COLUMBIA LIBRARIES OFFSITE HEALTH SUI Nf.l STANDARD HX64 134873 =tC681 .V412 1920 The heart and the ao RECAP Columfria WLnihztfiity«j\A mtfjeCttpofJ^etoHork \ College of ^fjpsictang anb Hmrgeons Reference library ■ - - . THE HEART AND THE AORTA Digitized by the Internet Archive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/heartaortast4jdie00vaqu PUBLISHED ON THE FOUNDATION ESTABLISHED IN MEMORY OF WILLIAM CHAUNCEY WILLIAMS OF THE CLASS OF 1822, YALE MEDICAL SCHOOL AND OF WILLIAM COOK WILLIAMS OF THE CLASS OF 1850, YALE MEDICAL SCHOOL THE HEART AND THE AORTA STUDIES IN CLINICAL RADIOLOGY BY H. VAQUEZ Professeur agrege a la Faculte de Medecine de Paris Medecin de l'Hopital Saint-Antoine AND E. BORDET Chef de laboratoire adjoint a la Faculte de Medecine de Paris TRANSLATED FROM THE SECOND FRENCH EDITION BY JAMES A. HONEIJ, M.D., AND JOHN MACY, M.A. WITH 181 ILLUSTRATIONS NEW HAVEN YALE UNIVERSITY PRESS LONDON • HUMPHREY MILFORD • OXFORD UNIVERSITY PRESS MDCCCCXX COPYRIGHT, 1920, BY YALE UNIVERSITY PRESS THE WILLIAMS MEMORIAL PUBLICATION FUND THE present volume is the fourth work published by the Yale University Press on the Williams Memorial Publication Fund. This Foundation was established June 15, 1916, by a gift to Yale University by Dr. George C. F. Williams, of Hartford, a member of the Class of 1878, Yale School of Medicine, where three generations of his family studied — his father, Dr. William Cook Williams, in the Class of 1850, and his grandfather, Dr. William Chauncey Williams, in the Class of 1822. PREFACE TO THE SECOND EDITION THIS book has been received with such favor by the medical profession that the first edition, published in 1913, was quickly exhausted. We have decided to reprint it, notwithstanding the material difficulties which can well be imagined. We have taken this opportunity to modify some chapters and to add new ones, dealing with the measurement of cardiac hypertrophy by finding the index of depth, with the diagnosis of pulmonary and tricuspid insufficiency, and finally the localization of projectiles of war in the heart and the pericardium. We have tried to keep in this work the practical value which physicians have recognized in the first edition and more especially for those who, having the task of drawing up the" dossiers de reforme" for soldiers afflicted with cardiac affections, wished to add to the indications of current semeiology the more precise indications of radiological methods. February, 1918. PREFACE TO THE FIRST EDITION r ¥^HE semeiology of the cardio-vascular system has I been considerably enriched by adding graphic record- ing and radiology to the old methods of examination, such as percussion, palpation, and auscultation. Graphic recording has enabled us to analyze with pre- cision the mechanism of the cardiac rhythm, to distin- guish its different anomalies, and to refer to arhythmic actions their place in diagnosis and prognosis of diseases of the heart so important and long misunderstood. More recently radiology has come to take a place beside graphic recording, the importance of which is continually increasing. At the end of the last century it was not believed that the field of roentgenological exploration would ever pass beyond the domain of surgery. If we considered radiog- raphy perfectly capable of determining the exact lesion in the bones, w T e thought, on the other hand, that it was of doubtful value in the examination of the internal organs. To determine the relation of the lungs and the heart in the different pathological conditions, to judge the state of the pulmonary parenchyma, to give a rough estimate rather than a measurement of the volume of the heart, was all that we then expected of radiography. It did not seem that it could ever accomplish more. Progress of inestimable value has been made in precise radiology which enables us to obtain normal images of the heart according to the plane of projection or, to state it better, the exact configuration and the true contours of that organ. In the pathological state this configuration and these contours undergo variable modifications, but in direct relation to organic alterations of the heart. It follows, then, that we have a right to diagnose the lesion with which the heart is affected, upon a simple examina- tion of its exterior aspect. This notion, well established xii PREFACE TO THE FIRST EDITION by anatomical proofs, has been until our day only imper- fectly utilized in clinics, the processes of exploration being incapable of giving sufficiently precise indications. Eadiology of precision has come to fill this gap. Dur- ing the life of the patient it shows to the observer the heart as it appears on post-mortem examination, perhaps even less deformed, for it is animated by the circulation. Eadiology gives a precise objective description of patho- logical deformations and reveals the exact exterior con- figuration of the heart, which warrants our concluding the existence of different organic or valvular lesions. In spite of their importance, the data relating to these examinations have not yet in France been made the sub- ject of a complete work. It seemed to us therefore that it would be interesting to gather together ideas which have been scattered and to add to them the result of our personal observations. It is not our purpose, however, to issue a didactic trea- tise on radiology of the heart and the aorta, so the reader will not find the profusion of bibliographic references, citations, and names of authors which he might reason- ably expect in a work of this kind. Although we are compelled to tell what we have ob- served and indicate the methods used, we have also set forth the results arrived at by certain authors who have preceded us. When our opinion has agreed with theirs we have not failed to mention it. When we have differed, we have given the reasons, indicating the grounds for our conclusions. The work which we present today to the medical pro- fession may be useful to radiologists, who will- find here the description of the mechanical methods which we have used, as well as to physicians to whom it will furnish indispensable ideas about a method of exploration, a knowledge of which appears more and more necessary. H. Vaquez and E. Bordet. TABLE OF CONTENTS PAGE Preface to Second Edition ix Preface to First Edition xi CHAPTER I Radiological Methods I. Radiographic methods 2 1. Time radiography 2 2. Instantaneous radiography 3 3. Teleradiography 3 II. Radioscopic methods 4 1. Normal radioscopy 4 2. Orthodiascopy 5 3. Orthodiagraphy 7 4. Teleradioscopy 11 III. Personal technic 11 IV. Comparison of methods 12 CHAPTER II Normal Heart Shadow I. Positions of patient — Definitions 16 1. Direct positions 16 2. Oblique positions 18 3. Lateral positions 18 II. Study of heart images in the principal positions . . 18 A. Heart image in frontal position .... 18 Contours 20 Apex of the heart 23 Measurements of shadow 23 xiv CONTENTS PAGE Mobility of heart 33 Displacements due to respiration ... 34 Heart pulsation 36 B. Image of the heart in oblique positions . . 38 Right posterior oblique position .... 38 Left posterior oblique position .... 43 Right anterior oblique position . . . . 44 Left anterior oblique position .... 45 Lateral positions 47 III. Variations of the physiological form of the heart . 50 IV. Particular studies to determine ventricular develop- ment in depth 53 V. Summary and conclusions to follow in radiological examination of heart 58 CHAPTER III Heart Shadow in Pathological State Modifications affecting the whole heart ...... 61 Partial modifications 63 I. Determination of total ventricular volume . 64 II. Left ventricle 66 III. Right ventricle 68 IV. Left auricle . 71 V. Right auricle . . . . . . . . . 72 CHAPTER IV Valvular Affections Simple mitral stenosis 75 Examinations in direct anterior position ... 75 Interpretation of cardiograms and comparison with percussion 80 Examination in oblique positions 82 Mitral insufficiency 87 Functional mitral insufficiency 93 Mitral disease 96 CONTENTS xv PAGE Aortic insufficiency 102 Endocarditic aortic insufficiency 102 Aortic insufficiency of arterial origin 108 Aortic stenosis Ill CHAPTER V Congenital Affections of the Heart I. Stenosis of pulmonary artery with inter-ventricular perforation 115 II. Simple stenosis of pulmonary artery 123 III. Inter-ventricular perforation 127 IV. Congenital aortic stenosis 132 V. Cardiac ectopia and total inversion of the viscera . 131 CHAPTER VI Radiological Outline of Heart in Certain Pathological Conditions not Resulting from Valvular Lesions I. Cardiac hypertrophy and dilatation 142 II. Cardiac hypertrophy in the aged . . . . . . . 146 III. Cardiac dilatation 148 IV. Basedow's disease • 152 V. Arhythmic heart 155 VI. Cardiac insufficiency and asystolism 159 CHAPTER VII Affections of the Pericardium A. Pericardial effusions 161 B. Cardiac symphysis and partial adhesions of the peri- cardium 165 I. General data from radiological examination . . . 166 a. Pulmonary field 166 b. Pleural shadows . 167 c. Mediastinal shadows ........ 167 d. Heart volume ... - 168 xvi CONTENTS PAGE II. Data relative to existence of pericardial adhesions . 169 a. Shadows on the heart outline due to adhesions 169 b. Modifications of displacements of the shadow of heart and diaphragm 171 1. Apex of the heart 172 2. Displacements of heart outlines . . . 174 3. Movements of the diaphragm . . . 176 4. Outline of the heart 180 c. Respiratory outline 181 III. Particular data relative to the site of adhesions . . 183 1. Adhesions of base of heart 183 2. Adhesions of apex 183 3. Adhesions in diaphragmatic region .... 184 4. Adhesions to anterior thoracic wall .... 184 5. Posterior mediastinitis 185 6. Complicated cases . 185 IV. Comparison of the results of percussion and ortho- diagraphy 185 V. Clinical examples 186 CHAPTER VIII Aortitis I. Normal aorta 192 1. Frontal position 192 2. Oblique position 195 3. Nature of information obtained 197 A. Volumetric analysis (three dimensions method) 197 B. Qualitative analysis 201 II. Pathological aorta 204 A. Case in which diagnosis of aortitis is evident after objective examination 204 B. Cases in which subjective symptoms of aortitis are not accompanied by any objective sign . 210 CHAPTER IX Aneurisms of Thoracic Aorta I. General aspect of aneurismal shadows .... 217 II. Analysis of some radiological signs 226 CONTENTS xvii PAGE III. Diagnosis 229 A. Differential diagnosis of aortic aneurism from other thoracic or intra-thoracic affections . 231 B. Differential diagnosis of aneurism of the aorta from dilatations of other vascular organs . 233 C. Association of aneurism with other lesions . 233 CHAPTER X Localization of War Projectiles in Heart and Pericardium Statistics 235 I. Locating the projectile 237 II. Methods of localization 239 III. Anatomical localization 240 IV. Extraction of projectiles under fluoroscopic guidance 248 Bibliography relating to localization of projectiles . . . 250 Index 253 CHAPTER I RADIOLOGICAL METHODS WHEN one examines on a fluorescent screen a patient's thorax, one is struck by the clearness of the cardiac shadow. This results from the density of the heart which is relatively opaque to the x-rays, whereas the lungs are freely permeable. So from the very first, the idea arose of using radioscopy and radiography to study the heart, in the normal and pathological state. At first the results were of rather slight importance. Though it appeared relatively easy to estimate the modifications in the volume of the heart, provided they were already sufficiently marked, and to recognize the existence of voluminous aneurismal sacs, one did not feel justified in expecting radiology to give greater precision. Radiol- ogy was believed to be radically incapable of furnishing an exact measurement of the cardiac diameters, and of the changes which they may undergo during the course of the same affection. Difficulties which at first were not taken into account constantly occurred, arising primarily from the inadequacy of the methods of exploration and from the perpetually changing conditions of the heart. As the heart is continually in motion within a cavity, of which the limits themselves vary with the act of respira- tion, the result is that the roentgenological images pre- sent extremely diverse forms. It was important, then, before going further, to determine exactly the value and the significance of these variations ; but that was realized only gradually and in the course of the last few years. The first necessity was to modify the technic hitherto employed. 2 THE HEART AND THE AORTA Roentgen rays arising from a luminous source consti- tute a beam, the radiations of which follow a divergent or conical direction, and from that there results an evident deformation in the contour of projected images. It was necessary to attack the problem of correcting the causes of error due to this deformation of shadows and it will be shown that the problem has been successfully solved. There remain almost no great difficulties in the radio- logical examination of the heart and the blood-vessels. The technic has been so far perfected that the images obtained have a great degree of accuracy; the interpre- tation of them, though it may still be open to some dis- pute, is at least settled definitely in its broad outlines. Since the question of technic plays such an important part here, it is fitting to present a detailed and critical study. We do not intend to describe the apparatus neces- sary for the production of x-rays, as we assume it is well known, but we shall try to describe carefully the different radiological methods used in the study of the heart and the blood-vessels, to compare them with each other, and to indicate their respective advantages and faults. I. RADIOGRAPHIC METHODS 1. Time Radiography. This method consists in charg- ing a Roentgen tube of ordinary type with a low current of from 0.5 to 1 milliampere. The patient is placed on his back, the radiographic plate under him ; the tube is placed over the sternum, at a distance of 50 to 70 centimeters. The negatives obtained by this method require a pro- longed exposure, which results in the contours of the cardiac shadow becoming blurred, owing to the pulsation of the heart and the respiratory displacements of the heart, which are multiplied during the exposure. Be- sides, the projection is enlarged and deformed to such an extent that it is impossible to correct it. So images obtained by time radiography are records of no value. This method, then, should be rejected. RADIOLOGICAL METHODS 3 2. Instantaneous Radiography. Of late years, physi- cists and manufacturers have tried, at the request of radiologists, to construct apparatus and tubes capable of furnishing a secondary current of several milliamperes. This method, called intensive, allows of the passage into the Roentgen tube of 10, 20, 60 milliamperes and even more, during a very short space of -time, which can be measured in seconds and fractions of seconds. The quan- tity of rays produced in this way is enough to impress instantaneously supersensitive radiographic plates. The adjustment can always be made more sensitive by the addition of an intensifying screen. This method consti- tutes an important step forward. It puts at the disposal of the operator a large amount of Roentgen rays, and the negatives are obtained with very short exposures. Thus it is easy to radiograph the thorax of a patient while in the state of suspended respiration. By this the respira- tory displacements are eliminated, and the negatives gain much in clearness. A series of images taken during suc- cessive phases of respiration contribute to the study of the relations of the heart and the diaphragm during inspiration and expiration, which is very useful. In spite of these advantages, the image obtained is de- formed as in the preceding method, and if the contours are clearer, the estimate of the dimensions of the cardiac area is still only approximate. 3. Teleradiography. To avoid the deformations due to the conic projection of x-rays, Kohler (Wiesbaden) conceived the idea of enabling us to radiograph the heart from a great distance, by causing the rays which arise from the target of the tube to take a perceptibly parallel direction. To do this all that is necessary is to place the tube two meters from the subject, "the rays which form the tangents with the line of the circumference of the heart grazing it at almost equal angles. ' ' The parallel- ism of the rays is not absolute, but the errors of projec- tion are insignificant. 4 THE HEART AND THE AORTA The source of the rays used in such a case must be very powerful. Several types of apparatus of French and American make are capable of furnishing the necessary energy. The choice of a powerful and resistant tube con- stitutes an important problem. The intensive Pilon and Coolidge tubes, not to mention others, are excellent. To obtain a radiogram of the heart at a distance, the process is as follows : the patient is placed standing or sitting with his back to the tube, the tube being 2.5 to 3 meters away from him (the distance of 1.5 to 2 meters, recommended by certain operators is insufficient and causes deformations) ; a fluoroscopic examination is then made to determine the exact position. When this is done, a radiographic plate is substituted for the screen and a negative made, the anterior surface of the thorax being in contact with the plate. To radiograph the heart and the aorta in oblique posi- tions, the same procedure is followed, only the patient turns so that he forms with the plane of the plate an oblique angle (50 degrees on the average). The rays traverse the thorax obliquely from right to left or from left to right, from front to back or from back to front, according to the requirements of the examination. The teleradiograms give the corrected shadow of the heart with all its curves and all its angles, constituting, therefore, a real projection of the organ. They show, moreover, the relations of the heart with the skeletal shadows, with the lungs and the diaphragmatic arches, and also afford valuable records for the clinician, who then can measure the total area of the heart, its diameters and outlines, judge the position of its contours as well as the form of the silhouette obtained. II. RADIOSCOPIC METHODS 1. Normal Radioscopy. This method gives a good general view of the thorax and nothing more. When the patient is placed behind the screen of platino-cyanide of RADIOLOGICAL METHODS 5 barium and the Roentgen tube is charged, we see the shadows of the mediastinum outlined on the clear borders of the lungs. The heart pulsations are clearly perceived, the respiratory movements are interpreted by the verti- cal displacements of the heart, by the raising of the ribs and of the outline of the thoracic cavity, and by the lower- ing and raising of the diaphragm. By rotating the body of the patient from right to left or from left to right, the anterior and posterior mediastinal spaces are shown; these appear clear because of the slight density of the tissues, and it is easy to observe the outline of the denser organs, as well as to discover the additional shadows of pathological origin. Finally, examinations in the dorsal or lateral position complete in a very short time a series of observations of the thoracic shadows as a whole. This method, then, gives general information about the regions x-rayed, about the relations and the forms of the shadows, but it does not furnish any precise information about the real dimensions of the organs; nothing more, indeed, than the amplitude of the movements which animate them. 2. Orthodiascopy. To correct the deformations of Roentgen projections, radiologists have from the begin- ning suggested an arrangement by which, by moving the tube to a convenient distance, the organ under examina- tion should be made visible only at a point where the central beam of rays, emanating from the focus, traverses it perpendicularly to the plane of the screen. In this way, the normal ray being tangent at a determined point, the projection of this point is real and deformation no longer exists. If, for example, the normal ray is directed at a tangent to the apex of the heart, the shadow of the apex corresponds to its exact position in relation to the screen and to the body of the patient. In executing the same movement to determine the location of the right cardio- vascular angle, at the base of the heart, a new point of the organ is marked, and if the experiment is repeated 6 THE HEART AND THE AORTA with all points which lie on the contour of the cardiac shadow, the result is an accurate projection of the heart on the radioscopic screen. The diagram in Fig. 1 shows the differences of pro- jection obtained when the tube remains at a fixed point or when it is moved according to the orthodiascopic method. Fig. 1. DIAGEAMS OF EOENTGBN PEOJECTION Above, conic projection: F, focus; F m, normal ray; ghij, object; g'h'i' j', projection of the object; E, E', screen. Below, orthogonal projec- tion: A, A 1; A 2 , etc., foci occupying different positions, so that the normal ray, A b, Aj c, A 3 e, A 4 d, is successively tangent to the angles of the object, b c d e. In b' & d' e', projection obtained by this method. If the tube is immovable at F, the normal ray, F m, is directed toward the center of the object, the beam of rays emanating from the focus traverses divergently the ob- ject, ghij, and projects its image on the screen at g h' % j'. RADIOLOGICAL METHODS 7 The contour of the shadow obtained is much greater than the contour of the body exposed to the rays. It will be noticed that the normal ray follows a direction perpen- dicular to the plane of the screen ; in m and in m, it is in the geometrical center of the object and of its shadow. The projection of m is therefore normal ; but around this point the rays diverge more and more; the image is en- larged in proportion as the region under consideration is distant from the center, m. The figure, g h' i j' , conse- quently, does not represent a proportionate enlargement of the opaque body, but a deformed image of it. If the x-ray tube is movable and can be shifted on a plane parallel to the plane of the screen, there is nothing to prevent its being brought to position A, so that the normal ray shall be tangent to one of the angles of the object, b c d e, and shall follow, for example, the direction A b. This ray, or at least those immediately contiguous, passing the opaque body, will strike the fluorescent screen perpendicularly in the neighborhood of point b' , this point being the shadow of the angle b. It is easy to mark this point b' with an oil crayon on the glass of the screen. By shifting the tube successively to Ai, A3, A4, the angles, c d' e , of the shadow are determined, which correspond to the angles c d g of the object. It is evident that if these points of the shadow are connected by straight lines, a figure is obtained, the dimensions of which are exactly the same as those of the object. If, then, in a radioscopic equipment we possess means of moving the tube horizontally and vertically on the same plane, and if, moreover, we have an especial adjust- ment (formed by crossed wires over the diaphragm in the center of which passes the normal ray) by which we can know the point where the normal ray strikes the screen, it is possible to determine the different regions of the cardiac shadow to which the normal ray is tangent. 3. Orthodiagraphy. The method which consists in outlining the contour of the shadows according to their 8 THE HEART AND THE AORTA normal projection is the orthodiagraphic method. The orthodiagrams are constructed on the principle which we have just studied : continual estimation of the normal ray and of its point of projection on the screen, perfect mobility of the tube allowing the passage of the normal ray over the entire surface of the screen. Orthodiagrams are of different models. They are all open to criticism ; the best is that which each individual is accustomed to use. It is not enough to have an ortho- diagraph^ apparatus ; it is necessary to have acquired a certain dexterity. Some preparatory training is neces- sary to avail oneself of all the advantages which this method offers. Physicians who, in our opinion, depend too much on the mechanical means of investigation, con- demn orthodiagraphy because of the effort which it re- quires of the clinician, aside from the study necessary to interpret the outlines. The early difficulties of the method are soon overcome and give results which prove the accuracy of the investigator's observations. The first orthodiagraphic apparatus was constructed in Germany. Moritz was the first to show the importance of the records which orthodiagraphy gave relative to the pathological modifications of the volume of the heart. The principles of the method were applied with the same success by Levi-Dorn, Grtinmach, Groedel, etc., who con- structed apparatus which differs in manipulation and the methods of recording, but which answers the same gen- eral purpose. It is not necessary to study these types of apparatus ; a description only of the orthodiagraphic apparatus of Destot which is used in France will be given. This apparatus consists of a movable holder, one of the arms of which carries the tube with its diaphragm, the other the small recording screen, or, in the more re- cent models, the recording crayon. This holder is mounted on a double joint counterpoised and so regulated that the whole system is in equilibrium. RADIOLOGICAL METHODS 9 Behind the screen and parallel to it is fixed a frame of wood; on that is placed a block of pai^er on which the tracing is made. A crayon, held in the center of the screen, is jointed in such a way that it can be lowered to touch the sheet of paper, through a little opening ar- ranged in the middle of the screen. The adjustment of the apparatus is made in such a way that the point of the crayon is always in the prolongation of the normal ray, perpendicular to the plane of the screen and of the block of paper. When the small recording screen is not there, the crayon remains at the extremity of the holder which faces the tube, while the frame which holds the paper is replaced by a large screen, and the tracing is then made on the glass or on a small sheet of celluloid paper fixed on the screen. To take an orthodiagram, the procedure is as follows : the patient is placed standing, behind the fixed frame, in the position desired (frontal, for example, that is, the anterior surface of the thorax against the frame), and held in place by means of crossed straps. The current is turned on to the tube, and the thoracic image appears on the screen. As the crayon is moved, the tube is moved equally, for the two systems are coordinated; so that when the point of the crayon follows the contour of the shadow of the heart, the heart is made visible by a beam of x-rays, of which the normal ray is tangent to the out- line of the organ. By drawing the whole length of the shadow outline, the contour of the exact projection of the organ is traced. Orthodiagrams thus obtained are quite sufficiently precise when all the conditions of the experiment are minutely observed. Errors of technic are insignificant ; they vary from one to four and sometimes five millimeters. The orthodiagraphic apparatus of Destot can be placed in all inclinations between the vertical and the horizontal and so permits the examination of patients, as may be required, standing, sitting or lying. Moreover, the trac- 10 THE HEART AND THE AORTA ing of the outline can be made directly on the thorax of the subject. In order, however, to practice orthodiagraphy it is not necessary to possess a special apparatus. Some of the apparatus of normal radioscopy can be used for ortho- diagraphy. It is enough to realize these essential condi- tions : lateral and vertical movability of the tube in the same plane; absolute immovability of the screen in a plane perpendicular to the normal ray. But it is neces- sary that the operator be able easily to move, with his left hand, the control of the tube and of the diaphragm, in order that the right hand may be free to make the tracing; it is advisable, besides, that the screen should slide vertically in a rigid support and should be fixed at variable heights. We have given up the use of a screen rigidly connected with the tube and no longer trace blindly on a block of pa- per. We work on the lead glass of a large screen. The es- timating of the normal ray is done by means of the dia- phragm-iris. By reducing the rays to a small circular field we know that the normal ray is situated in the cen- ter of the luminous zone. To that point we bring the part of the outline which interests us and we mark on the glass, at the level of the shadow, a line with a broad crayon. By increasing and diminishing alternately the luminous field, the observer recognizes clearly the area which he is studying and its relation to neighboring re- gions. Moreover, the results can be easily verified, and by successive trials it can be proved whether the crayon marks and the cardiac outline coincide exactly; also the slightest displacement of the patient can be noticed and errors corrected. Correction is so easy and so rapid that it becomes useless to strap the patient, and this shortens the operation and allows a quick shifting to the different positions for examination. When the operation is completed, to transfer the tracing to transparent paper takes but a moment. RADIOLOGICAL METHODS 11 4. Teleradioscopy. Radioscopy from a distance, or teleradioscopy, offers the advantage of throwing on a screen the shadows of the thoracic organs with their real dimensions. The technic is extremely simple. All that is necessary is to place the patient before the screen in all the posi- tions necessary for examination. The radiologist has only to trace on the lead glass the contour of the cardiac shadow without going through any process of correction. III. PERSONAL TECHNIC / This is the technic which we employ at I'hopital Saint- Antoine. We use a powerful installation with a direct current of 110 volts, and a coil of 50 centimeters. With this appa- ratus we can practice orthodiagraphy, teleradioscopy and teleradiography. A special device facilitates the succes- sive examinations to which the patients are subjected. These examinations are as follows: we begin with fluoroscoping the thorax as a whole ; then, by moving the tube, we explore the different parts of the cardiac or aortic shadow which interest us; we study the pulsations and the respiratory play of the shadows. After this prelimi- nary examination, we take one or several orthodiagraphic tracings in the most favorable positions. When it seems to us opportune to make an x-ray plate of the most characteristic image, we place the patient away from the tube at a distance of at least two and a half meters. The distance of one meter, a meter and a half or even two meters gives too considerable deforma- tions. It is only at two meters and a half that the enlargement is reduced to its practical minimum ; the pro- jection of an object fifteen centimeters in size is aug- mented by only four or five millimeters, figures which correspond to the errors of technic accepted in ortho- diagraphy. It is necessary that the tube be properly 12 THE HEART AND THE AORTA centered on the region to be studied. When it is a ques- tion of the heart, for example, this is the procedure: we illuminate the, radioscopic screen and by means of a diaphragm with a circular opening we so adjust it that the image of the heart is exactly contained in the interior of the luminous circle, the diameter of which should correspond exactly to the greatest diameter of the heart. We then fix the patient and the tube in their respective positions ; we give the diaphragm a greater opening, we place a plate instead of the screen or between the screen and the thorax and set the apparatus in action. As to teleradioscopy, we make less and less use of it. It gives precise evaluations when the patient is in a direct position, especially the direct anterior, in which the thorax is maintained in contact with the screen. It is not at all the same in oblique positions ; the distance of cer- tain parts of the organs examined amplifies the shadows and deforms them in part. Moreover, since the teleradio- scopes necessitate a prolonged intensive use of the tubes, these deteriorate rapidly. Finally, the control of the tube and the diaphragm is difficult at a great distance, with the result that the operator is but poorly protected against the rays which forcibly overspread the lead glass of the screen. IV. COMPARISON OF METHODS A certain number of these methods are incapable of giving precise information ; these are the methods which do not permit the exact reproduction of the dimensions of the objects according to their plane of projection. Radiography at short distance is in this class ; it furnishes only useless stereotypes, because the shadows of the organs are deformed, which too often lead to gross errors. It is therefore necessary to reject this method because the sometimes contradictory data furnished have proved confusing to clinicians and it is all the more important to insist on this. It is necessary to make the clinician under- RADIOLOGICAL METHODS 13 stand that his misconception arises from the defective use of investigative methods and that besides simple radiog- raphy, which can give erroneous results, tfyere are other radiological methods which are quite reliable. These methods, three in number, are: teleradiography, orthodiagraphy, and teleradioscopy. The last two are identical in the information which they furnish and are designated here by the term radioscopy of precision. Teleradiography and radioscopy of precision have each its advantages. The association of the two methods is nearly perfect; but if one only is to be used, then an orthodiagraph^ examination leads to a more precise diagnosis than a teleradiography plate. The great advantage of radiography is to procure one or more radioscopic records of the heart shadows, blood- vessels, neighboring organs and the thoracic skeleton. Moreover, these shadows have the actual proportions of the organs which they represent according to their plane of projection ; finally the value of the shadow is propor- tional to the density of the tissues. Taking several plates in different positions multiplies the advantages of tele- radiography. Plates can thus be interpreted and dis- cussed by physicians in the absence of the patient, with- out recourse to successive verifications. All this consti- tutes the superiority of teleradiography over simple radiography, but does not exclude the advantages of radioscopic methods. Orthodiagraphic tracings, which for the sake of sim- plicity are called cardiograms, give an exactness as great as teleradiograms, and the exact measure of the shadow of the heart. But the great advantage of radioscopy of precision is to allow the observation of pulsations and of the displacements of the heart itself and their modifica- tions according to the varied position of the patient. Finally, precise radioscopy alone is capable of giving information on the following questions, the full impor- tance of which will be seen in the course of this work: 14 THE HEART AND THE AORTA (1) respiratory displacements of the heart; (2) move- ments of expansion of the diaphragm; (3) mobility of the apex of the heart; (4) respiratory outline of the thorax; (5) evaluation of the volume of the left auricle; (6) pul- sations of the right ventricle; (7) determination of the position of the left ventricle at the base (point G) ; (8) determination of the angle of disappearance of the apex in the right posterior oblique position; (9) meas- urement of the ventricular development in depth. Badioscopy of precision has, then, one point of supe- riority over teleradiography, that is, it produces the greatest amount of information in the shortest time. One may urge against it that its records do not guarantee impersonal evidence as offered by radiographic plates. But whether one or the other of these methods is used, no protection is afforded from causes of error which ought to be logically absent from every record called imper- sonal. The part played by observation is still consid- erable. The personal factor intervenes at every instant in the taking of a radiogram, in the position of the patient, in the centering of the tube and the placing of the plate. These different operations necessitate an experience and an ability which are not common to all. The proof of it is that the physician, before interpreting a record, does not fail to inform himself of the conditions under which it was made. Moreover, for studies in cardiac radiology, the ideally impersonal record would not do. An impersonal record is a dead record. If it gives evidence of a foreign body, the existence of a fracture, the conformation of a tumor, it has not the power to inter- pret the life of an organ perpetually in motion. When it is a question of the heart, its life is manifested by the energy of its pulsations, the extent of its displacements, the density of its shadows ; when one examines an artery, it is extremely instructive to note the amplitude of its pulsations, the flexuosity of its contours, the degree of RADIOLOGICAL METHODS 15 transparency or opacity of its walls. To know all that, requires a competent observer. But let no one misunderstand our opinion. We do not pretend that radioscopy of precision constitutes the only process of examining the heart and the aorta. As we have already said, we believe that radioscopy procures the greatest amount of useful information. The radio- graphic record is secondary, but it is evidently incom- parable for fixing by radiographic proof one or several exposures at intervals. Moreover, whichever of these processes of precision we employ, — orthodiagraphy, teleradioscopy, teleradiog- raphy, — we shall none the less be in final possession of the contour of the shadows of heart and blood-vessels, that is to say, of a cardiogram to be analyzed. It is, consequently, the interpretation of radiological images of the heart which will comprise the substance of the following chapters. CHAPTER II THE SHADOW OF THE HEART IN ITS NORMAL STATE I. POSITIONS OF THE PATIENT— DEFINITIONS THE shadow produced by the heart on the fluorescent screen varies according to the position of the patient. Therefore, to have images comparable with each other, permitting the methodical study of the contours of the organ as well as its relations with its surroundings, it is indispensable to define, first of all, the different positions for the study of the images desired. Theoretically, in order that the information be as exact as possible, the patient ought to be examined in all the positions through complete rotation. But such a pro- cedure is superfluous. It is sufficient to take the radio- scopic image at certain intervals to have all the indica- tions required. These different intervals correspond to typical positions, in which it is expedient that an image should be taken. These positions are first the direct position, called ante- rior and posterior, according to whether the examination is made from the front or back, then all the intermediate positions, oblique, and lateral, right or left, according as the patient in rotating presents to the fluorescent screen first the right shoulder, then the back, then the left shoulder. 1. Direct Positions. The direct positions are two in number: the frontal position or direct anterior, and the dorsal position or direct posterior. (a) In the frontal position or direct anterior, the pa- SHADOW OF HEART IN NORMAL STATE 17 tient faces the screen and the operator (radioscopy), or the radiographic plate (radiography). In this position he turns his back to the tube; the rays penetrate the posterior surface to the anterior surface of the thorax (dorso-ventral direction). (b) In the dorsal position or direct posterior, the patient turns his back to the screen or the plate, and the rays follow an antero-posterior direction (ventro-dorsal). In these two positions patients can be examined stand- ing, seated, or recumbent. The information obtained is of the same absolute value, on condition, however, that the position of the body be well specified, for the image of the heart is modified accordingly. In medical practice the choice of position is sometimes imposed by the condition of the patient. Certain cardiac patients suffering from dyspnoea cannot accommodate themselves to the prone position, others cannot keep the standing position. Besides, each of these positions offers special advantages. Examination in the prone position is recommended for two principal reasons: (1) the subject is perfectly im- mobile; (2) the orthodiagraph^ findings are exactly com- parable to the findings by percussion which one generally takes in the same position (with the patient in bed). Examination in the upright position is convenient for the rapid observation of the patient in all positions. By making him rotate, the observer places the patient suc- cessively in the frontal, dorsal, lateral, and oblique posi- tions. During these movements the progressive changes of the shadows are noted and, what is not less important, the relation of the projection of the heart with the verte- bral column, the thoracic walls, the blood-vessels, etc. The oblique examination is practicable only in the stand- ing position. When in this same position one takes the frontal outline of the heart or a radiogram of it, it is important to have the patient completely immovable. The lateral movements of the body, even those that are 18 THE HEART AND THE AORTA involuntary, are the most frequent. They can generally be avoided by holding the anterior region of the thorax against the screen or, if need be, by fixing the shoulders by means of crossed straps. The seated position gives information identical with that in the vertical position, provided that the patient rests on an elevated stool and that the trunk is held up- right. 2. Oblique Positions. (a) Right anterior oblique. In this position the patient faces the operator or the plate; his right shoulder is against the screen or the plate, and the plane of the body describes with the plane of the screen or the plate a more or less wide angle. (b) Left anterior oblique. The patient faces the oper- ator or the plate, the left shoulder against the screen or the plate. (c) Right posterior oblique. The patient turns his back to the operator or to the plate, the right shoulder against the screen or the plate. (d) Left posterior oblique. The patient turns his back to the operator or to the plate, the left shoulder against the screen or the plate. 3. Lateeal Positions. The patient describes with the screen or the plate an angle of 90 degrees, the right shoulder against the screen or the plate. It is then in right lateral position. Inversely, if the left shoulder is in contact with the screen or the plate, the position is left lateral. II. STUDY OF THE IMAGE OF THE HEART IN ITS PRINCIPAL POSITIONS A. IMAGE OF THE HEART IN THE FRONTAL POSITION The subject of study, in the following descriptions, will be the projection of the shadow of the heart obtained by orthodiagraphic tracings. It is self-evident that these SHADOW OF HEART IN NORMAL STATE 19 observations would apply equally well to the image ob- tained by long distance radiography, because the two processes furnish identical images, not deformed, which is of primary importance, and which could not be realized by other methods. Fig. 2. HEAET IN FRONTAL POSITION In order to understand the meaning of orthodiagraphy tracings it is necessary to know, first of all, the anatomic image of the heart in the frontal position. This is repro- duced in Fig. 2. It will be seen that the right ventricle occupies the greater part of the diagram. It is bounded above and at #the right (left in the figure) by the auricular-ventricular groove that separates it from the right auricle, which constitutes the upper two-thirds of the contour of the organ. On the left side (the right of the figure) the anterior inter-ventricular groove bounds on the outside a narrow band of the left ventricle from the base to the apex. The left outline of the organ is, then, in its whole length the left ventricle. At the base the aorta and the pul- monary artery arise, whose respective directions soon cross. In tracing on a record the contour of this anatomical figure, we obtain the outline of Fig. 3. On the right (left of the figure), in the fourth inter- costal space, the right ventricle; in the third space, the 20 THE HEART AND THE AORTA right auricle ; in the second space, the edge of the sternum behind which are the ascending aorta and the superior vena cava. Fig. 3. SCHEMATIC EECOED OF THE CONTOUES OF THE HEAET On the left (right of the figure), in the first space, the contour of the arch of the aorta ; in the second space, that of the pulmonary artery below which is the left auricle ; in the third, fourth, fifth spaces the left ventricle. In Fig. 3 we have indicated the outline of the clavicles (cl), of the sternum (st), and of the ribs. The study of the radioscopic image of the heart in frontal position, is as follows. Contours. If one follows the contour of the median shadow of the thorax (Fig. 4), one observes at the left of the figure, starting from the right diaphragmatic dome, a curved line, D'D, which circumscribes the right auricle. Above point D the contour follows straight up as far as the sterno-clavicular articulation, thus giving the outline of the sternum ; but in the case of many patients, other- wise normal, the ascending aorta runs slightly over the sternum and the shadow presents a projecture, not strongly accentuated, following the line DA. If we pass to the right side of the figure, that is, to the left side of the patient, the contours of the median shadow present three semicircular salients or three superimposed arcs: the superior or aortic arc (A' A") due to the out- SHADOW OF HEART IN NORMAL STATE 21 line of the descending portion of the arch of the aorta ; the middle or pulmonary arc (A"G) due to the salient of the pulmonary artery, below which is seen another small salient which corresponds to the left auricle; finally the inferior arc (GG') made by the outline of the left ven- tricle from the base to the apex. This last is very near the left dome of the diaphragm. Fig. 4. OETHODIAGEAM OF THE HEAET AND THE LAEGE VESSELS IN FEONTAL POSITION Particularly interesting contours for the study of the normal or the pathological heart are found between letters DD' and GG'. The line DD' defines in the normal state the contour of the right auricle. However, it may happen that, in certain patients, during radioscopic examination, clear pulsations are perceptible in the neighborhood of point D'. These are systolic pulsations and describe a faint movement above the diaphragm. They are due to the right ventricle, which shows itself at this point. Particu- lar conditions are necessary in order that this phenome- non should occur. If the heart presents a vertical form, if it lies on the median line, if the apex is a little lowered and turned in, which results in a slight lifting and a greater salience of the right side of the heart, it is easily 22 THE HEART AND THE AORTA conceivable that the position of the right ventricle may show above the diaphragm. But this is exceptional in the normal state. It is observable, on the contrary, in the course of several pathological conditions and in the following chapter its interpretation will be made clear. The line GG' demarcates the whole length of the border of the left ventricle. It follows a convex course outward in its upper third, and then turns round the apex at the level of the left diaphragm. The point G, from which the line GG' starts, is particu- larly interesting to plot exactly, for it corresponds to the position of the left ventricle at the base of the heart. In fact, it is below the contour of the vessels, at the inter- section of the middle arc and the lower arc. In order to determine it exactly in practice, it is necessary to have recourse to the orthodiagraphic method which permits the study of the different movements of the organ. Indeed, if the pulsations are observed which animate the whole left side of the mediastinal shadow, it is seen that at each systole some pulsations move outward and others inward. The shadow of the heart undergoes a retraction movement, while the vascular shadow de- scribes at the same time a movement of expansion. Between these two centers of pulsation, a small zone re- mains motionless; it corresponds to the left auricular appendage, which caps the left auricle, whose contrac- tions are imperceptible. It is at the foot of this neutral zone, where the ventricular pulsations cease, that point G should be marked. This point is usually opposite point D, either at the same height or a little above it, in tracings taken in the recumbent position, or slightly below in trac- ings made in the vertical position. It is evident that if as a result of a pathological modification of certain car- diac cavities, this point is lowered or raised to an exag- gerated degree, we may infer that the position of the ventricle lies higher or lower. The line GG', conse- quently, will be diminished or increased in length, and SHADOW OF HEART IN NORMAL STATE 23 this evidence will furnish an element in estimating the ventricular volume. It will be seen further how impor- tant the determination is of point G in the study of pure mitral insufficiency. In the normal state the relation of the lengths of the lines GG' and DD' may be written in the following way : GG' > DD', and that means that the contour of the left side is more developed than its congener. The excess in favor of the first is from one to three centimeters. Finally, it is to be noted that point G' is situated lower than point D'. This is because the heart, resting on the diaphragm from the back forward and from right to left, slightly depresses with its apex the muscle on which it rests and which offers only a feeble resistance on account of the mobility of the organs that lie under it. The Apex of the Heart. The apex of the heart corre- sponds to the vicinity of the left diaphragmatic shadow, sometimes a little above, sometimes a little below, when the subject is in a state of apnoea or superficial respira- tion. During the movements of deep inspiration the apex is detached from the diaphragmatic shadow as well as the inferior contour of the heart (Fig. 5). This latter is then separated from the abdominal shadow by a clear band more or less broad. The transparency of this region is due to the thinness of the pericardial folds, which are inserted in the center of the diaphragm, and this brings out the clearness of the pulmonary tissues situated behind. The apex and the inferior contour of the heart are sometimes outlined even when the diaphragm is not mis- placed downward very much. When the gas bubble in the stomach is large enough, the cardiac shadow is sharply outlined in this clear gaseous zone. Measurements of the Shadow. When the contours of the heart have been traced by the orthodiagraphic method or fixed on a teleradiographic plate,, the evaluation of the surface thus obtained gives the real measure of the organ 24 THE HEART AND THE AORTA according to its plane of projection ; this can be expressed in two ways : (a) by the measure of the area of projection, or (b) by the length of its principal diameters. (a) Measurement of the area. Measurement of the heart area is made either by means of the Amsler plani- meter, or by means of a sheet of paper ruled in milli- meters on which one traces the figure and counts the number of square millimeters to which it corresponds. Fig. 5. IN DEEP INSPIRATION THE APEX AND THE INFEEIOE CONTOUR OF THE HEAET SEPARATE FROM THE DIAPHRAG- MATIC SHADOW However, the figure on which one works contains arbi- trary elements. It is only in the pathological condition when the shadow of the heart is very dense that one is in a position to mark on the tracing the lines DGr, corre- sponding to the base, and D'Gr', corresponding to the inferior contour. In the normal condition this is not the case, and the construction lines are simply interpre- tative. And so the calculation of the area can be only approximate. Moritz, however, has judged it exact enough to serve SHADOW OF HEART IN NORMAL STATE 25 as a basis for a number of estimates relative to the size of the cardiac area compared with the stature of the subject. 