70

Uterine Rupture. There were two cases of complete r u p t u r e of the u t e r u s a n d one incomplete. All p a t i e n t s recovered. There were 2 stillborn infants. (1) K. F. 1326114461. A patient with placenta prmvia, had a simple forceps delivery following induction by P.O.M. Although para 7, and a minor degree of placenta praevia, the case would have been better handled by Cmsarean section. The baby was stillborn and weighed 8 lb. 4 oz. Shock developed after delivery of placenta with Yery little bleeding. Condition was restored by blood transfusion. There was evidence after recovery of a left broad ligament haematoma and an incomplete rupture was presumed. (2) S. O'B. 13813/3893. This case of complete rupture of tile uterus was associated with a sixth Caesarean section, and involved the bladder. A live baby was obtained by extension of the rupture, and repair of the bladder and uterus were e:ffected. This case is described in the special case notes on multiple Caesarean sections (p. 57). (3) J. P. 16068. The second case of complete rupture of the uterus occurred in a para 15, and was caused by ~bstructed labour and brow presentation with attempted correction before admission to hospital. Transfusion was started On the district and the patient moved as soon as possible. Immediate laparotomy and a rapid hysterectomy was performed. A very extensive rupture had occurred into the' right broad ligament. The patient had in all 6 pints of blood and made an excellent reco~cery.

Hysterectomy Associated with Pregnancy. Caesarean h y s t e r e c t o m y was performed o n 4 occasions. The i n d i c a t i o n s were r u p t u r e d uterus, m u l t i p l e previous sections c o m p l i c a t e d b y p l a c e n t a prmvia, a p l a c e n t a accreta ill a b i c o r u u a t e u t e r u s , a n d a d v a n c e d c a r c i n o m a of the cervix. All p a t i e n t s recovered, a n d the only i n f a n t lost was t h a t associated w i t h the case of r u p t u r e d uterus. D e t a i l s of these cases have all b e e n given u n d e r their various subheadings. I n 2 i n s t a n c e s tile h y s t e r e c t o m y was subtotal. A full W e r t h e i m operation was carried out for the c a r c i n o m a of the cervix, a n d a t o t a l i n the case of p l a c e n t a accreta. This proved to b e a v e r y fine pathological specimen and one half of the u t e r u s was sent to the R.C.O.G. P a t h o l o g i c a l Museum.

Destructive Operations. There were 4 craniotomies carried out d u r i n g the year. I n each case the p a t i e n t was a p r i m i p a r a . I n 2 there was some degree of outlet c o n t r a c t i o n a n d i n one of these tile F / H disappeared on a c c o u n t of Severe s t r a n g u l a t i o n of the cord. I n the r e m a i n i n g 2 cases the F ] H disappeared d u r i n g the course of a n i n e r t labour. C r a n i o t o m y was largely used to p r e v e n t u n n e c e s s a r y m a t e r n a l t r a u m a . The p u e r p e r i u m in no case gave rise to anxiety. One p a t i e n t was morbid. I n one i n s t a n c e Caesarean section should have b e e n employed w i t h o u t allowing labour to start. T h e u n s a t i s f a c t o r y r e s u l t of the other 3 were quite fortuitous.

INTERN MATERNAL DEATHS. THE MASTER, DR. ALAN BROWNE a n d DR. H. C. MOORE. There were 8 m a t e r n a l d e a t h s ; one p a t i e n t A. O'D. 15790A, died u n delivered. Six were u n b o o k e d cases. The i n t e r n m a t e r n a l m o r t a l i t y incidence is 0.20 per cent., " b o o k e d " cases, 0,05 per cent., a n d " u n b o o k e d " cases 1"9 per cent.

