- Email: [email protected]
The normal heart volume in man
THE G. LILJESTRAND,
NORMAL
HEART
VOLUME
IN MAN
E. LTSHOLM, G. NYLIN, AND C. G. ZACHRISSON STOCKHOLM, SWEDEN
HEN trying to dcterminc the size of the heart in the living subject reliance has usuall,v been placed mainly on the values established from measurements on the frontal orthodiagrams alone. Though t,he results thus obtained have sometimes been of importance-e.g., for comparative studies of the heart on different occasions-the practical USCof the method has been greatly hampered by the fact that the heart volume cannot he determined in this wa; with a sufficient degree of accuracy. The main objection is, of course, that frontal orthodiagrams alone can bc employed for this purpose only if the form of the heart is the same not only in one individua.1 under dif?erent conditions, but also in different individuals. As is well known this is far from being the case (see below), great variations often occurring in the form of the heart. Under these circumstances it has been found necessary to t,ry to arrive at more exact methods for establishing the heart volume. Thus Palmieril (1920), Lysholm2 (1926), and Wegeliu? (1934) made models of the heart with the aid of projections in several planes. This modeling procedure, however, takes a long time and will therefore hardly be of practical importance. It was a great advance in this field when it was shown independently by Rohrer* (3916-1917) and Kahlstorf” (1932) that it is possible to calculate the volume of the heart with satisfactory accuracy from the frontal and sagittal orthodiagrams. They assumedthat the heart is of a shape between a paraboloid and an ellipsoid. The size of the heart can then be calculated according to the formula V = 0.63 ’ F:, . L,,,,, where V is the vol~une of t.he heart, F’;, the arca of sagittal orthodiagram, and L lllL,Xthe masimum dept,h of the transversal orthodiagram. The reliability of this calculation was demonstrated by Kahlstorf, who investigated nine normal and three pathologic hearts from corpses. The hearts had been hardened in formalin and were mounted on a stand ; orthodiagrams were made in t,wo directions at right angles. Each preparation was investigated in three different positions, and the values obtained were compared with the volume as found by water displacement. The agreement was very good, the diff’erence between the calculated and observed volumes being not more than t 5 per cent. The method was applied to determinations of the normal heart volume in living persons by Rohrer in seven cases. In five of these the valnrs lay between 471 and 575 cc.; in one, obviously a very small individual (height 140 cm.), it was only
vu
pital
From medical clinic II and the roentgenologic department and the department of pharmacology of the Karolinska Received for publication Sept. 3, 1938. 4O(i
of the Seraphim? HosInstitute, Stockholm.
LILJESTR,AND
ET
AL.
:
NORMAL
HEART
VOLUME
IN
MAN
407
408
THE
AivfER.I(!AN
1IEAR.T
JOTJR.NAL
216 cc.; and in the remaining subject (height 170 cm.) 762 CC. Kahlstorf has examined a much larger group, comprising seventy men and fifty women. All of his determinations were made with the subject in the standing position, a fact of some import,ance, since it is known that the heart is considerably larger when the subjects are in the recumbent than when they are in the erect position (cf. Nyliq6 1934). Kahlstorf calculates his values in relation to the body weight (he finds a direct proportion between them) and arrives at the conclusion that the heart volume per kg. of body weight is at least 7 cc. in female and 8 cc. in male subjects, and t.hat it does not exceed 11 cc. For the erect? position Lysholm. Nylin, and Qnar&~ (1934) have determined the heart volume in thirty-three normal male subjects according to the RohrerKahlstorf formula. The average was 627 4 22 cc., the extreme limits observed being 393 and 860 cc.. As far as can be judged, their values agree well with those of Kahlst,orf. The following investigation on the normal heart volume was carried out on a larger number of subject,s ; they were young students, 20 to 30 years of age, and bank clerks between the ages of 37 and 47 years, all of whom were in perfect, health and exhibited no signs of heart or vascular disease. For our determinations the devices for biplane radiography were constructed around a Krogh ergometer bicycle and manufactured in the shops of Mr. G. In front of and at the side o’f the subject were Schonander in 1935 (Fig. 1). Corresponding to these were two 40 kw. roentgen placed two films at right angles. tubes with rotating anodes, mounted on special stands and placed at a distance of The high tension was adjusted to 90 kv. peak, the 1.5 and 2 M. from the films. The milliamperage was so regulated that the tube tubes being coupled in parallel. corresponding to the side view had a load of 250 Ma., and the other tube 200 Ma. The high tension switches (s in Fig. 2) enabled us to use each tube separately or both simultaneously. The arrangement was constructed in the autumn of 1935 by the firm of Siemens Reiniger Veifa, in Stockholm, and has since worked satisfaetorily. During the exposure, the front and the side of the chest were gently pressed against the two eassette-holders. The exposure time was one-twentieth second. To cut off scattered radiation during simultaneous exposures, two crossed Lysholm allmetal grids were used in each of the two planes. This arrangement satisfactorily eliminates the scattered radiation and prevents blurring in the roentgenogram. For the calculation of the heart volume, it is for the enlargement of the heart shadow on the suming the heart to be an ellipsoid, one gets %00-a 1 200-a v+, __. -. __. -m 200 2 200 2 are the axes of the ellipsoid on the frontal and a and b the distances from the center of the heart gave for a and b, 15 and 23 cm., respectively, V = 0.38 . 1 . m * n.
necessary to introduce a correction film. Fig. 3 illustrates this. Asthe volume V from the equation: 150-b n * __ 150 * -g-, where 1 and m n the axis on the lateral view, and to the films. Direct measurements so that the formula is reduced to
We have thus assumed the heart to have the form of an ellipsoid, whereas the Rohrer-Kahlstorf formula takes it to be something between
LILJESTRAND
ET
AL’.
