diet and DiaBet.i Composition: Glyburide 5 mg. Indications: Uncomplicated diabetes mellitus of the stable, mild, nonketotic, maturity-onset type not controlied by diet aione, in patients who have failed to respond to or cannot be maintained on other suifonylureas. Contralndicatlons: Severely brittie and juveniie diabetes, severe ketosis, acidosis, coma, thyrotoxicosis, frank jaundice and liver disease, severe renal impairment, severe infections, trauma, surge., pregnancy and gre-existing complications peculiar to diabetes. Careful selection of patients is important. It is imperative that there be riqid adherence to diet, careful adjustment of dosage, instruction of the patient on hypoglycemic reactions and their control and regular follow-up examinations. Administer with or immediately after a meal; lunchtime for patients eating a light breakfast. Periodic liver function tests, peripheral blood counts and ophthalmic examinations are advisable. The possibility of hyolcemia should be considered when certain suiphonamides, tuberculostatics, phenylbutazone, monoamine oxidase inhibitors, coumarin derivatives, salicylates, probenecid or propranolol are administered simultaneously. Use sedatives cautiously in patients receiving oral hypoglycemic agents since their action may be prolonged. The effects of oral hypoglycemic agents on the vascular changes and other long-term sequelse of diabetes are not known; patients receiving such drugs must be very closely observed for both short-and long-term complications. Intolerance to alcohol rarely occurs. Administer oral hypoglycemic agents with caution to patients with Addison's disease. Adverse reactions: Allergic skin reactions including photosensitivity, pruritus, headache, tinnitus, fatigue, malaise, weakness, dizziness have been reported in a small number of patients. Hypoglycemic reactions are infrequently observed. Thrombocytopenia is uncommon. Overdosage: Symptoms: Manifestations of hypoglycemia include sweating, flushing or pallor, numbness, chilliness, hunger, trembling, headache, dizziness, increased pulse rate, palpitations, increase in blood pressure, apprehensiveness and syncope in the mild cases. In the more severe cases, coma appears. Treatment: Administer dextrose or glucagon and dextrose. Dosage and administration: Total daily dosage ranges between 2.5 and 20 mg. 1. Newlydiagnosed diabetics: Initial dosage is S mg daily (2.5 mg in patients over 80 years of age) for S to 7 days. Adjust dosage by increments of 2.5 mg according to response. The maximum daily dose of DlA.ETA is 20 mg. Most cases can be controlled by 5-10 mg daily given as a single dose during or immediately after breakfast. 2. Changeover from other oral hypoglycemic agents: Discontinue previous oral medication and start DIA.3ETA 5 mg daily (2.5 mg in patients over 60 years of age). Determine maintenance dosage as in newly-diagnosed diabetics. 3. Chan9eover from insulin. Less than 20 units daily-discontinue insulin and start on DIA.PETA 5 mq daily (2.5 mg in patients over 60 years o age). Adjust dosage according to response. Between 20-40 units of insulin dali yreduce insulin by 30-50% and start DIAfiETA 2.5 mg daily. Further reduce insulin and increase DIAIJETA dosage according to response. 4. Combined treatment with biguanides. If adequate control becomes impossible with diet and maximum doses of DIA.ETA (20 mg daily), control may be restored by combining with a biguanide. Maintain D IA.ETA dosage and add 50mg of .henformln. 5. Combined treatment with Insulin. th (relative) insulin resistance can occasionally be more smoothly controlled by adding DIAI3ETA. Supply: White, oblong, scored 5 mg tablets Code (LDI) in boxes of 30 and 300. Product Monograph on request. References: 1. O'Sullivan, DJ. and Cashman, WF.: Brit. Med. J., 2:572, 1970. 2 Mueller, R. et al: Horm. Metab. Res. 1(suppl):88, 1969. 3. Krall, LP., Sinha, S. and Goldstein, H.H., Aust. & Ni. J. Med., 46(suppl):57, 1971. 4. Moses, AM., Howanitz, J. and Miller, M.: Ann. Intern. Med., 78:541, 1973. 5. Luntz, GRWN.: Postgrad. Med. J., 46(suppl)84: 1970. 6. Schoeffling, K.: Aust. & Ni. J. Med., 1(suppi):47, 1971.

rong-acting

Hoechst

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E..OECvSTA.ar...,..i,v..,ivG

