TM Bzrnm 1 49490 xmmLOKAISDElommmi s~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~SrDDEN ADUEPCEAND UNEXPECTED DEATHS.ETS (FimB. :.299 ige. further study of the subject, to greater accuracy In posW.- morten work, and so to less conflict of medical evidenoe in cVu dibrezO criminal trigls; ON It is desirable, however, that the work and opinions of such examiner should not lead to any neglect in obtaining SUDDEN AND UNEXPECTED DEATHS. the evidence of any medical practitioner who has been In attendance upon a deceased person, or present at his death, DELIVEIRED BEFORE THE ST. PANCRAS AND ,SLINGTON or calledin after death, because my experience makes me DIVISION OF THE BRITISH MEDICAL ASSOCIATION, yearly more and more confident that the simultaneous By WM. WYNN WESTCOTT, M.B., consideration of both these evidences can alone obviate H.M. CORONER FOR NORTH-EAST erroneous conclusions, which may lead to most serious mistakes. Some recent attempts to supplant the medical I HAvE found great difficulty in selecting practitioner In forensic duties by a specialist have led to tamiliar to myself and likely to be of interest unfortunate results, due to the loss by medical men not in member of this Dilvision of the British Medical Associa- affluent circumstances of a source of income they have so

tion. As, however, the majority of you are long enjoyed. It is, then, desirable, that any further medical practitioners, the sudden death of delegation-of poetnmortem work to special medical officers must always be a matter of concern should be authorized and regulated by new legislation, the reason for its occurrence a fitting subject and not undertaken' by any Individual public official, Investigation. however well-intentioned. As a coroner, my professional duty lies In the very proper desire to obtain accurate results there

to solve the problem of the causes of in has been for many years what I conceive to have been an

reported case, by means of general evidence exaggerated view of the importance of legal poet-morten

relatives and casual friends as well as examinationsin cases of sudden and violent deaths. The

observed by those present at or near the medicalprofe3sionappearstohavetaught the publicthatbya The Investigationis much simplifiedif of po8t-mortem examination alone could the causeaf any death a medical man conversant with the constitution of be ascertained, and that if an autopsy was made the cause of deceased person is available, and this is of still death was at once apparent. Unfortunately this viewis

greater valueif there has been attendance deceased not In accordance with the facts, for In very many cases for ailments of recent date. However theP08t-mortem appearances will only show the presence may appear to be in any case,itis probable of so much disease or Injury as would render death a has been, perhaps long pre-existent probable event fromits existence. Or it may show so cognized, and quiteunknnown to any observer, flaw much disease orinjury as would certainly lead to deathin In the structure and In the action of the immediate future. It is In only a minority of cases organs. We all know we must die some that such a lesion is found as is incompatible with con- very different views of the best course In tinued life. In considering the diseases andinjuries conduct towards the coming change. Some persons to which man Is liable, Itis almost impossible to say careless, others are living daily in nervous whatcircumstances must be fatal. Take, for example,

Some believe, and no doubt wisely, that the less allows what loss of blood isimposstble to be sustained; no one

the mind to think of illness and death the can state the amount, or even the proportion of the total one's Insight and outlook remain. OR blood In the body. How much brain injury must kill, it

there are many who have convinced themselves Is is vain to make any estimate; large areas may be ren-

only by constant attention to the mode life-to diet, dered uselees by softening or haemorrhage without causing

exereise, and regimen-that prolonged antici- a sudden death; whereas a puncturein the floor of the pated. Some bear in silence and gloom haunting fourth ventricle, orin a small area of the medulla of Infection and ultimate "cold gradations oblongata may causeinstant death. Some personsdie while others run about seeking advice medical suddenly from an angina pectoris, which the mere science or from quackery, In the belief valvular lesion in the heart may alone be found to explain. ingestion of drugs alone can health A man may die of a mere pinch of a healthy testicle, while Some people are haunted by fear of disease coming another may last for years with a cancerous tumour of the through an hereditary taint; others put testis, which may kill only by slow exhaustion. There In the knowledge of being descended from are hundreds of deaths from syncope or exertion, which lived ancestors. In the smallest community family cannot be explained by any cardiac or arterial lesion of circle even, we mayobserve almost every possible instantaneouso occurrence. Epilepsy, again, causes many tude of mind toward the approach of man's inevitable sudden deaths, and leaves no gross lesion In any organ by destiny. which it can be recognized, and the occurrence of a fit