71 (1) T . C . 12516. P a r a 2. A g e d 32 years. U n h o o k e d . Tiffs p a t i e n t w a s a d m i t t e d as a n e m e r g e n c y c a s e h a v i n g b e e n delivered a t h o m e a n d o u t s i d e t h e h o s p i t a l service. Site h a d . a t t e n d e d t h e h o s p i t a l A / N Clinic a n d h a d b e e n g i v e n a b o o k i n g b u t e l e c t e d t o r e m a i n a t h o m e a n d e n g a g e d a p r i v a t e midwife. T h e h i s t o r y w a s t h a t of a n o r m a l d e l i v e r y a f t e r a l a b o u r of o n l y 5½ h o u r s . H a l f a n h o u r a f t e r delivery t h e m i d w i f e a t t e m p t e d t o deliver t h e p l a c e n t a w i t h o u t success, a n d d e s i s t e d in h e r efforts o n n o t i c i n g t h a t t h e c e r v i x a p p e a r e d a t t h e v u l v a . T h e r e w a s no bleeding. T h e m i d w i f e s u m m o n e d m e d i c a l aid f r o m a local p r a c t i t i o n e r who, on arrival a t t h e h o u s e f o u n d t h e p a t i e n t shocked. H e m a d e o n e a t t e m p t to deliver t h e p l a c e n t a , also w i t h o u t success. H e w a s definite t h a t t h e r e w a s n o bleeding. I I e s e c u r e d h e r i m m e d i a t e a d m i s s i o n to h o s p i t a l . O n a d m i s s i o n t h e p a t i e n t w a s g r o s s l y shocked. B l o o d p r e s s u r e c o u l d n o t b e r e c o r d e d a n d t h e r e w a s no u r i n e in t h e bladder. I m m e d i a t e blood t r a n s f u s i o n w a s s t a r t e d b u t w a s difficult o w i n g to t h e collapse of t h e veins. T h e p a t i e n t was r e s t l e s s a n d c o m p l a i n e d of p a i n in t h e e p i g u s t r i u m a n d in t h e l e f t side of c h e s t . C o n t i n u o u s o x y g e n a n d blood were g i v e n b u t s h e died 30 m i n u t e s a f t e r a d m i s s i o n . O n p o s t m o r t e m e x a m i n a t i o n t h e u t e r u s w a s f o u n d to c o n t a i n t h e p l a c e n t a i n s i t u w i t h o u t e v i d e n c e of h~emorrhage. I t w a s n o t m o r b i d l y a d h e r e n t . T h e lower lobe of t h e l e f t l u n g c o n t a i n e d a t h i n walled c y s t of a b o u t 2 ¥ ' in d i a m e t e r w i t h superficial bull~e o v e r t h e surface. All o t h e r o r g a n s were n o r m a l . T h e c a u s e of d e a t h w a s g i v e n as " s h o c k following a t t e m p t s at e x p r e s s i o n of t h e p l a c e n t a , w i t h possibly as a c a u s a l or c o n t r i b u t o r y f a c t o r t h e r u p t u r e of a b u l l u s of t h e l u n g w i t h s p o n t a n e o u s pneu mothorax." (2) E. O'B. 13504/661. P a r a 3. Aged 30 years. U n b o o k e d , T h i s p a t i e n t w a s a d m i t t e d w h e n at 39½ weeks, on 27/2/'53, at 19.20 h o u r s , h a v i n g received a n t e n a t a l care o u t s i d e t h e service of t h e h o s p i t a l . O n a d m i s s i o n s h e g a v e a h i s t o r y of g e t t i n g a s e v e r e s u d d e n p a i n in t h e b a c k at 19.00 h o u r s o n 27/2/'53, s h e i m m e d i a t e l y c a m e into h o s p i t a l . Life w a s l a s t felt 20 m i n u t e s p r i o r to t h i s p a i n . B a c k a n d a b d o m i n a l p a i n w a s c o n t i n u o u s on a d m i s s i o n , t h e blood p r e s s u r e w a s 90]50, s k i n cold a n d c l a m m y , m o d e r a t e cedema of a n k l e s , n o u r i n e w a s o b t a i n e d on c a t h e t e r i s a t i o n , t h e u t e r u s w a s t e n s e a n d t e n d e r a n d larger t h a n dates. T h e a m o u n t of e x t e r n a l v a g i n a l loss w a s 1-2 o u n c e s , a n d t h e g e n e r a l c o n d i t i o n w a s o n l y fair. A t 20.35 h o u r s s h o c k w a s a p p a r e n t a n d t h e first p i n t of blood w a s s t a r t e d . A t 21.30 h o u r s , B . P . 