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February 25, 2021
Infective Endocarditis Byrom Bramwell

Byrom Bramwell (1847-1931)

Diseases of the heart and thoracic aorta. New York, D. Appleton & Co., Bond Street, 1884.

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Byrom Bramwell, physician and neurologist of Edinburgh, published his classic monograph in 1884. This textbook had an excellent review from Sir William Osler and became very popular in the medical community.

Although Bramwell did not have any original contributions to the knowledge of infective endocarditis, the chapter on this topic is extremely well-written and provides an excellent summary of the state of the knowledge in the 1880's.  This chapter deals with the etiology, anatomo-pathology, clinical history and symptoms, differential diagnosis, prognosis and briefly the treatment of this condition.

The most common term used at that time to describe infective endocarditis was "ulcerative endocarditis" based on the pathological findings of valvular lesions. As Bramwell mentioned in the beginning of his chapter, Osler objected with this term as "ulcerative" lesions were not present in all cases of endocarditis.

Several other terminologies were also used mostly based on the clinical presentation and its severity:

septic endocarditis, infectious endocarditis, diphtheritic endocarditis, endocarditis maligna and arterial pyaemia.

In his definition of ulcerative endocarditis, Bramwell wrote that "it was an acute inflammation of the endocardium, which is characterized, pathologically- by the formation of fungoid vegetation and usually ulceration of the endocardium; clinically-by great prostration, frequency of pulse, fever of an irregular or suppurative type, symptoms of a typhoid or pyaemic character, together with enlargement of the spleen, and the local manifestations of embolic infarctions of various organs."

He also mentioned that the endocardial lesions could be either "the primary local source through which the system becomes impregnated" or "a manifestation of a general pyaemic or diphteric condition."

These observations were a confirmation of kirkes' and wilks' works.

In the mid 1880's, Gram staining methods had become available and Bramwell remarked that "Some observers regard the micrococci, which are met with in the cardiac vegetations, and in many cases also in the embolic infarctions of distant organs, as the cause of the disease." He also expressed the view of others according to which vegetations were nidus in which micrococci could develop.  According to this second theory, vegetations were a product of inflammation comprising components of the blood. The origin of the vegetations was one of the major debates of that time.

William Osler in his early writing on endocarditis supported this second view: "Micrococci are not peculiar to the vegetations of the ulcerative form of endocarditis, but exists in the small beadlike outgrowths of the rheumatic and other varieties of the disease."  This confusion was born from the fact that at that time it was not known that cardiac valves affected by a disease such as rheumatic fever were more prone to infection.  This fact would be established later by William Osler himself who described this specific subgroup under the title, "chronic or subacute bacterial endocarditis."

Regarding anatomo-pathological lesions, Bramwell noted that left sided valves were significantly more affected than the right sided valves. He also gave a detailed account of valvular lesions such as vegetations, leaflet abscess and aneurysm, leaflet perforation, and chordal rupture. 

In commenting on leaflet aneurysms he remarked: "The valvular aneurysms vary in size, but are seldom larger than a marble. When the anterior segment of the mitral valve is affected, the aneurismal sac bulges into the auricle, the orifice of the sac being situated on the ventricular surface of the valve." He also mentioned that the base of the aorta (aortic root) was in many instances involved in endocarditis. He noted "An aneurism of this description is generally of small size.  It may project into the pericardium or into the pulmonary artery.  Occasionally its rupture is the immediate cause of death."

Bramwell provided several illustrations to demonstrate his observations. These illustrations on valvular lesions of endocarditis are magnificent and remarkably precise.

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Bramwell described the vegetations as follows:

"The vegetations may be of all sizes and shapes; they are usually of grayish colour, and often present a granular, fungating, or cauliflower appearance; occasionally they are smooth on the surface, as a rule they are very friable, though not unfrequently firmly attached to the surface of the endocardium, quite exceptionally they are tough throughout."

"on microscopic examination, the base of the vegetations is found to consist of the thickened endocardial and subendocardial tissue, in which granular particles and micrococci sometimes abound; the greater mass of the vegetations is made up of fibrin and granular debris, in the midst of which cellular elements, blood corpuscles, and in many cases immense numbers of micrococci, often in the form of ball like masses are embedded."

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Regarding the clinical presentation, Bramwell emphasized on:

1) Fever
2) Dyspnea
3) Tachycardia, Palpitation
4) Cardiac murmurs: diastolic murmur of aortic insufficiency or systolic murmur of mitral regurgitation
5) Precordial pain
6) Splenomegaly
7) Embolic infarctions involving the kidneys (abdominal pain and hematuria), the brain (paralysis, delirium, and convulsions)
8) Skin lesions with purpuric symptoms.

Finally, Bramwell wrote that "the duration of the disease varies considerably" and that "the termination is invariably fatal."

The entire chapter on "ulcerative endocarditis" is displayed.

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Hjalmar Heiberg Sir William Osler