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The mid-century revolution in thoracic and cardiovascular surgery: Part 5

12 Avenue Villardin, CH-1009 Pully-Lausanne, Switzerland

	1. The dramatic story of mitral commissurotomy

Top 1. The dramatic story...

 
1.1. Prologue

One can also say that the right man was at the right time in the right place! One had to know the man and his character to comprehend the exceptional performance of this 35-year-old army surgeon. In later years, because of my interest in mitral surgery from 1950 onwards, I came to know Dwight Harken well having spent many hours watching him operate and also being invited to his home, where we developed a friendly relationship and sympathy for each other. He was an outgoing extrovert personality, extremely ambitious and able to develop the best relationship with the surgical leaders of his time—mainly Churchill and Eliott Cuttler in Boston, as well as Tudor Edwards and Norman Barrett in London, men who were extremely helpful for his career. As a medical student at Harvard he was advised by Churchill to make thoracic surgery his career.

During his training at Bellevue Hospital, he obtained a traveling fellowship from the New York Academy of Medicine and spent the year of 1938 with Tudor Edwards and Barrett at the Brompton Hospital in London. In 1944, although already in active practice in Boston, he enlisted as an army surgeon when the USA entered the war. He arrived in England on SS ‘Queen Mary’ to take over the 160 Surgical Unit in the small village of Cirencester in the Cotswold Hills. Captain Harken first met with great resistance from his chief, Elliot Cuttler, a convinced general surgeon, when he wanted to set up his unit as a specialized thoracic surgical center. This concept, by the way, had already been implemented by General Churchill, chief in the Mediterranean theater of operations. Fortunately, through the intervention of Tudor Edwards, Harken obtained what he wanted—a thoracic surgical unit. Although, as a resident at Bellevue or later in Boston he did have experience in animal experimentation, especially for cardiac operations, such operations on human beings, American soldiers, were deemed too dangerous to be authorized. This time through the help of his mentor, Elliot Cuttler, Harken was finally authorized to proceed in his cardiac endeavor. As we have seen, with his indomitable determination he created the conditions so as to be ready for his cardiac operations when the first wounded soldiers arrived after Omaha beach and the invasion of France.

It is stunning to read a description of these operations under wartime conditions. Once the foreign body was localized and the stay-sutures for temporary hemostasis and final repair were in place, Harken ‘plunged’ an old fashioned Kocher clamp into the heart, grabbed the piece of metal and pulled it out: the gush of blood was luckily, sometimes with difficulty, arrested while the nurses pushed the blood transfusion. The surgeon quite often had to close the heart wound by holding his finger over it, occasionally sewing his rubber glove to the heart! Having gone through these maneuvers at least 50 times during his war experience, no wonder that in his mitral operations some years later he was rarely taken aback by a massive hemorrhage. Dwight Harken was maybe not the type of exceptional surgeon I described when remembering Sweet or Overholt. He seemed always under pressure and was constantly explaining to nurses and visitors how things were going. Nevertheless, he proved by his wartime series and later success that he was a highly determined and competent pioneer and, last but not least, devoted to his patients and... his mission!

1.2. Bailey–Harken–Brock

At the turn of the century, rheumatic fever was an almost epidemic disease with endocarditis and mitral valvular pathology as a frequent complication. Consequently, the search for a surgical solution led to the experimental work of Alexis Carrel and Tuffier in 1914, and 10 years later to the one-time attempts of Elliot Cuttler (1923) and Sir Henry Souttar (1925). As early as 1902, the British cardiologist Sir Lauder Brunton published what he called a preliminary note in the Lancet with the unmistakable title ‘Surgical operation for mitral stenosis’. Time clearly was not ripe and Brunton's suggestion provoked an immediate protest by one of the leading, more conservative professors who wrote: "It is possible to do many things that are useless and some that are harmful". Carrel and Tuffier, in 1914, published an important paper in the ‘Presse Medicale’ entitled, ‘Chirurgie des orifices du coeur’, and stated that "their experimentation had shown that mitral stenosis as well as certain cases of aortic and pulmonic stenosis under certain well-specified conditions might benefit from surgical intervention", reporting in detail their animal experimentation. It took another 10 years before the clinical one-time successes of Cuttler and Souttar. Elliot Cuttler and his cardiologist Samuel Levine, at the Peter Bent Brigham Hospital in Boston, successful with one transventricular mitral valvulotomy on June 2, 1923, abandoned further attempts after six subsequent postoperative deaths from massive mitral regurgitation. It is somewhat surprising that Cuttler's one and only patient survived miraculously considering the description of a really ‘frightful’ operation: "A slightly curved tonsil knife was pushed through the ventricle upwards until it encountered what seemed to us must be the mitral orifice. A cut was made in what we thought to be the aortic leaflet... The knife was quickly turned and a cut was made in the opposite side of the opening’!!

