THE 
MEDICAL EXAMINER, 
AND 
RECORD OF MEDICAL SCIENCE. 
NEW SERIES.—NO. LI. —MARCH, 1849. 
ORIGINAL COMMUNICATIONS. 
THE HEART-CLOT. 
To the Editors of the Examiner: 
Gentlemen : I beg leave, through the columns of your useful 
periodical, to present the statement of certain opinions I have 
long entertained, relative to points in pathogeny connected with 
the occurrence of endo-cardial coagula ; and I do so, because I con- 
sider them deserving of serious consideration by the practitioner. 
These opinions are connected with certain points of practice or 
treatment that are, in many cases, indispensably necessary for 
the safety of the sick ; and my sole desire in offering the com- 
munication, is founded on the hope that it may tend to prevent 
some disastrous events, which the want of a little reflection might 
allow. 
~ ' l"believe it is a fact, not to be controverted, that in an animal 
slowly bled to death, the first portions of blood extravasated, co- 
- agulate less readily than the last portions. If this doctrine is 
true, it follows that the coagulability of the blood left in the ves- 
sels after great hemorrhages is augmented : I have had several 
occasions to find that it is dangerously augmented. 
VOL. III. 142 
Original Communications. 
[March, 
To take one of the most ordinary cases of hemorrhage—I mean 
that occurring after labour, or in abortions—we have an instance 
in which, even after the arrest of the bleeding, the patient is exposed 
to mishap from the coagulability of the blood remaining in the ves- 
sels. Loss of blood produces a tendency to fainting, or lipothymia: 
during an attack of fainting, the motions of the heart are enfeebled, 
the diastole slow—torpid, for the blood moves languidly in both 
the venae cavae, pours itself out in a slow current into the auricle, 
which it sluggishly distends, and sometimes is then instantly con- 
verted into a solid clot. If a clot be formed in the right auricle, it will 
also be formed in the iter ad ventriculum dextrum filling up the cone 
of the tri-cuspid valve; and the nucleus of it will cause the coagulum 
at length to occupy the cavity of the right ventricle, and extend 
itself to a greater or less distance along the tract\g£ of the pulmo- 
nary artery. If the whole pulmonic side of the heart should be 
perfectly occupied in this way, the death of the individual would 
be instantaneous ; and I doubt not, that many of the examples 
of sudden death, after delivery in hemorrhagic labours, are pro- 
duced by the formation of cardio-morphous coagula whiph form 
in the instant of a state of fainting, or is under- 
stood, that the young Princess Charlotte, whose Tieath at Cler- 
mont cast a mournful gloom over the whole British Empire, died 
within fifteen minutes after the birth of the princess, and that 
there was no very considerable hemorrhage, no laceration, nor 
other incident that might fitly explain the suddenness of her de- 
cease. Many vvomen are known to perish in this manner. I have 
been the eye-witness of instances of the kind. I have also 
seen a very great number of persons, who appeared to me to be in 
danger of perishing in the same way, but who escaped a fate so 
deplorable. I am aware also of instances in which women, after 
considerable hemorrhagic losses, have been esteemed by their phy- 
sicians to be what is called doing well, during a space of from 
one to seven days, but who afterwards becoming instantly 
tremely ill, have perished without remedy in from two to twenty 
days thereafter. jj-Jr 
If a surgeon, desirous to reduce a luxated humerus, should 
attempt to do so, he might find the resistance of the muscular con- 
traction so great as to prevent his success, and he would therefore 
probably resolve to take away the resistance of the muscular con- 1S49.] 
Meigs On the Heart-Clot. 
143 
traction, by bleeding his patient ad deliquiinn. The surgeon 
knows that the deliquiura would take effect upon the loss of a 
much smaller quantity of blood if the patient should be placed 
upon his feet in a standing posture, than if he were to recline upon 
his bed in a low recumbency. He would bleed the man 
while in an erect position. This ordinary practice is conform- 
able with the dictates of experience in all cases of fainting, for it 
is well known that an individual will faint more readily in a ver- 
tical than in a horizontal position ; and the first idea that is 
obvious to any medical man in a case of fainting is this—that he 
shall cause the patient to be laid with the head very low, taking 
away for the time even the pillow. I have on many occasions, 
besides taking away the pillow, found myself under the necessity 
of elevating the foot of the bed by placing books or blocks under 
the lower bed-posts in order to favour the determination of blood 
to the encephalon; for I conceive that in all cases of fainting the 
brain has become oligsemic. 
