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March 29, 2017
19th Century Rene-Joseph Hyacinthe Bertin

Rene-Joseph Hyacinthe Bertin (1757-1828)

Traite des maladies du coeur et des gros vaisseaux. Paris, J.B. Bailliere, 1824

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Rene-Joseph Hyacinthe Bertin was one of the leading physicians of the first half of the 19th century in France. Bertin had a great interest in cardiovascular diseases and with his assistant Jean Baptiste Bouillaud contributed extensively to the knowledge of valvular heart disease. He published his outstanding work, "Traite des maladies du coeur et des gros vaisseaux," which was edited by Bouillaud in 1824. His monograph is regarded as the most comprehensive textbook on cardiovascular diseases of that era.

A systematic approach to clinico-pathological correlation was one of the principle characteristics of the French school of medicine of the 19th century.  Bertin, similar to Corvisart and Laennec, placed a great emphasis on post-mortem examination.

In his treatise, Bertin reported several cases of "cartilaginous induration" of cardiac valves. He accurately describes the clinical signs of mitral stenosis.  He was one of the early advocates of mediate auscultation. In three of these cases, he noticed the "bruit de soufflet" on auscultation using the cylinder [stethoscope].  The diagnosis of mitral stenosis was made in most patients during life and confirmed by a detailed autopsy examination.

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At autopsy, valvular lesions such as leaflet thickening and retraction, fusion of leaflets, and ossification of  leaflets leading to the narrowing of mitral orifice were noted with great precision. He also described carefully the dilatation and/or hypertrophy of cardiac chambers in patients with valve disease.

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Bertin also wrote on valvular vegetations. In that regard, he shared Laennec's views and agreed with his classification of vegetations on two types, "verruqueuse and globuleuse." He also expressed the opinion that these vegetations were not from syphilitic origin and rejected Corvisart's hypothesis. In this section of his work, he described several cases of valvular vegetation including one involving the mitral valve which is displayed here.

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In his monograph, Bertin also reported one of the first observations in the medical literature on papillary muscle rupture from infectious origin. He described the case of a 22 year-old female with presenting symptoms of high grade fever, cough and tachycardia.  She died 18 days after her hospitalization. At autopsy examination, he noted the presence of pus and vegetations in the right ventricle. He also mentioned multiple vegetations adherent to the subvalvular apparatus of the tricuspid valve with a papillary muscle rupture. 

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Following these observations, Betrin wrote a chapter in his treatise under the title, "Of the symptoms and diagnosis of induration, and vegetations of the valve of the heart."  In this section of his book, he discussed in detail the new art of auscultation and its great value in the diagnosis of valvular disease. The following quotation is of great interest:

"There is a method of exploration for ascertaining the contraction of the several orifices of the heart, which no other can supply: we refer to auscultation, either immediate or mediate. The symptoms which this mode of exploration furnishes, already pointed out by M. Laennec, are the following: 1st , When the disease affects the auriculo-ventricular orifice, we hear, during the contraction of the auricles, which continues longer than in the natural state, a very distinct sound, which resembles the sound of a blow given by a file on wood, or that of a bellows quickly pressed. 2nd. When the contraction is situated about the arterial orifices ( ventriculo-pulmonary and aortic) the sound of rubbing, to be presently described, is the same ; but it is coequal with the contractions of the ventricles, and of the pulse. 3d. If the left orifices are contracted, the pathognomonic sound will be heard more especially in the region of the cartilages of the fifth, sixth and seventh ribs: Whereas, if the contraction occupies the right orifices, the same sound will be more particularly heard at the inferior part of the sternum. 4th. The bellows-sound appears to coincide with the cartilaginous, or fibro-cartilaginous induration, and with the contraction produced by vegetations; that of the file, on the contrary, announces rather the contraction produced by open induration.  We have so frequently had occasion to confirm the absolute certainty of these symptoms, they have enabled us to ascertain the contractions of the orifices of the heart with so great facility that we do not fear to repeat, that the diagnosis of this disease may be established in the most positive manner."

Bertin had a great understanding of physical principles responsible for heart murmurs associated with valve stenosis.

"Nothing appears to us more easy to be conceived, than the mechanism of the sound which accompanies the constriction of the orifices of the heart. The blood being obliged to pass from the cavity of the auricles or the ventricles, across a very narrow opening, must necessarily produce more or less friction; and it is precisely this friction which produces the murmur, or jarring thrill of which we have spoken. In the same manner we may explain the vibratory tremor, which is heard in the precordial region, and which M. Laennec has justly designated by the term purring tremor (fremissement cataire)."

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Bertin is best known for his work on cardiac hypertrophy. He emphasized that early authors had confused hypertrophy and dilatation. Corvisart had used the term "active aneurysm" for hypertrophy and "passive aneurysm" for dilatation. He correctly stated that these two pathologic processes could often occur simultaneously, particularly in patients with valvular heart disease. He also stressed the fact that cardiac hypertrophy could happen without dilatation and vice-versa.
He distinguished three types of cardiac hypertrophy, simple, eccentric, and concentric. Simple hypertrophy was characterized by an increase in the thickness of the ventricular muscle without alteration in the size of the chamber. In eccentric hypertrophy, the thickness of the ventricular muscle was increased and its size was augmented. In concentric hypertrophy, the ventricular walls were thickened and the cardiac chamber size was decreased.

 

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REFERENCES

Bertin RJH. Traite des maladies du coeur et des gros vaisseaux. Translated by C.W. Chauncy, Philadelphia, Carey Lea and Blanchard, 1833

Ackerknecht EH. Medicine at the Paris Hospital, 1794-1848. Baltimore, Johns Hopkins Press, 1967

Fye WB. Profiles in cardiology: Rene-Joseph-Hyacinthe Bertin. Clin Cardiol 1993;16:273-274


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