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Tuesday, January 3, 2017

Rupture of the heart without external wound (a case from 1880)


A strange case was described in the British Medical Journal in 1880. A man had been run over and killed by an empty cart. One of the wheels had passed over his chest, but there was no external wound and no ribs had been broken. A postmortem examination showed that his heart had ruptured under pressure! Apparently, since he had suffered from a long-standing syphilis infection, the tissues of his heart were weakened, which greatly facilitated the rupture.

Henry Handford, Assistant House-Surgeon to the General Hospital in Nottingham, relates the incident thus:

"On Saturday, November 1st, a man, A. B., aged about 35, was brought to the General Hospital, Nottingham. A wheel of a light cart (empty) had passed over his chest. According to the statements of the men who witnessed the accident, he never spoke or moved after the receipt of the injury, but continued to make a moaning noise for a few minutes. When he was brought to the hospital, about ten minutes later, he was quite dead."

The postmortem examination showed the following:

"The body was well nourished; height about 5 feet 8 inches; muscular. Rigor mortis was very strongly marked. There was an incised wound about an inch long on the back of the head, and numerous syphilitic sores and scars on the penis, scrotum, and thichs. (He had been an in-patient of the hospital some mnonths previously for syphilis.) There was no trace of any wound or contusion on the chest, nor were any of the ribs broken. On examination of the thorax, the pericardium was found much distended; and on opening it, about eight or ten ounces of serum and imperfectlv coagulated blood escaped. While examining the heart in situ, a rupture about three-fourths of an inch long was discovered on the posterior wall of the left auricle. The aorta was distinctly atheromatous; and there was thickening of the mitral, and less so of the aortic and tricuspid valves. The endocardium lining the left auricle was markedly thickened in irregular patches, and of an opaque yellowish colour. The muscular fibres of the left auricle, taken from the immediate neighbourhood of the rupture, showed, under the microscope, well-marked pigmentary degeneration; i.e., an accumulation of pigment granules arranged more or less in rows in the region of the nucleus; but no distinct trace of fatty degeneration, though the fibres were not well striated. " 

The heart had given way at the weakest spot: the left auricle (a flap of heart wall on the anterior surface of the left atrium of the heart), which has the least support from surrounding structures. Dr Handford concludes:

"Death probably took place from compression of the heart by the blood effused into the pericardial sac; and the extreme rapidity of the death may, perhaps, account for the absence of marks of bruising on the skin of the chest."


Source:

Handford H. (1880) Case of Rupture of the Heart from External Violence without Penetrating Wound. Br Med J. 1(1012): 768.

Image: Wikipedia.






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