Canad. Med. Ass. J.Sept. 21, 1963, vol. 89 GIALLORETO AND TARDIF: MITRAL COMMISSUROTOMY 589

ABSTRACT

L'6tude .i long terme des r6sultats de lacommissurotomie mitrale permet d'6valuerl'efficacit6 6loign6e de cette chirurgie et lescauses d'une d6t6rioration .ventuelle.

Nous avons consid&6 389 malades op.r.spour st6nose mitrale, entre 1950 et 1957.De Ce nombre, 89 sent d6c6d6s et 38 n'ontPu .tre retrac6s. Au total, 262 furent r&examin6s.

Pour la p&iode post-op6ratoire de cinq ii12 ans le r6sultat a .t6 trouv6 satisfaisantchez 204 malades (77%) et non satisfaisantchez 58 (22%). Les causes possibles de d.-t.rioration sont examin6es isoh.ment.

Line deuxi.me commissurotomie a 6tt.faite chez 23 malades (8.7%) et la rest6nosea .t6 consid&6e rhumatismale chez unmalade, secondaire .. une premi.re ouver-hire insuffisante chez 13 et r.sultat d'unprocessus fibreux cicatriciel chez neuf mala-des.En conclusion, Ia commissurotomie mi-

trale est une op6ration palliative, fonction-nellement valable dans la st6nose mitraleserr6e. Pour une ouverture dynamiquementadequate, Ia dur6e de l'amdioration est enfonction de l'atteinte myocardique et de Iapossibilit6 de rechute rhumatismale. A causedes rest6noses fibrotiques, l'.ventualit6d'une deuxi.me commissurotomie est tou-jours .i retenir.

TABLE 1.-MITRAL COMMISSUROTOMY-LATE RESULTSPREOPERATIVE MATERIAL

( Gr.JI (92) 23.6%

Patients: 389 . 72.3%.Gr. III (222) 57 %d'27.7%.... IV (75) 19.3%Aur. fibrillation...(117) 30%Preop. R.V.F...(102) 26.2%Mitral orifice < 1 finger..(18) 4.6%.50yearsof age...(8) 2 %

72.3% of the patients were females, 27.7% males.In terms of the American Heart Association(A.H.A.) classffication, 92 patients (23.6%)belonged in Group II, 222 (57%) in Group III, and75 (19.3%) in Group IV. One hundred andseventeen patients had auricular fibrillation (30%);102 (26.2%) had suffered at least one episode ofright ventricular failure (R.V.F.); and eight (2%)were 50 years old or more at the time of surgery(Table I).The diagnosis of tight mitral stenosis was con-

firmed in all of these patients except 4.6%, inwhom the mitral orffice admitted more than thedistal extremity of the index finger.The total number of deaths, those occurring

during surgery and those occurring later, was 89.Thirty-eight patients were eliminated from thestudy because we were unable to trace them. Inall, the experience with 262 patients is reviewedin this communication (Table II).

TABLE 11.-MITRAL COMMISSUROTOMY-LATE RESULTSPOSTOPERATIVE MATERIAL

TABLE IV.-MITRAL COMMISSUROTOMY-LATE RESULTS

Excellent results.70 26.7% 76Good results.134 50 % 7%Poorresults.58 22.1%

Total.262 98.8%

TABLE 111.-MORTALITY

Surgical.30 7.5%

Late deaths.59-15.1%Cardiac failure 33-55 %Second operation 7-12 %Systemicembolism.4- 6.7%

Sub. bact. endoc... 1- 1.6%Miscellaneous.6-10 %Unknown.8-13 %

II- 5.4%. III 7.6%IV-1O.6%

12

canad. Med. Ass. 5.Sept. 21, 1963, vol. 89 GIALLORETO AND TARDIF: MITRAL CoM.vnssuxoToMY 591

results were still present in 68% in the tenth post-operative year.The unsatisfactory results were of the order of

18% for the first year: it should be noted how-ever that in this figure are included the non-surgical deaths which are considered separatelyfor the rest of the follow-up study. In the laterstages of follow-up, after the fifth postoperativeyear, the percentage of unsatisfactory results showsan annual increase of 1.3% on the average. Inthe tenth postoperative year, unsatisfactory resultswere present in 31%. In calculating this, the re-sults of the tenth and eleventh postoperative yearswere not considered because of reoperation; inthe twelfth postoperative year, the number of pa-tients was too small to permit statistical evaluation.The total findings can be summarized as follows:

in 26.7% of the cases the results were excellent, in50% they were good, and in 21.1% they were fairor negative. In other words, for 76.7% of the cases,the results remained satisfactory for an averagepostoperative follow up period of eight years.

