History and Geography

Sudden death in healthy individuals is a phenomenon that has occurred throughout history and in many cultures. Because of their sudden and unexpected nature, many of these deaths have been attributed to supernatural or psychological causes. There has been speculation that SUDS among Southeast Asian refugees in the United States may be triggered by such factors as stress, night terror, evil spirits, or culture shock.

Yet a number of older reports in the medical literature of the Philippines have identified a sudden nocturnal death syndrome known as Bangungut. Previously healthy males die during the night, making moaning, snoring, or choking noises. Bangungut means "to rise and moan in sleep" in Tagalog, reflecting the folk belief that the deaths are caused by terror from nightmares. The victims are men 20 to 50 years old. No consistent cause has been found for these sudden deaths, even though they have been extensively evaluated with autopsies. The main postmortem finding is hemorrhagic pancreatitis, a condition most observers believe is not a cause of the syndrome but, rather, an effect after death.

Physicians in the Emergency Department at Philippine General Hospital in Manila state that they see numerous cases of SUDS every year. The typical profile of a victim is a young male adult with a stocky build, usually a poorly educated construction worker who migrated from the Visayan Islands to work in Manila and who had either been on a drink- _ ing spree shortly before sleeping or had just eaten a fatty meal prior to retiring for the night. The victim is brought to the Emergency Room by fellow workers who are unable to wake him, but who remember his moaning and groaning in sleep. Nearly universally Filipinos have heard about Bangungut and believe in its authenticity. Many of them describe experiences as children being assigned to watch over their fathers' afternoon naps.

Similar episodes of sudden death among Filipinos living in the Hawaiian Islands were described in the medical and popular literature during 1930-60.

In Japan, there is a disease referred to as pokkuri, which is a sudden death similar to those described in Southeast Asians in the United States and in the Philippines. A study of 18,515 consecutive autopsies in Japan found cardiac death of unknown etiology in 76 cases. Almost all of these deaths occurred in young men who had been considered to be in good health and who died suddenly during sleep. Some Japanese pathologists believe that the cause of death is a fulminant deletion of myoglobin from myocardial fibers during a state of acute cardiac failure.

An American anthropologist and epidemiologist has studied SUDS in the refugee camps in Thailand. Although autopsies are not common in such settings, the deaths were very similar to SUDS deaths occurring among similar refugees in the United States.

Emotional trauma, voodoo, spirits, and magic have all been suggested as important factors for sudden unexplained death in folk cultures. Modern biomedical beliefs prescribe that psychological factors cannot cause deaths per se, but may trigger a fatal event. A different emphasis occurs in reports of sudden death among persons living in cultures where the concept of psychological sudden death has greater currency than in scientific Westernized cultures. For example, in Australia there was a belief among the northern Aborigines that a person who has been pointed at with a bone will die as a result. A government surgeon among the people of that region in 1897 wrote that he had witnessed three or four such cases. A phenomenon of wishful dying has been described among rural Bantu people in South Africa.

Several studies of the Hmong, the group hardest hit by SUDS in the United States, have proposed psychological triggers as explanations for their deaths. An extensive cultural study of SUDS focused on Hmong religion and its relationship to health concepts, but no correlation could be found between the deaths and religious preference, degree of belief in traditional religion, or anxiety over religious questions. The author concluded that one possible triggering mechanism for SUDS might be overwhelming and inescapable stress. Another study conducted in the United States by two anthropologists also considered stress as a potential trigger in SUDS. The authors interviewed relatives of 28 victims of the syndrome and concluded that night terror might have contributed to their deaths. The researchers specu lated that such terror was brought on by exhaustion, culture shock, family quarrels, or even the violent images found on television.

Neal R. Holtan

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