Artery mistaken for vein

Part 2 of a refutation of Benjamin Schmidt's article

[CAUTION: graphic images.]

In my last article, I addressed Benjamin Schmidt’s claim that, if Richard Hirschman had studied his embalming textbook properly, he would have realised that it is perfectly normal to extract clot from the leg arteries of the deceased. I showed, among other things, that in fact the leading textbook by Mayer teaches that the arteries are generally empty after death, and that arterial clot is generally limited to the aorta, with one mention of the common carotid artery as another possible location for arterial post-mortem clot. Injection from the iliofemoral region would tend to push clot in the aorta towards the head and arms. Injection from the common carotid would tend to push such clot towards the legs, but any fragments would be more likely to lodge on the trunk side of an iliofemoral arterial incision. In any case, Hirschman had not begun injecting in this particular instance, so had no reason to expect to find post-mortem clot in leg arteries.

Mr Schmidt’s next comments concern another scene (51:43 ff) from Died Suddenly where Hirschman, assisted by embalmer Nicky Rupright King, removes a large piece of whitish material from the common carotid artery of the deceased, accompanied by a sudden expulsion of fluid under pressure from the pump. Schmidt, however, states in error that Hirschman removed it from the ‘jugular vein’ (by which he must mean the inner jugular vein, which is commonly used by embalmers as a site for the drainage of the embalming fluid):

In this article, I explain that it should have been clear to Schmidt from the video sequence that the extraction was from the common carotid artery. In addition, I show that Schmidt’s suggestion that the material had been located in the right atrium of the heart would be implausible, even if it had in fact been extracted from the inner jugular vein.

Hirschman had begun to embalm from the iliofemoral region, with injection in the external iliac or femoral artery and drainage from the adjoining vein, as he explained in an interview with Dr Jane Ruby in May 2022. He was having an issue with drainage, and so opened the jugular vein as a second drainage site, as recommended by Mayer (p. 250):

As he explained to Dr Ruby :

[2:33] I normally like to embalm from the iliac region, and so I am pushing fluid but I am having an issue with drainage and I am having an issue with distribution of fluid going through, so I opened the jugular vein..

He explained further that the angular forceps that can be seen inserted into the neck area on the right side in this video still, which is taken from a later stage of the proceedings (52:15):

had been put into the jugular vein:

[2:45] .. that big long angular forceps is what is in the jugular vein..

as specifically recommended by Mayer (p. 253) for drainage from the right internal jugular vein:

It is a spring forceps, whose arms are wide apart unless squeezed together. Mayer explains (p. 101) that these come in a wide variety of lengths, and that there is also a straight version, this straight spring forceps being the instrument grasping the ‘clot’ in the image above. The angular version is used as a drainage instrument, generally in the internal jugular vein:

can have a ‘working length’ of up to 7 inches, and can be used to grasp and pull out a clot from within a vein:

Opening the right internal jugular vein can enable clots to be removed from the right atrium, the inferior vena cava or the upper portion of the right internal jugular vein, as described by Mayer above. But it would be of no direct help in clearing any obstructions from the arteries. Hirschman was still experiencing difficulties with distribution, so decided to open the right common carotid artery also, which lies next to the internal jugular vein (both being contained within the carotid sheath):

[2.45] that big long angular forceps is what is in the jugular vein - and then.. I am still having an issue.. so I open the carotid artery

Hirschman was injecting into the external iliac artery in both directions (legward and trunkward). To reach what were now the two drainage points in the external iliac vein and the internal jugular vein, his embalming fluid had to pass through the arterial system, through the capillaries, and into the veinous system. But to reach the right common carotid artery, it had a much more direct route through the common iliac artery, the abdominal aorta, the thoracic aorta, the arch of aorta, and the brachiocephalic artery, all of which are large in diameter:

so that there would be little resistance to flow in the absence of obstructions. But even when he opened the common carotid artery, there was still little fluid coming through, making it clear that there were indeed obstructions in these connecting arteries:

[2:52] I open the carotid artery and I am trying.. to allow.. some fluid to come out of there to see if I am getting fluid .. it should be going through there…

[4:22] I cut into the carotid artery and I am looking to see as I am pushing fluid in, is it coming out there, because if it is not coming out there, then it is not going in to the head.. so as I opened that up, I am not getting enough fluid, I’m like there’s something’s wrong, something is blocking this - and that’s why I am trying to open it up to allow whatever is blocking it to come out.

