Observations on Endo-Cardial Coagula. By Marcus Dana, M. D.,
of Seneca county, Ohio.
The heart-clot, as cause of sudden death, has been almost en-
tirely overlooked, and is probably of much more frequent occur-
rence than many of the Medical profession suppose.
Formerly, in the course of autopsies of persons who died
suddenly, if either ventricle of the heart was found occupied by a
recent coagulum, it was, generally, supposed to have been formed
after the death of the individual.
The white clot, which has been noticed from time to time, was
considered as a polypoid concretion, and was supposed to originate
in a morbid condition of the heart itself; though in some French
reports w’hich I have seen recently there are some intimations of
its true character.
A monograph was offered at the Concours for the chair
Pathologie Interne at the Faculty of Paris, when MM. Piorry,
Broussais, Dubois, and Gibert were candidates. M. Piorry was
elected. The subject was, “Changes of the Blood in Disease,” and
some observations were made which have- a bearing upon the sub-
ject under consideration, showing, however, that it was quite im-
perfectly understood at the time when those reports were made.
The polypiform concretions of the heart admitted by Malpighi,
(oper. omn. 1666, de polypo cordis) and by many later writers, es-
pecially the philosopher and skilful practitioner Fr. Hoffmann,
(Med. ration. Systemat. tom. 4, p. 3, 1738, Cap. 1, De Palpita-
tione Cordis,) and by the celebrated Vanswieten, (Comment, in
Aphor. tom. 3, in 4to. 1758, §1010,) who ascribed to them the
symptoms of grave organic lesions of the heart, were disputed by
Morgagni, Senac, Pasta. Epist. de Cordis polypo in dubium re-
vocat. Bergame 1739, and Lieutaud. Corvisart and Laennec
hardly admitted their formation during life, except in some rare
cases, and a short time before death. Recent facts have demon-
strated that such concretions may exist during life.
M. Ferris at one of the sittings of the Academy of Medicine,
(1828) reported that in a venesection, he had drawn from the vein
of an arm, which became suddenly swollen and of a livid or blue
color, a coagulum of considerable length. M. Velpeau exhibited
at the same time to the same audience a vena cava filled by a cen-
tral non-adherent coagulum, which had been arrested by the emul-
gent veins, and exhibited in some places a degeneration like
medullary matter.
Bouillaud (Traite des Maladies du coeur) offers among other re-
markable examples the curious fact of a heart, the right auricle of
which was nearly filled with a soft glutinous coagulum, contain-
ing in its centre vesicles filled with a semi-concrete fluid, tra-
versed by an infinite number of bright and dark red vessels.
M. Blaud de Beaucaire in a memoir in the 4th vol. 1833 of the
“Revue Medicale,” has collected a great number of facts derived
from various authors and from his own practice, which go to es-
tablish the existence of these polypiform concretions of the heart.
According to him many cases of sudden dyspnoea, deranged circu-
lation, asthmatic affections, and palpitation of the heart, appearing
suddenly and inexplicably, depend on such concretions during
life.
The principal causes to which modern writers have attributed the
formation of these clots, are the stasis of the blood during syncope,
or organic lesions of the heart, or inflammation of its membranes.
Among the late writers on this subject, (who are few) Prof.
Meigs has contributed largely, and I believe is the first to call the
attention of the profession in the United States to this subject, and
I am not aware that any author on either side of the Atlantic has
so clearly pointed out its true pathological character. He has es-
tablished the fact that this clot can form in a moment during syncope
under certain conditions of the system arising from- great loss of
blood, and that such an accident may cause death instantaneously
if the clot is large, filling the pulmonic side of the heart. Or
if partial, the action of the heart upon recovery from the syncope
may press out the red corpuscles after a time, leaving the fibrinous
portion retained within the cavity of the heart, constituting the
white clot. In this case the individual may linger in a miserable ex-
istence for days, months, or years. On this particular point, he has
given his views on sundry occasions before his Class in Jefferson
Medical College, (which views he has entertained for many years)
and also in an article which appeared in the March number of the
“ Medical Examiner,” for 1849. To that interesting article
the reader is referred particularly for the post mortem appearances
there reported, as .they go to establish the position he has taken.
This throws a flood of light upon the cause of many of those
sudden deaths which every practitioner of experience must have
observed to take place during or soon after syncope, from great
loss of blood, particularly connected with parturition.
It is now admitted to be a fact, that the last portions of blood ef-
fused in an animal slowly bleeding to death, will coagulate much
sooner than the first portions extravasated. The tendency to coagu-
lation within the vessels, it will be inferred, will then be in a ratio
to the loss of this vital fluid. What gives it this tendency in propor-
tion to its exhaustion is not exactly known. The coagulation of
the last portions mentioned, will take place much more quickly
than the first, but the clot will be less firm. The coagulability at
the natural temperature of the blood is due to the fibrin it contains.
But the question that here presents itself is, what produces the
tendency to such a sudden coagulation ? Carpenter says that
“ simple arrestment of nervous influence favors the coagulation of
blood within the vessels ; clots being formed a few minutes after
the brain and spinal marrow have been broken down.”
