Introduction


  
    To operate on an ailing heart while it is still beating and supporting vital circulation was a difficult task that faced pioneers of cardiac surgery at the turn of the Twentieth Century. The heart was an unknown dark frontier, and approaching it with an operation was filled with shadows of death and possible shame. Even the mere suggestion of a surgical approach to treat the heart was an adventure that was met with strong opposition and caustic accusations.
 


Early operations

   

      The German surgeon Ludwig Rehn (1849-1930) performed the first successful cardiac operation. He repaired a right ventricular stab wound, and the patient survived. Thus, the year 1896 is considered by many historians as the birthday of cardiac surgery. Eleven years later, Rehn reported 124 operations to suture cardiac wounds with a survival rate of 40 %. Rhen’s operations moved cardiac surgery from the realm of unethical adventure to possible success in saving lives.



   
The amazing early research of Tuffier


  

    The French surgeon Theodore Tuffier (1857-1929) should be considered as one of the amazing pioneers of thoracic and cardiovascular surgery. Not only was he an outstanding clinical surgeon, but also he was constantly involved in experimental research in Paris and at the New York Rockefeller Institute with Alexis Carrel (1873-1945). His three most remarkable contributions were in the field of intratracheal anesthesia, pulmonary resection and experimental cardiac surgery. In 1896 he published his experiments on artificial respiration using intratracheal intubation with an inflatable cuff tube. Tuffier was also the first to describe extrapleural pneumothorax in the treatment of tuberculous cavities. In 1891 he performed the first ever pulmonary resection for tuberculosis. Finally, with Alexis Carrel in 1914, he published his amazing paper on experimental beating heart surgery. They described operations on the cardiac valves in animals performed with caval occlusion. The heart did tolerate most of these aggressive procedures, but all animals died of cerebral anoxia due to the caval occlusion. Nevertheless Carrel and Tuffier’s experiments encouraged later surgeons to proceed with closed valvular surgery, knowing the heart is quite resistant to surgical aggression. In 1912, Theodore Tuffier performed the first attempt to palliate severe aortic stenosis by invaginating the aortic wall into the stenosed valve orifice to digitally dilate it. The patient survived and was reported to be alive twelve years later. Tuffier should be considered a real pioneer in clinical and experimental cardio-thoracic surgery. Carrel received Nobel Prize in 1912 for his work on vascular anastomosis and organ transplantation.

 

  The agony of clinical research


       
  The story of mitral valve repair is one of the best illustrations of the agony of clinical research and the stresses imposed on courageous pioneers who work so hard against all odds to realize their hopeful vision. This story I will tell in details using the actual words of these great researchers to have a clear appreciation of their situation, their feelings and their ambition.
  

                                                                                                                                                                                                  

The vision and the controversy


   
In 1897, Less than a year after Rehn’s landmark report, an article was sent to the Lancet by Herbert Milton, the Director of Kasr El-Einy Hospital in Cairo in which he described sternum splitting incision for easy access to the heart. He also remarked with amazing prophecy that: “Heart Surgery is still quite in its infancy, but it requires not a great stretch of fancy to imagine the possibility of plastic operations of its valvular lesions”. Brief communication from Daniel Samways (1857-1931) was also published in the Lancet in April 1898. He predicted: “… and I anticipate that with the progress of cardiac surgery some of the severe cases of mitral stenosis will be relieved by slightly notching the mitral valve orifice”. The note was completely ignored until 1902 when Sir Lauder Brunton (1844-1916), the distinguished Scottish internist, started a storm of controversy with a paper entitled: “Preliminary note on the possibility of treating mitral stenosis by surgical methods”. Based on his experience in post-mortem opening of mitral valves using transventricular tenotomy knife he wrote: “On looking at the contracted mitral orifice … one is impressed by the hopelessness of ever finding a remedy which will enable the auricle to drive the blood through the small mitral orifice… one could divide the constrictions as easily during life as one can after death. The risk of such operation might well be worth while… but no one should be justified in attempting such a dangerous operation as dividing a mitral stenosis on a fellow-creature without having first test its practicability on animals… The good results that have been obtained by surgical treatment of wounds in the heart emboldens one to hope that before very long similar good results may be obtained in cases of mitral stenosis.”