I may assert the opinion that fainting is oligaemia of 
the encephalon, and that a hypersemia of the encephalic bulbs 
is the very converse of and absolutely incompatible with the 
state of swooning. To raise up a woman who has within the 
few days past lost a considerable quantity of blood is almost 
inevitably to bring on deliquium. Now, if the idea be just that 
hemorrhage renders the remaining blood more coagulable, 
then it follows, that to take the woman out of bed, or to let her 
sit up in bed, is to expose her to the hazard of forming a coagulum 
in the right auricle, which, by extension of the nucleus, may fill 
the ventricle, occupy the aperture of the tricuspid, and pass several 
inches upwards in the course of the pulmonary artery and its 
branches. Monthly nurses, and the ordinary attendants of the sick 
know nothing of these things, and they hesitate not, oft-times, to 
exhort or to permit the ansemical accouchee to rise and sit for a 
few moments for purposes that might be answered without quitting 
the horizontal position. — 
A lady was taken in labour in the afternoon. She saT"m her 
arm-chair all night without sleeping : at five o’clock in the 
morning she placed herself upon the bed and the child was born 
in half an hour. The placenta was spontaneously and perfectly 
extruded, nothing being left in the womb : it was her fifth labour. [March, 
144 
Original Communications. 
Within an hour she had hemorrhage—the vagina and uterus con- 
tained large coagula which were turned out by the physician, 
whereupon the hemorrhage ceased: she may have lost altogether 
some thirty ounces of blood. He remained near her for several 
hours. At mid-day, throughout the afternoon, and during the fol- 
lowing night, she appeared to be perfectly well. At half-past 
nine the following morning the physician made his visit; she was 
without pain or the least indisposition, nor had she any symptoms, 
save those that appertain to the condition of a healthy accouchee. 
Her pulse was about 75 beats per minute ; the respiration, tem- 
perature, and hue, satisfactory to the medical attendant; her 
complacency, physical and moral, was absolute. 
The physician left her at 10 o’clock in the morning. Being sum- 
moned again, he reached her apartment at one, P. M., and found her 
in a state, which led him to suppose that she might be near dying. 
The pulse was 164 per minute, very feeble and thread-like ; the 
hands were cold, and the respiration was performed apparently by 
the strong effort of her will only. XpeVespiratory acts were performed 
with great violence, and without rythm. Auscultation of the heart 
disclosed a feeble impulse, with great irregularity of the systolic 
action. She had lost no more blood beyond the ordinary lochial dis- 
charge ; the vagina wffiich was examined contained no coagulum. 
When I came into the apartment at 3 o’clock, P. M., she sup- 
posed herself to be in a dying state and asked me if I thought 
she would live half an hour. It is difficult to conceive of a 
spectacle of more extreme physical distress than that presented 
by this dying lady. Every respiratory act was attended with vio- 
lent pain referred to a place near the lower extremity of the 
sternum, as in angina pectoris. Palpation of the abdomen and 
questions relative thereto, showed nothing abnormal there. Upon 
retiring for consultation, I expressed to my medical brother the 
opinion that the pulmonary heart was filled with a coagulum or 
false polypus ; the prognostic, therefore, was necessarily fatal. 
She had been left at 10 o’clock in the morning with a pulse at 
75, and in the course of the forenoon she had been taken up from 
her recumbent position, and allowed to sit upon the close-stool 
for the purpose of evacuating the bladder of urine, immediately 
after which she was ill, and the physician sent for. 
I made this diagnostic upon these grounds, viz : I said, there 1849.] 
Meigs On the Heart-Clot. 
145 
is no pathogen ical principle that I know of that can explain 
the change of her pulse from 75 to 164, in so short a time, 
save that of a mechanical obstruction formed by a clot or 
tampon filling up the cavities of the heart. It is clear that 
there is no scarlatina, no variola, no fever of any kind—no attack 
of Asiatic cholera nor other malady, that is capable of making so 
soon, so great a change in the action of the heart as is here ob- 
served. The patient had hemorrhage yesterday, which has in- 
creased the coagulability of her blood ; she was taken out of her 
recumbent position and placed upright in bed, whereupon she 
became suddenly ill in consequence of the coagulation of blood in 
her auricle, and there is no power that is able to remove this tam- 
pon from the cavity of her heart; it will destroy her as effectually 
as would a musket ball deposited in the ventricle. 