:
NORMAL,
HEART
VOLUME
IN
MAN
409
a paraboloid and an ellipsoid. Thus they get the constant 0.63, whereas here it is 0.67. Our values will therefore be 6 per cent higher than those of Rohrer and Kahlstorf. In order to determine the margin of error for the method, we have made double exposures on ten healthy medical students. The values obtained are given in Table I. We find the margin of error as small as 30 cc., corresponding to 4.7 per cent of the mean value.
Rmt&.ube
I
Hish
Fig.
2.-Arrangement
Fig.
of
roentgen
tybes
%.--Scheme
for
correction.
(s,
tension trand. switches).
Before giving the details of our observations we should plify by means of two eases the paramount importance consideration two projections in different planes for the the heart volume. Fig. 4 shows the frontal and sagittal
like to esemof taking into estimation of teleroentgeno-
grams of a healthy nurse in a sitting position. On the frontal projection the heart looks enlarged, but the sagittal diameter is exceedingly short. The subject had a very flat chest. Calculating the heart volume according to the Rohrer-Kahlstorf formula, we get the normal value of 900 cc., or 450 c.c./m2 of body surface. On the other hand, if the heart volume is calculated only on the basis of the frontal roentgenogram with the help of Bardeen’s” formula (1918), it amounts to 1,300 cc., which is 45 per cent higher than tbc value obtained by the method first mentioned. Big. 5 illustrates the reverse situation in another normal subject, also in a sitting position. Here the hea.rt is tubular, as shown by the frontal roentgenogram, but the chest is deep, and the sagittal diameter fairly large. The heart volnnle according to Bardeen’s formula is 400 cc., but by the Rohrer-Kahlstorf method we obtain 490 CC.; thus with the former the estimate is 23 per cent too small. TABLE
Two DETERMINATIONS SUBJECT
I.
NO.
I II
OF HEART LENGTH CM.
BREADTH CN.
11 11
11.5 11.5
10.5 10.5
2.
:I
3.
I II
14.5 14.5 13 12
I
15.5
II I II
15
4. 5. 6. 7. 8. 9. 10.
I II I
II I
VOLUME
11
10.5 12 11.5
I ON EACH
OF TEN
SAGITTAL DIAMETER CM. 9.5 9.5
12 11.5 2.5 10 10
11.5
11.5
9.5
13
10.5
9.5
15 35
13 12 12
l-1.5 14.5
12
10
10 9.5
9.5
11.5 11
I II
15 15 12.5 I3
10.5
l-3
11
12
I II
14.5 14.5
12
10
II
12 12
NORMAL HEART VOLUME C.C. 580
580 690 665 800
550 710 660 560 495
STUDENTS DIFFERENCE C.C. 0
25 50 50 65
690 690
0
630 630
0
790
755 600 650 660 630
65 50 30
12 9.5 Mean of differences irrespective of signs = 34 cc. General mean = 641 c.C. Margin of the error for the method = 30 CC. = 4.7 per cent of the mean value.
The results of our determinations on healthy men are given in Tables II and III. In the first group of seventy medical students (Table II) the absolute volume of the heart varies between 480 and 970 CC., which is considerable. The corresponding limits are 5.6 and 14.2 C.C.per kilogram of body weight. The subject with the lower limit (No. 69) stands out as an exception, since in all the other subjects the heart exceeds 7.8 (corrected 7.4) CC. per kilogram, which is in fairly good agreement with Kahlstorf’s experiences. In seven cases,however, the values are higher than the upper limit given by Kahlstorf (11.1.06 = 11.7 cc.). In OUI
LILJESTRAND
ET
AL. :
NORMAL
HE,ART
VOLUME
IN
MAN
411
smaller group of men from 32 to 4’7 years of age, all are at or above eight (7.5 corrected) C.C. per kilogram, but here also some subjects, in all three, have a volume larger than 11.7 C.C. per kilogram. We are thus led to the conclusion that the upper limit for the size of the normal heart is somewhat higher than given by Kahlstorf.
Fig.
4.-Heart
Fig.
5.-Heart
volume
in a healthy
volume
in
nurse
a healthy
with
girl
extremely
with
a deep
flat
chest.
chest.
Since it has been observed in previous investigations (cf. DuBois,S 1936, and Grollman,10 1932) that metabolism and blood flow show a closer correlation to the body surface than to the body weight, it would seem natural also to correlate the heart volume with the body surface. Fig. 6 demonstrates the excellent correlation obtained in this way. On the basis of the above-mentioned determinations, we have worked out our material statistically. The calculation of mean values and standard deviations has been made in accordance with wellknown formulas.
412
TIIE
AMERICAN
HEART
Tnxrx HEART
1. 2.
3. 4. 5. 6. ., :t, k w:i 1,GT;:f 1% 12. 13. 14. 15. 1% 17. 1s.
19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30. 31. 32. 33. 34. 35. 36. 37. 38. 39. 40.
