Lorenz method. At the same meeting various members of the association reported results of treatment in a considerable number of cases treated by Lorenz during his American tour, and the general feeling was one of disappointment at the results secured. When at Philadelphia last June the writer saw a number of cases that had been operated upon by Lorenz and other surgeons, who

had followed his methods, and the average result was certainly disappointing.

Dr. Harry Sherman, of San Francisco, read a paper at the meeting above referred to, in which he very ably advocated operation by open incision, in preference to uncertain bloodless methods. He argued that we are not justified in submitting our patients to the primary dangers, and the subsequent prolonged after-treatment

of the Lorenz method when we know that not more than one in ten of those treated will realize a perfect anatomical cure. He was satisfied from his study of the anatomical conditions present in nearly thirty cases, upon which he had operated by open incision, that an anatomical cure was mechanically impossible by any purely manipulative method, except in a very small proportion of cases; and strongly urged that it was much better practice for the surgeon to open the joint, remove the mechanical obstructions to reduction, and thus work with certainty and precision.

Few operators on this continent have yet had sufficiently extended experience to reach final, independent conclusions. Without extending the scope of this paper so as to review the available evidence in detail I shall simply formulate a number of conclusions which I believe correctly represent the general trend of the most reliable professional opinion in regard to this important subject:

1. A certain proportion of cases of congenital dislocation of the hip are intrinsically incurable, owing to anatomical obstacles which are hopelessly beyond the surgeon's control. The acetabulum may be too shallow to retain the head in position; the head and neck of the femur may be so imperfect or deformed as to be quite unsuited for articulation; or there may be such contraction of the soft tissues as to form an insurmountable obstacle to reduction. The X-ray is of great value in many cases in determining the actual anatomical conditions.

2. Subcutaneous or open division of tendinous, muscular and ligamentous tissues which obstinately oppose reduction may be resorted to with benefit in certain cases when reduction by manipulation alone is impracticable.

3. In about ten per cent. of the cases treated by the Lorenz bloodless method, a perfect anatomical and physiological cure will be obtained.

4. In some of the cases of apparently perfect cure, redislocation may occur, even several months later. A repetition of the operation will be followed by ultimate success in some of these relapsed cases.

5. In probably sixty per cent. of the cases treated by the Lorenz method a true anatomical replacement is not secured, but an anterior transposition of the head of the femur is brought about. In a considerable proportion of these cases the condition. of the patient is greatly improved, the shortening being diminished, the limp lessened, and the characteristic deformity largely or completely obliterated. In a word, there is a large and distinct functional gain.

6. The ideal age for operation is from three to five years. Under three years of age replacement is easy but the difficulty of

keeping the plaster dressings from becoming very foul is almost insuperable. After five years reduction is often very difficult, but success may sometimes be attained up to the age of thirteen years, and even beyond. Within reasonable limits the age of the patient per se has less to do with success or failure than the anatomical conditions in and about the joint in the individual case. One may fail in a patient of seven years and succeed in another of ten or twelve.

7. The operation usually is perfectly safe. Accidents have occurred, however, both in the hands of Lorenz and other surgeons. The possible accidents are thus summed up by Ridlon: Paralysis from over-stretching; fracture of the neck of the femur; fracture of the shaft of the femur; fracture of the ramus of the pubes; fracture of the ischium; tearing of the perineum; rupture of the femoral artery; gangrene from cutting off the circulation through stretching the femoral vessels. He somewhat facetiously adds: "There may be others, but these are sufficient for the surgeon who has experienced one or more of them."

8. The results in the cases operated upon by Lorenz himself and by his followers on this continent have on the whole proved disappointing.

9. Open methods of operation, which permit some of the obstacles to reduction to be discovered and removed, and which afford the surgeon the opportunity to satisfy himself that his manipulations have really placed the head of the femur in the acetabulum, are likely to be largely adopted in the future, the bloodless method being reserved for very young patients, and cases where objections to the use of the knife cannot be overcome.

