SUDDEN DEATH IN THE PUERPERAL STATE.
Although puerperal affections ordinarily manifest themselves under one or another of the forms which we have described, it is not always so, and it suffices to refer to the descriptions given of puerperal fever by the older writers, and to the history of different epidemics, to see what diverse forms puerperal accidents may assume. Here it is phlebitis, there it is lymphangitis, here pleurisy, there scarlatina, which dominates the patho logical scene, and Hervieux's work contains the enumeration of all the dis eases which may affect the puerpera. But all these diseases, in order to lead to death, require a certain interval, pass through certain stages, give the acconcheur, in a word, a chance to fight, to test his drugs, in order to release the woman, if he can, from the danger threatening, and in many instances he is successful. There is, however, a further accident which threatens the puerperal woman and against which the physician is impotent, for it comes like a thief in the night in the majority of in stances, and it carries off the woman with a rapidity which is appalling. This is sudden death.
Mentioned for the first time by Dionis, in 1718, by Delamotte, 1766; and later by Ramsbotham, 1814, McClintock, 1853, and studied with care by Mordet and Moynier in 1858, sudden "'oath of the puerpera has since been the subject of numerous monographs, and each author, while admitting the occurrence, has given a different explanation, and each, basing his deductions on the cases he has seen, has interpreted it after a different manner, some attributing death to a lesion of the circulatory system, others to a lesion of the nervous system, of the respiratory system, others still to syncope, to puerperal poisoning, and finally, like Coste, almost exclusively to myocarditis.
We cannot discuss all the known cases, but we desire at the outset to mention the following conclusions: 1. Death is rarely sudden in the exact sense of the word. Usually it occurs after the lapse of a few hours. That is to say, we are not dealing generally with lightning-like death, such as follows rupture of the heart for instance; and it is possible from a careful examination of the predomi nating symptoms, to determine that the cause resides in one of the three organs, which Bichat has called the vstal tripod, the heart, the lungs, the brain.
2. As Hervieux remarks, it is ordinarily during deadly puerperal epi demics that sudden death is met with, and, therefore, he was led to seek in puerperal poisoning the most active and frequent cause of sudden death, and he makes a distinction betreen cases where death is prompt, and those where it is sudden in reality. " It is especially in case of prompt death that autopsy has revealed an appreciable lesion; under the term sudden death are to be classed all those cases where, no alteration competent to explain the fatal issue has been found." Coate, from a study of the majority of the reported cases, has reached the following conclusion: " Sudden death after delivery is due: either to hemorrhage, either to a thrombus in the pulmonary artery, or to myo carditis. Since hemorrhage results in more or less rapid death, and since, on the other hand, pulmonary thrombosis appears to be due to a degen eration of the myocardium, we may conclude that sudden death is always due, after labor, to a myocarditis." This conclusion seems to us at least premature, for, as is seen, Coste admits that the death may be more or less rapid, and he enters into the field of speculation when he says: " Myocarditis arising during gestation may cause sudden death in the first week following delivery, while from the form which occurs in the course of puerperal fever, death only results in the second week or even during convalescence." Every case of sudden death is not, in truth, preceded by affections oc curring rluring pregnancy or the puerperium, and although in many in stances we may find the cause after death, in many others there have been no disturbances of any kind during pregnancy or the puerperal state, and yet death occurs with absolute suddenness, without any premonition whatsoever. These instances are exceptional, and we are here in the presence of an as yet unknown factor which the future may reveal, but which, in the present, calls for prudent reserve in expression of opinion.