SPOILER ALERT
If you have not yet read The Unwanted Corpse, this information will give too much away! You have been warned…
HOW CAN A BLOW TO THE CHEST KILL A MAN?
While researching heart conditions and death from cardiac arrest, ranging across apoplexy, stroke and a host of other types of heart failure, I came across this extremely rare phenomenon. Naturally, I had to use it! I took something of a liberty in allowing that it could have been noted as occurring in the 18th century. After all, it is happens now, it must have happened then. Doctors would not have known why it happened, but they did know quite a lot about the heart.
The practice of learning anatomy by cutting up corpses was widespread at the time. Hence the illegal trade of grave robbing – highlighted in The Candlelit Coffin. This was in addition to legal autopsies by means of which surgeons gained a deal of knowledge about the human body and how it worked. By modern standards, the misunderstandings of the time were plentiful, but they did the best they could with the means at their disposal.
Thus, I hold that artistic licence is permissible in assuming some experience of the phenomenon known as:
Commotio cordis (Latin, “agitation of the heart”), also sometimes referred to as a concussion of the heart.
A similar occurrence is now known as Cardiac Contusion, which differs in that there are structural changes to the heart. On balance, I think my victim suffered from this one.
Here is a smattering of the data I used to arrive at this solution.
“Commotio cordis (Latin, “agitation of the heart”) is an often lethal disruption of heart rhythm that occurs as a result of a blow to the area directly over the heart (the precordial region) at a critical time during the cycle of a heart beat, producing what is termed an R-on-T phenomenon that leads to the condition. It is a form of ventricular fibrillation (V-Fib), not mechanical damage to the heart muscle or surrounding organs, and not the result of heart disease. The fatality rate is about 65 percent even with prompt CPR and defibrillation, and more than 80 percent without.
Commotio cordis occurs mostly in boys and young men (average age 15), usually during sports, most frequently baseball, often despite a chest protector. It is usually caused by a projectile, but can also be caused by the blow of an elbow or other body part. Being less developed, the thorax of an adolescent is likely more prone to this injury given the circumstances.
The phenomenon was confirmed experimentally in the 1930s, with research in anaesthetized rabbits, cats and dogs.”
Cardiac contusion
“Contusion can be distinguished from concussion and commotio cordis because the latter do not produce any structural change, even at the microscopic level. Contusions are usually, but not always, associated with an injury to the chest wall. Myocardial contusions may be completely silent or cause an arrhythmia (supraventricular tachycardia or ventricular fibrillation) or hypotension secondary to reduced cardiac output.
Ventricular fibrillation (VF) results in sudden faintness and loss of consciousness, cessation of respiration, and death.
During VF the heart muscle does not contract but “quivers”; therefore, there is no heartbeat (cardiac arrest) and no blood is pumped out of the heart. Death occurs within minutes if the abnormal heart rhythm is not corrected.”
Some data on symptoms and results
“…absence of structural damage to the sternum, ribs, or heart itself; and absence of any underlying cardiovascular abnormalities (such as other causes of sudden death).”
“Autopsy and forensic morphology both revealed no cardiac or pericardiac structural damage, evident lesions of other internal organs, or underlying diseases, along with negative toxicological analysis, conforming to criteria for diagnosis of commotio cordis.”
“An autopsy was performed in each case, and no structural cardiac damage, evident lesions of other internal organs or underlying diseases were found. Combined with the negative toxicological analysis, it was concluded that the cause of death was commotio cordis due to a blunt force to the anterior chest.”
“It is most commonly associated with a sports-related injury, wherein, there is a high-velocity impact between a projectile and the precordium. By virtue of this impact, malignant arrhythmias consequently develop leading to the individual’s immediate demise, accompanied by a relatively normal post-mortem analysis.”
“Arrhythmias are abnormalities in the rate, rhythm, or both of the heartbeat.
The development of abnormal rates or rhythms has many causes. Some of these causes are primary, and others are secondary. Primary causes are those that occur within the heart. Secondary causes are those that result from external forces that act on the heart indirectly to cause a change in its rate or rhythm.”
“It is a form of ventricular fibrillation (V-Fib), not mechanical damage to the heart muscle or surrounding organs, and not the result of heart disease, so this can happen to anybody!”
Two case showing the remarkable nature of this condition and associated age
“The authors present a case of unexpected sudden death due to commotio cordis associated with violence. In a house of detention, a 19-year-old boy was punched and kicked in the face, neck and chest during a fight with another suspect in their ward. Unfortunately, his precordium was the major injured region.
The victim turned pale, then lost the ability to resist and lost consciousness immediately. When the emergency medical personnel arrived, the victim was found in a condition of cardiac and respiratory arrest and he was pronounced dead at the scene without cardiopulmonary resuscitation.
Both autopsy signs and forensic morphology were in accord with the criteria for commotio cordis diagnosis, showing no cardiac or other organic fatal lesions and no underlying cardiac diseases; moreover, the toxicological screening was negative for alcohol, drug and common toxicants. In the present case, the whole fight was seen by some witnesses in their ward, and it was recorded by the monitoring unit. Based on the statements of the witnesses and the monitoring videotape, combined with the forensic pathological and toxicological examinations, all the testimonies supported the conclusion that the cause of death was commotio cordis.”
“A cardiac concussion is caused by a sudden, nonpenetrating, localized impact to the chest that is theorized to result in almost simultaneous sudden death from a disruption to the conductive system. The detailed external/internal forensic examination of the body reveals no evidence of structural, pathologic, or histologic signs of trauma to the heart.
A cardiac concussion is a rare and often overlooked cause of sudden death.
This type of sudden death is typically seen among younger individuals participating in sports involving projectiles and, to a lesser degree, where collisions occur. Cardiac concussions are clinically, pathologically, and chemically different from a cardiac contusion. The objective of this paper will be to define cardiac concussion, differentiate between cardiac concussion and cardiac contusion, and describe the clinical and pathologic features of a 32-year-old white male who died of a cardiac concussion following a collision with a catcher during a softball game.”