Sir Henry Souttar, a distinguished London surgeon, was also successful once, on May 6, 1925 (Fig. 1). He performed what I would call a transauricular finger dilatation, improving the condition of the patient who survived another 5 years. Souttar was certainly an experienced surgeon as he managed, under 1925 conditions, to take hold of a torn auricular appendage and instantly still a massive hemorrhage, ligating the appendage at its base. Souttar was spared the unfortunate experience of Cuttler with his six consecutive operative failures. Twenty-five-years later, when Harken asked him why he never followed up his initial success, he wrote back "because I could never get another case". At the time, it was the doctrine of cardiologists that what mattered was the condition of the myocardium, not the stenotic valve: time, in all evidence, had not succeeded in bringing about a fruitful cooperation between physicians and surgeons....

View larger version (108K): [in this window] [in a new window]   Fig. 1 Sir Henry Souttar (1875–). British general surgeon who carried out the first closed mitral ‘commissurotomy’ in 1925.

Twenty years later Bailey and Harken started an entirely new explosive era! The story of the 1948 breakthrough of Bailey's first successful ‘commissurotomy’ (June 10, 1948) (Fig. 2), and almost simultaneously Harken's ‘valvuloplasty’ (June 16, 1948) (Fig. 3) has been told over and over again-as well as the one about their epic priority discussions, a sometimes entertaining show at surgical or medical meetings. Bailey's terminology of commissurotomy was not only the correct name for the right operation while Harken, with his valvuloplasty accepted a ‘limited degree of regurgitation’. For someone who, at the time, was an active witness of these events two questions seem to be historically interesting. First the conversion of these two general thoracic surgeons to pioneers in cardiac surgery, and second their stubborn tenacity in going on in the face of distressing failures and harsh criticism by their peers. Bailey lost three or four patients and most of his hospital privileges in and around Philadelphia. However, this did not stop him, the extrovert showman he was, presenting his finally first ‘cured’ patient, one week postoperatively, at the meeting of the American College of Chest Physicians, having traveled with the patient by train all the way from Philadelphia to Chicago! It is still questionable whether, under today's ethical standards, Bailey and Harken could have gone through those painful failures, but once the technique as well as indications and postoperative care were established hundreds and thousands of patients were relieved of the misery of terminal mitral stenosis with the lowest possible postoperative complication rate.

View larger version (124K): [in this window] [in a new window]   Fig. 2 Charles Ph. Bailey (1910–1993) carried out the first mitral ‘commissurotomy’ on June 16, 1948.

View larger version (115K): [in this window] [in a new window]   Fig. 3 Dwight D. Harken (1910–1993) carried out the first mitral valvuloplasty on June 10, 1948.

Nevertheless, this general climate of despair did not keep Harken and Bailey from preparing their blind, closed heart surgery for mitral stenosis. One of our two pioneers, Dwight Harken, may have had the stronger motivation, given his extraordinary wartime experience with heart surgery. Bailey, on the other hand was the more brilliant technician and he had the spirit of an authentic, highly aggressive pioneer, as we will see. In Philadelphia, where Gibbon was the professor and dedicated scholar, Bailey was doubtless the number one thoracic surgeon at the Hahneman hospital and several other hospitals and sanatoria. At the time, I bought his book entitled ‘The Diagnosis and Management of the Thoracic Patient’ (Lippincott Co. 1945). Bailey personally wrote the 40-page chapter on ‘Resection for TB’, and the table of content lists everything from thoracoplasty to lung and esophageal cancer, as well as bronchiectasis and lung abscess without a single chapter on Blalock's, Gross's or Crafoord's operations. Nevertheless, the same year his book was edited, in 1945, Bailey had started his first unsuccessful operations for mitral stenosis before succeeding 3 years later, and 23 years after Sir Henry Souttar. Unfortunately, at the time I did not ask him why he completely abandoned his highly successful thoracic practice. I guess he was just too busy taking care of all the cardiac patients from all over the world. Bailey was not only taking care of patients, he was also a dedicated teacher and crusader for his cause. He introduced hundreds of young American and foreign surgeons to his technique of commissurotomy (cf. letters by R. Litwak and W. Neptune annexed).