1 These are the results at which he arrived : Stature : 153 to 157 cm., area of the heart varies from 80 cm2 to 100 cm2 , average 98 em2 . 161 to 169 cm., area of the heart varies from 87 cm2 to 108 cm2 , average 102 cm2 . 171 to 178 cm., area of the heart varies from 92 em2 to 126 cm2 , average 109 cm2 . Bouchard and Balthazard, 2 examining 13 men and 36 women, found that the average of the surface of the heart in men was 89.5 cm2 , with variations from 78 cm2 to 104 cm2 ; in women 76 square centimeters, with variations from 60 to 96 square centimeters. Gruilleminot and Chiron 3 obtained an average of 79 em2 in young people (medical students) from 25 to 30 years old, with variations from 69 cm2 to 98 cm2 . Claytor and Merrill,* in studying the cardiac area com- paratively with height and weight, have shown that there is no regular relation between the first two values. On the contrary there is a very clear relation between the cardiac area and the weight. These authors show in the study of 37 men that for an increase in weight of 60 per cent the cardiac area increased 39 per cent ; this progres- sion began to decline when the weight was more than 65 kilos ; in women it is only 25 per cent for 60 per cent in- crease in weight. These findings are, moreover, in accord with those previously made by Dietlen and Groedel. (b) Measurement of diameters. Moritz traces on the cardiac shadow the four following diameters. iMoritz, Munch. Med. Woeh., 1912. 2 Bouchard et Balthazard, 1900. 3 Chiron, these de Paris, 1905. 4 Claytor and Merrill, The Amer. Jour, of the Med. Sciences, Oct., 1909. 26 THE HEART AND THE AORTA The longitudinal diameter (Langsdurchmesser) e f (Fig. 6), extending from the base of the heart to the apex. The transverse diameter (Querdurchmesser) g h, per- pendicular to the preceding and following approximately the right auriculo-ventricular groove. The two other diameters, distance from the middle to the right (median-ab stand rechts) a b, and distance from the middle to the left (median-ab stand links) c d, are established in the following manner : After having traced a vertical line passing through the middle of the sternum on the heart shadow a point of this line is joined hori- zontally to the most salient point of the right auricle contour. In this manner a b is determined whose length indicates the development of the right side of the heart. By uniting a point of the median line with the most salient opposite point of the left ventricular contour, the diam- eter c d is obtained, which indicates the development of the left side of the heart, Fig. 6. DIAMETEES OF THE HEAET ACCOEDING TO MOEITZ e f, longitudinal diameter ; g h, transverse diameter ; a t, diameter from the middle to the right ; c d, diameter from the middle to the left. The measure of these four diameters has enabled the author to draw up the following table according to the height of the patients : SHADOW OF HEART IN NORMAL STATE 27 MEN OF 17 TO 56 YEARS Orthodiagraphy Projection in Horizontal Recumbency Diameter Diameter from middle from in iddle Longitu- dinal Transverse Height- to right to left diameter diameter m cm. in em. m cm. in cm. III rill. 153-157 Average Maximum 4.4 4.8 7.9 8.0 13.0 13.5 10.2 10.5 Minimum 4.0 7.8 11.5 10.0 161-169 Average Maximum 4.4 5.0 8.3 9.3 13.4 14.5 10.5 10.8 Minimum 3.5 7.5 12.8 9.0 Average 4.6 9.8 14.0 10.3 171-178 Maximum 5.9 15.3 15.3 11.3 Minimum 3.0 12.5 12.5 9.0 Claytor and Merrill have proceeded otherwise. They estimated that to measure two diameters was sufficient; a longitudinal diameter starting from the base of the heart, at the intersection of the cardiac curve and of the Fig. 7. DIAMETERS OF THE HEART ACCORDING TO CLAYTOR AND MERRILL LD, diameter longitudinal ; MR + ML = transverse diameter. 28 THE HEART AND THE AORTA origin of the blood-vessels, and extending to the apex, and a transverse diameter which represents the total of the two half -diameters (middle to left and middle to right according to Moritz — see Fig. 7). Finally they took as the basis of comparison not the height but the weight of the patients : CLAYTOE AND MEEEILL Table I. Orthodiagrams of Men in Vertical Position Weight in pounds Transverse diameter in cm. MB-\- ML Longitudinal diameter)* in cm. 109-117 Minimum Average Maximum 10.7 10.9 11.3 11.8 12.6 13.5 118-126 Minimum Average Maximum 11.0 11.8 12.5 12.0 13.2 14.0 127-135 Minimum Average Maximum 11.0 11.9 13.1 12.0 13.4 14.5 136-144 Minimum Average Maximum 11.5 12.3 13.0 12.5 13.5 15.0 145-162 Minimum Average Maximum 12.0 12.4 13.8 14.0 14.6 15.3 163-181 Minimum Average Maximum 11.0 12.9 13.4 14.0 14.7 15.8 ! SHADOW OF HEART IN NORMAL STATE 29 CLAYTOR AND MERRILL Table II. Orthodiagrams of Women in Vertical Position Weitjht in pounds Transit rse (Humclrr in cm. Longitudinal diameter in cm. 91-99 Minimum Average Maximum 9.9 10. L> 10.5 12.0 12.1 12.3 100-108 Minimum Average Maximum 10.0 10.7 11. 1 11.5 11.9 12.4 109-117 Minimum Average Maximum 10.2 11.0 12.2 10.5 12.2 13^8 118-126 Minimum Average Maximum 9.6 11.2 12.6 11.2 12.4 13.3 127-135 Minimum Average Maximum 10.0 11.1 11.8 12.2 12.7 13.2 136-144 Minimum Average Maximum 10.9 11.6 12.8 12.3 12.9 14.2 145-159 Minimum Average Maximum 10.6 11.7 12.6 11.8 12.6 13.2 The process which we have adopted and usually em- ploy differs little from the preceding. We thought it necessary to reject the method of Moritz, because it seemed to us to be based on an erroneous conception. Moritz established the measurement of the heart by con- sidering it as a perfect ovoid, the figure thus obtained believed to be geometric. This is not true to fact. We thought it more logical to adhere to the method of tracing 30 THE HEART AND THE AORTA only diameters that terminate in real salients in the con- tour of the heart. It is sufficient to know two diameters only in order to have an exact idea of the volume of the organ. Now, these two diameters to be determined are the longitudinal and the transverse or horizontal. The diameter of the height or the longitudinal diame- ter begins from the intersection of the right contour of the heart and of the origin of the blood-vessels and ends at the apex (line DG of Fig. 8). A3 Fig. 8. DIAMETERS OF THE HEART (VAQUEZ AND BORDET) d I, longitudinal diameter ; h -\- h', horizontal diameter. The transverse or horizontal diameter is determined a little differently. It ought to represent the greatest dis- tance which separates the right border from the left border, but it is exceptional that the greatest develop- ment of each of the two sides of the heart should corre- spond to a horizontal line ; most often it is a more or less oblique line uniting the two extreme points. Now it is interesting to have the horizontal direction of this line preserved. We arrive at this by bringing two lines start- ing from the right and from the left side of the heart to the point where each of them is most distant from the SHADOW OF HEART IN NORMAL STATE 31 sternum and ending on the medio-sternal line. By adding these two half-diameters, we have the horizontal line we seek. In the recumbent position, as we have said, the two diameters, longitudinal and horizontal, are perceptibly equal. Sometimes, however, the first is greater than the second by from 5 mm. to about 1 cm. ; in exceptional cases it is less by several millimeters. In the standing position, the longitudinal position may be increased a little, which is, however, very rare; on the contrary, the horizontal diameter always diminishes. It then becomes inferior to the other by from 5 mm. to 1 cm. The results which we have obtained in the course of many measurements are fairly comparable to those of Claytor and Merrill. Like these authors, we have seen that the variations in the volume of the heart were pro- portionate to the weight rather than to the height of the it patient. But it should be understood that the weight here expresses the physical and muscular development and not excess of fatty tissue. It is interesting to note that this is the conclusion reached by Polain and Vaquez, from measurements taken after percussing the heart area in young patients. A third diameter of secondary value (Fig. 8a) is ob- tained by joining the base of the left ventricle (or point G) with the right cardio-diaphragmatic angle (or point D'). This is designated as diameter D'G. Its length indicates the distance which separates the point of origin of the right ventricular outline from the point of origin of the left ventricular outline, in other words, by develop- ment in size of the base of the ventricles. Van Zwaluwen- burg and Warren 5 and Otten 6 have drawn attention to the practical interest of this diameter. It is shown on the s Van Zwaluwenburg and Warren, Archives of internal medicine, f ol. 1911. 6 Otten, Die Bedeutung des OrthodiagrapJiies fur die ErTcennung der ieginnenden Herzweiterung, Deuts. Arch. f. Kl. Medi., Febr., 1912. 32 THE HEART AND THE AORTA figure, either by connecting D' and Gr by a straight line or by dropping from D' and Gr two perpendicular lines to the longitudinal diameter. In the latter case, the sum of the two half-diameters thus traced gives the diameter D'Gr. The evaluation of this measurement is sometimes useful in translating into figures the hypertrophy of the ven- tricles at their base. It is evident that if, for example, the walls of the left ventricle increase in thickness, the point G' will be pushed to the left, and consequently the line DGr' will be increased in proportion. The same fact arises if, on the contrary, it is the point D' which is thrown toward the right as a result of dilatation or of hypertrophy of the right ventricle. In a series of exami- nations of the same patient, this diameter may be the only one to vary, while the other two are but little modi- fied, which gives added means of studying the changes in the volume of the heart (see below the figures in Chapter V). / D y /"" / s^"'~ G ^ Fig. 8a. DIAMETEES OF THE HEART.* DG', longitudinal diameter; D'G, third diameter; O, point of intersection. * This figure was omitted from the French text which the translators used, a text printed in the stress of war. It appeared among the plates received from France after the English version was in type. Hence the irregularity in the numbering. — Tr. SHADOW OF HEART IN NORMAL STATE 33 The point of intersection of the diameter D'G and of the longitudinal diameter (or point 0), the position of which varies according to the degree of inclination of these two diameters, has led Van Zwaluwenburg and Warren to study the relation of the two distances DO and OG'. This relation is approximately proportionate to the relation of the auricular area to the ventricular area. The ratio DO : OG' would represent the relation of the areas of the auricles and the ventricles. The figure obtained, or index, would vary in normal subjects between 0.534 and 0.704. It would increase when the area of the auricles increases and it would diminish when the area of the ventricles predominates. These authors have found, indeed, in mitral stenosis the index 1000, and in a. case of interstitial nephritis the index 280. Mobility of the heart. To test the mobility of the heart, the patient, placed behind the radioscopic screen, is made to bend the body from right to left of the vertical axis. "When the inclination is toward the left, the heart de- Fig. 9. LATEEAL INCLINATION OF THE BODY TO THE LEFT The black lines are the outlines of the heart in the vertical position (drawn on the skin). The dotted lines are the outline in left lateral inclination. 34 THE HEART AND THE AORTA viates from the median line by about one to two centi- meters, which is easy to determine if one is careful to mark on the skin of the patient the two successive tracings of the contour of the apex in these different positions (Fig. 9). The position of the heart varies equally when the pa- tient passes from the vertical position to the horizontal recumbent (Fig. 10). In the vertical position the heart Fig. 10. Black lines, projection in recumbent position. Dotted lines, standing position. pulls on the insertions of the base and on the blood- vessels, it rests more on the diaphragmatic dome, and in consequence is lowered as a whole. In the recumbent position, the heart seems to spread, compressed as it is above and behind. Displacements due to respiration. During deep inspira- tion the heart follows the movements of the diaphragm and is lowered. At the same time, the organ changes a little in form and its diameters vary slightly; the longi- tudinal diameter increases and the horizontal diameter diminishes ; the result is an elongation and a narrowing of the shadow of the heart. SHADOW OF HEART IN NORMAL STATE 35 During deep expiration, the contrary is observed. Under the pressure of the diaphragm, the heart is raised and spreads; both diameters increase, the horizontal more than the longitudinal. Here, for example, are the figures noted in the case of a normal subject thirty years old. Average Forced Forced respiration inspiration expiration Longitudinal diam. in cm. 11.5 11.8 13.5 Horizontal diam. in cm. 11.5 11.2 15.1 The preceding considerations bear only on forced movements of inspiration and expiration. If the respira- tion is quiet, the volume of the heart, as Groedel 7 has remarked, does not change notably. Not less important are the modifications which the respiration causes in the relations of the heart with the diaphragm : (a) In recumbency, forced inspiration lowers the heart and the diaphragm much below their average position (or as in quiet inspiration). The descending movement of the diaphragm extends to a distance of 3 to 5 centimeters. During forced expiration, the heart and the diaphragm are raised only very little above their average position in quiet expiration. (See Fig. 11.) (b) In the vertical position it is, on the contrary, forced expiration which causes the most considerable movement of the heart and of the diaphragmatic contour, but in this case it is the height, whereas forced inspiration lowers to only a moderate degree the heart and the diaphragm below their average position (Fig. 12). 7 F. M. Groedel, Mudes radio-cinematographiques relatives a I'influence de la respiration normale sur la grandeur et la position du ceeur. (Zeits. f. Klin. Med. Band LXXII, pp. 292, 310.) 36 THE HEART AND THE AORTA When the patient is standing, the heart, suspended in the pericardial sac, tends to weigh npon the diaphragm and drop nnder the influence of its own weight; forced inspiration adds very little to this movement. It is quite otherwise in recumbency. The heart is then placed higher. But the insertions of the base hold it only lightly, yielding very easily to the tension which the diaphragm makes on it during deep inspiration. Fig. 11. TRACINGS MADE IN RECUMBENCY The black lines, quiet respiration. Dotted lines, forced expiration. Dot- and-dash lines, forced inspiration. Heart pulsation. The radiological study of the pulsa- tion of the heart has not advanced much yet, not because it lacks interest, but because of difficulties of a technical nature. Radioscopy gives only a glimpse of the heart pulsations, but this little is of sufficient value in different cardiopathies to attract attention. It will be necessary in order to record the constant movement of the different parts of the heart that cine- mato-radiography should become a method more con- stantly used. It alone will be able to record the heart changes, that is, the succession, the amplitude, even the form of the contraction of the different parts of the heart. We shall perhaps be able then to easily recognize aortic SHADOW OF HEART IN NORMAL STATE 37 insufficiency by simply observing the ample systolic re- traction of the ventricular shadow; cardiac insufficiency by the lagging undulation of the left side of the heart; tachycardiac attack by the sudden explosion of the pulsa- tions; mitral stricture by the intensity of the auricular contraction, etc. Fig. 12. TEACINGS TAKEN IN THE VERTICAL POSITION Black lines, quiet respiration. Dotted lines, forced expiration. Dot-and- dash lines, forced inspiration. A. W. Crane, 8 starting from the work of Gocht and Rosenthal, has succeeded in making radiographic trac- ings of the heart pulsation. He proceeds in the following manner: he covers the precordial region with a sheet of lead, in which he makes narrow horizontal openings, in such a way that only certain parts of the cardiac outline are projected on the sensitive plate. These openings may be multiplied over the ventricular, auricular, aortic and other contours. A radiographic film is slipped in front of these openings, with the rapidity requisite, during ex- posure of the thorax to the x-rays from back to front. Tracings are thus obtained comparable to sphygmograms and electro-cardiograms. The strength or the weakness 8 A. W. Crane, Roentgenology of the Heart. (American Roentgen Ray Society, annual meeting, Sept. 6, 1916.) 38 THE HEART AND THE AORTA of the pulsations of the different heart cavities is inter- preted by the variations in the amplitude of the curves. These readings furnish valuable elements in diagnosis. B. IMAGE OF THE HEAET IN OBLIQUE POSITIONS Right posterior oblique position. In this position the patient rests his right shoulder against the screen with his back to the observer. His left shoulder is, conse- quently, the farthest from the screen and its distance is maximum when the line which passes through the two shoulders (the bi-scapular axis) forms a right angle with the plane of the screen. As the left shoulder ap- proaches the screen, the angle of obliquity of the body diminishes. When in the right oblique posterior position the pa- tient is made to pivot round a fixed point which is the right shoulder, in such a way as to make the left shoulder gradually more distant, the angle of obliquity of the body passes successively from 20 to 25, 30, 35 degrees, etc. During this movement, the shadow of the thoracic organs is necessarily modified according to the incidence of the beam of rays. The shadow of the vertebral column which was in the middle of the screen is displaced toward the left, that of the left ventricle, which projected markedly to the left, is transferred toward the right. These two shadows, traveling in opposite directions, finally cross, then the apex of the heart approaches the vertebral column and finally disappears behind its shadow. In calculating, then, the angle formed by the bi-scapu- lary axis of the patient with the plane of the screen, we have the angle at which the apex disappears. This nota- tion, made only during orthodiascopic examination, has unquestionable practical value; for the angle at which the apex of the heart disappears in this position is an indication of the development of the organ. To know the degree of it is added evidence in estimating the volume of the heart. In normal subjects this angle is generally SHADOW OF HEART IN NORMAL STATE 39 from 25 to 30 degrees (Fig. 13) ; if it is 40, 45, 50 degrees, it can be concluded that the ventricular cavities are increased in volume. Fig. 13. ORTHODIAGRAM OF A NORMAL HEART IN THE RIGHT POSTERIOR OBLIQUE POSITION AT 30 DEGREES The apex of the heart disappears behind the shadow of the vertebral column. To determine precisely and rapidly the degree of ob- liquity of the body, Boulitte has constructed an angle indicator or goniometer which is of practical value. This apparatus consists of a horizontal wood rule to which are fastened two perpendicular pieces of wood, the distance between which can be regulated by a series of grooves and which allows them to be fixed at any point. In the posterior position the patient turns his back to the rule and the two perpendicular pieces are placed in the center of the scapular regions. In the anterior position, these two pieces hold the patient, either as we have just ex- plained, or as is preferable in oblique angles of less than 50 degrees, on the anterior surface of the body, at the external third of the clavicle. The bi-scapular axis of the body then remains parallel to the direction of the rule. The rule pivots on one end which is fastened to the frame of the screen, which, for this examination, should have a fixed position. The joint end of the rule has a divided dial. Since the apparatus is fixed to the body all that is necessary for determining the angle of obliq- 40 THE HEART AND THE AORTA uity is to lower the rule by means of a screw and to read the figure indicated on the dial. (See Fig. 14.) Fig. 14. GONIOMETEE OF VAQUEZ AND BOKDET If we continue the movement just described until the patient is in the right posterior oblique position, at an angle of 50 degrees, an image is obtained of the mediasti- nal organs represented by Fig. 16. In order to under- stand it, it is necessary in the first place to know to what part of the organ the outline of the shadow corresponds. An examination of the subjoined diagram (Fig. 15) will show it. It is evident that the normal ray n n' enters the left wall of the thorax and comes out at the right wall ; tangent to SHADOW OF HEART IN NORMAL STATE 41 the heart on the side of the vertebral column, it reaches the left auricle, the walls of which form the most salient part of the heart on a level with the eighth cervical verte- bra. By picturing the anatomical aspect in elevation, we deduce that it is the ventricular surface only which ought to develop below the auricle and if the ray passes a little lower it is then the shadow of the left ventricle which is projected on the screen. Fig. 15. DIAGEAMMATIC ANATOMICAL CEOSS-SECTION (AFTEE LUSCHKA). EIGHT POSTEEIOE OBLIQUE POSITION T, Boentgen tube; n n', course of the normal ray; E E, screen; VG, left ventricle; VD, right ventricle; OG, left auricle; OD, right auricle. By turning to the orthodiagraphic tracing (Fig. 16, from left to right) and studying the details, the following is found: P G, a clear zone, the left lung ; c, the shadow of the vertebral column; e, the retro-cardiac clear space; OG (below the outline of the aorta), the contour of the left 42 THE HEART AND THE AORTA auricle, above the outline of the left ventricle, VG; VD, the outline of the right ventricle; finally, PD, the clear field of the right lung. The most interesting part of this figure is the left auricle, OGr. This is outlined sharply in the position which is very favorable for the examination of this cav- ity, which occupies here the postero-superior two-thirds of the cardiac shadow. Fig. 16 Fig. 17 Fig. 16. OETHODIAGEAM TAKEN IN EIGHT POSTEEIOE OBLIQUE POSITION AT 50 DEGEEES Fig. 17. PEOJECTION IN EIGHT POSTEEIOE OBLIQUE POSITION OF A SOUND AND OF A TUBE IN THE CESOPHAGUS; THE TUBE EESTS ON THE LEVEL WITH THE EIGHT AUEICLE To make sure of it, we objectified the auricle pulsations by means of a tube introduced into the oesophagus and connected with a recording stylus. The tube was filled with bismuth. Now, the patient being in front of the screen, it was seen that the visible pulsations of the auricle were produced just at the moment when the tube was in the region indicated above (Fig. 17). SHADOW OF HEART IN NORMAL STATE 43 The distance which separates the outline of the heart from the shadow of the vertebral column diminishes as the angle of obliquity diminishes ; very narrow at 40 de- grees, it is much larger at 50 degrees. This latter inci- dence is the most favorable for the study of the heart walls outlined in the retro-cardiac clear space, especially for the study of the left auricle. However, in the case of patients whose thorax is underdeveloped or narrow, the angle of obliquity should be as great as 60 degrees. When the volume of the left auricle is increased, the salience of its shadow is accentuated and its contour approaches the vertebral column, the reasons for which have just been indicated. Its development is known only if it is known at what angle the patient was placed. Left posterior oblique position. In this position at an angle of 50 degrees the normal ray penetrates the right antero-lateral thoracic region and comes out at the left Fig. 18. ANATOMICAL CKOSS-SECTION IN LEFT POSTEEIOE OBLIQUE POSITION 44 THE HEART AND THE AORTA posterior thoracic region; at the oesophageal zone level, it is tangent to the posterior wall of the two auricles, especially the right auricle. The left auricle and the left ventricle are nearest the observer and the major axis of the heart nearly parallel to the plane of the screen (Fig. 18). The apex of the heart on the left ought then to be seen and a projection obtained extending to the external wall. This is exactly what is shown on the orthodiagram (Fig. 19). On the other hand, in this latter figure, it is seen that the contour of the heart outlines in the clear space the auricles, notably the right, and toward the diaphragm the lower part of the left ventricle. At the right of the figure the tracing outlines the auricles above, Fig. 19. ORTHODIAGRAM TAKEN IN THE LEFT POSTERIOR OBLIQUE POSITION AT 50 DEGREES OD, right auricle; OG, left auricle; VG, left ventricle; p, apex of the heart. the left ventricle below; during radioscopic examination, the pulsations of the apex at p are clearly seen. Right anterior oblique position. This position is in a way the inverse of the preceding. The normal ray enters at the left posterior thoracic wall and comes out through SHADOW OF HEART IN NORMAL STATE 45 the right antero-lateral thoracic region (Fig. 20) ; the right auricle and the right ventricle are nearer the observer. Fig. 20. ANATOMICAL CROSS-SECTION IN THE RIGHT ANTERIOR OBLIQUE POSITION In Fig. 21, the left contour, the outline of which is seen in the retro-cardiac clear space, does not show, at 50 de- grees at least, the right but the left auricle. The posterior wall of this cavity is found to be nearest the dorsal wall of the body. If the bi-scapular axis describes an angle greater than 50 degrees, the left auricle shows more; if, on the contrary, the angle is less than 50 degrees, it is the contour of the right auricle which appears. Below the auricular shadow, in the clear space, the right ventricle is outlined. At the right of the figure the contour of the organ out- lines the right auricle above; below and all along the diaphragm, the right ventricle. Left anterior oblique position. The normal ray enters 46 THE HEART AND THE AORTA Fig. 21. OETHODIAGEAM TAKEN IN THE EIGHT ANTEEIOE OBLIQUE POSITION AT 50 DEGEEES OG, left auricle; OD, right auricle; VD, right ventricle. n, T E Fig. 22. ANATOMICAL CEOSS-SECTION IN LEFT ANTEEIOE OBLIQUE POSITION SHADOW OF HEART IN NORMAL STATE 47 the right posterior thoracic wall and comes out at the left antero-lateral costal wall (Fig. 22). At 50 degrees the orthodiagraph^ tracing is obtained as seen in Fig. 23. The outline of the heart in the clear space shows the left auricle in the upper part and the left ventricle in the lower part. At the level of the diaphragm, the contour curves sharply to the left downward. The apex of the heart lies at p and is near the observer. In short, in this position, the major axis of the heart follows, from back to front, the same direction as the normal ray. At the right the line of the contour delimits the right auricle above and the right ventricle below. Tig. 23. ORTHODIAGRAM TAKEN IN THE LEFT ANTEEIOR OBLIQUE POSITION AT 50 DEGREES OD, right auricle; OG, left auricle; VD, left ventricle; p, apex of the heart. Lateral positions. The lateral positions, right and left, are obtained by placing the patient in such a way that with either the right shoulder or the left shoulder in con- tact with the screen, the bi-scapular axis forms an angle of 90 degrees. The cardiac shadow is separated behind from the verte- 48 THE HEART AND THE AORTA bral column by a narrow, clear band; this is the retro- cardiac clear space. In front it is separated from the sternal outline by another clear band (Figs. 24 and 25) which is the retro-sternal clear space. This space may be much reduced or completely dis- appear at the lower part when the heart is enlarged in volume or when adhesions fix the mediastinum to the sternum. In the right lateral position there is a good view of the proximal and terminal portions of the arch ; in the left lateral, the superimposed dilatations of the pulmonary and aortic arches are seen. In these positions it is convenient to observe the outline of the thorax. If during inspiration and during expira- tion the sterno-abdominal contours are successively drawn, two lines are obtained perceptibly parallel for most of their length. They meet only at the level of the umbilical region (Fig 26) . Wenckebach has shown that in the case of extensive pericardial adhesions, the amplitude and form of these respiratory outlines are more or less modified. Later reference will be made to this question of cardiac symphysis. Fig. 24. EIGHT LATEEAL POSITION A, ascending aorta. SHADOW OF HEART IN NORMAL STATE 49 Fig. 25. LEFT LATEEAL POSITION A, aorta; P, pulmonary area. ; Fig. 26. EESPIBATOEY OUTLINE (OETHODIAGEAPHIC) OF A NOEMAL SUBJECT . Black line, forced expiration; dotted line, deep inspiration. 50 THE HEART AND THE AORTA III. VARIATIONS OF THE PHYSIOLOGICAL FORM OF THE HEART In the preceding description we have taken as a type the form of the heart most common among normal adults of average weight and height. It corresponds to what investigators call the oblique type. But, even in the physiological state, the form of the heart can vary a little. Two other variations have also been described, the hori- zontal and the vertical. The horizontal heart rests more on the diaphragm than the oblique. The vertical heart is narrower and more elongated (Fig. 27). These particular variations of the heart result in slight modifications in diameter, which when interpreting the tracings must be taken into account. Most often it is necessary to ascribe these different forms of the heart to a special conformation of the thorax. The horizontal type of heart is met with especially in subjects of small stature and short thorax, and the verti- cal type in individuals whose thorax is narrow and long. The vertical or small heart has been wrongly consid- ered a pathological variation and thought to be a sign of pulmonary tuberculosis. It is frequently found in this Fig. 27. VEETICAL HEART SHADOW OF HEART IN NORMAL STATE 51 disease, but that is not due to tuberculosis, but to the fact that the tuberculous usually have a narrow elongated thorax. The same form of heart can be found among patients free from tuberculosis, whose thorax has caused the same condition. There should be mentioned among the physiological forms of heart displacement, that form which has been given the name of dropping heart (Tropfherz, cor pendu- lum, cuore a goccia, cceur suspendu). It is well under- stood that this displacement is quite different from that of cardioptosis, which constitutes a pathological varia- tion. Cor pendulum differs from it in that the heart is not lowered as a whole, but is simply held in suspension by its attachments to the vessels of the base and to the ligaments of the neck, the heart apex resting a slight distance from the diaphragm, which drops below it, leav- ing a clear and sometimes rather broad band between the heart and diaphragm. According to Wenckebach, this abnormal configura- tion results from the lowering of the insertion of the diaphragm coincident with an elongation of the thorax; he thinks, moreover, that it is accompanied by rhythmic lowering movements of the larynx, resulting from the pull which the heart exerts on the muscles of the larynx during systole. This idea, if it is correct, would take away much of the value of the rhythmic lowering of the larynx, or Oliver's sign, which is generally considered a sign of aortic aneurism. Two other peculiarities may be mentioned, which might wrongly be considered of a pathological nature, but which are, however, compatible with the normal. The first consists of a shadow on the diaphragm, at the level of the attachments of the pericardium, which in- creases during deep inspiration and then takes on the aspect of a triangle, the base of which rests on the dia- phragm itself (Fig. 28). This image appears at first different from that which 52 THE HEART AND THE AORTA is usually found. It is admitted that the fibrous peri- cardial sac, which is inserted over the dome of the dia- phragm and adheres closely to the phrenic center, gives only an inappreciable shadow above the left portion of the diaphragm. Besides, this shadow disappears entirely in forced inspiration, the heart being then separated from .the diaphragm by a clear space which corresponds to the base of the left lung and the lower edge of which is out- lined for the greater part of its length against the clear- ness of the pulmonary tissue. s^\ r\ Fig. 28. INSERTION OF THE PERICARDIUM VISIBLE DURING DEEP INSPIRATION ON THE LEVEL OF THE CARDIO- DIAPHRAGMATIC SINUS However, it is not uncommon that instead of this posi- tion the image represented in Fig. 28 is obtained, in physiological hearts, and in patients indiscriminately fat or thin. It is due, very likely, to a certain thickening of the pericardial folds. Images produced by the presence of shadows due to pathological adhesions can be distin- guished by the fact that one may there recognize the inferior contour of the heart apex, always darker than the shadow of the pericardial-diaphragmatic tissues, and SHADOW OF HEART IN NORMAL STATE 53 this is ordinarily impossible when adhesions exist; on the other hand, the movements of the heart keep their normal amplitude during respiratory displacements and the expansion of the diaphragm. The other condition that might equally well lead to a false conclusion as to the presence of adhesions of the pericardium is found in certain obese patients, whose left cardio-diaphragmatic sinus, instead of being clear, is filled by a shadow, less heavy, it is true, than that usually cast by the heart. This shadow may be due exclusively to the existence of a fatty cushion surrounding the apex of the heart. Schwartz 9 has proved this by his studies on cadavers. IV. PARTICULAR STUDIES TO DETERMINE VENTRICULAR DEVELOPMENT IN DEPTH The observation of the heart in the right posterior oblique position allows the determination at what angle the apex disappears behind the shadow of the vertebral column. This angle determines the function of the left cardiac border outline. The goniometer shows that it is small, 25 degrees for example, in the case of a vertical heart, and a little greater, about 30 degrees, in the case of a horizontal heart. Our procedure has been subjected to some modifica- tion by several investigators. Josue, Delherm and La- querriere 10 have used, instead of the goniometer, a revolv- ing platform on which the patient is placed, and which gives the degree of obliquity of the body. Beaujard 11 calculates not the angle at which the apex disappears, but another sagitto-spino-ventriculo-tangential, or ventricu- lar volumetric angle which is equal to it. 9 G. Schwartz, Sur une caracteristique radioscopique du cosur des ooeses et sa raison d'etre anatomique. (Wiener Klin. Woch., 1910, no. 51, p. 1850.) i° Josue, Delherm and Laquerriere, Bulletin de la Societe de Radiologie, 1914. 11 Beaujard, Bulletin de la Reunion Medicale de la 7e Region, 15 sept., 1917. 54 THE HEART AND THE AORTA In a general way these methods confirm the results at which we have arrived; but they necessitate apparatus more or less complicated. We have found more simple another procedure which gives, not the angle at which the apex disappears in the right posterior oblique position, but a practical and rapid estimate, in depth, of the ven- tricular development. The calculation of the angle of disappearance already gives us this information, for it is an action, not only of the outward push of the apex, but also of ventricular enlargement behind. To this latter factor preponderant importance is attributed. We know that the left ventricle forms very little of the anterior surface of the heart and that its position is, for the most part, deep and mediastinal. The result is, then, that to diagnose incipient ventricular hypertrophy, it is neces- sary to be able to determine the degree of enlargement of the left ventricle in depth. , Our procedure adopts the radioscopic method in plot- ting the depth of foreign bodies. It is based for the most part on the relation of like triangles. The principal out- lines are these : In Fig. 29, let be the projectile to locate ; E, the radio- scopic screen; A, the tube, which is 60 centimeters from the screen. In position A, the tube gives a normal ray which passes through the foreign body 0, the image of which falls at C. This first projection is marked with a crayon on the glass of the screen. The tube is moved from A to A', a known distance, 10 centimeters. The beam of rays reaching projects the image at C. This is marked on the glass, C. It is easy to calculate by means of a millimetric rule the distance CC which sepa- rates the two crayon marks. On the other hand, AC and AA' are known. These three elements allow the graphic construction or the mathematical calculation to be made, which, given the two like triangles AOA', COC, gives the value OC, that is to say, the distance of the foreign body from the screen. SHADOW OF HEART IN NORMAL STATE 55 A' A Fig. 29. FIGUBE EEPEESENTING THE METHOD OF DEVIATING THE TUBE IN OEDEE TO LOCALIZE FOEEIGN BODIES E, screen; AA', two positions of the tube; O, projectile; CC, projections of the foreign body. By repeating the same method, having for the object the apex of the heart of a normal subject, and not a foreign body, and by bringing the ray AN tangent to it (Fig. 30, black lines), a projection is obtained of the apex that is not deformed. Mark with a crayon on the screen point N, which coincides with the outer edge of the shadow; then move the tube 10 centimeters toward the left of the operator. The image of the apex is seen to have become deformed and displaced toward the right. Mark a second point (N') to fix the amplitude of the dis- placement. A millimetric rule allows of its calculation. A case of hypertrophy of the left ventricle is presented here as an example (Fig. 30, contours and lines dotted). The enlargement in volume has only a bearing on the mediastinal contour of the left ventricle. The apex is not pushed out, it occupies the same lateral position as in the physiological condition (black lines). The normal ray, 56 THE HEART AND THE AORTA tangent to the apex of the heart, unites in the two cases. But when the tube is moved the oblique ray meets the con- tour of the left ventricle sooner than in a normal organ, and it projects the outline of it, not at N', but at G', much farther from N than from N'. The deviation is consider- able. ' It shows, obviously, an increase in volume of the left ventricle in depth. A A' A A Fig. 30 N N'DD Fig. 31 Fig. 30. DIAGRAM OF THE METHOD FOR FINDING THE INDEX OF DEPTH IN CASE OF HYPERTROPHY OF THE LEFT VENTRICLE AA', positions of the tube; NN', GG', projections of the normal ray and of the oblique ray. Fig. 31. SAME METHOD IN CASE OF ENLARGEMENT OF THE RIGHT VENTRICLE AA', positions of the tube; NN', DD', projections of the normal ray and of the oblique. SHADOW OF HEART IN NORMAL STATE 57 It will be noted on the figure that it is not the depth of the apex which this method reveals, but the maximum of salience of the posterior contour of the heart, situated behind the apex and in the path of the oblique ray. Greater depth may be present outside of it. The process then does not give the antero-posterior diameter of the heart, but valuable indications as to a point on the pos- terior surface of the organ. When the right ventricle alone is increased in volume, the result of the tube manipulation gives the following (Fig. 31, contours and lines black and dotted) : The normal ray ends at D, the oblique ray at D'. The deviation is a little greater than in the case of a physio- logical heart, but less considerable than in the case of an hypertrophied left ventricle. The importance of the pro- jecture of the apex does not influence the oblique ray. It is the depth of the apex that determines the deviation DD'; so in the actual case, its maximum of posterior salience is hardly more accentuated than in a normal case. The principal development of the right ventricle is ante- rior, and consequently is out of the course of the oblique ray. In practice this fact can be verified equally well by the calculation of the angle of disappearance of the apex in the right posterior oblique. Beaujard and Caillods have pointed it out. In order that the index of depth be raised, in cases of increase in volume of the right ventricle, it is necessary that the right ventricle press the left ventricle down or that the latter increase concurrently in volume. Definite information on the enlargement of the right ventricle should not be expected from this procedure. The ordinary signs of the enlargement of this cavity are sufficient. On the other hand, the method of moving the tube on the scale becomes extremely important when it is a question of determining in depth the development of the left heart. When there exists no other radioscopic 58 THE HEART AND THE AORTA indication, incipient hypertrophy of the posterior wall of the left ventricle may be recognized by it. The technic is simple : the patient is placed behind the fixed screen, 60 centimeters away from the anticathode. The patient may be in the prone or upright position. The vertical position is preferred, as the body is made im- movable by the contact of the anterior surface of the thorax with the screen. The method is essentially this: (1) center the tube on the apical region and indicate on the glass with crayon the extreme outline; (2) place on the screen a rule fur- nished with two points 10 centimeters apart. The scale on the right coincides with the first crayon mark and with the cardiac outline; (3) move the tube to the left of the observer until the normal ray passes through the second point on the rule; (4) open the diaphragm wide, raise the rule and mark a crayon point opposite the first, on the new outline of the apical area; (5) count the number of millimeters that separate the two crayon marks. The figure thus obtained shows the development of the heart in depth. All the points of the cardiac outline left and right can be investigated in the same way. In normal subjects the figure varies at the apex from 7 to 14 millimeters. It is generally about 10. It has the same value — sometimes 1 or 2 millimeters more — on the left side toward the base. At the apex and at the base it may be raised to 18, 20, 25, and 30 millimeters in the course of different cardiac affections. V. SUMMARY AND CONCLUSIONS: RULES TO FOLLOW IN RADIOLOGICAL EXAMINATION OF THE HEART The details of the radiological examination of the heart being known, the technic is as follows : 1. The first step is the radioscopic examination of the SHADOW OF HEART IN NORMAL STATE 59 heart as a whole. This examination, under the fluoro- scope, will give a general view of the heart, its form as well as its relations to the thoracic cavity contents : lungs, pleurae, pericardium and posterior mediastinum. The patient will be in the vertical position and will in turn present front, back and oblique positions to the screen; the latter positions will show the degree of transparency of the retro-cardiac space. 