In the endeavour to account for a sudden death, cannot be proved In the absence of evidence of the events the items of evidence already referred of the hours before the death oecurred. monly thought that the results of a poet. mortem examina- By the interdependent healthy action of the brain, the

tion may be relied upon to explain the causwe heart, and the lungs, life is maintained, said the great death.' In our cities and towns such Is French physiologist Bichat, and he added that death now made In almost all cases; but in country districts It begins at either the heart, lungs, or brain; 'this Is no is frequently neglected. It must be doubt true, especially when we refer to the appearances value of a poet-mortem examination seen at the hour of' death, but we are now in search of a depend upon the skill and experience more exact answer to the question, Why did this person In this country the local medical practitioner has die P known the deceased, the doctor who most We desire a definite answer for several reasons. First, recently, or the doctor who was called In for personal and family satisfaction, and In regard to life almost Invariably been chosen to make examination Insurance; secondly, for legal reasons, so as to be assured for legal purposes. On the Continent, that no person Is to be blamed for the death; thirdly, In In Scotand, this work Is entrusted order to secure accuracy In death registration; and, expert appointed by the judicial authorities lastly, to gAide survivors and their medical advisers In Such a doctor, having all the sudden their efforts to preserve the lives of other persons in the of the district brought to his personal community.

soon become more able to reason correctly pos- There have been several definitions of a sudden death, mortem appearances than a private medical practitioner but it is not now my purpose to attempt any definition of who Is only called upon to investigate sudden the term, but rather to refer in general to such deaths as death as an exceptional incident. Again, It occur with little or no warning-, or are -preceded by no desrable that a doctor In geueal In midwifery such symptoms as have led to any anticipation of a fata prattise should -be occupied with poet-morte work. issue at the time when it occured.Dea1 i following Renee -we may observe a growing tendency -employ external wounds and injuries are not within the 'present upecialitsinmmorbid pathology to investigate the causies view. isIt ficult matter to offer -any classificationof of death.. is hoped hat the creation, of a, new public sudden deaths, either by means of the organ affected or and offi cer-a edical forme ei exaLmn er-.d w lead by symptoms preeediag death,i so t is proposedo tocefe r Tim Bitnm FinA., 29, 190g8.] SUDDEN AND UNEXPECTED DEATHS. LMNDIcAL Jou3rAI , 49g1

