A Method of Approximating the Time of Death.-Vaughan in a communication to the Journal of the American Medical Association (Feb. 26, 1921), calls attention to the fact that medicolegal volumes fail to reveal any method whereby one can determine even approximately how long a body has been dead. When a dead body is discovered the police naturally turn to the physician for information as to the probable time of death. We are, therefore, confronted by the problem of discovering some method that can be relied on to give fairly accurate information on this subject.

Vaughan has found that, taking advantage of the fact that those portions of the body farthest from the heart-namely, the extremities are the first to cool, it is possible, by dividing the lower extremities into ten parts, to determine the approximate time of death with a fair degree of accuracy. The method is as follows:

Divide the leg from ankle to knee into three imaginary parts, take the region of the kneepan as the fourth part and divide the thigh into six parts, making ten parts in all, and make allowance of one hour for each division; then by sense of touch note the difference in temperature in each section. Allowing one hour for each section and starting with section 1 (section 1 being the lowest third of the leg above the ankle), if section 1 is found to be frankly cold as compared with section 2 (middle third of the leg above the ankle), one may state that the body has been dead about one hour. If in section 2 one finds frank coldness as compared to section 3, the body has been dead about two hours, and so on up the leg and thigh until one is able to state approximately how long a body has been dead, if death has occurred within ten hours.

This method has been proved to be fairly accurate in more than a hundred examinations conducted by Assistant Medical Examiners Martin and Boettiger, of Kings County, and by Drs. Hala and Atchley of Kings County Hospital, together with the author. The tests have been conducted only where the prevailing atmospheric temperature ranged from 40 to 80 F.

This method is so simple that every person connected with a hospital or with the police force can determine the approximate time of death to his own satisfaction, and in my opinion it should be of material aid to the ambulance surgeon, who is likely to be the first whose opinion is asked at the scene of

Indications for Tonsillectomy.-T. L. Deavor in the International Journal of Surgery (Jan., 1921) declares that constitutional symptoms, in many instances, should be taken more seriously than the degree of hypertrophy. Most of the tonsil, when diseased, is out of sight, even tho there is marked projection into the pharynx. Both tonsils should always be removed, tho the toxic element may reside in only one. The larger of the two is often quiescent. As the tonsil hypertrophies, the pillars are put upon the stretch, intermittent or continuous. The result of tension so produced is to force the infective material into the lymphatic circulation. Prima donnas and public speakers have acquired disfavor toward removal of the tonsils-largely because much damage has, at times, been done to surrounding tissues, limiting the usual flexibility of the anterior and posterior pillars. Greatly enlarged tonsils may seem otherwise innocent, yet, during removal, fluid resembling pus can frequently be expressed from them which was not discovered on examination. Thru tonsillectomy, patients are relieved of lassitude, earache, erratic pains, headache, rheumatic tendencies, cervical adenitis and cardiovascular depression. Not a few individuals gain in weight. If results are good, but not wholly satisfactory, an associated lesion will always be found. Look for nasal obstruction, necrosis of bone. sinusitis, or defective teeth. A diseased tonsil may be secondary to any of the above conditions. In case of cervical adenitis, especially the fluctuating type, the tonsil should be dealt with first. In this way one limits the number of unsightly scars about the neck. Again, if the tonsil is the primary focus and is left, enlarged glands, when removed, are soon replaced by others. It is along these lines that more concerted action is needed on the part of three men, the surgeon, the physician and the dentist.

Artificial Impregnation.-Dickinson takes up in detail the problem and technic of artificial impregnation and gives the following as obstacles which may interfere with its success: 1. The possibility of infection of the tube and peritoneum.

2. Old tubal disease may be lighted up anew. It may, for a tubouterine orifice never closes.

For the present, at least such cases should be avoided.

3. It is possible that all that injection of semen accomplishes is to open the tube, in which case other fluids would do as well, and antiseptics be safer as used by Stone and Bovee. Only tests can tell.

4. One can have no assurance that coitus subsequent to the treatment was not the real agent in procuring conception. This may be true and this is the reason that the veterinary surgeon can offer proofs which we cannot.

5. It fails with semen which is not vigorous. It was devised for just such cases and it has not helped so far.

6. The field is very limited because patients revolt at the idea, or give it one trial instead of half a dozen. They prefer laparotomy. All this is exact, but it does not relieve us of the responsibility of preventing the patient taking the greater risk should there be a simpler way, did we but have the will to face the distastefulness of working it out.

