whether she is breathing or no, and the pulses of the heart have almost ceased, while the radial artery has wholly ceased to beat. If now, this dangerously coagulable blood continues to ooze rather than flow into the right ventricle to slowly fill it, lingering as if doubtful whether to move or rest, it may die there, in the heart, because the heart being scarcely alive and most of the vessels quite still, they are without nervous force to be inducted into the blood. The blood dies in the heart's auricle by coagulating there, just as it would in a cup or vase. If the woman in such a state should now be aroused by any means, the heart will recommence its pulsatory motion but can not expel the clot that has been moulded by its cavity. The auricle, the ventricle and the pulmonary artery, filled with an immovable coagulum, which stops off the pulmonic circulation, causes the woman to experience what is called want of breath. She breathes, indeed, and breathes violently, with greater and still greater effort, but can get no oxygen out of the circumambient air, because the lesser circulation is cut off by the clot, which acts as effectually as any ligature, and she must die.

There is not, in the whole field of medical experience, a more pitiable sight than that presented by some of these heart-clot cases. The distress is truly inexpressible, and the gestures as well as the voice are fit to melt a heart of adamant. Those are to be esteemed the most fortunate in whom the clot, when it does come, is so great and strong as to preclude the possibility of any further movement of the heart, for such persons die on the spot; but in such as form a smaller clot, the efforts of the heart to dislodge or expel it from its cavities are terrible indeed; small quantities of blood only can be poured into the auricle, and pass onwards between the clot and the walls, into the pulmonary circulation. The diaphragm redoubles its exertion to pour over the scanty rill a copious flood of oxygen, which the hydræmical stream can no longer take up and carry forwards, so that the tissues and the whole brain and cord are left in fatal destitution of the life-giving reagent.

Should an instance occur so threatening as to lead to the greatest apprehensions of a fatal result, it may be still possible, by wise precautions, to indulge hopes of a recovery; which will depend upon the size of the clot formed during the state of fainting. A clot that should quite fill the whole cavities must preclude the possibility of any recovery; whereas, a smaller one would not prevent the blood of the cava from entering into, and being expelled from the heart, but with difficulty and imperfection depending on the magnitude of the clot. In the case of the Princess Charlotte, whose death within a few hours after the birth of the child cast a deep gloom over the whole British

empire, there is reason to believe that a clot in the heart brought her existence to an almost instant close. We have a clear relation of the circumstances attending that deplorable occurrence in a letter from one of the physicians who was summoned to Osborne House at the time of her lying-in; and I shall make use of the present opportunity to lay it before the Student, that he may consider whether or no her death should be accounted for by the supposition of a sudden heartclot. Dr. Sims's letter to the late Dr. Joseph Clarke, of Dublin, was originally printed in a Short Sketch of Dr. Clarke's Life, by his sonin-law, Dr. Robert Collins, Master of the Dublin Lying-in Hospital, and author of an important work on Midwifery. Dr. Collins says it is the only authentic account of the case that has been published. I copy the letter from Dr. Collins' short sketch, &c. The letter is as follows:

LONDON, November 15, 1817.

You

"MY DEAR SIR: I do not wonder at your wishing to have a correct statement of the labor of Her Royal Highness, Princess Charlotte, the fatal issue of which has involved the whole nation in distress. must excuse my being very concise, as I have been and am very much. hurried. I take the opportunity of writing this in a lying-in chamber. "Her Royal Highness's labor commenced by the discharge of the liquor amnii about 7 o'clock on Monday evening, and pains followed soon after; they continued through the night and a great part of the next day, sharp, short, but very ineffectual. Towards the evening, Sir Richard Croft began to suspect that the labor might not terminate without artificial assistance, and a message was dispatched for me. I arrived at 2 on Wednesday morning. The labor was now advancing more favorably, and both Dr. Baillie and myself concurred in the opinion that it would not be advisable to inform Her Royal Highness of my arrival. From this time to the end of the labor, the progress was uniform, though very slow, the patient in good spirits, pulse calm, and there never was room to entertain a question about the use of instruments. About six in the afternoon, the discharges became of a green color, which led to a suspicion that the child might be dead; still, the giving assistance was quite out of the question, as the pains now became more effectual, and the labor proceeded regularly, though slowly. The child was born, without artificial assistance, at 9 o'clock in the evening. Attempts were for a good while made to reanimate it by inflating the lungs, friction, hot bath, &c., but without effect; the heart could not be made to beat even once. Soon after the delivery, Sir Richard Croft discovered that the uterus was contracted in the

middle, in the hour-glass form, and, as some hemorrhage commenced, it was agreed that the placenta should be brought away by introducing the hand. This was done about half an hour after the delivery of the child, with more ease and less loss of blood than usual. Her Royal Highness continued well for about two hours; she then complained of being sick at stomach, and of noise in her ears; began to be talkative, and her pulse became frequent, but I understand she was very quiet after this, and her pulse calm. About half-past 12 o'clock, she complained of severe pain at her chest, became extremely restless, with a rapid, irregular, and weak pulse. At this time I saw her for the first time, and saw immediately that she must die. It has been said we were all gone to bed, but that is not a fact. Dr. Croft did not leave the room, Dr. Baillie retired about eleven, and I went to my bedchamber and laid down in my clothes at twelve. By dissection, some bloody fluid (two ounces) was found in the pericardium, supposed to be thrown out in articulo mortis. The brain and other organs all sound except the right ovarium, which was distended into a cyst, the size of a hen's egg; the hour-glass contraction of the uterus still visible; a considerable quantity of blood in the cavity of the uterus; but those present differ about the quantity, so much as from 12 ounces to a pound and a half; the uterus extending as high as the navel. The cause of Her Royal Highness's death is certainly somewhat obscure; the symptoms were such as attend death from hemorrhage, but the loss of blood did not appear to be sufficient to account for a fatal issue. It is possible that the effusion into the pericardium took place earlier than what was supposed, and it does not seem to me to be quite certain that this might not be the cause. As far as I can judge, the labor could not have been better managed. That I did not see Her Royal Highness more early was awkward; and it would have been better that I should have been introduced before the labor was expected; and it should have been understood that, when the labor came on, I should be sent to, without waiting to know whether a consultation was necessary or not. I thought so at the time, but I could not propose such an arrangement to Croft. But this is entirely entre nous.