      The editorial comment in the Lancet the following week was caustic: “We gather that he has proceeded no further than the table of the dead-house in making his investigation… This is somewhat unusual course to pursue and we think that Sir Lauder Brunton would have been better advised to have himself completed his experiments…We think that these surgical difficulties have been under-estimated and that the very technique of the operation will prove fatal… If the narrowed valve is divided what hope is there that the incision in the valve will heal without renewing the contraction?... the operation might convert the valvular lesion from a mitral stenosis into a mitral regurgitation with very doubtful benefit to the patient.”
The editors had the courtesy to publish Sir Brunton’s response: “I am quite aware of the responsibility that rests upon me for my suggestion, but I must state that while my experiments on the valves were made only on dead animals my knowledge of the manipulation of the living heart and of the effect upon it of wounds and punctures is based upon very numerous experiments made at intervals during the last 35 years.” In the same issue of the Lancet, letters were published about this hot debate by Arbuthnot Lane, Theodor Fisher, Lorriston Shaw, and Samways who said that surgical treatment of mitral stenosis: “merits, I think, serious consideration at the hands of experienced surgeons.”



Early Experiments
 

Sir Henry Souttar (1875-1964) His first and only successful closed mitral commissurotomy was in 1925.

Sporadic experimental attempts of surgical approach to the mitral valve were reported between 1906 till 1922 by McCallum, Cushing, Branch, Berheim, Schepelmann, Carrel, Tuffier, Allen and Graham. The First World War interrupted some of this work until 1923 when Samuel Levine (1891-1966), a Bostonian cardiologist, and Elliot Cutler (1888-1947), thoracic surgeon, reported their first successful mitral operation after two years of experiments in the lab. The patient was 12 year old girl with severe mitral stenosis which confined her to bed for 6 months. Mitral valvulotomy operation was performed successfully on May 20th, 1923. Opening the mitral stenosis was done using a valvulotomy knife through the left ventricular wall. Their detailed account of the operation must be read by all cardiac surgeons of these days: “the valvulotome … was plunged into the left ventricle … until it encountered what seemed to us must be the mitral orifice … a cut made in what we thought was the aortic leaflet [of the mitral valve], the resistance encountered being very considerable. The knife was quickly turned and a cut was made in the opposite side of the opening. The knife was then withdrawn and the mattress sutures already in place were tied over the point at which the knife had been inserted.” The patient survived the operation for about 5 years and died then of bronchopneumonia. In their report, Cutler and Levine displayed their full awareness of research performed by others in this field and correctly stated: “… so far as we can determine, this is the only case on record of such a surgical attack upon a mitral stenosis being completed. Doyen [Eugenie Doyen, France] previously attempted a similar case [pulmonary valvotomy, 1912] but his patient did not survive the operation … McCallum, Cushing and Branch, Bernheim, Schepelmann, and Carrel and Tuffier from 1906 to 1914 described fully the experimental methods in use … In 1922 Allen and Graham … used a cardioscope in which a small knife was carried and by inserting the instrument via the left atrial appendage …” In 1922, Duff Allen and Evart Graham (1883-1957) reported that they planned to do the operation on a very sick girl with severe mitral stenosis in two stages; at first they only did the chest wall incision. At the second operation, they had only entered the pleura when the patient’s condition became so critical that the operation had to be stopped. At the third operation, they had gotten to the point of introducing the cardioscope when she suddenly collapsed and died. That was their first and only clinical attempt to use their cardioscope.

     In 1925, Sir Henry Souttar (1875-1964) of London used trans-atrial approach to open stenotic mitral valve with his finger. The patient was 19 year old girl who survived the operation representing the first successful digital mitral commissurotomy. Souttar reported these fine details: “the moment that [the finger] passed into the orifice of the mitral valve the blood pressure fell to zero, although even then no change in the cardiac rhythm could be detected … it was decided not to carry out the valve section which had been arranged, but to limit intervention to such dilatation as could be carried out by the finger. It was felt that an actual section of the valve might only make matters worse by increasing the degree of regurgitation, while breaking down adhesions by the finger might improve the condition … The information given by the finger is exceedingly clear, and personally I felt an appreciation of the mechanical reality of stenosis and regurgitation which I never before possessed … I could not help being impressed by the mechanical nature of these lesions and by the practicability of their surgical relief.” Later on he wrote in a letter to a friend: “I feel that the success owed much to her [the patient’s] courage in the face of very great handicap … she lived in very fair health for five years. At the end of that time she suddenly developed a cerebral embolus … and died … I was naturally unable to obtain another case … In those days opening the chest was an adventure.” Much later in 1961, Sir Souttar wrote to Dwight Harken: “I did not repeat the operation because I could not get another case. Although my patient made an uneventful recovery the physicians declared that it was all nonsense and in fact that the operation was unjustifiable. In fact it is of no use to be ahead of ones time!”