70/40, a n d t h e m e m b r a n e s were r u p t u r e d w i t h o u t anaesthetic. Cephalic p r e s e n t a t i o n , e x t e r n a l os 3 fingers d i l a t e d a n d well applied, a n d a n a d e q u a t e a m o u n t of clear liquor w a s released. T h e 2 n d p i n t of blood w a s r u n n i n g at 22.10 h o u r s , a n d t h e p a t i e n t h a d a s p o n t a n e o u s d e l i v e r y at 22.25 h o u r s . T h e b a b y w a s stillborn a n d w e i g h e d 6 lb. 15 oz. T h e p l a c e n t a w a s d e l i v e r e d i m m e d i a t e l y w i t h ~-~1 3 p i n t of old blood clot. T h e p l a c e n t a w a s i n f a r c t e d b u t n o t g r o s s l y so. No u r i n e o b t a i n e d on catheterisation. 28/2/'53, at 00.20 h o u r s , p a t i e n t o n 3rd p i n t of blood w h e n s u d d e n d e t e r i o r a t i o n of condition. C o n t i n u a l slight d a r k n o n - c l o t t i n g v a g i n a l loss. D e s p i t e e r g o m e t r i n e u t e r u s n o t r e t r a c t i n g well. B y 02.00 h o u r s c o n d i t i o n u n c h a n g e d e x c e p t p a t i e n t slightly less m e n t a l l y alert. H a l f - p i n t of 30% d e x t r o s e followed t h e 3rd p i n t of blood b u t t h e r e w a s s ' i l l n o u r i n a r y secre*ion. C o n t i n u o u s o x y g e n w a s g i v e n b u t d e a t h o c c u r r e d at 06.15 h o u r s 28/2/'53. C a u s e of d e a t h , " s h o c k following t o x m m i c a c c i d e n t a l h m m o r r h a g e . " A t p o s t m o r t e m e x a m i n a t i o n 2 - 3 p i n t s of blood s t a i n e d fluid were p r e s e n t in t h e p e r i t o n e a l c a v i t y . T h e u t e r u s w a s Couvelaire w i t h e x t r a v a s a t i o n s a t b o t h c o r n u a a n d into b o t h b r o a d l i g a m e n t s w i t h s o m e p e r i t o n e a l splitting. (3) S. P. 13610. P a r a 3. A g e d 25 y e a r s . Booked. A booked c a s e w h o a t t e n d e d t h e A / N Clinic, a n d w a s a k n o w n m i t r a l s t e n o s i s g r a d e II. She w a s a d m i t t e d a t 38 w e e k s in l a b o u r (no h o s p i t a l i s a t i o n p r i o r t o labour). :Had a s p o n t a n e o u s delivery w i t h o u t a n y e v i d e n c e of cardiac failure. F o u r h o u r s a f t e r delivery while b e i n g t r a n s f e r r e d f r o m t h e L a b o u r W a r d to t h e P u e r p e r a l W a r d , h a d a c u t e cardiac failure ill t r a n s i t . She b e c a m e c y a n o s e d , e x t r e m e l y dyspno~ic a n d developed a p u l s e r a t e of 140 w i t h r e g u l a r r h y t h m . D i a g n o s i s of a c u t e left-sided failure m a d e . o m n o p o n } given i n t r a m u s c u l a r l y w i t h d i g o x i n 0.75 m g m s . i n t r a v e n o u s l y . It was t h e n discovered t h a t s h e h a d a h i s t o r y of i n f l u e n z a prior to a d m i s s i o n . T h e condition i m p r o v e d slightly a f t e r r e t u r n to bed, b u t s h e r e m a i n e d dyspnceic a n d cyanosed, a n d coarse rules were h e a r d o v e r b o t h lungs. She w a s t r e a t e d w i t h f u r t h e r o m n o p o n , a t r o p i n e , a u r e o m y c i n a n d penicillin. C o n d i t i o n r e m a i n e d static, w i t h a fast p u l s e b u t r e a s o n a b l e blood p r e s s u r e (150/90). Slight i m p r o v e m e n t w a s n o t e d a p p r o x i m a t e l y 4 h o u r s a f t e r t h e original a t t a c k , b u t t h i s w a s n o t m a i n t a i n e d a n d s h e died 17 h o u r s a f t e r t h e original o n s e t of cardiac failure.