Is it not probable that the temporary paralysis of the small
branches of the pneumogastric and sympathetic nerves (which are
distributed to the inter-cellular passages and air cells of the lungs
during syncope,) may have the principal agency in this pheno-
menon?” Thus the flow of blood through the lungs being arrested,
the pulmonary artery is immediately distended with blood, and can
receive no more from the heart. The vena cava continues pouring
blood into the right auricle, and at this moment, by slowly dis-
tending it, the blood is converted into a clot.
“ If a clot be formed in the right auricle, it will also be found
in the iter ad ventriculum dextrum, filling up the cone of the tri-
cuspid valve, and the nucleus of it will cause the coagulum to
extend into the cavity ' of the right ventricle and pass to a
greater or less distance along the tractus of the pulmonary artery.
If the whole pulmonic side of the heart is occupied in this way, the
death of the individual would be instantaneous.”—{Prof. Meigs.)
It will be seen that the first link in this chain of morbid phenomena
is encephalic anaemia. It therefore follows that if this paralysis,
dependent on anaemia of the encephalon, should in most cases be
temporary, reaction would take place upon the application of
proper means to restore the circulation to the brain, were it not
for the mechanical interference with the heart’s action; perma-
nent asphyxia taking place, which might under other circumstances
have been of a temporary character.
That coagulation does take place under these circumstances, is
sufficiently proved by the white clot which is seen on examination
of persons who have died under symptoms arising from a sudden,
though not complete, interference with the due arterialization of
blood, which in this, as well as other forms of asphyxia, is the
immediate or proximate cause of death. And yet a sufficient
amount of oxygen has in many such cases been furnished to support
the system for an indefinite period of time, depending on the ex-
tent of coagulation.
Inferior animals undoubtedly would be found to perish in the
same way, if it could be shown that great bodily exhaustion is pro-
ductive of a condition of the nervous and vascular system similar
to that developed in man. It is no uncommon circumstance to see
that noble animal, the horse, (which a moment before, to all appear-
ance, was in good health, excepting from exhaustion from severe
muscular exercise,) fall and expire in a few moments, or partially
recover and linger for some time, but never afterwards to be fit for
service. He is said then to be “ overheated ” or “ broken-winded.”
The case of my own horse, given hereafter, is supposed to be appro-
priate to the present question. It may go for what it is worth, to
show that great bodily fatigue may produce the clot in question.
I will first proceed to describe a few cases of heart clot, as I am
at present convinced they were, though at the time of occurrence of
the first two mentioned, the cause was veiled in mystery, so far as
my own knowledge went.
In the Fall of 1838 I was called to attend Mr. H., about 30
years of age, of good constitution, but who had been attacked
some two or three weeks previously with nasal hsemorrhage, which
recurring daily, had reduced him very much, so that he was com-
pelled from weakness to keep the recumbent position. The haemor-
rhage was produced by lifting heavy weights, producing deter-
mination to the head. I encountered much difficulty in arresting
the epistaxis, but in a few days it ceased. He continued some
days in a very debilitated state, and at length began slowly to
convalesce. During this time his pulse was about 60 to 65 and
regular, with respirations at 16—appetite good, bowels regular. I
could discover no signs of organic or functional disorder about him.
In about a week from the cessation of the haemorrhage he
rose up for the first time, in the act of taking nourishment.
Deliqium ensued immediately. He was replaced in the horizontal
position, and partially recovered. At this time I was sent for, as
he continued in great distress. I arrived in an hour and a half
from the time of the fainting fit, but he had expired only a few mo-
ments before my arrival.
From his wife, a very intelligent woman, one who had had
much experience as a nurse, I obtained the following history of the
last symptoms of the man’s case: After the fainting as above de-
scribed, his respiration became laborious, with great heaving of the
chest, and distress there. The pulse, which before he was raised was
about 65, now became about 160, or, as she said, as fast as she
could count. (She had been instructed to examine his pulse
from time to time whilst the case was in my charge.) Coldness
of the extremities; and great anxiety of countenance were noticed.
These symptoms becoming more and more aggravated, he at length
expired, as if by suffocation, accompanied by slight convulsive
struggles, retaining his mental faculties till a short time before
death. There was no blueness about the face, or turgidity of the
vessels of the neck.
In August, 1840, I was called to attend Mrs. P. in her second
accouchment, accompanying which no untoward circumstance oc-
curred, save rather profuse hemorrhage in consequence of a too
adherent placenta. She lost a considerable quantity of blood
before the cause could be obviated, and had a fit of syncope.
Reaction soon took place, the w’omb contracting to its normal size
after labor, and becoming sufficiently firm, and the patient cheerful.
I now considered her safe. The night being well spent, and my
own residence some eight miles distant, I concluded to tarry till
morning, and retired, charging my patient to keep herself per-
fectly still, as possibly a renewal of flooding might ensue. About
an hour afterthis she insisted on getting up, in obedience to calls
produced by some kind of purgative which she had taken in the
early period of labor.