Dickinson summarizes as follows: In women presenting histories or pelvic findings pointing to the sealed tube following milder types of salpingitis, entirely quiescent, injection into the uterine cavity of active semen produced no results in twelve instances. Strong pressure was not deemed warranted.

In women with no gonorrheal histories or findings, free from cervical inflammations and evident uterine, tubal or ovarian lesions or abnormalities, living semen of the poorer grades produced no results in nineteen patients. No infection followed except in one possible instance and that of mild type. Several of these received three trials.

With fairly normal pelvic organs and semen of good quality, five pregnancies followed and are believed to have been due to tubal insemination. The knee-chest posture, the curved pipette fitting the internal os and carried nearly to the fundus, injection into the tubes, horizontal rest, and repetition three to six times-these are considered important. Trial of this method may well precede resort to operation-save those done for external obstructions.

Medical Treatment of Incipient Cataract.— Scalinci (Riforma Medica, Sept. 11, 1920) lays stress on the fact that cataract is especially prone to develop in persons with a special diathesis or dyscrasia. He recalls that an iodide solution undoubtedly passes into the interior of the eye and may restore the local metabolism to approximately normal and thus arrest the tendency to opacity. Good results have been reported from electrolytic introduction of iodide salts, but this, like subconjunctival injections, must be reserved for exceptional cases. However, bathing the eye with iodide solution is a simple and easy procedure. The solution should not be stronger than 0.25 or 0.5 per cent. at first. Smarting usually indicates that impurities are present. He advises a 1 per cent. solution of sodium iodide or rubidium iodide with addition of a trace of

calcium phosphate. Very little if any benefit can be looked for secondary, congenital or stationary cataract. The best results are obtained when the lens is first beginning to show a tendency to opacity, especially incipient diabetes. The lens may still be transparent, but changes in refraction show disturbance in the molecular imbibition of the hydrogel of the lens, and conditions may be restored to normal by the local iodide treatment. The widest field for its application is incipient senile cataract of the subcapsular, cortical type, which may be regarded as a manifestation of dyscrasia. The diathesis or dyscrasia should be combated at the same time. Dor asserts that of every ten patients with incipient cataract, eight can have the process arrested, one can be cured and only the tenth finds his condition not modified. Others are less enthusiastic, but Scalinci remarks in conclusion that this local iodide treatment is well worth a trial.

The Benzyl Treatment of Persistent Hiccough.-Macht, of Johns Hopkins University has done more than any one else to establish the field of the therapeutic application of benzyl benzoate. Some time ago, he called attention to its value as an antispasmodic and anodyne in the painful and distressing conditions arising from spasms of the smooth-muscle tissues, such as dysmenorrhea, renal colic, dysentery and asthma. Many drugs, which often are announced in high notes of enthusiasm, prove disappointing in practice; scores could be named. This does not seem to be true of benzyl benzoate. Reports indicate that it is generally coming up to the recommendations of its sponsor in his earlier writings.

Pursuing his investigations, Macht has found other uses for the ester.

In the Medical Record (New York), he has recently shown its application in the treatment of persistent hiccoughs in both adults and children. Not only is it useful in the ordinary forms so common to infants, but also in the severer form that lasts some days and threatens to kill the patient by exhaustion.

The drug acts best, says Macht, in 20 per cent. alcoholic solution; of this, he directs the patient to take from 20 to 40 drops in water or milk. This dose should be repeated, at hourly or half-hourly intervals, as required for effect.

Several cases are reviewed in this paper in which benzyl benzoate was so used, in all with good results.

The Induction of Premature Labor.-The induction of labor for the preservation of maternal and fetal life is carefully considered by Phillips (Lancet, Oct. 9, 1920) with some enthusiasm of laminaria tents which if kept in alcoholic solution 1 to 1000 remain aseptic over a long period. In the afternoon the laminaria tents are introduced into the cervix, from one to three of the long variety, fresh from the solution, and within 18 hours are

removed, when the cervix will be found to admit a finger, also quite soft and dilatable, enabling one to insert, after a little digital dilatation under an anesthetic, a small de Ribes bag.

He gives an analysis of his results in 161 cases, recording seven deaths of mothers and twenty-four of children. His maternal deaths were due to acute bronchitis (1), multiple fibroid with twins (1), contracted pelvis and acute yellow atrophy (1), ventrofixation and bilobing of uterus (1), placenta previa (1), acute albuminuria and eclampsia (2).