2. The next step is to take a radiogram. According to the apparatus at one's disposal, this will be an orthodia- gram or a long-distance radiogram, or better, both in suc- cession. These are the first steps in studying the heart. Its volume is also determined by fixing the contour of the real projection of the heart shadow. The patient will be in the frontal position, upright or prone as the case may be, but care should be taken to have him perfectly immovable and held in a plane parallel to that of the screen or of the plate. On the radiogram thus obtained the diameters of the heart can be established, and an examination made of the development of the right and left contours, their rela- tions, the position of the apex, its form and its distance from the left contour of the thoracic cavity. 3. The next step is to determine some points of detail. For this the orthodiagraphic method is applied, which alone can give special information concerning: (a) The position of point G. (b) The index of the development of the heart and particularly of the left ventricle in depth. (c) The amplitude of the respiratory displacements of the heart and the diaphragm. (d) The degree of mobility of the apex of the heart. (e) The development of the inferior contour of the heart observed during deep inspiration. (f) The nature of the pulsations which animate the contours of the heart. 4. The final step is the examination of the heart in 60 THE HEART AND THE AORTA oblique positions. The patient is placed successively in all the oblique positions described, so that a more pre- cise analysis may be made of the various modifications of form already studied, and especially, that the angle of disappearance of the apex in the right posterior oblique position may be determined. In this way the respective increases in volume of the different cardiac cavities can be measured, the size of the retro-cardiac clear space and the outline of the heart shadow at its level. Though this latter examination need not be conducted in as regular a manner as the others, and though it can be made equally well by radioscopy or by intensive radiography, never- theless it is indispensable to know the angle of obliquity at which the patient was placed during the examination. It is unnecessary to point out that the modifications of this or that part of the heart at a given angle may lead to interpretations which differ but are always helpful in diagnosis. CHAPTER III THE SHADOW OF THE HEART IN THE PATHOLOGI- CAL STATE THE pathological changes in the volume of the heart are complete or partial: complete, when they affect the organ as a whole; partial, when they concern only certain cardiac cavities. The shadow cast by the organ determines certain modi- fications which will be studied with the assistance of cer- tain clinical facts, in order to give examples instead of diagrams. MODIFICATIONS AFFECTING THE WHOLE HEART These are shown by an increase or diminution in the surface of the shadow. The estimate of the shadow as a whole is made by measuring its area (by means of Amsler's planimeter or millimetric ruled paper) and the diameters of the pro- jection. This double measurement is necessary because the diameters may change in the same patient, according to the different phases of the disease, without any varia- tion in the total surface. Sufficiently precise data are had from a first examina- tion to judge whether the heart shadow of a patient is increased or diminished in volume. Moritz, Dietlen, Groedel, Claytor and Merrill have drawn up tables of normal areas and diameters according to age, height, weight and sex; these will be merely referred to, care being taken to compare the figures with those of the 62 THE HEART AND THE AORTA tracings taken in the same positions, for the diameters vary according as the patient is examined in the upright or prone position. According to Dietlen 12 the volume of the heart is in- creased as soon as a tracing exceeds the normal corre- sponding tracing by five millimeters for the diameters and five square centimeters for the area ; it is diminished when the measurements are less than those which corre- spond to the smallest normal tracings taken in the same conditions of position, age, weight, and sex. These deductions, however, should not be accepted without reservation, and if the orthodiagraphic method is sufficiently accurate clinically, it is far from having, even in experienced hands, a geometric precision. Al- most always, moreover, modifications affecting the whole heart are transitory and it is rather from the comparison of several serial tracings taken at different intervals in the same patient that conclusions can be drawn, and, in general, it is sufficient to superimpose the tracings in order to read the changes in volume. The list of succes- sive measurements of areas and diameters explains equally well the anatomical pathological variations in the heart volume. Increases in the heart as a whole are met with espe- cially in the course of infectious diseases : diphtheria, pneumonia, typhoid fever (Dietlen). They are particu- larly important in cases of myocarditis. Fig. 32 shows the successive contours of the shadow of the heart in a man of forty-four with very severe alcoholic myocarditis, benefited by intravenous injections of strophanthine 3 The line in dots and dashes gives the image of the heart before treatment ; the dotted line, the result after the first injection; the black line shows the cardiac shadow when 12 Dietlen, Munch. Med. Woch., 6 October, 1908. 13 Vaquez et Leconte, Les injections intra-veineuses de strophantine dans le trait ement de 1 'insuffisanee eardiaque. (Soc. med. des hopitaux, 26 mars, 1909.) HEART IN THE PATHOLOGICAL STATE 63 Fig. 32. ALCOHOLIC MYOCAEDITIS By comparing the three superimposed tracings marked by different lines, one can follow the progressive decrease in the volume of the heart under treatment. The tracing in black lines was taken the day the patient left the hospital. finally, three months later, the patient left the hospital cured. The diameters and areas were : Area Longitudinal Diameter in cm. Horizontal Diameter in cm. October 29, 1908 November 4, 1908 January 28, 1909 168om2 159cm2 132em2 17.7 cm. 17.7 cm. 15.8 cm. 18. cm. 17.5 em. 15.3 cm. PARTIAL MODIFICATIONS The ascertaining of partial modifications in the volume of the heart is more important than determining modifi- cations in the heart as a whole, for valuable information is had as to the reaction of the different cavities of the organ upon its organic lesions. 64 THE HEART AND THE AORTA I. DETERMINATION OF THE TOTAL VENTRICULAR VOLUME The increase in volume of the two ventricles is shown by the abnormal development of the outline in the left pulmonary field on a cardiogram taken in the frontal position. In this case the apex is pushed out toward the thoracic wall, which it sometimes touches. Moreover, it is de- pressed and may, in certain cases, be seen only at two or three and more centimeters below the diaphragm in deep inspiration. Its form becomes rounded or globulous. The longitudinal diameter is elongated, sometimes 18 to 20 centimeters and more, and the horizontal diameter increases, especially in that portion which meets the left border. This border is longer on account of the apex being lowered, the area of origin elevated (point Gr), and the external convex curve accentuated. The importance of the ventricular area may be equally well determined by another more rapid method, which consists in finding under what angle of obliquity of the body the heart shadow disappears behind the vertebral column shadow in the right posterior oblique position. In a normal subject it ceases to be visible at an angle of 30 degrees on an average. This examination is made before a fixed screen, keeping the normal ray tangent to the apex and making use of a movable back which indi- cates the angle of obliquity of the body. The disappear- ance of the cardiac shadow behind the vertebral column at an angle of obliquity of 40 degrees or more warrants the conclusion that the ventricular area is increased in volume 14 in proportion to the increase in the angle. "We have seen it exceed 65 degrees in certain cases of aortic insufficiency. i*It is evident that these considerations cease to be exact if, for reasons independent of the variations in the volume proper of the heart, such as pleural adhesions, effusions, etc., the organ is displaced either to the right or to the left of its vertical axis, or depressed in depth. HEART IN THE PATHOLOGICAL STATE 65 The tracings in Figs. 33 and 34 are of a man of forty- eight, 1 m. 68 cm. in height, suffering from mitral dis- ease, with easily provoked dyspnoea, pulse small and arhythmic. Examination in frontal position, prone (Fig. 33), shows that the apex is pushed out and lowered (by palpation, pulsation was felt in the sixth intercostal space) ; the longitudinal diameter measures 17 centi- meters (normal average at this height, 13 to 14 centi- meters) ; the horizontal diameter is 15.9 cm. (average, 13 to 14 centimeters), the middle arc is exaggerated and the point Gr is lowered ; finally, in right posterior oblique position (Fig. 34) the ventricular shadow is still visible 50 degrees to the left ; it disappears behind the vertebral column only at an angle of 55 degrees. Fig. 33. INSUFFICIENCY AND MITRAL CONTRACTION The exaggerated development as seen on this tracing is due to the in- crease in the volume of the two ventricles. In analogous cases we can estimate the development of the ventricles in depth by using the method with the tube on a sliding scale, as has been described. The index figure in the case of right and left ventricular enlarge- ment, but especially left, rises to 20, 25 millimeters and more. If hypertrophy of the right ventricle is predomi- nant, the index remains nearly normal. 66 THE HEART AND THE AORTA It will be of interest therefore to examine the ortho- diagraphic data relative to the modifications in volume of each of the cardiac cavities. Fig. 34. SAME HEAET AS IN FIG. 33, IN EIGHT POSTERIOR OBLIQUE POSITION At 50 degrees the ventricular area has not yet disappeared behind the vertebral column. II. LEFT VENTRICLE Clinically this is a typical case of left ventricular hypertrophy. Fig. 35 is of a patient thirty-three years of age, weighing 67 kilos, height 1 m. 71 cm., suffering from aortic insufficiency with compensation. The. first important point in this figure is that the apex of the heart is pushed outward only a little, but it falls below the diaphragm even during deep inspiration. The hori- zontal diameter measures 12.8 cm. and the longitudinal diameter, 13.5 cm. By referring to Moritz's tables, the longitudinal diameter for a man 1 m. 71 cm. in height would be 12.5 cm. It is increased then by one centimeter. On the other hand, the horizontal diameter remains in this case nearly normal. Point Gr is raised, the general form of the left contour is modified, its convexity is accentuated, the apex of the heart is rounded. HEART IN THE PATHOLOGICAL STATE G7 In the right posterior oblique position the cardiac shadow disappears behind the vertebral column at an angle of 40 degrees. The index in depth exceeds 15 milli- meters. The conclusion is plain : the ventricular volume is exaggerated. Oblique examination and examination in depth complete the data of the tracings made in the frontal position, especially in cases in which anatomical changes are not marked. It is understood, moreover, that in the right posterior oblique position the least Fig. 35. HYPERTROPHY OF THE LEFT VENTRICLE (AORTIC INSUFFICIENCY) The apex of the heart is at G', lowered, rounded, the left ventricular out- line GG' is elongated. changes in volume of the left ventricle are easily seen. This cavity corresponds especially to the posterior part of the organ ; when it increases, it does so not only toward the left, but also in its antero-posterior diameter. As it is the projection of the postero-lateral contour of the left ventricle which is shown on the screen in the right poste- rior oblique position, it is quite natural that this shadow, when it corresponds to an enlarged cavity, should dis- appear slowly. It is also understood that in finding the index in depth, the oblique ray encounters the contour 68 THE HEART AND THE AORTA of the Heart lower down and projects the shadow of it further toward the left. When the hypertrophy of the left ventricle is more pronounced, the apex is pushed further out and lower, the contour of the left border is more convex and longer, the heart takes the shape of a pear, as described by Destot and Arcelin ; 15 the elongation of the diameters in- creases, the angle of disappearance of the apex in the right posterior oblique position is larger, as also the index in depth. n r> Fig. 36. CONGENITAL PULMONAEY STENOSIS The right ventricle, alone increased in volume, rests on the left diaphragm, which it depresses; the left ventricle is pushed up and outward, the apex is seen at P (heart in the form of a "sabot"). III. RIGHT VENTRICLE This will be taken as an example of an affection in which the left ventricle ordinarily keeps its normal vol- ume, while the right ventricle is greatly enlarged, as occurs in lesions of the pulmonary artery. Fig. 36 represents the frontal projection in the prone position of a heart of a child fourteen years of age with congenital pulmonary stenosis accompanied by marked cyanosis and dyspnoea. In a general way a notable arterial saliency is observed due to the dilatation of the pulmonary artery (Pul) and a considerable enlargement is Arcelin, Les formes de I 'aire de projection du cceur patliologique. Lyon, 1906. HEART IN THE PATHOLOGICAL STATE 69 of the right ventricle. In detail the tracing is analyzed as follows : The longitudinal diameter measures 12.5 cm., which is too much for a child of fourteen ; the horizontal diame- ter is still greater, 13.2 cm. The apex (P) is pushed out- ward and raised. On this account the position of the left ventricle, (Gr) is higher than normal, but the total length of the ventricular contour keeps its usual dimensions (7.3 cm.). Moreover, its double undulation is not modi- fied. The shadow thus formed at the apex belongs to the right ventricle, the lower border of which can be followed below the diaphragm. When, as is not unusual, it is difficult to fix the outline by a simple examination on the screen, it can be done more surely by giving the patient two solutions in succession : one of bicarbonate of soda, the other of citric acid, which forming a gas render the stomach transparent. If this contour were that of the left ventricle it would have a more vertical direction and the apex would hang like the bottom of a purse, whereas here the form of the cardiac shadow resembles somewhat that of a "sabot." The enlargement of the right ventricle is seen on the right by an exaggeration of the outline in its lower third below the auricle. To make sure that it is the ventricle and not the auricle which projects at this level, take the patient's pulse and note that each radial pulsation coin- cides- with the systolic retraction of the shadow in the region examined, whereas the pulsation would be pre- systolic if it were a question of the auricle. Further than that, the same outline of the shadow at the right of the sternum can be found in cases in which the ventricle, not increased in volume, is only pressed toward the right by the hypertrophied left ventricle. But this compression is not accompanied by signs which show the enlargement of the right ventricle, the lengthen- ing of the diameters, especially the horizontal, the push- TO THE HEART AND THE AORTA ing outward and elevation of the apex and the lowering of the inferior contour of the heart. In left anterior oblique position an outline is obtained which confirms the preceding data. By referring to Fig. 37, the line of contour of the heart, situated at the left of the image, limits the right auricle above, then the right ventricle as far as the diaphragm. The shadow is seen to be very markedly increased, which corresponds to the enlargement in volume of the right ventricle. The dotted line indicates schematically the normal contour in this position. Finally, in the right posterior oblique position the angle of disappearance of the apex cannot be exag- gerated. It has been seen that the projection of the apex toward the left is not enough in itself to increase this angle and that it is necessary that the development of the area in depth be increased in order that this take place. The determining of the index leads to the same results, on the left, at least. In cases where the right ventricle projects toward the right and pushes the auricle up, the index in depth may be exaggerated on the right, while it is normal or nearly so at the apex. Fig. 37. LEFT ANTERIOR OBLIQUE POSITION, 50 DEGREES The beam of x-rays penetrates the right back and comes out in the left mammillary zone, thus following the large axis of the heart. At the left of the figure, and consequently in the right lung, the outline of the right ventricle (VD) is seen, the shadow of which forms a considerable salience below the right auricle (OD). The dotted line indicates the normal ven- tricular contour. HEART IN THE PATHOLOGICAL STATE 71 IV. LEFT AURICLE It is in the oblique positions that the degree of develop- ment of the left auricle can best be studied. In the right posterior oblique, as in the left anterior oblique, the normal ray passing the posterior mediasti- num is tangent to the margin of the left auricle. When this auricle is hypertrophied or dilated, its con- tour develops behind and to the left of the heart and projects its shadow for some distance into the clear retro- cardiac space. The degree of enlargement of the auricu- lar shadow is naturally proportional to the enlargement of the cavity. This deformation is very characteristic in simple mitral stenosis. However, the same obscurity of the retro-cardiac clear space may be produced by the presence of easily recognizable pathological pulmonary or pleural shadows, or by a considerable augmentation in the volume of the ventricle, which, besides, is rare in cases of mitral stenosis. Fig. 38 illustrates a typical case of hypertrophy of the left auricle in right posterior oblique position at 50 de- FiG. 38 Fig. 39 Fig. 38. SIMPLE MITRAL STENOSIS Right posterior oblique position at 50 degrees. The much enlarged left auricle casts a shadow which obscures part of the retro-cardiac clear space. Fig. 39. SAME CASE, IN LEFT ANTERIOR OBLIQUE POSITION AT 50 DEGREES 72 THE HEART AND THE AORTA grees. The salience which is noticed here and which lies in the postero-superior part of the cardiac shadow can only correspond to the left auricle; in the retro-cardiac clear space there is only a small transparent triangle included between the ventricular contour, the vertebral column and the diaphragm. Examination in the left anterior oblique position leads to identical proofs and conclusions (Fig. 39). The frontal position, without giving the same precise details, indicates, nevertheless, an increase of the median arc, especially manifest in its inferior portion which is at once salient and lowered in the region corresponding to the auricle (see Fig. 44. Mitral stenosis). V. RIGHT AURICLE The favorable position for the examination of the right auricle is the frontal, the oblique positions being only accessory.. In the frontal position the right auricle is in outline at the right of the sternum and its salience is increased as the auricle is increased in volume. It is in the superior portion of its contour (at the level of the arrow in Fig. 40) that it can best be observed, for the right ventricle may, if it is hypertrophied or dilated, be noted projecting on the right side, but in the lower third or half of the shadow. In such circumstances, the auricle, pressed back and up, is visible only in the neigh- borhood of the superior vena cava. There is consequently always good reason for studying it in this high position. In case of doubt, the rhythms of the pulsations determine whether it is the auricle or the ventricle : the movements of presystolic retraction are due to the auricle, the move- ments of systolic retraction to the ventricle. Figs. 40, 41, and 42 show a case of tricuspid insuffi- ciency in which the right auricle is abnormally developed. In Fig. 40, frontal position, will be noted the marked HEART IN THE PATHOLOGICAL STATE 73 development of the right heart area and the exaggeration of its curve in the upper half. In this place (at the level of the arrow) there were visible on the screen very clear movements of presystolic retraction which can be due to the auricle only. Fig. 41, taken in the left posterior oblique position at 50 degrees, shows that the shadow of the right auricle effaces a part of the retro-cardiac clear space. Fig. 40. TRICUSPID INSUFFICIENCY In frontal position the shadow of the right auricle is much enlarged, especially in the zone indicated by the arrow. Finally, in left anterior oblique position (Fig. 42) the contour of the right auricle describes a curve of large diameter projecting over the shadow of the right ven- tricle, which is contrary to what has been described in Fig. 37, where the ventricle is very large in relation to the auricle. Sometimes the shadow of the right auricle may be in- creased without a corresponding increase in the volume of this cavity. This is a fact observed in mitral stenosis. It is explained by the elevation of the right cavities and their closeness to the sternum as a result of the marked development of the left auricle. The obliquity of the 74 THE HEART AND THE AORTA heart from back to front is diminished ; the projection of the auricle is increased as a result of the displacement of the organ and not because of its increase in volume. Fig. 41 Fig. 42 Fig. 41. SAME CASE AS PBECEDING FIGUBE, IN LEFT POSTEKIOE OBLIQUE POSITION AT 50 DEGEEES In this position the shadow of the enlarged right auricle merges with the shadow of the vertebral column. Fig. 42. SAME HEAET AS IN FIGS. 40 AND 41, BUT IN LEFT ANTEEIOE OBLIQUE POSITION AT 50 DEGEEES The outline of the enlarged right auricle (OD) makes a greater salient in the right lung than the left ventricle. The preceding considerations concern the partial modi- fications in the volume of the heart in connection with the enlargement of one or another of the cavities. But it fre- quently happens in practice that several cavities are in- volved at the same time and to an unequal degree. New images then result, in which the radioscopic signs are combined. The study of these images gives, as will be seen presently, valuable assistance in the diagnosis and the prognosis of a large number of cardiac diseases. CHAPTER IV VALVULAR AFFECTIONS VALVULAR lesions produce on the exterior form, of the heart characteristic changes which are well known to pathologists. These lesions can often be inter- preted during the life of the patient and most clinicians can readily distinguish at first sight a "mitral lesion" from an "aortic lesion." Sometimes they are not suffi- ciently characteristic to be obtained by the usual methods of diagnosis. The progress of radiography has been such that it has given the means of demonstrating the deforma- tions of the cardiac outline even to the slightest detail and furnishing precise information for the diagnosis of valvular lesions. SIMPLE MITRAL STENOSIS Radiological diagnosis of mitral stenosis rests on two principal points : the volume of the left ventricle on the one hand, and that of the corresponding auricle on the other. The positions favorable for estimating them are : the direct anterior and the oblique. EXAMINATIONS IN THE DIEECT ANTERIOR POSITION Orthodiagrams of the heart in the frontal position or the direct anterior offer typical characteristics which are (see Fig. 43) : 1. A considerable development of the left median arc, especially marked in the inferior portion. 2. A left ventricular outline of slight dimension. 3. A modification of the right contour, by an exaggera- 76 THE HEART AND THE AORTA tion of the shadow to the right and by raising of its extreme points D and D'. Left median arc. Examination of the mediastinal shadow outline on the left, from the clavicle to the dia- phragm, shows that in most cases of mitral stenosis, the line of contour, after having marked the aortic half circle, takes an oblique direction from within outward to the heart apex. The outline shows only a notch, sometimes hardly perceptible, which corresponds to point G, at the level of which is observed the general seesaw movement of which this point constitutes the fixed axis. The phe- nomenon is here perfectly clear. The point Gr lies lower than normal; it is much below point D which is opposite to it. The line which rises from Gr to the aortic arc thus limits the median arc which is exaggerated. The upper two-thirds of the outline, which constitutes the portion relatively the least salient, corre- sponds to the pulmonary artery and shows systolic move- ments of expansion; the lower third of the median arc, which bulges the most, corresponds to the left auricle and has only very feeble pulsations. Left ventricular outline. The line GGr' which limits the shadow of the left ventricle is rather short and does not present, in most cases, a convexity as marked as in the normal state. The slight distension of this cavity ex- plains why there is a decreased convexity of the walls. Apex of the heart. The apex is near the left diaphragm. It generally appears as a rather acute angle, which leads Destot to state that in mitral stenosis "the apex of the heart is pointed. " It is the more so, the greater the ste- nosis, and the smaller the left ventricle; when the ste- nosis is not very pronounced, the apex is slightly rounded as in the normal. It is always distinctly separated from the left thoracic contour, and is often pushed a little more inward and downward than in the normal state, but it does not follow from that that the ventricular contour is elongated, for point Gr, where the ventricular contour Fig. 44. TELEEADIOGEAPH OF SIMPLE MITEAL STENOSIS VALVULAR AFFECTIONS 77 begins, is itself lowered, so that the total length of the line GG' does not change. Right contour. The area of projection of the heart extends very noticeably beyond the right edge of the sternum. Its contour is shown by a curved line which deviates from the sternum at its origin (point D) and approaches it again near the diaphragm (point D'). The right heart outline often takes, below D', a vertical direction to the diaphragmatic shadow; it then limits the shadow of the inferior vena cava which is more visible than in the normal state. Fig. 43. SIMPLE MITRAL STENOSIS. WOMAN 52 YEAES OF AGE The length of the line DD' is generally greater than normal. By comparing it to the length of the left outline GG', the relation of the two sides of the heart is estab- lished. Now, GG' is, in a normal subject, greater than DD', whereas in simple mitral stenosis GG' but slightly exceeds, equals, or is even less than, DD'. Diameters. The longitudinal diameter is usually exag- gerated; this is due in part to the elevation of point D and in part to the lowering of the apex. As for the horizontal diameter, it is, in spite of the development of the right area, always much less than the longitudinal diameter. 78 THE HEART AND THE AORTA Clinical Cases. The diagrams which are published here are always comparable one with another. Figs. 43 and 45 are cases of marked mitral stenosis. All the points emphasized in the foregoing are found, and here radiology only serves to confirm clinical findings. Fig. 43 is of a woman fifty-two years of age, suffering from right hemiplegia with aphasia, supervening in the course of mitral stenosis, the diagnosis of which had al- ready been made by Duroziez. Palpation gave a presys- tolic thrill very clear in the region of the apex ; ausculta- tion, a rhythm typical of mitral stenosis : diastolic rumble with presystolic reinforcement, the first sound rough, the second diminished. Further, percussion in the back, at the level of the left scapula gave rise to that peculiar pain, or auricular stitch in the side, which one of us has noted in patients with this affection. The cardiogram shows in frontal position a marked increase in the median arc, whereas the outline of the left ventricle is almost normal. The area of the right auricle is exaggerated; the longitudinal diameter measures 14.5 cm. and the horizontal diameter, 12.6 cm. Finally, exami- nation in the oblique position shows an increase in volume in the left auricle. Fig. 45 is that of a young man twenty-four years of age of frail constitution, affected from infancy with mitral stenosis. This had caused an almost constant cyanosis of the extremities and dyspnoea so severe that the patient had to abandon his profession of violinist. Objective examination gave a marked presystolic thrill, and auscul- tation the characteristic signs of the lesion. The cardiogram shows a very marked lowering of point G. The ventricular contour is almost vertical, but instead of being convex it is slightly concave. The left outline, GG', measures 8 cm. ; the right, DD', is longer, measuring 9 cm. ; the longitudinal diameter is 15 cm. and the horizon- tal 12.6 cm. Fig. 46 is of a child eight years of age, with simple VALVULAR AFFECTIONS 79 mitral stenosis. The stenosis was of recent date. The cardiogram nevertheless is absolutely typical, showing that the lesion, though barely established, already had given the usual characteristics. Fig. 47 is still more interesting. No heart affection was suspected by subjective signs and only auscultation gave a mitral rhythm, difficult to interpret, but sug- gesting a lesion. But it was unmistakably present as a radiological examination proved. The diagram demon- strates the exaggerated saliency of the median arc, the lowering of point Gr, and the excessive development of Fig. 45. SIMPLE MITEAL STENOSIS, MAN 24 YEAES OF AGE Fig. 46. SIMPLE MITEAL STENOSIS, CHILD 8 YEAES OF AGE 80 THE HEART AND THE AORTA the right side of the heart. However, the apex of the organ is less acute than in the preceding cases. The left ventricular contour is a little convex as in the normal, but the relation of the outlines and the diameters is none the less modified in the manner expected. The left side, GG', measures 8 cm., whereas the right side, DD', meas- ures 9.5 cm. The diameters are: longitudinal, 13 cm., horizontal, 8 cm. Fig. 47. SIMPLE MITRAL STENOSIS, NOT SEVERE. MAN 33 YEARS OF AGE Interpretation of cardiograms and comparison with percussion. In the great majority of cases the tracings obtained by percussion agree with the radioscopic out- lines (Fig. 48). The contour of the left side and the posi- tion of the apex with their precise form and location are shown. The smallness of the cardiac area on this same tracing corresponds to the underdevelopment of the organ, proved by precise radioscopy. In simple mitral stenosis, therefore, the left ventricle is small, which agrees with the anatomical findings and clinical examinations made by Briquet, Merklen and by Potain and Rendu. On this point clinicians are not all agreed and contend that in simple mitral stenosis the heart is increased in VALVULAR AFFECTIONS 81 volume. The argument advanced for this is that the apex is lowered and that its pulsations occur in the lower part of the fifth space, and even lower. This sometimes occurs, but is not conclusive evidence, and to judge the enlarge- ment of the heart it is necessary to measure exactly the area of dullness. The area of dullness is not diminished, as is shown by the percussion and radiological outlines. The apex is displaced because, as has been said, the heart is lowered as a whole, and it is radiology that demon- strates this. Radioscopy is superior to percussion in determining the development of the right side of the heart. Percus- sion gives only approximate information. Radioscopy is more precise, showing early a notable increase in size of the right cavities, while there are no symptoms, and com- pensation appears perfect. The numerous tracings that we have been taking and which are easy to interpret have given confidence. In mitral stenosis, the heart is lowered and at the same time undergoes a displacement from right to left, from behind forward, so that the right cavities are slightly raised towards the sternum. Examination of the projected images indicates this with certainty. In these conditions, the right curve of the heart must neces- FiG. 48. SIMPLE MITEAL STENOSIS Black lines, orthodiagram; dotted lines, percussion. 82 THE HEART AND THE AORTA sarily be raised in the upper part to the level of the large vessels, as well as in the diaphragmatic portion, .and shows an exaggerated development outside the sternum. Thus in mitral stenosis the heart undergoes a slight double displacement ; a movement downward which forces the apex below the normal position and a seesaw move- ment which pushes the right auricle toward the right, without a real enlargement of that cavity. EXAMINATION IN OBLIQUE POSITIONS Enlargement of the left auricle constitutes one of the principal changes in mitral stenosis. There is great inter- est in recognizing the existence and the degree of it. The method used up to the last few years was that of dorsal percussion suggested by Germe (Arras), which consists in percussing the area between the scapulae and the verte- bral column, between the fifth and tenth dorsal vertebras and the left auricle. The zone of dullness thus outlined is limited in the normal but increases in marked degree when it is hypertrophied or dilated. But this method requires skill, and though the auricle is hypertrophied, it may not be near enough to the thoracic wall to give an appreciable change on percussion. Radioscopic examination is preferable. Santiard 16 has reported a case of mitral stenosis in which posterior per- cussion did not show an enlargement of the left auricle. He states, however, that as shown by two radioscopic tracings outlined on the left of the heart, on the anterior image, a shadow was seen certainly produced by the dilated left auricle. On the posterior tracings, the hyper- trophied auricle outlined above the ventricle is clearly visible. Galli, 17 in 1908, published a tracing of mitral stenosis is P. Santiard, fflude de I 'aire de projection du coeur sur la paroi tho- racique par la radiographic These de Paris, 1900, p. 57. 17 G. Galli, L'orthodiagraphia nella diagnosi delle malatti di cuore. (Policlinico, partie med., 1908, XV, 2.) VALVULAR AFFECTIONS 83 which shows a salient surmounting of the left ventricle, attributed to the projection of the enlarged left auricle, as the pulsations were clearly presystolic. These examinations were made in direct position and do not solve the problem. The salience which was noted between the arch of the aorta and the origin of the left ventricle, that is, at the level of the median arc, corre- sponds not to the auricle but to the auricular appendage. The auricular salience is due in part to the fact that the auricular appendage is compressed by the hypertrophied auricle, in part to the lowering of the heart which puts a tension on the vessels, making the outline of the pulmo- nary artery more rectilinear, and finally to the underde- velopment of the left ventricle which makes the projection of the pulmonary artery and left ventricle more appar- ent. It is not surprising, therefore, that examination in the frontal position brings out the points mentioned by these investigators, which are, however, only indirect signs and more common in mitral stenosis. The modifications found in the right posterior and the left anterior oblique positions are more important as they allow the contour of the left auricle to be marked more precisely towards the lower third of the retro-cardiac clear space. When it is hypertrophied or dilated, its out- line is modified ; it makes a greater salience than normally in the retro-cardiac area, its curve increases, approaches the shadow of the vertebral column and may even merge into it, the clear space ceasing to be visible at the level of the auricle. To estimate exactly the importance of the development of the auricular shadow it is necessary to know the de- gree of obliquity of the body during the examination. In fact, according as the bi-scapular axis describes with the plane of the screen an angle of 45, 50 or 60 degrees, the retro-cardiac clear space is naturally larger and larger, and the outlines of the heart further from the vertebral column, so that in the first place an examination should be 84 THE HEART AND THE AORTA made at 50 degrees. If at this angle the clear space is obscured, it may be concluded that the left auricle is en- larged; that it is considerably enlarged if the retro- cardiac clear area does not appear at an angle of inci- dence of 60 degrees. But in order that the examination should be conclusive, the pulmonary spaces should neces- sarily be transparent, which is not always the case in patients with mitral stenosis ; it is necessary also that -the region should not be obscured by pathological glandular or pulmonary shadows, by a tumor, or in the case of a woman, by large breasts. Care should be taken that the patient raises his arms, and breathes deeply, and, in short, that the best possible conditions for the demonstration of the auricle be pro- cured. If necessary, the examination should be made several times, the patient being moved until the best posi- tion is found and the angle of incidence of the body noted each time. Except in special circumstances, previously mentioned, the shadow of the auricle is finally always sharply outlined in the retro-cardiac clear space, and has only to be traced quickly at the moment when it is visible. Fig. 49. EIGHT POSTEEIOE OBLIQUE POSITION, 50 DEGEEES A, aorta; OG, left auricle; VG, left ventricle; Diaphr., diaphragm; Col., vertebral column. VALVULAR AFFECTIONS 85 The indications given by examination in the oblique position complete the radiological diagnosis of simple mitral stenosis. Fig. 50 Fig. 51 Fig. 50. SAME CASE AS FIG. 45. EIGHT POSTERIOE POSITION, 50 DEGREES Fig. 51. SAME CASE AS THE PRECEDING, IN LEFT POSTERIOR OBLIQUE, 50 DEGREES Fig. 49 shows the same patient as Fig. 43, which gives the details of examination in the frontal position. It will be seen there that the greatly enlarged left auricle ob- scures with its shadow all the middle third of the clear space. In the lower part of this figure, the transparent triangle is found included between the lightly developed outline (VG-), the vertebral column (Col.) and the dia- phragm (Diaphr.). Above on the level of the aortic prom- inence (A), the clear space is readily distinguishable, but it soon ceases to be visible and the contour of the auricle joins the vertebral column. The examination of Fig. 50 leads to the same conclu- sions. This figure is of a patient whose cardiogram in frontal position has been given in Fig. 45. Here the left auricle is still very large, as is shown in the tracings taken in the right posterior oblique and the left anterior oblique positions (Figs. 50 and 51). 86 THE HEART AND THE AORTA Moreover, percussion showed enlargement of the auri- cle. In Fig. 52 these points are less marked. The left auri- cle, it is true, is very much increased in size, since it forms a visible salient in the retro-cardiac space. However, its development is not as considerable as in the previous cases, for at 50 degrees there still exists a narrow, clear band between the shadow of the heart and that of the vertebral column. Not all the tracings are as typical, and it will be under- stood that a moderate hypertrophy of the auricle does not cause the same deformations. However, to be convinced that the auricle is not normal, we have only to examine attentively the configuration of the curve which extends behind the origin of the blood-vessels, at the level of the diaphragm. It is seen that (Fig. 53) the highest point of this curve, instead of being at the level of the ventricle, corresponds to the level of the auricle ; that is conclusive evidence that the auricle is increased in volume. To sum up, every patient examined in the oblique posi- tion at 50 degrees who shows the shadow of the heart completely obscuring the retro-cardiac clear space at the height of its middle third, must be considered as having a Fig. 52. SIMPLE MITEAL STENOSIS. EIGHT POSTEEIOE OBLIQUE POSITION, 50 DEGEEES. LESS ACCENTUATED ENLAEGE- MENT OF THE LEFT AUEICLE VALVULAR AFFECTIONS 87 considerable hypertrophy of the left auricle. The degree of hypertrophy is measured by the extent of the reduction of the retro-cardiac clear space, a slight reduction corre- sponding to a moderate increase in the volume of the auricle, provided, of course, that the obscuring of the posterior mediastinum is not due to another cause. Fig. 53. BIGHT POSTEEIOE OBLIQUE POSITION, 50 DEGBEES. MODEEATE DILATATION OF THE LEFT AUEICLE MITRAL INSUFFICIENCY The clinical history of mitral insufficiency presents problems, the solution of two of which, at least, is not easy. The first is whether the systolic murmur heard at the apex belongs simply to the category of anorganic murmurs (Potain) ; the second is to recognize the cause of it, as the murmur may be symptomatic of a valvular lesion or of functional insufficiency. In this respect the indications furnished by semeiology are often uncertain and radiological examination may be of very great assist- ance. The radiograms of a typical case of mitral insufficiency of rheumatic origin which has not given rise to marked circulatory disturbances will be studied first. This case is a patient twenty-five years of age, with a loud murmur heard at the apex of the heart during the whole systole 88 THE HEART AND THE AORTA and transmitted toward the axilla. The affection began in adolescence (Fig. 54). Fig. 54. MITEAL INSUFFICIENCY WITH COMPENSATION. 25 YEARS OF AGE MAN The form of the area of projection somewhat resembles that of a normal horizontal heart, resting on the dia- phragm. Its development, however, is clearly exagger- ated on the right. Moreover, on the screen, pulsations could be seen in the vicinity of the diaphragmatic shadow (at the level of the arrow), which could only be caused by the right ventricle. The contour of the left ventricle appears normal, its left point not elevated. The apex lies at the level of the left diaphragmatic shadow ; it is not lowered, but pushed outward and rather pointed. The changes seem to affect only the right heart area and this is confirmed by the measurement of the diame- ters : longitudinal diameter, 14 cm. ; horizontal diameter, 14.5 cm. The longitudinal diameter does not exceed the normal for a man twenty-five years of age, of average weight, but the horizontal diameter is 5 mm. greater than the longi- tudinal: this difference confirms the radiological diag- nosis, which is a transverse enlargement of the heart due to the development of the right cavities. VALVULAR AFFECTIONS 89 In the right posterior oblique position, moreover, the apex of the heart disappeared behind the shadow of the vertebral column only at an angle of 42 degrees instead of at 25 to 30, the normal figure. That could be explained only by a ventricular enlargement in which the left ven- tricle was involved to a certain extent but less than the right. Finally, in the oblique position the left auricle did not appear to be changed. These signs agree with the pathological findings which show that in mitral insufficiency a slight hypertrophy of the left ventricle exists, an insignificant enlargement of the right ventricle which varies with the severity of the symptoms. It is not surprising, therefore, that the ven- tricles are accentuated when mitral insufficiency is com- plicated with dyspnoea, cyanosis, oedema of the extremi- ties, etc. (See Fig. 55.) Fig. 55. MITEAL INSUFFICIENCY. MAEKED ENLAEGEMENT OF THE EIGHT HEAET. MAN 34 YEAES OF AGE This shows that the heart is greatly enlarged and that the enlargement is of the two ventricles, principally the right. On the left, the ventricle bulges, its contour is 90 THE HEART AND THE AORTA elongated, its apex pushed out but not lowered and on the other side the salience of the shadow corresponds to the lower part of the contour or to the region of the right ventricle, and further evidence is the presence at this point of systolic pulsations. The two diameters measure : horizontal, 19.2 cm. ; longitudinal, 17.3 cm., instead of 14. Both, then, have increased, especially the horizontal, which denotes a generalized hypertrophy, but predomi- nant on the right. Fig. 56. MITEAL INSUFFICIENCY. ASYSTOLIC PERIOD Fig. 56 shows a patient with confirmed asystolic changes in which these characteristics are still more accentuated. The transverse enlargement of the heart is considerable ; it is very much lowered on the right where its greatly elongated contour deviates progressively from the median line to the level of the diaphragm. The apex is elevated and pushed to the left, toward the thoracic wall. Both diameters are increased and the horizontal is much greater than the longitudinal. On the screen pulsa- tions were seen to be very feeble, especially in the right ventricular area. VALVULAR AFFECTIONS 91 In these cases, radiological examination only confirms an evident diagnosis. There are other cases in which the clinical signs were less clear and in which radiological examination nevertheless gave the same results. Orthodiagram 57 is of a woman who had an apical sys- tolic murmur but who showed no functional trouble that would indicate a cardiac lesion. By fluoroscopic examination there seemed to be no notable modifications. The diameters measured: hori- zontal, 10.5 cm. ; longitudinal, 11.2 cm., about the normal Fig. 57. SLIGHT MITEAL INSUFFICIENCY. WOMAN 32 YEAKS OF AGE figures. However, the right outline was slightly exag- gerated, and in deep inspiration the inferior contour of the heart clearly projected over the diaphragm, which could be explained only by an enlargement of the right ventricle. Moreover, by goniometer readings, the apex disappeared behind the shadow of the vertebral column only at an angle of 40 degrees. The heart, therefore, was pathological, and the changes found, such as an increase 92 THE HEART AND THE AORTA of the right contour, lowering of the inferior margin of the corresponding ventricle, disappearance of the apex at too great an angle of incidence, proved that a moderate but indisputable enlargement of the heart, especially of the right ventricle, existed, indicating mitral insufficiency. These proofs are of practical importance in relation to differential diagnosis of systolic murmurs of the apex, which is at times difficult. Frequently these kinds of murmurs are of anorganic nature and their characteris- tics are not always clear enough to distinguish them. They occur less frequently than as stated by Potain for the reason that functional murmurs were not included. If a mitral lesion, however well compensated, were always accompanied by changes visible on the radioscopic screen, the question would be settled. This is not absolutely so, but nevertheless radiological examination does give valu- able information in this respect. It may be considered in the following manner : Any patient who by radiological examination shows no abnormal heart changes, no increase in the volume of the ventricular cavities, must be regarded as free from lesions of insufficiency, irrespective of the results of clini- cal examination. On the other hand, any patient in whom auscultation reveals the existence of a murmur, the nature and position of which would tend to put it in the category of anorganic sounds, should be suspected of mitral insuffi- ciency, if radiological examination demonstrates all or part of the changes previously described. The accuracy of these statements has often been veri- fied. In individuals with a superficial anorganic murmur, constantly varying with change of position, radiological examination has not shown any heart changes, and when the murmur did not present these characteristics, investi- gation, at first not convincing, finally showed a slow but progressive enlargement of the volume of the heart which enabled a diagnosis to be made which had previously been questionable. VALVULAR AFFECTIONS 93 FUNCTIONAL MITRAL INSUFFICIENCY. Another interesting question is to determine the nature of a mitral insufficiency which has been recognized by the usual clinical signs and by radiological examination. Mitral insufficiency does not always have the same origin. It results either from an endocarditis, or from a sudden or slow dilatation of the left ventricle ; in this case it may disappear under the influence of appropriate care and treatment, or may continue indefinitely. This latter type of insufficiency is called functional. Its diagnosis, often difficult, depends on anamnesis, the habitual but not constant presence of an arterial hypertension or gallop- ing sound, and especially on the percussion and palpa- tion findings which reveal a considerable increase of the left ventricle. These signs, however, are not always con- clusive, and radioscopic examination is then of great assistance. Here is an example : A patient forty-six years of age, subject for two years to dyspnoea on exertion, had been in the hospital in 1908 and in January, 1910, for suffocating attacks of an oedem- atous nature. In March, 1910, he entered our depart- ment, with a similar attack which yielded to a copious phlebotomy. Examination showed that the heart was enlarged and dilated, and that at the apex there was, together with a very clear purring thrill, a somewhat modified systolic murmur, superficial, rather rough and lying below and within the heart apex. Arterial pressure was 15 cm. by sphygmometer. The urine contained a considerable quantity of albumen. The logical diagnosis from these findings should be as follows : mitral insufficiency with beginning cardiac insuf- ficiency. The principal points of the case, notably the pulmonary cedematous attacks and the absence of periph- eral oedema, are not explained. Finally, no history of infectious disease was found which could have given rise to mitral endocarditis. 