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Operations for Mitral Stenosis
801
standards of purity required for foodstuffs. Joint subcommittees have been dealing with assistance conventions, including treatment at spas, and with rehabilitation : the latter is now dealt with by The convention on social and a separate committee. medical assistance, which will shortly be signed, provides that nationals of one of the four countries who are normally resident in another country and Are without sufficient resources shall benefit (with certain exceptions) on an equality with the nationals of the host country from the legal provisions for social and medical assistance : it thus does not apply to visitors. The scope and results will largely depend on the administrative agreements on its application, which have yet to be worked out. Perhaps the question on which the greatest practical advance has so far been made is that of simplification of health control at seaports and particularly airports. The principle has been adopted of treating the five countries as one country for this purpose, which means the abolition of all health controls for aircraft and passengers making flights within the five countries -save in exceptional circumstances-and instituting one health control only for aircraft and passengers arriving from outside : this sounds comparatively simple, but has involved much detailed work. The British Ministry of Health have already anticipated this on a limited scale in the so-called " Paris experiment," whereby passengers from Paris no longer have to fill up the personal declaration of origin and health; so its inquiries into where the previous fourteen nights have been spent will no longer be a source of ribald comment. Finally, there is the intricate question of the relation of the ’’ get together " activities of Western Union to those of the Council of Europe and of the World Health Organisation. Clearly there are some health questions now being considered by Western Union which are susceptible of treatment on a European or world-wide scale : but it seems that preliminary consideration and action by the Western Union powers has been advantageous, and that comparative strangers should not be. admitted too quickly to family conferences. As in other health matters, political considerations may provide a stimulus but should be the servants and not the masters of sound technical progress. _
Operations
for Mitral Stenosis
IN operating on the mitral valve to relieve stenosis, two considerations have to be borne in mind. The first is that with extreme stenosis of the valve the left ventricle is small ; at necropsy the posterior surface-i.e., the wall of the left ventricular inflow tract-appears short and the coronary vessels tortuous
though unaffected by atheroma.l The second consideration is that artificial mitral regurgitation is poorly tolerated by experimental animals with normal hearts, and extensive cutting of the anterior valve carries a high mortality-rate.23 Both HARKEN and his team2 and BAILEY 3 have based their work on these facts ; by approaching
even
1. 2.
Kirch, E. Verh. dtsch. Ges. inn. Med. 1929, 41, 324. Harken, D. E., Ellis, L. B., Ware, P. F., Norman, L. R. Engl. J. Med. 1948, 239, 801. 3. Bailey, C. P. Dis. Chest, 1949, 15, 377.
New
through the left auricular appendage they aim at relieving the stenosis without causing extensive regurgitation. HARKEN, whose various methods have already been reviewed,4has attempted to mobilise the rigid cusps by dividing the commissures (valvuloplasty) ; and he has also removed a segment of the posterior leaflet. BAILEY, on the other hand, has confined himself to commissurotomy," in which he "
extends the cut into the normal tissue surrounding the fibrotic area of the valve, believing that the raised auricular pressure will keep the artificial opening patent. Of 10 patients operated on by him, 7 died. Among the causes of failure were cerebral embolism on the sixth day after operationan error in technique by cutting across the valve leaflet ; postoperative obliteration by fibrin deposits of a small, calcified mitral orifice which did not permit of adequate cutting ; postoperative intrapleural haemorrhage attributed to the unnecessary use of heparin and incorrect fluid administration ; and severe haemorrhage due to friability of the auricular wall (which he has often encountered in mitral stenosis). To these dangers may be added two recorded by HARKEN-namely, tachycardia and dislocation of the heart from its natural position. Thus the risk of operating on the mitral valve is still great, even in the hands of experienced cardiac surgeons familiar with the precautionary These include permanent electrocardiomeasures. graphic control and the administration of procaine drips to combat tachycardia and myocardial irritability. (This precaution is now held to be more efficacious when the procaine is injected intramurally in a 2% solution.5) The latest development is that MURRAY,s of Toronto, has succeeded in animal experiments, and in two patients with mitral stenosis, in removing one mitral leaflet and replacing it by an artificial leaflet consisting of a section of cephalic vein turned inside out and strengthened with palmarislongus tendon. Of the indirect surgical procedures, which are designed to relieve pulmonary symptoms due to mitral stenosis, two have already been mentioned in these columns.7 One of these, designed to produce an artificial interauricular shunt, was inspired by the observation that mitral stenosis associated with a natural defect of this nature (Lutembacher’s syndrome) may run a mild course, and that serious symptoms, such as pulmonary oedema and haemoptysis,’, HARKEN and his team4 hold are then rare. that an artificial auricular septal defect is indicated only when the cardiac output is normal and increases and when stenosis and regurgitation on exertion, otherwise the fall in left-auricle pressure coexist ; cause insufficient blood to reach the left ventricle may the stenosed valve. Another objection to this through procedure is that the artificial defect may become obliterated and that embolism may ensue ;however, work is in progress in the U.S.A. with the purpose of ensuring that the defect is both large enough and permanent. The second method, which is less hazardous, consists in creating an extra cardiac venous shunt between the right dorsal-segmental inferior pulmonary vein and the nearby azygos vein by non4. 5. 6. 7.
