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February 19, 2017
19th Century Jean-Nicolas Corvisart

Jean-Nicolas Corvisart (1755-1821)

Essai sur les maladies et les lesions organiques du coeur et des gros vaisseaux. Paris, Mequignon- Marvis, 1806.

Nouvelle methode pour reconnaitre les maladies internes de la poitrine par la percussion de cette cavite. Paris, De Migneret, 1808.

Jean-Nicolas Corvisart
Portrait of Jean-Nicolas Corvisart
Portrait of Jean-Nicolas Corvisart


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Jean-Nicolas Corvisart was the personal physician of Napoleon and professor of medicine at the College de France.  He is remembered as one of the most distinguished physicians of the first half of the 19th century.

He published one of the most important monographs in cardiology more than 50 years after De Senac's treatise. The monograph was based on Corvisart's clinical lectures and as he was an extremely busy physician, it was assembled and written by one of his pupils, C. N. Horeau, under his direct supervision.  His work became a classic and was translated into English and German. It influenced generations of physicians and was quoted by his peers until the late 1800's. Corvisart should be remembered as a great physician who placed significant emphasis on clinical diagnosis and popularized the technique of percussion. Corvisart was a strong believer in clinico-pathological correlation and all his clinical observations were followed by a detailed postmortem examination.

Corvisart's chapter on valvular diseases includes section on "cartilaginous induration" and "ossification" of cardiac valves, clinical signs associated with narrowing of valve orifices, and cardiac valve vegetations. He was the first physician to distinguish two types of valvular lesions: cartilaginous indurations with or without ossification (calcification) and vegetations.

Corvisart described several cases of cartilaginous induration of cardiac valves, and particularly the mitral and tricuspid valve. He mentioned that the left-sided valves were more affected than the right -sided valves.  Corvisart was convinced that the obstruction of the cardiac valves would lead to disturbances in the blood circulation and that would lead to the clinical manifestations. He also suggested that valvular obstruction would produce ventricular hypertrophy or dilatation (he used the term active or passive aneurysm throughout his book to describe these two phenomena respectively).

He provided an accurate account of clinical signs of mitral stenosis including dyspnea, orthopnea, palpitation, and irregular pulse. 

In the postmortem examination of a patient with mitral stenosis, he remarked the dilatation of the right atrium and ventricle and "the widening of the orifice between these two cavities." He also noted a significant dilatation of the left atrium with an osseous transformation of the mitral orifice with a very narrow opening ("...l'orifice [mitrale] formait une espece de fente osseuse a travers laquelle une piece de monnaie aurait a peine passer"). In other observations, he described valvular pathology in detail with leaflet thickening, fusion and ossification, and chordae thickening, fusion and ossification. Corvisart stressed the fact that these ossifications were often localized in the area between the two leaflets, referring to the commissural fusion and calcification.   He was the first to describe clinical signs and the autopsy findings in tricuspid stenosis.

The etiology of valvular diseases was not discussed by Corvisart although the rheumatic etiology was already mentioned by Baillie in 1797. This causative relationship would be definitely established by Bouillaud in 1836.  

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Corvisart was the first to describe the palpable precordial thrill or "bruissement" on physical examination in mitral stenosis:

"...there is a certain thrill (bruissement) difficult to describe, perceptible when the hand is applied to the precordial region, a thrill which comes without doubt, from the difficulty which the blood finds in passing through an orifice which is not large enough for the quantity of blood which it is supposed to let pass. This same thrill is also recognizable, but is much less marked, by the hand, which studies the phenomena of the pulse.  This characteristic is not the only one, by which the pulse shows the existence of a narrowing of the left orifice; it is more irregular in the case of narrowing of the right orifice, but less irregular than when the aortic orifice is changed.  Moreover, it shows that neither the force, the hardness, nor the fullness, because the quality of blood, which the left ventricle puts out is proportional to that which it receives from the left auricle, which does not empty completely, because the action of the ventricle is not so vigorous since it is only feebly stimulated by the small quantity of blood."

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Corvisart also described a second type of valvular disease with lesions compatible with infective endocarditis.  He coined the term vegetation to describe "excrescences or soft vegetations" on cardiac valves. He specifically mentioned that these vegetations should be distinguished from "osseous asperities" that could be observed on the mitral and aortic valves.  He also described their similarity to "venereal excrescences" and postulated that they might be syphilitic.  He finally mentioned that these vegetations could cause narrowing of the valvular orifices blocking the blood circulation.  Among his observations, there was the first case of mitral valve endocarditis with rupture of multiple chordae of the anterior leaflet. This topic is further discussed in the section on Infective Endocarditis.

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Corvisart reported in the section of his monograph, "Of the partial rupture of the heart," cases of mitral regurgitation due to papillary muscle  or chordae rupture at postmortem examination. All these cases occurred in young patients and appeared to be post-traumatic. From historical point of view, Corvisart reported the first detailed account of post-traumatic papillary muscle rupture.

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Corvisart also wrote extensively about cardiac enlargement and used the term aneurysm. He distinguished between cardiac hypertrophy (active aneurysm) and cardiac dilatation (passive aneurysm). In the first scenario, ventricular wall thickness was augmented and the contractility force was increased. In the second case, the thickness of myocardium was diminished and the contractility force was reduced.

In 1808, Corvisart published his second monograph on the technique of percussion under the title, "Nouvelle methode  pour reconnaitre les maladies internes de la poitrine par la percussion de cette cavite."

Leopold Auenbrugger (1722-1809), an Austrian physician, invented the percussion of the chest for the diagnosis of cardiothoracic disorders. He was the son of an innkeeper and working with his father who was tapping casks to determine the level of wine in them, he got this genius idea.

He described his invention in a small book, "Inventum novum ex percussione thoracis humani ut signo abstrusos interni pectoris morbos detegendi," in 1761. The English translation of the title would be "A new discovery that enables the physician from the percussion of the human thorax to detect the diseases hidden within the chest."  Auenbrugger's discovery was received with skepticism and the procedure went unnoticed until Corvisart initiated its use in his clinical practice.

Corvisart's monograph was a translation of Auenbrugger's book augmented with his own experience of more than twenty years and included further refinement of this new diagnostic modality.  With a great sense of honesty, Corvisart wrote in the preface of his book:

"I could have raised myself to the rank of an author by revamping the work of Auenbrugger and publishing a work on percussion. But by that I would sacrifice the name of Auenbrugger to my own vanity, that I do not wish to do: it belongs to him, it is his beautiful and rightful discovery (Inventum novum, as he justly says) which I wish to bring to life."

Corvisart was a strong advocate of percussion in physical diagnosis. Following the publication of his work, the percussion technique was applied by an increasing number of physicians. This procedure, which had remained obscure for about 50 years, was broadly accepted in Europe in a very short period of time and became an integral part of physical examination.  Percussion was used for the diagnosis of diseases of the lungs, empyema, and pleural and pericardial effusions. This technique was also employed until the early decades of the 20th century to determine the size of the heart by delineating its left border.

REFERENCES

Corvisart JN. An Essay on the organic diseases and lesions of the heart and great vessels. Translated by J. Gates. Boston, Bradford and the Read, 1812


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