certain misdeeds which an insane man may commit but for which he ought not to be punished. For instance to send an undoubted kleptomaniac to prison for stealing or to punish a woman suffering from puerperal mania for trying to kill her infant. These same acts, however, when done by sane persons, are justly punishable and should be freed from all legal technical complications. The third proposition is perhaps the more difficult to gain your assent than those just stated, for it asks you to recognize that it is in many cases of insanity just and right to punish an insane person for wrong doing. This, I admit, is contrary to common belief and legal opinion, but it nevertheless expresses the actual truth, and the sooner we adopt its humane practical application, the better for both the legal and medical professions, as well as society in general. The adoption of the foregoing rules have already been accepted by many of the leading members of the medical profession and are ably advocated by Dr. Chas. Mercier of London, the well known alienist in his recent publication on "Criminal Responsibility." That many of the insane have powerful control of their actions when, by such restraint, they know they are to receive a certain premium or privilege, is well understood. The prevalent notion which expresses horror and disgust at the idea of ever punishing an insane person under any circumstances and for any kind of criminal conduct is, therefore, a false doctrine, and should be repealed. That this false sentimentalism is the responsible agent for the prevalent plea of immunity from punishment by the murderer on the ground of insanity is very clear. In conclusion, it would therefore seem that the following deductions are admissible: (1) That epilepsy is a symptom of some brain disease; (2) that its continual presence usually tends toward mental deterioration; (3) that the mental responsibility of the epileptic depends upon the extent to which mind or self-control has been impaired by the epilepsy; (4) that the legal test of insanity is not sufficient as mental irresponsibility is not incompatible with a knowledge of right from wrong; (5) that epileptics are, to some degree at least, responsible for criminal acts, more especially when the epilepsy is produced by their own. fault; (6) that criminal acts of epileptics appeal to medicine rather than to law for their proper adjudication; (7) that in all cases of murder in which epilepsy is proven the law should be amended to allow of like commitment to an insane hospital rather than to the penitentiary; (8) that the mental responsibility of the epileptic in case of murder should be referred to a medical commission, appointed by the court, which again may be referred to local or county medical societies to name its members. *DIVERTICULITIS. Diverticula of the alimentary canal may occur anywhere from the esophagus to the anus, but the anatomical arrangement of the intestinal canal is such that the condition is found more often in certain localities than in others. I prefer the classification of congenital and acquired diverticula to that of true and false, and will therefore adhere to it in this paper. The congenital form of Meckel's diverticulum has been known since the early part of the Eighteenth Century to be the not inFrequent cause of intestinal strangule tion and during the last fifty years, 1 has been known to be the occasional cause of peritonitis from perforation. While the whole field of diverticula is manifestly too large to be satisfactorily covered in the iimited time at my disposal, yet, I think I can consistently say something about congenital diverticula that will be of interest *Paper read at the seventh annual meeting of the Frisco System Medical Association. held in Kansas City, Mo., May 25, 1908. in distinguishing the two conditions. The congenital or Meckel's diverticulum is a remnant of the communication between the intestine and the vitelline duct or omphalic mesenteric vessels, and can therefore be found only in one place, and is always single. Sidney Jones, in 1858, was perhaps the first to mention congenital diverticula, and he reported a case which resulted in peritonitis with adhesions to the bladder and intestinal-bladder fistula. Congenital diverticula is said to occur in about two per cent of individuals and is found in the lower one-third of the ileum, and usually in the neighborhood of the ileocecal valve, and like the acquired, only gives symptoms when infection, adhesion, or perforation takes place. Leon Cahier describes a Meckel's diverticulum as possessing the following characteristics: It is single, it has a rectangular implantation into the free border of the terminal portion of the ileum, generally in the neighborhood of the ileocecal valve; it is made up of all the coats of the intestine; it is generally more than two centimeters in length, and it has a terminal filament which may be free or attached to the abdominal wall, the mesentery, or another part of the intestine. Formerly those diverticula that were composed of all the layers of the bowel wall, were classed as congenital or Meckel's diverticula, but recent experience goes to show that an acquired diverticulum may, and often does, resemble in its anatomical structure, a congenital one. It has not been long since an acquired diverticulum was looked upon as a pathological curiosity. The excellent paper of Dr. Edwin Beer of New York, published in the July number, 1904, of the American Journal of the Medical Sciences, has done more to bring the importance of this condition prominently before the medical profession than anything before or since. Dr. George Emerson Brewer, also of New York, has recently contributed a very excellent and in structive paper on left-sided, intra-abdominal suppuration, in which he reports six cases which he believes to have been suppurative diverticulitis. In July of last year there appeared associates, in "Surgery, Gynecology an article by Dr. W. H. Mayo and his and Obstetrics," reporting five proven cases and four suspected ones of acquired diverticulitis. They describe the pathological condition more in detail than has heretofore been done. The acquired diverticula are, as a rule, multiple, small, thin-walled and round or ovoid