     By 1929, Cutler’s group reported 6 additional cases of mitral valvulotomy, all but their first patient died. The World’s experience in surgical management of cardiac valve disease at that time amounted to 10 patients, all died except the first case of Cutler and that of Souttar.
 

The Agony of Success
 

Dwight Harken (1910-1993). His first successful closed mitral commissurotomy was on June 16th, 1948. Remarkable series of removing foreign bodies from the mediastimun, the heart and great vessels in 134 patients without any mortality in 1945.

 

Charles P. Bailey (1910-1993). His first successful closed mitral commissurotomy was on June 10th, 1948.

The Second World War interrupted the surge of cardiothoracic surgery. Yet, it also gave the chance for Dwight Harken (1910-1993) as director of the Thoracic Center of the 160th General Hospital of the US Army in England to accomplish with his team the extra-ordinary successful series of 134 operative removal of bullets and shrapnel from the mediastinum, the heart and great blood vessels without any mortality. Harken’s report in 1945 is the first consistently successful series of elective cardiac operations. He attributed this success to thoughtful preoperative care, endotracheal anesthesia, fine surgical teamwork, safe blood transfusion, and meticulous postoperative care using penicillin and vigorous physiotherapy.
After World War II, surgical attack on the mitral valve was renewed. Still impressed by Cutler’s belief that it is mandatory to create some degree of mitral regurgitation to cure mitral stenosis, Charles Bailey (1910-1993) did his first mitral operation late in 1945 using a valvulotome through the left atrium. The patient died due to extensive hemorrhage. His second patient also died after digital dilatation of the stenosed mitral valve. Meanwhile, Harken and Ellis proceeded with their methodical surgical approach to mitral stenosis using the concept of “selective insufficiency” in which wedge resection of the commissure bridges is performed using a valvulotome to achieve maximal mitral function (valvuloplasty). Harken’s experimental work in animals convinced him that it is important to maintain the integrity of the anterior mitral leaflet. His first mitral operation was performed in 1947. The patient died due to severe mitral regurgitation and tachycardia.



The Landmark Year of 1948

Horace Smithy (1912-1948) His first successful closed mitral partial valvectomy was on Jan. 30th, 1948.

 

Lord Russell Brock (1903-1986). His first successful closed mitral commissurotomy was in September 1948. Pioneer of pulmonary valvotomy.

The year of 1948 witnessed significant development in cardiac surgery. In January of 1948, Horace Smithy (1912-1948) at the Medical College of South Carolina in Charleston performed the first successful mitral valvulotomy operation in a 21 year old woman by introducing a special valvulotome, which he designed, through the apex of the left ventricle. The patient survived the operation only to die 10 months later due to a false aneurysm of the left ventricular apex. In March 1984, Smithy’s second operation was unsuccessful due to heavy calcification of the mitral valve and the patient died. His third patient one week later also died postoperatively due to pneumonia. However, his next four patients all survived the operation. Unfortunately, the brilliant career of this young surgeon ended in October 1948 when he died at the age of 34 years, ironically due to aortic stenosis.

     In June 1948, Bailey performed his third mitral valvulotomy. The patient died on the fifth postoperative day as a result of improper fluid and anticoagulation therapy. On June 10th, 1948 Bailey performed two such operations. The first case was performed at the Philadelphia General Hospital. It was difficult due to extensive pleural adhesions and irritable heart. Intravenous quinidine was given and the heart stopped. The patient died despite open cardiac massage and a desperate digital mitral commissurotomy. Just few hours later, Bailey operated on a 24 year old woman at the Episcopal Hospital in Philadelphia. This time the operation was fast and smooth. The postoperative course was uneventful and the patient survived. Meanwhile, just six days later in Boston, Harken performed a successful mitral valvulotomy in a 27 year old man, and the patient made an uneventful recovery too.

    Simultaneously, in England, Lord Russell Brock (1903-1986) and his team had success with operative relief of pulmonary stenosis, and they were convinced that mitral valvotomy could be similarly approached. His first mitral operation was performed in September 1948 and was successful. By 1950 he reported six similar successful cases.
 