Montreal

136117096E

How medicine speaks for the dead to protect the living DAVID WOODS

Coroners, according to their unofficial motto, "speak for the dead in order to protect the living." But beyond this quite accurate definition of its function, the coroner's system, despite its existence in some form or another for more than 1000 years, seems to be only vaguely understood by the two professions ii affects most - medicine and the law. And yet most practising physicians - saving, perhaps, dermatologists, whose patients are uncharitably said never to die and never to get well will at some time in their careers find themselves involved with the coroner. Their unpreparedness for this event may stem from inadequate medical school training in law, from the mutual antipathy said to characterize relations between doctors and lawyers, from a misty notion of coroners as people to be found only in Agatha Christie novels or from misguided optimism. In any event, coroners are very much a fact of life (and of course death) in this country; moreover, paradoxical as it may sound, they have probably done more for preventive medicine than any other group. The coroner's investigative and preventive function has remained remarkably stable for centuries. As physicianlawyer Dr. David Marshall points out in his book "The Physician and Canadian Law": "In a 13th century inquest from the coroner's rolls the jury's verdict in a case involving the death of a child in a ditch finds that the death is an accidental one by drowning and further recommends that the township be ordered to fill in the ditch." This verdict and recommendation, says Marshall, "could well be that of a coroner's jury in Canada today." The word coroner comes from crowner, a keeper of crown pleas. In Canada coroners are provincially appointed, usually by the LieutenantGovernor-in-Council; in most jurisdictions coroners are licensed medical practitioners, although this isn't everywhere the case. In Nova Scotia, for example, the local sheriff holds the appointment, and in parts of the US funeral directors are known to serve as coroners - as clear a case of conflicting interest as one might find. The coroner's duty is to investigate those deaths described in each province's act. In Ontario, for example, this means death as a result of violence,

406 CMA JOURNAL/FEBRUARY 19, 1977/VOL. 116

misadventure, negligence, misconduct or malpractice; by unfair means; during pregnancy "or following pregnancy in circumstances that might reasonably be attributed thereto"; deaths that are sudden and unexpected; the result of disease or sickness not treated by a legally qualified medical practitioner; from any cause other than disease, or under such circumstances as may warrant an investigation. There are also provisions for inquiring into deaths occurring in homes for the aged- and other institutions. Other provinces' rulings on coroners inquests are similar, being either more or less specific. In New Brunswick, for example, the act makes particular reference to deaths "as the result of being struck or run over by a railway train or automobile", and the Alberta legislation provides that "where a person dies within 30 days after an operation upon him" the provincial chief coroner must be informed. General duty Whatever the categories of reportable deaths, the acts generally specify that every person who has reason to believe death was attributable to any of the reasons listed shall immediately notify a coroner or police officer of the facts. In many cases, of course, physicians bear the responsibility of reporting this information, but all too often, says one of Ontario's 380 parttime coroners, Dr. Nicholas Pohran of Niagara Falls, they don't even know the provincial Coroner's Act. Pohran, 50, a McGill-trained family doctor, reckons he spends about 5 or 6 hours a week being a coroner and conducts some 10 or 12 inquests a year. How does one get to be a coroner? In Ontario, says Dr. Pohran, provincial appointments are made when vacancies occur, and usually they're offered to active local MDs in general practice, general surgery or internal medicine. They hold the job until they no longer want it, until they leave the locality or until they reach age 70; they may, of course, be removed from the position if their names should also happen to be removed from the medical register. In Ontario at present, there's no formal training for coroners, although, as the province's chief coroner Dr. H.B. Cotnam told me, "We do provide

courses in Toronto for new coroners and refresher sessions for old ones". The part-time coroners, unlike Ontario's six full-time regional ones who are paid salaries by the provincial government, work on a fee-for-service basis; this, in light of what they do and of the accusations that fee-for-service leads to "overutilization", takes on a slightly macabre aspect. So let it be said at once that the coroners are paid for their time, not for "procedures". In some instances, coroners are paid a flat amount for each body. "Most calls for our services," says Dr. Pohran, "come from other doctors or from the local hospital, where they're usually about DOAs." Pohran describes the death certificate as a primitive and inaccurate document - if not a work of fiction, then often one of imaginative guesswork. Demise attributed to, say, bowel obstruction may be nothing of the sort, and the coroner system allows for an objective appraisal, with the often-needed intervention of a pathologist to provide a final, accurate verdict. Coroners wield considerable power. They cannot, for example, be overruled in calling for an inquest or an autopsy - not even (since a dead body is technically the property of the state) by the deceased's family.., and not by the chief coroner either, although he may order the local coroner to hold an inquest or an autopsy where such has not previously been called for. However, coroners may not hold inquests just because someone has died: if it's not covered by the act - no inquest; further, they are not empowered to hold a second inquest on the same body. Definitive answers The inquest, says Nicholas Pohran, is designed to determine how, when, where and by what means the deceased came to his death. The coroner, with the help of expert medical, legal and police testimony,. attempts to reach definitive answers to those questions. It is here, in the coroner's court, that the law and medicine come into conflict, Pohran believes, because the MD cast in the role of judge is resented by the lawyer for the interested parties, while the "judge" is aware that the lawyer knows more about law than he does. What, you may ask, has all this really got to do with the competent practising physician? Well, a glance at the Coroner's Act for your province will quickly show that death by misadventure, or "sudden and unexpected" death, or "death under any circumstances that may require investigation" cover a pretty broad