The ladies present tried in vain to persuade her to abide by my
injunctions, and endeavor tomanage without rising. She replied that
“ the Doctor is asleep and will not find it out,” and succeeded in
getting out of bed. Syncope took place immediately. The “Doc-
tor” was aroused from his repose to witness one of the most ap-
palling spectacles that can be imagined—the sudden and unex-
pected death of his patient. There were a few struggles, appa-
rently to get breath ; small vibrating or fluttering pulse, and cold
extremities. She lived but a few minutes. In this case there
had been but little hemorrhage from the time of the complete
extraction of the placenta, and the womb was contracted to the
normal size.
I then became convinced that there was great danger in sud-
denly changing the position of persons who were reduced by
haemorrhage, but what that danger really consisted in, was not
easily defined. I now believe that this poor woman might have
been saved by a simple anodyne injection, given immediately
after delivery, to obviate the necessity of rising so soon.
Not having permission to examine the bodies of these persons,
in consequence of superstitious prepossessions too prevalent in the
country against disturbing the dead for the good of the living, I
could only say, that they were cases of fatal syncope at the time
of their occurrence.
In June, 1848, I attended Mrs. C. in her sixth confinement; she
was a woman of good constitution, about 32 years of age, and
had a good easy labor, but very profuse hemorrhage came on
without any apparent cause, which continued rather profuse for
several days. She became very much reduced. At length the
hemorrhage ceased, and I supposed she was out of danger, if
managed with discretion ; and being under necessity of leaving home
for three days, insisted that she should not be raised at all in my
absence, and emphatically observed that there would be imminent
danger in so doing. But in my absence her after pains became a
little troublesome. A neighboring physician was called in who
deemed it proper to administer cathartic medicine, during the
operation of which she was forced on the close stool; syncope soon
followed, from which she partially rallied. This took place a short
time before my arrival at home, and I was immediately solicited to
take charge again of the patient. Upon entering the room about
two hours after the syncope, I found her laboring under the greatest
difficulty of respiration. Every inspiratory action was produced
by voluntary power, and very irregularly. I approached her and
found a pulse scarcely perceptible, and numbering 150 in a minute,
with cold extremities. I warned her husband of what I believed
to be the approaching fate of his wife, and did not hesitate to de-
clare that forcing her up had been the procuring cause of her for-
lorn condition ; that a clot had formed at the instant of syncope,
produced by suddenly changing her position, and would necessarily
prove fatal.* Laudanum and acetate of lead injections were used
to quiet the bowels, sinapisms, and warmth applied to the ex-
tremities, stimulants internally, galvanism—but all to no purpose,
and I thought the stimulants internally given did harm.
* For this opinion I am indebted to the article before alluded to in the
{t Examiner.”
The poor woman lingered along under these symptoms, the most
horrible that can be imagined ; the countenance expressive of the
greatest anxiety and distress ; saying, as long as the powers of
speech remained, and after that by gesture, “ Oh Doctor ! do help
me if you can.” In short, she was anaemic from haemorrhage.
She took the cathartic in the morning, it forced her up at noon, in
consequence of which, some great change took place in the respi-
ratory function, and at sun-set she was where pain and trouble
could not reach her.
I ought to have mentioned, that this woman told me herself, that
she was very comfortable before attempting to get up, (save from
after pains and physic.)
That great muscular efforts and consequent exhaustion of
nervous power may induce those conditions which favor the
sudden formation of clots in the heart, the following case of an
animal would seem to prove:
One evening, in the autumn of 1848, while urging a horse of
mine forward in great haste to see a person said to be alarmingly
ill, and the animal having been used to excess during the day, he
stopped short on the highway, staggered and came near falling,
acting precisely like a person in a state of syncope ; great difficulty
of breathing came on at once ; the poor fellow seemed to be in
the utmost distress. He partially rallied, and I succeeded in lead-
ing him home, a distance of two or three miles at a very slow walk:
for the instant I attempted to hurry him, symptoms of suffocation
would ensue. His legs became cold at once ; his tongue and mouth
pale and bloodless ; respiration laborious and hurried : very quick
pulse. Thus he lingered on for several days in great distress, and
became dropsical in the limbs before death.
Suspecting some affection of the heart or lungs, I proceeded to
examine him soon after death. Upon opening his chest, the peri-
cardium was found very much distended with serum. The left
auricle and ventricle were empty, but the right ventricle was
nearly filled with an enormous mass of white fibrinous matter, ex-
tending some portions into the right auricle. I could detect no
other sign of disease in this animal. I had owned him two years,
and he always carried the appearance of health until this sudden
seizure.
I now leave this subject in the hands of the candid enquirer to
form his own conclusions, and say if anything but the clot in ques-
tion could account for the sudden deaths here related. Admitting
this position, and the management of persons in a state of exhaus-
tion from haemorrhage or any other cause, will readily suggest
itself to any intelligent person. Too much emphasis cannot be
placed upon the propriety of confining such cases to the horizon-
tal position until a sufficient amount of blood has been acquired to
obviate the danger of syncope, and this can, in general, be de-
termined by the force of the pulse, together with the general ap-
pearance of the patient. But even then their position should be
gradually changed, examining closely the effects on the circulation.