94 THE HEART AND THE AORTA Radioscopic examination gave, on the other hand, vain- able information (Fig. 58). Fig. 58. FUNCTIONAL MITEAL INSUFFICIENCY. OF AGE MAN 46 YEAES It enabled recognition at once of the ordinary signs of mitral insufficiency: apex slightly lowered bnt pushed outward, with enlargement of the right ventricle; it showed, moreover, certain anomalies. The contour of the left ventricle was more marked than in cases of endocar- ditic mitral insufficiency; the apex, instead of being pointed, was rounded, slightly globulous. Finally, the longitudinal diameter measured 16.8 cm., while the hori- zontal was only 16.3 cm., so that there was a difference in favor of the longitudinal diameter contrary to what we have indicated in the foregoing. 18 In conclusion, in estimating the total increase in the volume of the heart, hypertrophy of the left ventricle played a much greater part than in the case of simple mitral insufficiency. The impression derived from clinical examination, is In analogous cases the figure of the index of depth is singularly in- structive; it rises to 20, 25 centimeters and even more, which indicates marked enlargement of the left ventricle. VALVULAR AFFECTIONS 95 namely, that it was a mitral insufficiency of functional origin, was therefore confirmed. The evolution of symptoms soon showed that this was correct. After some days of rest, the patient having been placed on a milk diet and treated with digitalis, the dis- turbances steadily diminished. The murmur at the apex disappeared and was replaced by a galloping rhythm in the left preventricular region. It was not a cardiac but a cardio-renal case and this conclusion was due to radiological examination. The diagnosis could therefore be made : cardiac hypertrophy, dilation of the left heart, functional mitral insufficiency in a patient with renal sclerosis. The case shown in the following tracing (Fig. 59) gave rise to the same problem which was solved in the same way. The patient was a man fifty-three years of age with mitral insufficiency due in the absence of previous infec- tions to a generalized alteration of the arterial system. Fig. 59. MITEAL INSUFFICIENCY AND AETEEIAL SCLEEOSIS. MAN 53 YEAES OF AGE Eadioscopic examination showed a considerable en- largement of the left heart, the apex was lowered and rounded, the right ventricle bulged a good deal to the 96 THE HEART AND THE AORTA right, the diameters measured : horizontal, 15.2 cm. ; lon- gitudinal, 16.6 cm. — a deviation the inverse of what is seen in endocarditic mitral insufficiency. The aorta, moreover, was very much dilated, its walls were dense, and pulsations feeble. These findings proved that the patient was affected with cardio-vascular sclerosis and that mitral insufficiency was only a secondary symptom developed in the course of his affection. MITRAL DISEASE There are cases in which the radiological tracing is sufficiently characteristic in itself to justify the suspicion of a lesion apart from the clinical examination of the patient. The following is an example : A young woman was seen by one of us at the request of a colleague who had previously made an orthodia- graphic examination of the patient's heart. The whole pathological history was clearly presented. The heart and the auricle showed deformations which could be ex- plained only by a double mitral lesion. Moreover, the very visible increase of the contour of the right ventricle presupposed the existence of marked failure of compen- sation, so that before we saw the patient the follow- ing diagnosis was justified: mitral stenosis complicated with insufficiency, together with cardiac insufficiency — which clinical examination confirmed. This method of procedure is not difficult and with little experience the interpretation of orthodiagraph^ tracings can be made. Fig. 60 illustrates this. It is seen here that in the frontal position the point G is surmounted by a salience and that the right contour shows an unusual development. These are characteristics peculiar to mitral stenosis. In the oblique position, it is necessary to put the patient at an angle of 60 degrees in order that the retro-cardiac clear space should appear as a narrow band in which a shadow is seen, due to the VALVULAR AFFECTIONS 97 hypertrophy of the left auricle (Fig. 61). These are the particular characteristics of mitral stenosis. In direct position, the apex, moreover, is not sharp as in simple mitral stenosis ; it is rather rounded and is de- pressed below the diaphragm and during deep inspiration the inferior contour of the heart is below the diaphrag- matic shadow. Finally, in determining at what angle the apex of the heart disappears behind the shadow of the Fig. 60 Fig. 60. DOUBLE MITEAL LESION. Fig. 61 GIRL 11 YEAES OF AGE Fig. 61. SAME PATIENT. DOUBLE SALIENCE OF LEFT AURICLE AND OF LEFT VENTEICLE IN EIGHT POSTEEIOE OBLIQUE POSITION, 60 DEGEEES vertebral column, it is found to be 45 degrees, a high figure and indicating that the left ventricle is enlarged. A further proof of this is that in left posterior oblique position at 60 degrees the ventricle projects below the left auricle in the retro-cardiac clear space. In this tracing, changes are found which belong on the one hand to mitral stenosis and on the other to insuffi- ciency. This diagnosis was further confirmed by the clinical findings, as the patient had a purring thrill at the apex, a diastolic rumble and a presystolic and systolic murmur. The increase in the volume of the left auricle and the hypertrophy of the left ventricle, which with double 98 THE HEART AND THE AORTA mitral lesions give special radioscopic findings, are seen in all cases of mitral disease. Figs. 62 and 63, a patient Fig. 62 Fig. 63 Fig. 62. DOUBLE MITEAL LESION IN THE ACUTE STAGE. 20.YEAES OF AGE MAN Fig. 63. SAME PATIENT, IN EIGHT POSTEEIOE OBLIQUE POSITION, 40 DEGEEES with double mitral lesion in the acute stage, can be inter- preted in the same manner. In the frontal position (Fig. 62), a salience of the left median arc and a notable enlargement of the left ventricle are seen ; the diameters of the heart are exaggerated, the longitudinal measures 15.2 cm., and the horizontal, 15.7 cm. In right posterior oblique position (Fig. 63), the retro-cardiac clear space is completely obscured by the left auricle and the left ventricle shadows. These characteristics are somewhat modified when the cardiac lesion is complicated by asystolic phenomena; the right ventricle then plays a more and more important part in the enlargement of the heart, its lower contour makes a salient which is greater according as there is more hypertrophy or dilatation of the ventricle, while VALVULAR AFFECTIONS 99 the apex of the heart is pushed outward. The index of depth shows in a clearer manner the degree of posterior development of the heart. Examinations in the oblique position confirmed these findings. But what is more, sometimes radioscopic examination determines the respective part played by stenosis and insufficiency in the case of a double mitral lesion. Fig. 64 shows a girl eight years old in whom ausculta- tion gave all the signs of a similar affection, and it shows what clinical examinations could not discover, that mitral stenosis had much more to do with the case than insuffi- ciency. In the frontal position, the median arc is much exag- gerated. Point D is elevated; the upper portion of the right contour is abnormally developed. Here are all the signs of a marked dilatation of the left auricle." On the other hand, the left ventricle is moderately enlarged, for if the apex does not separate from the diaphragm during deep inspiration, it disappears in the right posterior oblique position behind the vertebral column only at a slightly greater angle than normal. In the right posterior oblique position at 50 degrees (Fig. 65), the auricle is very large and completely ob- Fig. 64 Fig. 65 Fig. 64. DOUBLE MITEAL LESION WITH MITEAL STENOSIS PEEDOMINANT. GIEL 8 YEARS OF AGE Fig. 65. SAME CASE, IN EIGHT POSTEEIOE OBLIQUE, 50 DEGEEES 100 THE HEART AND THE AORTA scures the retro-cardiac clear space. The shadow of the left auricle is not large, for the lower part of the retro- sternal space is visible as a small transparent triangular zone. The conclusion is decisive, and if there is a double mitral lesion, stenosis is more marked here than insuffi- ciency. Radiological examination has allowed the objectifying of deformations of the heart due to the regular evolution of a mitral lesion, and also those which are the result of superadded complications. These may have various origins. Fig. 66. PULMONAEY INSUFFICIENCY COMPLICATING MITEAL DISEASE Exaggeration of the pulmonary arc. Heart ' ' en sabot. ' ' They result either from mechanical disturbances or from the secondary localization of infectious processes at the site of the regions previously affected. Stell in 1886, and again in 1906, called attention to the curious fact, that mitral lesions, especially stenosis, could provoke, following increase of pressure in the smaller vessels, an insufficiency of the pulmonary orifice of func- tional nature, demonstrated by a soft diastolic murmur, heard along the left border of the sternum. Since then VALVULAR AFFECTIONS 101 further cases have been reported and we have also ex- amined a certain number. This association adds a diffi- culty to the diagnosis, since the diastolic murmur may reasonably be considered symptomatic of an aortic lesion. Radioscopic examination, however, removes all doubt respecting diagnosis. Fig. 66 demonstrates this. The case is that of a woman with a double mitral lesion, stenosis being predominant over insufficiency. This pa- tient had had several attacks of severe dyspnoea which were later less severe when a new sign appeared, a dias- tolic murmur with the characteristics previously indi- cated, undoubtedly due to pulmonary insufficiency. The proof of it is furnished by the orthodiagram in question. A marked development of the pulmonary arc is seen, a no- table dilatation of the right cavities giving the heart the appearance of the "sabot" which is usual in lesions of the right heart. The configuration bears no resemblance to what is found in aortic lesions. Pulmonary insufficiency, however, may still be mani- fested, as Lutembacher 19 has noted, in the course of one of those variations of secondary subacute endocarditis which are common among cardiacs. In the case which we are considering, the inflammatory process is not con- fined to the endocardium, but extends to the pulmonary circulatory system and gives rise to a pulmonary endar- teritis with embolism or thrombosis, which on ausculta- tion is accompanied first by an exaggeration of the second pulmonary sound, then by a diastolic murmur characteris- tic of functional insufficiency of the orifice. On the radioscopic screen, changes identical with those which have just been indicated are noted. The only dif- ference consists in this, that they develop rapidly, the pulmonary arc presenting, at least in the course of a few days, a great exaggeration of its diameters (Fig. 67). As is readily seen, radioscopic images are not always i 9 E. Lutembacher, Endocardite subaique chez les cardiaques. (Archives des maladies du cceur, des vaisseaux et du sang, aout, 1917.) 102 THE HEART AND THE AORTA the same in cases of mitral lesion, bnt their dissimilarity is due to the fact that the anatomical configuration of the heart is modified according to the type and degree of the lesion. These images enable the diagnosis to be confirmed and, in a certain measure, the progress of the lesion to be followed ; but in order to be able to interpret them prop- erly, it is necessary to have at the same time a complete clinical and radiological knowledge. Fig. 67. PULMONARY INSUFFICIENCY IN THE COURSE OF A SECONDARY SUBACUTE ENDOCARDITIS Exaggeration of the pulmonary arc. Heart "en sabot." AORTIC INSUFFICIENCY The two principal types of insufficiency will be studied : endocarditic aortic insufficiency and aortic insufficiency, either arterial or subsequent to changes of the vessel, extending to the semilunar valves. ENDOCARDITIC AORTIC INSUFFICIENCY Fig. 68 is of a patient with typical aortic insufficiency, of rheumatic origin, with as yet no serious failure of compensation. VALVULAR AFFECTIONS 103 It shows the shadow of the heart occuj>ying a some- what median position and the apex, which is lowered, only slightly pushed outward; moreover, it is rounded and is not separated from the left diaphragm during forced inspiration. The general form suggests somewhat a purse, the bottom of which would correspond to the heart apex. The contour of the left ventricle is elongated, convex, but not exaggerated. Point Gr, though not very abnor- mally elevated, lies a little too high, being on the same line as the corresponding point D. Finally, the whole length of the left outline shows systolic pulsations of marked amplitude and force. The right contour is normal and this contour, more- over, is not modified except at the period when functional disturbances appear ; the presence of systolic pulsations, perceptible rather high above the diaphragm, does not necessarily indicate hypertrophy or dilatation of the ven- tricle to the right ; it may simply mean that the ventricle is pushed back as a result of the lowering of the heart and its displacement toward the median line, because of the weight of the left ventricle. Fig. 68. AOETIC INSUFFICIENCY. PEEIOD OF COMPENSATION. MAN 40 YEAES OF AGE 104 THE HEART AND THE AORTA Finally — and this agrees with the preceding data — the longitudinal diameter exceeds the normal, and the hori- zontal diameter is decidedly less. In the right posterior oblique position (Fig. 69), the apex of the heart disappears behind the vertebral column only at a wide angle, a fact which is easily explained, if it is granted, as has been shown, that hypertrophy of the left ventricle in its early stage affects the mediastinal area. Sometimes the enlargement is so slight that it can be shown only by determining index depth. Fig. 69. SAME CASE, IN EIGHT POSTEEIOE OBLIQUE POSITION At an angle of 40 degrees, the apex of the heart has not yet disappeared behind the vertebral column. The preceding images, therefore, lead to the conclusion that the patient is suffering from marked hypertrophy of the left ventricle without involvement of the other cavities. This view of the heart is characteristic of severe aortic insufficiency when it has not yet given rise to grave symptoms. It is necessarily completely modi- fied when it is caused by asystolic disturbances which provoke secondary deformations of the other cardiac cavities. The hypertrophy of the left ventricle is sometimes so slight in the course of aortic lesions that it might easily escape attention if recourse were not had to the different Fig. 70. TELEEADIOGEAPH OF AORTIC INSUFFICIENCY VALVULAR AFFECTIONS 105 methods indicated. In this case we might conclude that the heart is normal and if clinical signs are not char- acteristic, admit that valvular cardiopathy does not exist. The following is an example. On auscultation, the patient gave a rather accentuated diastolic murmur at the aortic area but of questionable character. In the frontal position orthodiagraphic ex- amination showed no pathological characteristic; the diameters of the cardiac shadow were normal; the apex was a little low and globulous. It was insufficient to prove, however, that the left ventricle was enlarged. Yet the index of depth was slightly but definitely exaggerated. Finally, in the right posterior oblique position it was necessary to place the patient at an angle of 35 degrees (instead of 30, the normal figure) to cause the apex to disappear. After that it was necessary to revise the negative conclusions of the examination made in the frontal position. The globulous form of the apex, the exaggeration of the angle at which it ceased to be visible in right posterior oblique position, the increase in the index of depth, were sufficient evidence that hypertrophy of the left ventricle existed, slight, it is true, but indis- putable. On the contrary, there are cases in which aortic insuffi- ciency, however well compensated, is accompanied by a considerable ventricular hypertrophy readily perceptible by the ordinary methods of radiological examination. The teleradiogram (Fig. 70) is a typical case. The ap- pearance of serious functional disturbances only in- creases ventricular hypertrophy, which may attain ex- cessive dimensions, as shown in Fig. 71. Radiological examination is able also to demonstrate the coexistence with aortic insufficiency of valvular cardi- opathy, notably of mitral stenosis. This is interesting, for it has been assumed, for purely theoretical reasons, that the association of these two lesions was a rather favorable condition. But in the great majority of cases 106 THE HEART AND THE AORTA the coexistence of a mitral stenosis with aortic insuffi- ciency has been based only on the presence of a presys- tolic murmur at the level of the apex. This is not suffi- cient, and today we know that simple aortic insufficiency is often accompanied by a murmur which has nothing to do with mitral stenosis and which is due exclusively to intra-ventricular circulation provoked by the reflux of the Fig. 71. AOETIG INSUFFICIENCY, ASYSTOLIC PERIOD Considerable hypertrophy of the left ventricle, dilatation of the right cavities. blood; what has been known as Flint's murmur. It is not surprising that aortic insufficiency accompanied by a murmur should generally be a favorable prognosis, for aortic insufficiency alone is not accompanied by any other lesion. On the other hand, where there is a combination of aortic insufficiency and mitral stenosis, the prognosis is always more serious. In pathology as in arithmetic, one and one make two, and an isolated lesion of the heart entails less risk than a double lesion. But how shall it be determined whether aortic insuffi- ciency is complicated with mitral stenosis, when the most VALVULAR AFFECTIONS 107 characteristic sign of this latter affection, the murmur, is found in both cases ? There is only one way of deciding it : that is to determine the volume of the left auricle, which is always increased in the case of mitral stenosis, and is normal, contrary to what Potain and Rendu have said, in aortic insufficiency alone. It is difficult to esti- mate the volume of the left auricle by the ordinary means of examination, and the method of dorsal percussion em- ployed is not always successful, whereas radiology gives conclusive information (see Fig. 72). Fig. 72 is of a patient who showed positive signs of aortic insufficiency and signs which gave the impression without affirming it, that a mitral stenosis was also present. The view of the heart in the frontal position recalls, indeed, what is found in aortic insufficiency. The left ventricle is greatly enlarged and the right contour is almost normal. The apex of the heart is pushed out but not elevated ; it is rather lowered, rounded and globulous. To this should be added the fact that the left ventricle Fig. 72 Fig. 73 Fig. 72. AORTIC INSUFFICIENCY AND MITRAL STENOSIS Fig. 73. SAME CASE, IN RIGHT POSTERIOR POSITION, AT 50 DEGREES 108 THE HEART AND THE AORTA pulsations showed in the course of radioscopic examina- tion an unusual amplitude. On this same tracing, however, the median arc is seen to be increased, which leads to the supposition that the auricle must be abnormally developed. In the right posterior oblique position (Fig. 73), this last sign becomes clear. It is seen that in the retro- cardiac clear space is a shadow due in part to the left ventricle, and in part also, in the upper region, to the auricle. For this to occur, the auricle itself must neces- sarily be enlarged. Both examinations then showed that there was indeed a combination of the two lesions : aortic insufficiency and mitral stenosis. AORTIC INSUFFICIENCY OF ARTERIAL ORIGIN In the preceding cases aortic insufficiency constituted, as stated, the entire disease, the aorta presenting no changes. This type of lesion, relatively favorable, is con- sistent with a more or less long life. But it is not the case with a valvular lesion when it coincides with exten- sive changes in the vascular system, principally of the aorta, and the prognosis then is entirely different. It is always important to know exactly the condition of the aorta in cases of aortic insufficiency. Radioscopy fur- nishes in such cases more information than other methods of examination. The orthodiagram in Fig. 74 is of a man fifty-three years of age, with a diastolic murmur at the base char- acteristic of aortic insufficiency. This lesion did not cause much disturbance. The preceding year, however, follow- ing common grippe, severe symptoms of cardiac failure appeared without any history which might explain the cause of a valvular lesion. The supposition was correct then, that it must be of arterial origin, although palpation and percussion did not show enlargement of the aorta. Orthodiagram 74 confirms the diagnosis of aortic in- VALVULAR AFFECTIONS 109 sufficiency. It is seen here, that in the frontal position the left contour is elongated and dilated, that the apex is rounded and lowered, which is evidence of serious ven- tricular hypertrophy. Examination of the aortic out- line, moreover, shows that the vessel is dilated at its Fig. 74 Fig. Fig. 74. AOETIC INSUFFICIENCY WITH DILATATION OF THE AORTA AT ITS POINT OF ORIGIN. MAN 53 YEARS OF AGE Fig. 75. SAME PATIENT IN RIGHT ANTERIOR OBLIQUE POSI- TION AT 45 DEGREES. THE CALIBER OF THE AORTA IS LARGER AT THE ORIGIN THAN AT THE LEVEL OF THE ARCH origin from the valvular ring to the level of the arch where it resumes its normal caliber. On the right it projects over the sternum, and at this point (at the level of the arrow) the aortic shadow shows very ample pul- sations. In the right anterior oblique position (Fig, 75), the aortic shadow assumes the form of a cone, the largest part of which corresponds to the base of the heart. The conclusion from the examination of these two figures is that there was aortic insufficiency, as ausculta- tion indicated, but that this lesion was, so to speak, only an epiphenomenon occurring in the course of aortitis. In the following case (Fig. 76), the clinical and radio- 110 THE HEART AND THE AORTA scopic signs were still more emphasized. A man thirty- nine years of age with Hodgson's disease, presenting serious functional disturbances : dyspnoea on exertion, vertigo and anginose attacks. The tracing shows in the frontal position a considerable enlargement of the area of projection of the heart. The longitudinal diameter measures 16 cm., the horizontal, 13.2 cm.; the apex is Fig. 76. AOETIC INSUFFICIENCY OF ARTERIAL ORIGIN. MAN 39 YEARS OF AGE rounded and lowered. In the right posterior oblique position it disappears behind the vertebral column only at an angle of 48 degrees. On the screen the left contour of the heart, greatly enlarged, showed ample pulsations ; the ascending portion of the aorta was dilated, tortuous, dense, and at each systole the arch as a whole showed forcible pulsation. There were found characteristics of both lesions : aortitis and valvular insufficiency. But these lesions were accompanied, besides, by an interesting peculiarity. Whereas in cases of simple aortitis the vascular contour VALVULAR AFFECTIONS 111 is muck reduced in its rhythmic expansion, because of the thickening of the arterial walls, here, on the contrary, the arch was animated at each systole by forcible pulsa- tions. The forcible contraction of the left ventricle dis- placed the arch entirely, and these displacements were especially noticeable in the left superior arch. This showed that the aorta but feebly resisted the pressure of the blood. AORTIC STENOSIS Anatomical findings in cases of aortic stenosis suggest that the changes in the heart ought to be similar to those of aortic insufficiency. These changes should consist of an even more marked enlargement of the left ventricle and in the frequent coexistence of lesions of the aorta. That is in point of fact what is found in the tracings. Orthodiagram 77 is of a patient forty years of age with serious aortic stenosis, with no sign of cardiac insuffi- ciency. The point to be noted here is the excessive devel- opment of the volume of the heart ; the longitudinal diam- eter measures 17.5 cm. ; the horizontal, 17.8 cm. ; the aorta shows no lesion. In this case the clinical diagnosis was apparent and radioscopy confirmatory. Fig. 77. AORTIC STENOSIS WITHOUT AORTITIS. MAN 40 YEARS OF AGE 112 THE HEART AND THE AORTA It is not always so. Often it is difficult to know whether or not aortic stenosis exists, for the systolic murmur at the base is difficult to interpret, and hypertrophy of the left ventricle always present in this disease is not suffi- ciently marked to be obtained by palpation or percussion. It is in such cases that radiology is most effective, and several times in debatable cases, aortic stenosis had to be determined by the single fact that screen examination demonstrated the presence of a left ventricular hyper- trophy. Fig. 78. AORTIC STENOSIS. DILATATION AND FORCIBLE PULSA- TION OF THE AORTA. YOUTH 17 YEARS OF AGE This examination leads to other findings which have an important bearing on the prognosis of aortic stenosis, which varies according as the lesion is simple or accom- panied by more or less extensive changes of the aorta. These findings should be interpreted with great care, as the following case shows. A youth seventeen years of age affected with aortic stenosis as shown by a systolic murmur at the base. The orthodiagraphic tracing (Fig. 78) confirmed the diagno- sis, for all the objective signs were characteristic. On VALVULAR AFFECTIONS 113 superficial examination, it might have been thought that there were at the same time marked lesions of the vessel, which would have given an unfavorable prognosis. In the frontal position, an evident enlargement of the arch was observed, its total transverse diameter being 7.5 cm. instead of 4 or 5 cm., the normal figure. However, in the right anterior oblique position the enlargement was barely appreciable, for the diameter of the aorta meas- ured only 2.2 cm., which is but a slight deviation from the physiological. On the screen, the arch of the aorta was greatly dilated at each systolic pulsation and in the course of full pulsations its walls deviated 5 or 6 mm. from their normal position of rest. The necessaiy conclusion, then, was that the increase in volume of the aorta was due to a functional dilatation rather than to a permanent dilata- tion, that the arterial walls had retained all their elastic- ity, which led to a revision of the dubious prognosis re- sulting from the first examination. In this connection, insistence should be made on the value of fluoroscopic examination, as conclusive information is thus obtained. If a radiographic tracing only had been taken, there is no doubt that it would have been found like Fig. 78, and that Fig. 79. AOETIC STENOSIS WITH AORTITIS. MAN 56 YEAES OF AGE 114 THE HEART AND THE AORTA a serious lesion of the aorta would have been suspected which, in point of fact, did not exist. On the other hand, when aortic stenosis is accompanied by aortitis affecting the thoracic aorta in its visible por- tion, a tracing is obtained analogous to that of Fig. 79, which leaves no room for doubt. This figure is of a man fifty-six years of age with aortic stenosis. The tracing shows hypertrophy of the two ventricles, especially of the Fig. 80. DOUBLE AOETIC LESION. MAN 59 YEAKS OF AGE \ left, and in addition a uniform enlargement of the aortic shadow, in the frontal and oblique position. On the screen, this dark shadow shows no marked pulsations. The contrast between this case and the preceding gives information of practical value. These indications, diagnostic of one or the other of the valvular lesions of the aorta, may be equally instructive in the diagnosis of associated lesions (Fig. 80). They permit of the determination of the signaletic state of the aorta which is, in this case, usually altered. They will be studied in more detail in one of the following chapters (see Aortitis, Chap. VIII). CHAPTER V CONGENITAL AFFECTIONS OF THE HEART RADIOLOGY plays a more or less important part in the diagnosis of congenital lesions of the heart. This diagnosis is ordinarily easily made when it is a question of the most common lesion, that is, stenosis of the pul- monary artery with inter-ventricular perforation; it is on the contrary very difficult when it is a question of mal- formations which on auscultation and percussion give no sign or when they result from disturbances in the respec- tive positions of the several cavities. Radiology does not attempt to remove all uncertainties, and it is true that it cannot demonstrate the persistence of patent ductus arteriosus, the transposition of the great vessels, etc.; but in demonstrating the modifications which certain mal- formations impress on the configuration of the heart, it allows at least suspicion as to the cause. To complete the study which has just been undertaken, it is necessary to accumulate observations, to compare them with each other, and to draw conclusions which will facilitate further research. A report, therefore, of the cases examined and of the indications furnished by radio- logical examination will be given in the following chap- ters. I. STENOSIS OF THE PULMONARY ARTERY WITH INTER- VENTRICULAR PERFORATION This affection, the most frequent of the congenital lesions, is ordinarily revealed by cyanosis from birth, increasing progressively as time goes on, and accompa- \j nied by more or less pronounced dyspnoea. Palpation 116 THE HEART AND THE AORTA gives a systolic thrill, in two areas, one at the origin of the pulmonary artery, the other at the median region of the heart. Auscultation gives a rough systolic murmur, in the second intercostal space, transmitted toward the left clavicle, and sometimes another murmur, also sys- tolic, of deeper tone, heard at its maximum in the third intercostal space and transmitted transversely toward the axilla. However, these signs are not constant and the inter- pretation of them is difficult, especially in inter-ventricu- lar perforation associated with stenosis of the pulmo- nary artery, a communication most difficult to determine. In these cases radioscopic examination gives precise information, as the following show: 1. Mme. M., age twenty-five years, dyspnoea on exer- tion from early infancy. Dyspnoea has increased for sev- eral years and causes paroxysms which oblige the patient to go to bed for weeks and months at a time. No cyanosis evident. Examination of the eyes (Dupuy-Dutemps method) does not reveal retinal cyanosis ; but the arteries are darker than normal. No oedema of the legs. No dis- turbance with elimination of chlorides. Blood examina- tion: EC = 3,910,000; WC = 14,000. On examination of the heart a slight systolic thrill is noticed in the second and the third left intercostal space transmitted transversally toward the axilla. Ausculta- tion gives a murmur which is clearly systolic, rough in the second space, softer in the third and fourth spaces, transmitted toward the clavicle, the neck, the axilla, and sharply audible in the back between the left scapula and the vertebral column. In this patient the clinical diagnosis of stenosis of the pulmonary artery with inter-ventricular perforation is obvious by the combination of functional symptoms and objective signs characteristic of the affection, notwith- standing the absence of congenital cyanosis. The orthodiagraphic tracing in the frontal position CONGENITAL AFFECTIONS 117 (Fig. 81) shows that the left contour presents nothing abnormal, that the apex of the heart rests on the dia- phragm, from which it separates in deep inspiration. The right contour, more developed than in the normal state, overlaps considerably the medio-sternal shadow. On the lower part, corresponding to the right ventricle, may be noted ample pulsations of the cardiac shadow. In general, however, the diameters of the heart are not exaggerated. Longitudinal diameter 13 cm Horizontal .12.5 cm D'G 10 cm Fig. 81. MME. M., 25 YEAES OF AGE PULMONAEY STENOSIS AND INTEE-VENTEICULAE PEEFOEATION In this figure, however, an anomaly exists which is important to note : there is an exaggerated saliency of the median arc in the upper part at the level of the pulmonary artery shadow (P). The cross marked on this figure corresponds to the site of the murmur and of the purring thrill. In the right posterior oblique position at 50 degrees 118 THE HEART AND THE AORTA (Fig. 82), the outlines of the left auricle (OGr) and of the left ventricle (VG) present nothing abnormal. On the contrary, in the retro-cardiac clear space downward under the aortic shadow (A), an exaggerated salience of the pulmonary artery (Pul) is seen. In the right anterior oblique position at 50 degrees (Fig. 83), the shadow of the left ventricle is normal, but the salience of the pulmonary artery in the retro-sternal clear space is considerable. In the retro-cardiac clear space downward below the aortic shadow (A), an exag- gerated projection of the pulmonary artery is seen (Pul), with an increase in the outline of the right auricle (OD) and with an enlargement of the right ventricular (VD) shadow. The findings, therefore, in the three positions give simi- lar information: the left ventricle is of normal dimen- sions ; the right cavities, especially the ventricle, are en- larged ; finally, the pulmonary artery in its entire visible portion is much dilated. Fig. 82 Fig. 83 Fig. 82. SAME PATIENT, IN EIGHT POSTEEIOE OBLIQUE POSI- TION AT 50 DEGEEES A, aorta. Pul, pulmonary artery. OG, left auricle. VG, left ventricle. Fig. 83. SAME PATIENT, IN EIGHT ANTEEIOE OBLIQUE POSI- TION AT 50 DEGEEES CONGENITAL AFFECTIONS 119 2. Mile. C, twenty-five years of age; since childhood subject to attacks of dyspnoea which had become almost incessant so that she had had to stop work four months previously. Moderate cyanosis of the face and the hands showing more when active; slight retinal cyanosis (Dupuy-Dutemps). Blood findings: RC = 4,200,000; WC = 14,000. Fig. 84. MLLE. C, 25 YEARS OF AGE PULMONARY STENOSIS AND INTER-VENTRICULAR PERFORATION Examination of the heart gives a very intense purring thrill greatest at the level of the second left intercostal space ; on auscultation, a rough systolic murmur is heard all over the precordial region, most marked at the level of the left second intercostal space and transmitted toward the clavicle and to the back. The clinical characteristics indicate stenosis of the pulmonary artery with inter- ventricular perforation. Orthodiagraphic examination presents, beside the gen- eral characteristics common to this lesion, some other changes. In the frontal position (Fig. 84), the usual en- largement of the pulmonary arc in its main portion is noticed. But especially is the increase of the cardiac shadow, both right and left ventricle, more marked here than in the preceding case. The shadow of the aorta dis- appears in the right posterior oblique position at an angle 120 THE HEART AND THE AORTA of 40 degrees instead of 30, the normal figure. The meas- urement of the diameters is : Longitudinal diameter 13 cm. Horizontal 12.5 cm. D'G 10.5 cm. In the oblique positions (OPD and OPGr, Figs. 85 and 86) examination shows that the right auricle is especially enlarged. Finally, a slight dilatation of the right ventri- cle was observed on exertion. The result was that if these signs confirmed the diagnosis, they demonstrated also that the heart by reason of its enlargement and increase of the right cavities was beginning to show signs of failure of compensation. 3. Mile. Mo., twenty-three years of age, presents also subjective and objective signs characteristic of congenital lesion of the pulmonary artery. Examination of the tracing (Fig. 87) shows that the pulmonary arc or the median arc is considerably devel- oped, which is evidence of dilatation of the pulmonary artery to a very marked degree. On the other hand, the contour of the left ventricle is strongly accentuated, the Fig. 85. SAME PATIENT AS FIG. 84, IN EIGHT POSTERIOR OBLIQUE POSITION AT 50 DEGREES Fig. 86. SAME PATIENT, IN LEFT POSTERIOR OBLIQUE POSITION AT 50 DEGREES CONGENITAL AFFECTIONS 121 right contour itself is exaggerated and all the diameters are increased : the longitudinal diameter and the horizon- tal measure 15 cm. ; the line D'G, 12.6 cm. The apex of the heart, pushed sharply outward and slightly lowered, dis- appears in the right posterior oblique position at an angle of 50 degrees. The conclusion is then that the effect of the lesion on the heart is much more manifest than in the preceding cases. Fig. 87. MLLE. MO., 23 YEARS OF AGE PULMONARY STENOSIS AND INTER-VENTRICULAR PERFORATION 4. The modifications just indicated are not peculiar to old lesions, and are found in very young children, as dem- onstrated by the orthodiagram shown in Fig. 88, which Fig. 88. CHILD 17 MONTHS OLD PULMONARY STENOSIS AND INTER-VENTRICULAR PERFORATION 122 THE HEART AND THE AORTA is of a child seventeen months old with congenital cyano- sis, presenting signs ordinarily characteristic of stenosis of the pulmonary artery, accompanied by inter-ventricu- lar perforation. In a general way, it recalls the other tracings. The heart is pushed outward, the development of the right cavities is exaggerated and the pulmonary arc makes an abnormal salience. The radiological data in the case of stenosis of the pul- monary artery with inter-ventricular perforation may be summed up as follows : QJ) (a) Exaggerated development of the shadow of the right ventricle and often of the right auricle. (b) No increase, or slight increase at the beginning, of the contour of the left ventricle; more considerable in- crease in a later phase of the disease. (s£/ ( c ) Exaggeration of the median arc or the pulmonary arc, especially in its superior portion. The first two findings agree with the pathology. Both methods of examination demonstrate that the right ven- tricle becomes progressively hypertrophied in order to overcome the resistance offered to the blood stream by the contraction of the pulmonary orifice, and that in the end the circulatory difficulties fall upon the right auricle. Though the left auricle shows no notable changes in the beginning, later, however, it becomes hypertrophied, especially when functional disturbances are marked. Dilatation of the pulmonary artery would not seem, according to anatomical evidence, to constitute a constant symptom of this disease, though it has been noted in sev- eral cases. But radioscopic examinations showed that it was never lacking. The necessary conclusion from this is that in life the artery is much distended, but that this distension rarely results in a permanent dilatation, so that after death very little evidence is found and only in a very inconstant manner. Later this interesting ques- tion will be dealt with again. CONGENITAL AFFECTIONS 12:3 II. SIMPLE STENOSIS OF THE PULMONARY ARTERY Stenosis of the pulmonary artery is characterized solely by a systolic murmur at the base, intense, vibrant, sometimes rasping, heard in the left second intercostal space and accompanied, on palpation, by a purring thrill. It is transmitted up toward the left clavicle, but is absent in certain cases, notably when stenosis affects the vessel to a sufficiently great extent. On percussion, the transverse dullness of the heart is increased and overlaps the right contour of the sternum, which indicates a more or less marked hypertrophy of the right cavities. As to functional signs, they are extremely variable. If dyspnoea is frequent with palpitations supervening even during rest, cyanosis, on the contrary, is very inconstant and may even be absolutely lacking. Three observations of this affection are presented here: 1. Child fourteen years of age with intense cyanosis and considerable dyspnoea with paroxysmal attacks. Localized purring thrill at the left second intercostal space, no clear murmur heard. The orthodiagraphic tracing of this patient (Fig. 89) presents the characteristic form known as "en sabot" : the heart apex is pushed outward and elevated ; below it Fig. 89. PULMONARY STENOSIS p, apex of the left heart; p', apex of the right heart. sabot. ") ( Heart ' ' en 124 THE HEART AND THE AORTA the apex of the right ventricle is rounded and the inferior contour of the heart descends much lower than normally. The right contour greatly overlaps the sternum. In the vicinity of the diaphragm very ample systolic pulsations of the hypertrophied right ventricle are seen. Finally, the left median arc or pulmonary arc shows an abnormal salience in its upper part. 2. Nina P., twenty-three years of age, with Fried- reich's disease (case reported by Babinski), gives a very localized murmur in the left second intercostal space, transmitted toward the clavicle. Slight tremor attacks of paroxysmal tachycardia with syncope. Slight cyano- sis. Fig. 90. NINA P., 23 YEAES OF AGE CONGENITAL PULMONARY STENOSIS The orthodiagraphic tracing of this patient (Fig. 90) presents the same characteristics as the preceding, but with the following differences : a greater development of the heart, apex of the left ventricle elevated and pushed outward, lower contour of the right ventricle exaggerated and displacement of the right cavities toward the right. The diameters are: Longitudinal diameter 15.4 cm Horizontal 15.2 cm D'G 11.9 cm CONGENITAL AFFECTIONS 125 Finally, the median arc or the pulmonary arc makes a considerable salience. 3. Mile. Mu., twenty years of age; systolic murmur heard in the second left intercostal space, purring thrill, dyspnoea. Fig. 91. MLLE. MU., 20 YEAES OF AGE CONGENITAL PULMONAEY STENOSIS Here the orthodiagraphy characteristics (Fig. 91) are less definite than in the first two tracings. The volume of the organ is nevertheless exaggerated. The apex of the heart is pushed slightly outward but is not elevated. The contour of the left ventricle which appears rather large does not, however, indicate that the cavity is increased. The salience of the left ventricle, in fact, is not abnormal in the right posterior oblique position. Hypertrophy of the right ventricle is evident exclusively by its sharp projection to the right and by the pulsations (at the level of the arrow). The diameters are : Longitudinal diameter 12.8 cm Horizontal 11.9 cm D'G 10.1 cm The median arc or the pulmonary arc is manifestly exaggerated. 126 THE HEART AND THE AORTA It will be seen that in the case of simple stenosis of the pulmonary artery, the essential data obtained by radiological methods, consist : (1) in the enlargement of the right ventricle;^) in an abnormal salience of the pulmonary arc, a salience which can be determined, at least, in the majority of cases; ^(3) in the absence of apparent modifications in the volume of the left ventricle. The enlargement of the right ventricle is a constant fact; besides, pathological anatomy demonstrates that it is seldom lacking. It is not due to a dilatation of the cavity, but to a real hypertrophy of the wall described by Moussous 20 as follows: "The ventricular cavity is not very voluminous, it contains less fluid than it ought to contain, and its walls are extremely thick. The columnae carneae are strongly marked as well as the papillary muscles. The muscular development assumes an unusual importance. Sometimes the thickness of the walls is due to a slight sclerosis ; there is diffuse or localized myocardi- tis. Histological studies on this subject, however, are very scant. The results of some microscopic examina- tions justify the statement that hypertrophy properly so called is the principal fact. ' ' As for the dilatation of the pulmonary artery, observed in all the cases which we have studied, and which is not considered as persisting after death, that may be ex- plained in different ways: in the first place it can be admitted that when stenosis, instead of being limited to the orifice, affects to a great extent the vessel, there is no dilatation. We have observed a case of this type. In others it is fair to suppose that the dilatation must have been of functional origin and for that reason was not found on autopsy. The absence of modifications in volume of the left ven- tricle is easily understood, for this cavity is not in any way concerned in the lesion which affects only the right heart. 