With regard to the maternal deaths, none of them can be attributed to the actual induction, as a fatal result would, in all probability, have occurred without the operation; induction of labor may, therefore, be looked upon as a procedure which, per se, should be unattended by any mortality.

The writer believes that in cases in which rapid delivery in a primigravida is necessary, such as in puerperal convulsions and complete placenta previa, it would perhaps be preferable to perform Cesarean section, but should the case be that of a multipara digital dilatation and a de Ribes bag would be the best course to pursue. If there is no urgency and the case can be taken deliberately, bougies, followed by digital dilatation or a de Ribes bag, is the preferable course.

Bronchopulmonary Spirochetosis (Castellani). Levy, in the New York Medical Journal, January 29, 1921, says: The attention of the profession was recently directed to the numerous cases of Castellani's bronchitis being reported from various parts of the world, and to the probability of like infections occurring in this country. That this was most probable was suggested as a result of the close association of the American troops in France, Germany, and Italy, with groups from areas which were known to have been infected with the spirochete.

The symptoms in acute cases usually disappear after a few days' rest in bed. For the rheumatoid pains, salicylates or codeine may be necessary. If hemorrhage is a prominent feature, the usual remedies as employed in other pulmonary disorders are advised, such as morphine, icebag to the chest, calcium lactate, or, in severe cases, blood transfusions. The anemia is combated by the usual tonic remedies, of which iron in some form is the basis. In the way of specific treatment arsenic has given better results than any other drug used. Recently much success has attended the intravenous use of one of the arsphenamine products.

The report of these two cases is made with the hope that a more careful study of the sputum of patients suffering from chronic cough will reveal other cases of bronchopulmonary spirochetosis. In study of seventy-nine cases of chronic cough, Thompson found the spirochete present in thirty-nine. In view of the wide distribution of the infection as evidenced by reports the world over, it is our belief that more cases will be brought to light by more

careful investigations. The close similarity of the symptoms of bronchopulmonary spirochetosis to influenza, and especially to pulmonary tuberculosis, should constantly be borne in mind, and as a conclusive differential test from tuberculosis we would recommend an iniculation of the suspected sputum into a guinea pig.

Treatment of Displacements of the Uterus.Bland, writing in the N. Y. Med. Jour. (November 6, 1920), gives the following summary of his views on this subject: 1. Therapeutically there is a distinct need for a specific line of division between medical and surgical malpositions. 2. The symptomatology of uterine displacements, in general, as taught today is erroneous. This is confirmed by the small percentage of so-called cures following operation. 3. Uncomplicated malpositions should be treated by medical and mechanical means. Operative measures should be applied to those associated with distinct surgical complications. 4. Operative intervention should not be utilized in the simple malpositions of virgins or young married women. 5. The infantile uterus never requires, nor is the condition benefited by surgery. Endocrine dysfunction as an etiologic factor should be remembered. This condition should be treated and not the uterus. 6. Nerve and muscle relaxation (backache) should be regared as a causative factor and not the result of uterine malposition. 7. Restoration of nerve and muscle power should be restored in all cases and is best accomplished by rest and generous feeding. 8. In no case of retroflexion or retroversion will the patient recover in the presence of obstinate constipation or bladder overdistention. Overcome constipation and malpositions will largely disappear. 9. The prolapsus of old women with low surgical resistance is best treated mechanically by the Menge pessary.

Purification and Sterilization of Drinking Water with Lime.-Smith (Mededeel. v. d. Burg. Geneesk. Dienst, Java, Nov. 3, 1920) asserts that his extensive experiments with lime have confirmed its sterilizing and clarifying power for river water. He refers to the turbid, brown rivers of Java in which the amount of dissolved impurities and content of ammonia is small. The addition of milk of lime causes flaking of the colloid particles responsible for 'the turbidity. Ordinary laboratory filter paper retained practically all bacteria when the fluid passed thru it had been rendered alkaline. His tabulations show that there is a possibility of obtaining nearly sterile water from turbid and greatly polluted water by mix

ing lime with it for just a few seconds, and passing the mixture thru ordinary coarse filter paper, provided the first 250 c. c. be thrown away. His tests do not prove that the method can be applied on a large scale, with sand instead of paper, but they render it strongly probable. He reiterates that the filtrate only requires neutralization with carbon dioxid, which is harmless, to give a completely reliable, sufficiently soft and palatable water.