TABLE V.-MITRAL COMMISSUROTOMY-LATE RESULTS

ResultsFactors considered Excellent Good Poor

Incomplete mitral opening.Auricular fibrillation.Preoperative R.V.F.Calcification.Associated valvulopathies

mitral.aortic.tricuspid.

Rheumatic reactivation.

10111724

228

112

12.631.221.328.9

45.737.735.552.1

in 12.6% of those with good results, and in 45.7%of those whose results were judged to be fair ornegative.The fact that an insufficient mitral opening can

be associated with an excellent long-term resultseems to signify that the postoperative mitralcalibre is not the sole element responsible for theresult.

Auricular FibrillationEleven per cent of the patients showing excellent

results manifested fibrillation before operation.Among those classified as good, and as fair or nega-tive, this figure was 31.2% and 37.7%, respectively.After surgery, the percentage of patients withauricular fibrillation increased to 24% in theexcellent category, 59.5% in the good, and 69.1%in those patients showing fair or negative results.These figures show that the occurrence of

auricular fibrillation is not prevented by mitralcommissurotomy; nor is its incidence dependenton the postoperative results, because it appearswith practically the same frequency in the threegroups. That the functional damage resulting fromauricular fibrillation is not, of itself, an inevitablecause of unfavourable results is evidenced by thepercentage of the fibrillating patients in the groupsin whom satisfactory results were obtained.

Preoperative Right Ventricular Failure43.1 56.3 In considering this factor we wished to determine9.8 15.9 whether the preoperative appearance of right1.7 25.54 9.5 ventricular insufficiency, considered to be a rela-

tively late complication in the evolution of mitralye have taken stenosis, could be of proguostic siguificance.might have In the entire series, 102 patients had an episode

n of and/or of total cardiac insufficiency preoperatively: nineexisting pre- of these died as a result of surgery (8.8%) andh as auricular 20 (19.6%) died later; 90% of these latter deathsiated valvulo- occurred during the first five postoperative years.lure; factors Among the re-examined patients, 30 (34.5%)as insufficient suffered at least one postoperative episode of totalissurotomy or cardiac insufficiency, despite supportive therapyas rheumatic and adequate medical control.ar fibrillation, In the long-term evaluation, 17% of those pa-These factors tients showing an excellent result suffered at leastatients in the one episode of right heart insufficiency preopera-

tively. Among the patients with good results, thefigure is 21.3% and among the fair or negative,35.5%.

rnissurotomies C.ficationthe diameterkrtial unicom- Twenty-four per cent of the patients having anly restore the excellent postoperative result also had a calcffied.untered fre- mitral valve. This figure increased to 28.9% and.e of surgery, 52.1% in the groups showing good, and fair orer limited to negative results, respectively..stroyed and The appearance of new calcffication has not beenequate mitral observed in the postoperative follow-up period re-ellent results, ported here. It should be noted, nevertheless, that

592 GIALLom.To AND TARDIF: MITRAL COMMISStTROTOMY

although all the patients have had fluoroscopic ex-amination during their follow-up, only a limitednumber have had a radiographic examination.

Associated Valvular PathologyAmong the types of associated valvular path-

ology, mitral insufficiency occurs most frequently.It has been found in 22% of the subjects withexcellent results and in 34.1% and 56.3% of thosewith good, and fair or negative results, respectively.Although the percentage of patients with pre-operative mitral insufficiency is 4.5% for the entireseries, the majority of the cases of mitral insuffi-ciency appeared postoperatively.