Leading article, Lancet, 1949, i, 572. Smithy, H. G. Dis. Chest, 1949, 15, 385. Murray, G. Ibid, p. 394. Annotation, Lancet, 1949, i, 660.
802
anastomosis with Blakemore’sVitallium ’ BLAND and SWEET,8the originators of this technique, have now reported their operative results in 5 patients, all of whom had frequent attacks of pulmonary oedema and haemoptysis ; in each of these patients pulmonary hypertension was associated with significant further rise of the. pulmonary pressure on gentle exercise, and the left-auricle pressure was 400-500 ml. of water-i.e., 4-5 times the normal. Their hearts were not grossly enlarged. In 1 case, biopsy of the lung during operation revealed haemosiderosis with thickening of the walls of the small arteries and the alveoli. BLAND and SwEET believe that these cases belong to a group in which the patients eventually succumb not to cardiac but to pulmonary failure, though hypertrophy of the right ventricle usually develops : " They die before their time as far as their hearts are concerned." At operation, as soon as the anastomoses were established and the pulmonary clamp released, blood rushed with great force through the channel from the pulmonary into the azygos vein, and the pressure in the left auricle fell. Of the 5 patients, 4 did remarkably well ; exercise tolerance improved and they remained free from pulmonary oedema and haemoptysis for 12, 5, 4, and 2 months respectively. The 5th patient, a woman of twenty-five, died on the llth day after operation. Before operation she had shown signs, of active carditis, which was later confirmed at necropsy when a fresh antemortem clot was also found to have occluded the anastomosis ; and BLAND and SwEET point out that before operation smouldering carditis should be carefully sought. As to technique, they suggest that anastomosis without the intermediate vitallium tube may prove preferable. The sine-qua-non for this kind of escape-valve operation is a high pressure-gradient from the pulmonary to the systemic vein, as has been emphasised by SwAN9 who, apparently independent of BLAND and SwEET, conceived the idea of the same kind of venous shunt, which he has performed in normal animals. Whether the shunt was accomplished by the tube method or by end-toend suture, it remained patent only when a high pressure-gradient was introduced. If further trials prove that the artificial channel remains unoccluded, the indirect approach may well be preferred by the clinician, whose main concern is to relieve dyspnoea, recurrent pulmonary oedema, and haemoptysis. Shunt operations that bring about a flow of blood from the left auricle or pulmonary vein to the right auricle or systemic vein must inevitably inflict an increased load on the right heart ; but so far there is no evidence that failure of the right heart ensues, and in Lutembacher’s syndrome such failure does not usually develop until a late stage. With its great capacity and established hypertrophy, the right heart-unlike the left ventricle-is prepared to deal with an increased volume of blood, provided of course that the cavity is not grossly dilated and the myocardium is not damaged. Under certain conditions of stress the increased activity of such a hypertrophied right ventricle may flood the lung, theg outlet side being partly blocked at the mitral valve. It is therefore surprising that so far apparently no vent operation to relieve pulmonary hypertension suture
tube.
,.
"
9. Bland, E. F., Sweet, R. H. J. Amer. med. Ass. 1949, 140, 1259. 8. Swan, H. Amer. Heart J. 1949, 38, 367.
carried out ; it might seem that such a, procedure, consisting perhaps in creating an artificial incompetence of the pulmonary valve, would be technically easier than the " shunt " procedures. Certainly direct mitral-valve surgery is still a formidable undertaking, fraught with great technical difficulties and dangers ; and the cardiac surgeon will always have to remember that even after the has been
most brilliant technical achievement on the mitral ostium, the ultimate result rests with the myocardium
of the left ventricle, which has become accustomed to receive and eject a reduced amount of blood.