12 East Bloor Street, Toronto.

THE DIAGNOSIS OF MODIFIED SMALLPOX (SO-CALLED).*

BY CHARLES A. HODGETTS, M.D., L.R.C.P. (LOND.),

Secretary of the Provincial Board of Health of Ontario; member of the Sanitary Institute of Great Britain.

THE term "modified smallpox" given in the title is somewhat misleading, for heretofore the word "modified" has been reserved for cases of smallpox occurring in vaccinated persons only; it has, in short, been considered a synonym of varioloid. The continuance of variola in a mild form for the past five years has led to the application of the term "modified" to all cases where the course has been considered in any way atypical. By the setting up as a clinical standard a certain chain of symptoms, which has for many decades been considered diagnostic of variola, there has become engrained into medical practitioners the idea that these are the only symptoms which could be found in a case warranting the diagnosis "smallpox."

The infallibility of this doctrine has, like many other of the "sure things" of this world, been proved to be fallacious. Like others of the group exanthemata, we know, as indeed have all writers of authority upon the subject, that smallpox is capable of every degree of modification, from the initial stage through each successive stage, until that of complete recovery is reached.

That this long continuance of smallpox in so mild a form is perhaps unprecedented, is true, certainly, as far as modern medical history is concerned; but a careful study of the writings of those who have discussed the subject at any length, cannot fail to convince one that in outbreaks where the mortality was high, atypical (mild cases) were always to be seen. Most cases were severe, and so the description recorded corresponded with the type. In like manner one writing now would describe in detail the progress and symptoms of the type of case as observed, incidentally referring to the severe or very mild ones as atypical of this epidemic.

Again the modified cases have for the past one hundred years been considered as those upon which vaccination has had a controlling influence, and at this date to apply the term "modified " to a large series of cases upon which the beneficial effects of vaccination cannot claim to have exercised any modifying influence, is most misleading.

It is, therefore, preferable to consider all cases which occur in the unvaccinated as smallpox, no matter of what type, reserving the terms "varioloid" and "modified smallpox " for

Read before the Ontario Medical Association (by request), June 15th, 1904.

those cases happening in persons who have derived any immunity from a successful vaccination or re-vaccination, or previous attack of smallpox. The possibility of an inherited immunity derived from vaccination in a line of ancestors as being a factor in the cause of the mild type characterizing the recent epidemic, is not substantiated by observations extending over the whole period of its presence.

For the past five years perhaps no subject has called forth more discussion than that of smallpox, chiefly from the fact that the mild type, which characterized the first cases of the disease, has been almost constant throughout that period. True it is that individual instances have not been wanting where all the virulent symptoms have been present, but these typical cases have been like oases in the desert, and their appearance has cheered the heart of many an anxious medical health officer, whose diagnosis had at last been confirmed, his hope being often realized that virulence would be followed by public alarm, which would result in precautionary measures being taken with more alacrity.

Before considering the differential diagnosis, the presentation of a brief review of the symptoms which have characterized the disease as it has occurred in Ontario, is desirable.

History. Some five years ago the first cases appeared in Essex County, and in the following year the disease became widely scattered in the lumber camps of Northern Ontario before its presence was known. In both instances it came from. the State of Michigan. At first considerable difference existed as to the diagnosis. By some it was considered to be chickenpox; while others were as confirmed in their opinion that it was impetigo contagiosa; and a number expressed the opinion that it was some new cutaneous disease without a name; and for a time, at least, the opinion was expressed that it was of a syphilitic character.

This latter opinion was, no doubt, due to the fact that male adults seemed to be the chief persons attacked, but soon it became apparent that it was not limited either by age, race or sex; and, although it spread somewhat insidiously, yet those unvaccinated became its victims when brought into contact with it. Usually it required more than a passing exposure, but frequently cases occurred where the contact was but slight. When it occurred in schools, unchecked, it was particularly interesting to observe that a period of several weeks would elapse between the appearance of the first case and the general outbreak, the first cases being those occupying seats contiguous to the initial one, it being clearly evident that the infection was of a mild character. A very noticeable feature, and one that was emphasized as the cases. became more numerous, was the immunity of those who had been