Aortic valvular pathology, never of sufficientseverity to contraindicate mitral commissurotomy,was found in 8% of the patients with excellentresults, 9.8% of those with good results, and 15.9%of those with fair or negative results.With regard to the patients with tricuspid valvu-

lar pathology, those with functional insufficiencywere eliminated and only those with lesionsconsidered to be organic were retained. Among thepatients with good results, 11% had tricuspidvalvular pathology. The corresponding figure was1.7% and 25.5% for the patients with good, andfair or negative results, respectively.

Other FactorsAmong the numerically secondary factors,

broncho-pneumonic disorders were seen most fre-quently, and occurred in 6% of the group classedas excellent, and in 6.3% and 15.9% of those con-sidered as having good, and fair or negative results,respectively.

Systemic embolic complications were notedamong 2% of patients with excellent operative re-sults, among 2.8% of those with good results, andamong 12.9% of those with fair or negative results.It should be noted, however, that we classifiedpatients who had a cerebral embolism and hemi-plegia as having fair or negative results. Accord-ing to the functional result, patients with cerebralor peripheral embolic accidents that were followedby good recovery, were placed in one of the othertwo groups.

Coronary insufficiency was seen in 2% of patientswith excellent, in 4.6% of those with good, and in9.5% of those with fair or negative results.

Bacterial endocarditis was seen as a complicationin 1% of those patients with results consideredexcellent, and in 0.5% and 2.1% of those with good,and fair or negative results, respectively.

Arterial hypertension occurred in 1% of thosewith excellent results, in 0.5% of those with goodresults, and in 3% of those with fair results.

Rheumatic RecurrencesThe frequency of the episodes in which objective

evidence was obtained for the diagnosis of rheu-

Canad. Med. Ass. 3.Sept. 21. 1963, vol. 89

matic recurrence was 2% among the patients withexcellent results, 4% among those with good re-sults, and 9.5% among those with fair or negativeresults. Doubtful rheumatic episodes were not in-cluded in these percentages.

Reoperaticm

A second mitral operation was performed on 25patients (9.5%): in two cases (8%) because ofmitral insufficiency produced during the first com-missurotomy, in one (4%) because of restenosis,possibly rheumatic in origin, in 13 (52%) becausethe first commissurotomy was inadequate, and innine because of restenosis, possibly secondary toformation of a fibrotic cicatrix.With the exception of two patients with mitral

insufficiency and one patient who had an in-complete commissurotomy and underwent surgeryfor the second time during the first postoperativeyear, more than 50% of the second operations wereperformed after the end of the first five years.

Seven patients (24%) died during their secondoperation (Table VI).

TABLE VJ.-MITRAL COMMISSUROTOMY-LATE RESULTSREOPERATIONS

Severe mitral regurgitation (surgery).Second commissurotomy

Rheumatic reactivation.Inadequate first commissurotomy.Fibrotic restenosis.Total recommissurotomy.

Total reoperations.Calcification.Surgical deaths.

2

1139

232557

8

452365.99.5

2024

DIscussIoN

It appears evident from these results that insome patients the initial improvement from mitralcommissurotomy is affected by a gradual deteriora-tion that is marked after the fifth year. Despitethis deterioration, more than half of the patientsoperated on maintain a satisfactory result in thepostoperative follow-up period of between five and11 years. The percentage of favourable results was,in fact, 83% in the fifth year and 68% in theeleventh year. We have not considered the effectof the twelfth year in our total results because thenumber of patients was insufficient for statisticalevaluation.When a patient with a good surgical result de-

teriorates, one is inclined to think the surgery wasinadequate, or became so. However, we have notedin our series that 22.6% of the patients in whichthe mitral opening was considered inadequate con-tinued to have a good result more than five yearslater. It appears, therefore, that the mitral opening,beyond a critical calibre indispensable for the dis-appearance of the pulmonary symptomatology, isnot the determining element in the progress of thedisease, at least, as an isolated factor.

Canad. Med. Ass. J.Sept. 21, 1963, vol. 89

The importance of auricular fibrillation as an Un-favourable factor in the results has already beenimplicated because of the functional disadvantageit induces.