in shape, and as said before, may be found in any part of the intestinal canal, but are more frequent in the left colon and the rectum and, in reality, most of them are hernial protrusions of the mucous membrane through the separated fibres of the muscular coat of the intestine. It seems, from what I can glean from the literature on this subject, that among the earlier investigators, the belief was general that all, or at least a great per cent of acquired diverticula, occurred on the mesenteric side of the intestine, and their experiments were directed toward ascertaining why this weakness should exist, and after they had decided that the cause of this weakness in this mesenteric location was due to perforation of the intestinal wall by the nutritive arteries and their accompanying veins and nerves, there still remained a condition with which they had not reckoned. There still remained the fact unexplained that diverticula occurred on the free surface of the bowel, especially the colon. Owing to the observations of Klebs, Heschl, Hanau, Good, Hansman, Fisher and Graser, as well as Beer and Brewer, of this country, more attention has been paid to acquired diverticula and gradually their importance. in relation to other abdominal conditions is becoming better known, and yet when one begins to search for literature on the subject, he very soon concludes that the etiology and pathology are still not very well under stood, for a unanimity of opinion does not exist. Experiments which have been made for the purpose of ascertaining the location of the weakest parts of the intestinal wall where the diverticula would naturally ocur, have proven useless. It was learned that an intestine of a human corpse injected with a fluid would almost invariably rupture on the mesenteric side, which led the experimenters to conclude at once that this was the weakest point; and according to their conclusions, all diverticula shold occur there. This would perhaps have been satisfactory had not some meddlesome surgeons discovered that diverticula really occurred in other parts of the intestinal wall. Chlumsky's series of experiments upon the intestine of the living dog, proved that the rupture always occurred opposite the mesenteric attachment, while if the intestine were injected ten hours after the death of the animal, the rupture would occur on the mesenteric side. It would appear from an etiological standpoint then, that the research work of these gentlemen was worthless, and that we must look for other causes. It wold seem that there must be a cause that underlies all forms of acquired diverticula whether composed of all the layers of the intestinal wall or of those which are composed only of the mucosa, sub-mucosa, and the peritoneum, and whether they occur on the mesenteric side of the bowel or elsewhere. So far as we know now, acquired diverticula occur most frequently in middle aged and old people, whose history is that of chronic constipation and in whom there is muscular deficiency; and in this muscular weakness, from whatever nature, the cause of the formation of acquired diverticula must be sought, and this weakness in conjunction with other factors of less importance, but which must be classed as factors, are to be found the true causes of acquired diverticula. In summing up the causes of acquired diverticula, I would say that the following be considered the order of their importance: (a) Weakness of the muscular structure of the intestinal wall; (b) Pulsion from the presence of retained fecal concretions; (c) Separation of the muscular fibres of the weakened intestinal wall, forming an intestinal hernia of the mucosa; (d) Trauma or ulceration of the layers of the bowel except the serosa; (e) Influence of arteries and veins on the mesenteric side of the bowel; (f) Mesenteric tension in the small intestine. It occurs to me that the weakening of the musculature of the bowel wall may be congenital or be caused by some debilitating condition such as old age, with obesity or constipation, in which the muscular fibres are overstretched and worked out. This diminished muscular strength will explain the production of diverticula in the mesenteric and non-mesenteric parts of the bowel as well. Pressure from within, from retained enteroliths or fecaliths in the haustra of the colon, whose defective musculature will slowly yield and become pseudo-cystic, retaining all of the anatomical layers of the intestinal wall, resembling a congenital diverticulum, is not an imaginary condition; but the most common form of the disease is where the muscular fibres gradually separate and form an intestinal hernia composed of mucosa, sub-mucosa and serosa. This sacculated condition may enlarge to an enormous size, whether it consists of all the normal layers of the intestine or not, and be filled with intestinal contents, become infected, rupture and cause local or general peritonitis, or it may anastimose with other abdominal viscera, and fecal fistula, diverticulitis, and peridiverticulitis result; or when this diverticulum protrudes between the plates of the mesentery, there may occur an extra peritoneal abscess, which may rupture on the surface or be opened externally by surgical means. All diverticula, from whatever cause, may take on the same pathological When such men as Beer, Brewer, Mayo, Ashhurst and Deaver have reported so many cases with so few diagnoses before exploratory incision, one would conclude that a positive clinical diagnosis was an impossibility. It is well, however, to bear in mind that such a disease as diverticulitis exists when some obscure intra-abdominal trouble is presented for diagnosis. The history of the reported cases is that they usually occur after 45 years of age in the obese. These attacks are often recurrent and may extend over a period of several years, and as that portion of the colon which stores waste products for intermittent elimination is the portion most often attacked, we would expect to find the pain in the left side and usually in the left lower quadrant. The pain is sometimes very much like appendicitis. Dr. W. J. Mayo reports a case in which the patient said that the pain was exactly like his attack of appendicitis except that it was on the left side. The primary attack