The respiration in this case was carried on, at the time of my 
arrival, solely by the force of the voluntary power. There seemed 
to be no rythmical respiration whatever; when she ceased to 
breathe by her volition, her respiration appeared to be suspended 
altogether. As might be expected, these voluntary aspirations were 
not rythmical, but interrupted, uncertain, having long intervals. 
The blood that came up from the inferior cava and down from the 
upper cava, must have passed with great difficulty between the 
superficies of the clot, and the paries of the heart. It must have 
moved in small quantities only through the tricuspid, and when 
distending the pulmonary ventricle, that ventricle could contain 
but a small portion of fluid blood, being mainly occupied by 
the coagulum. A similar difficulty existed as to the efflux 
of the blood along the pulmonary artery, which was tamponed 
at the time with a cylindrical clot extending several inches 
along the vessel and its principal branches. Under these 
circumstances, the quantity of carboniferous blood entering the 
lungs by the pulmonary artery, for aeration, could be a small 
quantity only; hence the violent almost spasmodic protracted 
efforts to aspire the air of the atmosphere ; efforts which, however 
great, must measurably fail of the purpose of abolishing the direful 
sense of pulmonary oppression, or respiratory distress, or to 
use a more concise term, asphyxiation. The quantity of blood in the 
lungs was too small to receive the endowment of oxygen which is 
requisite to preserve any individual from a feelii g of suffocation ; 146 
Original Communications. 
[March) 
and however thorough might have been the aeration of the small 
quantity that was there, however brilliant and florid may have 
been its arterial hue after being breathed upon, the quantity of 
oxygen imparted to it must necessarily be insufficient so to act 
upon the nervous mass, the neurine, as to hinder the conscious 
principle from perceiving the sense of asphyxiation. With a heart 
situated in this manner—with the utter impossibility of thoroughly 
oxygenating the sanguine mass, the innervation gradually fails— 
a failure which is manifested in the decadence and ultimate over- 
throw of the various functions. All the functions are but the ex- 
pressions of the biotic force that is sent down by the encephalic 
bulbs and spinal cord to the distal points of the nerve-fibrils in the 
organs. Every acinus of a gland is alive solely by the nervous 
force which comes into it by the fibril that connects it with 
the nervous mass, to obey whose mandate is to live, while to fail 
of receiving it is command to die ; the same is true of every part 
and particle of the histological constitution. 
As the encephalic bulbs certainly cease to irradiate the organs 
when they themselves cease to receive through the oxygeniferous 
streams injected into them by the carotids and vertebrals, the 
supplies of oxygen which alone enable them to evolve the life force, 
the nerve force, the lebenslcraft, the biotic force—it follows, that 
the organs die in the same ratio as those bulbs fail and perish. 
One is not surprised, therefore, upon observing that a person in 
good health, like this unfortunate lady, the right side of whose 
heart becomes suddenly, instantaneously tamponed by a coagulum, 
should fall a victim, and that speedily, not to the presence of the 
clot alone, but to disease developed in other parts, whose life is 
overthrown in consequence of the obstruction of the prime organ 
of the circulation. Only a few houis could pass with a large 
coagulum in the heart, before the pericardium would begin to be 
filled with serum, or the embarrassments in the pulmonary circula- 
tion seek in vain for relief, by pouring out a vast effusion 
of wrater into the cavities of the pleura ; or the innervative force 
being withdrawn from the viscera contained within the abdomen, 
whose venous blood is prevented from flowing off through the 
pulmonary artery, there is set in motion in the peritoneal sac, a tide 
of effusion filling it up in the course of a few hours. 
In all such cases as those of which I am speaking, the escape 1849.] 
Meigs on the Heart-Clot. 
147 
of the blood from the venous side of the sanguine circle is 
retarded, with the effect of producing enormous engorgements 
of all those venous branches, which usually and readily allow their 
products to run off through the ascending and descending cavse. 