Annotations CHARGE FOR PRESCRIPTIONS IT is a little ironical that, sixteen months after the introduction of free medical care, insured persons should now be asked to pay for their medicines-for the first time since 1911. Unfortunately, though oldage pensioners are to be excused the new charge of up to a shilling " for each prescription, there are others to whom it may mean the re-erection of a barrier, if a small one, in the way of medical treatment, and the charge should perhaps be remitted in the longer illnesses -e.g., after four weeks’ incapacity. The prospect of paying several shillings for medicine may keep some people away from the doctor, but at least it is better that they should pay for drugs and dressings than for mere access to the surgery. Practical difficulties may arise over the collection of payment by rural doctors who do their own dispensing and sometimes send the medicine to the patient by the local bus ; and the Prime Minister did not say whether hospital dispensaries will make a charge-as they presumably should if patients are not to seek repeat medicines in outpatients. To those who are anxious to see the National Health Service create better conditions of practice it has been galling to watch it fostering rather than restraining the bottle-of-medicine habit. The rise in the average annual pharmaceutical cost per person at risk from 4s. 9d. under National Health Insurance to just under 8s. last Februarywas partly due to higher dispensing fees but also partly to a larger number of prescriptions per person : in Middlesex, for example, this rose from 1-93 in the last six months of 1947 to 2.47 in the last six months of 1948. As everyone knows, a great many of these prescriptions have been for household remedies for which the doctor should never have been bothered at all, and there is reason to think that this abuse, so far from diminishing has lately grown. In so far as the new arrangement helps to " reduce excessive, and in some cases unnecessary, resort to doctors and chemists " it will be welcomed by the profession. "
TREATMENT
OF AMŒBIASIS IN Britain during the later years of the war a good deal of dissatisfaction was expressed over the results of treating chronic amoebic dysentery with any of the standard remedies. Most of the authorities favoured emetine bismuth iodide by mouth, reinforced with arsenicals (e.g., carbarsone), bismuth, or quinoline compounds (chiniofon, diodoquin) according to taste. Some of the failures were probably due to the type of cases treated-soldiers with many previous relapses and secondary bacterial invasion in the large intestine. These were often much benefited by courses of penicillin and succinyl sulphathiazole which suppressed the bacteria and cleared the way for emetine to work on the amoebae. 1. Seventh Report from the Select Committee Session 1948-49. H.M. Stationery Office. 1949. 2. Pharm. J. Sept. 10, p. 191.
on
Estimates.
Pp. 54.
standards of purity required for foodstuffs. Joint subcommittees have been dealing with assistance conventions, including treatment at spas, and with rehabilitation : the latter is now dealt with by The convention on social and a separate committee. medical assistance, which will shortly be signed, provides that nationals of one of the four countries who are normally resident in another country and Are without sufficient resources shall benefit (with certain exceptions) on an equality with the nationals of the host country from the legal provisions for social and medical assistance : it thus does not apply to visitors. The scope and results will largely depend on the administrative agreements on its application, which have yet to be worked out. Perhaps the question on which the greatest practical advance has so far been made is that of simplification of health control at seaports and particularly airports. The principle has been adopted of treating the five countries as one country for this purpose, which means the abolition of all health controls for aircraft and passengers making flights within the five countries -save in exceptional circumstances-and instituting one health control only for aircraft and passengers arriving from outside : this sounds comparatively simple, but has involved much detailed work. The British Ministry of Health have already anticipated this on a limited scale in the so-called " Paris experiment," whereby passengers from Paris no longer have to fill up the personal declaration of origin and health; so its inquiries into where the previous fourteen nights have been spent will no longer be a source of ribald comment. Finally, there is the intricate question of the relation of the ’’ get together " activities of Western Union to those of the Council of Europe and of the World Health Organisation. Clearly there are some health questions now being considered by Western Union which are susceptible of treatment on a European or world-wide scale : but it seems that preliminary consideration and action by the Western Union powers has been advantageous, and that comparative strangers should not be. admitted too quickly to family conferences. As in other health matters, political considerations may provide a stimulus but should be the servants and not the masters of sound technical progress. _
Operations
for Mitral Stenosis
IN operating on the mitral valve to relieve stenosis, two considerations have to be borne in mind. The first is that with extreme stenosis of the valve the left ventricle is small ; at necropsy the posterior surface-i.e., the wall of the left ventricular inflow tract-appears short and the coronary vessels tortuous
though unaffected by atheroma.l The second consideration is that artificial mitral regurgitation is poorly tolerated by experimental animals with normal hearts, and extensive cutting of the anterior valve carries a high mortality-rate.23 Both HARKEN and his team2 and BAILEY 3 have based their work on these facts ; by approaching
even
1. 2.