may subside after a thorough evacuation of the bowels and the trouble may to all appearances be perfectly relieved, usually however, there is a tenderness and sometimes an indurated mass will remain for some time afterward; or, rupture of the diverticulum may occur, producing shock or collapse and the scene close with general peritonitis, the real cause of the peritonitis never having been suspected. Th fact that this is the cancer age is productive of obscurity in diagnosis and there have no doubt been many cases diagnosed cancer of the sigmoid flexure and resections made, or the case may have been considered inoper able and left to the fate of those who are so unfortunate as to be the host of a carcinoma, I think, it is not stretch ing the imagination to the danger point to believe that cancer cells may become implanted in the walls of a diverticula and a benign condition be converted ino a malignant one. I think that many of the ischeo-rectal abscesses or absceses about the rectum are caused by an infected diverticulum. The prognosis of diverticulitis is not always favorable even to life and recovery with a fecal fistula is not uncommon. eRsection of a portion of the colon sometimes becomes imperative. Mayo says that these cases naturally drop into three groups; first, those in which an intra-peritoneal abscess forms with spontaneous evacuation into a neighboring viscus or evacuation externally by means of operation; second, those cases giving rise to acute or chronic obstruction necessitating operation; third, those in which the symptoms are mild and recovery occurs spontaneously. In conclusion, I wish to report a case which has been of very great interest to me and in which good men failed to make a diagnosis: Mr. M. C. C., aged fifty-eight, very large and obese, good personal and family history, but very much inclined. to constipation, especially for the last few years. Has had recurrent attacks of left-sided pain for the past fourteen years although at first they were of short duration, and not close together. For the past two years, however, there have been a number of attacks followed by more constitutional disturbance than formerly. Four months ago, the present attack began, after ten days of constipation. This attack was very severe, commencing with great pain in the abdomen, not localized, but general over the entire abdomen. During this attack, there was considerable vomiting followed by followed by high temperature, and great distention, but after the bowels moved well, from a large dose of castor oil, he felt better for three or four days, when he was seized with pain again. The pain now became localized in the lower part of the left side or left lower quadrant of the abdomen. There was constant tenderness now and a large mass could be outlined between the umbilicus and the crest of the left ilium. His pulse was somewhat accelerated and his temperature, a little above normal for several weeks. Septic infection being evident, operation was advised and on the thirty-first day of November an incision was made through the left rectus muscle into the abdominal cavity and the following condition found: Omentum and intestines firmly adherent to the mass, and upon separating the omental adhesions, ruptured into a cavity filled with fecal accumulations, debris of some kind and foul smelling pus. After evacuating the contents of this cavity, an examination proved it to be a diverticulum of the sigmoid communicating with the bowel by an opening about three-fourths of an inch in diameter. The wound was closed with drainage and while recovery has been prolonged, I believe complete recovery will result. ACUTE CHEST DISEASES." T. W. COTTON, M. D. I thought possibly I might present something of interest by offering some observations on acute chest diseases as gathered from memory and gleaned from notes taken in hospital clinics; in doing so I have dealt primarily with pneumonia and with some other diseases rather incidentally or as complications. The last United States census placed the number of deaths from pneumonia during the census year at 106.1 in every one thousand deaths from all causes; some investigators claim that *Paper read at the seventh annual meeting of the Frisco System Medical Association. Feld in Kansas City, Mo., May 25, 1908. its fatalities are on the increase, other deny this, be that as it may, all are agreed that the number taken away annually by this one disease is enormous and our treatment today perhaps has little or no decided gains over that used half a century ago, as demonstrated by results. While no treatment entirely satisfactory has been evolved yet scientific research has given to the world much information concerning its etiology and pathology and the signs of the times are hopeful that a more effectual treatment may come. The ideas given are not based upon text book teaching and are probably not altogether orthodox, neither has any effort been made at systematic arrangement. classed as typhoid, etc., not as an inPneumonia is a specific disease and flmmation, because an inflammation has no definite time to stop, that is, not self limited. Again an inflammation does not tend to spread, a pneumonia does. By the term pneumonia as here used is meant that form which is always associated with the pneumococcus or in fact caused by this diplococcus and a pneumococcus inflammation in other tissues than the lung as middle ear peritoneum, piamater or pleura, presents much the same characteristics, so far as the clinical features are concerned. A lung infection by the streptoccus, staphylococcus, bacillus of diphtheria and so on or not of the lobar type usually but rather a bronchoneumonia, that frequently terminates by lysis. The pneumococcus is a germ that loses its virility rapidly making it difficult to produce a serum from it. This fact probably explains why it is that a considerable per cent of people have this germ in their air passages without inconvenience. inconvenience. The life of the pneumococcus is about six or seven days but under certain conditions appears to be much longer, for instance after an acute attack of pneumonia the bacillus lingers in the air passages in a virile state for some time, probably responsible for recurring attacks later in |