It is of interest to note that commissurotomydoes not prevent the development of auricularfibrillation, which occurs with equal frequency inthe three postoperative groups. This seems toindicate that the appearance of auricular fibrillationis not necessarily a consequence of abnormal hemo-dynamic conditions in the left auricle, but that itpossibly reflects the progress of the myocardialpathology. That auricular fibrillation is not incom-patible with a favourable result is demonstrated bythe percentage of patients having an excellentresult who had auricular fibrillation (24%). Inaddition, we have noted a definite difference duringthe subsequent progress of those patients in whomfibrillation took place before surgery when com-pared with those in whom it took place after sur-gery. In the former group those who had achievedgood results maintained this improvement in greatmeasure throughout the whole period of theirfollow-up progress. In the latter group, on theother hand, the appearance of auricular fibrillationduring the postoperative period, in the majority ofcases, brought on or coincided with an obvious de-terioration in the functional result. This finding,which is more than coincidence, suggests anotherrelationship between auricular fibrillation and myo-cardial damage. When myocardial damage doesnot progress, auricular fibrillation, despite thefunctional deficiency it causes, is compatible witha good result over a long period. On the other hand,the deterioration of a good result, coinciding withand gradually progressing after the appearance ofauricular fibrillation, is possibly related to a re-currence of rheumatic activity or to spread of themyocardial fibrotic process.Another factor that contributes to a significant

percentage of the unsatisfactory results is pre-operative right ventricular insufficiency. Sixty-fourper cent of the patients who had suffered pre-operative episodes of right ventricular insufficiencyprogressed unfavourably. This factor, nevertheless,does not have the same significance in all patientsbecause the circumstances in which it appears aredifferent. That extensive myocardial damage maybe involved is suggested by the high frequency withwhich valvular pathology other than mitral isfound among this group (65%).The presence of valvular calcification does not

appear to represent a determining factor in post-operative progression. Its principal importance liesin the obstacle it presents to satisfactory com-missurotomy: among the patients operated on fora second time, 20% had calcification of the mitralvalve structure.Among the associated types of valvular pathology,

mitral insufficiency is the most frequent, and in themajority of cases it first appears postoperatively.Except for massive insufficiencies that progress

CIALLORETO AND TAIWIF: MITRAL COMMISSUROTOMY 593

rapidly towards the patient's death, or should havebeen repaired during extracorporeal circulation,mitral insufficiency is very often well tolerated andis compatible with satisfactory surgical results,unless other factors complicate the patient's pro-gress. We have noted how poor the correlationis between the evaluation of regurgitant flow atthe time of surgery, the clinical manifestations ofsuch insufficiency and the subsequent progress ofthe disease. It is possible that a variable factorexists, related to some immediate, transitory, post-operative condition, which could explain this di-vergence.

Associated aortic valvular pathology does notappear to play a significant role in the postoperativeevolution in these cases. With the exception of tightaortic stenosis treated at the same time as mitralstenosis, the other associated forms of aortic val-vular pathology, either insufficieiicy or stenosis, donot contraindicate mitral commissurotomy or in-fluence the result unfavourably.

Associated tricuspid involvement is chiefly repre-sented by tricuspid insufficiency; stenosis, at leastthe surgical type, has been a rare occurrence inour experience. Tricuspid damage that is sufficientlyevident to be considered organic seems to operateas an unfavourable factor in the patient's progress,possibly because it is related to very widespreadmyocardial damage.The presence of chronic or repeated broncho-

pulmonary pathology may constitute an unfavour-able factor; the period during which satisfactorypostoperative progress can be maintained is, how-ever, fairly long in the absence of other compli-cating factors.

Independently of the results of commissurotomyper se, we have placed the complication of systemicembolism with hemiplegia and poor functionalrecovery in the "bad result" category. The inci-dence of this complication in this series of patientswas 12.9%; other patients (4%) who suffered asimilar systemic embolism but whose recovery wassatisfactory are not included among the "negative"results.The presence of coronary insufficiency at some

time during the patient's course seems to be com-pletely independent of the operative results, evenif, from a functional point of view, it results in achange in the A.H.A. classification of the patient.Its frequency is higher among the patients withfair or negative results and also among those whopresent more widespread myocardial damage; thismay be due to the existence of some degree ofrheumatic coronary arteritis.Frank objective manifestations of reactivation of

the rheumatic process were rare in our series. Thefact that all of the younger patients were protectedby prophylactic treatment and that this treatmentwas extended to patients whose postoperative pro-gress, for no discernible reason, was unfavourablemay be of signfficance in the incidence of this

