Oct. 9th temp. A. M. 98 P. M. 100.6

No more fever and no pain after 24 hours from the first dose of vaccine unless caused by moving, and even that disappeared after a few days. Recovery has been slow and tedious but steady and, considering what he has passed through, satisfactory.

While this is only one case, it shows very positive results of the vaccine treatment, especially the relief from pain and the general change for the better in his whole condition, and I believe saved his life. He was undoubtedly a "carrier," and carried the bacilli from one attack to another.

MEDICO-LEGAL ASPECTS OF ARTERIO-SCLEROSIS.*

BY FREDERICK W. SEWARD, M. D., Goshen, N. Y.

In the consideration of the medico-legal aspect of arterio-sclerosis or the atheromatous condition of the arteries it is unnecessary to go into the etiology or pathology of the affection further than to refer to the reduced calibre of the artery found in the arterio-capillary fibrosis form and the mechanical effect of such obstruction upon the circulation of the blood. For it is precisely this effect upon the circulation of the blood; lessening blood supply, hence nutrition to different parts of the body, that we get the secondary effects of this form of atheroma. And, when it refers to brain tissue, these effects, resulting in altered mental processes, bring the subject clearly within the realm of medico-legal discussion.

All mental processes result from the functioning of the brain. So long as such functional action is normal, the mental process will be rational. Whatever cause operates to interfere with such normal functioning tends to produce an irrational mental process.

Read before the New York State Homoeopathic Medical Society, February 12, 1913.

The

degree of this irrationality is infinite and determined by the area extent of area of brain tissue involved.

6 point footnote.

and

Arterio-sclerosis is a disease which is peculiar to advanced age in almost all cases, although a syphilitic complication may bring on arterial degeneration earlier in life, but this form usually terminates in paresis. The progress of the non-syphilitic form is usually exceedingly slow and its beginning insidious and ofttimes long. undetermined.

Let us take now these three characeristics, advanced age, extreme slowness of progress in loss of nutrition to the brain, and the consequent and very gradual interference with normal functional action of the brain, and we get a situation which underlies a vast number of exceedingly complicated and long drawn out legal complications which are dealt with in our Criminal, and more particularly our Probate Courts.

There are doubtless many instances in criminal practice where the question of responsibility on the part of the accused may be determined by the fact that the party is a subject of this condition of the arteries, and yet it is rarely recognized. The question of "testamentary capacity" is, however, of very frequent inquiry in probate practice and in very many instances will be rightly solved by a careful and intelligent inquiry as to the existence of this pathological change in the maker of the will and the extent thereof. To the legal mind, insanity or mental incompetency is regarded as a fact. If it exists, testamentary capacity is lacking. The rule is a hard and fast one, possessed of no flexibility. The truth is, however, a subject may be in a degree insane and incompetent and yet undoubtedly possessed of testamentary capacity.

The recital of a case which came within our experience will illustrate my meaning. B. was a farmer; widower, 56 years of age, had been industrious and had accumulated several thousand dollars, which were invested by him in various ways. Two daughters and one son besides himself composed the immediate family. The daughters had married well and were living in villages remote from the farm. The son had also married and, at the solicitation of the farmer had taken up his residence in the farm home, making a home for the father, and the father and son had worked the farm together under a business arrangement mutually satisfactory. The father made a will, leaving to each daughter a legacy of two thousand dollars, as I recall, and the residue of his estate, both real and personal, amounting, as per inventory, to something like fourteen thousand, to the son. Subsequent to the making of this will the father became ill. His physician and a consultant diagnosed the

condition as one of acute alcoholism and, because of his mental excitability, he was committed to a State Hospital for the Insane. His history while in this institution showed him to have been excitable, profane and abusive for a few hours, but in a short time he was given his parole to go and come as he pleased. In all respects he was considered rational. If there was a condition of arterio-sclerosis it was not discovered. At all events it was not written in the record. patient, on his own request, was promptly discharged as cured. It was also developed that gradually and for months before this commitment, the farmer was using alcohol with increasing liberality until the crisis came. After his admission he had no alcohol.

This

For seven years subsequent to his discharge from the State Hospital, this man lived in his home, circulating among his neighbors and friends as always, bought and sold stock, grains and implements for his farm, loaned his money on notes and mortgages, collected his interest money, conducted his affairs with banks and stores without question.

Remembering that he had executed his will only a short time prior to his illness and commitment to the State Hospital and thinking possibly the will might be attacked on the ground of incompetency, and because of such commitment, he had a new will drawn by a different attorney and witnessed by two individuals other than those who witnessed the first will. In substance the second was precisely a duplicate of the first will.

After living these seven years in a manner so rational that his condition was absolutely unquestioned, the use of alcoholic stimulants was again resumed, and again he became ill and this time very distinctly maniacal. Again he was committed to the Hospital, but lived only a few days. Autopsy disclosed now a pronounced condition of arterio-sclerosis and this was assigned as cause of death.