Avocado Fat.-Among the fruits that enter into the dietary of man the avocado, or alligator pear, takes an almost unique place because of its richness in fat, says an editorial writer in the Journal of the American Medical Association (March 27, 1920). A few fruits may furnish a noticeable quota of real nutrients in the form of starch and, particularly, sugars; thus an ordinary sized banana is rated at a food value of 100 calories or more. But for the most part the fruits that enter into the ordinary regimen, however palatable, wholesome and dietetically valuable they may be, can scarcely be rated as significant sources of energy. The part that they play in nutrition must be estimated from other standpoints. Accordingly, an edible fruit that may exhibit as much as 20 per cent. of fat in its make-up is worthy of special consideration. It may prove, for example, to become a valued adjuvant to the dietary of the diabetic, from which the carbohydrate content of many common fruits unfortunately excludes them. The possibilities of the avocado have been further promoted by recent investigations in California and Washington, both of which agree in assigning an excellent utilization to avocado fat, even when as much as 124 gm. (about 41⁄2 ounces) a day were consumed. Heretofore the market price of this fruit has prohibited a very widespread use of what now appears to be a nutritious as well as palatable food. The avocado is indigenous to tropical and sub-tropical regions in the western hemisphere; but it is being cultivated to an increasing extent in Florida and California, and may ultimately become available at more reasonable prices in harmony with the history of some other tropical fruits. Dietotherapy will testify that the enrichment of the dietary with a really palatable source of fat will not be unwelcomed in the management of certain nutritive disorders. Ordinary cream rarely exceeds the avocado in available fat content.

vaccine, being a living virus, is easily destroyed by summer temperature.

4. Careful instructions should be given the patient as to the subsequent care of the vaccination, and cleansing or treatment of the vaccinated area is necessary. The patient should be instructed to return in a day or two to the physician for examination.

5. It should be remembered that vaccination is a surgical procedure and a suppurative wound, unless properly looked after, is an excellent culture field for the growth of foreign bacilli.

Unfortunate occurrences can be entirely prevented if the patient is kept under observation of the physician until the vaccinated area is completely healed.

6. Glycerinated virus is the only form of vaccine prepared at the present time. Only fresh vaccine should be employed, and the physician should be sure that the virus has been carried in a refrigerator and not exposed to heat.

7. Glycerinated vaccine is milder and slightly slower in action than other forms-the vesicle usually forming on the eighth day in primary vaccination, possibly as late as the tenth day. The formation of the typical vesicles should be considered as proof of successful vaccination.

Preservation of Vaccine.-Vaccine should be kept on ice until used.

Vaccine not kept at low temperature soon becomes inert and will not "take."

Extensive studies in the Mulford Laboratories show that:

Vaccine kept at 140° F. for five minutes is killed.

Vaccine kept at 98° F. for three or four days is dead. (This body temperature is about the temperature at which the vaccine would be kept if carried in the pocket.)

Vaccine kept at 70° F. for one to three weeks is weakened but not dead. Vaccine kept at 50° F. for three to six months is still active. (This is about refrigerator temperature.)

Vaccine kept at 10° F. for four years is still active.

The lesson is: Keep vaccine in the refrigerator until used. Don't expect to get "takes" from vaccine that has not been kept at a low temperature. Vaccinate

during the spring and winter months whenever possible.

Special Points to be Remembered About Vaccination in Smallpox.-Stewart (Western Medical Times, January, 1921) says:

1. Rigid cleanliness should be exercised in preparing the patient for vaccination and in the after-care of the vaccinated area.

2. Deep scarification should be avoided; no blood should be drawn.

3. Vaccination should be preferably in the winter or spring, to get the best results, as the

The Mosaic Unloosed Shoe and Divorce.There is a Mosaic requirement for marriage with a deceased brother's wife, states The Urologic and Cutaneous Review, March, 1921, for not obeying which Onan was slain, which has a strong influence on certain orthodox Jews. Some years ago a widow went from the United States to South Africa to carry out the ceremony of offering to marry her brother-in-law and then having his shoe unloosed. It is really a sur

vival of polyandry. The law as laid down in Deuteronomy XXV, 5-10, is as follows:

"If brethren dwell together and one of them die and have no child, the wife of the dead shall not marry without unto a stranger; her husband's brother shall . . . take her to him to wife and perform the duty of a husband's brother unto her. And it shall be that the first born which she beareth shall succeed in the name of his brother which is dead, that his name be not put out of Israel. And if the man like not to take his brother's wife, then let his brother's wife go up to the gate unto the elders and say, My husband's brother refuseth to raise up unto his brother a name in Israel; he will not perform the duty of my husband's brother. Then the elders of his city shall call him and speak unto him: and if he stand to it and say, I like not to take her; then shall his brother's wife come unto him in the presence of the elders and loose his shoe from off his foot and spit in his face and shall answer and say, So shall it be done unto the man that will not build up his brother's house. And his name shall be called in Israel the house of him that hath his shoe loosed."

While Deuteronomy is ascribed to Moses, the intrinsic evidence is that it was written much later. In a recent case a Jew asked the Supreme Court of New York to annul a marriage because his wife brought it about by false statements.

The fraud alleged is that the wife represented that she had "observed, aided by, and gone thru a certain Jewish orthodox religious practice which requires a widow who has never had children, and whose deceased husband has a brother surviving, to ask said brother of the deceased husband to marry her, and if said brother is either unwilling or unable, the required ceremony is for the widow to remove his shoe with a certain ceremony."

As the parties were married by the orthodox Jewish ritual the deceit would be sufficient for divorce.

The Results of Familial Syphilis.-The families of syphilitic patients admitted to the Psychopathic Hospital have been examined as a routine procedure. The patients are all in the late stage of the disease and are divided into three groups: (1) general paresis, (2) cerebrospinal syphilis, and (3) late syphilis without involvement of the nervous system. This division is made to determine if the familial problem is different in cases of central nervous system involvement from those in which the central nervous system escapes. The families of 555 syphilitic patients were examined and the following findings were obtained:

1. The family of the late syphilitic abounds with evidence of syphilitic damage.

2. At least one-fifth of the families of syphilitics have one or more syphilitic members in addition to the original patient.

3. Between one-third and one-fourth of the families of syphilitics have never given birth to a living child. This is much larger than the

percentage obtained from the study of a large group of New England families taken at random which shows that only one-tenth were childless.

4. More than one-third of the families of syphilitics have accidents to pregnancies; namely, abortions, miscarriages, or stillbirths.

5. The birth-rate in syphilitic families is 2.05 per family; whereas the birth-rate in the New England families mentioned above is 3.8 per family, or almost twice as great.

6. Two-thirds of the families show defects as to children (sterility, accidents to pregnancies, and syphilitic children).

7. Only one-third of the families show no defect as to children or Wassermann reaction in spouse.

8. About one-fifth of the individuals examined show a positive Wassermann reaction; more of these are spouses than children.

9. Between one-fourth and one-third of the spouses examined show syphilitic involvement. 10. Between one in twelve and one in six of the children examined show syphilitic involvement.

11. One-fifth of all children born alive in syphilitic families were dead at the time the families were examined. This does not differ materially from the general average in the community.

12. One-fifth of the pregnancies are abortions, miscarriages, or stillbirths, compared with less than one-tenth of the pregnancies in nonsyphilitic families.

13. The average pregnancies per family is 2.58, compared with 3.88, 4.43 and 5.51 in nonsyphilitic families.

14. There are 3.52 stillbirths per 100 live births in the syphilitic families, as compared with the 3.79 reported by the Massachusetts Census, showing that there is no very marked difference in this regard.

15. A syphilitic is a syphilitic, whether his disease is general paresis, cerebrospinal syphilis, or visceral syphilis without involvement of the central nervous system, and the problems affecting his family are the same in any case.

The family of every syphilitic patient should be examined, irrespective of the stage of the disease or the symptomatology presented by the patient when first seen. If this is done, cases of conjugal and congenital syphilis will be discovered which would otherwise be neglected. They will often be found at a period when symptoms are not active, and thus treatment may be instituted before irreparable destructive lesions have occurred. An opportunity is offered to prevent the development of such disabling condition as general paresis, tabes dorsalis, aneurysms, and the like. The possibility of bearing healthy children may be increased. Every clinic dealing with syphilitic patients, whether it is primarily a syphilitic clinic, a neurological clinic, a cardiac clinic, or an internal medicine clinic should be equipped with the machinery for bringing the members of the syphilitic's family to the clinic for examination.-Social Hygiene quoted in The Urologic and Cutaneous Review, March, 1921.