20 Moussous, Maladies congenitales du cceur. Collection .Leaute. CONGENITAL AFFECTIONS 127 III. INTER-VENTRICULAR PERFORATION This condition, which has been described by Roger,- 1 is accompanied by a systolic purring thrill at the level of the third left intercostal space, a thrill which is appar- ently lacking when the patient is on his back, but which almost always reappears in left lateral recumbency. Auscultation gives a systolic murmur, unchanging, rough, intense, high pitched, at its maximum heard in the inner part of the third intercostal space and the fourth rib, and which is transmitted outward but diminishes rapidly. On percussion there is an increase in the transverse dullness of the heart. There are generally no functional signs, but less constantly than Roger thinks, for in a cer- tain number of cases dyspnoea and cyanosis are found, less marked, it is true, than in the preceding cases, and always occurring later. Observations of such cases are presented here : 1. Mile. V., ten and one-half years of age, height 1.51 m., weight 25 kilograms ; apparent health entirely normal. No dyspnoea, patient can run without the least discom- fort ; there is no trace of cyanosis. Auscultation gives an intense systolic purring thrill, especially in left lateral recumbency at the level of the third intercostal space, transmitted outward but not to the axilla. Radioscopic examination shows a heart of considerable volume and abnormal in form (Fig. 92). The right and left contour are markedly developed on both sides of the medio-sternal line. Synchronous systolic pulsations are visible in both contours. The diameters are : Longitudinal diameter 13.9 cm. Horizontal 14.6 cm. The apex of the heart, markedly globular, is pushed out- ward and elevated; the contour of the right ventricle is rounded below the diaphragm during inspiration and 2i Roger, Academie de Medecine, 1879. 128 THE HEART AND THE AORTA projects markedly to the right. The right ventricle shows a marked hypertrophic dilatation; the left ventricle is also increased in volume. The vascular arcs show no exaggeration. 2. Mme. Sch., forty years of age. Subject since in- fancy to attacks of dyspnoea. For some time these attacks have become very severe and frequent, accom- panied by palpitation, pain at the level of the second left intercostal space, and extra-systolic arhythmia. No cya- nosis. The general state of health has been, nevertheless, fairly satisfactory. Six confinements. Three children died in infancy. Examination of the heart shows an intense systolic thrill, localized in the third left intercostal space and limited to this space. Cardiac dull area slightly enlarged, overlapping the sternum at the base. On auscultation, there is heard over the entire precor- dial region a systolic murmur, rough, rasping, high pitched, at its maximum in the third left intercostal space, near the sternum and transmitted transversally toward the left ; it is not heard under the clavicle. Fig. 93, an orthodiagraphic tracing, shows a cardiac Fig. 92. MLLE. V., 10y 2 YEAES OF AGE INTER-VENTRICULAR PEKFORATION Very large globular heart, median, equally enlarged right and left; ample systolic pulsations on both sides. CONGENITAL AFFECTIONS 129 area markedly developed on both sides of the medio- sternal line, left contour elongated, convex, rounded apex descending below the diaphragm and level with it in deep inspiration; the right contour projects broadly, especially in its upper portion (auricular). At the level of the arrow are seen ample systolic pulsations of the hypertrophied right ventricle. Fig. 93 Fig. 94 Fig. 93. MME. SCH., 40 YEAES OF AGE INTEE-VENTEICULAE PEEFOEATION A, aorta; P, pulmonary artery. Fig. 94. SAME PATIENT, IN LEFT POSTEEIOE OBLIQUE POSI- TION AT 62 DEGEEES The vascular arcs are moderately accentuated and pul- sate very actively. The aorta and the pulmonary artery do not appear dilated. In the left posterior oblique position the clear space appears, much reduced, at an angle of 62 degrees. The outline of the heart indicates an enlargement both of the right auricle and of the right ventricle (Fig. 94). In the right posterior oblique position, the apex of the heart disappears at the slightly wide angle of 35 degrees. 130 THE HEART AND THE AORTA In another case, on account of the existence of a systolic murmur heard entirely in the central region of the heart, a diagnosis of inter-ventricular perforation without stenosis of the pulmonary artery was affirmed by radio- scopic examination with certain reservations. This trac- ing (Fig. 95), in fact, shows that the heart is markedly developed on both sides of the medio-sternal line, as in the preceding cases, and that the hypertrophy of the right ventricle is greater than that of the left ventricle ; but, on the other hand, an enlargement of the left median arc is observed indicating a slight dilatation of the vessel. The patient was also slightly cyanotic. Therefore after hav- ing affirmed clinically the absence of stenosis of the pul- monary artery, finally, on radioscopic examination, an opinion was given that alteration of the pulmonary artery was present. Fig. 95. ALBERT D., 33 MONTHS OF AGE POSITIVE INTER-VENTRICULAR PERFORATION Pulmonary stenosis probable because of the marked salience of the median arc. Besides these cases, in which the radiological aspect of the heart has very definite characteristics,, patients are found affected with Roger's disease, in whom orthodia- graphic examination demonstrates only a slight influence of the lesion on the volume of the heart. The slight hypertrophy of the two ventricles can be shown as fol- lows : convex left contour ; apex pushed outward, slightly elevated and globular ; inferior contour of the right heart lowered ; right outline overlapping the pulmonary field to some extent; horizontal diameter slightly greater than CONGENITAL AFFECTIONS 131 the longitudinal. Finally, as in other observations, no changes in the vascular arcs. The cardiogram (Fig. 96) represents this aspect of the heart. It is to be noted also that the importance of the changes is not always in relation to that of the lesions. The exte- rior configuration, however, conforms in all respects to the anatomical changes of the septum which has been described. Fig. 96. DEL., 32 YEAES OF AGE INTEE-VENTEICULAE PEEFOBATION To summarize, therefore, the findings in Roger's dis- ease, the radioscopic characteristics are as follows : v 1. The cardiac shadow usually shows an increase as a whole and is developed equally on both sides of the medio- sternal line ; however, hypertrophy of the right ventricle is more important than that of the left ventricle. In some less characteristic cases, the increase in volume of the heart is not so marked and the outlines are scarcely de- formed. Nevertheless, the usual signs of hypertrophy of the two ventricles are found. V 2. Clear, full pulsations of the left and right contour may be demonstrated. J 3. There is no change in the vascular arcs. In a general way these data confirm the pathological 132 THE HEART AND THE AORTA findings which show that cardiac hypertrophy chiefly affects the right ventricle. However, Merklen has de- clared that there is in addition a rather marked dilatation of the pulmonary artery, as in the cases in which there is stenosis of the orifice. The last observation would seem to confirm this statement of Merklen, but it may be pointed out that this observation has not seemed con- vincing and that on this point some reservations had to be made relative to the possible coexistence with inter- ventricular perforation of a lesion of the pulmonary artery. Perhaps the same was true in the cases observed by Merklen. IV. CONGENITAL AORTIC STENOSIS Congenital stenosis of the aorta presents in a general way the same objective signs as acquired aortic stenosis : purring thrill more or less marked at the area of the ori- fice, systolic murmur transmitted toward the right clavi- cle, marked enlargement of the left ventricle. The func- tional signs consist in the early appearance of palpitation, of dyspnoea on exertion, etc. In a case which was examined, radiological investiga- tion confirmed the diagnosis, and determined an interest- ing detail, the significance of which already has been dis- cussed when congenital stenosis of the pulmonary artery was considered, namely, dilatation of the vessel below the lesion. Carmen P., thirteen years of age, sickly and emaciated, of keen intelligence, but constrained to relative immo- bility, the least movement causing attacks of palpitation and dyspnoea. These disturbances appeared as soon as the child began to walk. Examination of the chest shows the existence of forcible impulsive pulsations in the aortic region. The pulsations of the aorta, perceptible in the sternal notch, are accompanied by an intense thrill. The orthodiagraphic tracing (Fig. 97) shows the left contour of the heart convex and elongated ; the apex is CONGENITAL AFFECTION S 133 rounded, depressed, pushed slightly outward. The right contour is not modified; only the left ventricle is hyper- trophied. Fig. 97 Fig. 98 Fig. 97. CAEMEN P., 13 YEARS OF AGE CONGENITAL AORTIC STENOSIS. Hypertrophy of the left ven- tricle, dilatation of the aorta. Fig. 98. SAME PATIENT, IN RIGHT ANTERIOR OBLIQUE POSITION Diameter of the ascending aorta: 1.8 cm. The diameters are : Longitudinal diameter 10.5 cm Horizontal 9.5 cm D'G 8.6 cm The right median arc and the left superior arc are exaggerated, and in the frontal position this corresponds to an enlargement of the aortic arch. In the right ante- rior oblique position (Fig. 98), the shadow of the ascend- ing aorta is enlarged. The volumetric description of the aorta 22 by the method of the three dimensions gives the following results : Transverse diameter 5.5 cm. Chord 2.0 cm. Descending aorta 1.8 cm. 22 See below (Aortitis) the study of the volume of the aorta by the three dimensions method. 134 THE HEART AND THE AORTA The caliber of the vessel is about 2 cm., a figure that is high for a girl thirteen years of age. Finally, rather ample pulsations along the aortic walls are noted. The pulmonary artery is not dilated, the left median arc is normal; pulsations here were marked and more ample than those of the aorta. The result of this observation is that aortic stenosis is characterized from the radiological point of view by hypertrophy of the left ventricle and dilatation of the aorta. Ventricular hypertrophy is easily understood and agrees with the pathological findings. As for the dilata- tion of the aorta, it is a matter for discussion, because not ordinarily found in autopsies. It is very probable that it is to be explained in the same way as dilatation of the pulmonary artery, in case of congenital stenosis of the orifice, and that it is due to a distension of functional nature, so that it may be perceptible during life but not found after death, though it has been noted. The congenital origin of aortic stenosis, therefore, may be suspected in a young patient affected with this lesion whenever radioscopy shows more or less marked dilata- tion of the vessel. 23 V. CARDIAC ECTOPIA AND TOTAL INVERSION OF THE VISCERA We have twice observed this malformation, which is, moreover, only of documentary interest. In the first case, the patient was affected with cardiac ectopia fol- lowing congenital sternal malformation. Union had not taken place in the lower three-quarters of the body of 23 We have had occasion to observe other cases of congenital stenosis of the aorta in children. The radiological characteristics agreed absolutely with those which we have just presented. We found the dilatation of the vessel above the lesion, such as described. On the screen, the aorta showed very ample pulsations. CONGENITAL AFFECTIONS 135 the sternum with separation of the xiphoid appendage. A hernia of the heart resulted. Other malformations were also noted : inter-ventricular perforation, double superior vena cava, etc. The heart was very voluminous, especially because of the hyper- trophy and the dilatation of the right cavities, auricle and ventricle. The aorta was small, the pulmonary artery very much dilated. These findings naturally could not have been obtained until after death, and diagnosis of the ectopia alone was made during life. Fig. 99. CAEDIAC ECTOPIA Inter-ventricular perforation. Marked hypertrophy of the right ventricle. Radioscopic examination gave only a very incomplete image of these multiple malformations. In the frontal position (Fig. 99), a very marked development of the cardiac shadow, right and left of the median axis, was noted. In the left posterior oblique position at 50 de- grees (Fig. 100), at P and at P' two centers of superim- posed pulsations were observed, which gave the impres- sion of two apices of the heart. In fact, it was the apex of the left ventricle which pulsated at P and the lower edge of the right ventricle at P\ These exceptional obser- vations may be made use of by observers in analogous cases. The second case was a question of dextrocardia with total inversion of the organs. Radioscopy confirmed the 136 THE HEART AND THE AORTA displacement of the heart and showed that it was not due solely to a torsion of the organ at the base, nor to cardiac fixation caused by old adhesions ; in short, it was not an acquired dextrocardia. All the relations of the inverted heart with the neighboring organs were normal. Radios- copy also demonstrated the inversion of the other organs, which is the rule in congenital dextrocardia. Figure 101, which shows this anomaly, is taken in the frontal or direct anterior position ; it looks like an ortho- diagram taken in the dorsal position. The apex of the heart is on the patient's right, the ascending aorta on the left, the arch goes from left to right, the stomach is on the right, the liver is on the left. The patient was sixty- two years of age and has been able to lead a normal existence up to the present time. These cases of congenital conditions are the only ones that conclusions can be drawn from. According to cer- FiG. 100. CAEDIAC ECTOPIA SEEN IN THE LEFT POSTEEIOE OBLIQUE POSITION AT 50 DEGEEES P, apex of the left ventricle; P', apex of the right ventricle; B, gastric air -bubble. CONGENITAL AFFECTIONS 187 Fig. 101. INVERSION OF THE ORGANS B, gastric air-bubble; F, liver. tain writers, notably Groedel, 24 Anheim, Hoffmann, 25 the persistence of Botal's duct (ductus arteriosus) could be equally well shown by the particular aspect of the heart on radioscopic examination. According to them, the heart with this lesion would keep its normal dimensions, but a very special enlargement of the median arc would exist, which corresponds, as is known, to the region of the pulmonary artery, of the auricula and the left auricle. Enlargement of the upper part would indicate simply that there is a dilatation of the pulmonary artery, whereas a simultaneous enlargement of the inferior part which corresponds to the left auricle would favor the persistence of Botal's duct. We have not had occasion to verify this fact. 24 Th. et Fr. Groedel, Sur la forme de la silhouette du cceur dans les affec- tions cardiaques congenitales. Deutsches Arch. f. Klin. Mediz. B. CTII, 13, juillet, 1911. 25 Hoffmann, L'examen fonctionnel du cosur, 1911. 138 THE HEART AND THE AORTA Up to the present time the persistence of the ductus arteriosus has not been the subject of conclusive clinical evidence. In one case where it was suspected, it existed, with the usual signs on auscultation, a dilatation affect- ing at the same time the aorta and the pulmonary artery. These data and de la Camp's observations of the ab- normal force of the pulmonary artery pulsations have only a documentary value. The study of the radiological findings just discussed in the diagnosis of congenital lesions of the heart shows the importance of the information furnished radiologically in cases which were suspected because of functional and physical signs but could be affirmed only with certain reservations. Besides these cases there are others where it is impos- sible to specify the nature of the cardiac changes, the existence of which is evident as cases of progressive con- genital cyanosis, accompanied by more or less acute dyspnoea, etc., in which by auscultation or percussion no diagram of the configuration of the heart and of the lesions can be even approximately established. It is true that these signs may be considerable, and it is known that some cases with extensive stenosis of the pulmonary artery and others with wide inter-ventricular openings may not give any auscultatory signs. In some of these cases, however, radiology demonstrates sufficiently so that an almost positive diagnosis from the outline of the heart and its vessels can be made. Some of the most convincing cases are given here : Recently one of us with Laubry reported to the Societe medicate des hopitaux 26 a case of a patient twenty-seven years of age, since infancy affected with progressive cyanosis accompanied by polycythemia (seven million 26 Laubry et Bordet, Vn cas de cyanose congenitale. Signs perepheriques marques, signes stethoscopiques legers. Nettete de I'^xamen orthodia- graphique. Soc. med. des hopitaux, 13 octobre, 1911. CONGENITAL AFFECTION S 139 red corpuscles). On auscultation no abnormal sound was heard except a slight galloping rhythm on the right and a metallic hardness of the secondary sound at the pulmo- nary area. In the frontal position (Fig. 102), the ortho- diagram showed a considerable increase of the area of cardiac projection, also a marked projection of the right ventricle ; the amplitude of the pulsations was marked to the right of the sternum. The contour of the ventricle descended below the line of the diaphragm and the apex of the heart was elevated. Fig. 102. MLLE. B., CONGENITAL CYANOSIS There was therefore a marked concentric hypertrophy of the right ventricle. The left ventricle was normal. Finally, the left median arc showed a marked enlarge- ment in its superior portion, which indicated a dilatation of the pulmonary artery. In the right posterior oblique position (Fig. 103), the left auricle appeared to be normal, whereas in the left posterior oblique position (Fig. 104), the contours of the right auricle and ventricle formed an exaggerated sali- ence. The combination of these signs warranted the con- clusion that a pulmonary stenosis existed, situated pos- sibly at the level of the valves, but also extending to a considerable portion of the superadjacent artery. 140 THE HEART AND THE AORTA At the beginning of this chapter it was stated that radioscopy applied to the study of congenital lesions of the heart allowed not only a final diagnosis to be made that had been doubtful or even impossible, but that the evolution of the lesion could be prejudged by the nature of the evidence which it could furnish, either after a single examination or after a series of examinations. By re- ferring to the history of Mile. C, this point is brought out. (See observation No. 2.) Case of stenosis of the pulmonary artery with inter-ventricular perforation (Figs. 84, 85, 86). In this case examination of the ortho- diagraphic tracings (Fig. 105) taken before and after physical activity such as walking quickly and lowering and raising the body several times in succession, showed a very sharp variation in the two diameters of the heart. Whereas before and after physical exertion, the longitu- dinal diameter did not vary, the horizontal diameter increased from 11.4 cm. to 11.8 cm., while diameter D'Gr increased from 10.5 cm. to 11.2 cm. This difference could Fig. 103 Fig. 104 Fig. 103. SAME CASE, IN EIGHT POSTERIOR OBLIQUE POSITION No exaggerated salience of the left auricle (OG). Fig. 104. SAME CASE, IN LEFT POSTERIOR OBLIQUE POSITION Exaggerated salience of the right auricle and ventricle. CONGENITAL AFFECTIONS 14-1 be explained only by the enlargement of the right inferior arc of the heart, which had a direct relation to the dilata- tion of the right ventricle. Radioscopy allows, therefore, the opportunity to obtain, at the outset, the first signs of cardiac failure which later developments confirm. Fig. 105. MLLE. C, PULMONARY STENOSIS WITH INTER-VEN- TRICULAR PERFORATION Dotted line shows the right contour of the heart after physical exertion. CHAPTER VI RADIOLOGICAL OUTLINE OF THE HEART IN CER- TAIN PATHOLOGICAL CONDITIONS NOT RESULTING FROM VALVULAR LESIONS I. CARDIAC HYPERTROPHY AND DILATATION CARDIAC hypertrophy is not due exclusively to val- vular lesions. It may be due to other causes, the most frequent of which, according to many writers, is Bright 's disease. The question arises as to whether it is the direct result of sclerosis of the kidney, as Potain be- lieves. This is probably not so and it is necessary rather to agree with Traube's opinion that it results from the arterial hypertension which accompanies this disease. The evidence of this is that it appears in patients with hypertension before there is any renal lesion. It con- stitutes, therefore, a defensive reaction against circula- tory disturbances, whereas dilatation indicates that the resistance of the heart has begun to fail. The interest there is in knowing the degree and nature of the enlarge- ment of the heart in patients with arterial hypertension is evident ; it is here a question of prognosis which radios- copy is better able to make than any other method of in- vestigation, as the following cases show, some in which arterial hypertension and cardiac hypertrophy consti- tuted the only pathological signs, others in which they were complicated with confirmed Bright 's disease. Cardiogram 106 is of a man fifty years of age who suffered from painful precordial attacks with irradia- tions to the left arm, especially when exercising. The RADIOLOGICAL OUTLINE OF THE HEART 148 only abnormal sign was had on auscultation, which gave an accentuation of the second aortic sound. Arterial tension was very high, being 22 cm. on the sphygmograpli. Radioscopy showed that the aorta was not affected, but that the left ventricle was enlarged. In Fig. 106, the aortic outline is much- elongated, the apex of the heart is pushed outward and rounded, and the longitudinal diameter is considerably increased. Fig. 106. HYPEKTKOPHY OF THE LEFT VENTRICLE Hypertension. Man 50 years of age. Fig. 107 gives analogous information in a patient whose clinical symptoms closely resemble those of the preceding case : attacks of angina, arterial hypertension as high as 27 cm., etc. But here the radioscopic signs were much more accentuated ; the left contour of the heart was mark- edly developed, the apex was pushed outward and low- ered ; the longitudinal diameter measured 19 cm., the hori- zontal diameter, 17 cm. Moreover, the aorta was dilated and elongated. On the screen it was particularly dense. The radioscopic signs are still clearer when arterial hypertension is accompanied by chronic interstitial nephritis. Figs. 108 and 109 are two typical cardiograms of renal 144 THE HEART AND THE AORTA heart. The form of the left contour seen here is mark- edly convex in its upper third, so that the line which marks this contour takes from point Gr an external direc- tion with superior convexity. The apex of the heart is rounded, globular, and pushed somewhat outward. Point G is elevated and lies higher than point D. In short, left Fig. 107. MARKED HYPERTROPHY OF THE LEFT VENTRICLE Very high tension. Man 56 years of age. ventricular hypertrophy affects especially the base and the middle third of the cavity wall, for though all the diameters of the heart are increased, it is especially the diameter D'G which shows the most apparent increase. Besides hypertrophy of the left heart, sometimes con- siderable hypertrophy of the right heart occurs in pa- tients who have hitherto shown no cardiac manifestation. Lutembacher 27 has described a terminal tricuspid syn- drome which appeared in the course of fibrous emphy- sematous lesions of the lung, of chronic bronchitis, and of fibrous tuberculosis. This syndrome is characteristic 27 Lutembacher, Syndrome tricuspidien terminal dans les lesions chro- niques du poumon. Archives des maladies du cceur, de^ vaisseaux, et du sang, avril, 1916. RADIOLOGICAL OUTLINE OF THE HEART 145 of a cardiac insufficiency which rapidly becomes chronic. Early diagnosis of this complication therefore is of great importance. Radioscopic examination gives early evi- dence of cardiac failure when there is still time to give proper treatment. The radiological image of the heart is "en sabot." The right ventricle is very large, rounded, occupies the Fig. 108. EENAL HEAET. MAN 57 YEAES OF AGE Fig. 109. LAEGE EENAL HEAET. MAN 50 YEAES OF AGE 146 THE HEART AND THE AORTA whole anterior surface of the heart and pushes the apex upward and outward, thus showing the lower extremity of the right ventricle, which is normally obscured by the shadow of the diaphragm. The left outline of the heart, oblique from above downward and from within outward, corresponds, in its upper half, to the left ventricle, and in the lower half, convex from without inward, to the right ventricle. Moreover, an exaggeration of the upper part of the median arc, corresponding to a dilatation of the pulmonary artery is often noted, due, apparently, to the high tension of the smaller blood-vessels. The heart, in this type of tricuspid insufficiency, is like that in stenosis of the pulmonary artery. Its outline is clearly differentiated from that observed in cases of functional tricuspid insufficiency, in which the heart is enlarged in its transverse diameter as a result of dilata- tion which affects principally the right auricle and in which the right ventricle is much less affected. Finally, when hypertension exists of the larger and smaller blood-vessels in bronchitic emphysematous pa- tients, radioscopy shows the "round heart" due to asso- ciated hypertrophy of the right and left ventricle. All these points are confirmed by autopsy. Clinically we find the signs of right and left ventricular cardiac insuffi- ciency. 28 II. CARDIAC HYPERTROPHY OCCURRING IN THE AGED In old people enlargement of the heart may be due exclusively to a moderate but diffuse sclerosis of the arterial system which causes special deformations which it is necessary to recognize clearly. The senile heart ordinarily shows the peculiar charac- teristics observable in Figs. 110 and 111. The left con- tour is convex in the upper third, the apex is globular, pushed outward ; the heart rests on the diaphragm, which gives the radioscopic image a special configuration. 28Lutembacher, loc. cit., p. 30. RADIOLOGICAL OUTLINE OF THE HEART 147 The appearance of the aortic shadow which in a sense caps the heart, gives it the form of a " Phrygian bonnet. ' ' The artery itself is slightly dilated, dense and elongated ; at its point of origin it encroaches on the right pulmo- nary field and its arc points decidedly outward under the left clavicle. Fig. 110 Fig. Ill Fig. 110. SENILE HEAET. WOMAN 64 YEAES OF AGE Fig. 111. APPEAEANCE OF SENILE HEAET IN A EELATIVELY YOUNG MAN, 45 YEAES OF AGE In the course of the examinations we have been struck by the fact that this appearance of the senile heart, so often found, is not, however, exclusively confined to old age. We have met it, though not often, in patients of middle age ; but in such cases close observation has always shown at the same time the existence of pathological signs of cardiac debility, of vascular sclerosis indicating a real though not severe affection of the circulatory system. In such cases, prematurely old, radiological investigation has shown changes which might be sus- pected but the nature and distribution of which were not shown by other methods of examination. Cases of this class warrant the statement that deforma- tion of the heart in the old cannot be considered as simply physiological and analogous to those we have just de- 148 THE HEART AND THE AORTA scribed. The causes have not been completely studied, but their effects are certainly due to a pathological condition. III. CARDIAC DILATATION It has frequently occurred, in the course of our studies, that examples of dilatation of the heart have been found affecting either the left or right ventricle, associated with hypertrophy of one or the other of these cavities. Usually these were cases threatened with cardiac insufficiency, and radioscopic examination only confirmed the clinical findings. However, there are cases in which moderate dilatation of the heart is hardly perceptible by the ordinary methods of examination, but in which prognosis is of great im- portance and which calls for early therapeutic attention. These are cases with Bright 's disease or patients with valvular lesions in whom only a slight murmur is found, dyspnoea slightly more accentuated than usual, without notable organic reaction. It is very important there- fore to recognize such cardiac dilatation as soon as it appears in order that the required therapeutic measures be immediately adopted. Radioscopy is here the prefer- able method of determining the existence of cardiac dilatation, however slight it may be, when percussion and palpation fail. The information is of still more value if, after several radioscopic examinations have been made of the same patient without giving new indications, the cardiac shadow is suddenly seen to change and assume the particular configuration which is symptomatic of dilatation of one or the other of the cavities. Still more interesting are the radioscopic findings in cases in which there is no valvular lesion and in which there has not previously been recognized a ventricular hypertrophy associated with some general circulatory disturbance, but where signs of cardiac failure are found of uncertain origin and degree. RADIOLOGICAL OUTLINE OF THE HEART 149 Without recurring here to the question of functional insufficiency, which was treated in another chapter, it is well to recall that cardiac dilatation, when it reaches a certain stage, causes patency of the auriculo-ventricular orifice of the left as well as of the right side. Mitral in- sufficiency is not always caused by an infectious endo- carditis. There are many cases in which it appears only as an epiphenomenon in the course of cardiac dilatation. In these circumstances the important thing to know is the precise degree of this dilatation, even more than the existence of a systolic murmur at the apex. Though auscultation enables a diagnosis of this murmur to be made, it is incapable of revealing the pathogenic condi- tions which have produced it. It is probable also that the evolution of the disease may give the impression that the murmur is of organic or functional origin; but if to this uncertain information the idea of a rapidly devel- oped cardiac dilatation is added in a patient hitherto free from cardiac affection, then the study will be simplified. Radioscopy furnishes here information which aids in interpreting these disputed cases. The following, for example (Fig. 112), is the ortho- FiG. 112. ALCOHOLIC MYOCARDITIS. MAN 52 YEARS OF AGE 150 THE HEART AND THE AORTA diagram of a man fifty-two years of age, free from cardiac disease in his youth, who for some months past has suf- fered from slight dyspnoea on exertion. For fifteen days the dyspnoea had been severe, continuous, and provoked by the slightest exertion; the face was cyanotic, the ex- tremities slightly cedematous; the pulse was very rapid and feeMe ; the systolic pressure did not exceed 12 centi- meters. It is evident that this was a case of rapidly progressive dilatation of the heart. Moreover, percus- sion showed that the right cavities overlapped by two finger-breadths. the right edge of the sternum; the apex of the heart was lowered and pushed outward. On aus- cultation the sounds were dull, and there was a manifest irregularity of the pulsation probably associated with constant arhythmia. The history showed that the patient was markedly alcoholic and presented all the symptoms of it. In the region of the apex also a slight systolic murmur was heard, due to mitral insufficiency. This case may be interpreted as being due to an organic insufficiency accompanied by acute dilatation of the car- diac cavities or it may be thought that this murmur was due only to a functional insufficiency related to alcoholic myocarditis. The clinical findings just described point to this second interpretation, but it is not a definite con- clusion. On the other hand, radioscopic examination, by showing an enlargement of the heart in all its diameters, indicated that the heart was in a state of dilatation affecting the right and left cavities. Doubtless the mur- mur must have been related to a functional insufficiency, which had supervened in the course of an acute asystolia in a patient with alcoholic myocarditis, rather than to an old infectious endocarditis of which there is no trace. If the dilatation is accompanied by a considerable hypertrophy of the right and left ventricular walls, the radiological appearance is that of a large globular heart, a typical aspect which allows of a diagnosis of myocar- ditis. Fig. 113 is an example. It is a man sixty-five years RADIOLOGICAL OUTLINE OF THE HEART 151 of age with chronic myocarditis and aortitis. The two principal diameters of the organ are exactly the same length (18 centimeters) ; the contours of the two ven- tricles show an excessive but regular convexity ; the apex of the heart is perfectly rounded. This patient died of cardiac insufficiency, and the anatomical evidence was then compared with the orthodiagraphy tracing; this tracing demonstrated exactly the globular development of the organ. Fig. 113. ALCOHOLIC MYOCARDITIS. MAN 65 YEAES OF AGE When the dilatation is very marked, it is not unusual to find a murmur of tricuspid insufficiency associated with the murmur of mitral insufficiency. This is shown in Fig. 114, where the dilatation affects all the cavities equally, but especially the right cavities including the auricle. In this case the right contour of the heart shows an extreme development from the cardio-vascular angle to the level of the diaphragm. The radiological signs, therefore, of cardiac dilatation are characterized, at the outset, by a total increase of the area of the heart and its diameters (Fig. 112) ; at a more advanced stage the form of the shadow becomes perfectly globular with equal exaggeration of both diame- 152 THE HEART AND THE AORTA ters (Fig. 113) ; finally, when the dilatation reaches a con- siderable degree, the outlines of the heart assume a tri- angular aspect with the base resting on the diaphragm (Fig. 115). Other signs of dilatation as shown by radios- copy are : the weakness of contractions which appear in the form of dragging undulations, and a peculiar defor- mation of the contours of the shadow occasioned by dis- placement of the organ. In the following chapter, other examples will be found in which radioscopy was of value in diagnosis of dilata- tion of the heart and in the prognosis which it permits. Fig. 114. ALCOHOLIC MYOCAKDITIS Considerable dilatation of the right cavities. IV. BASEDOW'S DISEASE The prognosis of Basedow's disease is closely related to the condition of the heart. Patients with this disease very often succumb to cardiac disturbances. For a con- siderable period there has been marked interest in the nature of the murmurs which are so commonly heard; these, according to some writers, are usually anorganic, while others think they are related to functional insuffi- ciencies, transitory or permanent. Fig. 115. TELERADIOGRAPH OF A CASE OF CAEDIAC DILATATION RADIOLOGICAL OUTLINE OF THE HEART 153 In the course of Basedow's disease murmurs may occur which are not referable to any change in the orifices, but the number of these cases appears more limited than Potain states. In fact these murmurs appear only in patients with severe forms of the disease, in whom a certain degree of cardiac insufficiency is present. The radioscopic examinations which have been made have, moreover, confirmed this, for they have shown that there was always a more or less notable degree of cardiac dilatation in patients with these murmurs. Fig. 116 is the cardiogram of a patient forty years of age who had all the signs of Basedow's disease. The affection was severe, tachycardia was very pronounced, and there existed, also, with dyspnoea on exertion, a pre- cordial distress indicating serious circulatory disturb- ance. On percussion the heart seemed slightly increased in volume, but its limits did not appear greatly exagger- ated. Eadioscopy showed that the cardiac dilatation had reached a much more advanced degree than was sus- pected. The right and left contours of the heart were exaggerated on both sides of the median line. The longi- tudinal diameter measured 16.7 cm., the horizontal, 16.4 cm. Moreover, fluoroscopic examination showed an in- teresting change seen during inspiratory displacements of the heart. The left contour, deformed in its middle third, was not convex but concave, as if the ventricular wall were in an excessively flaccid condition. This condi- tion, especially noticeable during inspiration, and par- ticularly in the recumbent position, appeared to be related to an abnormal flaccidity of the heart and to be of con- siderable prognostic importance, for it occurred in sev- eral cases of myocarditis and cardiac insufficiency. This impression was confirmed by the rapid and feeble pulsa- tions of the heart. There is no doubt that in this case radioscopic examination corrected the auscultatory find- ings, for the impression obtained was that it was purely 154 THE HEART AND THE AORTA an anorganic murmur, whereas the heart was seriously affected and the prognosis considered to be very grave. Fig. 117 furnishes analogous indications. A case of a woman forty-nine years of age, with marked hyper- trophy of the thyroid gland, exophthalmia, tachycardia and the heart enlarged on percussion. The condition of Fig. 116. DILATATION OF THE HEAET IN A CASE OF BASEDOW'S DISEASE The contour in dotted lines shows the deformation of the left outline during deep inspiration. Fig. 117. BASEDOW'S DISEASE. FLACCID HEAET RADIOLOGICAL OUTLINE OF THE HEART 155 this patient, however, was complex. There were symp- toms of renal origin : albuminuria, galloping sound, slight malleolar oedema. As the figure shows, the area of pro- jection of the heart is notably increased, the apex is rounded, lowered, but the contour of the left ventricle is not convex as seen in the renal heart; marked concavity of the middle third of the left contour is also found, the pulsations rapid, feeble and retarded. Here dilatation predominates. V. ARHYTHMIC HEART The numerous radiological observations made of pa- tients affected with arhythmia have led to some interest- ing remarks which will be only mentioned in passing. It would evidently be premature to say that characteristic outlines exist of such and such arhythmic types, for these may be associated with very diverse cardiac affections. Moreover, radiology should not be compared with graphic recording or other methods of examination, to demon- strate the nature of an arhythmia ; but it is always worth while to use the results of fluoroscopic examination or orthodiagraphy to obtain supplementary information the interpretation of which may lead to results of real prac- tical value. We have examined several patients with paroxysmal tachycardia, in whom during the course of this arhythmia the question was determined whether the heart was en- larged. Certain writers, notably Martius, have stated that the heart was larger than normal. Hoffmann has not agreed with this opinion. A case is presented here which shows that Martius' opinion is erroneous. Fig. 118 represents, in the black lines, the orthodiagram of a woman thirty years of age, with paroxysmal tachycardia of auricular origin, whose history has previously been reported. 29 The tachycardia was unusual, since it ex- 29 Vaquez et Pezzi, Tachycardie paroxystique de type auriculaire. Societe medicale des hopitaux, seance du 22 mars, 1912, p. 360. 156 THE HEART AND THE AORTA ceeded 300 pulsations a minute. During the attack, as can easily be seen, the heart was of small dimensions, its longitudinal diameter measured 12.2 cm. and its hori- zontal diameter, 12.1 cm. Fig. 118. PAEOXYSMAL TACHYCAEDIA Black lines, contour during the attack; dotted lines, contour of the heart after the attack. A second examination was made a week after the ter- mination of the attack, the patient being in the same recumbent position and under the same conditions of examination. As the orthodiagram shows, the diameters of the heart have increased or rather they have resumed their normal dimensions : the longitudinal diameter is 13 cm. and the horizontal diameter is 12.4 cm. Moreover, on the screen, the pulsations, almost imperceptible during the attack, had become ample and forcible. We have also examined several other patients with paroxysmal tachycardia in which the results agreed with these. The evidence in these cases has been sufficiently conclusive so that it is believed that diminution in the volume of the heart in the course of an attack is a usual phenomenon. Chronic arhythmia, referred to as auricular fibrilla- tion, is always a grave symptom, though a certain num- RADIOLOGICAL OUTLINE OF THE HEART 157 ber of cases become compensated to this condition and suffer only moderately during a period of months or years. However, when it occurs in cases with valvular lesions, it is always the sign of cardiac insufficiency, the prognosis of which is based on the condition of the heart itself. Electrocardiograms and jugular tracings indicate only a marked modification in the type of contraction of the auricle, without giving information as to the condi- tion of the other parts of the heart. Radioscopy shows that, together with cardiac changes consistent with the associated valvular lesion, there occur, sometimes, un- suspected changes and more or less marked dilatations which must be considered in making a prognosis. The orthodiagraph^ tracing in Fig. 119 is of a man thirty-nine years of age, subject for a long time to dyspnoea on exertion and palpitation. He had been obliged six months previously to give up his work as valet because the symptoms became so aggravated. On examination a systolic murmur was heard at the apex and at the same time a complete characteristic arhythmia. After some days of rest the signs of cardiac insufficiency Fig. 119. CHEONIC AEHYTHMIA Mitral disease. Dilatation of the heart. 158 THE HEART AND THE AORTA appeared to be relieved and the only abnormal sign re- maining was the persistence of the arhythmia. With only these indications it would have been difficult to determine the prognosis, since chronic arhythmia does not consti- tute, as we have just said, a sufficient sign of irremedi- able failure of the heart. But radioscopic examination showed, on the contrary, that there was reason for con- sidering the prognosis as very grave. The orthodiagram reproduces the usual image of a mitral lesion, which was also recognized by auscultation ; but it demonstrates, moreover, an enormous development of the heart. On the other hand, in right posterior oblique position at 50 degrees, the left auricle obscured the retro-cardiac clear space, and at this angle the apex of the heart did not disappear behind the vertebral column. There was reason to infer then the existence of a marked dilatation of the heart with an increase of all the diameters. Some months later the patient re- entered the hospital with severe symptoms of asystolism. Irregularities of the heart, notably paroxysmal tachy- cardia and chronic arhythmia, often have the effect of muffling the stethoscopic signs of the associated valvular lesions. Sometimes it is the chronic arhythmia which, by modifying profoundly the mode of contraction of the auricles, suppresses the presystolic rumbling and renders difficult the diagnosis of mitral stenosis. Sometimes it is the paroxysmal tachycardia which, by a very different action, weakens the orificial murmurs or the presystolic rumbling to such an extent that they can no longer be recognized by auscultation. In these different cases radioscopic examination, by giving the characteristic out- lines of this affection, makes possible a final diagnosis. An opportunity was given to examine two patients with paroxysmal tachycardia, in whom, during the attacks, it was impossible to determine whether or not a valvular lesion existed. Fluoroscopic examination showed that the patients were affected with mitral stenosis; the RADIOLOGICAL OUTLINE OF THE HEART 159 diagnosis was confirmed by auscultation when the crisis had passed. VI. CARDIAC INSUFFICIENCY AND ASYSTOLISM We have had an opportunity in the course of these stud- ies to observe several times the radioscope signs which enabled us to make a diagnosis of cardiac dilatation (which usually precedes asystolic symptoms and which accompanies myocardial insufficiency). To recognize the early dilatation does not only complete a diagnosis but it immediately establishes a prognosis; in order that this prognosis be of value, it must not be based only on the objective and subjective functional signs which are ob- tained by the ordinary investigation methods : peripheral stasis, oedema of the extremities, enlargement of the liver, marked dilatation of the right cavities with tri- cuspid insufficiency, etc. This prognosis has a greater value (since it leads to early therapeutic intervention) if it is still impossible to recognize in a patient the symp- toms that precede cardiac insufficiency. In such cases as has been shown, radioscopy gives evidence of consid- erable importance. We merely mention the many cases in which early dilatation of the cavities without threaten- ing symptoms was revealed by radioscopy, cases in which cardiac debility was marked, moreover, by the modifica- tion and retarding of pulsations along the ventricular contours, by flaccidness, and slight amplitude of the myo- cardial contractions, or in short by evidence of severe disturbances in the cardiac systole. Myocardial changes can therefore best be studied by radioscopy. Several times we have had occasion to demonstrate the marked changes in the exterior appearance of the heart and to make an unfavorable prognosis because of the progressive cardiac dilatation and of the early appear- ance of the signs of asystolism. The different degrees through which a patient passes before chronic asys,tolism is reached could be determined and it was not surprising 160 THE HEART AND THE AORTA after weeks or months to see the outline of the cardiac shadow change completely and assume the form of pro- nounced asystolic conditions. This is shown in Fig. 120, a man thirty-nine years of age with chronic asystolism. Fig. 120. ASYSTOLISM The extreme dilatation of all the cavities is shown here as is seen by increase of the diameters, the longitudinal being 21 cm., the horizontal being 22.5 cm. The enlarge- ments of the right auricle and ventricle are indicated by the considerable projection of the left contour, which is level with the external thoracic wall ; moreover, the right diaphragmatic shadow is very high and is formed by an almost horizontal line, which indicates an enormous development of the liver. CHAPTER VII AFFECTIONS OF THE PERICARDIUM A. PERICARDIAL EFFUSIONS THE diagnosis of pericardial effusions should be, ac- cording to some writers, relatively easy. It is not always so in practice, and if fluid in the pericardial cavity is accompanied ordinarily on palpation by elongation of the heart apex, on percussion by increase of the cardiac dullness, and on auscultation by the disappearance of the normal sounds, nevertheless any one of these signs may be consistent with some other affection. Radiological examination is then of great value, because very often it shows in the heart outlines peculiarities which make diagnosis more positive. Unfortunately it is not always easy to proceed with such an examination, for it requires perfect radiological equipment and special precautions on account of the patient's generally serious condition. Pericardial effusions bring about a combination of radiological signs, which are: (a) Globular increase of cardio-pericardial shadow. * (b) Peculiar modifications of the form of this shadow. J (c) Diminution and sometimes even abolition of the y/ cardiac pulsations. (a) The increase __ of the cardio-pericardial shadow is sometimes considerable; the pulmonary fields are en- croached upon by a shadowy mass, which enlarges from above downward and is at its maximum at the level of the line of the diaphragm. The result is an unusual elongation of the horizontal diameter, especially as com- pared with the longitudinal diameter. On Fig. 121, the 162 THE HEART AND THE AORTA horizontal diameter is 19.5 cm., whereas the longitudinal does not exceed 17 cm. This fact, which is rather rare, although it may be found in cases of dilatation of the heart, is invariably the rule in effusions of the pericar- dium, and the difference between the two diameters is never so great as in this affection. Fig. 121. PEEICAEDIAL EFFUSION (b) The form of the cardio-pericardial shadow has a peculiarity which is not found in any other disease. First, as Dietlen has noted, the pedicule is very short, that is to say, the shadow has only a slight development in its middle portion, upward under the clavicle ; more- over, from this point downward, the contours expand suddenly right and left, but especially to the left where the outline of the shadow takes an almost horizontal position, reaching the external portion of the thoracic wall (Fig. 122). In these less accentuated cases the general form of the cardio-pericardial shadow is globular and similar to the image seen in myocarditis (Fig. 123). (c) The study of the heart pulsations is particularly suggestive, and even in the cases in which the amount of fluid is not yet abundant, a very notable decrease of the pulsation is noticed, owing to the fact that the pulsation transmitted in all directions at once by the contact of the AFFECTIONS OF THE PERICARDIUM 1C3 heart with the fluid cushion arrives much weakened at the walls of the pericardial sac. However, none of these findings is pathognomonic of an effusion in the pericardium. But if all three coexist, the diagnosis is usually correct independently of all negative or positive clinical signs. Beclere 30 has been able to establish radioscopically the diagnosis of chronic pericarditis and that of acute pericarditis with effusion, in cases which have finally been confirmed by the progress of the disease. Fig. 122 Fig. 123 Fig. 122. LAEGE PEEICAEDIAL EFFUSION Fig. 123. MODEEATE PEEICAEDIAL EFFUSION, OF TEAUMATIC OEIGIN Nevertheless, radiological examination is not always sufficient to form a positive diagnosis, notably when the amount of fluid is not abundant and the heart is very much enlarged; its pulsations are then transmitted al- most entirely to the limits of the pericardial sac. Inversely, the markedly increased shadow of the heart due to cardiac dilatations may be mistaken for an effu- sion, for example, in alcoholic myocarditis. In this case, the increase of the cardio-pericardial shadow is accom- soBeclere, Traite de radiologie du Pr. Bouchard, 1904. 