a to several groups of cases whichoome prominently before greatly excited by exertion orin very hot weather, and a the coroner's notice. heavy meal of solid food In old people may lead to a fatal Many fewer Inquests uponcases of sudden death ae fainting. held In oauntry districts than in London; first, because Syncope may also occur from sudden changes of so manyooroners will not hold inquests unlees there is pressure on the blood-vessels, such as occurs from- the some suspicion of foul play, and also becauee country tapping of a dropsy of the abdomen, or a pleuritic effasion, doctors are much more ready than London practttioners in or the quick emptying by a catheter of a greatJy over- poor neighbourhoods to offer a certificate of the cause of filled urinary bladder. death, basedupDn presumptton andhearsay, In the Sudden syncope is not uncommon after severe burns; in absence of observation during medical attendance. This thesecases we often find peritonitis from Inflammation laxtty of practice robs death registration ofits accuracy, and perforation of the duodenum. and may occasionally enshroud active criminality,as well Simple fatty degeneration of the heart muscle is the as negligence amounting to misdemeanour. only lesion foundin some cases of fatal syncope in From a tabulation of inquests held by me I have found delicate persons, whether obese or emaciated. Victims of that the chief factorin sudden deaths has been cardiac chronic alcoholism are extremely likely to die suddenly 60 per cent., cerebral 30 per cent., and pulmonary 10 per from a syncope; and this occurs during attacks of cent., so far as obvious symptoms and gross organic delirium tremens and also durlig the periods of exhaus- lesions can show, but such classificationis not very tion withnausea which follows drinking bouts, as well as definite, as cases- oocur in which It becomes uncertainin in the late and well-recognized stages of debility from whichoategory to place a death; forinstance,it a man liver and kidney disorganization which close the lives of die of syncope, exhaustion, haemoptysis, and phthisis, many drunkards. In such casey a post-morten view sh6ws the death may be put down to cardiac or to pulmonary only a pale and flabby state of the cardiac muscles, with disease. some dilatation of the cavities. SYNCOPE FROM HAEMORRHAGE, ETC. A calcul'tion made by me in 1891 of 1,000inquests Sudden deaths from syncope are marked by loss of sense showed 210 verdicts of death from syncope; of these' and motion accompanied by pallor and sighing, fading there was evidence of alcoholic excessin47 cases. Of respiration. 77 cases of fatty degeneration of the cardiac muscle there External bleeding is an obvious cause, and so is internal were 33 chronic inebriates. bleeding appearing externally, as is seenin the haemo- Sudden heart failure Is well known to have been due to ptysis of phthisis, the haematemesis of ulcer and cancer mentalimpressionE-such as fright, terror, and emotion- of the stomach, and of alcoholic gastritis; also of acute acting on a heart of feeble muscular structure, one congestion of the liver; then there Is the haemoptysts of affected by fatty degeneration or disordered Innervation. aneuryamal raptures of the thoracic blood vessels, and of The occurrence of a sudden pain of great violence, as some cardiac valvular lesions, notably of mitral stenosis. from operations, tooth extraction, or the passage of gall The bleeding of pulmonary apoplexy may also be shown stones, of renal calculi, etc., and from sudden blows on by bloody expectoratton. A few persons die of syncope the testie, epigastrium, belly, or chest, may produce a from epistaxis, and a few also from the rupture of varicose suddenly fatal iesue. Certain poisons, of course, cause a veins of the legs and vulva, although the pressure of a sudden fatal syncope, such as aconite and thecyanides. finger would save life. The bleeding of piles and of I must not omit to notice that simple fatal syncope may cancer of the bowel, as well as menorrhagia, post-partum be due to muscular exhaustion. especially during or after haemorrhage, and all the forms of haemorrhage due to sexual intercourse; among 1,100 Inquests a year, I have organic disease of the womb may give rise to syncope. about four such occurrences, always of males. More rarely bleeding from the kidneys and bladder may cause a fatal faint. ASPHIXIAAM D LUNG DISEASE. Internal and concealed haemorrhage is a somewhat Lung diseases existing alone do not afford, so far as my frequent cause of a sudden syncope, as from placenta experience has gone, a large proportion of unexpected praevia, rupture of the womb in parturition, or of a sudden death, except from the arterial haemorrhage of Fallopian tube In extrauterine pregnancy. Aortic phthisis. Pure asphyxia Is rare, except from pneumo- thoracic aneurysm frequently causes a fatal but only thorax, apart from quite recognizable attacks of pneu- lnternal bleeding, and occasionally this occurs with monia, etc., which take the cases out of