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September 23, 2017
Infective Endocarditis Jean Baptiste Bouillaud

Jean Baptiste Bouillaud (1796-1881)

Traite cliniques des maladies du coeur. 2vols, Paris, J.B. Bailliere, 1835.

Jean Baptiste Bouillaud
Portrait of Jean Baptiste Bouillaud
Portrait of Jean Baptiste Bouillaud


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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. The contributions of Bouillaud were significant in cardiology and particularly in valvular heart disease. Bouillaud published his authoritative monograph, "Traite cliniques des maladies du coeur," in 1835. In his monograph, Bouillaud gave a detailed account of endocarditis which is considered the most classic up to this time by medical historians.

Bouillaud 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 Bouillad described first the presence of inflammatory lesions of the endocardium and more specifiacally the valves. He emphasized about the presence of redness which was a sign of inflammation for him. In addition, he emphasized that this redness is accompanied by thickening and swelling of valve leaflets. He also described the presence of pus at the level of leaflets. Here obviously he was describing both cases of acute valvulitis from rheumatic origin and acute infective endocarditis. During this acute phase, "it is common to observe ulceration, erosion and perforation of valves, myocardial walls, and interventricular and interatrial septum."  Finally, he described a hyperacute form of endocarditis, that he named "endocardite gangreneuse or maligne" (gangreneous or malignant endocarditis). In his description, he noted high grade fever, tachycardia, sepsis, and neurologic compromise.  The outcome was fatal in a short period of time.

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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, mentioned that these substances could also be localized on the endocardium. Subsequently he wrote these vegetations could be detached from their valvular insertion and they may become larger and cause valvular obstruction.

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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.

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In the first stage, Bouillaud obviously included all types of acute endocarditis either from infectious or inflammatory origin. In the second phase, he described cases of subacute endocarditis and finally the third stage referred to chronic or healed valvular lesions. It is important to stress that the germ theory of disease was not yet identified in 1835. Furthermore, infective endocarditis and rheumatic valve disease were not known as distinct clinical entities and were reported under the same title "inflammation of the endocardium."

There is a section in Bouillaud's monograph dealing with the symptoms of acute endocarditis. He mentioned that three of the four "general symptoms" of inflammation, heat-redness and swelling were often absent in these patients. Pain was often absent but could occasionally be present.  He also noted that "a fairly high fever usually accompanies acute endocarditis."  He emphasized the importance of physical diagnosis with percussion and auscultation. Bouillaud detected the presence of a below sound ("bruit de soufflet") on auscultation in patients with acute valve endocarditis. Finally, he described respiratory and neurologic symptoms observed in these patients. Below is a classic account of a case of acute endocarditis:

"A young girl, 18 years old, of delicate and scrofulous constitution, was admitted to the Clinic on December 22, 1832. She had been coughing excessively for 2 weeks, was expectorating a lot of mucous substance and complained of feelings of suffocation and general discomfort... Large bubbles of mucous rale were detected on both sides of the chest. When the lungs were auscultated from her back we were surprised to hear a distinct, extremely short puffing systolic murmur during ventricular contraction...

 Diagnosis: general bronchitis with blockage of the lungs; thickening starting with the valves of the heart with slight blockage of one orifice. Our observations during the earlier part of the disease and the absence of any indication of organic heart disease before the current affection left us in doubt as to the lesion which really caused the bellows murmur..."

The clinical situation of this patient deteriorated and she died on December 31st. An autopsy was performed and the following observations were made: "...The aortic valves were red but not thickened. The mitral valve was thicker and its free end completely covered with multiple, convergent vegetations resembling leeks or venereal cauliflower; they were fibrinous, friable and easily crushed by the blade of the scalpel... The condition of the valve obviously impeded its movement and thus prevented total blockage of the orifice at which it is located."

This observation is displayed here.

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REFERENCES

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


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