Kirch, E. Verh. dtsch. Ges. inn. Med. 1929, 41, 324. Harken, D. E., Ellis, L. B., Ware, P. F., Norman, L. R. Engl. J. Med. 1948, 239, 801. 3. Bailey, C. P. Dis. Chest, 1949, 15, 377.
New
through the left auricular appendage they aim at relieving the stenosis without causing extensive regurgitation. HARKEN, whose various methods have already been reviewed,4has attempted to mobilise the rigid cusps by dividing the commissures (valvuloplasty) ; and he has also removed a segment of the posterior leaflet. BAILEY, on the other hand, has confined himself to commissurotomy," in which he "
extends the cut into the normal tissue surrounding the fibrotic area of the valve, believing that the raised auricular pressure will keep the artificial opening patent. Of 10 patients operated on by him, 7 died. Among the causes of failure were cerebral embolism on the sixth day after operationan error in technique by cutting across the valve leaflet ; postoperative obliteration by fibrin deposits of a small, calcified mitral orifice which did not permit of adequate cutting ; postoperative intrapleural haemorrhage attributed to the unnecessary use of heparin and incorrect fluid administration ; and severe haemorrhage due to friability of the auricular wall (which he has often encountered in mitral stenosis). To these dangers may be added two recorded by HARKEN-namely, tachycardia and dislocation of the heart from its natural position. Thus the risk of operating on the mitral valve is still great, even in the hands of experienced cardiac surgeons familiar with the precautionary These include permanent electrocardiomeasures. graphic control and the administration of procaine drips to combat tachycardia and myocardial irritability. (This precaution is now held to be more efficacious when the procaine is injected intramurally in a 2% solution.5) The latest development is that MURRAY,s of Toronto, has succeeded in animal experiments, and in two patients with mitral stenosis, in removing one mitral leaflet and replacing it by an artificial leaflet consisting of a section of cephalic vein turned inside out and strengthened with palmarislongus tendon. Of the indirect surgical procedures, which are designed to relieve pulmonary symptoms due to mitral stenosis, two have already been mentioned in these columns.7 One of these, designed to produce an artificial interauricular shunt, was inspired by the observation that mitral stenosis associated with a natural defect of this nature (Lutembacher’s syndrome) may run a mild course, and that serious symptoms, such as pulmonary oedema and haemoptysis,’, HARKEN and his team4 hold are then rare. that an artificial auricular septal defect is indicated only when the cardiac output is normal and increases and when stenosis and regurgitation on exertion, otherwise the fall in left-auricle pressure coexist ; cause insufficient blood to reach the left ventricle may the stenosed valve. Another objection to this through procedure is that the artificial defect may become obliterated and that embolism may ensue ;however, work is in progress in the U.S.A. with the purpose of ensuring that the defect is both large enough and permanent. The second method, which is less hazardous, consists in creating an extra cardiac venous shunt between the right dorsal-segmental inferior pulmonary vein and the nearby azygos vein by non4. 5. 6. 7.
Leading article, Lancet, 1949, i, 572. Smithy, H. G. Dis. Chest, 1949, 15, 385. Murray, G. Ibid, p. 394. Annotation, Lancet, 1949, i, 660.
802
anastomosis with Blakemore’sVitallium ’ BLAND and SWEET,8the originators of this technique, have now reported their operative results in 5 patients, all of whom had frequent attacks of pulmonary oedema and haemoptysis ; in each of these patients pulmonary hypertension was associated with significant further rise of the. pulmonary pressure on gentle exercise, and the left-auricle pressure was 400-500 ml. of water-i.e., 4-5 times the normal. Their hearts were not grossly enlarged. In 1 case, biopsy of the lung during operation revealed haemosiderosis with thickening of the walls of the small arteries and the alveoli. BLAND and SwEET believe that these cases belong to a group in which the patients eventually succumb not to cardiac but to pulmonary failure, though hypertrophy of the right ventricle usually develops : " They die before their time as far as their hearts are concerned." At operation, as soon as the anastomoses were established and the pulmonary clamp released, blood rushed with great force through the channel from the pulmonary into the azygos vein, and the pressure in the left auricle fell. Of the 5 patients, 4 did remarkably well ; exercise tolerance improved and they remained free from pulmonary oedema and haemoptysis for 12, 5, 4, and 2 months respectively. The 5th patient, a woman of twenty-five, died on the llth day after operation. Before operation she had shown signs, of active carditis, which was later confirmed at necropsy when a fresh antemortem clot was also found to have occluded the anastomosis ; and BLAND and SwEET point out that before operation smouldering carditis should be carefully sought. As to technique, they suggest that anastomosis without the intermediate