95 



which are known in certain circumstances to predispose to 

 fibrillation. The invariable or almost invariable occurrence 

 of coronary lesions in cases of fatal angina is a matter of 

 general agreement. Sir Clifford Allbutt has adduced a 

 wealth of facts and considerations marshalled with his usual 

 skill, in favour of his view of the aortic origin — as con- 

 trasted with coronary and myocardial origin — of anginal 

 pain. But this veteran clinician at the same time recog- 

 nizes that the question of a fatal issue to an anginal 

 attack is essentially associated with the condition of the 

 myocardium. 



2. The recognition by numerous observers, in some anginal 

 attacks, of acceleration of the heart's action with irregu- 

 larities, extra-systoles, etc. ; such are known in many con- 

 ditions to herald the onset of fibrillation. Among others, 

 Windle recorded a fatal attack of angina in which the 

 heart rate rose from 75 to 150 and became very irregular. 



3. Though some slight slowing of the heart may occur in 

 an anginal attack, there seems to be no direct evidence of 

 the occurrence of pronounced inhibition, such as might, if 

 somewhat intensified, threaten a suddenly fatal issue; the 

 degrees of inhibitory slowing observed have been far removed 

 from determining circulatory failure or even causing any 

 considerable fall of blood pressure. There seems to be no 

 relation between the severity and duration of the pain and 

 the tendency to die in the paroxysm. 



4. Death often occurring at the beginning of an anginal 

 attack or in one that is relatively slight as regards pain, 

 etc., is probably of the same mechanism as absolutely sudden 

 death occurring between attacks or in persons y^ho are not 

 subjects of angina; the considerations bearing on such 

 deaths are probably applicable to deaths during anginal 

 attacks. 



5. In the case of death between attacks or during rela- 

 tively slight pain there is no evidence of such powerful 

 aflFerent excitation as might be supposed to produce cardiac 

 inhibition of such intensity and duration as to be fatal. 



Of course it would be rash to dogmatize at the present 

 time on an exclusive application of one mechanism as being 

 the only one operative in all instances of anginal death ; it 

 may be that one or other form is present under different 

 conditions. But there is a strong case for fibrillation as a 

 common mode of death in anginal subjects, whatever the 

 precise mechanism of pain production in angina may be. 



Conclusions as to Sudden and Unexpected Death of 

 Cardiac Origin. 

 Rupture of the heart is a very rare accident. Simple 

 standstill of the ventricles in complete heart-block can only 

 be a rare cause — assuming thai; such standstill may some- 

 times kill without fibrillation as the terminal event. As 