the liat of sudden abdominal aneurysms; of these seven out of ten are of deatbs. msles. Phthisical haemothorax must not be overlooked A diffase pulmonary apoplexy may occur very rapidly, as the cause of a sudden death. and cause aspbyxia, and Is not denoted by any profuse Internal bleeding from a rupture of the spleen is external bleeding. occasionally found, especially in the tropical countries, Deaths from the complications of pleurisy may occur after the slightest of external inijuries, and the same may somewhat rapidly, and without warning. be said of the pancreas, liver, and kidneys. Remember I have myself seen and recorded sudden deaths from also the liability tp sudden syncope from perforation of asphyxia from purulent fluid, due to the rupture of un- the bowel in about the third week of typhoid fever, and suspected abscesEes In the medlastinum Into the bronchi In some cases of colitis such as are now called appen- or trachea. dicitis. Apart from internal haemorrhage of serious Thoracic aneurysms have, I believe, led to sudden fatal amount, fatal syncope may occur from the shock of asphyxia from preesure on the pneumogastric nerve. rupture of the stomach, bowels, or womb, etc. In the course of cases of chronic Bright's disease we may anticipate the occasional ccurrence of a fatal result I SYNCOPE FROM HEART DISEASES, ETC. from asphyxia due to oedema of the lungs; this is It has been estimated that 60 to 70 per cent. of all especially the case after surgical operations, and if acute sudden deaths end in syncope and are due to diseases bronchitis intervene. Asphyxia will also be caused by of the heart; most of these have originated in acute oedema of the glottis, whether from disease or Injury by rheumatism, from searlatina, or from, alcoholic fatty scalding, or watsp or bee stings. degeneration of the heart muscle. The others from the During the puerperal state, sudden death Is not unf heart strain of bodily labour, of army duties, or of athletic common from thrombosis of large vessels, and from exercises. Of cardiac valvular diseases, those of the embolism of the brain or lungs; such cases may end by aortlc valves are most often suddenly fatal, and next coma, asphyxia or syncope. those of the mitral valve, while diseases of the pulmonary Sudden deaths from asphyxia are observed from over- and tricuspid valves are seldom found as a cause of sudden dense atmosphere, as when working in caissons and and unexpected death. Angina pectoris apparently due mines; or from over-rarefaction- of the air, as in balloons; to atheroma of the coronary arteries appears to kill by the or from the presence of poisonous or irrespirable gaseis, shock of a sudden spasm of pain. Cardiac rupture is not especially of carbonic oxide. Our present-day illumi- a very rare event In London, and may occur without any nating gas is much more fatal to life than that of earlier definite extra effort being used. General atheroma of the years, being largely-composed of gas from water, which great thoracic arteries is also often assigned as a prime contaims much carbonic oxide, and less from coal, which factor of a sudden syncope. contained more hydrogen and marsh gasj Sudden desth from syncope has also been attributed to Persons may die asphyxiated from hydrophobia,tetanus, the ingestion of a large.quantity of cold water when from,strychnine poisong, from the effects of such drugs Txz BAITISK 49149MZDICALMEIA JOURN"tlJoKrIISSUDDEND E ANDN UNEXPECT"N X E T D DEATHS.D A H .[E.2,io[FICB. 29, 1908. as conia or woorara, or from a respiratoTy palsy caused by Cases of Addison's disease are very likely to end fatally an embolism, or a haemorrhage about the cerebral centres In a sudden manner. which stimulate the muscular breathing apparatus. Of recent years the unexpected deaths of children have It the respiration is suddenly stopped death occurs in been frequently attributed to an enlarged tbymus gland, about three minutes, as is well seen after Immersion in which is supposed by its pressure on the trachea or on water, when this occurs without a fatal syncope. the pneumogastric or recurrent laryDgeal nerves to pro- voke anginal seizures. It has been said that a proportion of infants found dead in bed with mothers and nurses, 'COMA AND BRAIN DXISASES. bave not been suffocated by clothing or by the adult's Sudden deaths accompanied by coma are mostly due to body, breast, or arms, but by sudden congestion affecting diseases of the brain or to apoplexy-that is, haemorrhage an overgrown thymus gland. Poet-morten examination of into its structure, or upon its upper or lower surface. such cases would show the signs of asphyxisa and an Tamours and abscees of its substance cause prolonged enlarged gland, but It would be difficult to exclude the ilness and arise from tubercle or syphills. All these factor of deprivation of air by light clothing, etc, causes are found fairly easily by post nmortem examination. lnsufficient to cause pressure markse. The cases difficult of explanation are the deaths from I am inclined