72 A t p o s t m o r t e m e x a m i n a t i o n t h e c a u s e of d e a t h w a s g i v e n a s (a) s u b a c u t e a n d c h r o n i c r h e u m a t i c carditis ( m i t r a l stenosis), a n d (b) a c u t e b r o n c h o p n e u m o n i a w i t h u n d e r l y i n g chronic v e n o u s c o n g e s t i o n . T h i s case h a s b e e n f u r t h e r d e s c r i b e d u n d e r T a b l e I (p. 25). (4) L. M. 13899. P r i m i g r a v i d a . A g e d 26 y e a r s . Booked. This patient was a booked case and developed fulminating toxmmia. This was succeeded b y e c l a m p s i a w h i c h w a s t r e a t e d b y P e n t o t h a l / d e x t r o s e m e t h o d (See E e l a m p s i a Table, p. 32). She w a s delivered b y L.S.S. a n d failed to r a l l y a f t e r o p e r a t i o n . A t p o s t m o r t e m e x a m i n a t i o n c a u s e of d e a t h (a) (b) (c) (d)

e c l a m p t i c lesions of liver a n d k i d n e y . cerebral haemorrhages. u t e r i n e a n d o v a r i a n haemorrhages. inhalation suppurative bronchopneumonia.

I t w a s felt t h a t t h i s p a t i e n t m a y h a v e b e e n o v e r t r e a t e d a n d it is n o t e d t h a t s h e h a d 9.5 g r m s . of P e n t o t h a l in 25 h o u r s . (5) K. :~¢L 14425. P r i m i g r a v i d a . A g e d 3 0 y e a r s . U n b o o k e d . T h i s p a t i e n t w a s a n e m e r g e n c y a d m i s s i o n w i t h b r e e c h p r e s e n t a t i o n a n d a h i s t o r y of 24 h o u r s ' l a b o u r . O n a d m i s s i o n g e n e r a l c o n d i t i o n good. T h e b r e e c h w a s p r e s e n t i n g w i t h p a r t i a l d i l a t a t i o n of t h e cervix. L a b o u r p a i n s were poor a n d irregular. T h e r e w a s no F / H . A v a g i n a l e x a m i n a t i o n w a s m a d e 5 h o u r s a f t e r a d m i s s i o n . T h e c e r v i x w a s half-dilated. U n d e r g e n e r a l a n m s t h e t i c a leg w a s b r o u g h t d o w n a n d a w e i g h t a t t a c h e d . T h e p a t i e n t w a s of n o r m a l build a n d t h e pelvis a d e q u a t e in size. F u r t h e r l a b o u r w a s a w a i t e d . F o r t h e n e x t 20 h o u r s l a b o u r w a s i n e r t a n d little a d v a n c e w a s m a d e . She w a s e x a m i n e d a g a i n a n d t h e c e r v i x w a s f o u n d t o be a l m o s t full w i t h a t h i n r i m only. T h e r e m a i n i n g e x t e n d e d leg w a s b r o u g h t d o w n b y groin t r a c t i o n a n d t h e d e l i v e r y of t h e b a b y w a s effected w i t h o u t difficulty or t r a u m a . T h e p e r i n e u m w a s n o t e v e n l a c e r a t e d . T h e cord w a s t i g h t l y looped r o u n d t h e t h o r a x a n d a r m s , w h i c h w a s e v i d e n t l y t h e c a u s e of t h e e a r l y d i s a p p e a r a n c e of t h e F / H . T h e r e were e a r l y s i g n s of m a c e r a t i o n . T h e p l a c e n t a w a s easily r e m o v e d m a n u a l l y , h a v i n g failed t o s e p a r a t e w i t h . i n t r a v e n o u s e r g o m e t r i n e . T h e r e w a s n o p o s t p a r t u m haemorrhage. N o a n x i e t y w a s felt a b o u t t h e p a t i e n t ' s condition. T h r e e h o u r s a f t e r d e l i v e r y t h e p a t i e n t h a d n o t f u l l y r e c o v e r e d f r o m t h e anaesthetic a n d a p p e a r e d t o be in a v e r y p o o r c o n d i t i o n . She w a s s l i g h t l y c y a n o s e d a n d t h e p u l s e w a s r a p i d a n d of p o o r v o l u m e . T h c r e were n o a b d o m i n a l s i g n s of t r a u m a a n d n o a b n o r m a l v a g i n a l