1.3. Charles Philemon Bailey (1910–1993)

Be that as it may, we should never forget the enormous contribution of this man. He told me in a significant letter dated September 21, 1987: "I am one of those fortunate (or unfortunate) individuals who found it necessary (or advisable) to change careers. Now I am in my third one (insuring doctors against malpractice), although it depends heavily on the knowledge I amassed during my practice of the first two (medicine and law). As a surgeon he had 3 years of training at the Seaview Hospital—essentially a TB-hospital—on Staten Island while ‘moonlighting’ at the Hahnemann Hospital. Eventually, he advanced to chief of cardiovascular surgery at Hahnemann where I, among many others, trained for our own pioneering in mitral commissurotomy at home.

While Bailey was still Chairman at his hospital in New Jersey he taught at New York City College and St Barnabas Hospital in the Bronx, but he also enrolled in Fordham University Law School where he graduated in 1973 and passed the New York Bar Examination. He then started to defend doctors in the more and more frequent malpractice suits before founding his own insurance company. Wilford Neptune in 1995 wrote to me: "I am certain you know Doctor Bailey well enough to know that he was always thinking ahead...! Bailey decided that there was a place for malpractice insurance, especially for doctors wishing to cut down on their practice. In his New York Insurance Company Bailey was able to keep his premiums at an absolute minimum, requiring certificates and proofs of continuous postgraduate update and education as the best arguments in malpractice defense suits. He also had a sliding premium scale for different, more or less exposed specialties and the amount of work the doctors actually did...". As Bailey himself wrote to me: "The doctors are taking the brunt of responsibility... and not a few lawyers have realized how to make a living out of their shortcomings (1987)! And so I became a lawyer and now can understand how to ‘resolve’ the difficulties in a practical sense. Mainly I tell the ‘good’ doctors how to keep out of trouble and advise the ‘litigation-prones’ to take a ‘rehabilitative’ educational course (3–6 months)! It works pretty well for those who are willing to try. I am sure you don't have these problems in Switzerland—yet (sic)."

Now, I will add just a few words about his outlook on the future of cardiac surgery. He was, from the start, more interested in valve reconstruction than in valve replacement, and expressed some ideas about coronary surgery, transplantation and a mechanical heart and concluded his letter: "You and I came along too early but our ‘spiritual sons’ will persist and our ‘grandsons’ will succeed!" Bailey definitely deserves a place of honor having stimulated a whole generation of cardiac surgeons thus definitely opening the road to modern cardiovascular surgery.

As to his personal life Neptune writes: "First he developed a carcinoma of the prostate and eventually had a radical prostatectomy. He then developed congestive heart failure, secondary to an aortic stenosis. He went down to Houston and had an aortic valve replacement by Denton Cooley, from which he made an excellent recovery, and continued running his insurance company and went back to exercising by walking his dog. Eventually he died of his carcinoma of the prostate". Finally, Hahnemann Hospital after merging with the Woman's Hospital saw the light and shortly before his death in 1993 set up a ‘Charles P. Bailey professorship in cardiovascular disease for women’. A very late honor indeed! My own training with Bailey at Hahnemann was due to the fact that my Boston teacher Overholt and Bailey, one concentrating on pulmonary, the other on cardiac surgery, had organized a fellowship exchange program. Therefore, I had the opportunity to spend one week with Bailey at the end of my 1950 Boston training, and another week following the 1951 spring meeting of the AATS in Atlantic City.

