Lumleian Lectures on Endocarditis
Authors: T. Horder
Journal: BMJ (1926)

ENDOCARDITIS.attachment, however, was very thin, and as a precaution was sewn over; the hole in the transverse mesocolon was closed.The 9mentum and the gastro-hepatic omentum were then separated from their attachments to the stomach.Massage of the Heart.At this stage the patient suddenly stopped breathing and his heart ceased to beat.His head was lowered and oxygen only was passed down the intratracheal tube under intermittent pressure.The stomach was rapidly separated, between clamps, from the duodenum and thrown over to the left side of the abdomen.The heart was then gently massaged through-the diaphragm at the rate of about sixty to the minute, artificial respiration being kept up meanwhile; 10 minims of 1 in 1,000 adrenaline were injected into the heart muscle through the chest wall.Three minutes elapsed before any sign of heart movements was noticed, when a single forcible contraction was felt; this was followed by fibrillary, twitchings for about ten seconds, and was then succeeded by a series o regular, rapid, feeble beats until gradually it beat with its normal rhvthm, but at rather a rapid rate.Shortly after the heart began to beat the patient commenced to breathe.Hot packs were placed on the chest wall and the operation was proceeded with, a Billroth No. 1 anastomosis being made, after having excised the distal half of the stomach with the gastrp- 3ejunal anastomosis.This operation took forty minutes to com- plete, the anaesthesia being continued with pure nitrous oxide- oxygen through the tracheal catheterIn the excised portion of stomach there was no sign of the old gastric ulcer, but there was a small gastro-jejunai ulcer, a third of an inch in diameter, surrounded by an indurated wall, on the left side of the junction.At ftr-History.The patient was returned to bed with hot-water bottles and was given rectal injections of saline and glucose.His pulse rate remained very rapid and its volume was very small, but at the end of three hours heshowed signs -of recovery and became extremely restless.His temperature remained normal, but the respiratory and pulse rates were raised for about ten days.Some suppuration took place in the abdominal wall.Ten days after the operation he had a severe haematemesis, which was followed by another two days later.He was put on a modified Lenhartz diet.From this time onwards he began to improve and made an uninterrupted recovery.When discharged from the hospital, on November 21st, he was taking a light diet, was free from symptoms, and was putting on weight.He has remained well, witlhout any further symptoms.The wound was healed and the pulse, temperature, and respiratory rates were normal.A barium meal, given just prior to his departure from the hospital, demonstrated that the new channel was working satisfactorily.He saw me on March 17th, 1926, stating that he had no symptoms, was quite fit, and was leaving for Uganda.There are some points worthy of comment in this case, apart from the recovery of the patient.Up to the moment of his collapse there was no indication that-this was about to happen; in fact, only just prior to the moment I had commented to the anaesthetist that he was standing the operation well.,In the second place, it is surprising that in addition to obtaininig a recovery of the heart's action, it was possible for me to complete the operation, which took at least another forty minutes.Naturally, the com- pletion of the operation was carried out under a severe stress, and it is my belief that the haematemeses -were of ,he nature of secondar-v haemorrhages, probably due to faulty technique.e Cases of recovery after massage of the heart are, of course, on record, although in many instances failure occulrs; the patients survive.the operation, but either never regain consciousness or die of some lung, complication.In some cases the abdomen has required to be opened in order to perform necessary manipulations.In this case, however, althouglh some,preliminary manceuvres had to be effected, owing to the nature of the operation in hand, in order to reach the diaphragm, very little time was lost before massage was commenced.In addition, it is possible that recovery was naturally aidedc by the presence of a tracheal catheter in position at the moment of cardiac failure, which permitted the immediate inflation-of the lungs with oxygen -nder pressuire; so thaOt while the heart was being massaged ,he.artificial circulation provided sufficient oxygenated *blood to the brain to obviate the cerebral anaemia which usually proves fatal in these cases.The production of a pink coloration of the patient's face with each artificial pulsation of the heart was a very noticeable feature.The diaphragm was not incised, but the heart was squeezed by the right hand inserted under the diaphragm while the heart was pressed against the anterior chest wall.So far 'is could be observed, both before and after the operation lhere was no heart lesion.b I am inldebted to myr house-surgoon, Mr. Dodd, and to the &naestheti,st, Mr. Hewer, for s.Q ably assisting