The heart and the aorta; studies in clinical radiology

Front matter

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HX64 134873 =tC681 .V412 1920 The heart and the ao

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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 recording and radiology to the old methods of examination, such as percussion, palpation, and auscultation.

Graphic recording has enabled us to analyze with precision the mechanism of the cardiac rhythm, to distinguish 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 radiography perfectly capable of determining the exact lesion in the bones, wTe 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 examination of its exterior aspect. This notion, well established xii PREFACE TO THE FIRST EDITION

by anatomical proofs, has been until our day only imperfectly utilized in clinics, the processes of exploration being incapable of giving sufficiently precise indications.

Eadiology of precision has come to fill this gap. During 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 pathological deformations and reveals the exact exterior configuration 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 subject 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 treatise 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 reasonably expect in a work of this kind.

Although we are compelled to tell what we have observed 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 profession 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.

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 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

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

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

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. Radiology 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 respiration, the result is that the roentgenological images present 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.

Roentgen rays arising from a luminous source constitute 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 radiological 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 interpretation of them, though it may still be open to some dispute, 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 necessary 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 charging 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 prolonged 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. Besides, 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.

2. Instantaneous Radiography. Of late years, physicists 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 quantity 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 constitutes 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 respiratory displacements are eliminated, and the negatives gain much in clearness. A series of images taken during successive 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 deformed 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 parallelism of the rays is not absolute, but the errors of projection are insignificant.

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 constitutes 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 positions, 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 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 vertical displacements of the heart, by the raising of the ribs and of the outline of the thoracic cavity, and by the lowering 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 beginning suggested an arrangement by which, by moving the tube to a convenient distance, the organ under examination 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 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 projection obtained when the tube remains at a fixed point or when it is moved according to the orthodiascopic method.

Above, conic projection: F, focus; F m, normal ray; ghij, object; g'h'i' j', projection of the object; E, E', screen. Below, orthogonal projection: A, A1; A2, etc., foci occupying different positions, so that the normal ray, A b, Aj c, A3 e, A4 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 object, ghij, and projects its image on the screen at g h' % j'.

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 perpendicular 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 enlarged in proportion as the region under consideration is distant from the center, m. The figure, g h' i j' , consequently, 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 adjustment (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 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 orthodiagraph^ apparatus ; it is necessary to have acquired a certain dexterity. Some preparatory training is necessary 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, condemn orthodiagraphy because of the effort which it requires 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 constructed apparatus which differs in manipulation and the methods of recording, but which answers the same general 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 recent models, the recording crayon. This holder is mounted on a double joint counterpoised and so regulated that the whole system is in equilibrium.

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 arranged 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 outline 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 tracing 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 orthodiagraphy. It is enough to realize these essential conditions : 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 necessary 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 paper. We work on the lead glass of a large screen. The estimating of the normal ray is done by means of the diaphragm-iris. By reducing the rays to a small circular field we know that the normal ray is situated in the center 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 regions. 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.

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 positions 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 apparatus we can practice orthodiagraphy, teleradioscopy and teleradiography. A special device facilitates the successive 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 preliminary 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 deformations. It is only at two meters and a half that the enlargement is reduced to its practical minimum ; the projection of an object fifteen centimeters in size is augmented by only four or five millimeters, figures which correspond to the errors of technic accepted in orthodiagraphy. It is necessary that the tube be properly centered on the region to be studied. When it is a question 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.