matic heart an ideal condition for the use of digitalis, and it is in this condition that we get the best results by digitalis, irrespective of the valve involved, not because the myocardium is diseased, but because it is overworked. should be adopted which aid in combatting the hypertension and the nephritis. These three classes of cases include the majority of the serious cardiac insufficiency from pure valvular lesions in Class 1; insufficiency from valve and coronary sclerosis in Class 2; insufficiency from chronic myocarditis in Class 2; insufficiency from syphilitic processes in Class 2; insufficiency from nephritis in Class 3. We thus have left insufficiency from chronic pulmonary conditions which dam the blood back into the heart, producing an overworked heart muscle, insufficiency from fatty changes in the heart, and from general malnutrition, and cachexia. Digitalis is the sheet anchor in all cardiac insufficiencies. A good reliable preparation when properly used will give results. These results are most marked in pure valvular lesions. The results in the insufficiency due to a dilating heart in nephritis are next best. The other classes of insufficiency are benefited by digitalis in most. cases. Insufficiency from sclerotic changes have a different location of the pathologic changes and consequently a different physiology. These sclerotic changes have a predilection for the body and base of the valve together with the coronary arteries. The favorite seat of such changes is the semilunar valves and the structures of the aortic ring and the coronary arteries which take their origin in this region. In this type of valvular lesion we have, in addition to the change in the valves, a disturbance in the nutrition of the heart muscle and therefore a diseased myocardium. Here, too, we often find cardiac arhythmias and heart blocks. Rheumatic hearts are not so often accompanied by arhythmias except in broken compensation and in stenotic lesions. In the sclerotic hearts the common therapeusis is digitalis. Sometimes digitalis gives results by tuning up the heart Digitalis preparation, such as the tincture, muscle, but the results are not so striking as in infusion, leaves, and the preparations, such as rheumatic hearts, and should not be long con- digitalein, digalen and digipuratum, differ tinued. The treatment in these cases should be materially in the rapidity of their action. A along the lines for the treatment of generalized physician should know thoroughly the use of at arteriosclerosis. If there is a syphilitic history, least one reliable preparation. Digitalis should brilliant results are often produced by antiluetic be used in large doses and pushed to the physiotreatment. I well remember a post-mortem logic limit and then stopped for a time or given which was diagnosed rheumatic endocarditis. in much smaller doses for a time, followed The findings were roughening and sclerotic again by large doses. The time should come changes in the base of the semilunar valves and and will come, I believe, when all digitalis will the mouth of one of the coronary arteries was be prepared so that it can be used by the hypopractically closed by a syphilitic process. I dermic needle. believe that in this case brisk antiluetic treatment would have produced good results. The many causes of arteriosclerosis should be considered in treating these cases. Digitalis may be useful, but is not the basic remedy as in rheumatic hearts. Insufficiency from nephritis is frequently incorrectly diagnosed and treated. This type of heart disease is in the well-known cardionephritic cases. These cases come under the observation of the physician with an apparent valvular lesion, often with an arhythmia and hypertension. The physician hears a murmur and too often no further study is made of the case. He considers the case an ordinary rheumatic heart and cardiac tonics, especially digitalis, are used. Fortunately, some of these cases with passive congestion and edema do well on such treatment, because there is no real disease of the valve, only a relative insufficiency due to a dilating, overworked heart muscle. The heart trouble in these cases is due to a nephritis which precedes or perhaps follows general sclerotic changes. This fact should be realized by the physician, and his attention should not be centered on the heart alone, but also on the nephritic condition of the patient. Measures In some cases long-continued use of digitalis is necessary. In some ways digitalis is a dangerous drug and the physician who is prescribing it should not let his patients shift for themselves while they are taking it. We must not forget that other aids to treatment must be used in many of these cases. Other cardiac tonics, such as strophanthus, the caffein group, strychnin, etc., are to be used as the conditions arise. In treating these cases we should first and always try the effect of rest on such crippled hearts. Exercise, venesection, diet, hygienic measures, etc., should not be forgotten in our zeal for the use of digitalis. A troublesome disturbance of the heart, the so-called functional disease of the heart, often causes much anxiety, both to the patient and the physician. The patient fears for health and even for life in many of these functional disturbances. These disturbances include the toxic neuroses from alcohol, tobacco and excessive coffee and tea. They also include reflex neuroses from the respiratory organs, and especially from gastro-intestinal derangement. They include the so-called nervous heart. These disturbances manifest themselves by palpitation of the heart, extrasystoles, varied arhythmias and pains in and about the heart. Neuroses of the heart, like hysteria and neurasthenia, are diagnosed too frequently. Some physicians diagnose a cardiac neurosis when a little study and thought would show an organic disease. Some of these neuro are difficult to distinguish clearly from organic disease except by modern methods of investigation, and even then it is often impossible. Our best way of considering these cases is to consider all cardiac disease organic until proved otherwise. Intermittent hearts, extrasystoles, arhythmias, etc., are frequently the precursors of more serious heart disease. The treatment of functional heart disease rests on the cause of the trouble, if that can be determined. Toxic causes, such as alcohol, tobacco, coffee and tea and eating, are frequently cured by removal of the cause. Frequently the damage is too severe and removal of these toxic causes merely gives relief. Removal of these causes and rest are the main factors in the treatment. In