TRAUMATIC RUPTURE OF THE RIGHT VENTRICLE AN UNUSUAL CASE

WILLIAM STEIN, M.D., AND EUGENE REVITCH, M.D. NEW BRUNSWICK, NEW JERSEY

I

N 1935, Claude S. Beck1 reviewed the subject of contusions of the heart and outlined the following mechanisms by which rupture of a

heart takes place as a result of nonpenetrating forms of trauma to the chest.

1. Contusion of the heart, with subsequent softening. This softening is usually greatest during the second week, and there is the possibilit! of cardiac rupture at that time.

2. Increasing intracardiac pressure by the application of compression force to the legs or abdomen.

3. Broken ribs driven into the heart. 4. Bursting the heart by compression between sternum and vertebrae. In the safne year, Bright and Beck2 completely reviewed 152 cases of

cardiac rupture in the literature up to that time, and cited only one in which rupture was caused by compression of the heart between the sternum and spine; this would fall into Group 4, as outlined above. Review of the literature since then shows no similar case.

CASE REPORT

S. E., a well-nourished and well-developed white boy (age, 12 years; height, 5 feet 2 inches; weight, 145 pounds), had always been well except for measles. There was no history of rheumatic fever, syphilis, or congenital cardiac anomaly.

On February 1, 1941, he was riding on a sled, face down. The sled was tied to the rear of an automobile and was being pulled at a slow speed for the pleas- ure of the boy. A companion jumped directly on him to share the ride. He flung himself lengthwise on the boy as children often do. The latter let out a peculiar noise that alarmed the lad on top of him, and he, in turn, called on the driver of the car to stop. When they looked at the victim he was quiet and nonresponsive. They immediately rushed him to the hospital. where the intern (one of us, E. R.) pronounced him dead.

Autopsy was performed by Dr. William C. Wilentz. External examination re- vealed the following significant points. The body was flaccid and cold. The lips were cyanotic. There was a 3 inch by 1 inch brush abrasion contusion mark over the right anterior portion of the chest wall at the level of the nipple and to the right of the sternum. There was no further evidence of external injury or violence. Internal examination revealed no evidence of any fracture of the ribs, but slight hemorrhage was present in the intercostal tissues directly underneath the external contusion abrasion. The right lung was normal. The left lung was normal in size, but the lowermost part of the lower lobe was severely contused, and, on sec- tion, showed much hemorrhage. The pericardial sac was tremendously distended

Department of Medicine, Middlesex General Hospital. New Brunswick. N. J Received for publication June 26, 1941.

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with free and clotted blood. The right ventricle was ruptured throughout its entire length (Fig. 1). The heart was otherwise normal. The liver, spleen, and kidneys were normal in size and appearance, but showed mild congestion. The remaining viscera and cavities were normal.

It was evident that the child had died immediately of cardiac tamponade caused by rupture of the right ventricle.

Fig. I.-Traumatic rupture of the right ventricle.

COMMENT

Bright and Beck,2 Hawkes3 and Barber47 5 call attention particularly to the fact that living cardiac muscle is very susceptible to rupture by abnormal external forces. No one part of the heart is injured more than any other, when all of the reported cases are considered.

The Cause of the death of this child was’no doubt the same as in most other cases. The compressive force was probably applied to the chest when the cardiac cycle was at the end of diastole or beginning of systole, when the heart was filled with blood. If, in addition, the glottis hap- pened to be closed and the chest was in the inspiratory phase, conditions for transmission of the compressive force from the chest to the heart would be particularly favorable.

It seems to us that the right ventricle ruptured in this particular instance because its wall is thinner than that of the left ventricle.

STEIN AND REVITCH: RIYTURE OF RIGHT VENTRICLE 705

SUMMARY

A case of complete rupture of the right ventricle, resulting in hemo- pericardium, cardiac tamponade, and immediate death, is reported. The rupture was caused by the application of a sudden compressive force to the chest.

REFERENCES

1. Beck, Claude 5.: Contusions of the Heart, J. A. M. A. 104: 109, 1935. 2. Bright, E. F., and Beck, Claude S.: Nonpenetrating Wounds of the Heart. A

Clinical and Experimental Study, AM. HEART J. 10: 293, 1935. 3. Hawkes, 5. Z.: Traumatic Rupture of the Heart and Intraperirnrdial Structures,

Am. J. Surg. 27: 503, 1935. 4. Barber, Hugh: Trauma of the Heart, Brit. M. J. 1: 433, 1938. 5. Barber, Hugh: Contusion of the Myocardium, Brit. M. .J. 2: 520, 1940.