41. 42. 43. 44. 45. 46. 47. 48. 49. 50.
51. 52. 53.
VOLUME
21 22 22 22 22 22 22 22 22 22 22 22 22 22 22 22 23 23 23 23 23 23 23 23 2. 3 23 23 23 23 23 23 24 24 24 24 24 24 24 24 24 24 24 24 24 24 24 34 2-l 25 25 25 25
OF &XENT~Y
160 193 173 177 184 190 176 176 190 184 179 172 171 174 185 168 205 170 177
184 175 181 180 176 181 172 184 176 183 182 168
180 184 182 156 180 182 172 179
169 161 173 183
181 187 153 182 170
180 li3
176 175
II
HEALTHY MEDICAI, YEARS OF AGE
57
91 58 73 66 86 63 62 7s
81 62 65 61 64 83 68 7.9 66 72 67 62 76 65 67 68 6ti 75 60 78 69 65 77 78 71 79 77 63 69 65
71 51 65 78 7s
Ql 78 in 75 68 76 i4 84
1.58 2.22 1.70 1.89 1.57 2.14 1.77 1.76 2.06 2.04 1.77 1.77 1.72 1.77 2.07 1.78 2.20 1.77 1.87 1.87 1.76
1.96 1.83 1.81 1.78 I.78
1.97 1.74 2.01 1.68 1.74 1.96 3.01 1.92 2.02
1.96 1.83 1.81 1.83 1.81 lA3 1.78 2.n1 1.81) 2.17 2.01 1.90 1.86 1.87
1.01 1239 1.99
SWJDENTS BETWEEN 21 AND 30
620 850 650 850 650 850 650 680 710 660 600 830 750 530 800 660 900 700 730 550 550 600 520 750 so0 520 600 480 750 650 590 850 750 680 900 830 520 800 750 750 430 550 660 650 780 610 620 580 800 750 750 970
390 380 380 450 350 400 370 390 350 320 340 470 440 470 390 370
410 400 390 290 310
310 280 410
450 290 310 280 370 390 340 430 370 350 450 420 280 440 410 410 280 310 330 330 360 300 330 310 430 390 410 490
10.9 9.3 11.2 11.6 9.8 9.9 10.3
11.0 9.1 S.1 9.7 12.8 12.3 13.0 9.6 9.7 11.5 10.6
10.1 8.2 8.9 7.9 8.0 11.2 11.7 7.9 it 9:s 9.4
9.1 11.0 9.6 9.6 11.4 10.7 8.3 11.6
11.5 10.6 8.4 8.5 8.5 8.3 8.6
7.8 8.9 7.7
11.8 9.9 10.5 11.5
-'
LILJESTRAND
55. 56. 57. 58. 59. 60. 61. 62. 63. 64. 65. 66. 67. 68. 69. 70.
ET
25 25 25 25 25 25 26 26 26 26 26 26 27 27 29 30
AL.:
NORMAL
75 71 69 65 67 76 75
172 175 176 176 184 186 184 175 181
176 1Sl 179
175 183 180
HEART
600 600 550
2.01 1.84 1.84 1.50 1X
760 830 930
1.98
2.20
65 64 68 71 75 64 85 45
1.79 1.82
550
780 730 750 780 600 480 850
1.84 1.91 1.94
1.78 2.07 2.04
IN
&TAN
300 330 300 440 380 380 420 420 320 430 400 390 400 340 230 420
800 690
1.98
96
VOLUME
413
8.0 8.5 8.0 12.3 10.3 10.0 11.1
9.7 9.0 12.1 10.7 10.6 10.4 9.4 5.6 10.0
We have considered as normal limits the mean value decreased and increased by two standard deviat,ions. The mean value for the heart volume for the 70 young students is found to be 700 cc., and for the somewhat older men it amounts to 750 cc. Calculated per kilogram of body weight (Table IV), the mean heart volume amounts to 9.8 cc. for the younger group and 10.4 CC. for the older one. The corresponding values per m2 of body surface are 372 and 395 cc., respectively. The normal limits for these 101 healthy male subjects, estimated as mentioned above, are 7.0 and 13.0 CC. per kilogram body weight and 250 and 490 CC. per m2 of body surface.
1.8
I.6 1.v 1.2 1.0 Jo0 Fig.
B.-Correlation
500
500 between
600
700 heart
&IO
900 1000
volume
and
body
surface.
414
THE
AJIERICAh-
I-IE,ART TABTX
HEARV
VOTJJME
OF TI-ITRTY-ONE
E 1. 2. 3. 4. 5. 6. 7. 8. 9. IO. 11. 12. 13II. 14. 15. 16. 17. 18. 19. 20.
182 172 17s
92 61 i3 69
66
1.54 2.02
2.03 1.7s 2.14
174
63
187
811
181
is
176 176
84
2.15 1% 1.76 2.06 1.99 2 .02 1.84 1.x5 1.66 1.x7
6X 6-l
57
72 si
lS6 178 172
ti7
Ii $0 i (Xl 67
is 67 IiSI s 01
32 AND 47
730 850
410 400
440
900 Xi0
450 420
750 700 550
410 380 330
800 700 850 6511
430 330
11.1 x.n
450
12.7 10.5 9.6 13.4 10.3 12.4 10.3 9.9
350
420 400
730 700
410
650 600
2.13 1.8X 1.74 1.75 1.75 7.04 1 .
