IN patients having massive pulmonary fibrosis, or “fibrothorax,” the conventional roentgenogram fails to reveal the essential features of the thoracic cardiovascular system. However, visualization of these structures is now possible, for, recently, we have developed a method for the visualization of the chambers of the heart, the pulmonary circulation, and the, great vessels (1, 2), and have reported examples of its value in the normal individual (3) and in patients having heart (4) and lung (5) disease. It has been possible to see the cavity and wall of each chamber, the interventricular septum, the pulmonic and aortic valves, the pulmonary artery and wall, the entire pulmonary circulation, and the thoracic aorta with its wall and the branches from the arch. In this paper we wish to illustrate the value of this method in a patient in whom there was displacement and obscuring of the heart by pulmonary and pleural fibrosis and to show that it is now possible to visualize the cardiovascular structures as well as the esophagus and the tracheobronchial system. Method and Roentgenographic Technic.—Visualization studies were made in the lateral, the left anterior oblique, and the frontal positions. By using a rapid stereoscopic cassette shifter, we were able to make two exposures per injection and, thus, to visualize both sides of the heart and the large vessels. The right cephalic vein, which measured 8 mm. in diameter when distended, was used for each injection since it was the only large vein available; the injections were made through a special 12-gauge needle-stopcock unit. Before injection of the contrast substance, the arm-to-pulmonary and the arm-to-carotid sinus circulation times were determined and found to be three and eight seconds, respectively. Thus it was possible to learn the time of the arrival of the contrast substance in both the right side of the heart and the pulmonary arterial tree, and the left chambers and the aorta. The patient was then seated before the cassette and 35 c.c. of a 70 per cent solution of diodrast injected in two seconds. In addition to the usual wave of heat felt immediately after injection, the patient developed a small area of edema of the lower lip which was promptly relieved by 0.2 c.c. of epinephrine, and subsequently was prevented by premedication with this drug. Immediately after injection, the patient was allowed to go home. The absence of detectable injury to the vein was proven by careful examination and by its repeated use (1, 2). For the frontal views, the following exposure factors were used for this patient in whom the postero-anterior diameter of the chest was 7.5 inches; milliamperage, 300; distance, 72 inches; exposure, one-twentieth second; 66.2 kv. (peak) for the control film (Fig. 1) and 80.5 for the contrast films (Figs. 4, 5, and 6).
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Steinberg et al. (1939) studied this question.