Judith N. Wagner, MD
Klinikum Grosshadern, LMU München, Germany
|Figure 1. A pointing bone used for voodoo spells.|
“Their medicine men have tremendous power over them: if they doom one of them to die, the unfortunate will accept his fate, isolate himself from his family and pass away within a short time.” I vividly remember the octogenarian, fragile but lively lady occupying the seat beside me on a flight from Windhoek, Namibia, back to Frankfurt. She had emigrated from Germany at a young age to spend her life running a farm in Angola. During the long hours of the flight, she related the details of her eventful life, especially those concerning the customs and habits of the local people. I filed away this particular story about “death by voodoo” as an elderly woman’s fairytale without attributing too much importance to it (Figure 1).
A couple of months later I was reminded of this incident. While working on a palliative care ward, I met a patient suffering from pancreatic cancer with liver metastases. In spite of his serious disease, the man was in a relatively good physical state, still able to walk and care for himself. He was admitted to the ward to optimize his pain medication. However, with every day that passed he became more bed-ridden and less responsive, finally dying peacefully four days after admission. After his unexpected death, his wife—even more unforeseeably—told me that the moment he had set foot on our ward, her husband had confided to her: “This is the place where I want to die.”
This experience led me to reconsider my perception of the voodoo tale: does something like “self-willed death” exist? Can a person or situation exert that strong a nocebo effect to actually terminate a human being’s life? Is there such a thing as “death by voodoo?” In the ensuing paragraphs, I will review the relevant literature—anthropological observations and medical reports alike - to investigate the existence of a “voodoo syndrome” and its possible causes.
For his groundbreaking review on voodoo death, Walter Cannon - one of the leading physiologists of his time and specialized in the physiology of human emotions—collected reports he considered trustworthy on hex death occurring in tribes of South America, Africa, Australia, New Zealand, the islands of the Pacific, and Haiti.1 Cannon summarizes that those convinced to be befallen by such a hex will “pine away; his (the victim’s) strength runs out like water; and in the course of a day or two he succumbs,” unless the spell can be reverted. As an example, Cannon relates a report received by Dr. S. M. Lambert of the Western Pacific Health Service, working with a mission in North Queensland, Australia. On one occasion, Dr. Lambert is called to the mission to examine Rob—a converted native and the missionary’s helper—whom he finds in a dire state of health. “From the missionary he (Dr. Lambert) learned that Rob has had a bone pointed at him by Nebo (a “witch doctor”) and was convinced that in consequence he must die. Thereupon Dr. Lambert and the missionary went to Nebo, threatening him that his supply of food would be shut off if anything happened to Rob and that he and his people would be driven away from the Mission. At once Nebo agreed to go with them to see Rob. He leaned over Rob’s bed and told the sick man that it was all a mistake, a mere joke—indeed, and that he had not pointed a bone at him at all. The relief, Dr. Lambert testifies, was almost instantaneous; that evening Rob was back at work, quite happy again, and in full possession of his physical strength” (Figure 2).
|Figure 2. A medicine man of the Igbo tribe, an African ethnic group in Nigeria.|
Various such reports exist on voodoo death in tribal and indigenous societies.2 But even within Western societies, niches prevail where voodoo rituals still hold strong. Meador reports on an African American patient hailing from a small US town who was admitted to the local hospital in the early 1960s. He showed signs of “being bewitched” by the community’s powerful voodoo priest, and could only be cured by a “counterhex” performed by the canny physician in charge. Based on his extensive review on this and similar occurrences, Meador formulates three essential elements which have to be fulfilled in order for a death hex to come into effect:
(1) The victim, all acquaintances, and family members must accept the ability and power of the witch doctor to induce death by hexing….
(2) All known previous victims of hexing must have died; no one should have been known to survive a hexing, unless the hex had been removed by the same, or another, witch doctor.
(3) Everyone known to the victim, especially family and friends, must believe the victim will die and act on that belief. The friends and relatives usually perform a death dance and then leave the victim utterly and completely alone3
Hence, the strong conviction of the effectiveness of the hex on the part of the victim and his significant others is essential for the magic to work.
