Jean Baptiste Bouillaud was one of the most prominent clinicians of the 19th century from the French School. He was the pupil of great physicians such as Guillaume Dupuytren, Francois-Joseph Broussais, Jean-Nicolas Corvisart, and Francois Magendie. He was Bertin's assistant before becoming a professor at the hospital de la charite. In 1823, Bouillaud published his medical thesis on the clinical signs and diagnosis of aortic aneurysms. Bouillaud contributed extensively to the knowledge of valvular heart disease. He is best remembered for his "law of coincidence" establishing definitely the relationship between rheumatic fever and heart disease.
Bouillaud published his authoritative treatise, "Traite cliniques des maladies du coeur," in 1835. In the first section of this book, Bouillaud described the anatomy of cardiac valves in detail.
He made one of the first accurate postmortem measurements of the heart weight and its external dimensions. He also provided measurements of the circumference of the annulus of different cardiac valves and the height and thickness of their leaflets. These quantitative measurements were made in three groups of patients: those with normal heart, those with dilated heart and finally those with "atrophic heart."
He gave detailed accounts of valvular heart diseases affecting left-sided and right-sided valves. He differentiated between acute and chronic forms. He also distinguished mild from severe forms of mitral and aortic stenosis. His description of symptoms was detailed and remarkable and correlated with pathological findings discovered at autopsy. He also described detailed findings of physical diagnosis using percussion and auscultation. Bouillaud had one of the biggest clinical practices of his time in Paris and his experience was based on the analyses of several hundred patients who were referred to him.
Bouillaud made major contributions in cardiac auscultation. He described the opening snap of mitral stenosis. He also described in mitral stenosis the "bruit de rappel" which represented the false reduplication of the second sound at the apex. Finally, he first recognized the split second heart sound, a finding that he attributed to asynchronism in the closure of the aortic and pulmonic valves.
Bouillaud gave one of the best accounts of endocarditis up to this time. He coined in the introduction of his book, the term endocardium ("endocarde") and the term endocarditis ("endocardite") for the inflammation of this structure.
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He described three periods in the development and progression of anatomic alterations of endocarditis:
1) Period of sanguinary congestion, of softening,of ulceration and suppuration ("Periode de congestion sanguine, de ramollissement, d'ulceration et de suppuration")
In this phase Bouillaud described first the presence of inflammatory lesions of the endocardium and more specifically the valves. He described the redness of valvular tissue, a great sign of inflammation. In addition, he emphasized that this redness was accompanied by thickening and swelling of valve leaflets. He also described purulent formations on the leaflets. Bouillaud was obviously reporting both inflammatory and infectious lesions affecting cardiac valves. He stated: "during this acute phase, it is common to observe ulceration, erosion and perforation of valves, myocardial walls, and interventricular and interatrial septum." Finally he discussed a hyperacute form of endocarditis, that he named "endocardite gangreneuse or maligne" (gangreneous or malignant endocarditis). In his account, he noted high grade fever, tachycardia, sepsis, and neurologic compromise. The outcome was fatal in a short period of time.
2) Period of organization of secreted products or of a portion of fibrinous concretions ("Periode d'organisation des produits secretes, ou d'une portion des concretions fibrineuses")
Bouillaud wrote that during this phase, the secreted substances were organized into vegetations and granulations with a preference for cardiac valves. He, however, recognized that these substances could also be localized on the endocardium. Subsequently, he wrote these vegetations could be detached from their valvular insertion or they may become larger and cause valvular obstruction.
3) period of cartilaginous, osseous or calcareous induration of the endocardium, with or without narrowing of the orifices of the heart ("Periode d'induration cartilagineuse, osseuse ou calcaire de l'endocarde, avec ou sans retrecissement des orifices du coeur")
Bouillaud commented that this chronic phase was characterized by the induration and osseous transformation of the endocardium and more specifically the valves. He reported that these lesions affect with a greater frequency the free margin of the atrioventricular valves and the fibrous zone of the valve orifices. He also recognized that they could extend and involve the subvalvular apparatus. He described that these valvular lesions may lead to varying degrees of stenosis depending upon the residual mobility of the leaflets. More interestingly, he identified valvular lesions in which the thickened leaflets were completely retracted and immobile. Bouillaud stressed the fact that in these cases valvular regurgitation was obvious and that annular dilatation could be present.
In the first stage, Bouillaud obviously included all types of acute endocarditis either from infectious or inflammatory origin. It is important to note that the germ theory of disease was not yet described in 1835. In the second phase, he was referring to cases which included subacute endocarditis and finally the third stage included chronic or healed valvular lesions.
Bouillaud described in detail the morphologic lesions of mitral stenosis:
"...The degrees of narrowing of the orifices of the heart are very variable. In extreme degrees, one can hardly introduce the tip of the little finger, or even the tip of a writing pen, into the narrowed orifice. The opening which is left between the thick, indurated valves or those valves united by their neighboring borders is permanent, or constantly open. It is sometimes rounded, oval or elliptic. It resembles in many cases a buttonhole or a glottis of which the lips are represented by the rounded borders of the thickened valve leaflets. This comparison applies particularly to certain narrowings of the left auriculo-ventricular orifice. In a few cases, the leaflets of the bicuspid valve have acquired an enormous thickening and protrude from the side of the auricle; then the retracted orifice may be compared to the orifice of the cervix uteri, and like this imitates a fish mouth. Seen from the auricular side, the circumference of the retracted auriculo-ventricular orifice presents a very pronounced folding, as if this circumference had been folded upon itself; this disposition gives it the appearance of the external circumference of the anus or the opening of a purse drawn together with cords."
Bouillaud also described the particular scenario in which he had observed the adhesion of the leaflets to the ventricular wall. He then specified that in the mitral position, only the posterior leaflet was enrolled, shortened and adhesive to the ventricular wall. Bouillaud then remarked that most these patients suffered from mitral regurgitation and that it was extremely difficult to distinguish valvular regurgitation from narrowing ("retrecissement") on physical examination. Although Bouillaud did not discuss the etiology of these cases, they were probably related to chronic lesions of rheumatic fever.
In 1836, he published his monograph entitled, "Nouvelles recherches sur le rheumatisme articulaire aigu en general."
Although a few authors had reported observations on rheumatic arthritis and carditis, Bouillaud's treatise was the first comprehensive work in which the relationship between rheumatic fever and its cardiac manifestations was discussed extensively. In this work, he defined his law of coincidence (two phenomena occurring simultaneously):
"In the great majority of cases of acute generalized febrile articular rheumatism, there exists a variable degree of rheumatism of the serofibrous tissues of the heart. This coincidence is the rule and the non-coincidence the exception."
In 1840, Bouillaud published his extended experience in a new treatise, "Traite clinique du rhumatisme articulaire, et de la loi de coincidence des inflammations du coeur avec cette maladie." An excerpt of this book is reproduced here.
Bouillaud's treatise was accompanied with a series of illustration demonstrating the anatomy of the heart and the pathology of cardiac valves as shown below.
Bouillaud JB. Nouvelles recherches sur le rhumatisme articulaire aigu en general, et specialement sur la loi de coincidence de la pericardite et de l'endocardite avec cette maladie...Paris, Bailliere, 1836. Translated by James Kitchen, Philadelphia, Haswell, Barrington, and Haswell, 1837.
Bouillaud JB. Traite clinique des maladies du coeur (1835). Translated by Erich Hausner,MD, Amsterdam, New York.
Rolleston JD. "Jean Baptiste Bouillaud (1796-1881). A pioneer in cardiology and neurology" . Proc Roy Soc Med 1931; 24:1253-62.