    Thus within one year four surgeons working independently and with no knowledge of the others’ methods had established successful surgical treatment of mitral stenosis. These four men, Smithy, Bailey, Harken, and Brock, made closed cardiac operations for valvular heart disease an undisputed reality. Thousands of such operations followed their pioneering experience. Almost half a Century after Milton, Samways and Brunton’s shy introduction of the idea of probable feasibility of an operative treatment of mitral stenosis, the idea was finally realized. It is also important to note that the comments of their opponents, editors of the Lancet, were also proved correct in their alarming remark about the possible detrimental effect of creating acute regurgitation while dilating stenosed mitral valve.



Continuous Progress
 

Charles Hufnagel (1916-1989). The first implantation of a prosthetic valve in 1952.

Effective blunt mitral valve dilators were developed by Brock, Bailey, Dubost, and Tubbs to facilitate and improve the results of closed mitral commissurotomy. Harken and Bailey extended the scope of cardiac surgery to include various operations for diseases of the aortic and tricuspid valves as well. By 1952, after years of research, Charles Hufnagel (1916-1989) successfully implanted a mechanical ball-and-cage valve in the descending thoracic aorta of a 30 year old woman with severe aortic insufficiency. This was the first case of prosthetic valve implantation in history. Subcoronary implantation of prosthetic valves had to wait till early 1960s and the development of open heart surgery.

    The era of closed heart surgery also involved surgical approach to the great vessels and some congenital cardiac defects. The saga of patent ductus arteriosus, coarctation of the aorta, and ingenious methods to close atrial septal defect without the convenience of cardiopulmonary bypass deserves yet another full episode in our tour of the history of cardiothoracic surgery of the Twentieth Century.¨
 

Hufnagel valve implanted in the descending thoracic aorta for treatment of severe aortic incompetence in 1952. The clip is used to fix the valve without sutures.

Reference:
 

1. Robert S. Litwak. “The growth of cardiac surgery: Historical notes”. Cardiovasc Clin 1971;3:5-50.

2. Richard H. Meade. “A History of Thoracic Surgery”; Bannerston House, 1961;pp.

3. Louis Acierno. “The History of Cardiology: Men, Ideas and Contributions”. Informa Health Care, 1994;pp.

4. Stephen Westaby and Cecil Bosher. “Landmarks in Cardiac Surgery”. Informa Health Care, 1998;pp.

5. Andreas P. Naef. “The mid-century revolution in thoracic and cardiovascular surgery: Part 5”. Interactive Cardiovasc & Thoracic Surg. 2004;3:415-22.



                                       

DENTAL DRILL                            If there is one reason people don't like going to the dentist, it's because of the dentist's drill. With its gleaming metal tip and high-pitched scream, it is so often seen as an instrument of torture. Yet it is truly an engineering miracle. Enamel is the hardest substance in the body and the dentist's drill can cut through it with exquisite precision at an incredible number of revolutions a minute. Primitive dental drills were in use almost 2,000 years ago. Doctors must have recognized early on that simply yanking out teeth at the first sign of decay was a bit draconian. Much better to drill out the bad part and leave the rest of the tooth in place. Around AD 100 the Roman surgeon Archigenes developed a drill that was powered by rope; one can only imagine the look on his patients' faces as he approached them. It took about 1,500 years for anyone to do much better. John Greenwood, an American dentist who made George Washington's dentures, used a spinning wheel to power a drill in 1788. For the next century and a half progress remained painfully slow. A key development came with the launch by Dr Samuel White in 1944 of a flexible shaft drill, allowing the rotating bit to be powered from any angle. It gave the dentist more freedom of movement, and thus a lower risk of hurting the patient. Dr White cleverly spotted that his invention had applications beyond people's mouths, and he sold it for a tidy sum to Henry Ford, who used it for the speedometer cable in his motor cars. In 1957, dental drill technology took a big leap forward with the advent of air turbine power. Compressed air squirted into the drill drove the bit to astonishing speeds of 200,000 rpm and more. Such speeds greatly reduced the amount of time and effort, and thus pain, involved in drilling out decay. But they also made unprecedented demands of the bearings in the drills. To put their work load into perspective, an average domestic cordless drill will run at 800-1,000 rpm, while a very fast power-tool might reach 4,500 rpm. Only recently have ball bearings been manufactured to a sufficiently high tolerance and standard of design to allow high-speed drills to operate without excessive failures. Yet such are the tolerances of today's precision ball bearings that even at these high speeds a modern dental drill requires a change of bearings only every 18 months or so. James Dyson, History of Great Inventions.                                                                                              James Dyson, History of Great Inventions. .