Let the reader perpend for a moment the condition of that portion 
of the vascular system which receives aortic injections by the 
caeliac and the superior and inferior mesenteric arteries: let him 
reflect that the whole of this torrent, which is entirely expended 
upon the chylopoietic and alimentary organs, is first col- 
lected by the capillary radicles of the portal vein, then dis- 
tributed again among the capillary termini of the hepatic porta, 
whence it is a second time collected to flow off by the hepatic 
veins. Now, if the auricle and ventricle are tamponed by an endo- 
cardial coagulum, this whole torrent is inevitably arrested, and 
the cavities become immediately engorged by the continued injec- 
tions from the aorta, leaving no grounds of astonishment as to 
sudden or fatal derangement of the healthy states of the tissues 
that are developed by it. 
The time required for extinguishing the life of the sufferer is a 
variable time; one relative to the magnitude and extent of the coag- 
ulation. Y^varvJjj»ag-kuuthat-in-the Pr 
alpeady-al-k-Kled eoa g uium-Av-a-s—forrne(1 wh-i-eh-fi-l Irebffrfr-h-e-art 
SCLimm-ple t e 1 y -to-i-trs-a-e-t ion-- wrttrirrffftxl7TTrTmin-utte s 
pr incase. My-paticnt-abovc m-sn-ttetreffi lived 
forty-eight hours after the occurrence of the accidentTcluring 
which time she suffered the most inexpressible respiratory distress. 
She filled her pericardium with serum, while her peritoneal cavity 
became also the subject of a great effusion. Upon examining the 
heart twenty-four hours after her decease, one might feel surprised 
that her life could be so long protracted, since the auricle, tricuspid, 
and ventricle were completely tamponed with a clot which was 
not an enthanasial clot, but consisted apparently of a firm, 
whitish-yellow mass of fibrine, out of which every particle of 
heematoglobulin had been washed away, or expressed. An entha- 
nasial clot is, in my opinion, necessarily a red one; a pre- 
enthanasial one ought to be white. 
A patient in this city was delivered early in the morning. Soon 
after the birth of the child and the delivery of the placenta, the 
physician descended to the breakfast room, having given strict 148 
Original Communications. 
[March, 
charge that the patient should preserve the recumbent position, 
and be kept quiet. While at his breakfast, cries from the top of 
the stairway called him, for “ God’s sake,” to hasten to the assist- 
ance of the patient. In a moment he was at her bed-side, where 
he found her already dead, having fallen backwards across the bed 
with her legs hanging over its side. He was told that she had 
said to her nurse, “ I wish to get up,”—“ The Doctor says, 
madam, you must not get up, if you please.” “ But I must get 
up, I will get up.” She threw her feet out of the bed, and rose 
up sitting upon its edge ; her head reeled to and fro, and she fell 
back and expired. No examination was made of the dead body, 
but I ask the reader to explain the cause of this sudden death, 
otherwise than by the rationale that her heart ceased to beat be- 
cause it became instantly filled with an immovable clot. 
Man cannot die, save by the cessation of activity in the brain, 
or in the heart, or in the lungs : he lives within this triangle, and 
can only escape at one of its angles. He must die by the brain, 
or by the heart, or by the lungs. It is to the last degree improbable 
that this woman perished solely because her brain ceased to evolve; 
but if it did not instantly cease to evolve, it must 
to be the cause of motion everywhere. If the heart, as I suppose, 
became instantly filled with congealed blood, so that it could no 
longer receive nor discharge any portion of that .fluid, the nervous 
mass would cease to live as soon as i-t should have consumed all 
the oxygen contained within its capillary vessels at the moment of 
the arrest of the cardiac circulation. The patient died by the heart. 
A lady was confined in a natural labour, giving birth to a healthy 
child, at term. She lost a considerable quantity of blood at the 
time of the extrusion of the placenta, which left her feeble and 
pale. Her physician directed her to be kept quiet. She had a 
good day, and following night. At the morning visit the physi- 
cian found her comfortable, and her condition was satisfactory to 
him. Soon after he left her apartment she was seized with vio- 
lent alarming illness, whereupon he was recalled, and was again 
present after the lapse of about an hour. Her pulse was extremely 
frequent, feeble, and small; it continued frequent until the moment 
of her death, which took place about the nineteenth or twentieth day. 