So far as my knowledge of the case extends the question as to the effects of alcohol upon his condition was not considered, but it seems to me all circumstances indicate its prominence as a factor. My experience also demonstrates to me that alcohol when used by subjects of brain disturbance is always a cause of aggravation of mental symptoms. This is particularly illustrated in cases of paranoia. There is no question in my mind but this case had in a slight degree a condition of arterio-sclerosis even prior to his first incarceration, but not to an extent which affected his mentality, but the use of alcohol induced the acute mania, which was alcoholic, and his ability to make a will was good, both before and after the seizure. Whereas, some years after, the progress of the arterial obstruction had become so extreme that the renewed use of stimulants precipitated a fatal termination.

Instances wherein men who have displayed good judgment all through their careers as business men gradually, mysteriously and unaccountably, as they advance in age, begin to sustain money losses, to manifest a warped and defective judgment, to manifest. marked and unfortunate traits of character, are numerous indeed and the same is almost uniformly the effect of a sclerotic condition. of the arteries which by reason of its partial occlusion of the blood vessels cuts off in a measure the blood supply to the brain, and also by the organic change in the walls of the blood vessels interferes with the process of osmosis. These considerations, then, show the importance of this pathological state in connection with legal processes in which the mental capacity or responsibility of a subject is in question.

Aside from any legal question this condition of arterio-sclerosis, marking as it does in very many instances the beginning of mental decadence which results in loss of property, domestic complications, social entanglements, a grave responsibility rests upon the family. physician requiring an early recognition of the malady on his part and an intelligent management of the case in the direction of safeguarding the interests of patient, family and friends.

Without doubt you can all recall instances within your personal experiences where the vagaries of the early stages of senile dementia, due to this sclerotic affection, have resulted in just such complications as we read of daily in the public press, a notable example of which has very recently distressed us all. A man justly honored for services rendered to his country in her time of need, a man honored for the display of the attributes of true manliness through a long career, is, in the declining period of his life, portrayed in our press as a deliberate violator of his domestic obligations and an embezzler of public funds committed to his care, and he, his family and friends subjected to the gross indignity of his arrest at the instance of the legal representative of this great State, when, as I venture to affirm, the man is a victim of a pathological change which has affected his brain action to a degree which renders him clearly irresponsible in a legal, and also moral sense. While expert testimany may have fallen into a degree of ill repute, is it not desirable that due and scientific inquiry should be made in doubtful cases before criminal action be instituted or even criticism offered?

A CONTRIBUTION TO THE STUDY OF TUBAL, OVARIAN
AND TUBO-OVARIAN HERNIAS.

BY AIME PAUL HEINECK, M. D., Surgeon to
the Cook County Hospital, Chicago.

In the female, the frequency of hernias and especially of hernias of the internal genitalia has been and is still underestimated. Owing to the lack of study heretofore given to this clinical entity, hernias of the uterine adnexae are often overlooked, not uncommonly misdiagnosed, and therefore subjected to injudicious treatment, harmful alike to the individual and to the hernial contents, prejudicial alike to the patient's general well-being and to her reproductive powers. Impressed by the clinical importance of the condition and surprised at the insufficient consideration given to the subject in even the most modern gynecological and surgical text books, I have collected the following data which may prove of service to some of my professional colleagues as well as to future investigators of the subject. Knowledge of the occurrence and familiarity with the symptomatology of a clinical condition lead to its more frequent and more timely recognition.

Soon after beginning the consideration of the subject, we became convinced that deductions and conclusions, to be valuable, should be based solely upon the study of cases whose accuracy of diagnosis is self-evident. Therefore in the preparation of this paper we have only considered cases in which the hernial contents were demonstrated at the dissecting, autopsy or operating table.

We have conformed to the nomenclature in actual use; but, to better insure precision of classification and a more intelligent discussion of the subject, we define, at times, the terms employed. The word hernia signifies the permanent or temporary protrusion. of one or more viscera from their normal situation through a normal or abnormal opening in the walls of the cavity within which they are contained. It implies the existence of a hernial ring, of a hernial sac, of hernial sac contents and of sac coverings. In the hernias discussed in this article, the protruding organ was always either an ovary, an oviduct, or Fallopian tube and an ovary. In some cases, as associated hernial contents we find omentum, a segment of the alimentary canal, a part of the urinary bladder, a rudimentary uterine horn, or the entire uterus, be the latter organ rudimentary, infantile, or of normal development. The tube or ovary or both in part or in their entirety may be herniated. All the hernias herein considered are external hernias; that is, their outermost overlying saccular covering is skin, and each, after reaching a certain stage. of development, gives rise to a more or less visible, more or less

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