vitallium tube may prove preferable. The sine-qua-non for this kind of escape-valve operation is a high pressure-gradient from the pulmonary to the systemic vein, as has been emphasised by SwAN9 who, apparently independent of BLAND and SwEET, conceived the idea of the same kind of venous shunt, which he has performed in normal animals. Whether the shunt was accomplished by the tube method or by end-toend suture, it remained patent only when a high pressure-gradient was introduced. If further trials prove that the artificial channel remains unoccluded, the indirect approach may well be preferred by the clinician, whose main concern is to relieve dyspnoea, recurrent pulmonary oedema, and haemoptysis. Shunt operations that bring about a flow of blood from the left auricle or pulmonary vein to the right auricle or systemic vein must inevitably inflict an increased load on the right heart ; but so far there is no evidence that failure of the right heart ensues, and in Lutembacher’s syndrome such failure does not usually develop until a late stage. With its great capacity and established hypertrophy, the right heart-unlike the left ventricle-is prepared to deal with an increased volume of blood, provided of course that the cavity is not grossly dilated and the myocardium is not damaged. Under certain conditions of stress the increased activity of such a hypertrophied right ventricle may flood the lung, theg outlet side being partly blocked at the mitral valve. It is therefore surprising that so far apparently no vent operation to relieve pulmonary hypertension suture
tube.
,.
"
9. Bland, E. F., Sweet, R. H. J. Amer. med. Ass. 1949, 140, 1259. 8. Swan, H. Amer. Heart J. 1949, 38, 367.
carried out ; it might seem that such a, procedure, consisting perhaps in creating an artificial incompetence of the pulmonary valve, would be technically easier than the " shunt " procedures. Certainly direct mitral-valve surgery is still a formidable undertaking, fraught with great technical difficulties and dangers ; and the cardiac surgeon will always have to remember that even after the has been
most brilliant technical achievement on the mitral ostium, the ultimate result rests with the myocardium
of the left ventricle, which has become accustomed to receive and eject a reduced amount of blood.
Annotations CHARGE FOR PRESCRIPTIONS IT is a little ironical that, sixteen months after the introduction of free medical care, insured persons should now be asked to pay for their medicines-for the first time since 1911. Unfortunately, though oldage pensioners are to be excused the new charge of up to a shilling " for each prescription, there are others to whom it may mean the re-erection of a barrier, if a small one, in the way of medical treatment, and the charge should perhaps be remitted in the longer illnesses -e.g., after four weeks’ incapacity. The prospect of paying several shillings for medicine may keep some people away from the doctor, but at least it is better that they should pay for drugs and dressings than for mere access to the surgery. Practical difficulties may arise over the collection of payment by rural doctors who do their own dispensing and sometimes send the medicine to the patient by the local bus ; and the Prime Minister did not say whether hospital dispensaries will make a charge-as they presumably should if patients are not to seek repeat medicines in outpatients. To those who are anxious to see the National Health Service create better conditions of practice it has been galling to watch it fostering rather than restraining the bottle-of-medicine habit. The rise in the average annual pharmaceutical cost per person at risk from 4s. 9d. under National Health Insurance to just under 8s. last Februarywas partly due to higher dispensing fees but also partly to a larger number of prescriptions per person : in Middlesex, for example, this rose from 1-93 in the last six months of 1947 to 2.47 in the last six months of 1948. As everyone knows, a great many of these prescriptions have been for household remedies for which the doctor should never have been bothered at all, and there is reason to think that this abuse, so far from diminishing has lately grown. In so far as the new arrangement helps to " reduce excessive, and in some cases unnecessary, resort to doctors and chemists " it will be welcomed by the profession. "
TREATMENT
OF AMŒBIASIS IN Britain during the later years of the war a good deal of dissatisfaction was expressed over the results of treating chronic amoebic dysentery with any of the standard remedies. Most of the authorities favoured emetine bismuth iodide by mouth, reinforced with arsenicals (e.g., carbarsone), bismuth, or quinoline compounds (chiniofon, diodoquin) according to taste. Some of the failures were probably due to the type of cases treated-soldiers with many previous relapses and secondary bacterial invasion in the large intestine. These were often much benefited by courses of penicillin and succinyl sulphathiazole which suppressed the bacteria and cleared the way for emetine to work on the amoebae. 1. Seventh Report from the Select Committee Session 1948-49. H.M. Stationery Office. 1949. 2. Pharm. J. Sept. 10, p. 191.
on
Estimates.
Pp. 54.