Cart to heart

On wounds of the heartIn 1837 the Dublin Medical Journal published a short article by a Dr Lees entitled, simply, ‘Wounds of the Heart’. According to popular belief at the time, injuries to the heart were inevitably fatal, and often instantaneously. Many doctors still subscribed to this notion, but there was a growing body of evidence to the contrary. Dr Lees collected a number of cases to demonstrate that – surprisingly – there were plenty of cases in which patients had survived for several days after a serious cardiac injury, or even made complete recoveries.

The first chapter of my forthcoming book The Matter of the Heart (a history of heart surgery) deals with the treatment of cardiac injuries [now available for pre-order on Amazon! Buy it here! End of gratuitous plug] – but two interesting cases uncovered by the diligent Dr Lees were new to me. This one is particularly striking:

In the Museum at Martinique is preserved a heart, with the end of a sword five inches in length impacted in it. The case was that of an officer, who in a duel received a sword wound in the right side of the chest, the point of the weapon broke, and the seconds, supposing it to have been lost in the grass, walked with him to the hospital, where he expressed so little uneasiness, that the surgeon, supposing it to be a mere flesh wound, allowed him to return on board his ship, where he continued without any suffering the whole of that day, but at night very severe symptoms supervened, and he died next day; on examination, it was found that the point of the sword had passed through the right auricle, and wounded the left lung.

Gray's Anatomy heartThe right auricle is what we would now call the right atrium, the chamber into which blood flows from the major veins before being pumped through the lungs. (Confusingly, the term ‘right auricle’ is today used to describe a different cardiac structure, a small muscular pouch attached to the right atrium and also known as the right atrial appendage).

If anything, the case that follows is even more extraordinary:

In the museum at Park-street, Mr. Thomas Hart had the kindness to show me a preparation of wound of the right auricle; and Mr. Wilkin, who was clinical resident in Stephens’ Hospital at the time it occurred, has given me the particulars of the case. It was that of a brewer’s man, who had fallen under a dray, when it was heavily laden, which passed over his chest.

A dray, commonly used to transport barrels, was the horse-drawn equivalent of a flat-bed truck.

He was lifted up, and complained of pain and weakness, but was able to continue sitting on the side of the dray driving the horse for nearly an hour, when being in the vicinity of the hospital he thought he might as well get himself examined.

A sensible precaution. But nobody expected the sequel:

He walked in, and lay on a bed, but on turning on his side he suddenly expired. On dissection, it was found that the fifth rib was fractured, and that the extremity of one portion had penetrated the pericardium, but had freed itself from the heart…

The pericardium is the tough fibrous sac surrounding the heart.

…and this, as Mr. Wilkin observes, accounts for the sudden death of the man. For it is probable, that the portion of rib had filled up the wound of the heart, and thus prevented any haemorrhage until his arrival at the hospital; when, on his coming out, the sudden effusion of blood into the pericardium caused sudden death; there had no blood escaped outside the pericardium.

From which it appears that the cause of death was cardiac tamponade. If blood escaping from a heart wound becomes trapped inside the pericardium, the pressure of the distended sac prevents the heart from filling as it should. It becomes virtually incapable of pumping, and since little blood is finding its way to the rest of the body, death can follow rapidly. If there’s a lesson to be learnt here, it is perhaps that if a cart runs over your chest it is better to seek medical attention sooner rather than later.



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