The Surgery of Mitral Stenosis 1898-1948: Why Did It Take 50 Years to Establish Mitral Valvotomy?
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Ann R Coll Surg Engl 1995; 77: 145-151 The surgery of mitral stenosis 1898-1948: why did it take 50 years to establish mitral valvotomy? Tom Treasure MD MS FRCS Consultant Cardiac and Thoracic Surgeon St George's Hospital, London Arthur Hollman MD FRCP FLS Emeritus Consulting Cardiologist University College Hospital, London, and Honorary Senior Lecturer Department of Medicine, University College London Medical School The first suggestion that surgery might relieve mitral she had a floppy valve and the diagnosis of rheumatic stenosis was in 1898 (1) and yet it was not until 1948, mitral disease was wrong. We have taken the heart out of fully 50 years later, that the operation of mitral valvotomy its pot and studied it. She had rheumatic disease and died became established (2-4). In 1925, Henry Souttar (Fig. 1) without restenosis. Souttar explained the rationale, operated on a 15-year-old girl with rheumatic mitral valve described the operation and performed it. What was it disease at the London Hospital (5). He had foresight, and that halted progress until after the Second World War, a clarity of thought, which makes him stand out among all and what happened then to permit progress to continue? the other pioneers whose writings we have studied. He First, we must appreciate that we are unlikely to find realised that: "the heart is as amenable to surgical the full story in the medical literature. Case reports, single treatment as any other organ". The valvular conse- or in series, are heavily biased in favour of reporting quences of rheumatic fever were common and he was achievement. Many ofthefailures that occur inthe course of familiar with the pathological appearance of mitral medical progress, pass unrecorded. Claims are made in stenosis and predicted that large print while retractions, if they are ever made, command less prominent coverage in the medical press, just the consecutive changes to which these lesions may have despite as in the popular press. Furthermore, the medical literature given rise in the cardiac muscle, the relief of the lesions reports facts in a way that enables us to identify landmarks, themselves would undoubtedly be of immense, service to the a at not patient and must be followed by marked improvement in his while tide ofopinion that is evident the time may be general condition (5). readily accessible and is lost to us. We can see what was written but we cannot guess what the contemporary reader His patient survived, left hospital at 2.5 weeks and went in the 1920s may have read between the lines. on to live an improved life, dying of cerebral embolism in There is plentiful literature in the late 1940s and early 1932 (6,7). 1950s, the renaissance of a surgical approach to mitral In retrospect, this report is recognised as a surgical stenosis, when Bailey (2), Harken et al. (3), Baker et al. landmark, but why did Souttar fail to repeat the (4) and others (8) added many successful surgical cases operation? Why did it take until 1948 for mitral to the literature. They were at last able to vindicate valvotomy to become routine practice? It has been said Souttar's opinion that "the problem is to a large extent that Souttar had operated on other patients with mitral mechanical, and as such should already be within the valve disease who died. If so, where is the evidence? It has scope of surgery". They demonstrated that structural been said that Lily Hine, his 19-year-old patient had abnormalities of the heart not only contributed to the predominant regurgitation, not mitral stenosis. An symptoms and morbidity of the patient, but were informed reading of the operation note confirms that amenable to anatomical correction. there was tight stenosis. It has even been suggested that There are two further interesting phases in the evolution of treatment of mitral stenosis. The first was the Correspondence to: Professor Tom Treasure, St George's refinement of the surgery of mitral stenosis by performing Hospital, Blackshaw Road, London SE17 OQT the operation on cardiopulmonary bypass, under direct 146 T Treasure and A Hollman obviously a puzzle and Samways writes: "a stenosed and incompetent valve may be present and regurgitation with its accompanying systolic murmur be absent, as is so frequently found". We now use the words incompetent and regurgitation interchangeably, but here there was obviously a different connotation. Later, there seems to have been an inherent assumption that stenosis could only be relieved at the expense of regurgitation. Brock appreciated that freeing the commissures did not necessarily induce regurgitation but might actually reduce existing valvular incompetence (16). Samways concludes his article: ... I anticipate that with the progress of cardiac surgery some of the severest cases of mitral stenosis will be relieved