594 GIALLORETO AND TA1uIF: MImAL COMMISSUROTOMY

complication; doubtful cases have not been takeninto consideration.On the whole, none of the unfavourable factors,

at least as isolated entities, considered in the fore-going paragraphs are incompatible with a favour-able result. Because the frequency of each factorincreases as we pass from the excellent result to thegood, and from the good to the poor result; andbecause it is in this last group that the highestpercentage of each unfavourable factor is encount-ered, it seems evident that it is the combinationof these factors that produces an unfavourableprognosis.

In the entire series, 25 patients were submittedto a second operation: if the two patients who wereoperated on this second time for mitral insufficiencyproduced during the first intervention are ex-cluded, 23 patients have undergone a second com-missurotomy. In one case only could rheumaticreactivation have been involved in the restenosis. Innine patients the first operation was quite adequate,but during the second operation the surgeon onceagain found a tight mitral stenosis; a specific cica-tricial process may, perhaps, have accounted forthis development. In 13 cases, it was necessary torepeat the operation because the first commissu-rotomy was incomplete and inadequate.The mortality among the reoperated patients

was particularly high (24%). However, it is neces-sary to take into consideration the inclusion inthis series of two patients with mitral insufficiencydue to severe valvular lesions, the transventricularapproach for heavily calcified valves, and the intro-duction of extracorporeal circulation with thehazards this entailed in the beginning. The numberof repeat commissurotomies performed among thepatients who survived the first operation repre-sented 8.7% of this group; the number of recoin-missurotomies which have already been proposedto our patients, however, greatly exceeds this valueand will probably grow progressively.

CONcLUSIONS

From the foregoing results, which in most re-spects are in accord with similar studies of others,it can be said that mitral commissurotomy is a pal-liative but nevertheless valuable operation. Sincethe purpose of this operation is to correct a me-chanical obstacle, its efficacy cannot be expected toinfluence the factors or the conditions that led tothe valvular stenosis. When properly performed,commissurotomy can, in varying degrees, correctthe hemodynamic abnormalities created by themitral obstacle, mainly in the pulmonary vasculartree, and can consequently provide relief of thesecondary symptomatology and possibly prolongsurvival. Because it does not affect establishedrheumatic lesions of the myocardium or theiractive or fibrotic progress, the final prognosis ofthese patients is, therefore, dictated by these con-

Canad. Med. Ass. 3.Sept. 21, 1963, vol. 89

ditions and by the possibility of a new rheumaticattack.

In patients with pure and tight mitral stenosis,commissurotomy is a valuable procedure that, byrelieving the pulmonary vascular overload, iscapable of protecting the patient against the acutemanifestations of the disease and the late compli-cation of pulmonary hypertension. Provided theorifice remains sufficiently and dynamically open,the patient's subsequent progress is mainly de-pendent on the extent and the progress of therheumatic myocardial pathology. Direct evaluationof this factor is still impossible; however, a certainprognostic orientation may be provided by a con-sideration of the presence and combination ofcertain secondary factors, such as plurivalvular in-volvement, early right ventricular failure and auri-cular fibrillation.

It should be emphasized, however, that in ad-dition to the initial damage, the term "myocardialfactor" implies a potential and evolVing menace,whether it acts as an active process or as a fibroticcicatricial process. The appearance of auricularfibrillation at some definite time during the progressof the disease and independent of the commis-surotomy is, perhaps, an indication of this patho-logic progress.

Because of the practical impossibility of estab-lishing the presence of an active myocardial factor,we believe that antirheumatic treatment and pro-phylaxis are warranted whenever the postoperativeprogress is unfavourable despite a satisfactory com-missurotomy and the absence of prejudicial factors.The possibility of restenosis by frank, objective

rheumatic reactivation exists to very limited degree.In this series, the largest number of recommissu-rotomies was necessary among the patients withincomplete and adynamic mitral openings and wasgenerally limited to those operated on during theearly years of use of this surgical technique. Longerperiods of evaluation have revealed, in addition, thepossibility of restenosis of an orffice that was pre-viously insufficiently opened. Such an eventuality,possibly connected with a particular process ofcicatricial fibrosis, appears to be unavoidable in an,as yet, undefined percentage of patients. The pos-sible eventuality of a second intervention shouldthus be kept in mind for each patient subjectedto commissurotomy.