to think that in women the cbange of life coma (profound insensibility, loss of mind and motion, is occasionally the reason for a sudden death which leaves without any necessary asociation with loss of cardiac no definite post-morten signs. The stoppage of a recurrent power, or asphyxia) which display to the pathologist no drain on the system leads to a gross lesion of the brain, spinal cord, or other vital organ. congestion of vital I organs, as well as to a uterine plethora, and I nave heard refer to such cases as the sudden death in coma after of several cases showing a short period of suffocative attacks of convulsions. Ia persons known to have bad sensation ending in a quite unexpected death. previous epileptic fits it Is usual to allege epilepsy as the cause of the death, but this is not capable of any patho- CONVULsIONS FROM VABIOUS CAUSES. logical proof. Some similar cases are attributed to A sudden death In convulsions, apart from any definite uraemia, If a test of the urine found in the bladder shows coma, may occur in epilepsy, and is also often seen in the presence of albumen. In other cases the discovery of infancy associated with the first dentition, and a form of grape sugar in the urine Is considered to be sufficient still more rapid death is notIced from the localized spasm proof that death has been due to diabetes. Perhaps In commonly called laryngismus. The final convulsive the future the microscope may throw further light upon twitchings of asphyxia due to croup and diphtheria may these obsctre deaths from coma. fairly be called a mode of sudden death. A somewhat sudden death from coma with or without Of deaths from self-generated poisons, in addltion to convalsions arising from uraemic impurity of the blood is those from uraemia there are somewhat sudden deaths aild to follow the pressure of a retroverted gravid uterus due to cholaemia during jaundice and due to diseaEe of upon one or both ureters, but this must be very rare, as I the liver or derangements of the bile ducts. have found no cMe among 15,000 inquests. Acetone circulating in the blood in the course of cases A sudden end by coma occurs in the course of long- of diabetes is also considered to be likely to cause a sudden standing diseasee of the middle ear with ruptured mem- death. brana tympani and a purulent discharge; there is danger If a person be found dead with water In the air psassges, it the discharge ceases. Such cases are generally due to drowned in only a few inches of water, a mere puddle, tuberculosis. it is almost surely a case of epileptic convulsions and Deahs from coma may be due to external violence of coma. which there has been no witness, and for which there may Sudden death with asphyxia and convulsions is not be seen no external mark; in such cases pet-nortem seldom found due to choking by a foreign body, food, examination may disclose a fracture of the skull with teeth, jujube, lozenge, etc. depression of the bone, or with cerebral compression due The sudden onset and fatal issue of convulsions arising to haemorrhage. This fracture may be of the vault or of from oedema glottidis must not be overlooked, whether the base, or through the Imkportant regions of the ear. from laryngitis, insect stings, or Ludwig's angina. This Such aninjury may happen after an apoplexy, which'may oedemalias been noted In cases of diabetes and Bright's cause the sufferer to have a sudden and violent fall. disease. In deciding upon the cause of an unexpected or sudden KIDNEYS AND UBRA1EMIA. death (as in making a diagnosis) it is necessary to con- A healthy state of the kidneys is as neceseary to life sider whether It has been to the interest of the perEon as the integrity of the heart, lungs, and brain-which who has died, or of any other person, to assist In obscuring Blchat called the "tripod of life"; but death from your judgement as to his recentstate of health; and this kidney diseases has no fourth type of death to supple- again needs.to be revised by an opinion as to whether if, ment syncope, aspbyxia, and coma, so affections of the against his or her real interest, he or she may not be kidneys end in one of the already recognized three under control of some hysterical prepoesession. Remem- ways. ber also that women will occasionally be found to hide Modern physicians of great repute allege that kidney diseases and symptoms from a bashfulness and modesty diseases are among-the commonest causes of sudden so great and perverse-as to be hardly credible. Ihave death. A- fatal termination often rapidly follows the knownEeveral cases of female deaths reported as sudden onset of coma and convulsions of a uraemic nature set and of cause unknown, when the medical man called in up by failure of the kidneys to purify the blood; these during the latter hours of life has been quite unaware symptoms are a recognized termination of cases of that his lady patient was dying of gangrene, of a strangu- chronic Bright's disease and of acute scarlatinal nephritis, lated femoral hernia, or was bleeding