by slightly notching the mitral orifice and trusting the auricle to continue its defence. He had not seen the possibility of splitting the commissures and his notion that the atrium would ensure onward flow by a peristalsis-like action was an interesting if ingenious error. But his anticipation that cardiac surgery would be the solution to mitral stenosis was fully 50 years ahead of its time. Samways was not alone in his preoccupation with a mechanical solution to mitral stenosis. Sir Lauder Brunton's 'Preliminary note on treating mitral stenosis by surgical methods' appeared in 1902 (17). He was impressed by the widespread suffering caused by this Figure 1. Sir Henry Sessions Souttar (1875-1964) Henry disease and the completely ineffectual treatment available. Souttar took a double first in mathematics and also He saw the stenosed mitral valve as amenable to surgical studied engineering at Oxford. He was a clinical student treatment: at the London Hospital where he qualified in 1906. (Biographical details from Robinson RHOB, Le Fanu On looking at the contracted mitral orifice in a severe case of this WR. Lives of the Fellows of the Royal College of Surgeons of disease one is impressed by the hopelessness of ever finding a England 1952-1964. Edinburgh and London: E & S remedy which will enable the auricle to drive blood in a sufficient Livingstone, 1970.) stream through the small mitral orifice, and the wish unconsciously arises that one could divide the constriction as easily during life as one can after death. vision (9-11). Then a return to the closed approach for Brunton addressed two important technical questions. pure, uncomplicated mitral stenosis with a transatrial Namely, the choice of approach, atrial or ventricular, and balloon closely mimicking Souttar's approach (12). Could whether to split the valve along its commissures, or to cut there be a better vindication of all that Souttar believed the cusps at right-angles to the orifice. Both became major about the importance of the valve lesion and that it was issues in Souttar's time and were again debated in the largely amenable to a mechanical solution, best achieved postwar era. by reopening the commissural fusion? (13-15). Brunton's choice of ventricular incision did not eventually prove to be the best way, but he made the correct choice regarding the technique of relieving the The first ideas stenosis itself. The first question that arises is whether the mitral orifice should In 1898 Samways wrote a short paper entitled 'Cardiac be enlarged by elongating the natural opening or whether the peristalsis: its nature and effects' (1), pointing out that valves should be cut through their middle at right angles to the atrial contraction continues after ventricular contraction normal opening. I think there can be little doubt that the former has begun. He saw this as "peristaltic contraction in would be the better plan. sequence, with overlapping of the contractions of adjacent Samways appears in the correspondence column a segments". At first sight this seems obscure and later with a witty but, as it turns out, a in fortnight irrelevant, but Samways saw practical application inappropriate trivialisation of this critical surgical detail. that the contracting atrium may aid onward flow of blood even in the face of an incompetent mitral valve. This is The question which Sir Lauder Brunton raises whether to important in our attempts to understand some of the elongate the natural opening or cut the valves transversely is a arguments of the day. Valvular regurgitation was problem somewhat similar to 'which foot should be drawn down Surgery of mitral stenosis 147 in podalic version?' Probably in practice they may be congratulated who succeed with either (18). The nuances of bringing down the foot may be lost on many of us, but the alternatives in opening a stenosed mitral valve are not equivalent. The American surgeon, Cutler, knew Brunton's paper but chose to ignore this clearly expressed advice when he came to operate for mitral stenosis in 1923 (19). That was an important error which probably marred his results and may have been a major factor in halting progress towards mitral valvotomy. At the time, Brunton was not let off lightly. Arbuthnot Lane wrote to say that he had the idea "some years ago" and was prepared to go ahead and operate but was dissuaded by his physician colleague (20). Others were Figure 2. The heart from Souttar's patient is still even less receptive of Brunton's views. The Lancet preserved in the museum of the Royal London Hospital published an editorial comment the following week where we were fortunate to be allowed to examine it. (21). Brunton's opinions themselves, and his right to Professor M J Davies (British Heart Foundation express them at so early a stage in the evolution of his Professor of Cardiac Pathology) noted the evidence of ideas, were both roundly criticised; surely not by the very rheumatic heart disease.