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CORRESPONDENCE ,1JBRrTSH 1269 drugs. However, although it is not possible to prove this the responsibility of fluothane for the jaundice seems convincing. While many drugs have been indicted as causes of liver damage, this patient received no other agent even suspected of hepato-toxicity. Intra-abdominal operation near the liver and antibiotics have also been blamed; however, this lady was in hospital for immediate and delayed suture of her ulnar nerve, and antibiotics were not administered later than seven weeks before the onset of jaundice.

The recent death of Sir Henry Souttar and re-reading his paper on his operation for mitral stenosis (Souttar, 1925) has made me wonder again why there was such a long interval after these first attempts in 1922-26 before the successes in 1948-50.In 1922, Allen and Graham of St. Louis reported an extensive series of operations on dogs that were important in two ways. First because the valve that was to be divided could be seen through a cardioscope. Secondly because they concluded that the approach to the mitral valve through the left atrial appendage was the best and safest method, and that this was applicable to man.In 1923, Cutler and Levine of Boston reported the first operation for mitral stenosis. The girl had been in hospital for eight months with severe hiemoptyses and was certainly improved for she lived for four years, though with several re-admissions.In 1924, Cutler, Levine, and Beck gave a much fuller account of the subject. They had prepared for the operation with careful work on animals, so that they felt at home with entering the heart and handling it, but had not been able to practise the division of a stenosed mitral valve. Though they do not seem to have had special difficulties with the ventricular approach, it was probably unfortunate that they decided to use this rather than the left atrial approach. They gave several theoretical reasons for their choice, but none based on experimental work. They reported three more patients operated on in the same way, but all had died within the first few days. In the fourth and all later patients they used a valvulotome that cut a hole in the valve and must have produced or increased mitral regurgitation.Also in 1924, Allen reported much more fully on his experimental work in dogs. It was in this year or late in 1923 that he carried out his only operation for mitral stenosis. The woman, aged 32, had a stormy operation and died before he had been able to cut the valve. The only account of this case I have found is in Cutler and Beck (1929). In a later paper, Allen and Barker (1926) proved with continuous electrocardiograms in dogs that the ventricular approach often produced paroxysmal ventricular tachycardia and sometimes ventricular fibrillation, while the atrial approach rarely caused any significant arrhythmia.In 1925, Souttar of London reported a successful operation on a girl aged 15, a patient of his medical colleague Dr. Otto Leyton. He followed Allen in his approach through the left atrial appendage and commented on the relative ease of handling the heart and, in spite of some hemorrhage, on the relative smoothness of the operation, which may have been due to the skill of John Challis, his young anicsthetist at the London Hospital. The mitral orifice admitted his finger so he decided not to increase its size and contented himself with breaking down the adhesions that tethered the cusps, since he did not wish to increase the mitral regurgitation. He felt this regurgitation and in later life described it as like the jet of a fire-hose playing on h...

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