9.6 10.2 11.1 9.2 9.x 11.0 10.6 11.1 8.7 s.s 10.4 8.1 11.:: 10.0 X.1 11.7 10.1 11.0 10.9 9.6
750 760 750 6.30 650
1.98
185
440 400
i5 68 94 67
173
YOO 800 900 F(10 SO0
72
BETWEEN
d i 5 $2 8g
2; se x2
181 131
176 163 1% 172
CLERKS
1.72 1.91 1.82 1.72 1.85 1.85
63
172 175
22. 23. 24. "3. 26. 27. 28. 29. 30. 3 1.
HEART
43 8X
lS3
21.
TOTAL
152 173 171
177 190
11 I
HEALTHY BANK YEARS OF AGE
-
172 167 168
JOUKNAI.
X50 320 3x0 350
400 360
320
370 :330
575
900 SO0
510
,43n
160
iO0 1000
380 410
390
Vo~rms, HEAIX VOLT-m PER SQUARE METER OF BODY PER KILOGRAM OF RUDY WEIGIIT OF 101 HEALTHY MEX STAND&VERAGE PLRD DEVI n1 C.C. ATION Ll -__
---
70 medical students aged 21-30 years
Heart Heart Heart
volume volume volume
C.C. c.c./m% c.c./kg.
700.7 371.7
31 men aged 32-47 years
Heart Heart Heart
volume volume volume
e.e. c.c./mz. cc/kg.
750.0
394.5 10.4
We have not been able to estal>lish with tions
any
pronounced
there
is a tendency
difference toward
a larger
I
9.8
between heart
the
106.5 45.8 1.3
11.6
volume
hLEAN ERROR z (ar)
V 17.4 15.8 16.5
age
i\bx
-
121.9 58.9 1.6
certainty
ST-RFA(Y?
ni T 20
7.0
-__ 457-945 254490
0.2
0.16-13.0
14.6
14.2 12.4
from these investigagroups, at
even
a more
though advanced
LILJESTRAND
ET
AL.
:
NORMAL,
HEART
VOLUME
IN
415
MAN
age. In a previous paper, Nylin’l (1935) calculated the heart volume of twelve healthy girls between twelve and fourteen years of age, and found that the mean value (standing) was 315 cc. per m2 of body surface. Comparing the results obtained for the girls and the results of this investigation (Table V) , there appears to be a tendency toward an increase in the heart volume per m2 of body surface with increasing age, but unfortunately the youngest group was not of the same sex as the other two groups. TABLE TOTAL
HEART
VOLUME
V
AND HEART VOLUME PER SQUARE AT DIFFERENT AGES
METER
OF BODY
SURFACE
-_ HEART AGE (YR.) 12 girls 70 men 31 men
C.C.
12-14 21-30 32-4i
417 701 750
VOLUME
C.C./W. --ET-372 xxi
ix 7 20 c.c./m. 255-375 254490 303-486
SUMMARY
We have determined by simultaneous roentgenograms, in two tions at right angles, values for the volume of the heart in 101 men, aged from 21 to 47 years, and found that the normal heart varies between 7.0 and 13.0 cc. per kilogram body weight and 250 and 490 cc. per m2 of body surface.
projechealthy volume between
REFERENCES
1. Palmieri, G. G.: Sul valore della ricerca dell’ “angolo di scomparsa della punta” (metodo Vaquez-Bordet) come indice de1 volume relativo de1 eunre; variaeioni di tale angolo nello stesso individus e loro cause, Malat. d. cuore 4: 184, 1920. 2. Lysholm, E.: Riintgenoskopischer Modellierungsapparat such fiir Quersektion und Lokalisation, Acta radiol. 7: 189, 1926. :L Wegelius, C.: Untersuchungen iiber die Miiglichkeiten einer dreidimensionalen, rizintgenographischen Abgrenzung innerer Organe des menschlichen Korpers, Helsingfors, 1934. 4. Rohrer, F.: Volumbestimmung von Kiirperhohlen und Grganen auf orthodiagraphischem Wege. Fortschr. a. d. Geb. d. Rizintgenstrahlen. 24: 285, 1916. 5. Kahlstorf, A.: Ueber eine orthodiagraphische Herzvolumenbestimmung, Fortschr. a. d. Geb. d. Riintgenstrahlen. 45: 123, 1932. Kahlstorf, A. : MSgliehkeiten und Ergebnisse rSntgenologischer Herzvolumenbestimmungen, Klin. Wchnschr. 17: 223, 1938. 6. Nylin, G.: Relation Between Heart Volume and Stroke Volume in Recumbent and Erect Positions, Skandinav. Arch. f. Physiol. 69: 237, 1934. 7. Lvsholm. E.. Nvlin, G.. and QuarnL, K.: The Relation Between the Heart ” Volume and Stroke Volume tinder Physiological and Pathological Conditions, Aeta radiol. 15: 237, 1934. 8. Bardeen, C. R. : Determination of the Size of the Heart by Means of the X-Rays, Am. J. Anat. 23: 423, 1918. 9. DuBois, E. F.: Basal Metabolism in Health and Disease, Ed. 3. Philadelphia, 1936, Lea & Febiger. 10. Grollman, A.: The Cardiac Output of Man in Health and Disease, Sprir@ield, 1932, Charles C. Thomas. 11. Nylin, G.: The Physiology of the Circulation During Puberty, Acta med. Scandinav. Suppl. 69, 1935.