Does the relevance of “voodoo” extend solely to tribal/indigenous societies and isolated communities still pursuing such a lifestyle within the Western world? One of the cases Meador presents in his paper on hex death suggests otherwise. A patient with a contemporary US-American “non-voodoo” background had been diagnosed with oesophageal cancer. The technical investigations available at that time (1973; nuclear liver scan) had suggested extensive metastatic liver involvement. The patient, informed of the unfavorable prognosis, strongly wished to spend Christmas with his family one more time. He was discharged from hospital and did remarkably well up to the holidays. Afterwards he was readmitted to the ward, where he deteriorated rapidly and died within 24 hours. Autopsy revealed a small (2 cm) cancerous nodule in his liver and slight bronchopneumonia. No other signs of local neoplasia or metastasis were found—the liver scan had rendered a false positive result.
Meador concludes that in this patient all the above mentioned elements required for a hex death were present: the patient himself, his wife, and all the physicians treating him were informed of the diagnosis and its dire prognosis, they firmly believed the patient to be faced with a palliative situation and acted accordingly.
Apart from these individual cases, population-based evidence demonstrates increased mortality in times of emotional upheaval—be it positive or negative—revealing the decisive role of the psyche in matters of life and death. Engel reports eight categories of life events associated with an increased death toll:  the impact of the collapse or death of a close person;  during acute grief;  on threat of loss of a close person;  during mourning or on an anniversary;  on loss of status or self-esteem;  personal danger or threat of injury;  after the danger is over;  reunion, triumph, or happy ending.4
Tragic events—and in particular the death of a spouse—seem to have a particularly important impact: according to Rees et al, the death of a close relative increases the risk of dying within one year by a factor of seven.5 As the politician and poet Sir Henry Wotton (1568 - 1639) laconically phrased it in an epigram on the death of the widow of his fellow diplomat Albert Morton:
He first deceased; she for a little tried
To live without him; liked it not, and died.5
But even joyous occasions may prove disastrous for longevity: three of the first five US Presidents died on a 4th of July, the date of the American Independence.
What is the possible mechanism behind the association of emotional commotion and increased mortality? Or—as generations of philosophers have pondered—where is the interface of the psyche and the physical, of the ethereal soul and the material body?
|Figure 3. Left: A ventriculogram showing apical ballooning in Takotsubo syndrome.
Right: The eponymous traditional takotsubo jug.
Walter Cannon postulated a persistent hyperactive state of the sympatico-adrenal system causing a contraction of the arterioles, which—combined with reduced intake of food and water—leads to protracted hypotension with subsequent hypoxic damage to the heart and other vital organs. Although seeming somewhat oversimplified, this assumption may point into the right direction. Wittstein et al have described several types of cardiac alterations occurring after acute stressful events in patients even without coronary disease. These changes include ECG abnormalities such as T-wave inversions and a prolonged QT interval, as well as increased troponin I, myofibrillary degeneration (a specific structural alteration of the myocardiocytes including contraction of the cells and mononuclear infiltration), and Takotsubo cardiomyopathy.6 The latter denominates a left ventricular systolic dysfunction presenting as wall-motion anomaly associated with normal myocardial perfusion and abnormal sympathetic innervation7. Its name stems from a traditional Japanese jug used to trap squids. This receptacle resembles the apical ballooning of the left ventricle found in Takotsubo syndrome (Figure 3). The same changes have been found in dogs after intracoronary infusion of catecholamines and after induction of stress in rats after previous sensibilization to adrenalin effects by cortisol.8,9 Furthermore, they are also present in animals with artificial cerebral lesions and in patients suffering from cerebral injuries, particularly those involving the limbic system.10-14 Hence, the heart-rending chain of events in stress-induced death may be the following: stress affects the limbic cortex, which in turn stimulates intramyocardial secretion of catecholamines via hypothalamic projections. The hyperadrenergic state causes microvascular dysfunction and increased cellular calcium intake, leading to myofibrillary degeneration. These cardiomyocytic alterations may be the origin of fatal arrhythmias and cardiogenic shock.