bleeding. A t e n t a t i v e d i a g n o s i s of c e r e b r a l e m b o l i s m w a s m a d e . O n e h o u r l a t e r s h e w a s m u c h m o r e c y a n o s e d a n d r e s t l e s s . T h e t e m p e r a t u r e w a s 99.6 °. A f u l m i n a t i n g anaerobic i ~ f e c t i o n w a s c o n s i d e r e d a n d penicillin 1,0Off,000 u n i t s w a s given. S h o r t l y a f t e r w a r d s a blood t r a n s f u s i o n w a s s t a r t e d b u t t h e p a t i e n t l a p s e d into c o m a a n d died a few m i n u t e s later. A t p o s t m o r t e m e x a m i n a t i o n t h e c a u s e of d e a t h w a s obscure. T h e u t e r u s w a s n o r m a l w i t h n o evidence of t r a u m a . Anaerobic c u l t u r e w a s n e g a t i v e . T h e o n l y positive findings were s u b e n d o c a r d i a l h a e m o r r h a g e s a n d s u b p l e u r a l petechi~e. T h e h i s t o l o g y r e p o r t o n t h e l u n g t i s s u e is of i n t e r e s t . " T h e r e is a p r o n o u n c e d b u t p a t c h y infiltration of t h e i n t e r a l v e o l a r walls w i t h p o l y m o r p h o n u c l e a r l e u c o c y t e s . T h e blood v e s s e l s b o t h capillaries a n d arterioles are p a c k e d w i t h p o l y m o r p h s . O c c a s i o n a l l y s u c h a n i n t e r s t i t i a l p n e u m o n i t i s is a c c o m p a n i e d b y h0emorrhage into t h e alveoli a n d / o r t h r o m b o s i s of arterioles. T h e t h r o m b u s or e m b o l u s r e s e m b l e s fibrin. N o obvious m u c o u s epithelial s q u a m e s n o r m e c o n i u m seen. O e d e m a is n o t p r e s e n t . T h e b r o n c h i a n d bronchioles do n o t c o n t a i n cellular e x u d a t e - - i n a few t h e r e is debris a n d t h i s is a s s o c i a t e d w i t h s o m e m o n o n u c l e a r r e a c t i o n in t h e n e i g h b o u r i n g alveoli b u t it is n o t a s s o c i a t e d t o p o g r a p h i c a l l y w i t h t h e c h a n g e s d e s c r i b e d above. T h e r e is n o consolidation. " C o m m e n t : t h e c a u s e s of t h e l u n g c h a n g e s a r e obscure. T h e closest parallel is w i t h ' a m n i o t i c fluid e m b o l i s m ' b u t f u r t h e r s t u d i e s are r e q u i r e d . " (6) S. R. 14667/142. P a r a 9. A g e d 38 years. U n b o o k e d . T h i s p a t i e n t h a d o n l y 1 v i s i t t o t h e A / N Clinic a n d considered a n u n b o o k e d case, w a s a d m i t t e d a n d h a d a s p o n t a n e o u s c o m p l e t e m i s c a r r i a g e . She w a s 26 w e e k s p r e g n a n t w h e n t h i s occurred. T h e m i s c a r r i a g e s h o w e d a t y p i c a l a c c i d e n t a l h m m o r r h a g e s y n d r o m e . T h e r e w a s a b o u t 1 p i n t of old blood clot b e h i n d t h e p l a c e n t a . T h e c a s e w a s r e g a r d e d a s a c o m b i n e d a c c i d e n t a l ha~morrhage. Oliguri~ d e v e l o p e d o n 3rd d a y a n d v i r t u a l a n u r i a o n t h e 4 t h d a y . She w a s t r e a t e d w i t h modified B u l l ' s diet, b u t on t h e 10th d a y it w a s n e c e s s a r y to i n s e r t a c a r d i a c c a t h e t e r , in order t o i n f u s e 50% glucose. T h r e e d a y s l a t e r c a t i o n e x c h a n g e r e s i n w a s c o m m e n c e d , b u t t h e p a t i e n t died on t t e following d a y . At p o s t m o r t e m e x a m i n a t i o n t h e c a u s e of d e a t h w a s (a) g r o s s r e n a l cortical necrosis, (b) necrosis cf t h e a n t e r i o r lobe of t b e p i t u i t a r y , (c) Couvelaire u t e r u s . See also A p p e n d i x " A ".