NORMAL
HEART
VOLUME
IN MAN
E. LTSHOLM, G. NYLIN, AND C. G. ZACHRISSON STOCKHOLM, SWEDEN
HEN trying to dcterminc the size of the heart in the living subject reliance has usuall,v been placed mainly on the values established from measurements on the frontal orthodiagrams alone. Though t,he results thus obtained have sometimes been of importance-e.g., for comparative studies of the heart on different occasions-the practical USCof the method has been greatly hampered by the fact that the heart volume cannot he determined in this wa; with a sufficient degree of accuracy. The main objection is, of course, that frontal orthodiagrams alone can bc employed for this purpose only if the form of the heart is the same not only in one individua.1 under dif?erent conditions, but also in different individuals. As is well known this is far from being the case (see below), great variations often occurring in the form of the heart. Under these circumstances it has been found necessary to t,ry to arrive at more exact methods for establishing the heart volume. Thus Palmieril (1920), Lysholm2 (1926), and Wegeliu? (1934) made models of the heart with the aid of projections in several planes. This modeling procedure, however, takes a long time and will therefore hardly be of practical importance. It was a great advance in this field when it was shown independently by Rohrer* (3916-1917) and Kahlstorf” (1932) that it is possible to calculate the volume of the heart with satisfactory accuracy from the frontal and sagittal orthodiagrams. They assumedthat the heart is of a shape between a paraboloid and an ellipsoid. The size of the heart can then be calculated according to the formula V = 0.63 ’ F:, . L,,,,, where V is the vol~une of t.he heart, F’;, the arca of sagittal orthodiagram, and L lllL,Xthe masimum dept,h of the transversal orthodiagram. The reliability of this calculation was demonstrated by Kahlstorf, who investigated nine normal and three pathologic hearts from corpses. The hearts had been hardened in formalin and were mounted on a stand ; orthodiagrams were made in t,wo directions at right angles. Each preparation was investigated in three different positions, and the values obtained were compared with the volume as found by water displacement. The agreement was very good, the diff’erence between the calculated and observed volumes being not more than t 5 per cent. The method was applied to determinations of the normal heart volume in living persons by Rohrer in seven cases. In five of these the valnrs lay between 471 and 575 cc.; in one, obviously a very small individual (height 140 cm.), it was only
vu
pital
From medical clinic II and the roentgenologic department and the department of pharmacology of the Karolinska Received for publication Sept. 3, 1938. 4O(i
of the Seraphim? HosInstitute, Stockholm.
LILJESTR,AND
ET
AL.
:
NORMAL
HEART
VOLUME
IN
MAN
407
408
THE
AivfER.I(!AN
1IEAR.T
JOTJR.NAL
216 cc.; and in the remaining subject (height 170 cm.) 762 CC. Kahlstorf has examined a much larger group, comprising seventy men and fifty women. All of his determinations were made with the subject in the standing position, a fact of some import,ance, since it is known that the heart is considerably larger when the subjects are in the recumbent than when they are in the erect position (cf. Nyliq6 1934). Kahlstorf calculates his values in relation to the body weight (he finds a direct proportion between them) and arrives at the conclusion that the heart volume per kg. of body weight is at least 7 cc. in female and 8 cc. in male subjects, and t.hat it does not exceed 11 cc. For the erect? position Lysholm. Nylin, and Qnar&~ (1934) have determined the heart volume in thirty-three normal male subjects according to the RohrerKahlstorf formula. The average was 627 4 22 cc., the extreme limits observed being 393 and 860 cc.. As far as can be judged, their values agree well with those of Kahlst,orf. The following investigation on the normal heart volume was carried out on a larger number of subject,s ; they were young students, 20 to 30 years of age, and bank clerks between the ages of 37 and 47 years, all of whom were in perfect, health and exhibited no signs of heart or vascular disease. For our determinations the devices for biplane radiography were constructed around a Krogh ergometer bicycle and manufactured in the shops of Mr. G. In front of and at the side o’f the subject were Schonander in 1935 (Fig. 1). Corresponding to these were two 40 kw. roentgen placed two films at right angles. tubes with rotating anodes, mounted on special stands and placed at a distance of The high tension was adjusted to 90 kv. peak, the 1.5 and 2 M. from the films. The milliamperage was so regulated that the tube tubes being coupled in parallel. corresponding to the side view had a load of 250 Ma., and the other tube 200 Ma. The high tension switches (s in Fig. 2) enabled us to use each tube separately or both simultaneously. The arrangement was constructed in the autumn of 1935 by the firm of Siemens Reiniger Veifa, in Stockholm, and has since worked satisfaetorily. During the exposure, the front and the side of the chest were gently pressed against the two eassette-holders. The exposure time was one-twentieth second. To cut off scattered radiation during simultaneous exposures, two crossed Lysholm allmetal grids were used in each of the two planes. This arrangement satisfactorily eliminates the scattered radiation and prevents blurring in the roentgenogram. For the calculation of the heart volume, it is for the enlargement of the heart shadow on the suming the heart to be an ellipsoid, one gets %00-a 1 200-a v+, __. -. __. -m 200 2 200 2 are the axes of the ellipsoid on the frontal and a and b the distances from the center of the heart gave for a and b, 15 and 23 cm., respectively, V = 0.38 . 1 . m * n.
necessary to introduce a correction film. Fig. 3 illustrates this. Asthe volume V from the equation: 150-b n * __ 150 * -g-, where 1 and m n the axis on the lateral view, and to the films. Direct measurements so that the formula is reduced to
We have thus assumed the heart to have the form of an ellipsoid, whereas the Rohrer-Kahlstorf formula takes it to be something between
LILJESTRAND
ET
AL’.