He pulled out one smaller piece from the common carotid artery before starting to record video:

[3:03] When I first cut it open, I pulled out another clot out of the carotid artery which is not on the video

but was still having problems, so tried to widen the artery to free the obstruction:

[3:12] but then I continued having problems and so I am having to try and open that.. [artery] up because the artery is stretchable, it is like a rubber band and his arteries were in good shape, they weren’t sclerotic

It was presumably a combination of these efforts and the fluid pressure from the pump that moved the obstruction towards the incision until Hirschman was able to grasp one tentacle of it (1:53):

and then the main piece [1:55]:

before extracting it. A comparison with a photograph taken afterwards:

shows that the end that was pulled out first is the top end, lying on the gloved fingers. Possibly the first piece that was extracted was broken off from that end.¹

Hirschman cut the piece of material in two and preserved it in formalin. It was predominately white in colour when he held it up to the camera less than a week after extraction (7:19):

Dr Ruby suggested (5:05 ff) that it had not formed in the common carotid artery but in a vessel closer to the heart, and Hirschman mentioned (5:29) the innominate (brachiocephalic) artery as one of these. He also suggested (7:41) that one of its branches might have extended into the subclavian artery, which could be consistent with the main piece being in the brachiocephalic:

The main section of the piece on the hand looks to be about 6 cm long, which is around the upper limit for the length of the brachiocephalic artery;² possibly it could have extended some way into the arch of aorta, whose internal diameter is of the order of 3 cm.³ If this is where it was located then the two top branches could possibly have extended into the right common carotid and the right subclavian artery, and the two main bottom branches, one of which has a further long thin branch coming off it, could possibly have extended into the arch of aorta and the ascending aorta.

The internal diameter of the brachiocephalic artery is 1.1 - 1.4 cm. In width and breadth the material looks comparable to the little finger, at say 1.2 - 1.6 cm, so would fill this artery if that is where it was located. Both the brachiocephalic and common carotid arteries are considered to be of the elastic rather than the muscular type,⁴ making it more plausible that blood could have got past the obstruction at each pulse from the heart. Hirschman's understanding (8:20) was that the deceased had been in good health the day before he died:

From what I understand this individual was totally fine the day before.

If this death were to be investigated, then obstruction of an artery by this piece of material, wherever it was located, would surely have to be considered as a possible cause.

Schmidt’s error of perception

Returning to the scene in Died Suddenly where this footage was shown, it is clear that the angular forceps are in one vessel and the obstructing material is in another (52:18):

The arterial wall can be seen like a sheath around the material:

Oddly, Schmidt states that Hirschman is using angular forceps to remove the obstructing material, with his reference to it being an instrument used for grasping clots making it clear that he has in mind the instrument Hirschman is using to pull on the material:

They are certainly straight forceps that Hirschman is using to grasp the material (52:21):

while the angular forceps remain in the other vessel.

Later he suggests that ‘the “monster clot” from the jugular vein’ could be what he terms a ‘white fibrin clot’ and that it could have been brought up from the right atrium of the heart with angular forceps:

He had previously stated that ‘white fibrin clots’ are often found in the right atrium of the heart:

Is Schmidt suggesting that this large piece had formed in the right atrium? He believes it is post-mortem clot. Post-mortem clot is formed if stationary blood in the blood vessels and heart chambers congeals. It takes the shape of the vessel or chamber it is in, albeit somewhat shrunken⁵ :

The right atrium is a chamber with the shape of an irregular ellipsoid:

very different from the shape of the material Hirschman extracted, whose main body has more less constant transverse dimensions, like the lumen (the internal space) of an artery or vein.

If post-mortem clot forms in the right atrium (‘right auricula’ in the illustration from Gray’s Anatomy below), and takes its shape, then how could it pass through the superior vena cava, the right brachiocephalic (innominate) vein:

and the internal jugular vein as far as the drainage point:

unless it were broken up into smaller pieces?

Mayer explains (p. 250) that angular forceps inserted in the internal jugular vein towards the heart can be used for precisely this function, that is to fragment coagulum in the right atrium:

and again similarly (p. 253) that this instrument can be used to break and remove large masses of coagula from the superior vena cava as well as the right atrium:

The use of angular forceps in the internal jugular vein to facilitate the removal of veinous clots through the drainage is thus common embalming practice. Perhaps this is why Schmidt apparently jumped to the conclusion that this was all Hirschman was doing. He did have his angular forceps in the internal jugular vein, but the material did not come out of this vessel.

Schmidt also does not seem to have thought through his suggestion that the material had been located in the right atrium of the heart. If it had somehow been squeezed intact through the superior vena cava and right brachiocephalic vein to the drainage point in the internal jugular vein, it would have had the shape of the right atrium, not of a blood vessel.

And if he had observed the video footage carefully, he would have seen that Hirschman extracted the material from the common carotid artery not the internal jugular vein, using straight forceps not angular.

Andrew Chapman

1. As suggested by Hirschman, personal communication.

2. See https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7505533/, Table 1.

3. See https://www.jtcvs.org/article/S0022-5223%2812%2900023-2/pdf, Figure 1.

4. http://www.drjastrow.de/WAI/EM/EMArterienE.html See also http://histologyguide.com/slideview/MH-063-carotid-artery-and-brachiocephalic-vein/09-slide-1.html where the ‘carotid artery’ is described as an elastic artery; and the Medical Dictionary (https://medical-dictionary.thefreedictionary.com/elastic+artery)

5. P. Saukko & B. Knight, ‘Knight’s Forensic Pathology’, 3rd edition, p. 341.