suring not only that good medicine is practised but is seen to be practised. Holmesian

Ontario's chief coroner, Dr. H.B. Cotnam

area. And, in more and more instances, local coroners are investigating deaths - in Ontario last year about half of the 61 000 deaths came under such investigation. Increasingly then, since only a small number of these are in the whodunit class, but many are in the precisely whatdunit category, physicians are going to be involved in the coroner's system. This raises the question of whether that system is, or ought to be, a mechanism for disciplining doctors, since many of the deaths investigated are "medical" deaths. Says Dr. Pohran: "Physicians must not only know the Coroner's Act, they must act on it; if their patient dies under circumstances that call for investigation they should take the initiative.., contact the coroner." In all too many such cases, he says, it's the nurse who has to prompt the doctor. Inquiries into medical and surgical deaths are evidence of how coroners "speak for the dead in order to protect the living" and in doing so become arbiters of good medical care. So the system, like it or not, has built into it the capacity to discipline physicians, and also, more important, to forewarn and forearm them. This is particularly true in the case of operating room deaths which, though not strictly reportable according to the letter of the act, are usually classified as misadventure. In such cases the coroner generally orders an autopsy automatically and conducts exhaustive enquiries with OR staff procedures which, says Dr. Pohran, may engender defensiveness on the part of the operating surgeon but which fulfil an advocacy function for the deceased and his family, as well as en-

What kinds of people become coroners? Clearly, with the varying degrees of human mutilation and decomposition that they're confronted with, there's no place for squeamishness; beyond that there are the expected Holmesian qualities of patience, tenacity and analytical and problem-solving skills, coupled with a certain desire to right wrongs and see virtue triumph. Certainly they're not in it for the money. Ontario's six full-time regional coroners, says that province's deputy chief coroner Dr. Ross C. Bennett, earn far less than they would in private practice, and the part-timers could hardly get rich from their avocation. Bennett, who admits to being a devotee of detective fiction, agrees none the less with Dr. Pohran that there's a pressing need to make the medical profession more aware of what reallife coroners do - and what the coroner's system is all about. To do this, he says, "I'd advocate more comprehensive teaching of jurisprudence in the medical schools, and especially of the coroner's system, which touches on every doctor's practice at some time or another." The problem, Dr. Bennett suggests, is one of ostrich-ism - physicians prefer not to think about death, and, so far as the coroner's system is concerned, they take an attitude of "if I don't bother with it, it'll go away." At the very least, he says, the practising doctor should have enough knowledge to get through an inquest without looking foolish or inept, should understand the function of coroners as policemen in medical society, should know the purpose of the coroner's system and, above all, should be totally familiar with the Coroner's Act for the province in which he practises. In Ontario, the coroner's system is conducted and coordinated from the coroner's building on Grenville Street in Toronto; it is perhaps the most centralized system in Canada and comes under the jurisdiction of the solicitorgeneral for the province and has a budget of $3.5 million a year. Here, as well as the conducting of courses for coroners, a great deal of educational and investigative work takes place. A newsletter goes out to coroners; coroners are despatched to speak to medical and hospital groups about the system; there's a pathology section and a section of forensic services; there's a morgue that can accommodate 100 bodies, and all autopcontinued on page 419

CMA JOURNAL/FEBRUARY 19, 1977/VOL. 116 407

Hydergiri0 in the treatment of diffuse cerebral insufficiency PRESCRIBING INFORMATION DOSAGE for4 weeks

.

for 6 weeks QD .D .D Afterward the daily dose can, if warranted, be reduced to 2 tablets. Patients should be convinced of the necessity and importance of taking their medication regularly every day, preferably with their meals and at bedtime. The difference between success and failure is often directly related to the way the patient follows the dosage schedule. Composition - Tablets: Each 1 mg tablet contains the methanesulfonates of dihydroergocornine, dihydroergocristine and dihydroergokryptine in equal proportions. Ampoules: Each 1 ml ampoule contains 0.3 mg Hydergine consisting of the methanesulfonates of dihydroergocornine, dihydroergocristine and dihydroergokryptine in equal proportions.