:
NORMAL,
HEART
VOLUME
IN
MAN
409
a paraboloid and an ellipsoid. Thus they get the constant 0.63, whereas here it is 0.67. Our values will therefore be 6 per cent higher than those of Rohrer and Kahlstorf. In order to determine the margin of error for the method, we have made double exposures on ten healthy medical students. The values obtained are given in Table I. We find the margin of error as small as 30 cc., corresponding to 4.7 per cent of the mean value.
Rmt&.ube
I
Hish
Fig.
2.-Arrangement
Fig.
of
roentgen
tybes
%.--Scheme
for
correction.
(s,
tension trand. switches).
Before giving the details of our observations we should plify by means of two eases the paramount importance consideration two projections in different planes for the the heart volume. Fig. 4 shows the frontal and sagittal
like to esemof taking into estimation of teleroentgeno-
grams of a healthy nurse in a sitting position. On the frontal projection the heart looks enlarged, but the sagittal diameter is exceedingly short. The subject had a very flat chest. Calculating the heart volume according to the Rohrer-Kahlstorf formula, we get the normal value of 900 cc., or 450 c.c./m2 of body surface. On the other hand, if the heart volume is calculated only on the basis of the frontal roentgenogram with the help of Bardeen’s” formula (1918), it amounts to 1,300 cc., which is 45 per cent higher than tbc value obtained by the method first mentioned. Big. 5 illustrates the reverse situation in another normal subject, also in a sitting position. Here the hea.rt is tubular, as shown by the frontal roentgenogram, but the chest is deep, and the sagittal diameter fairly large. The heart volnnle according to Bardeen’s formula is 400 cc., but by the Rohrer-Kahlstorf method we obtain 490 CC.; thus with the former the estimate is 23 per cent too small. TABLE
Two DETERMINATIONS SUBJECT
I.
NO.
I II
OF HEART LENGTH CM.
BREADTH CN.
11 11
11.5 11.5
10.5 10.5
2.
:I
3.
I II
14.5 14.5 13 12
I
15.5
II I II
15
4. 5. 6. 7. 8. 9. 10.
I II I
II I
VOLUME
11
10.5 12 11.5
I ON EACH
OF TEN
SAGITTAL DIAMETER CM. 9.5 9.5
12 11.5 2.5 10 10
11.5
11.5
9.5
13
10.5
9.5
15 35
13 12 12
l-1.5 14.5
12
10
10 9.5
9.5
11.5 11
I II
15 15 12.5 I3
10.5
l-3
11
12
I II
14.5 14.5
12
10
II
12 12
NORMAL HEART VOLUME C.C. 580
580 690 665 800
550 710 660 560 495
STUDENTS DIFFERENCE C.C. 0
25 50 50 65
690 690
0
630 630
0
790
755 600 650 660 630
65 50 30
12 9.5 Mean of differences irrespective of signs = 34 cc. General mean = 641 c.C. Margin of the error for the method = 30 CC. = 4.7 per cent of the mean value.
The results of our determinations on healthy men are given in Tables II and III. In the first group of seventy medical students (Table II) the absolute volume of the heart varies between 480 and 970 CC., which is considerable. The corresponding limits are 5.6 and 14.2 C.C.per kilogram of body weight. The subject with the lower limit (No. 69) stands out as an exception, since in all the other subjects the heart exceeds 7.8 (corrected 7.4) CC. per kilogram, which is in fairly good agreement with Kahlstorf’s experiences. In seven cases,however, the values are higher than the upper limit given by Kahlstorf (11.1.06 = 11.7 cc.). In OUI
LILJESTRAND
ET
AL. :
NORMAL
HE,ART
VOLUME
IN
MAN
411
smaller group of men from 32 to 4’7 years of age, all are at or above eight (7.5 corrected) C.C. per kilogram, but here also some subjects, in all three, have a volume larger than 11.7 C.C. per kilogram. We are thus led to the conclusion that the upper limit for the size of the normal heart is somewhat higher than given by Kahlstorf.
Fig.
4.-Heart
Fig.
5.-Heart
volume
in a healthy
volume
in
nurse
a healthy
with
girl
extremely
with
a deep
flat
chest.
chest.
Since it has been observed in previous investigations (cf. DuBois,S 1936, and Grollman,10 1932) that metabolism and blood flow show a closer correlation to the body surface than to the body weight, it would seem natural also to correlate the heart volume with the body surface. Fig. 6 demonstrates the excellent correlation obtained in this way. On the basis of the above-mentioned determinations, we have worked out our material statistically. The calculation of mean values and standard deviations has been made in accordance with wellknown formulas.
412
TIIE
AMERICAN
HEART
Tnxrx HEART
1. 2.
3. 4. 5. 6. ., :t, k w:i 1,GT;:f 1% 12. 13. 14. 15. 1% 17. 1s.
19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30. 31. 32. 33. 34. 35. 36. 37. 38. 39. 40.
41. 42. 43. 44. 45. 46. 47. 48. 49. 50.