On the eighteenth day, I think, I saw the lady, and formed the 
opinion that she was perishing on account of a false polypus, 1849.] 
Meigs On the Heart-Clot. 
149 
clot, or tampon in the heart, established there by the imprudent early 
uprising after a hemorrhage. After her death a great quantity of 
water was found in the cavity of the right pleura, while a firm 
white coagulum, entirely destitute of corpuscles, was detected in 
the right auricle, filling up very much the cone of the tricuspid, 
while the ventricular end of it seemed to be torn or threshed to 
pieces by the cordae tendinese, which during so many days, had 
been vainly occupied in the endeavour to demolish it. The filling 
up of the pleura wTith serum was a natural consequence of the con- 
dition of the respiratory organs, quite as much so, but not at all 
more so, than was the filling up of the peritoneum and pericar- 
dium in the former case, consequences of the arrest of the circu- 
lation in the cava and its branches. 
Towards the end of the year 1848, a primapara gave birth to 
her first child. She was tall, very slender, and delicate; the pla- 
centa was not removed ; she lost a good deal of blood. Between 
forty and fifty hours after the birth of the child, upon being called 
to her succor, I removed the placenta from the cervix uteri in 
which it was grasped and detained. I removed it with the index 
finger of my right hand. The stench of it was noisome to the last 
degree. The putrid odour of it remained upon my hand for 
twenty-four hours, notwithstanding every effort to remove it. The 
patient was pale, and her pulse somewhat frequent, presenting the 
usual characteristics of the anaemical pulse. On the following 
day she was comfortable; the milk was secreted,the lochia healthy, 
and she was doing well, though still very pale. On the seventh 
day, she was placed in a chair before the fire, sitting up : she imme- 
diately felt sick, was put to bed, and I being called in to see her, told 
her friends that she had formed a fatal coagulum in the heart. She 
lived about forty-eight hours after the accident; I did not examine 
her body. I leave the reader to judge whether my diagnostic 
was or was not probably correct. She had a pulse upwards of 
160—the impulse of the heart feeble—the respiration disturbed— 
frequent. 
On a great many occasions since I have been a practitioner 
of medicine, I have been called to see patients, who, after 
hemorrhagic labours, have disobeyed my injunctions as to horizon- 
tal rest, and who being prematurely lifted upright in bed, had faint- 
ed. I have not a doubt that among those of these persons in whom 150 
Original Communications. 
[March, 
I found the heart fluttering, irregular and feeble in its action on my 
arrival, incipient coagulation existed. I have thought as I entered 
the room of a patient, that her auricular blood had begun to thicken, 
but was driven out from the auricle before its thorough coagu- 
lation, in consequence of the startling effects of a dash of cold 
water upon the face, or of clapping the hands, or snatching the pil- 
low from under the head and shoulders, allowing the head to fall 
so as to favour the restoration of its vascular tension or even hy- 
peraemia, and thereby re-establishing the perfect and powerful ex- 
trication of its innepative force. The re-excitation of the innerva- 
tive force of the brain would probably soon enable a heart so 
situated to discharge itself of the inchoate coagulum. 
It is not needful that I should draw out this paper to any great 
length; nor that I should discuss the reasons why so many autop- 
sies present the evidences of the endo-cardial clot of which 
I have spoken, without having excited in the mind of the attendant 
practitioner, the suspicion of its presence before the death of the 
patient. It appears to me, to be enough for the present occasion, 
to propound the question, Can a patient with a white clot in the 
auricle and ventricle recover ? If such a clot be a small one, the 
pulmonary circulation, although checked, is not necessarily sus- 
pended, but the nucleus of such a clot, like the nucleus of an 
urinary calculus, tends constantly to increase in size, and hence 
a small coagulum, which strangely disturbs the action of the heart, 
may consist with a considerable protraction of the struggle against 
its fatal power over the circulation. The gradual augmentation 
of the volume of the clot, and its extension into the pulmonary 
artery and its branches must in every case lead to an inevitable 
dissolution. I have not the least confidence in the power of alka- 
line medicines to dissolve such coagula, nor do I admit that the 
dull white endo-cardial coagulum so often discovered is the result 
of a state of endo-carditis; but I rather attribute its occurrence to 
a temporary stasis or near approximation to stasis during a state 
of fainting in an exhausted patient. Its occurrence after hemor- 
rhagic labours, or upon the almost total suspension of the circula- 
tion at the cessation of an attack of puerperal eclampsia ought not 
to excite surprise. If a coagulum should fill the auricle and the 
tricuspid valve completely and at once, the death would be al- 
most instantaneous and the clot would be found red. If the pro- 1849.] 
