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“Sudden Death at Impasse” is a fascinating subject, and, as in the two patients noted by Dr. Saul, both male aged 40 and 45 years respectively, coronary insufficiency is probably the most common explanation. In both of those cases autopsy is said to have shown myocardial infarction but this can happen without any actual infarction and simply from the coronary insufficiency itself. I myself have never seen a patient who died suddenly without adequate pathological explanation, and I know of only one case in a series of two thousand reported by Dr. H. Martland,1 a coroner, some years ago which was not explained by obvious pathological findings at autopsy.
That one case was a young colored man who came to a clinic to have treatment for a skin blemish on his face. He had hoped that this might be removed by some local application, but he was told that it had to be treated by cautery or excision and for this purpose it was necessary to use local anesthesia. He protested but was finally persuaded to allow the doctors to go ahead, but he was obviously terrified by the idea. He dropped dead at the moment that the needle was approaching his skin, and at post mortem examination no abnormalities were found. This is quite probably one of the rare cases of cardiac standstill or ventricular fibrillation induced reflexly by fright or some nervous mechanism such as Dr. Saul has described.
I suppose that the young woman with her status asthmaticus reacted to her impossible situation in life in a similar manner, but by a different mechanism.
We do know that vagal and other influences superimposed on a sensitive S-A nodal pacemaker can cause cardiac standstill both in animals and in man, but death therefrom is of course extraordinarily rare, unless there is already serious disease, most commonly of the coronary arteries.