73 (7) A.O'D. 15790A. Primigravida. Aged 23years. Unbooked. This patient was admitted when 19 weeks pregnant. She was an emergency admission from another general hospital, with a history of persistent vomiting. A few days prior to admission she had been involved in an incident, during which she received blows on the head and arms. She was kept under observation for 24 hours, and the vomiting became more pronounced. T~enty-seven hours after admission, the vomitus was fmcal and she was becoming dehydrated. There was no clinical evidence of intracranial lesion. Her C.N.S. was normal. A diagnosis of intestinal obstruction was made and the Consultant Surgeon (Mr. Gill) was called. Tkle diagnosis was confirmed and laparotomy was performed at once. She had an intestinal obstruction at the junction of ileum with cmc~m. The obstruction wss caused by t~o thin fibrous bands. There were many caseous tuberculous glands in this area. The constricting bands were divided and the obstruction released. Six hours after operation the intravenous drip was changed, and the patient thought to be better. Ten hours after operation she collapsed and the pulse became irregular. Ten minutes later she was worse and died shortly afterwards. A postmortem examinatioll was performed and the causes of death were as follows : - (1) Tuberculous mesenteric adenitis (with clinical acute intestinal obstruction due to adhesions) ; (2) acute broncho-pneumonia ; (3) pregnancy 26-28 weeks, undelivered ; (4) Periorbital h~ematoma. (8) M. H. 15845. Para 3. Aged ,~8 years. Unbooked. Emergency admission from Dr. Steevens' Hospital, in labol, r at 28 weeks, while undergoing investigation for a "thoracic inlet syndrome." On admission the patient was grossly distressed with marked congestion of lhe face and neck, and with distended jugular veins. The heart sounds were normal and blood pressure 130190. The patient was delivered 22 hours after admission without difficulty. The baby was grossly premature and died later in the Nursery. There was no appreciable change in the patient's condition following delivery and she was returned to Dr.Steevens. I-Iospital on her 4th puerperal da 3 . She died in hospital approximately 1 month later. The final diagnosis was carcinoma of the lung which was confirmed by autopsy.

Commentary. O f t h e 8 m a t e r n a l d e a t h s w h i c h o c c u r r e d in t h e I n t e r n D e p a r t m e n t 3 w e r e possibly avoidable, and 5 definitely unavoidable. The possibly avoidable d e a t h s c o n s i s t of t h e f a t a l cases of e c l a m p s i a , a c c i d e n t a l h ~ e m o r r h a g e a n d p o s t p a r t u m shock. I n t h e f a t a l c a s e of e c l a m p s i a p o s s i b l y e a r l i e r s e c t i o n a n d less e x t e n s i v e t h e r a p y w i t h s o d i u m p e n t o t h a l m i g h t h a v e r e s u l t e d in t h i s p a t i e n t ' s s u r v i v a l . I n t h e l i g h t of f u r t h e r cases of a s o m e w h a t s i m i l a r n a t u r e i t is f e l t t h a t t h e p a t i e n t d y i n g f r o m t o x m m i c a c c i d e n t a l h m m o r r h a g e w a s p r o b a b l y suffering f r o m a b l o o d c o a g u l a t i o n defect. T h e a d m i n i s t r a t i o n o f . h u m a n f i b r i n o g e n m i g h t h a v e h e l p e d in t h i s case. T h e p a t i e n t w h o died f r o m p o s t p a r t u m s h o c k w a s t h o u g h t t o be suffering f r o m e m b o l i s m , a n d t h e e v e n t u a l p a t h o l o g i c a l findings w e r e obscure. A n u m b e r of cases of s e v e r e s h o c k h a v e b e e n e n c o u n t e r e d w h e r e t h e a c t u a l b l o o d loss w a s m i n i m a l . T h e s e h a v e r e s p o n d e d t o v e r y r a p i d a n d copious t r a n s f u s i o n . H t h i s t y p e of c a s e w e r e to be e n c o u n t e r e d again, I c e r t a i n l y t h i n k t h a t t h i s ( n a m e l y , m a s s i v e r a p i d t r a n s f u s i o n ) should b e t h e i m m e d i a t e line of t r e a t m e n t . I t is possible t h a t t h i s p a t i e n t m i g h t h a v e s u r v i v e d h a d t h i s b e e n d o n e . I t is a d m i t t e d t h a t t h e g i v i n g of b l o o d in t h e absence of b l o o d loss a p p e a r s e s s e n t i a l l y to be i r r a t i o n a l . T h e m a t e r n a l d e a t h d e t a i l s will i n d i c a t e w h y I c o n s i d e r t h e o t h e r 5 d e a t h s to ,be c o m p l e t e l y u n a v o i d a b l e . H a d t h e c a r d i a c case n o t n e g l e c t e d herself w h e n c o n t r a c t i n g i n f l u e n z a one w e e k before a d m i s s i o n , she m i g h t h a v e survived.