SUMMARY

Three hundred and eighty-nine patients operatedupon for severe mitral stenosis between February 1950and December 1957 were studied. The follow-upperiod was from five to 12 years. Eighty-nine patientsdied either during operation or during the follow-upperiod and we were unable to trace an additional 38.Two hundred and sixty-two of the 389 patients havesurvived. In all except 4.6% of the patients subjectedto operation the diagnosis of severe mitral stenosis wasconfirmed during surgery.The total surgical mortality was 7.5%. The late

mortality during the subsequent years was 15.1%.

Canad. Med. Ass. 3.Sept. 21, 1963, vol.89 GIALLORETO AND TAIWIF: MImAL COMMISSUROTOMY 595

The operative results were graded as excellent in26.7% of cases, good in 50% and poor or bad in 22.1%.The deterioration occurring in the first group has beengradual at a rate of 1.4% per year.

Analysis of the cases in this series indicated that aninadequate opening of the valve is compatible withan excellent postoperative result. Atrial fibrillation,right-heart failure before operation and valvular calci-fication could, as isolated factors, also be compatiblewith good results. Of the other associated valvularlesions mitral regurgitation was the most frequent anddeveloped in the majority of cases in which it wasfound, after mitral commissurotomy had been per-formed.

Recommissurotomy was carried out on 23 patients(8.7% of the series). In only one of these was thereany evidence of rheumatic activity; the remaining re-operations were occasioned either by probable cicatri-cial restenosis (36%) or inadequate commissurotomy(50.2%).

It is concluded that for tight mitral stenosis com-missurotomy is a valuable operation, despite the factthat it may be only palliative. By relieving the ab-normal.ties of the pulmonary vascular tree it improvesthe symptomatology associated with the stenosis andfavourably changes the vital prognosis.

Assuming that the commissurotomy is adequate andwill remain so, the late functional result seems to berelated to the extent of the rheumatic myocarditis andto the possibility of its recurrence.

Because of the possibility of fibrotic restenosis evenafter a satisfactory commissurotomy, the eventuality ofa second operation should be kept in mind.

REFERENCES

1. SOLOFF, L. A. AND ZATUCHNI, J.: .7. A. M. A., 154: 673,1954.

2. D'ALLAINF,5, F. et al.: Un. Med. Canada, 87: 254. 1958.3. LIKOFF, W. AND URICCHIO, J. F.:.7. A. M. A., 166: 737,

1958.4. The surgical treatment of mitral stenosis; report of the

Section on Cardiovascular Surgery of the AmericanCollege of Chest Physicians: Dis. Chest, 35: 435, 1959.

5. BELOHER, J. R.: Brit. Heart .1.. 20: 76, 1958.6. BAILEY. C. P. AND MORSE, D. P.: J. mt. Coil. Surg., 31:

8, 1959.

7. PATTERSON, G. C. AND MARSHALL, J. R.: Brit. Heart J.,21: 174, 1959.

8. IiOWTHER, C. P. AND TURNER, R. W. D.: Brit. Med. J.,1: 1027, 1962.

9. GIALLORETO, 0., BERNARD, A. AND DAVID, P.: Un. MtkL.Canada, 88: 1377, 1959.

RESUME

Trois cent quatre-vingt ned malades op6r6s pour st6nosemitrale serr6e, entre f6vrier 1950 et d6cembre 1957, ont6t6 consid&6s pour cette 6tude. La p6riode d'observationsvane ainsi de cinq A 12 ans. Quatre-vingt ned maladessont d6c6d6s A l'op6ration ou dans 1'6volution successiveet 38 ont 6t6 perdus de vue. Le nombre de maladessurvivants est de 262. Ghez tous les malades, moms 4.6%,le diagnostic de st&iose mitrale serr6e a 6t6 confirm6 Al'op6ration.La mortalit6 op6ratoire totale est de 7.5% et la mortalit6

6loign6e au cours de l'6volution successive est de 15.1%.Les r6sultats ont .t6 divis6s en excellents, bons et m&

diocres ou nuls. Les r6sultats excellents se cbiffrent A26.7%, les r.sultats bons A 50% et les r6sultats n.diocresou nuls A 22.1%. Ceci repr.sente une d&6rioration de 17.6%entre la premi.re et la cmqui.me ann6e et une moyennede 5.5% par ann6e pour les cinq autres ann6es d'6volution.