51. 52. 53.
VOLUME
21 22 22 22 22 22 22 22 22 22 22 22 22 22 22 22 23 23 23 23 23 23 23 23 2. 3 23 23 23 23 23 23 24 24 24 24 24 24 24 24 24 24 24 24 24 24 24 34 2-l 25 25 25 25
OF &XENT~Y
160 193 173 177 184 190 176 176 190 184 179 172 171 174 185 168 205 170 177
184 175 181 180 176 181 172 184 176 183 182 168
180 184 182 156 180 182 172 179
169 161 173 183
181 187 153 182 170
180 li3
176 175
II
HEALTHY MEDICAI, YEARS OF AGE
57
91 58 73 66 86 63 62 7s
81 62 65 61 64 83 68 7.9 66 72 67 62 76 65 67 68 6ti 75 60 78 69 65 77 78 71 79 77 63 69 65
71 51 65 78 7s
Ql 78 in 75 68 76 i4 84
1.58 2.22 1.70 1.89 1.57 2.14 1.77 1.76 2.06 2.04 1.77 1.77 1.72 1.77 2.07 1.78 2.20 1.77 1.87 1.87 1.76
1.96 1.83 1.81 1.78 I.78
1.97 1.74 2.01 1.68 1.74 1.96 3.01 1.92 2.02
1.96 1.83 1.81 1.83 1.81 lA3 1.78 2.n1 1.81) 2.17 2.01 1.90 1.86 1.87
1.01 1239 1.99
SWJDENTS BETWEEN 21 AND 30
620 850 650 850 650 850 650 680 710 660 600 830 750 530 800 660 900 700 730 550 550 600 520 750 so0 520 600 480 750 650 590 850 750 680 900 830 520 800 750 750 430 550 660 650 780 610 620 580 800 750 750 970
390 380 380 450 350 400 370 390 350 320 340 470 440 470 390 370
410 400 390 290 310
310 280 410
450 290 310 280 370 390 340 430 370 350 450 420 280 440 410 410 280 310 330 330 360 300 330 310 430 390 410 490
10.9 9.3 11.2 11.6 9.8 9.9 10.3
11.0 9.1 S.1 9.7 12.8 12.3 13.0 9.6 9.7 11.5 10.6
10.1 8.2 8.9 7.9 8.0 11.2 11.7 7.9 it 9:s 9.4
9.1 11.0 9.6 9.6 11.4 10.7 8.3 11.6
11.5 10.6 8.4 8.5 8.5 8.3 8.6
7.8 8.9 7.7
11.8 9.9 10.5 11.5
-'
LILJESTRAND
55. 56. 57. 58. 59. 60. 61. 62. 63. 64. 65. 66. 67. 68. 69. 70.
ET
25 25 25 25 25 25 26 26 26 26 26 26 27 27 29 30
AL.:
NORMAL
75 71 69 65 67 76 75
172 175 176 176 184 186 184 175 181
176 1Sl 179
175 183 180
HEART
600 600 550
2.01 1.84 1.84 1.50 1X
760 830 930
1.98
2.20
65 64 68 71 75 64 85 45
1.79 1.82
550
780 730 750 780 600 480 850
1.84 1.91 1.94
1.78 2.07 2.04
IN
&TAN
300 330 300 440 380 380 420 420 320 430 400 390 400 340 230 420
800 690
1.98
96
VOLUME
413
8.0 8.5 8.0 12.3 10.3 10.0 11.1
9.7 9.0 12.1 10.7 10.6 10.4 9.4 5.6 10.0
We have considered as normal limits the mean value decreased and increased by two standard deviat,ions. The mean value for the heart volume for the 70 young students is found to be 700 cc., and for the somewhat older men it amounts to 750 cc. Calculated per kilogram of body weight (Table IV), the mean heart volume amounts to 9.8 cc. for the younger group and 10.4 CC. for the older one. The corresponding values per m2 of body surface are 372 and 395 cc., respectively. The normal limits for these 101 healthy male subjects, estimated as mentioned above, are 7.0 and 13.0 CC. per kilogram body weight and 250 and 490 CC. per m2 of body surface.
1.8
I.6 1.v 1.2 1.0 Jo0 Fig.
B.-Correlation
500
500 between
600
700 heart
&IO
900 1000
volume
and
body
surface.
414
THE
AJIERICAh-
I-IE,ART TABTX
HEARV
VOTJJME
OF TI-ITRTY-ONE
E 1. 2. 3. 4. 5. 6. 7. 8. 9. IO. 11. 12. 13II. 14. 15. 16. 17. 18. 19. 20.
182 172 17s
92 61 i3 69
66
1.54 2.02
2.03 1.7s 2.14
174
63
187
811
181
is
176 176
84
2.15 1% 1.76 2.06 1.99 2 .02 1.84 1.x5 1.66 1.x7
6X 6-l
57
72 si
lS6 178 172
ti7
Ii $0 i (Xl 67
is 67 IiSI s 01
32 AND 47
730 850
410 400
440
900 Xi0
450 420
750 700 550
410 380 330
800 700 850 6511
430 330
11.1 x.n
450
12.7 10.5 9.6 13.4 10.3 12.4 10.3 9.9
350
420 400
730 700
410
650 600
2.13 1.8X 1.74 1.75 1.75 7.04 1 .