"I am glad to hear that your son is well, and, with all my family, wish to be remembered to him; we were happy to hear that he was agreeably married.

"I remain, my dear Doctor,
"Ever yours, most truly,
"JNO. SIMS.

“P. S. This letter is confidential, as, perhaps, I might be blamed for writing any particulars without the permission of Prince Leopold."

I believe that few persons die with scarlet-fever, or smallpox, or consumption, who are not hurried to the grave by means of coagula formed in the heart, late in the progress of the cases, in consequence of the debilitation or lessening of that inducted-life that passes from the vessel to the living blood. I have many times, in the closing scenes of pulmonary consumption, and other lingering, and some acute maladies, perceived, from the running and fluttering pulse, and the augmented respiratory distress, that the last fatal blow was struck by the formation of a heart-clot of greater or less size.

But these coagulations, that ordinarily take place in the last days of lingering chronical disorders, are different from the sudden and blasting power of the same accident in our midwifery practice.

I cannot doubt that the lady whose case I have related as having been under Dr. James's care, must have died from the coagulation of the blood in her heart. A mere deliquium is recovered from very soon after the body is placed in a horizontal posture. I should think that a fainting fit could hardly prove fatal per se; but, if a heart-clot should be formed during the deliquium, it seems unlikely that the blood could again move in its circle. No examination was made of the dead body of Dr. James's patient. No one knew anything of sudden heart-clot. She did not die with hemorrhage. What was it that destroyed her life? what could have destroyed it so suddenly save a deliquium, during which the heart filled with a solid clot, that precluded the possibility of re-establishing the circulation, the oxygenation, and the innervation of the unfortunate lady?

Bichat has taught us the important truth, that man cannot die save by the cessation of life or power in the lungs, or in the heart, or in the brain. By lungs, he means oxygenation of the living mass. By heart, he means the sanguine circulation; and by brain, he means the nervous mass, particularly the nervous mass of the medulla oblongata, in which essentially resides the innervative force of the respiration, and so, the oxygenating force. Man must, therefore, die by the brain, the heart, or the lungs. It is to the last degree improbable that Dr. James's patient died solely because her brain ceased to evolve nervous force; but, if it did not wholly cease to do so, it must have continued to be the cause of some motion, everywhere within. But if, as I suppose, the heart became instantly filled with an immovable clot, so that it could no longer receive nor discharge any blood, the nervous mass would die as soon as the last remaining atoms of oxygen in its capillaries should have become exhausted: for the function of the capillaries is to take the oxygen out of the blood which is thus converted into venous or black blood. Dr. James's patient died by the heart, as do

all those who have the misfortune to form a heart-clot of considerable size.

I have had the unhappiness to witness several fatal terminations of puerperal eclampsia. In the paroxysms of this sort of convulsion, the patient's face ordinarily grows darker and darker, and the tongue and lips blacker and blacker, as the paroxysm goes on, until the pulse almost ceases to be felt; the respiration becomes nearly suspended, and at last the patient lies still. This scene, at the greatest height of the struggle betwixt life and death, is one of almost complete asphyxiation; the innervations have become so reduced that the physician is led to look with an anxious eye to see whether or not life has become wholly extinct.

If death does not supervene, there comes a slow recuperation of the forces. Now, if the patient rises upon her elbow, or attempts to escape from the bed (and it is sometimes very difficult to hold her down); if she stares wildly about her and breathes with difficulty or violence, she will surely die; and that, because, during the extremest intensity of the late asphyxiation, a soft clot has filled the right auricle, ventricle, and pulmonary artery. I have not seen such a patient, so struggling and so breathing, escape from the fatal termination. Indeed, it would be difficult, à priori, to imagine a condition more likely to lead to the heart-clot than that of a woman in a violent eclampsia, especially if an unmeasured use of venesection should have been employed.

CASE.-A lady was confined, and with a natural labor, giving birth to a healthy child at term. She had lost a good deal of blood with the expulsion of the placenta, which left her weak and pallid. The physician directed her to be kept quiet, so that she had a good day and following night. On the following morning the physician found her in all respects as well as could be wished. Very soon after he had withdrawn from her chamber, she became alarmingly ill and he was sent for, and returned, having been absent about one hour. The pulse was now extremely frequent, weak, and small, and it continued so until her death, which took place on the 18th or 19th day. It was upon the 18th day that I was invited to the consultation, and at once formed the opinion that she had a heart-clot, as the cause of all her dreadful symptoms, and which acting as a tampon of the heart, deranged the circulation, respiration, and innervations of the dying lady. After her decease, which occurred the next morning, a white, fibrinous coagulum was found in the right auricle, nearly filling it and projecting through the tricuspid valve into the right ventricle; the tail of the clot was whipped into cords by the threshing action of the chorda tendineæ of the