. Brown, Arthur. Literature and the Impossibility of Death: Poe’s ‘Berenice.’ Nineteenth-Century Literature. 1996; 50:448-463. Dayan, Joan. The Identity of Berenice, Poe’s Idol of the Mind. Studies in Romanticism. 1984; 23: 491-513.

12. Poe, Edgar Allan. The Facts in the Case of M. Valdemar. Broadway Journal. 1845; 2:365-368.

13. Poe, Edgar Allan. Some Words with a Mummy. American Review. 1845; 1:363-370.

14. Poe, Edgar Allan. The Cask of Amontillado. Godey’s Lady’s Book. 1846; 33:216-218.

15. Some representative headlines: Against Premature Burial: Italian Doctors to Decide How to Prove Apparent from Real Death. New York Times. 1897 Sept 26;8. Buried Alive. New York Times. 1889 Nov 24;11. Died in His Coffin. New York Times. Lord Burton’s Odd Will: Ordered Spine Cut and Heart Taken Out to Prevent Premature Burial. 1909 Mar 21;3. Premature Burial in France. New York Times. 1887 Aug 27;3. 1887 Jan 23;5. Reported Premature Burial. New York Times. 1877 Aug 18;8.

16. Adams, Norman. Buried Alive. The British Medical Journal. 1877; 2:819.

17. Premature Burial. British Medical Journal. 1904; 1:2250.

18. Whiter, Walter. A Dissertation on the Disorder of Death. Cambridge (MA): Brighton and Son; 1819. p. 362.

19. Tebb, William, Vollum, Edward. Premature Burial and How It May Be Prevented: With special reference to trance, catalepsy, and other forms of suspended animation. London: S. Sonnenschein; 1896. p. 263.

20. Tebb. Premature Burial. p. 262.

21 Premature Burial (Reviews). The British Medical Journal. 1896; 1:1835.

22. Against Premature Burial: Italian Doctors to Decide How to Prove Real from Apparent Death. New York Times. 1897; Sept 26.

23. Tebb. Premature Burial. p. 262.

24. Tebb. Premature Burial. p. 263.

25. Gaubert, B. Les Chambres mortuaries d’attente, devant l’histoire, la legislation, la science, l’hygiène et le culte des morts: Le péril des inhumations précipiteés en France. Paris, 1895. p. 251-3. (French)

26. Knowles, James (editor). “Premature Burial.” The Nineteenth Century and After. London: Spottiswood and Company; 1907. p. 558. 

27. The Nineteenth Century and After. p. 557.

28. Crosby, Edwin, Henry, Ell, inventors. Apparatus for signaling from graves. United States patent 766171. August 2, 1904; Vester, Franz, inventor. Improved Burial Case. United States patent 81,437. August 25, 1868;

 Windsor, H. H. (editor). Odd Family Vault Prevents Premature Burial. Popular Mechanics Magazine. 1921; 36:47-48.

29. Possibly the origin of the phrase “dead ringer.”

30. Behlmer, George. Grave Doubts. p. 210.

31. Santa de Pietra, M., Joltrain, P., Monin, P. (editors). La Mort Reélle et la Mort Apparente. Journal d’Hygiène, 1897; 22:104-108. (French)

32. Santa de Pietra, M., Joltrain, P., Monin, P. (editors). La Mort Reélle et la Mort Apparente. Journal d’Hygiène, 1897; 22:104-108. (French)

33. Tebb and Vollum. Premature Burial. p. 215.

34. Laborde, Jean B. Tractions Rhythmeés de la Langue: Moyen rationnel et puissant de ranimer la function respiratoire et la vie. Paris, Germer Baillière; 1894; Lawrence, Ghislaine. Tobacco smoke enemas. The Lancet. 2002; 9315:1442.

35. To Stop Premature Burial. New York Times. January 18th, 1899.

36. Rosenberg, Mark. “Risk-Free Burial.” Pediatrics. 1996; 98:960.

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