Although this model can plausibly explain the causal relationship between an external stress factor and the ensuing death of the individual, its endpoint of cardiac arrhythmia or cardiogenic shock would call forth corresponding clinical signs and symptoms. So what about our patient suffering from pancreatic cancer? Rather than succumbing to a sudden cardiac death, his case resembles the evolution described by Milton in a subgroup of patients on learning that they suffer from fatal disease:
The patient, when first confronted with the problem of his malignant disease appears to disregard it and be extraordinarily cheerful … Overnight the patient’s whole manner changes and he is physically and mentally transformed. He literally turns his face to the wall and lies inert in bed … He does not seem to be terrified but … shows bland indifference. Within a month of the onset of his syndrome the patient will almost certainly be dead. If a necropsy is carried out … there will often appear to be no adequate explanation for the cause of death.15
These cases have been termed “self-willed death” or “given-up-giving-up complex” in literature.15,16 Whether they occur against the backdrop of a tribal culture with its ancient voodoo rites or in the context of contemporary Western medicine—they constitute fascinating epitomes of the power of the mind and still elude sufficient scientific explanatory models.
- Cannon WB., "Voodoo death.” Am J Public Health. 2002; 92:1593-1596.
- Elkins AP. The Australian Aborigines, Sydney.1968: 311.
- Meador CK. “Hex Death: Voodoo Magic or Persuasion?” Southern Medical Journal. 1992;85:244-247.
- Engel GL. “Sudden and rapid death during psychological stress. Folklore or folk wisdom?“ Ann Intern Med. 1971;74 :771-782.
- Rees WD, Lutkins SG. “Mortality of Bereavement.” British Medical Journal 1967;4:13-16.
- Wittstein IS, Thiemann DR, Lima JA, Baughman KL, Schulman SP, Gerstenblith G, Wu KC, Rade J J, Bivalacqua TJ, Champion HC. “Neurohumoral features of myocardial stunning due to sudden emotional stress.” N Engl J Med. 2005;352:539-548.
- Banki NM, Kopelnik A, Dae MW, Miss J, Tung P, Lawton MT, Drew BJ, Foster E, Smith W, Parmley WW, Zaroff JG. “Acute neurocardiogenic injury after subarachnoid hemorrhage.“ Circulation 2005;112 :3314-3319.
- Barger AC, Herd JA, Liebowitz MR. “Chronic catheterization of coronary artery: induction of ECG pattern of myocardial ischemia by intracoronary epinephrine.“ Proc Soc Exp Biol Med. 1961;107 :474-477.
- Raab W, Stark E, Macmillan WH, Gigee WR. “Sympathogenic origin and antiadrenergic prevention of stress-induced myocardial lesions.” Am J Cardiol. 1961;8:203-211.
- Melville, K. I., Blum, B., Shister, H. E., Silver, M. D. “Cardiac ischemic changes and arrhythmias induced by hypothalamic stimulation”. Am J Cardiol. 1963;12:781-791.
- Porter RW, Kamikawa K, Greenhoot JH. „Persistent electrocardiographic abnormalities experimentally induced by stimulation of the brain.“ Am Heart J. 1962;64:815-819.
- Connor RC. “Myocardial damage secondary to brain lesions.” Am Heart J. 1969;78:145-148.
- Jacob WA, Van Bogaert A, De Groodt-Lasseel MH. “Myocardial ultrastructure and haemodynamic reactions during experimental subarachnoid haemorrhage.“ J Mol Cell Cardiol. 1972;4:287-298.
- Ay H, Koroshetz WJ, Benner T, Vangel MG., Melinosky C, Arsava E M, Ayata C, Zhu M, Schwamm L H, Sorensen AG.” Neuroanatomic correlates of stroke-related myocardial injury.” Neurology 2006;66:1325-1329.
- Milton G W, “Self-willed death or the bone-pointing syndrome.” The Lancet 1973:1435-1436.
- Engel, G L, “A psychological setting of somatic disease: the `giving up - given up' complex.” Proc R Soc Med. 1967:553-555.
JUDITH N. WAGNER, MD, graduated from Freiburg University in 2004 after studying in Freiburg (GER), London (GB), Mendoza (ARG) and Boston (USA). From January 2005 to January 2014 she has been working in the Department of Neurology, Klinikum Grosshadern, University of Munich, Germany. Currently, she is completing a psychiatry rotation with the Max Planck Institute for Psychiatry in Munich.