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February 27, 2017
Rheumatic Heart Disease Jean Baptiste Bouillaud

Jean Baptiste Bouillaud (1796-1881)

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

Nouvelles recherches sur le rhumatisme articulaire aigu en general, Paris, J.B. Bailliere, 1836.

Traite clinique du rhumatisme articulaire, et de la loi de coincidence des inflammations du coeur avec cette maladie, Paris, J.B. Bailliere, 1840.

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.

Jean Baptiste Bouillaud was the first physician to establish the definite relationship between rheumatic fever and carditis and defined "the Law of Coincidence." He coined the term endocardium ("endocarde") and its inflammation, endocarditis ("endocardite"), in the introduction of his monograph.

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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.

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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, 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.

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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. 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.

Moreover, Bouillaud was the first physician to indicate the high incidence of valvular lesions in rheumatic fever and to demonstrate that these lesions were often permanent leading to severe forms of valvular dysfunctions. He provided a detailed account 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. He also reported several cases of multivalve disease and several cases of left-sided valve disease with secondary tricuspid regurgitation. All these findings were based on Bouillaud's personal clinical experience which was one of the largest in Paris.

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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.

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Bouillaud first noticed the relationship between rheumatic fever (acute articular rheumatism) and its cardiac manifestaions (pericarditis or endocarditis) in 1832. At this time, he was extensively investigating cardiac auscultation and noticed the high incidence of abnormal cardiac sounds in patients with rheumatic fever. He followed these patients very closely and in 1836, Bouillaud wrote: "We have stated that in about half of cases of acute articular rheumatism, this disease coincided with the inflammation of both layers of serofibrose tissues of the heart [pericardium and endocardium]."

Bouillaud believed that in severe forms of acute articular rheumatism, endocarditis was the rule rather than the exception and defined the "law of Coincidence" in his second book entitled, "nouvelles recherches sur le rhumatisme articulaire aigu en general," which was published in 1836. In this treatise, he established definitely the etiologic relationship between acute articular rheumatism and heart disease :  "In the great majority of cases of acute articular rheumatism with fever, there exists in a variable degree a rheumatism of the serofibrous tissues of the heart. This coincidence then 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.

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REFERENCES

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


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William Charles Wells Karl Albert Ludwig Aschoff


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