to death from the but these forms of illness are not likely to be overlooked, bowel, or from ruptured varices of the vulva. and so'such deaths are hardly included in my subject as In the holding of inquests upon cases of sudden death, unexpected and sudden. Chronic kidney diseases, especi- one notable fact has often been remarked-that the ally granular contracted kidney, associated with the deceased had been apparently specially wellimmediately weakness of a hypertrophied and often dllated heart, preceding the death. There has always been a popular are a not infrequent cause of the sudden fatal syncope Idea that in lingering life and gradual death from illness of middle-aged persons who have lived freely, and this there often occurs a" lightening before death." occurs without any well-marked period of definiteillness. Roman Catholics have a speciallnterest in the subject In a similar manner gout, has been classed as a cause of of sudden death, because that Church desires the oppor- budden death; chronic gout Is often a companion of dis- tunity of spiritual ministration, of baptism, conditional Xorganized kidneys, which obstruct the circulation, lead absolution, extreme unction, or of penance and the to cardiac hypertrophy and dilatation, and to sudden Eucharist. The priest desires to know, If possible, how syncope. The sudden retrocession of acute gouty inflam- long life may last, and how long consciousness will nation- from a joint has often been followed by an remain, and it is highly desirable that no one should die unexpected deathi. unshriven. Sufferers from kidney disease bearinfectious diseases When death seems imminent the members of a Roman badly, very often get septicaemia after surgical operations, Catholic house send for their own or any ptiest. If the and are specially liable to death under anaesthetice. patient be dead on the arrival of the prieet, he leaves x FEB. 29, I908.]-~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~EDC,SUICIDE BY SUFFOCATION. B'm7ORA 493 without doing anything. So that it is very desirable in means of curing diseaee and preserving health. Apart such cases to decide the moment of dtatb. Roman from correct treatment -and advice, patients cani only be Catholl physicians have noted the recovery, sometimes warned in whick direction thetr allments and imperfec- only for a sbort time, of many cases of apparent death. tions may threaten a fatal isSue. So long as a patient )s Dr.. A. -O'Malley, of the United States, narrates thirty actually under medical attendance he will generally con- cases of apparent death (query, who eaid "death" had form to rules, but when urgent symptoms have passed and occurred?) in four of whtch entire recovery, followed he is left to his own devices, the lull force of the old fact- suitable skilful treatment. humaftum eat errare-comes into play, and Death secures I remember one case where I entered the chamber and his victims with considerable ease. was told the patient, an aged woman, had been dead many minutes, when, on giving brandy on a sponge in the mouth, the lady recovered and lived until the next day. UNUSUAL CASE OF SUICIDE BY Roman Catholic authorities have Eaid that in caEe of a AN sudden and unexpected death, such cases of resuecitation SUFFOCATION. should authorize a priest in giving conditional absolution BY J. MILL RENTQN, MB., CEr.B., or baptism within an hour or two alter apparent death, EXTRA-DISPENSARY SURGEON, WESTERN INFIRMARY, GLASGOW. especially in cases of violent death of healtby persons. They add: "We do not know when the soul enters the THE patient, a middle-aged man, was brought to the work- body, and there is the same doubt as to the moment when house by the police with a history of delusions. On the soul deEerts the body, so give every possible benefit of examination, no definite signs of insanity were found, religlous observance." but it was thought desirable to' keep him under Roman Catholic doctrine recites that the death without obi ervation. the "rites of the church" of an ailing member whose On the evening of the same day, quite suddenly, he death may be anticipated by a medical attendant is a became violent and excited, and, in oider to eneure hia matter of grave concern. The times for death may be safety, he was placed in a padded room. Alter ,being anticipated with much certainty in many acute diseases, removed there he became much quieter, and finally lay and warning given to the priest, while in most chronic down and went to gleep. An attendant visited him regu- diseases the end can be calculated very nearly. Still, larly, and he appears to have eltpt scundly for several we must remember the old eas ing, " Death alwa3 s comes hours. When seen at 9 p m. he was fast asleep, but at unexpectedly.' 