9.6 10.2 11.1 9.2 9.x 11.0 10.6 11.1 8.7 s.s 10.4 8.1 11.:: 10.0 X.1 11.7 10.1 11.0 10.9 9.6
750 760 750 6.30 650
1.98
185
440 400
i5 68 94 67
173
YOO 800 900 F(10 SO0
72
BETWEEN
d i 5 $2 8g
2; se x2
181 131
176 163 1% 172
CLERKS
1.72 1.91 1.82 1.72 1.85 1.85
63
172 175
22. 23. 24. "3. 26. 27. 28. 29. 30. 3 1.
HEART
43 8X
lS3
21.
TOTAL
152 173 171
177 190
11 I
HEALTHY BANK YEARS OF AGE
-
172 167 168
JOUKNAI.
X50 320 3x0 350
400 360
320
370 :330
575
900 SO0
510
,43n
160
iO0 1000
380 410
390
Vo~rms, HEAIX VOLT-m PER SQUARE METER OF BODY PER KILOGRAM OF RUDY WEIGIIT OF 101 HEALTHY MEX STAND&VERAGE PLRD DEVI n1 C.C. ATION Ll -__
---
70 medical students aged 21-30 years
Heart Heart Heart
volume volume volume
C.C. c.c./m% c.c./kg.
700.7 371.7
31 men aged 32-47 years
Heart Heart Heart
volume volume volume
e.e. c.c./mz. cc/kg.
750.0
394.5 10.4
We have not been able to estal>lish with tions
any
pronounced
there
is a tendency
difference toward
a larger
I
9.8
between heart
the
106.5 45.8 1.3
11.6
volume
hLEAN ERROR z (ar)
V 17.4 15.8 16.5
age
i\bx
-
121.9 58.9 1.6
certainty
ST-RFA(Y?
ni T 20
7.0
-__ 457-945 254490
0.2
0.16-13.0
14.6
14.2 12.4
from these investigagroups, at
even
a more
though advanced
LILJESTRAND
ET
AL.
:
NORMAL,
HEART
VOLUME
IN
415
MAN
age. In a previous paper, Nylin’l (1935) calculated the heart volume of twelve healthy girls between twelve and fourteen years of age, and found that the mean value (standing) was 315 cc. per m2 of body surface. Comparing the results obtained for the girls and the results of this investigation (Table V) , there appears to be a tendency toward an increase in the heart volume per m2 of body surface with increasing age, but unfortunately the youngest group was not of the same sex as the other two groups. TABLE TOTAL
HEART
VOLUME
V
AND HEART VOLUME PER SQUARE AT DIFFERENT AGES
METER
OF BODY
SURFACE
-_ HEART AGE (YR.) 12 girls 70 men 31 men
C.C.
12-14 21-30 32-4i
417 701 750
VOLUME
C.C./W. --ET-372 xxi
ix 7 20 c.c./m. 255-375 254490 303-486
SUMMARY
We have determined by simultaneous roentgenograms, in two tions at right angles, values for the volume of the heart in 101 men, aged from 21 to 47 years, and found that the normal heart varies between 7.0 and 13.0 cc. per kilogram body weight and 250 and 490 cc. per m2 of body surface.
projechealthy volume between
REFERENCES
1. Palmieri, G. G.: Sul valore della ricerca dell’ “angolo di scomparsa della punta” (metodo Vaquez-Bordet) come indice de1 volume relativo de1 eunre; variaeioni di tale angolo nello stesso individus e loro cause, Malat. d. cuore 4: 184, 1920. 2. Lysholm, E.: Riintgenoskopischer Modellierungsapparat such fiir Quersektion und Lokalisation, Acta radiol. 7: 189, 1926. :L Wegelius, C.: Untersuchungen iiber die Miiglichkeiten einer dreidimensionalen, rizintgenographischen Abgrenzung innerer Organe des menschlichen Korpers, Helsingfors, 1934. 4. Rohrer, F.: Volumbestimmung von Kiirperhohlen und Grganen auf orthodiagraphischem Wege. Fortschr. a. d. Geb. d. Rizintgenstrahlen. 24: 285, 1916. 5. Kahlstorf, A.: Ueber eine orthodiagraphische Herzvolumenbestimmung, Fortschr. a. d. Geb. d. Riintgenstrahlen. 45: 123, 1932. Kahlstorf, A. : MSgliehkeiten und Ergebnisse rSntgenologischer Herzvolumenbestimmungen, Klin. Wchnschr. 17: 223, 1938. 6. Nylin, G.: Relation Between Heart Volume and Stroke Volume in Recumbent and Erect Positions, Skandinav. Arch. f. Physiol. 69: 237, 1934. 7. Lvsholm. E.. Nvlin, G.. and QuarnL, K.: The Relation Between the Heart ” Volume and Stroke Volume tinder Physiological and Pathological Conditions, Aeta radiol. 15: 237, 1934. 8. Bardeen, C. R. : Determination of the Size of the Heart by Means of the X-Rays, Am. J. Anat. 23: 423, 1918. 9. DuBois, E. F.: Basal Metabolism in Health and Disease, Ed. 3. Philadelphia, 1936, Lea & Febiger. 10. Grollman, A.: The Cardiac Output of Man in Health and Disease, Sprir@ield, 1932, Charles C. Thomas. 11. Nylin, G.: The Physiology of the Circulation During Puberty, Acta med. Scandinav. Suppl. 69, 1935.