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A black male nurse first began having syncope at the age of 30 years and when heart block was documented, a permanent electronic pacemaker was inserted. He died nine days later of a massive pulmonary embolus. There was a family history of sudden death. Special examination of this patient's heart demonstrated the following anatomical findings in the cardiac conduction system: (1) There was such diffuse fibrosis in the midportion of the His bundle that only a few tenuous connecting strands of fibers remained; the local blood supply appeared adequate. (2) The atrioventricular (A-V) node was located centrally in the interatrial septum, rather than under the right atrial endocardium as is normal, and was poorly formed with several separated fragmentary components. (3) The central fibrous body con-

circulation

De Subitaneis Mortibus. XXI. Adult onset syncope. with comments on the nature of congenital heart block and the morphogenesis of the human atrioventricular septal junction.