164 THE HEART AND THE AORTA panied by more or less marked feeble pulsations, and the combination of the two conditions might lead to a diag- nosis of fluid. Fig. 124. Black lines the contour of the shadow when the patient entered the hospital; dotted lines, contour of the heart a month and a half later; the effusion reabsorbed. Lutembacher 31 has recently reported a case of aneurism of the left auricle measuring 400 cu. cm. which because of the considerable dimensions and configuration of the radioscopic tracing had been mistaken for a time for a pericardial effusion. But in the case of cardiac dilatation the form of the shadow differs from that of effusion; moreover, though the pulsations may be slight they never disappear completely; in a word, the radiological syn- drome described above is not found. Finally, radioscopy is the preferable method by which to study thoroughly the development of pericardial effu- sions. The progressive increase in the quantity of fluid and its diminution are interpreted by variations in the form and the diameters of the shadows, variations which .are easily read on cardiograms or plates without defor- mations. Fig. 124, a man forty-two years of age with an exudative pericarditis, is an example in point. The con- si Lutembacher, Anevrisme de I'oreillette gauche. Archives des maladies du eceur, des vaisseaux et du sang, avril, 1917. AFFECTIONS OF THE PERICARDIUM 165 tour in black lines shows dimensions of the cardio-peri- cardial shadow at the time when the pericarditis was at its height. The contour in dotted lines, taken a month and a half later, when there was improvement, indicates a very clear diminution of this shadow. In addition the pulsations, barely perceptible at the time of the first tracing, had become normal at the time of the second. B. CARDIAC SYMPHYSIS AND PARTIAL ADHESIONS OF THE PERICARDIUM The term cardiac symphysis, which designates the total adhesion of the two pericardial folds, is also applied to adhesions which unite the outer surface of the pericar- dium to the neighboring organs. The multiplicity of anatomical forms of symphysis explains why the visible signs of this affection are so numerous and why they vary according to the location of the adhesions. What is of utmost importance to know is first whether adhesions of the pericardium exist and then whether they are generalized or localized; whether the folds of the pericardium are simply united with each other ; whether the heart is still mobile or is fixed to the costal wall, to the diaphragm and to neighboring organs; finally, whether there is at the same time a posterior mediastinitis. It is the more important to solve these questions because the treatment of pericardial symphysis depends, in a certain measure, on surgery, and before proceeding with surgical intervention it is indispensable to know what results it may have. The indications and the counter-indications of Brauer's operation can be fixed only by radioscopic examination of the adherent heart. This accounts for the long explanation that is given of this question. Pericardial adhesions cause the many and varied modifications of the cardiac image, modifications which may be called immediate or mediate according as they 166 THE HEART AND THE AORTA are in direct or indirect relation with the adhesions. Among the first to be mentioned are changes in the gen- eral appearance of the heart, in the extent of its displace- ments occasioned by different positions of the body, in the amplitude of the movements of the diaphragm and of the costal wall, etc. Among the second: concomitant changes in the lungs, in the pleura and the diaphragm, enlargements of the heart caused by associated lesions, etc. To recognize these it is necessary to employ all the radiological methods : fluoroscopic examination, orthodiagraphy, teleradiography. The study of this subject will be taken up as follows : *s I. General data from radiological examination. J II. Particular data relative to the existence of peri- cardial adhesions. •/ III. Data relative to the location of the adhesions. •j IV. Comparison of the results of percussion and orthodiagraphy. J V. Clinical observations. I. GENERAL DATA FROM RADIOLOGICAL EXAMINATION The preliminary examination of the shadows of the thoracic cavity gives information on the condition of the lungs and the pleura. This study demands the greatest care, for some radiological signs may be common to symphysis and to other cardiac affections. a. Pulmonary field. Certain pulmonary affections, notably tuberculosis, give rise to respiratory disturbances due to the lack of elasticity of the lung and are accom- panied by diminution of the amplitude of the diaphrag- matic and rib movements. These disturbances occur also in patients who have pericardial adhesions. But before attributing them to this latter affection it is necessary to make sure that tuberculosis is not the cause. That is recognized by the existence of characteristic shadowy areas. However, the question of differential diagnosis AFFECTIONS OF THE PERICARDIUM 107 is not settled by the fact of having verified the presence of pulmonary tuberculous lesions, for these coexist fre- quently with certain forms of chronic pericarditis. The object of radiology here is only to determine as exactly as possible the anatomical condition of the lungs and the influence which the parenchymal lesions may exert on the movement of the diaphragm and the ribs. In cases where there is reason to think that certain functional disturbances are due to pericardial adhesions, this opinion is confirmed if radiological examination of the lungs is negative. b. Pleural shadows. It will be necessary first to deter- mine whether the functional disturbances which might suggest pericardial symphysis, are not due simply to the presence of a pleural effusion which can always coexist with pericardial symphysis. Also pleuro-pulmonary adhesions may be mistaken for pericardial symphysis, for like it they cause changes in the respiratory displacements of the thoracic organs and changes in the position of the heart. In that case the radiological findings are most important; if they show that the pleuras are free from adhesions, that will estab- lish a strong presumption in favor of the diagnosis of cardiac symphysis. But this diagnosis ought not to be rejected in case pleuro-pulmonary adhesions are found, for they frequently exist with pericardial symphysis. The diagnosis of this affection will then depend on other clinical and radiological signs. c. Mediastinal shadows. Examination of the medias- tinum in the frontal position allows the elimination of tumor of the mediastinum as a cause of functional dis- turbances, for, if one exists, it will be easily recognized by the aspect of its contours. This done, the next thing is to make radiological observations of the anterior mediastinum and the poste- rior mediastinum in oblique and lateral positions. In the normal and in these positions, the anterior 168 THE HEART AND THE AORTA mediastinum appears as a clear space between the shadow of the heart and that of the sternum. If there are adhesions uniting the pericardium with the sterno- costal wall, this space is reduced or completely dis- appears. Fig. 125. Considerable increase in the volume of the heart in a patient 20 years of age with cardiac symphysis. It is the same with the retro-cardiac transparent area, when there is posterior mediastinitis. d. Volume of the heart. It is hardly necessary to state that the heart shadow should be determined with the greatest care, either by distant radiography or orthodiagraphy. In the cases which are of interest here the heart always shows enlargement. The right and left contours are markedly developed (Fig. 125), and hypertrophy of the heart is sometimes accompanied by a marked lowering of the apex. This can be due exclusively to the symphysis without any associated valvular lesion. But if symphysis does exist at the same time, radiological examination will allow the usual descriptive characteristics to be noted. Thus in the patient shown in Fig. 126 signs of double AFFECTIONS OF THE PERICARDII JM 169 mitral lesion are recognized; salience, above point G, of the pulmonary artery, and of the auricle compressed by the dilated left auricle; increase of the left ventricular contour; apex pushed outward, etc. II. DATA RELATIVE TO THE EXISTENCE OF PERICARDIAL ADHESIONS Pericardial adhesions show radiological ly in two ways : either they are directly visible on the screen and on the plate, because they are sufficiently dense to throw a shadow and because they occur in regions normally trans- Fig. 126. DOUBLE MITRAL LESION IN A PATIENT WITH SYMPHYSIS parent ; or they are not directly perceptible and are indi- cated only when affecting the mobility of the heart and the adjoining organs during respiration or during changes in the position of the body. a. Shadows on the heart outline due to adhesions. These shadow outlines are best studied closely on a radio- graphic plate. They have been described by Beck, 32 32 Beck, Roentgen Bay, Diagnosis and Therapy, Appleton & Co., New York. 170 THE HEART AND THE AORTA Benedikt, 33 Sturtz, 34 Moritz, 35 Lehmann and Schmoll. 36 They are irregular according to Lehmann and Schmoll, jagged, bordering both sides of the heart shadow and making its contour vague and indistinct. These shadows are due to extensive adhesions; at the site of the ad- hesions the pulsation of the heart is effaced. (Fig. 127.) In a case reported by Sturtz he says that "one can clearly see adhesions at the left border of the heart and at the summit of the left diaphragm. Starting from these areas fine shadows of adhesions are also seen." Lehmann and Schmoll state that it is necessary to distinguish these shadows from those which are attrib- uted "to symptoms wholly pleural which have no direct bearing on the pericardium but which are simply super- imposed upon the projection of the heart shadow. On the other hand, the indentations, the points, the irregu- larities of the contour of the heart due to pericardial adhesions are marked in too clear a manner to be ex- plained by the unreliable evidence against which Moritz warns." Besides these indentations in the contour of the heart the writers have described shadows obscuring one or both of the angles formed by the heart and the diaphragm. Lehmann and Schmoll have published radiographs show- ing these shadows which enabled them to diagnose peri- cardial diaphragmatic adhesions. Beclere 37 says on this point: "In the normal state the right and left sides of the cardiac shadow curve in slightly toward the median line before meeting the contour of the shadow of the diaphragm, in such a way that they limit with this shadow two very small sinuses which may be called the cardio-diaphragmatic sinuses. In deep 33 Benedikt, Weiner med. Woch, 1900, no. 9. 3* Sturtz, Fortschritte auf d. Geoiete d. Boentgenstrahl, Bd. VIII, Heft. 5. 35 Moritz, Munch, med. Woch., 1900, no. 29. 36 Lehmann et Schmoll, Fortschritte auf d. geo. d. Boentgenstrahl, Bd. IX, 1905-1906, p. 196. 3T Beclere, Trait e de radiologic midicale du Pr. Bouchard, 1904. Fig. 127. SHADOWS OF PEEICAEDIAL ADHESIONS, AFTER LEHMANN AND SCHMOLL AFFECTIONS OF THE PERICARDIUM 171 inspiration these two sinuses become in the normal larger and deeper, as if the heart separated from the diaphragm. On the contrary, if pericardial symphysis exists, the two sinuses disappear almost completely, and the contour of the cardiac shadow, in the neighborhood of the diaphrag- matic shadow, invariably keeps the same form at the end of expiration and inspiration." When adhesions are present on the contour of the heart the shadows are seen on the screen and especially on the plates; on this point our observations confirm those already cited. However, the presence of these shadows is far from being constant, and we have rarely found them. As to the costal-diaphragmatic or cardio-dia- phragmatic sinuses being obscured, to which Lehmann and Schmoll attribute great importance as a sign of adhesions, it has not, in our opinion, that significance except with certain reservations. In the first place it may happen that the increase in density of the pericardial folds, at the point of their left phrenic insertion, may produce an obscurity which is purely physiological. The disappearance of the cardio- hepatic sinus may be due to a similar thickening of the folds of the pericardium, or to an abnormal distention of the inferior vena cava, or even to an inflammation or dilatation of the right ventricle. Finally, it sometimes happens that the left cardio-diaphragmatic sinus is covered by the hypertrophied heart. Now, it is rather difficult to be sure that these condi- tions do not intervene in the obscuring of the cardio- diaphragmatic sinuses, which makes the value of this sign somewhat uncertain. The radiographic plates which ought to be useful are technically often defective, how- ever carefully they are taken. On the contrary, the signs about to be studied are in more direct relation to the adhesions at the apex of the heart. b. Modifications of displacements of the shadoiv of 172 THE HEART AND THE AORTA the heart and of the diaphragm. Displacements of the heart observed in the physiological state are caused either by changes in the position of the body or by respi- ration which modify the intra-thoracic pressure. These displacements are naturally more or less reduced or even rendered impossible if the heart is attached to the thorax or to the neighboring organs by adhesions. It is im- portant therefore to make a detailed study of them. These displacements affect either the heart as a whole or more especially its apex. 1. Apex of the Heaet. The apex of the heart, nor- mally mobile, is displaced outward from 2 to 2.5 cm. when the body is inclined toward the left; moreover, it descends and rises during inspiration. It is the amplitude of these displacements, the lateral displace- ment and the vertical displacement that must be observed in order to know the degree of mobility of the apex. If the lateral displacement is abolished, the contours of the cardiac shadow, traced on the skin of the patient, first in the vertical position, then in the left inclination, are exactly superimposed. Sometimes the immobility both of the ventricular contour and of the apex is com- plete ; or, the apex being very clearly fixed, the ventricular contour alone is displaced slightly outward. Then, espe- cially if the heart is large, the left ventricle is seen to fill markedly during the change of position until it pushes against the thoracic wall (Fig. 128), whereas the position of the apex remains unchanged. When the lateral displacement only is reduced, the successive contours which indicate the apex are very close together. This sign is found in cases where the apical adhesions are loose; but adhesions of the right side of the heart may produce the same effect. The mobility of the apex does not exclude the diagnosis of pericardial adhesions nor does its fixity establish the diagnosis. In fact, we have always found the apex fixed v in cases of adhesions, but, theoretically, it is conceivable AFFECTIONS OF THE PERICARDIUM 173 that adhesions, confined to the base of the heart, should leave the apex mobile. On the other hand, it is not con- ceivable that other causes than adhesions should be capable of completely immobilizing the apex of the heart. In practice a considerable cardiac enlargement may have the effect of pushing it against the thoracic wall and on the diaphragm which becomes depressed and thus offers complete resistance to displacement of the apex. The result will be an error in interpretation which will there- fore lead to a wrong diagnosis. Fig. 128. IMMOBILITY OF THE APEX WITH MOVEMENT OF THE LEFT SIDE TOWAED THE EXTERNAL THOEACIC WALL DUR- ING INCLINATION OF THE BODY TO THE LEFT Dotted lines, contour of left side during inclination. Apex fixed at level of the cross. Vertical displacement of the apex is observed during respiratory movements. During deep inspiration the apex is lowered and moves slightly inward ; during deep expiration the apex is raised and moves outward. In cardiac symphysis these displacements are usually diminished or abolished. The following conditions may occur : (a) The adhesions fix the apex to the thoracic wall. 174 THE HEART AND THE AORTA The apex is then not associated with the movements of the diaphragm but maintains constant relations with the thorax. (b) Adhesions fix the heart to the thoracic wall and to the diaphragm. The vertical displacements of the apex are much diminished or disappear, and the movement of the left diaphragm is much reduced, at least in its medial portion. (c) Adhesions exist only between the apex and left diaphragm. In this case the lateral displacements are ^ abolished and the vertical movements remain. The apex, fixed to the diaphragm, lowers and rises during inspira- tion and expiration. This sign should be accepted only with reservation as a sign of local symphysis, when the heart is enlarged. It may be added that absence of verti- cal displacements does not always mean that the apex is adherent, for solid adhesions of the anterior surface may make the whole organ immobile. 2. Displacements of the Heakt Outlines. Briefly, the heart, during respiratory movements, undergoes marked displacements which not only lower it and elevate it as a whole in the thoracic cavity but which result in deformations of its contours : in deep inspiration the car- diac shadow is elongated and contracted, whereas in forced expiration it broadens and is enlarged from right to left. All these modifications may be completely transformed if adhesions exist. The respiratory displacements are sometimes less extended on one side, either to the left or right (Fig. 129) ; sometimes a small part of one of the contours is less mobile ; at other times one of the sides remains fixed while the other is displaced (Fig. 130) ; and, finally, the entire contour of the heart is sometimes displaced, excepting the apex which remains immobile (Fig. 131). These variations are explained by the different posi- tions of the adhesions. If, for instance, the left side only is attached to the AFFECTIONS OF THE PERICARDIUM 175 costal wall to a slight extent, it can be assumed that the heart does not follow the diaphragm in its inspiratory movement, and since the rest of the organ is free, the right side retains its normal movements. When the adhesions of the left side or of the anterior surface of the heart are extensive and very adherent, the contours of the heart are absolutely immobile and the lines which mark them on the screen successively during inspiration and expiration are exactly superimposed. It may happen in certain cases that a rather para- doxical phenomenon is found, namely, elevation of the contour of the heart during deep inspiration, the oppo- site of what happens normally. This is explained by the close adhesion of the organ to the sterno-costal plastron ; the heart consequently follows the forward and upward movements of the sternum during inspiration. For this to occur it is necessary that the lower region of the heart be free from adhesions and that the bottom of the peri- cardial sac be sufficiently extensible so that the heart is not pulled during the lowering of the diaphragm. Fig. 129 Fig. 130 Fig. 129. M., 16 YEAES OF AGE The respiratory displacements of the heart are much reduced, especially on the left. Fig. 130. LEON P., 7% YEAES OF AGE Immobility of the left contour. Diminished mobility of the right con- tour during respiratory movements. 176 THE HEART AND THE AORTA Finally, if the lower part of the heart, the diaphragm, and the thoracic wall are closely united on one side, there will be no displacements in this region, but fairly ample ones on the other side. Fig. 131. TH., 20 YEAES OF AGE The contour in dotted lines shows that in deep inspiration the heart is lowered, except the apex. 3. Movements of the Diapheagm. The pericardium is inserted in the center of the diaphragm, the two halves of which, the right and left, have in the normal almost synchronous downward and upward movements. The right dome of the diaphragm is a little more ele- vated than the left because of the position of the liver. The movements are, on the contrary, generally somewhat more extended on the right. According to Lange 38 they should be 3 cm. on the right, 2.8 cm. on the left in deep inspiration. During quiet inspiration they should be 1.25 cm. on the right, and 1.2 cm. on the left. Taking succes- sively the orthodiagraph^ tracings in deep inspiration and expiration we have found higher figures for the dis- tance between the centers of the domes of the diaphragm, 3.5 cm. to 4.5 cm. on the right, 3 cm. to 4 cm. on the left, ss Sidney Lange, The Eelations of the Diaphragm as Eevealed by the Eoentgen Eay, Journ. of Amer. Med. Assoc, Feb., 1908. AFFECTIONS OF THE PERICARDIUM 177 in man. In woman the amplitude of these movements is less. If for some pathological reason one of the diaphragms is rendered immobile or its movements merely reduced, the other diaphragm may keep its normal degree of excursion (Figs. 129, 130, 131, 132). When there is no pathological disturbance in the lungs, the pleurce, and the liver to explain the diminutions of the diaphragmatic movements, the modifications observed are attributable to adhesions between the heart, the peri- cardium and the diaphragm. The mobility of the phrenic muscle is only slightly diminished by these adhesions. To have it reduced or abolished, it is necessary that the pericardium and the heart adhere on the other side, either to the thoracic wall or to the organs of the posterior mediastinum. When a patient is examined, one should not be content simply to mark with two superimposed points the maxi- mal distance of the excursion of the diaphragm. All the outlines of the contours of the phrenic muscle by the Fig. 132. THE EXPANSION OF THE DIAPHEAGM IS MUCH EE- DUCED ON THE LEFT IN THE INNEE THIED, A LITTLE FULLEE IN THE OUTEE TWO-THIEDS, NOEMAL ON THE EIGHT. 178 THE HEART AND THE AORTA orthodiagraph^ method give, in certain cases, interest- ing information : the movement of the two diaphragms is sometimes immobilized in part, the inner portion for example, while the outer or costal portion shows decided movements up and down (Fig. 132). It is often interesting to study the movements of the diaphragm in vertical position and in dorsal recum- bency. The normal forced inspiration lowers the dia- Fig. 133 Fig. 134 Fig. 133. GERMAINE D., liy 2 YEAES OF AGE Diminution of the excursion of the diaphragm in vertical position. Fig. 134. SAME CASE Equally marked diminution of the excursion of the diaphragm in recum- bency. phragm and the heart much less in the vertical position than in recumbency. If the heart is large, as is generally the case in cardiac symphysis, the organ, by its own weight, depresses the diaphragm, especially on the left, and obstructs its movements. In order to make sure that the decrease of excursion is not due solely to this cause, a second observation in recumbency should be made, the position in which the weight of the heart has no effect. If as marked a reduction of the movements is found, then the hypothesis that adhesions reduce the excursion of the diaphragm (Figs. 133 and 134) can be considered. AFFECTIONS OF THE PERICARDIUM 179 By examining the movement of the diaphragm, the mechanism of a sign described by Broadbent, 39 which con- sists in the systolic retraction of the posterior thoracic wall at the level of the lower ribs, can also be explained. It can be done by fixing an opaque index over the region Fig. 135. PATIENT EXAMINED IN SLIGHTLY OBLIQUE POSITION (EIGHT ANTERIOR) On the left thoracic contour the shadow of the lead index is shown situated in the zone in which appears Broadbent 's sign. In dotted lines, the contour of the diaphragm stretched at each systole. of the maximum movement of retraction ; then it is seen, if the patient is placed obliquely, that this index corre- sponds exactly to the posterior costal insertions of the diaphragm and that the muscle is under tension at each cardiac contraction (Fig. 135). It is necessary, then, to obtain Broadbent 's sign, that the heart and the pericar- dium should adhere not only to the diaphragm but also to the anterior thoracic wall. However, this sign is of no pathognomonic value. It is found independent of car- diac symphysis when pleural adhesions diminish the dia- phragmatic movement and when the heart, increased in 39 Broadbent, Diseases of the Heart, London, 1897. 180 THE HEART AND THE AORTA y volume and strongly depressing the diaphragm, transmits its pulsations to it. 4. Outline of the Heart. By placing the patient in the lateral position, the anterior outline of the heart can Fig. 136. M., 25 YEAES OF AGE Symphysis of the heart and the anterior wall. In right lateral position, the anterior clear space disappears in its lower half during forced inspira- tion. be traced behind the sternal border. In the normal, they are separated by a clear triangular zone which is very wide at the level of the vessels and grows narrower as it approaches the shadow of the diaphragm. This clear zone grows wider and becomes clearer during deep inspiration. If the heart is attached to the anterior thoracic wall, it becomes impossible to find the anterior clear space, even with forced inspiration (Fig. 136). This sign, in spite of its value, is not, however, pathog- nomonic. It is found in cases in which there are no adhesions, notably when the heart is considerably hyper- trophied. On the contrary, if the retro-sternal clear space keeps its normal transparency, it is safe to say that there is no adhesion between the heart and sternal border, on condition, however, that the radioscopic examination has been made exactly at an angle of 90 degrees. AFFECTIONS OF THE PERICARDIUM 181 c. Respiratory outline. The study of the respiratory outline of the thorax, that is, the movements of projec- tion and retraction of the sternum, observed with the patient in the lateral position, does not belong exclusively to the domain of radioscopy. Wenckebach has made use of photography to establish the details. But observation by orthodiagraphy is easier and quicker, and we usually use this method. In the normal the two lines which indicate the respira- tory outline in deep inspiration and expiration are equi- distant in the greater part of their length ; they unite at the level of the abdominal region (Fig. 137). This respiratory outline should always, according to Wenckebach, be markedly modified in case of cardiac symphysis. The sternum should then maintain, in its lower third, such a degree of immobility that the two lines which represent its displacement should cross at a fixed point (Fig. 138). The crossing of the two lines, otherwise called the "crossed outline" of Wenckebach, is, to be sure, very rare. We have met it only in cases of adhesions of the I Fig. 137. NORMAL RESPIRATORY OUTLINE Black line, deep expiration; dotted line, deep inspiration. 182 THE HEART AND THE AORTA base of the heart. Less value should be attached to the simple diminution of the divergency of the two outlines (Fig. 139), which is merely a suggestive indication. On the contrary, its absence should not cause the rejection of the diagnosis of cardiac symphysis, as has been noted, when pericardial adhesions were present. Fig. 138. CROSSED RESPIRATORY OUTLINE, ACCORDING TO WENCKEBACH 1/ K Fig. 139. RESPIRATORY OUTLINE OF SLIGHT EXCURSION AFFECTIONS OF THE PERICARDII^ 183 III. PARTICULAR DATA RELATIVE TO THE SITE OF ADHESIONS In this study, adhesions will not be considered which unite the two folds of the pericardium, the heart remain- ing mobile in the united sac. These adhesions are not accompanied naturally by any fluoroscopic modification. Besides, they have not much importance ; they do not give rise to functional disturbances and Laennec stated that this condition did not constitute a real disease of the heart. Only cases which are clinically important w T ill be considered in which the heart united to its pericardial sac has consequently contracted adhesions with the thoracic wall, mediastinum and diaphragm. 1. Adhesions of the Base of the Heart. These can be demonstrated by the following signs : a. Irregular notched shadows on the upper contour of the heart. These shadows sometimes occupy a large sur- face and extend round the great vessels or toward the thoracic wall. Their visibility is not constant and de- pends on their development outside the stern o-vertebral and cardiac shadow. b. Absence of lateral displacements of the base of the heart. In the left lateral inclination, the displacements of the organ, which are rather slight in the normal, are absolutely non-existent. c. Diminution or abolition of the respiratory displace- ments of the heart in the upper third of its projection. During deep inspiration, for example, the upper contour of the heart remains immobile, while toward the apex, the shadow of the organ is elongated and consequently lowered. d. Slight modifications of the mobility of the dia- phragm. The excursion of the diaphragm is slightly diminished during deep respiration, as a result of the fixity of the base of the heart. 2. Adhesions of the Apex. a. Presence of shadows of adhesions. If the heart is 184 THE HEART AND THE AORTA not too large, we see the denticulations made by the shadow of the adhesions projected all ronnd the apex; they unite with the diaphragm and obscure the left cardio-diaphragmatic sinus. ,/ b. Immobility of the apex. The immobility of the apex is absolute in the lateral direction and almost com- plete in the vertical. In order to affirm that adhesions are localized only at the apex, it is necessary to prove the persistence of dis- placements of the left side, to the exclusion of the apex. 3. Adhesions in the Diaphkagmatic Region, a. The adhesions exist only between the lower edge of the heart, the pericardium and the diaphragm. They extend either to both diaphragms or to only one. In the first case, the movements of the two diaphragms are appreciably dimin- ished, especially during deep inspiration and in the inner portion of their contour. In the second case, the difficul- ties of diaphragmatic excursion appear only on one side. b. In most of the adhesions above, the pericardium is in symphysis with the thoracic wall. The diaphragmatic movements are then greatly reduced, sometimes abolished in the greater part of their contour. The value of these observations is relative. Their bearing on the symphysis will be established only if no thoracic lesion exists (such as simple pleuro-pulmonary adhesions) capable of reducing the field of excursion of the diaphragm. 4. Adhesions to the Anteeioe Thoracic Wall. When large adhesions fix the anterior surface of the heart to the thoracic wall, the movements due to the displacement of the body and the respiratory movements of the organ are much diminished, or abolished, or occasion the paradoxi- cal phenomenon of inspiratory raising of the heart. The fixity of the organ hinders the excursion of the diaphragm f whose movements are reduced. In lateral position, the retro-sternal clear space remains dark during forced inspiration. AFFECTIONS OF THE PERICARDIUM 185 5. Posterior Mediastinitis. Posterior mediastinitis has only a secondary interest, but as it may complicate cardiac symphysis, it is necessary to know whether it exists or not. For this radioscopy in the oblique position is used. In this position, as Lambour 40 reminds us, fol- lowing Holzknecht, von Dehn, and Radonicic, mediasti- nal involvements manifest themselves by shadows which obscure the retro-cardiac clear area. 6. Complicated Cases. In order to present as precise a description as possible of the findings of radiology in cases of pericardial adhesions, they have to be schema- tized. It is evident that in practice more complicated sit- uations are met with, for adhesions may exist at the same time in different regions. The signs which have just been described will then be found associated, but the diagnosis will not on that account be rendered more difficult. It will demand simply more minute attention. It may be added, however, that more frequently than is thought, the adhesions affect in their disposition one or the other of the areas which have been described. IV. COMPARISON OF THE RESULTS OF PERCUSSION AND ORTHODIAGRAPHY Radioscopy and percussion give some information common to both and other findings which are special to each method. So these two methods, far from being mutually exclusive, assist each other and thus increase the means of diagnosis. Common Findings. Orthodiagraphic tracings and the tracings of percussion taken in the frontal or direct ante- rior position can most often be superimposed. They both give the measure of the heart area, its degree of hyper- trophy or of dilatation. However, orthodiagraphy is more accurate than percussion in outlining exactly the contour of the right side. The same is also true for the position of the apex and its degree of mobility. Findings Peculiar to Radiology. These concern more 40 P. Lambour, These de Paris, 191]. \S J 186 THE HEART AND THE AORTA especially the shadows of adhesions on the contours of the heart, the respiratory displacements of the organ, the modifications of the diaphragmatic movements, the ob- scuring of the anterior and posterior mediastinum. Findings Peculiae to Percussion. The most impor- tant is that which establishes the relation of absolute to partial dullness. It is known that very often in cardiac symphysis, the surface of complete or absolute dullness is considerable. The nature of this clinical sign, the value of which has always appeared to us important, is not here interpreted. It need only be said that no radiological sign corresponds to it : the shadow of the heart projected on the screen or on the plate corresponds only to the surface of relative dullness. Another sign obtained in certain cases by percussion consists in the invariability of the line of cardiac dullness during inspiration and expiration. This is explained by an adhesion of the heart to the sterno-costal wall, such an adhesion that pulmonary tissue no longer lies between the edge of the heart and the wall during profound inspira- tion, which suppresses all difference of sound on percus- sion. It is evident that this sign relates to percussion only because it consists in tone modifications. But it can al- ways be rectified by examination on the screen, which sometimes will show an absolute immobility of the con- tours of the heart which percussion might have missed. It should be noted, however, that Ceyka has doubted the value of this sign and according to him immobility of the pulmonary outlines might cause it as well as pericar- dial symphysis. V. CLINICAL EXAMPLES The following cases "are reported to demonstrate the value of radiological examination in the diagnosis and position of pericardial adhesions. The first is a case of symphysis of the apex in which the radiological signs confirmed the clinical diagnosis. AFFECTIONS OF THE PERICARDIUM 187 Th. L., twenty-two years of age, subject to rheumatic attacks since five years of age, has been in the hospital frequently. He entered our service January 7, 1909, with marked dyspnoea associated with painful palpitations. Clinical examination. Apex in the fifth intercostal space pushed slightly outward. Apparently displaced half a centimeter when the patient changed from the dorsal to the left lateral recumbency. Seesaw movement of the wall with systolic elevation of the apex and systolic retraction of the wall in the fourth intercostal space two fingerbreadths above and inward from the nipple line. Broadbent's sign at the left. The outline of the heart on percussion gives : area of relative dullness increased, measuring 120.65 square centimeters ; increase of absolute dullness. Auscultation: diastolic murmur at the aortic area transmitted along the right border of the sternum; double crural murmur. Pulse regular, bounding, 54 pulsations a minute. Systolic tension, 16-17 (sphygmo-signal). Liver slightly enlarged, overlapping the false ribs two fingerbreadths. Clinical diagnosis : aortic insufficiency, pericardial symphysis. Radiological examination : Dimensions of the heart. Area of projection, 127 square centimeters. Left side, 15.6 cm. long; right side, 8.3 cm. Longitudinal diameter, 16.8 cm. ; horizontal diameter, 15.3 cm. Apex rounded, lowered, pushed out- ward. Marked hypertrophy of the left ventricle (Fig. 140). Respiratory displacements of the heart. During deep inspiration and expiration, the displacements of the heart contours are very marked ; they are normal on the right, but on the left side, especially the middle part, they are 188 THE HEART AND THE AORTA very great, whereas there are no displacements at the level of the apex (Fig. 141). Fig. 140. TH. L. SYMPHYSIS OF THE APEX Aortic insufficiency. Hypertrophy of the left ventricle. Apex of the heart. It is immobile during left lateral inclination. When the patient is inclined far to the left, the contour of the shadow of the left ventricle, above the apex, approaches the external thoracic wall. Movements of the diaphragm. During deep inspira- tion, the right diaphragm is depressed 4.5 cm., whereas the left has a reduced displacement of about 0.5 cm. (Fig. 141). Outline of the heart. In lateral position at 90 degrees, the retro-sternal clear space is not visible in its lower third, even during forced inspiration. Respiratory outline. Form normal, ample. No abnormal shadows on the heart contour, nor in the pulmonary field. Conclusion. Signs of adhesions of the heart apex. Its immobility and the greatly reduced movements of the left diaphragm can be explained only by the fixation of the apex to the anterior thoracic wall on one side and to the left diaphragm on the other. In another case, the adhesions were on the anterior and superior surfaces of the heart. AFFECTIONS OF THE PERICARDII \\I 189 H., 15 years of age, entered la salle Lorain in June, 1911, for dyspnoea. No rheumatism in his history. Ob- jective examination shows the apex beat in the sixth inter- costal space in the nipple line. It is immobile when the patient passes from dorsal to lateral recumbency. Aus- cultation gives a systolic murmur of mitral insufficiency, accentuation of the second pulmonic sound. Broadbent's sign on the left. Orthodiagraphy gives the following (Fig. 142) : (a) Absolute immobility of the apex in lateral dis- placements; slight mobility in vertical displacements. (b) Very marked diminution of the res juratory dis- placements of the left side, which presents in its upper third, to a slight degree, the paradoxical sign of inspira- tory elevation in the vertical position. On the right, the respiratory displacements of the heart are maintained. (c) Diminution of the excursion of the diaphragm, both sides, especially left. (d) Cardiac area moderately increased: longitudinal diameter, 15 cm. ; horizontal diameter, 15.5 cm. Fig. 141. TH. L. IMMOBILITY OF THE APEX Bespiratory displacements of the right and left contours of the heart of normal size, excluding the apex. Marked diminution of left diaphrag- matic movement. 190 THE HEART AND THE AORTA (e) Respiratory outline reduced. Conclusion. The clinical signs warrant the diagnosis of cardiac symphysis. Radiological examination local- izes the adhesions on the anterior surface of the heart because of modifications in the respiratory displacements of the left side and the lateral immobility of the apex. These cases will suffice to illustrate the method fol- lowed in examining by fluoroscopy patients supposed to have pericardial adhesions. There are cases, however, in which no positive diagno- sis can be made. Ordinarily, these are young patients with valvular cardiopathies, most often aortic, and at the same time with considerable cardiac hypertrophy which, in a degree, immobilizes the heart. In these cases, the radiological and the clinical signs may easily be mis- taken for symphysis. In a case like this which we exam- ined (Fig. 143), there was a clear rolling movement on the surface of the heart, almost complete immobility of the apex, systolic retraction of the last intercostal spaces posteriorly and to the left (Broadbent's sign) ; in addi- tion to these signs there was a slight decrease of the respiratory displacements of the heart and a very marked Tig. 142. L. H., 15 YEAES OF AGE. Adhesions of anterior surface of heart. Black lines, deep expiration. Dotted line, deep inspiration. AFFECTIONS OF THE PERICARDIUM 191 diminution of the diaphragmatic movement on the left. This combination of symptoms led to the assumption that pericardial adhesions existed. Autopsy, however, showed that there were none and also explained the error in Fig. 143. V., 20 YEAES OF AGE. COB BOVINUM Pleuro-pulmonary adhesions. No cardiac symphysis. interpretation. The weight of the greatly enlarged heart pressed on the diaphragm which it rendered immobile; its mass was such that it prevented respiration affecting the normal heart changes. Finally, contact of the ventri- cle with the wall over a large area prevented the lung from slipping under the sterno-costal plastron at the moment of systolic retraction when separation occurs be- tween heart and thoracic wall, and this, because the tho- racic wall was flexible (young patient), accounted for the precordial retraction and the rolling movement found during life. The retraction of the intercostal spaces was due to pleuro-diaphragmatic adhesions, results of pleu- risy which the patient had previously had. It is evident that such complex cases are rarely met with and the fact that they may appear does not detract in the least from the value of radiological examination. CHAPTER VIII AORTITIS IT is common to find on post-mortem examination many different lesions of the aorta which have not been recognized during life. Sometimes considerable dilata- tions or aneurisms are seen, more often those "middle states" of aortitis, consisting of moderate enlargement of the vessel together with gelatiniform or atheromatous patches on the walls. These types of aortitis may escape observation completely and not be indicated by any per- ceptible sign on percussion or auscultation. The number of these accidental autopsy findings will diminish with the progress of radiology which already shows the most minute alterations in the shape of the aorta in the in- cipient stages. I. THE AORTA IN THE NORMAL Radioscopic examination of the right aorta should be made in two positions: (1) frontal position, the screen in contact with the sterno-costal wall; (2) oblique position, the patient standing, in profile, three-quarters, etc., behind a fixed screen, parallel to the plane in which the tube moves. 1. Frontal Position. The examination may be made in two ways and the patient observed in the vertical position or in recumbency; it is always necessary to specify which has been used, as the contours of the aorta present, as the case may be, slightly different images. In general, the tracing shows on the right above D (Fig. 144) a sinuous line reentrant as far as Ca and ap- preciably rectilinear from Ca to A. In its first course, AORTITIS 193 this line marks the superior vena cava ; in its second sec- tion, it marks the contour of the ascending aorta. This contour rarely goes beyond the sternal shadow in young patients ; but in adults it may overlap it slightly without a pathological condition being indicated. Fig. 144. CONTOUR OF THE AOETA AND THE HEART IN FRONTAL POSITION The examination of the left side of the patient (right side of Fig. 144) shows that from A' to A" is a semi- circular contour of especial interest for it represents the projection of the upper descending portion of the aortic arch. In this curved line there are two points to con- sider: first, the importance of its development which is naturally greater according to the space occupied by the aortic arch, and then, the distance which separates its point of origin from the sterno-clavicular articulation (st). The aortic semicircle is very clear in adults, still more marked in the old ; it may be lacking in children and the young. When there is a volumetric alteration in the vessel, it presents a more or less considerable increase and the estimate of it constitutes one of the essential elements of the description of the aorta. This will be considered presently. 