920 p.m. it was noticed that his bedclothes had been Hippocrates wrote that the moat difficult question asked thrown off, and on farther examination he was found to of the doctor was, Will the patient live? His chapter be dead. ."On the Progress of Disease" may still be read with When seen by me a short time afterwards, the body advantage. was lying on its back with the arms outstretched. The face was placid, and no marked cyanosts was present; The occurrence of sudden death from a legal point of there was, however, lividity of the lips, ears, flnger view is often a happening of the gravest importance. and toe nails; there was also some dried blood, on the Apart from tbe serious results often reaulting from lips. The mouth was closed but the jaws were not intestacy, the loEs of a personality in almost all buli- clenched, and were easily opened by the fingers. Inside nesEes is a matter which upsets all arrangements and the mouth a piece of flannel about 1 It. long by 1 in. terminates many contracts. It lccks up banking accounts broad was found, and behind this were two almost similar and stops payment of cheques already drawn but not strips. The last of theEe was so firmly packed down over cashed. A isdden death often intervenes between the the epiglottis that it was withdrawn with some difficulty. service of a summons as juror or witness and the date of le had obtained these strips by teazing up his blanket, the duty required, and Euch a death may lead to the loss and had evidently suffocated himself by packirg them of suits which would surely have been gained. down his throat. The occarrence of a sudden death of which the cause is I record this case,'as suicide by this method, is com- unknown involves the holding of a coronet's inquest, with paratively rare, and only a few similar cases are men- all its unpleasantness to family life, and it may give rise tioned in medico-legal literature. Casper, in speaking to serious, even if unfounded, suspicions of foul play by of the subject, says: relatives or friends; or of neglect, which may be very difficult to disprove. Experienee teaches that suicide by stuffing the air passages Deaths from the felonious administration of poisons are with foreign bodies is a most unheard-of affair. no doubt a rarity to-day, but in former times the sudden Taylor also coneiders it to be very rare, but gives death of a notable person was often attributed, and no details of 3 somewhat similar cases. One of these is -doubt rightly, to secret poisoning. Madame Brinvilliers specially interesting, as the patient had been examined in France and the Borgias in Italy certainly caused many and certified as dying from "1 apoplexy," and it was only sudden unexplained deaths. accidentally that a plug of cotton was found In the Having now passed In review in a cursory, manner the tbroat.1 Three other cases are recorded in the BRITISH causes of sudden death and noted the unfortunate results MEDICAL JOURNAL Of 1882, and one of these was resus- whiQh may arise, It may be permissible to say that it may citated by prompt medical treatmfnt being adopted in yet be to the recipient a great blessing. Members of the time. Glaister also mentions a case of a similar nature, Church of England are accustomed to pray every week of where a man forced cloth down his throat by means of a their lives to be delivered from sudden death*; is it wise wooden spoon, but he considers the occurrence to be very to do so if the fervent prayer of a zighteous man avalleth uncommon. much? Doctors and nurses see most of slow deaths from Cases of this nature emphasize the neceEsity of always disease; how many of such long for ja slow dying? examining the mouth and throat In cases of sudden Relatives and friends who have just left the deathbed of death. I was interested at the time to note that' appa- a dear one who has Eufferedlong theterrors of pain- rently no effort had been made by the man to withdraw bleedings, vomitings, hiccougbh, puraings, and delitium- even the last strip of flannel, as I found it well back In do they not always say, " May I be spared a long the mouth. Considering the fact that death probably illness "? took place comparatively slowly, it is strlking that, while The frequent suicides of those who suffered severely yet in a semi-conscious state, he should not instinctively show that a sudden violent death is preferred to a slow have withdrawn at least one piece.' lt, however, only natural dying. goes to show the extraordinary perversion of the pilmitive The present discussions on an artificial euthanasia also instincts in a determined suicide. show that death, by natural illness is a disaster to I e I have to thank Dr. Edmunds, of Chesterfield, for avoided. permission to publish this case. There remains our duty as medical men; it has from REFERENCE. the time of Hippocrates been a perfectly definite artlele Handyside, Edinburgh Medical and Surgical Jcarnal, 1842. of rightful duty to protect life as far as is possible. BIBLIOGRAPHY. The means of deferring death areidentical with the Casper's Medical Jurisprudence. Taylorfs Jedical Jurisprudence. -* But theologians tell us that this word "sudden" means "'unpre- Glaister's Medical Jurisprudese, Toxicology, and Public Health. pared for."-W. BRITISH MEDICAL JOU}RNAL, VOI. ii, 1882.