Although the field of radiology continued to expend strongly during the first three decades of the 20th century, its application to cardiovascular diseases remained limited. In late 1920's, Sir James Mackenzie, one of England leading cardiologist wrote: "I am doubtful if an X-ray examination of the heart has ever thrown the slightest light on any cardiac condition."
During that period, as new surgical procedures were developed to treat patients with a variety of cardiothoracic diseases, surgeons were very interested in knowing the anatomy of the chest and therefore showed a great interest in the exploration of the chest with radiologic examination.
In 1930's, X-ray examination was performed with an increasing frequency and the radiologic study of the heart was recognized as a valuable diagnostic tool in patients with cardiovascular diseases.
Hugo Roesler published his classic monograph entitled, Clinical roentgenology of the cardiovascular system, in 1937. This first comprehensive treatise was divided into 14 chapters covering all aspects of cardiovascular disorders. The chapter 8 entitled: "Cardiovascular disease from the viewpoint of structural changes" includs a large section on acquired valvular lesions.
Roesler described several cases of mitral stenosis and regurgitation and reported very precisely the radiologic findings. Although most his patients presented with advanced rheumatic valve disease, similar chest X-rays are commonly observed today particularly in developing countries.
The section on mitral valve is reproduced here:
Mackenzie J. chronic disease of the heart. in:Christian HA,Mackenzie J, eds. The Oxford medicine. Oxford:Oxford University Press,1920