194 THE HEART AND THE AORTA The distance which separates point A', origin of the aortic semicircle, from the sterno-clavicnlar articulation (st), varies according to the age of the patient and the more or less considerable development of the arch of the aorta. In normal adults the line which marks the left outline of the sternum from the clavicle to point A' is on the average 2 to 3 centimeters. Its length diminishes in the old, and point A' may be close to the sterno-clavicular articulation, especially in patients with a short thorax. The upper point of the aortic semicircle never does over- lap the line which marks the shadow of the left clavicle unless aneurism of the aortic arch is present. The preceding figure is much modified according to the position of the body and by successive respiratory acts. In the vertical position, the pericardial sac and its con- tents draw the vessels at the base to the medial line and cause them to undergo a certain elongation; the image of the aorta is then attenuated and elongated. In dorsal recumbency, on the contrary, the heart is pushed up and the aortic arch is broadened (Fig. 145). Fig. 145 Black lines, projection in recumbent position; dotted lines, standing position. AORTITIS 195 Respiration causes the same modifications. The arch is lowered, elongated and seems to contract in inspira- tion; in expiration it rises, broadens out, and its trans- verse diameter is increased. These modifications, which are as a rule purely physiological, might, if they were not known, lead to erroneous interpretations. It is impor- tant, therefore, to compare with each other tracings taken only in identical positions and in shallow respira- tion. Fig. 146. EIGHT ANTERIOR OBLIQUE POSITION AT 45 DEGREES 2. Oblique Position. Examinations in the oblique position are conveniently made in the vertical position only, which allows the body to be in the required obliquity and so to dissociate the vascular shadows from the shadow of the vertebral column. The right anterior oblique position is the most favor- able for the examination of the ascending aorta. It is obtained by holding the patient's right shoulder in con- tact with the screen, the bi-scapular axis forming with the plane of the screen an angle of varying degree. Between 40 and 45 degrees the image shown in Fig. 146 is obtained. Above the shadow of the heart another shadow will be noticed stretching to the right, digitiform, with parallel contours, which rises almost vertically to 196 THE HEART AND THE AORTA the region of the clavicle. The border AD is sharply silhouetted on the clear field of the left lung and marks the outside of the ascending portion of the aortic arch. The inner outline joins a penumbra A' A" which begins toward the superior part of the aortic contour and grows larger as it descends toward the auricular shadow. This penumbra is due to the projection of the descending por- tion of the arch and is less dense than the first because the vessel is on the left of the patient and consequently farther from the screen. Between the projection of the descending aorta and that of the vertebral column is a Fig. 147 Fig. 148 Fig. 147. EIGHT ANTEEIOE OBLIQUE POSITION AT 50 DEGEEES Fig. 148. ANTEEIOE OBLIQUE POSITION AT 60 DEGEEES clear band of unequal size which descends to the level of the dome of the diaphragm; it is known as the retro- cardiac clear space. A greater obliquity, 50 degrees, for example, accen- tuates the shadow of the descending aorta, which begins at a higher point (Fig. 147). The image obtained with an obliquity of 60 degrees is one of the most instructive (Fig. 148). The gray shadow of the descending aorta occupies a still more important AORTITIS 197 place in the retro-cardiac space. Its strongly convex out- line stands out clearly from the shadow of the ascending aorta, with its rectilinear outlines. Here the top of the arch presents a new appearance ; it seems to enlarge in the form of a beak which is turned toward the vertebral column and gives a dense shadow; this is the fore- shortened projection of the horizontal portion of the arch. The aortic shadow in oblique position is one of the most interesting to examine closely ; if it is uniformly enlarged in the form of a club, it can be concluded that there is a fusiform dilatation of the vessel; if it shows in pointed form a sac, superadded but dependent on the aorta, it may be concluded that an aneurismal sac exists ; if it is only more sinuous, with contours denser than usual, this alteration of the image is probably due only to marked modifications in the disposition and the anatomic structure of the vessel. Examination in the other oblique positions does not give this same information. However, in left anterior oblique position, above the distention of the pulmonary artery a portion of the ascending aorta is observed, the shadow of which is not covered by the penumbra of the descending aorta; at a proper angle, the contour of its outlines is clearly seen; it is also easy to measure the deviation and to check the figure of the diameter obtained with that found in right anterior oblique position. 3. Natuee of the Information Obtained. Orthodia- graphic examination gives a projection of the vessel which is not deformed; quantitative or rather volumetric information is obtained by measuring its different ele- ments. Fluoroscopic examination will have shown the more or less marked flexuosity of the vessel, the amplitude of its pulsations, the transparency or the opacity of its walls, all indications which are, so to speak, qualitative. A. Volumetric analysis. Three dimensions method. In order to have as exact an idea as possible of the dimen- 198 THE HEART AND THE AORTA sions of the thoracic aorta, it is necessary to make on each one of the two orthodiagrams, one in the frontal, the other in the right anterior oblique position, measurements in the regions determined on, before making fixed marks on the skin. The right anterior oblique tracing (Fig. 147) gives the image of the ascending aorta in the standing position. A horizontal line drawn from one to the other of the parallels which delimit the artery in its middle portion, gives the measure of their distance apart (line d). The caliber of the vessel in its ascending course will thus have been established. That is the first fixed mark. On the tracing in the frontal position, two other bear- ings are taken: the first corresponds to the transverse diameter of the arch, the second to the chord which sub- tends the left aortic semicircle. The transverse diameter of the arch is represented by the maximal distance which separates the contours of the aortic shadow on the right and left of the sternum. The two most salient points, not being at the same height, cannot be joined by a horizontal line. So the two greatest semi-diameters are taken terminating in the medio- sternal line (lines t and t' of Fig. 149), and together they give the measure of the transverse diameter. In recum- bent position this diameter exceeds by about five milli- meters that in the vertical position. The measure of the chord which subtends the left aortic semicircle gives good practical indications (line A' A" Fig. 150). This chord is thus defined: above, the point where the convex line which marks the arch issues 'from the mediastinal shadow and begins its outline on the left pulmonary field; below, the point of intersection of the semicircle with the contour of the pulmonary artery (point A"). Anatomically, this measurement is open to criticism, and, moreover, it corresponds to only a part of the de- scending aorta; it presents, according to the age of the AORTITIS 199 patient, a remarkable constancy. But in order that it should have its full value it is necessary that the varia- tions should not be assignable to any extrinsic cause, for example to a pushing back toward the left of the medi- astinal organs, caused by a tumor, an effusion, or ad- hesions. Fig. 149 Fig. 150 Fig. 149 The lines t and t' represent the two transverse semi-diameters. Fig. 150 Line A'A" is the chord which subtends the left aortic semicircle. It may be noted that the chord of the left aortic semi- circle varies in length according to the position of the patient. In a general way, up to about the age of forty years, it is 3 to 5 millimeters longer in the standing than in the recumbent position. To summarize, therefore, the volumetric analysis of the aorta depends on the evaluation of three points of measurement which 'have just been studied. From a large number of healthy patients, the figures corresponding to these three dimensions have been taken and are presented in the following table: 200 THE HEART AND THE AORTA TABLE OF THREE DIMENSIONS Normal Subjects. Men. Standing Position Age Transverse diameter in cm. Chord of aortic arch in cm. Diameter of ascending aorta in cm. 16 to 20 years 20 to 30 years 30 to 40 years 40 to 50 years 50 to 60 years Over 60 years 4 to 5 5 5 to 6 5.5 to 7 6 to 7 6 to 8 to 2.5 2.5 2.5 to 3.3 2.8 to 3.5 3 to 3.7 3 to 4 1.5 to 2 2 2 to 2.5 2.5 to 2.8 2.5 to 3 3 In women the figures are generally somewhat lower. It is hardly necessary to take account of the stature and weight of the patient, which give only slightly appre- ciable differences; however, a man with well-developed muscles will usually show the extreme dimensions indi- cated in the table. With these reservations, it is evident that the age of the patient is the most important factor in the variations of these measurements; that is the conclusion recently arrived at by a Japanese writer, Iwakichi Kam. 41 He has examined systematically the caliber of the large arter- ies of the body, on post-mortem, and has shown that the circumference of the aorta increases progessively from birth to the most advanced age, its caliber being greater at the same age in man than in woman. The figures which have just been given, though they are only relative, nevertheless constitute a practical guide in estimating the volume of the aorta. Though their relations cannot be expressed by mathematical constants, yet by analyzing them carefully important deductions may be drawn for the diagnosis of the existence and the variations of aortic dilatations, however slight they may be. 4i Iwakichi Kam, Virchow's Archiv, fiir patliol. Anat., Bd. CCI, 1910. AORTITIS 201 An increase in the three diameters indicates that the aorta is enlarged equally in all parts. A predominant increase of the transverse diameter, that of the ascending aorta being normal and the chord slightly developed, ought to lead to the conclusion that the aorta broadens under the costal plastron, the arch describing a curve of large radius. A greater increase of the length of the chord than of the two other dimensions without elevation of the top of the arch means only, if it is assumed that there is no aneurism, an enlargement of the aorta, very low and due to thoracic aortitis. Finally, a marked enlargement of the chord and trans- verse diameter with elevation of the top of the arch, the caliber of the vessel remaining normal, indicates a very sinuous and elongated aorta. B. Qualitative analysis. Radioscopy furnishes indi- cations concerning the state of the arterial walls, based on the study of the aortic pulsations, density of the shadow, appearance of the contour, and on the height of the arch. (a) Aortic pulsations. In general, the pulsations of the aorta are distinct and of moderate expansion. Per- ceptible at the level of the left aortic semicircle and along the right outline of the ascending aorta, they become feeble pulsations or localized undulations at the level of the wall, or, again, more extended oscillations, displacing rhythmically the entire arch at each systole. This latter phenomenon is found especially in patients over sixty years old, and only when the elasticity of the arterial tunicce is diminished. In atheromatous patients or in the course of aortitis with thickening of the walls, the pulsations become barely perceptible or disappear. In other cases, on the contrary, the pulsations are greatly increased in amplitude, and especially in young patients this may occur without any organic lesion. (b) Density of the aortic shadow. The density of the 202 THE HEART AND THE AORTA shadow cast by the aorta should be observed carefully in the course of radioscopic examination; it may vary more or less according to the condition of the arterial walls. In a normal subject the appearance of the overlying portions of the shadow is modified according to the age. In the adult and adolescent this shadow is plainly gray, but the contour is very visible and sharply outlined against the transparency of the lungs. Its opacity is always less than that of the shadow of the left ventricle. In the aged the density is greater and approaches that of the cardiac shadow. In the pathological state, the density of the aorta may be as great as that of the heart, sometimes even greater. Sometimes the opacity of the vessel affects the whole image of the aorta; sometimes it appears as spots and patches, irregularly distributed over the surface. When these spots are clearly perceptible in the intercostal >/ spaces they correspond to calcareous plaques. On the other hand, in certain cases usually accompanied with dilatation, the shadow becomes extremely light, as com- pared with the cardiac shadow. Finally, it may happen that the aortic shadow retains its normal density, even though the vessel may present evident signs of enlargement. The density of the shadow, then, has no direct relation to the volume of the vessel, nor, consequently, to the amount of blood in it. It is the condition of the walls, their thickness, and especially the presence of calcareous plaques which greatly accentuate the opacity of the shadow, as has been proven by examining anatomical material. The density of the shadow can also be studied in oblique position. In the adult the shadow of the ascending aorta and the penumbra of the descending aorta are sometimes difficult to dissociate. At forty, and especially over sixty years AORTITIS 203 of age, the ascending portion is much denser and cuts into the clearer shadow of the descending portion. This contrast of densities is even more marked in case of an atheromatous artery. (c) Contours. The shadows of the aorta are interest- ing to observe in the frontal and oblique positions. The portions which overlap the median shadow have, in the frontal position, a curvilinear contour with no irregu- larities ; the left salient is bounded by a circular arc. In the pathological state these contours, independent of their enlargement, show in certain cases abrupt angles or appreciable sinuosities. In the right anterior oblique position, the lines of the image of the ascending aorta were seen to be parallel and most often rectilinear. In the pathological state these may show unequal curves which describe perfectly characteristic sinuosities. The top of the arch sometimes shows a certain degree of distention. Finally, when the thoracic aorta is dilated or simply sinuous, the descending portion is outlined, in the oblique position, by a more or less irregular curve somewhat near the vertebral shadow. (d) Height of the arch. It has been indicated above how to estimate in the frontal position the height of the arch and its variations in the normal. This height in- creases in certain types of aortitis. This indication will be verified by examination in the oblique position, by noting the position of the transverse aorta in relation to the clavicle, the patient standing with arms hanging down. It may be said, therefore, that the general condition of the aorta, as determined by radiological examination, is represented by two series of parallel analysis : 1. Volumetric analysis depending on the three dimen- sions method : The transverse diameter of the arch ; The chord of the left aortic semicircle ; 204 THE HEART .AND THE AORTA The diameter of the ascending aorta. This analysis gives the real dimensions of the aortic shadow. 2. Qualitative analysis which furnishes important in- formation on the density of the arterial walls, their more or less great elasticity, the elongation, the spreading of the arch, the rigidity or flexuosity of the outlines. These data will be applied to the study of the pathologi- cal aorta. II. THE AORTA IN THE PATHOLOGICAL STATE Clinical observation gives two sets of facts which are very unlike but in each of which the aid of radioscopic and orthodiagraph^ examination is indispensable. The first category of cases concerns patients who, whether or not complaining of subjective disturbances which may be properly ascribed to a lesion of the aorta, nevertheless have such a lesion, as objective examination proves. The second category includes patients who have identi- cal disturbances logically ascribed to an analogous affec- tion which, however, cannot be confirmed by any of the methods ordinarily used. A. Case in which the diagnosis of aortitis is evident after objective examination. The subjective disturbances which point to an alteration in the aorta consist ordi- narily of dyspnoea on exertion, of permanent or parox- ysmal oppression, in the form of asthma or pulmonary oedema and in the pains which frequently accompany angina pectoris. The objective signs which give the cause of these dis- turbances are furnished by percussion and auscultation. The auscultatory findings are often doubtful; some- times altogether negative. Sometimes only a systolic or diastolic murmur or a double murmur at the base of the heart is obtained ; but that mean's only that the lesion has extended to the aortic valves. These murmurs may be AORTITIS 205 lacking even when the diagnosis of aortitis is, for other reasons, quite evident; they may exist without any altera- tion in the vessel beyond the valvular area. Often the pathological sounds are reduced to a metallic sound or to an accentuation of the second aortic sound. The resources of palpation and percussion are more valuable ; they consist in the determination of three signs which may exist together or singly: a superelevation of the right subclavian artery above the clavicle, a salience of the aortic dome in the sternal notch and an overlapping of the dullness of the aorta on the right side of the ster- num at the level of the first intercostal spaces. The figure resulting from this latter anomaly represents fairly well the crest of a helmet, whence the name "matite en casque" (Potain). When this sign is present, and especially when it is accompanied by the two other anomalies described above, dilatation of the arch of the aorta can be diagnosed. But if this sign is lacking the conclusion that there is no lesion of the vessel is not justified, because it may be altered in some other part causing the same subjective symptoms. In cases in which diagnosis of aortitis with dilatation of the arch is made by the combination of subjective dis- turbances and of signs furnished by direct examination, for example in Hodgson's disease, it might seem there- fore that radioscopy would be unnecessary. It is not so, because radioscopy enables the results of palpation and percussion to be checked and completed, which is an ap- preciable advantage, and the evolution of the lesion to be determined by examinations made at different stages. Orthodiagraphy has demonstrated the value of per- cussion : this assertion is true for percussion of the heart, and equally so for percussion of the aorta. In all the cases in which percussion has shown that a dilatation of the vessel at its point of origin existed, orthodiagraphy has confirmed it. One example is given here : A man forty years of age complains of subjective dis- 206 THE HEART AND THE AORTA turbances which make possible a diagnosis of Hodgson's disease. Objective examination shows an elevation of the aortic arch above the sternal notch and of the subclavian above the clavicle. Percussion of the aorta shows the existence of a dull area in the form of a helmet. Fig. 151 Fig. 152 Fig. 151. AOETA SLIGHTLY ENLARGED, AECH ELEVATED Fig. 152. SAME CASE, IN RIGHT ANTERIOR OBLIQUE POSITION AT 50 DEGREES Orthodiagraphic examination gives the images shown in Figs. 151 and 152 and the description of the aorta may be expressed in the following manner : Volumetric analysis: three dimensions method: Transverse diameter = 8 centimeters. Chord = 4 centimeters. Diameter of the ascending aorta = 3 centimeters. Qualitative analysis: (a) Pulsations very weak. ,, (b) Dense shadow; ascending aorta distinctly visible, v (c) Contours flexuous, abrupt angles (in frontal posi- tion). ''(d) Top of the arch elevated. Conclusion: Aorta slightly enlarged, arch raised, ivalls thickened. AORTITIS 207 As will be seen, the radiological indications confirm the percussion findings. The distention of the vessel is affirmed and its exact position determined, at the same time the facts which might escape the ordinary methods of investigation are accurately given, namely, diminution of the elasticity of the arterial walls, their flexuosity and thickening. If it is sometimes difficult, clinically, to verify the ex- istence of aortic changes, it is still more difficult to judge, some months later, the way in which they have developed. The interpretation of the data furnished by ordinary methods of investigation leads too often only to uncertain results. The interpretation of subjective symptoms is no less deceptive. Prognosis remains often most obscure in cases of aortitis. Under such circumstances radiology seems most val- uable by giving precise information. Two convincing cases are reported here. In the first case orthodiagraphy confirmed the clinical impressions by showing a clear re- gression of the aortic lesions corroborated by a corre- sponding amelioration of the subjective symptoms. In the second case, on the contrary, it revealed a progressive aggravation of the lesions of the aorta and thus revised a prognosis which according to the ordinary methods of clinical investigation would not have been considered unfavorable. The first was a man fifty-eight years of age examined March 6, 1910; he had been suffering for some months from dyspnoea which grew worse after exertion. Several times during exertion he had attacks of frothy and bloody expectoration. Marked increase of arterial pressure, marked increase of the aortic dullness "matite en casque," with an overlapping of about 2 centimeters on the right side of the sternum. The right subclavian was perceptibly above the clavicle. The heart was hyper- trophied ; the pulsation of the apex was in the lower part of the sixth intercostal space, below the nipple. 208 THE HEART AND THE AORTA In June, 1910, the patient was treated at Royat by Heitz. In July he returned much improved. The sub- jective symptoms had moderated and percussion indi- cated a regression of the signs previously found. The apex of the heart had lifted, the area of cardiac dullness had diminished and the aorta only slightly overlapped the right side of the sternum. The resulting favorable impression was confirmed by radioscopy (Fig. 153). Fig. 153. CASE OF IMPEOVEMENT Black lines, first tracing ; dotted lines, tracing after treatment. An earlier examination, made in May, 1919, furnished the following results : Aorta. Volumetric analysis: Transverse diameter = 9.5. Chord = 5.6. Diameter of ascending aorta = 3.5. Qualitative analysis: (a) Pulsations weak. , (b) Shadow rather dense. (c) Contours parallel. (d) Top of the arch slightly elevated, about 1 centi- meter below the sterno-clavicular articulation in frontal position. AORTITIS 209 Conclusion: Aorta regularly and notably enlarged and slightly thickened. Heart much enlarged. Longitudinal diameter = 20 centimeters. Horizontal diameter = 22.3 centimeters. Left ventricular outline markedly convex. Apex much rounded. Right ventricle descends 4 centi- meters below the diaphragm. In July, 1910, after treatment, the radioscopic descrip- tion is as follows : Aoeta. Volumetric analysis: Transverse diameter = 7.6 centimeters. Chord = 4.8 centimeters. Diameter of the ascending aorta = 3 centimeters. Top of the arch not so high. Heart. Longitudinal diameter = 19 centimeters. Horizontal diameter = 19.9 centimeters. The right ventricle has decreased in volume and de- scends only 2 centimeters below the diaphragm. The improvement is definite, as proved by the clinical examination and radiological findings but considering the precision of the radiological findings, it cannot be re- garded as superfluous. Here, on the other hand, is a case in which the aggrava- tion of the phenomena was distinctly brought out by radioscopy when other methods had failed to establish it. M. de B., fifty years of age, dyspnoea on exertion for some months, nocturnal oppression and palpitation. Objective examination shows a double aortic lesion with dilatation of the vessel at its point of origin, character- ized by dullness "matite en casque" and elevation of the right subclavian. The patient was immediately put under treatment. The attacks of oppression decreased and he was able to resume a very active life. A year later, the grave symptoms no longer appeared ; the objective signs continued but were not appreciably increased. On ortho- diagraph^ examination, a most manifest and serious 210 THE HEART AND THE AORTA modification in the condition of the heart and aorta was found. Fig. 154. CASE OF AGGBAVATION Black lines, first tracing; dotted lines, second tracing. The tracings (Fig. 154) show this. The dimensions of the heart and aorta are appreciably increased. The aortic arch shows increased transverse diameter and chord and a decidedly elevated top. The longitudinal diameter of the heart has increased from 18.4 cm. to 19.7 cm., and the horizontal diameter from 17.5 cm. to 19.5 cm. R-adiological examination was found to be correct as against clinical examination, the prognosis was therefore much more alarming than had been supposed. Some months later the patient was seized with an attack of acute aortitis with cardiac and aortic distention and succumbed immediately in full asystolism. B. Cases in which the subjective symptoms of aortitis are not accompanied by any objective sign. It occurs frequently that the diagnosis of aortitis ought to be sus- pected, in spite of the absence of definite objective signs, and because of the existence of subjective disturbances which are sufficiently characteristic to warrant it. Cases of this kind include acute and chronic progressive aor- titis. Examples are presented here : AORTITIS 211 A patient forty-eight years of age returned home in the morning after a fatiguing night. At the moment of retiring he was suddenly seized with severe pain in the retro-sternal region, extending toward the back between the shoulder blades with irradiations to the shoulders, especially the left and even to the jaws. The face was pale and drawn, respiration rapid and shallow. The pain lasted several hours, accompanied by fine rales in the chest, then it diminished progressively to reappear for a short time the next day, leaving behind a sensation of extreme prostration. From the combination of these symptoms, a diagnosis of acute aortitis with angina pectoris was made. The objective examination, however, gave no other indication. The arterial tension was normal. Percussion and auscul- tation were negative. Some days later radioscopic examination (Figs. 155 and 156) left no doubt of the existence of lesions which had only been suspected. Fig. 155 Fig. 156 Fig. 155. ACUTE AORTITIS Fig. 156. SAME CASE, IN RIGHT ANTERIOR OBLIQUE POSITION AT 50 DEGREES 212 THE HEART AND THE AORTA The detailed description of the aorta is as follows : Aoeta. Volumetric analysis: • Transverse diameter = 9.8 centimeters. Chord = 5 centimeters. Ascending aorta = 4 centimeters. Qualitative analysis: (a) Pulsations imperceptible. (b) Shadow rather dense in oblique position. (c) Contours parallel. (d) Top of the arch slightly elevated. Conclusions: Aorta uniformly enlarged in rather marked proportions ; the top of the arch is not elevated, but the vessel appears rather dilated below; the walls are thickened. Cases of acute aortitis of this kind are far from excep- tional ; we have met several similar cases in which radio- scopic examination showed alterations which had not been found by the ordinary methods of investigation. The same thing may occur in chronic aortitis. The following case bears this out. M. X., fifty-eight years of age, for six months previous had had typical attacks of angina pectoris. These oc- curred especially after eating and during rapid walking. They began in the epigastrium, then moved upward behind the sternum and finally localized over the chest causing the usual shooting pains. For some months the attacks had become especially painful. The obvious clinical diagnosis was angina pectoris due to aortitis or rather angina in its gastralgic form (angina abdominis) ; this diagnosis, however, depended exclu- sively on subjective symptoms, for objective examination, by percussion and auscultation, did not reveal any appre- ciable modification of the aorta. The result of radiological examination was quite dif- ferent (Figs. 157 and 158). It showed that a very marked alteration of the vessel existed since the transverse diam- eter measured 9.9 cm., the chord, 5 cm. ; the diameter of AORTITIS 213 the ascending 1 aorta was almost double the normal. The shadow of the vessel was very light. The top of the aortic arch was not much elevated, which explained the negative results of percussion and palpation. On the contrary the dilatation of the vessel was very slight, as was proved by elongation of the chord, and by the results of oblique examination of the aorta. In gastralgic or abdominal angina, this has been previously observed. Fig. 357 Fig. 15S Fig. 157. CHEONIC AORTITIS Fig. 158. SAME CASE, IN RIGHT ANTERIOR OBLIQUE POSITION AT 50 DEGREES Such conflicting results from the different methods of examination are easily explained. Percussion and pal- pation can determine only the existence of a dilatation of the aortic arch, for that is all that gives perceptible signs ; namely, the overlapping of the vessel on the right of the sternum as a result of the exaggeration of the curve of the arch, the elevation of the top of the aorta in the sternal notch, and the elevation of the subclavian above the right clavicle. These modifications are peculiar to Hodgson's disease and that is why this disease rarely escapes detection. The other types of dilatation are nat- urally not apparent by percussion and palpation. It is not the same with radiological examination which can, as the preceding case shows, give valuable evidence, even in 214 THE HEART AND THE AORTA cases in which the dilatation is located in another part of the vessel. There are, however, types of aortitis which are not accompanied by any modification of the quantitative or volumetric aortic signs; for this reason such types of aortitis do not cause deformations perceptible by fluoros- copy. Nevertheless, in an indirect manner, these types of aortitis can be determined by changes in the qualitative characteristics in the shadow of the vessel. Ordinarily these cases are shown on the tracings in the direct position. The transverse diameter is slightly in- creased, the salience of the left semicircle projects rather high under the left clavicle, as a result of the elongation and the tortuosity of the vessel. But in the oblique position its caliber maintains its normal dimensions. The conclusion can then be drawn, that there is no notable alteration. In spite of this, the diagnosis of aortitis should nevertheless be made when there is opacity of the vascular shadow coincident, fairly often, with spots and dense patches due to areas of calcareous infiltration, and the more or less complete absence of vascular pulsations, indicating thickening and rigidity of the walls of the artery. We have seen several cases of this kind. The essential subjective phenomenon which character- izes them consists in more or less violent pain, in the form of angina attacks, intense, repeated and lasting. This type of aortitis usually seems to imply a serious prog- nosis. It resists treatment, and it is not uncommon to note in the course of radiological examinations made at intervals of several months the progressive invasion of the aorta by sclerosis, the appearance of new opaque spots and the gradual increase in the diameters of the vessel. These types of aortitis, as a rule, cannot retrogress except when they are due to syphilis. But in that case treatment gives beneficial results. It diminishes the at- tacks of pain and acts on the lesion itself, for radiological AORTITIS 215 examination reveals a diminution in the opacity of the arterial walls with progressive reappearance of the pul- sations, indicating that the walls of the vessel are resum- ing their normal elasticity. The preceding considerations have a considerable im- portance. If lesions of the aorta have too often remained, up to the present time, resistant to therapeutic measures, it is because their usual cause is ordinarily misunderstood and the methods of treatment used not very efficacious; finally, intervention was too late, introduced when the alterations were already irremediable. The situation is different now. We know that syphilis plays an especially important part in the development of aortic lesions; we have in the Wassermann reaction a valuable method of verifying it. On the other hand, the therapeutic resources at our disposal have an efficacy which is no longer open to doubt. The part of the clini- cian here, as everywhere, is to recognize the lesion as soon as possible after its first appearance, for thera- peutic success depends on early diagnosis. Radiology will therefore enable the alterations of the aorta to be demonstrated at a stage in which they were hitherto not recognized. Radiology gives the exact description of the diseased aorta, allows the early recognition of the lesion, and permits us to follow its development ; it is the indis- pensable complement of every clinical investigation and the most reliable means of checking whatever therapeu- tic measures may be used. CHAPTER IX ANEURISMS OF THE THORACIC AORTA IN the preceding chapter, the study was limited to the more or less extended lesions of the aorta leaving aside aneurismal dilatations which are met with in cases of generalized aortitis but which also develop very often as isolated tumors affecting only a small portion of the vessel. Although it may be somewhat artificial to sepa- rate and consider aortitis on the one hand and aneurism on the other, for these changes are frequently due to the same cause, namely, syphilis, nevertheless the particular development of aneurisms justifies a special study of them. Radiological diagnosis of aneurism of the thoracic aorta is sometimes extremely simple, when the tumor is large and easily detected by fluoroscopy. When the aneurism is but slightly developed and concealed by medi- astinal shadows the significance of which must be deter- mined, the diagnosis is more difficult. The following technic seems necessary for a thorough examination. First, a complete radioscopic inspection of the thorax, which according to Holzknecht should be made in all the positions : direct anterior, direct posterior oblique and above all in right anterior oblique, noting the successive modifications of the shadows in changing from one to the other of these positions. The combination of these movements aims to make visible the different appearances of the aorta, to deter- mine whether its contours are regular or not and to estimate the degree of density. In order to carry out these procedures and to have an exact record of the out- ANEURISMS OF THE THORACIC AORTA 217 lines of the vessel, it is necessary to vary the angle of the rays and to bring the normal ray tangent to the entire extent of the artery outlines. After the examination on the screen, an orthodia- graphic tracing in the selective positions is taken as indi- cated by the preliminary radioscopic steps. Fig. 159 Fig. 160 Fig. 159. ANEURISM OF THE AOETA. HOUEGLASS FOEM Fig. 160. SAME CASE, IN EIGHT ANTEEIOE OBLIQUE POSITION I. GENERAL ASPECT OF ANEURISMAL SHADOWS A description of the different images of large aneu- risms will be given, those easily demonstrated by x-rays, in order to deduce the symptomatic characteristics which enable the more difficult diagnosis of smaller and dissimu- lated tumors to be made. The first case for illustration shows an aneurism visible in all positions like that shown in Figs. 159 and 160. In the frontal position the mediastinal shadow is deformed by an abnormal dense salience overlapping the sternum on the right in the first intercostal spaces, on the left at 218 THE HEART AND THE AORTA the level of the superior arch, and broadening out into both pulmonary fields. The mediastinal shadow appears as though formed of two superimposed globular shadows, in the form of an hourglass, the upper being formed by an aneurismal sac larger than the lower, which represents the heart. Fig. 161 Fig. 162 Fig. 161. ANEUEISM OF THE ASCENDING POETION OF THE AOETA Fig. 162. SAME CASE, IN EIGHT ANTEEIOE OBLIQUE POSITION In oblique position (Fig. 160), the aortic shadow be- comes completely atypical; the parallelism of the vascu- lar contours disappears, the image takes the form of an irregular sac with both anterior and posterior enlarge- ment. The extreme contours invade almost all the anterior clear space; the posterior clear space is filled by the shadow of the sac which at an angle of 50 degrees merges with the image of the vertebral column. This case is a question of a large aneurismal dilatation of the ascending and the descending aorta. This general disposition of the radioscopic shadows is found in all aneurisms that are easily seen ; but they are naturally modified in relation to the topographical dis- ANEURISMS OF THE THORACIC AORTA 219 position of the sac. The objective aspect varies accord- ing as the sac is on the ascending portion, on the top of the arch, or on the descending portion of the vessel. The images obtained under these circumstances are presented here. Fig. 161 is a woman forty-seven years of age with a large aneurism of the ascending portion of the aorta, especially at its origin. The aortic shadow in the right pulmonary field forms a very sharp angular salience. The contour is clear and without indentations, and there is no pulsation. In spite of the absence of this latter sign, the diagnosis is none the less positive. The development of the shadow gives evidence of a sac, for the transverse diameter of the arch is 12.7 cm. ; moreover, this shadow is dense and homogeneous. In the left pulmonary field, the aortic arc is greater in height than in depth; the chord of the arc measures 5.6 cm. The contours of the left semicircle are irregular but sharp and they pulsate synchronously with the pulse. If the patient is placed in the right anterior oblique position at about 45 degrees, the resulting image is that shown in Fig. 162. The top of the aorta, somewhat dilated, extends beyond the clavicle; lower, its shadow extends far to the right of the patient and obscuring the retro-cardiac clear space it merges with the shadow of the vertebral column. This abnormal salience is due to the angle made by the aneurism in the frontal position. "When the patient is placed in the right anterior oblique position, the mediastinal shadow is thrown entirely to the left, except the much distended sac to the right and toward the back which still remains partly in the right plane of the projection. This combination of data gives a diagnosis of an aneu- rism of the aorta, the greatest dimensions of which corre- spond to the ascending part of the vessel. Here the sac is developed not only outward but also toward the depth of the thorax. 220 THE HEART AND THE AORTA Figs. 163 and 164 are of a woman forty-six years of age with two dilatations, one at the top of the arch and the other of the descending aorta. It will be noted that this latter does not appear in the oblique position, which leads to the conclusion that it is not large ; on the contrary, the sac at the top is shown completely. Fig. 163 Fig. 164 Fig. 163. ANEURISM OF THE TOP OF THE ARCH AND OF THE DESCENDING AORTA Fig. 164. SAME CASE, IN RIGHT ANTERIOR OBLIQUE POSITION An example of the image formed by an aneurism of the descending portion of the aorta is shown in Figs. 165 and 166. In the anterior direct position (Fig. 165), it is the left aortic semicircle, otherwise called the superior arc, which is abnormally enlarged; the chord which subtends it measures 8.4 cm., and the transverse aortic diameter has the same length. In the right anterior oblique position (Fig. 166), the exterior contour of the ascending aorta which is com- pressed toward the outline of the thorax is traced first to the right, then the line curves in at the top of the arch and begins to descend. But presently it rises, goes toward the vertebral column and circumscribes in the ANEURISMS OF THE THORACIC AORTA 221 retro-carcliac clear space an irregular shadow which indi- cates an aneurism. This shadow is not very dense and its contours are rather light owing to the fact that the descending aorta is naturally distant from the plane of the screen. Only typical images have been presented here in which radiological examination has simply confirmed the clini- cal diagnosis, at the same time that the details of the lesion were more clearly noted. There are other cases, however, which are especially interesting, in which less developed aneurisms might escape clinical and even radio- logical examination if it were not made with an exact and appropriate method. This method depends on the analy- sis of special details which should be understood thor- oughly and which consist above all in the abnormal topographical disposition of the observed shadow, the atypical character of the aortic contours, their clearness in examination on the screen and their pulsations. It is the combination of these details which has enabled us, in the cases which are to be recorded, to arrive at a final diagnosis later confirmed by post-mortem. Fig. 165 Fig. 166 Fig. 165. ANEUBISM OF THE DESCENDING POETION OF THE AKCH OF THE AOETA Fig. 166. SAME CASE, IN EIGHT ANTEEIOB OBLIQUE POSITION 222 THE HEART AND THE AORTA Fig. 167 is not at all comparable to those that have just been described. The marked characteristic malforma- tions are not found in this case. In the frontal position, the aortic shadow overlaps only slightly, on both sides, the mediastinal shadow in the subclavian region. On the left it projects normally in the first intercostal space, forming an arc slightly exaggerated but not excessive. Fig. 167 Fig. 168 Fig. 167. ANEURISM OF THE TRANSVERSE PORTION OF THE ARCH Fig. 168. SAME CASE, IN RIGHT ANTERIOR OBLIQUE POSITION Also on the right, the protrusion is not considerable, but its position is quite abnormal; it is situated very high under the right clavicle ; this can be due only to the pres- ence of a sac. If it were a question of aortitis, that is to say, a cylindrical dilatation of the vessel, the salience of the arterial shadow would show itself, in the right field, much nearer the cardio-vascular angle than the sterno- clavicular articulation. Here it is quite the contrary. Besides, if there were any doubt about it, that would be removed by the fact shown in Fig. 167, that the top of the arch is elevated as far as the sternal notch and that not- withstanding the superposition of the vertebral and ANEURISMS OF THE THORACIC AORTA 223 sternal shadows, it is sufficiently clear to be indicated by a black line. Finally, at this point exaggerated pulsa- tions of the sac are seen on the screen. In the oblique position, the diagnosis is still more clear ; Fig. 168 shows that the aorta is deformed in the shape of a club. The conclusion to be drawn from these indica- tions is that there is an aneurism of the transverse por- Fig. 169 Fig. 170 Fig. 169. ANEURISM OF THE EIGHT CURVE OF THE ARCH Fig. 170. SAME CASE, IN RIGHT ANTERIOR OBLIQUE POSITION tion of the arch. The radiological characteristics which justify this conclusion are, principally, as has been indi- cated above, the anomalous position of the shadow, the atypical aortic contours, their clearness on the screen and their pulsations. Figs. 169 and 170 show a case of aneurism of the aorta in which the clinical and the radiological diagnosis were still more difficult, based only on a slight development of the sac and its unusual position. Clinically there was found in the first right intercostal space a very slight up- ward curvature with pulsations giving a thrill on palpa- tion. On the screen the atypical character of the tracing by its clearness was enough to establish a diagnosis. In 224 THE HEART AND THE AORTA Fig. 169 this atypical condition of the outlines showed itself by a bulging of the right aortic contour situated very high near the right clavicle. In the right anterior oblique position, the caliber of the aorta was enlarged, and moreover, there was a more marked dilatation above and at the right, giving to the top of the aorta a clublike form, the maximum salience of which corresponded to the external thoracic contour. The conclusion then was that there was a uniform dilata- tion of the aorta and, moreover, an aneurism at the point of the right curve. This diagnosis was definitely con- firmed by autopsy. Sometimes the interpretation of radiological images is still more difficult because the factors of diagnosis appear only in one of the positions, the other furnishing no indi- cation which can be depended on. It is then necessary to remember the rule, which has been insisted on, not to affirm the complete integrity of the vessel under observa- tion until after methodical radiological examination in all positions which it is possible to have the patient take in front of the screen. Here, also, the importance is apparent of adding to radiographic images orthodia- graphic tracings and at the same time the data resulting from fluoroscopic examination, for any one of these meth- ods used alone can lead only to uncertain conclusions. An example is given in Figs. 171 and 172. The case is of a woman fifty years of age with an enormous prester- nal pulsating tumor. Now, by examining Fig. 171 there is seen in the frontal position the shadow of the arch over- lapping the sternum on both sides in exaggerated propor- tions but not very considerable. A study of this image would leave no doubt of the importance of the aortic lesion; but in right lateral position (Fig. 172), the general appearance completely changes. An enormous sac is seen which projects across the sternum and exceeds it by 7 cm. If the lack of information on examination in the frontal position in contradiction to the importance of the findings ANEURISMS OF THE THORACIC AORTA 225 in the oblique position has only mediocre significance, assuming the certainty of the diagnosis, it is understand- able that it is not the same if the tumor is hidden in the mediastinum or if it escapes other methods of examina- tion. Fig. 171 Fig. 172 Fig. 171. LAEGE SAC IN THE POSTEBIOE-ANTEEIOE DIEECTION OF THE ASCENDING POETION Few signs in the frontal position. Fig. 172. SAME CASE, IN EIGHT ANTEEIOE OBLIQUE POSITION This is seen as well in aneurisms of the descending aorta, which often appear only on oblique examination, as in the case of the aneurisms of the antero-superior portion of the arch. Barjon 42 has described a typical example. Speaking of this type of aneurism he says : "This aneurism is situated on the median line, behind the sternum, below the sterno-clavicular articulation, at a point where the median shadow is broad and where the normal aorta regularly overlaps it on the left side. Noth- ing then is visible in frontal examination. If we are 42 Barjon, Anevrisms de I'aorte et tumeurs du mediastinum, Paris Medi- cal, 6 Janvier, 1912. 