Meigs On the Heart-Clot. 
151 
cess of its formation should be long protracted it would be dull 
white. 
I did not design in this paper, to speak at all of the entha- 
nasial coagulum ; it is perhaps quite normal that some portions 
of the blood last reaching the heart, at the moment of death, 
should congeal there. 
In regard to the diagnosis of cases in which the endo-cardial 
coagulum becomes suddenly constituted, as in the examples of 
which I have spoken, it appears to me that the medical observer, 
in order to make it, must resort to a method which is only to be 
fitly characterized as transcendental diagnosis. It is true that the 
feeble impulse and almost complete suspension of the sounds of 
the heart, might sene as a quasi physical diagnosis of however 
little value. 
By transcendental diagnosis I mean one made by a process of 
the mind, fitter to be called sentiment or conviction, than a 
ratiocinative progress. 
To enter an apartment one has quitted only half an hour be- 
fore, and to find a patient hopelessly ill with signs of imminent 
death, yet who had no serious symptoms of illness before—to find 
her making desperate voluntary efforts to breathe, without any 
signs of laryngeal or phrenic or pulmonic inflammation or acci- 
dent—to see the face pale and ghastly—to observe her conscious 
sense of impending asphyxiation from loss of oxygen—without 
the leaden or iodic hue of a general cyanosis—These are the 
grounds of a diagnosis which may be called transcendental, one in 
which the consciousness of the physician informs him that a 
mechanical obstruction within the heart exists, and that such an 
obstruction alone can give rise to the phenomena. 
In all the lingering or sudden progressions of the accidental 
disorders supervening in endo-cardial coagulum, no purely cyanotic 
manifestations have met my -—' ■ 
Writers on cyanosis mostly refer symptoms to the 
backing of the carboniferous blood of the veins into the capil- 
laries. You, Messrs. Editors, are aware that I have maintained 
the opinion that cyanosis is, in its essence, not blueness of the 
surface, but a state of the nervous mass produced by the absence 
of oxygen in the brain-capillaries. 152 
Original Communications. 
[Marcn, 
The writers, and among them, perhaps in chief, Professor 
Rokitansky in his Pathologischen Anatomie, contend that cyanosis 
depends most commonly upon constriction of the orifices of the 
great vessels of the heart, preventing the venous blood from esca- 
ping from the cavm by the routes of the heart. Now, I aver that 
no obstructions existing in the vessels of the heart can be more com- 
plete than that depending upon a large endo-cardial clot, or tampon; 
and yet I venture to say that under circumstances of such kind the 
victim perishes without manifesting the peculiar livor or cyanotic 
tinge which characterizes the forms of the malady, that are connected 
with open foramen ovale and imperfect action of Botalli’s valve. 
It is my clear conviction, that as long as the respiration can be 
carried on in endo-cardial clot, the blood, however small in 
quantity that reaches the lung passing along the superficies of 
the clot, is highly charged with oxygen. While, therefore, 
oxygeniferous blood continues to reach the brain, the patient, 
though conscious of the want of oxygen in due quantity, is in a 
state different from that of one who injects only carboniferous or 
venous blood into the neurine of the encephalon. 
My intention was to speak only of the white clot, the false 
polypus, to show the probability of its being formed under circum- 
stances of deliquium, in the oligaemia that follows uterine hemor- 
rhage ; and thereupon show how dutiful a thing it is on the part 
of the attendant physician, to issue the clearest and most precise 
orders as to the guidance of the hemorrhagic accouchee. I believe 
that a woman who has lost a very great quantity of blood, and 
who is prematurely taken out of her recumbent decubitus, and 
placed upright upon the close-stool; whether in bed or not, 
incurs a most dangerous risk of a miserable and premature death, 
from the sudden formation of a heart-clot. 
I am gentlemen 
Your ob’t servant, 
Charles D. Meigs.