Side Effects - Hydergine is usually well tolerated even in larger doses. Side effects are few and very slight. in addition to nasal stuftiness, there may be nausea, gastric pressure, anorexia, and headache, especially in patients with autonomic lability. In such cases, it is advisable to reduce the dose or administer it during or after meals.

Contraindications - Severe bradycardia and severe hypotension. Supply: Bottles of 100 and 500 tablets; Boxes of 6 and 100 ampou les. Full prescribing information is available upon request.

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intervention. The prisoner would then continue to receive normal medical supervision and food would be made available to, but not forced upon, the prisoner. To many, this statement was interpreted as an end to force-feeding in Britain. Yet force-feeding in that country, although declining, continues. Mr. Jenkins' statement in the Commons remains but suggestive; the prison rules place the responsibility for the prisoner's health solely in the physician's hands. The decision is made according to the personal views of the prison medical officer in charge. The situation in Britain has led to the suggestion that the physician is not the proper arbitrator as to the morality of force-feeding. An amendment to the prison rules would not only protect physicians from charges of inconsistency in their treatment of hunger strikers but also would insure them against the vagaries of common law. According to the above-cited article, the only existent authority resides in a directive by the Lord Chief Justice in 1909 to a jury trying an assault action brought by a suffragette who was force-fed. The directive states it is the duty of prison officials to preserve the health and lives of those in the custody of the crown. If then, as the directive implies, force-feeding is lawful, failure to do so could, in the extreme instance,

be interpreted as manslaughter by omission. It is, of course, unlikely that the decision not to force-feed would - in light of today's medical opinion - be equated with "gross negligence". Alternatively, it has been argued that the decision to force-feed could at least in Britain - be interpreted (under section 47 of the Offenses against the Persons Act 1861) as assault occasioning actual bodily harm. The physician then, at least hypothetically, is placed in that untenable position: damned if you do - damned if you don't. This dilemma was uniquely bypassed in what has delightfully been termed the "Cat and Mouse Act" passed in Britain expressly to handle the hunger strikes of the suffragettes. Under this act hunger strikers were released from prison and then re-detained once they were fit again. In Canada, failing specific legislation (and this is almost an impossibility, given that the situation is made-to-order for federal-provincial buck-passing) Canadian courts would presumably apply the common law that is largely inherited from England. But the courts would undoubtedly, in consideri'ng what is assault and what is acceptable medical practice, look at directions issued under the prison rules and any statements issued by an authoritative medical body, such as the CMA or a provincial college.E

CORONERS continued from page 407 sies for metropolitan Toronto are performed here. Sometimes, says Chief Coroner Cotnam, parts of bodies are sent to the coroner's building for analysis, and work in identification makes use of sophisticated techniques in such fields as forensic odontology. Dr. Cotnam explains that all local coroners' reports come to the Grenville Street building. He speaks of the sweeping changes that have occurred in, for instance, the Construction Safety Act as a result of investigations followed by recommendations, as well as in the Child Welfare Act and other legislation relating to battered children. According to the Ontario Coroner's Act, Cotnam's job is to "administer this act and its regulations; supervise, direct and control all coroners in Ontario in the performance of their duties; conduct programs for the instruction of coroners in their duties; bring the findings and recommendations of coroners juries to the attention of appropriate persons, agencies and ministries of government; prepare, publish and distribute a code of ethics for the guidance of coroners; (and) perform such other duties as are assigned to him by or

under this or any other act or by the regulations or by the LieutenantGovernor-in-Council." And there are, says Dr. Cotnam, many other acts that impinge on his work, among them those concerning vital statistics, cemeteries and mining. Cotnam believes strongly that attempts to bring some national uniformity to the coroner's system are long overdue; in fact, he was the first president of an organization designed to do that. "We need to get the statistical information out on a national basis," he says. Perhaps more important, at least a priority within the movement toward national conformity, Cotnam believes, is the need to ensure that coroners' work is handled by physicians. It may very well be that the coroner's lot, like the policeman's, is not a happy one. But it's one whose importance and effect are growing measurably. The coroner, if he is to act as what Dr. Ross Bennett calls "an ombudsman for the dead", must enjoy the full support and cooperation and understanding of medical practitioners throughout Canada in order to protect the living, too, by encouraging high standards of medical and general safety.E

CMA JOURNAL/FEBRUARY 19, 1977/VOL. 116 419