226 THE HEART AND THE AORTA looking, with our minds made up, for an aneurism, we shall easily find it in the oblique position. That happened to me in the case of a patient with paralysis of the left vocal cord which led me to suspect aneurism. There was a- regular rounded salience which, overlying the left edge of the aorta, filled the median clear space and touched the vertebral shadow" (Fig. 173). Fig. 173. ANETJEISM OF THE ANTEEO-SUPEEIOE PORTION VISI- BLE ONLY IN EIGHT ANTEEIOE OBLIQUE POSITION (BAEJON) II. ANALYSIS OF SOME RADIOLOGICAL SIGNS The study of the particular cases which have been taken as examples, in which there were aneurisms more or less easy to diagnose, has resulted in the recording of a cer- tain number of radiological characteristics which have only been mentioned. A detailed study will be taken up of each of these signaletic characteristics. (a) Lack of parallelism of the contours. The irregu- larity of the arterial contours is one of the most impor- J tant signs on which to rely in diagnosing aneurism of the aorta. It is in the oblique position, where the whole length of the aorta is seen and where both outlines of the ascending portion are clearly distinguishable, that we can best observe a modification in the parallelism of the con- ANEURISMS OF THE THORACIC AORTA 227 tours. If an aneurismal sac exists, the walls of the vessel diverge in all directions, their projection on a plane being represented by lines irregularly distant from each other, recurved and then decurved to make the ampullary form of aneurism. The resulting images appear immediately quite different from those in other pathological condi- tions; aortitis, even generalized, increases the caliber of the vessel, but it always keeps its cylindrical aspect; aortic insufficiency accompanied by an arterial lesion like- wise deforms the vessel, but the deformation is always situated at its point of origin and presents a regular conic form. On the contrary, the irregularity of the contours observed in a case of aneurism gives at once the impres- sion of vascular hernia or, in a word, of a sac. In the direct position, the lack of parallelism of the con- tours is represented by large curves and is distinct from the usual outlines of glands and tumors, which are gen- erally polycyclic and give the shadow an embossed appearance. (b) Precision of contours. The contours of an aneu- * rism are usually clear and linear. There is a striking con- trast between their shadow and the clear pulmonary fields. This demarcation is especially evident on radio- scopic examination. It is not always the same on radio- graphic plates, for, as Belot 43 has remarked, a pulsating tumor cannot on account of its pulsations give more than a hazy image on a plate, even if it is taken in a few seconds. Finally, in the case of aneurism, the curves are rounded and there are no sharp angles, no finger-like prolonga- t/ tions such as are seen in cancerous tumors, no polycyclic contours such as are made by glands. However, these characteristics are not pathognomonic. It may happen that the mediastinal tumors are marked by outlines of perfect clearness simulating arterial walls. On the con- trary, there are cases in which the vascular contour is very 43 Belot, Societe de Kadiologie, Seance du 12 avril, 1910. 228 THE HEART AND THE AORTA much blurred on radiological examination, when in point of fact there is an aneurism. It is necessary, then, to at- tribute this fact to the fibrous products of peri-aortitis, sufficiently dense to disturb the clearness of the arterial outline. (c) Homogeneity of the shadow. If we compare the image of an aneurism with that cast by a gland mass, it is j noted that the latter presents a shadow of unequal den- sity. It is formed of juxtaposed patches of varying depth. The aortic shadow is most often homogeneous. We say most often, because in some cases of multiple or irregular sacs zones much darker than the rest of the vessel are found. But then these regions correspond to the most enlarged parts of the outline in direct position or to the most marked saliences in oblique position. (d) Pulsations. One of the most important character- istics of aneurism consists in the arterial beats or pulsa- J tions which are found on the contour of the shadow. Still it is necessary to look at these very closely and to differ- entiate the pulsations of the shadow as a whole, which are sometimes only transmitted pulsations, from those of the walls which take the form of an undulation along the contour. But even if the pulsations are clearly arterial, the con- clusion should not be drawn that there is an aneurism; the same image may be given by a tumor of the medias- tinum. We have observed two cases of it. In the first the error made by a radiologist and by ourselves was cor- rected only by the development of the symptoms. In the other it was not recognized until after death, and autopsy revealed an enormous gland mass in the mediastinum. The lateral outlines of the mass were almost parallel and perfectly linear. The aorta passed through the gland mass and it was that which caused the pulsations during life. It may happen, on the contrary, that the pulsations are lacking on the contour of the aneurisms. Aneurisms ANEURISMS OF THE THORACIC AORTA 229 often have been found entirely without movement, either because the sac was filled with an organized clot or be- cause the vascular wall was infiltrated with atheromatous plaques. To summarize, therefore, if radioscopic examination is useful in diagnosing aneurism of the aorta, it is still, how- ever, open to mistakes. The most perfect radiographic evidence always requires intelligent interpretation. III. DIAGNOSIS Although the indications furnished by radiology in the examination of the aorta are numerous and significant, it does not, however, follow that the diagnosis of aneurism is always equally easy. To be sure, it presents no diffi- culty when the analysis of the tracings and of the radio- graphic images has enabled the details to be observed which have been noted in the course of this study, if noth- ing else has intervened to spoil the interpretation. But this is not always the case; in some circumstances the shadows have not the same clearness, or they may be deformed by secondary shadows with irregular contours, having only distant and indirect relations with the aorta, and a minute analysis is then necessary to distinguish what belongs to this vessel and what is due to lesions of the neighboring organs. The differential diagnosis of aortic aneurism is easily made when the tracings show the presence of an isolated tumor attached to the vessel, having sharp, clearly defined contours, the whole forming an opaque shadow, situated in the mediastinum, with perceptible pulsations on the screen which can be due only to a vascular tumor. These signs are sufficient to eliminate from the diagnosis a whole series of other tumors which may lie in the mediastinum but which do not originate in the aorta: such as lymphosarcomatous tumors at the level of the hilum of the lung; or pulmonary cancers which are sit- uated in the full parenchyma and which also extend some- 230 THE HEART AND THE AORTA times toward the median parts, but in an altogether sec- ondary and accessory manner. The question, therefore, seems always easy of solution ; but it is very necessary that it should present itself under all circumstances with the same simplicity. Aortic aneur- ism may be complicated with peri-aortitis, with pericar- dial symphysis, with pleural effusion, all lesions capable of obscuring the regions usually transparent, of obscur- ing the shadow produced by the aneurism itself, of making the contours diffuse, and therefore making the diagnosis difficult. Inversely, peribronchial or mediastinal glands, chronic infiltrations or tumors of the pulmonary parenchyma, pleural effusions, mediastinal tumors, etc., when their extent is considerable, may invade all one side of the thorax, from the neck to the diaphragm, and so far ob- scure the cardio-vascular contours as to make them un- decipherable and sometimes mistaken for an aneurism of the aorta which in point of fact does not exist. In these clinical cases, which are so much open to controversy, radiological examination is useful, not, to be sure, in deciding between two doubtful opinions, but in offering elements important in diagnosis. The first difficulty to surmount is to recognize or, rather, to mark the shadows of the vessels, the second is to dissociate them from superadded abnormal shadows. For that, investigation will have to be made of the differ- ent portions of the vessel, and the surface examined, then the outline, varying the angles of incidence. After this examination has verified, on the screen or on the tracings, the exact contours of the aorta, the diameters will be measured ; then the entire vessel traced, noting the points at which accessory shadows are superadded. The latter will be marked and often according to their very situa- tion the probable existence of an aneurism of the aorta will be considered. If, in the course of this examination, the aortic outline, at first normal, is suddenly lost in a ANEURISMS OF THE THORACIC AORTA 231 superadded mediastinal shadow constituting a real patho- logical salience of the vessel, the diagnosis of an aneurism will be justified. The conclusion will be different if the shadow presents only accidental relations with the vessel, and a mediastinal tumor is more likely. It will be unusual, then, if in varying the position of the patient there are not found in certain oblique positions, other dense masses of the same form probably as the original mass, which will exclude the idea of aneurism. Such dissociation, made on fluoroscopic as it would be made on post-mortem examination, is often very difficult, but usually if the pro- cedure is methodical a diagnosis is arrived at which, if not final, is at least probable. A. DIFFERENTIAL, DIAGNOSIS OF AORTIC ANEURISM FROM OTHER THORACIC OR INTRA-THORACIC AFFECTIONS Malformations of the skeleton. The error here is rather exceptional; usually, indeed, clinical examination of the patient shows the presence of such malformations, notably, deviations of the vertebral column. Pleuro -pulmonary adhesions. Lesions of the pulmo- nary parenchyma. Very heavy pleural adhesions of the middle region of the thorax rarely lead to confusion because of the irradiated aspect of their contours. They constitute simply a serious interference with methodical S examination. Pulmonary infiltrations, which give such extensive shadows in certain cases of pulmonary tuber- culosis, are in general rather easily dissociated from abnormal shadows of the aorta. Cancerous masses, syphilitic gummata, usually have their point of departure at the level of the pulmonary hilum. When they increase in extent, it is only in the form of prolongations either above or outside the clavicle, or more often toward the base of the lung. Interlobar pleurisy. Right interlobar pleurisy with large effusion often obscures such a great part of the 232 THE HEART AND THE AORTA pulmonary field that it may give the impression of a vast aneurismal sac. But the diagnosis of this form of pleu- risy is facilitated by the following signs : the tumor pre- sents a somewhat rounded aspect and its lower contour lies below the region ordinarily occupied by- aneurisms. Moreover, it is usual to find a transparent pulmonary band between the tumor and the diaphragm ; finally, suc- cessive examinations will show, according to the evolu- tion of the disease, a more or less rapid increase of the obscure zone, or, on the contrary, its progressive diminu- tion. If the effusion is only moderate, in the lateral or oblique positions, its shadow is seen isolated in the middle of the transparent pulmonary field and distinct from the medi- astinal shadows. Cysts of the lung. Hydatid cysts lying in the middle or upper portion of the lung may be mistaken for aneurism of the aorta. The same is true of large dermoid cysts in elevated position. In all these cases it is essential to establish accurately the topography of the shadows, their position and their characteristics in repeated examina- tions, in case of doubt, some days or some weeks apart. These tumors have usually a clearly circular form which differentiates them from aneurisms. Moreover, the modi- fications in their size are usually more rapid than those of aneurism. In other cases, however, the diagnosis remains doubt- ful, and radiology is unable to establish definitely the position and nature of the tumor observed. It is then that laboratory methods should be resorted to. They are especially valuable in cases of hydatid cysts, as shown by Guedini, Weinberg, Parvu, and Laubry. Tumors of the mediastinum. Thoracic adenitis, lym- phoma, sarcoma, lympho-sarcoma often show considerable shadows in the thorax difficult to interpret. Here the data must be applied obtained by the methods used in order to dissociate the vascular shadows, marking the ANEURISMS OF THE THORACIC AORTA 233 contours in all positions, and to determine the presence of a secondary tumor, the existence of which will favor the diagnosis. B. DIFFEKENTIAL DIAGNOSIS OF ANEURISM OF THE AORTA FROM DILATATIONS OF OTHER VASCULAR ORGANS The presence at the base of the heart of sacciform and expansile tumor does not clearly signify that there is aneurism of the aorta. Such tumors may depend either on the pulmonary artery (but that is rarely the seat of aneurisms) or on great dilatations of the conus arteriosus. There have also been described dilatations of the supe- rior vena cava which might be mistaken for an aneurism of the aorta. Dilatation of the left auricle and especially that of the left appendage may also cast shadow saliences like those of aneurismal sacs. Grallavardin has recently reported a case. Radiological diagnosis- of these different sanguine tumors depends on their topographic position ; most often it will be easy enough to determine their exact position and, from that, their origin. C. ASSOCIATION OF ANEURISM WITH OTHER LESIONS The association of a pleurisy on the left with aortic aneurism is most often encountered ; serous effusion then takes place in the large pleural cavity, and may obscure the left contour of the heart as far as the base. However, it seldom rises higher than the third intercostal space. If the aortic sac is much elevated, the contours of it will be seen above the shadow produced by the effusion ; if it lies on the descending portion, it will be obscured by the shadow of the effusion which will make it impossible to follow the inferior contour of the aneurism and to esti- mate the full extent of it. However, even in these cases, there is one sign which persists and which often allows the suspicion of an aneurism : that is, the abnormal devel- 234 THE HEART AND THE AORTA opment of the left superior arch. In these especially doubtful cases, diagnosis is rendered still more difficult by the fact that the indications can only be made use of when obtained in direct position. Indeed, in oblique posi- tions, the pleural fluid obscures the greater part of the retro-cardiac space, so that it is impossible to say whether or not another shadow exists produced by an aneurism. It is unusual to see gland masses associated with an aneurismal tumor. But these masses will be easily recog- nized by their position at the level of the hilum, by the appearance of their shadow which is very uneven; they only interfere with the reading of the outline of the vascular walls. The association of a cardiac affection with an aortic aneurism will be easily demonstrated by radiological examination, because of the characteristics peculiar to each of the diseases of the heart, which have been studied in the preceding chapters. Very often the heart shows no modification of volume when the aorta is the seat of a large aneurismal tumor. Fluoroscopic examination or the radiographic image will easily give evidence of this ; but in other circumstances it will not be surprising to find an enlargement of the heart coincident with a valvu- lar lesion of the aorta or with other cardiac affections ; the study of these associated lesions has only a limited in- terest. CHAPTER X LOCALIZATION OF WAR PROJECTILES IN THE HEART AND PERICARDIUM WOUNDS of the heart from projectiles are in the majority of cases rapidly fatal. However, it is not unusual to have patients survive with fragments of metal in the cardiac cavities or the pericardium. According to a review which we have made of medical literature, eight articles have been published of foreign bodies in the heart not extracted: Finzi (1915, 1 case) ; P. Delbet (February 2, 1916, 1 case) ; Grandgerard (August 17, 1916, 1 case) ; Ledoux-Lebard (1916, 1 case) ; Lobligeois (November 7, 1916, 1 case) ; Ascoli (January 1, 1917, 1 case) ; Lyle (1917, 1 case) ; Gilberti (February, 1917, 1 case). Thirteen cases in France which were surgically treated have been published: Beaussenat (May, 1915, April, 1916, 2 cases) ; Vouzelles (November, 1915, 1 case) ; Cou- teaud and Bellot (December, 1915, 1 case) ; Bichat (May, 1916, 1 case) ; Dujarrier (March, 1917, 1 case) ; Chauvel and Loiseleur (March, 1917, 1 case) ; Le Fort (May, 1917, 1 case) ; Fredet (June, 1917, 1 case) ; Hallopeau (June, 1917, 1 case) ; Petit de la Villeon— Juxta-cardiac projec- tiles (April, 1916, 3 cases). These thirteen surgical interventions resulted in three deaths and ten cures. Other cases are known, the reports of which have not yet been published. Ledoux-Lebard has examined seven cases of foreign bodies in the cardiac walls, three of which were operated on ; three cases of foreign bodies which had penetrated the pericardium, of which two were operated on. Bouchacourt has radiographed three patients with 236 THE HEART AND THE AORTA projectiles which were not removed; the first, a bullet in the apex of the heart, another, a bullet in the heart, and the third a splinter in the pericardium in the immediate vicinity of the posterior wall. Maingot has radiographed a case with a bullet in the left ventricle, extracted by Hart- mann, and a foreign body in the heart of a patient of Pauchet's. Finally, we have examined two cases of pro- jectiles not removed, a rifle bullet in the right auricle and a piece of shrapnel in the pericardium. Complete statistical data cannot be compiled now, espe- cially of cases in which the projectile was not removed. Many radiologists have observed foreign bodies in the heart and pericardium without publishing their observa- tions ; on the other hand, due to the frequent transference of the wounded and the frequent examinations made of them, the same patients must have been fluoroscoped by several specialists. Not until after the war will the Ser- vice de Sante be able to compile correct statistics. Of the thirty-eight cases, however, which have been brought to our attention, nineteen cases had surgical intervention. In half the cases the projectiles caused disturbances which necessitated their removal. These disturbances consisted in cardiac pains, in at- tacks of dyspnoea, permanent or an exertion. The aus- cultatory signs were insignificant or negative. However serious the functional disorders, the clinical symptoms did not warrant a definite diagnosis. Only radiological examination gave positive evidence. The importance of radio-diagnosis is therefore appar- ent. But though it is relatively easy to locate a foreign body in a limb, to indicate the depth in relation to a point on the skin, or by a bony prominence, the localization of a projectile in the heart or pericardium meets with seri- ous difficulties. These difficulties can be appreciated by reviewing the unprecise radiological indications which have been published concerning a few patients that have been operated on. To determine the presence of a metal- LOCALIZATION OF WAR PROJECTILES 237 lie body in the heart area is not sufficient. The surgeon demands, in order to operate intelligently, that the radio- logical report shall be full and precise. In the conference of November 10, 1915, of the Societe de Chirurgie, this question was discussed and Quenu laid down the following principles : 1. In all cases in which projectiles are deeply situated in limbs or in an organ, simple radiography is not suffi- cient, it only gives preliminary information. 2. In such cases, probing for a projectile is not per- missible until after localization, and this localization ought to be made by a skilled radiologist. 3. It is desirable that the surgeon should have at his disposal several methods of research, in case one should fail. 4. It is necessary that the search for foreign bodies be made in close collaboration by surgeon and radiologist. The best method of localization of foreign bodies in the cardiac region will now be considered. I. LOCATING THE PROJECTILE The first question is to determine whether a projectile is in the region of the heart, and this is done by making a general radioscopic examination. The pulmonary fields around the median shadow, the cardio-diaphragmatic sinuses, the hila, the vessels of the base and mediastinum, are examined in order to find out first the condition of the regions which surround the heart and to determine whether pulmonary lesions exist and pleural or pericar- dial effusions. In the latter case, the obscurity caused by fluid prevents a complete investigation or, at least, a conclusion being drawn from the examination, if no pro- jectile shadow can be demonstrated. But if no complica- tion exists, the examination is continued by inspecting the surfaces of the heart in the direct, oblique, and lateral positions. 238 THE HEART AND THE AORTA Shrapnel balls, rifle bullets, or fragments of some size as a rule are readily seen on the screen. It is not so with small metallic bodies. They may not attract attention. In Fredet's case, there were two small fragments, one intra-pulmonary which was noted several times,' the other intra-cardiac which was not noticed in the first examina- tion. If a foreign body in the heart is suspected, a long and careful search is sometimes necessary. The rays should be of great penetration. A hard tube with an easily adjustable diaphragm offers great advantages. Moreover, in the course of the examination, the intensity of the ray is varied according to the circumstances. The rays are passed over the entire cardiac area and the least differences in the homogeneity of the shadow is studied; then the rays are moved obliquely in order, if possible, to make them pass the foreign body at its greatest thickness, which accentuates the shadow, while the patient is placed at various angles in order to dissociate the superimposed shadows of the thorax. Sometimes only a slight move- ment of the tube or of the body is enough to show the fragment distinctly. After that the radiologist does not lose sight of it and is ready to make precise observations. When the projectile is free in a cavity, its movement renders it indistinct. By radioscopy we can observe its exceedingly rapid movements. Radiography is not satis- factory, for mobile projectiles give extremely vague shad- ows or leave no trace on the radiogram. However, some radiographers have arrived at excellent results with apparatus operating at one-fiftieth of a second. It is always useful under these circumstances to objectify the projectile by taking a radiogram. This is indispensable in cases where, in spite of clinical opinion, radioscopic examination remains negative. It may then happen that small splinters, not seen on the screen, are fixed on a good radiogram. This test is always necessary in order to draw a conclusion. If from this examination the evidence is positive, the LOCALIZATION OF WAR PROJECTILES 239 next step is to locate the foreign body as exactly as possi- ble. II. METHODS OF LOCALIZATION The purpose of localization is to determine the depth at which a projectile lies with relation to a determined point on the skin. If this has been fixed at the place where incision should be made, the surgeon knows in operating at what distance and in what direction he will encounter the foreign body. The calculation of the depth is obtained by a number of methods which depend, for the most part, on the geo- metric relations of similar triangles. The construction of these triangles is based on shifting the tube a known distance. The figure of the projections is completed either by means of instruments or by means of drawings, diagrams, or stereoscopic images. Instrumental methods are represented by the Hirtz compass and others derived from it. During the opera- tion an indicator marks the direction and the depth of the projectile. It is evident that the mobility of the region to be explored causes technical errors and difficulties. The extent of the movements of the thorax and the res- piratory displacements of the heart are not the same. If a mark is made on the skin, corresponding to a zone of the maximal oscillations of the foreign body, unexpected modifications of the respiratory rhythm during anesthe- sia may render it unsafe. In the course of the operation, the drawing up of the heart into the surgical opening changes momentarily all the surrounding relations. So the use of compasses does not seem strictly advisable in surgery of the heart. But that does not imply that all measurement of depth should be rejected. It is advisable to try it wherever possible. Among the most rapid methods are those of Ropiquet, Haret, Hirtz-Gallot, Aime, Barjon, Casel, etc. However approximate the indications may be, there will 240 THE HEART AND THE AORTA still remain, however, an interesting element of individual judgment. It lias been seen that the index of depth of the left ventricle in normal subjects varied from 7 to 14 milli- meters. The tables of calculation show that these indices correspond experimentally to a depth of 10 to 12 centi- meters for the portion of the posterior wall tangent to the oblique ray. The double measurement of the depth of the heart and the depth of the projectile, on condition that the latter is not very far from the zone of the apex, de- termines whether it is in the anterior or in the posterior segment of the organ, that is to say, in the right or in the left ventricle. The methods of localization are not of interest except when they help to locate the projectile anatomically. So it is this particular point of view that the radiologist ought to keep in mind. III. ANATOMICAL LOCALIZATION It is a question of finding out whether the projectile is in the pericardium or in the heart and in which cavity of the heart. Peojectiles in the Pekicakditjm. When the wound is recent, the hemo-pericardium interferes considerably with the examination and it may be impossible to give an opinion. If the amount of the effusion does not make the projectile invisible, the localization, though very difficult, may be conclusive. As a rule, the foreign body, after having penetrated the folds of the pericardium, falls into the bottom of the sac and is seen in the inferior diaphrag- matic portion of the shadow. But if, for some special reason, the piece of metal remains in the upper parts, if it is fixed there by adhesions, it is found by signs very much like those of projectiles lodged in the walls of the heart. We have not found observations which enable us to study this question in detail. When the effusion has been reabsorbed and the peri- cardial folds have become transparent again, the locali- LOCALIZATION OF WAR PROJECTILES 241 zation of the projectile in the inferior part of the sac is easily made. A number of characteristic signs are noted ; those that have been found in the course of an observation of this kind are presented here : A case of a gunner in the first artillery, with a shrapnel shell seen in direct anterior position, on the inferior con- tour of the right ventricle, at the level of the left outline of the vertebral column (Fig. 174). It lay about half Fig. 174. SHEAPNEL BALL IN THE PEEICAEDIUM, IN THE LOWEE PAET OF THE HEAET way over this line. It was separated from the central portion of the diaphragm by a transparent band which enlarged during inspiration. In lateral position, the projectile was under the ventricular mass, 3.5 cm. from the anterior thoracic wall (Fig. 175). The markings gave the following result: projectile lodged 3.5 cm. deep from the inferior sternal wall, on an antero-posterior line passing to the lower part of the right heart and tangent to the left side of the vertebral column. A study of the movements of the projectile was made to determine whether the ball was adherent to the ven- tricular wall or lay in the pericardium. 242 THE HEART AND THE AORTA These movements were of two sorts: (1) pulsations, (2) respiratory displacements. The pulsations were synchronous with those of the heart, but they had a much greater amplitude. They could be studied in right anterior oblique position at 20 degrees (Fig. 176). They spread vertically with a total Fig. 175. SAME CASE, IN LEFT LATEEAL POSITION Fig. 176. SAME CASE, IN EIGHT ANTEEIOE OBLIQUE POSITION AT 20 DEGEEES LOCALIZATION OF WAR PROJECTILES 243 excursion of 8 mm., 4 mm. up, and 4 mm. down, which showed that it was a question of transmitted pulsations. Fig. 177. SAME CASE, IN EIGHT ANTEEIOE OBLIQUE POSITION Bespiratory movements of the heart, the diaphragm, and the projectile. The respiratory displacements indicated in Fig. 177 (right anterior oblique, 45 degrees), were in the same direction but more extended than those of the heart, also in the same direction but less extended than those of the diaphragm. The anatomical localization, consequently, was as fol- lows : projectile lodged in the pericardium, in the vicinity of the ventricular wall. Intba-caediac Peojectiles. The cavities most often affected are the right cavities, ventricle and auricle, by reason of the superficial position which they occupy in relation to the anterior surface of the thorax. The left ventricle seems to be less often affected. To locate a projectile in one of these cavities, it is well to consider successively the topography of the region involved and the movements, pulsations , or displacements of the metallic bodies. The topographic indications furnish data which are 244 THE HEART AND THE AORTA recognized by the projection of the heart shadows in the different positions. The right ventricle occupies, in the frontal position, the median part of the cardiac shadow, between a rather nar- row band along the edge of the left ventricle and a trian- gular surface with the point down, which belongs to the right auricle. But if the middle zone corresponds in front to the right ventricle, it corresponds behind to the left ventricle. It is not enough, then, to prove the presence of a projectile in this region in order to locate it. It is just Fig. 178. EIFLE BALL IN THE WALL OF THE EIGHT AUEICLE here that measurement of depth is useful. It is desirable to make this before every intervention, since only opera- tion can verify this question, for the measurements made on the dead body are not comparable with the relations in the living body. In the case reported by Chauvel and Loiseleur, the rifle ball had been plotted 6.5 cm. in depth, rather near the apex. Eadiological localization supposed the projectile encysted in the right side of the heart. In point of fact, that is where the surgeon found it. A manipulation which may show which ventricle is affected consists in placing the patient in left anterior oblique position so that the normal ray passes through the major axis of the heart. An intense illumination LOCALIZATION OF WAR PROJECTILES 245 allows us to see the foreign body, and according as it occupies the anterior or the posterior segment, to plot approximately its position. The right auricle is outlined in the right hemithorax and we may consider as properly belonging to it the area defined on the outside by the right outline of the heart as far as the diaphragm, and on the inside by a schematic line from the cardio-hepatic angle to the median part of the base of the organ. Fig. 179 Fig. 180 Fig. 179. SAME CASE, IN LEFT POSTERIOR OBLIQUE POSITION Fig. 180. SAME CASE, IN RIGHT POSTERIOR OBLIQUE POSITION It is in this region that projectiles in this cavity are seen. Fig 178 is an example ; it is of a patient with a rifle ball in the wall of the right auricle. In left posterior oblique position, the right auricle is outlined in the lower two-thirds of the retro-cardiac clear space (Fig. 179) ; in right posterior oblique position this auricle corresponds to the median portion of the image of the heart. It is, in point of fact, in this region that we find the ball (Fig. 180). Projectiles are animated by variable movements ac- 246 THE HEART AND THE AORTA cording as they are free in the cavities or imbedded in the walls. In the first case, they show whirling movements which are absolutely characteristic. Lobligeois describes these movements in a patient he examined. It was a question of a shrapnel ball lodged in the left ventricle. "At the end of diastole, the ball rested on the inferior border of the heart, near the apex; when systole intervened, it veered rapidly from left to right (of the patient) along the lower border, evidently struck against the inter- ventricular partition and followed that from below up- ward in vertical direction. It thus arrived at the most elevated point of the ventricle, but against the right side of the ventricle. That was the end of the systole. It remained there an instant immobile, then redescended slowly, from above downward and from right to left, during diastole to resume, after that, the position near the apex of the heart and begin again a new evolution. It described, then, a right angle triangle in which the right angle might have been a little rounded; during the sys- tole it ran rapidly over the two adjacent sides of the right angle and descended slowly during the diastole along the hypotenuse." Barret has noted in a case with a projectile in the right ventricle whirling movements of extreme rapidity. He compares the agitation of the ball to that of the slug in a sleighbell. These movements are also observed in the right auricle. In the case of Ledoux-Lebard, the shrapnel ball described continuously a sort of ellipse with a major vertical axis of about two centimeters. The whirling movements are sometimes intermittent. Ascoli observed a shrapnel ball in the right auricle which described a rhythmic pendular oscillating movement in the transverse direction. Every four or five oscillations there appeared a sudden whirling movement, then the rhythmic movement was resumed. Ascoli noted that the LOCALIZATION OF WAR PROJECTILES 247 whirling increased during inspiration, doubtless because of the increase of the intra-thoracic negative pressure which favored the afflux of the blood toward the right auricle. These movements are considered characteristic of bodies in cavities since the first observation of Trendelen- burg. But according to Ascoli they can be observed in cases in which the projectile is lodged in the pericardium. Finally, it should be remembered that not all free intra- cardiac projectiles are animated by the same movements. In a case noted by Beaussenat a small fragment of shell showed regular movements of slight amplitude synchro- nous with the beats of the heart; operation, however, showed that it lay in the right ventricle where it was free. When the foreign body is immobilized against the walls of the heart, its movements are those which it would have if it adhered there closely or if it were enclosed in the myocardium. These movements are those of the walls of the heart. They consist of respiratory displacements, static displace- ments, and rhythmic pulsations. The respiratory displacements lift the projectile at the same time as the organ during expiration and lower it during inspiration. Static displacements deviate it one side or the other of the median line during the inclination of the body to the right or to the left. The rhythmic pulsations, synchronous with the pulsa- tions of the heart, offer special characteristics according to the region in which they are observed. Along the left outline they take an almost vertical direction, from above downward, during systole. At the apex, the movement of systolic retraction is from below upward and from with- out inward, following the longitudinal axis of the heart. At the base of the right ventricle the systolic pulsations go from right to left of the patient in a direction parallel to the inferior outline of the heart. On the anterior sur- face of the heart (right ventricle) they spread trans- 248 THE HEART AND THE AORTA versally. In the walls of the right auricle the movements of retraction are clearly presystolic and in a transverse direction. Finally, whatever the point is that is exam- ined, the amplitude of the oscillations of the projectile is equal to that of the pulsations of the walls. The localization of intra-cardiac or pericardiac projec- tiles necessitates, as will be seen, a series of delicate and often difficult examinations. It may be well to cite here as an example the observation of Digne in the case of Fredet. The radio-diagnosis was as follows : " Fragment the size of a pea, clearly pulsatile, at the base of the left hemithorax, slightly to the left of the median line, intra- cardiac, situated in the right ventricle probably close against the anterior wall, nearer to the inferior contour than to the longitudinal diameter of the cardiac image. ' ' Operation showed that the fragment was enclosed in the wall of the right ventricle two fingerbreadths from the apex and a good fingerbreadth from the inter-ventricular groove. Radiology, therefore, offers a certain method of investi- gation, it localizes by radioscopy the exact anatomical position of projectiles and is an essential aid to their surgical removal. IV. EXTRACTION OF PROJECTILES UNDER FLUOROSCOPIC GUIDANCE The radioscopic apparatus for the extraction of foreign bodies consists of a base, which supports the tube, placed under a wooden table. The source of the exciting current may be in the operating room, or, if possible, in a neigh- boring room. Certain surgeons operate by artificial light, red, violet, green, or yellow, which enables them to see at the same time as the roentgenologist the fluoroscopic image of the projectile. The use, which is becoming more and more common, of the "bonnet" fluoroscope, allows the surgeon to operate in daylight; he is guided by the LOCALIZATION OF WAR PROJECTILES 249 radiologist who examines intermittently the position of the foreign body. Intervention under fluoroscopic guidance offers the following advantages : Before incision, a rapid marking made on the skin of the patient in the operating position indicates the zone in which the surface projection of the foreign body is. During the search for the projectile, radioscopy gives the surgeon perfect security, for it permits him to verify his own impressions. When a pericardial effusion has been evacuated and the finger exploring the sac does not encounter the projectile, an inspection with the "bonnet" gives immediate information as to its presence or its absence. If it is a question of extracting an intra-cardiac foreign body, the surgeon, before making an incision in the wall, examines whether the form of the mass which he holds between his fingers corresponds to the projectile. Finally, if the projectile becomes displaced (and cases of unexpected migration have been noted), radioscopy is of great value. The last stage of the operation is also facilitated by the fluoroscope. The roentgenologist guides the operator in taking the projectile with the forceps and after the re- moval he searches for any fragments of metal that may remain. Radiology, therefore, plays a part of primary impor- tance in diagnosing, localizing war projectiles in the heart, and facilitating the different stages of surgical extraction. BIBLIOGRAPHY RELATING TO THE LOCALIZATION OF PROJECTILES Beaussenat. Plaie du cceur par eclat de grenade. (Academie de Medecine, 4 mai, 1915. Academie des Sciences, 10 avril, 1916.) Finzi. Case of a bullet in the heart muscle. {The Journal of the Roentgen Society, 1915, No. 43, pi. V, and No. 44, pi. VIII.) Vouzelles. Eclat de grenade libre dans le ventricule droit. (Bulletins et Memoires de la Societe de chirurgie, 10 novem- bre, 1915. Discussion.) Couteaud et Bellot. Extraction d'une balle dans l'oreillette droite du cceur. (Revue de chirurgie, decembre, 1915.) P. Delbet. Projectile loge dans la paroi posterieure du cceur. (Societe de chirurgie, 7 fevrier, 1915.) Petit de la Villeon. Trois cas de projectiles juxta-cardiaques extraits par trois procedes differents. (Societe de chirurgie, 12 avril, 1916.) Bichat. Extraction d'un eclat d'obus du ventricule droit. (So- ciete de chirurgie, 3 mai, 1916.) Grandgerard. Migration rapide dans le reseau veineux d'une balle de shrapnell libre dans l'oreillette droite. (Ref. in Presse Medicate, 17 aout, 1916.) Ledoux-Lebard. Balle de shrapnell libre dans l'oreillette droite. (Journal de Radiologic, 1916, No. I, p. 35.) Barret, Localisation radiologique d'un projectile intra-cardiaque libre et mobile dans le ventricule droit. (Journal de "Radio- logic, 1916, I.) Lobligeois. Une balle de shrapnell libre dans le ventricule gauche. (Academie de medecine, 7 novembre, 1916.) Ascoli. Projectile libre dans l'oreillette droite, apres passage a, travers la veine cave inferieure. (Le Malattie del cuore, ler Janvier, 1917.) BIBLIOGRAPHY 251 H. Lyle. Migration d 'un fragment d 'obus de la veine f emorale droite jusqu'au ventricule droit du cceur. Gilberti. Courte note sur un cas de projectile dans le coeur. {Le Malattie del cuore, fevrier, 1917.) Dujarrier. Balle dans la paroi anterieure du ventricule droit. Ablation. Guerison. {Societe de chirurgie, 14 mars, 1917.) Chauvel et Loiseleur. Plaie du cceur par balle. Projectile enkyste dans le bord droit du cceur. Extraction sous rayons. Guerison. {Societe de chirurgie, 14 mars, 1917.) Hartmann. Rapport. {Societe de chirurgie, 14 mars, 1917.) Le Fort. De l'extraction des projectiles de la face posterieure du cceur {cardiaques et juxta-cardiaques) . {Bulletin Academ. de Medecine, 15 mai, 1917.) Hallopeau. Plaie du coeur par eclat d'obus enkyste dans la pointe. Extraction sous rayons. Guerison. {Bulletin de la Societe de chirurgie, seance du 30 mai, 1917, p. 1, 213.) Fredet. Extraction d'un fragment d'obus loge dans la paroi anterieure du ventricule droit. Guerison. {Societe medico- chirurgicale militaire de la 14e Region. 5 juin, 1917. In Ly on-medical. ) INDEX Adhesions to anterior thoracic wall, 184 of apex of heart, 183 of base of heart, 183 in diaphragmatic region, 184 pericardial, data relating to existence of, 169 pericardial, partial, with car- diac symphysis, 165 site of, 183 Affections of heart, congenital, 115 of the pericardium, 161 valvular, 75 Anatomical localization, 240 Aneurism, aortic, differential diagnosis of: from dila- tation of other vascular organs, 233 aortic, differential diagnosis of: from other thoracic or intra-thoracic affections, 231 associated with other lesions, 233 diagnosis of (aortic), 229 shadows, general appearance of, 223 Aorta in the normal, 192-204 in pathological state, 204- 216 Aortic insufficiency, 102 insufficiency, arterial, 108 Aortic iiisufficiency, endocar- ditic, 102 pulsations, 201 shadow, density of, 201 stenosis, 111-114 stenosis, congenital, 132 Aortitis, 192 Apex of heart, 76, 172 in frontal position, 23 Arc, left median, 76 Arhythmia, chronic, 156 Arhythmic heart, 155 Artery, pulmonary, simple ste- nosis of, 123-127 Asystolism and cardiac insuffi- ciency, 159 Auricle, left, 71 right, 72 Basedow's disease, 152 Boulitte's goniometer, 39 Cardiac dilatation, 148 ectopia, 134 hypertrophy and dilatation, 142 hypertrophy in the aged, 146 insufficiency and asystolism, 159 symphysis and partial ad- hesions of pericardium, 165 254 INDEX Cardiograms, interpretation of and comparison with per- cussion tracings, 80 Cinemato-radiography, 36 Comparison of palpation and percussion with radiologi- cal findings, 185 Congenital affections of heart, 115 aortic stenosis, 132 Contours of heart in frontal position, 20 of heart, right, 77 Cysts of the lung, 232 Density of aortic shadow, 201 Depth, ventricular develop- ment determined by, 53 Destot's orthodiagraph, 8 Diameters of heart, 25-33, 77 Diaphragm, movements of, 176- 180 position during forced ex- piration, 35-36 position during forced in- spiration, 35-36 Diaphragmatic region, adhe- sions in, 184 Dilatation, cardiac, 148 Displacements due to respira- tion, 34 of heart outlines, 171 Dropping heart, 51 Ectopia, cardiac, 134 Effusions, pericardial, 161 Endocarditic aortic insuffi- ciency, 102 Extraction of projectiles under fluoroscopic guidance, 248 Functional mitral insufficiency, 93 Goniometer of Boulitte, 39 Heart, adhesions of apex, 183 adhesions of base of, 183 apex, 76, 172 apex in frontal position, 23 arhythmic, 155 congenital affections, 115 contours in frontal position, 20 diameters of, 25-33, 77 dropping type, 51 image in frontal positions, 18-38 image in oblique positions, 38-47 mobility of, 33 modifications affecting whole volume, 61-63 outline, 180 outlines, displacement of, 174 partial modification of vol- ume, 63-74 position during forced expi- ration, 35-36 position during forced in- spiration, 35-36 pulsation, 36 radiological outline in cer- tain pathological condi- tions not resulting from valvular lesions, 142 radioscopic examination of, 58-59 right contour of, 81-82 rules for radiological exami- nation of, 58-60 INDEX 255 Heart shadow in pathological state, 61-74 shadow, measurements of, 23 shadow, normal, 16-60 Horizontal type of heart, 50 Hypertrophy, cardiac, in the aged, 146 cardiac and dilatation, 142 Instantaneous radiography, 3 Insufficiency, aortic, 102-111 aortic, arterial, 108 aortic, endocarditic, 102 cardiac and asystolism, 159 mitral, 87-96 mitral, functional, 93-96 Interlobar pleurisy, 231-232 Inter-ventricular perforation, 115-122, 127 Intra-cardiac projectiles, 243- 248 Inversion of the viscera, total, 134-141 Lesions associated with aneu- rism, 233-234 valvular, 75 Localization, anatomical, 240- 248 methods of, 239-240 of war projectiles in heart and pericardium, 235-249 Lung cysts, 232 Median arc, left, 76 Mediastinitis, posterior, 185 Mediastinum, tumors of, 232- 233 Method, orthodiagraphic, 7-10 orthodiascopic, 5-7 Method, radiographic, 2-4 radiological, 2-15 radioscopic, 4-11 Mitral disease, 96-102 insufficiency, 87-96 insufficiency, functional, 93- 96 stenosis, simple, 75-87 Mobility of the heart, 33-34 Modifications affecting whole heart, 61-63 of heart volume, partial, 63- 74 Movements of the diaphragm, 176-180 Normal aorta, 192-204 Normal heart shadow, 16-60 Normal radioscopy, 4 Oliver's sign, 51 Orthodiagraph of Destot, 8 Orthodiagraphy, 7-10 Orthodiascopy, 5-7 Palpation, compared with ra- diological findings, 185 Pathological aorta, 204-215 condition of heart shadow, 61-74 Percussion compared with ra- diological findings, 185 Perforation, inter-ventricular, 115-122, 127 Pericardial adhesions, data re- lating to existence of, 169 Pericardium, affections of, 161 localization of war projec- tiles in, 235-249 Pleurisy, interlobar, 231-232 256 INDEX Position, direct anterior, 16 direct posterior, 17 dorsal, 17 left anterior oblique, 18, 45 left lateral, 18 left posterior oblique, 18, 43 prone, 17 right anterior oblique, 18, 44 right lateral, 18 right posterior oblique, 18, 44 seated, 18 upright, 17 Positions, direct, 16-18 lateral, 18, 47 oblique, 18, 82-87 Posterior mediastinitis, 185 Projectiles, extraction of, under fluoroscopic guidance, 248 intra-cardiac, 243-248 localization of in heart and pericardium, 235-249 Pulmonary artery, simple ste- nosis of, 123 stenosis of, with inter-ven- tricular perforation, 115- 122 Pulsation of heart, 36 aortic, 201 Respiration, displacements due to, 34 Respiratory outline, 181 Rules for radiological examina- tion of heart, 58-60 Stenosis, aortic, 111-114 aortic, congenital, 132 Stenosis of pulmonary artery with inter-ventricular per- foration, 115-122 of pulmonary artery, simple, 123-126 simple mitral, 75-87 Symphysis, cardiac, with par- tial adhesions of pericar- • dium, 165 Technic of orthodiagraphy, teleradioscopy and tele- radiography, 11-12 Teleradiography, 3-4, 13-14 Teleradioscopy, 12, 15 Thoracic aorta, aneurisms of, 216-235 Thoracic wall, anterior, adhe- sions to, 184 Time radiography, 2 Transverse diameter of heart, 26 Tumors of mediastinum, 232- 233 Valvular affections, 75-114 Variations of physiological form of heart, 50-53 Ventricle, left, 6Q right, 68 Ventricular development in depth, 53-58 outline, left, 76 volume, determination of, total, 64-66 Vertical type of heart, 50 Viscera, total inversion of, 134- 141 PRINTED IN THE UNITED STATES OF AMERICA .c^x_ HCbSi coo . \ •:■: ' : ■ ■