By the way, retrospectively, this was for me one of the most important meetings. Even young surgeons sometimes relax, and it was one evening at a bar during that meeting that by coincidence I met and drank the whisky of a lifelong friendship with another, 2 years younger, surgeon by the name of Walt Lillehei! He was 33 and I was 35-years-old. The scientific program of that 1951 meeting was extremely stimulating, the entire gamut of thoracic surgery. Alfred Blalock was the president and gave one more of his brilliant overviews on ‘Problems in Cardiac Surgery’, stating among other topics that according to his experience at Johns Hopkins mitral commissurotomy was a safe and efficient operation, referring in passing to the third little known pioneer Horace Smithy who died prematurely, himself of aortic stenosis. Russel Brock and his pulmonic valvotomy were also positively mentioned. Following the presidential address we listened to all the pioneers on topics of importance: Henry K. Beecher on anesthesia, Overholt on pericardiectomy, Arthur Vineberg about what later became the Vineberg operation, and William Cahan of the Sloan Kettering Cancer Institute on radical pneumonectomy with complete mediastinal lymph gland dissection: 50 years later you could not hear a better paper on the topic.

During the following week Bailey let me assist him for several commissurotomies and, to my great surprise, even made me split the commissure myself in one case. Four months later, back in Lausanne, we did the first commissurotomy in Switzerland, on August 21, 1951 (Fig. 4), probably one of the earliest ones in continental Europe. The following week we did our second case and, a few years later, our cardiologist Rivier reported on 71 cases with less than 10% mortality. Fortunately, we had our first sequence of nine cases without a death, thus obtaining the trust of cardiologists and patients. To be honest, for my first two cases I obtained a decent result with an insufficient timid finger dilatation. Both patients were re-operated a year later with the help of Tom O'Neill, one of Bailey's two associates and also a good friend of mine who was touring Europe at the time.

View larger version (121K): [in this window] [in a new window]   Fig. 4 Lausanne team for 1951 mitral commissurotomy: J.L. Rivier, cardiologist; A.P. Naef, surgeon, T.O. O'Neill of the Bailey–Glover–O'Neil group in Philadelphia, PA.

Charles Dubost (1914–1991) (Fig. 5) had become the leading continental French cardiac surgeon ever since Blalock's visit to the Broussais Hospital in 1947. As well as his contribution to improving mitral surgery, he performed the world's first resection of an abdominal aortic aneurysm in 1950, and later the first successful heart transplantation in France. He was an inspiring leader, teacher and surgeon and next to the internationally respected French pioneer, Alain Carpentier, his chief-resident and successor, and Francis Fontan, the name of Dubost in European cardiac surgery should never be forgotten. He made mitra1 commissurotomy a much easier and efficient operation when, in 1951 or 1952, he developed a technique using a mechanically expandable dilatator. Before that, introducing a finger guided Bailey-guillotine, a Dogliotti fingertip knife or any other sharp instrument; there was always the risk of tearing the auricular appendage. The Dubost dilatator still introduced blindly, following the exploring index, fitted snugly into the auricular tourniquet-loop and was extremely safe provided that the instrument was carefully guided into the mitral orifice. To my knowledge, Dubost was the first to use such an instrument blindly through the auricular appendage, although the instrument nowadays is called the Tubbs-dilatator. The British surgeon Oswald Tubbs, whom I knew as a pre-war Overholt-trainee, told me that he saw Andrew Logan use the instrument bimanually for aortic dilatation by way of the left ventricle controlling the movement through the auricular appendage. Tubbs then only had a calibrating device added by the ‘Genito Urinary Instrument Company’ who, from then on commercialized the instrument as the ‘Tubbs-dilatator’. In fact since 1950, Bailey had used, not very successfully, a bulky curved prototype of an expandable ‘umbrella-type’ dilatator for aortic valve stenosis. His team called the frightful instrument the ‘Cadillac’. So, in fact, the Bailey aortic dilatator (Fig. 6) became the Logan, before the Tubbs and finally the Dubost mitral-dilatator.

View larger version (101K): [in this window] [in a new window]   Fig. 5 Charles Dubost (1914–). Leading European cardiac surgeon. Introduced the mitral dilatator for closed commissurotomy.

View larger version (114K): [in this window] [in a new window]   Fig. 6 The Bailey aortic dilatator.

1.4. The Brock operation for pulmonic stenosis

View larger version (109K): [in this window] [in a new window]   Fig. 7 Lord Russel C. Brock (1903–1993). Outstanding British pioneer in thoracic and cardio-vascular surgery. Developed the Brock operation for pulmonic stenosis.

doi:10.1016/j.icvts.2004.05.001

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