L'analyse de certains facteurs particuliers a montr6qu'une ouverture valvulaire inad6quate est compatible avecun r6sultat post-op&atoire excellent. La fibrillation auri-culaire, l'insuffisance cardiaque droite pr6op6ratoire et lescalcifications valvulaires sont aussi des facteurs isol6mentcompatibles avec un bon r6sultat. Quant aux associationsvalvulaires, l'insuffisance mitrale est s(frement la plus fr6-quente et la majorit6 d'apparition post-op6ratoire.La fr6quence de recomrnissurotomies est de 8.7%, 6qui-

valant A 23 malades. Chez un seul de ces malades, on aPu mettre en &idence une activit6 rhumatismale, lesautres 6tant constitu6s ou par des rest6noses possiblementcicatricielles (36%) ou par des commissurotomies inad6-quates (50.2%).En conclusion, la commissurotomie mitrale est une op6-

ration valable mais palliative, capable, en am6liorant lesanomalies du circuit vasculaire pulmonaire secondaire AIa st6nose mitrale, d'am6liorer lii symptomatologie de lamaladie et de changer favorablement le pronostic vital.

Lorsque Ia commissurotomie est ad6quate et demeuretelle, le pronostic fonctionnel 6loign6 de la maladie semble.tre reli6 A l'6tendue de l'atteinte myocardique rhuma-tismale et aux possibilit6s de rechute rhumatismale.A cause de la possibilit6 d'une 6valuation fibrotioue

st6nosante chez des malades convenablement op6r6s l'6-ventualit6 d'une deuxi.me intervention doit .tre retentlecomme possible.

PAGES OUT OF THE PAST: FROM THE JOURNAL OF FIFTY YEARS AGO

The careful analysis of a large number of cases alwaysdemonstrates wherein future improvements can be made.This continually keeping track of the patients will in itselfstrongl.' impress the former patients with the hospital'sinterest in their we.are, and will stimulate them to urgetheir feriow companions to undergo the same treatment ifthey be taken ill.

These data to be of use must from time to time bethoroughly analyzed and published. You and I are con-tinually gleaning knowledge from the publications of othermen both on this and the other side of the water, buthow many of us are doing our share in the disseminationof knowledge? In fact we manifest a remarkable tendencyto become sponges instead of springs for the pouring forthof our medical experiences-experiences that other surgeonsshould know of and profit by. Follow up all your cancerpatients, see what has become of them. Many of themwill be dead, but some that you have lost track of arestill living and well. You will soon become so interestedin the return letters that you can hardly wait for the post-man to arrive, and when now and then a reply says that

the patient is alive and well at the end of ten or thirteenyears it will warm the cockles of your heart, it will morethan outweigh many of the disappointing results you havehad and will make you feel that after all the fight is wellworth the undertaking.A year ago I was asked to write the surgeons of the

Southern States to find out what their final results wereafter operation in cancer of the cervix. The results of myinquiries are given in Surgery, Gynecology and Obstetricsfor March, 1913. The vast majority had kept but scanthistories, and had finally lost track of their patients, sothat at the present moment few surgeons in the countryhave any adequate idea of what their labours have accomplished. Do let me urge upon you the systematicrecording of every cancer case, the employment of the mostthorough operation in these cases, and the tabulation atyearly intervals of the results. You will thus continuallyimprove your methods, will grow more enthusiastic in yourcampaign against this dread malady, and will at the sametime give valuable data to your colleagues in the profes-sion-Thomas S. Gullen: Canad. Med. Ass. J., 3: 670,1913.