functional disease from reflex origin, I wish to call especial attention to the stomach as a cause of many of these cases, perhaps a majority of all functional troubles. Hyperacidity, ptosis, hyperesthesia of gastric mucosa and especially gaseous distention of the stomach and intestines, are frequent causes of or accompanied by heart trouble. Treat the stomach in these cases and the heart will generally take care of itself. The so-called nervous or irritable heart is part of a symptom-complex of the neurotic. We may give a course of treatment based on hygiene, diet, drugs, rest, psychotherapy, etc., and think we have cured our patient, when the trouble breaks out anew and we start over again. The Eppinger and Hess theory of vagotonia helps in some small degree in these cases, but I feel we are still in the dark. The only advice in the way of treatment I can offer is that we study our neurotic cases more thoroughly, more intensively, for some cause of the neurosis. I feel sure we will find that many of the cases which we have labeled neurotics with functional heart disease will have some disease which will clear up the whole situation. The treatment of the Stokes-Adams syndrome. is difficult and uncertain. In cases with a syphilitic history and manifestations, antiluetic treatment has frequently given good results. The partial or incomplete heart blocks are also difficult to cure. In some of these cases atropin relieves the block and some good is accomplished. In the general treatment of heart. disease, if we would get the best results, we must know more of the physiology of the heart, more of the pharmacology of the drug used and more of the etiology of the disease. Humboldt Building. THE ROENTGEN METHOD IN ILEOCECAL DIAGNOSIS * E. H. SKINNER, M.D. KANSAS CITY, MO. It is becoming generally conceded that by the Roentgen method we are able to make a diagnostic map of the abdominal viscera which will present valuable information for outlining the medical or surgical compaign necessary to relieve the patient. The clinical history, laboratory tests and Roentgen evidence cannot be separated; their combination tends to exactness in diagnosis and prognosis. We believe that the Roentgen survey is as important to the successful treatment-medical or surgical of obscure abdominal lesions as is the geographical map to the general of a military campaign. The general of an army depends on his aids for the information necessary to plan an attack; just so the surgeon, who may have courage, skill and dexterity, but his surgical judgment is increased by the wealth of diagnostic facts which are now within reach. One year ago I had the pleasure of discussing the Roentgen evidence in the functional types of constipation. My theme to-day is the anatomic pathology of the ileum, cecum and appendix. While there may be roentgenologists who are ritualistic in their adherence to fluoroscopy or radiography in gastroduodenal pathology, there seems to be little doubt but that horizontal fluoroscopy is an essential in ileocecal roentgenology. The use of the radiograph, controlled by fluoroscopic palpation, adds greatly to the careful study of each case, but the physician who attempts to survey the right iliac region without fluoroscopic palpation on a horizontal Roentgen table will miss much information of value. Especially is this true in estimating adhesions to the visualized cecum, ascending colon and terminal ileum. The ability to recognize the bismuth-filled appendix obtains in a rather high percentage of the cases examined. The significance of such bismuth fillings has not been finally established. We may rightfully argue that the retention of bismuth in an appendix for a period after the cecum is entirely free from opaque shadows suggests the potential possibilities for danger in such an appendix. If bismuth masses are retained over a varying period may not infected residues be retained which could light up trouble when the individual is constipated? On the other hand, there are cases where the appendix refuses to fill at all, and there is definite Roentgen evidence and clinical symptomatology of * Read in the General Session of the Missouri State Medical Association, at the Fifty-Seventh Annual Meeting held at Joplin, May 12-14, 1914. cecal or ileal adhesions, in which case the appendix is so bound down by adhesions that a filling is impossible. When the appendix area is painful or tender to Roentgen palpation, without opaque shadows in the appendix, but with indefinite dyspeptic symptoms and chronic constipation of ascending colon type, we may reasonably infer an appendix obliterated or bound down by adhesions, if we have established the normality of the stomach, gall-bladder and duodenum. It may be difficult to say absolutely that this or that appendix is pathologic, but the mere retention of opaque shadows establishes the potential danger of retention of infectious fecal matter when the individual is constipated. The shadows of the appendix may show that it is kinked, abnormally long or twisted about residue. Through the accidental requirements of our laboratory hours for examining bismuth cases we have come to place some reliance on sixteen- to nineteen-hour ileal residues as an indication of a stasis dependent on constrictions of the terminal ileum or a patent ileocecal valve, or both. It seems that there is a growing importance to a patency of the ileocecal valve. This complication has been discovered in a percentage of cases which would formerly have been classed as Lane's kinks. It is also found with large atonic cecums without ileal adhesions. Ileocecal patency occurring from these two sources may possibly be explained as follows: Fig. 9.-Dr. R., aged 42. Stomach symptoms over period of seven years of indefinite character. Bismuth meals indicated normal stomach and duodenum, but the nineteen-hour interval showed this ileal stasis with arrows (2), (3), (4) and (5) indicating possible kinks or constrictions and arrow (1) a possible pericolic band over cecum. No appendix shadow visible. Operative proof. Appendix retrocecal. the terminal ileum. It may be seen acting as a suspensory ligament of a large ptosed cecum. It may be difficult to visualize the appendix which is imbedded in adhesions behind the bismuth-filled cecum, especially if the cecum and terminal ileum are immovable from adhesions. Possibly the appendix does not accept bismuth so readily in this situation or is obliterated. The question of ileal stasis is interesting. Some claim that a bismuth residue in the ileum nine hours after an opaque meal is sufficient evidence. Others require a twenty-four-hour |