with the acetabulum, so as to secure ankylosis in a greatly improved position.

Had the plan been adopted, which has been so strongly advocated by some writers, in order to secure ankylosis, of using the plaster spica, so as to maintain the relationship between the femur and the pelvis, this changed relationship between the femur and the acetabulum could not have been effected.

Loss of bone from disease and tilting upward of the pelvis on the affected side are not the only causes why the affected limb is made practically shorter than its fellow. During the course of disease in growing children, likely to be prolonged for several years, there is a marked lack of proportionate growth in the affected limb, so that this becomes another important factor to be reckoned with, and is a cause why the cure should be hastened as much as possible. In some cases where the actual shortening, through the loss of bone and lack of growth, has amounted to as much as two inches, it has been found, upon recovery, that no cork was necessary under the foot of that side, because the pelvis had been tilted downward on the side of the affected limb to an extent varying from one to two inches. In this way the actual shortening may be largely or entirely made up, and either a smaller amount of cork than otherwise required will prove sufficient, or in many cases the patient prefers to avoid it altogether.

If the principles of treatment here laid down, however, be consistently followed out, it will be found in most cases that shortening will be much less in extent than the amount just referred to because the period of treatment will be much shorter, and there need not be deformity through the riding upward of the femur in its relation to the pelvis.

There is one form of treatment which has been employed for many years, but which has been spoken strongly against in certain quarters, and which may be considered both local and constitutional, viz., injection of iodoform. Suspended in glycerine, it has proven a valuable aid. For twenty years this method of treatment has been employed by the writer, who has come to have the greatest confidence in its efficacy as a remedial measure. One may not be able to explain fully the method of action, nor is that essential, if the clinical evidence is clear as to its efficacy. It does not require a large stretch of the imagination, however, to hold that the nascent iodine which is set free from the iodoform should prove effectively a bactericidal agent.

In cases where, through neglect or from other causes, there is a very great amount of infiltration and tenderness at the hip joint, it is seldom found necessary to use any measures other than those just outlined. Under the very satisfactory rest which may be obtained, the tenderness and infiltration soon passes away. Some

times, however, a carefully applied plaster spica, extending from the toes to the crest of the ilia, and retained for a few weeks, while recumbency also is maintained, will be found a useful help.

The treatment by recumbency and sun exposure should be continued throughout the acute stage of the disease, until there is very positive evidence that cicatrization has well taken place. In nearly all cases the period that should thus elapse will amount to several months, and possibly it may extend into years, though, from the writer's experience, a longer time has never been required. Where doubt exists as to the condition of the tissues that will have to bear the body's weight, it is better to err upon the side of continuing the recumbency for a longer period of time. When deemed proper, however, to make the change, an effective brace should be employed, which will prove both a crutch to carry the body weight and an extending force to maintain traction upon the affected limb. The brace necessary for this purpose is exceedingly simple. It consists of a firm steel band, padded, which passes around the pelvis just above the level of the great trochanter, and a leg bar, secured without a joint to the pelvic band referred to, passes down the outer side of the leg to the bottom of the foot, and has a bolt which passes through a tube firmly inserted in the heel of the boot. Two perineal straps, passing from front to rear of the pelvic band referred to, afford counter-extension. In the application of this brace the pelvic band, passing under the perineum of the sound side, is kept tighter than the other one, in order to afford counter-extension upon the sound side, while the bolt in the heel of the boot makes extension of the affected limb. In this manner, a brace so simple will effectually prevent recurrence of adduction. When in bed at night the brace may be left off, and the Bradford frame, with extension, may be employed as it was used in the treatment of the acute stage of the disease.

The following is a brief statistical statement of cases referred to above as coming under observation since 1898:

The total number traced, 166.

The number of deaths were 8, as follows:

1. G. M. A man of about thirty years of age, who had an inoperable tumor in his neck, of which he died. The condition of the hip was improving.

2. M. M. C. A girl eight years old, died from asthenia, as a direct result of the disease.

3. S. S. A man twenty-five years of age; died of tubercular meningitis; hip at the time of death not improving.

4. R. P. A boy eighteen years of age, double hip disease. Died of asthenia and extensive suppuration.

5. C. S. A child, died of diphtheria.

6. W. L. A man twenty years of age; had had hip disease when a child; died of pulmonary tuberculosis.

7. F. D. H. A man thirty years of age; died of pulmonary phthisis.

8. A. Mac. A man thirty-six years of age; died of pulmonary phthisis.

From the foregoing it will be observed that the death rate due directly to hip disease is exceedingly small.

In two patients amputation was made at the hip joint. These were boys of about ten and twelve years of age. Extensive suppuration had continued for quite a long time, and recovery without amputation was deemed improbable. Both cases responded quickly and have made good recoveries.

What may be called fairly a first-class recovery has occurred in fifty-six of the patients. Such a term may be considered some-what indefinite. A small proportion of these have good motion at the hip joint, have practically no shortening and do not wear any cork boot. One and all of these are actively engaged in the various concerns of life and find themselves but little hampered. Some others of this number have complete ankylosis at the hip joint in a good position. A favorable position in such instances is one where there is about fifteen degrees of flexion and some amount of abduction. Real.shortening is nearly always present in these cases, but the abduction so compensates for the actual shortening as to permit many of them to go about without the use of a cork boot. Some few others find it necessary to wear a patten under the boot. In this way I have tried to define what I mean by first-class recovery.

Only seven would be classed as making a really poor recovery. Some of these have a femur that is movable upon the pelvis, so that a support worn constantly is necessary. Others have continued for a long time to have sinuses, or in some other ways still remain much disabled.

The remainder have made recoveries which enable them to engage to a greater or lesser extent in the varied activities of life, being somewhat hampered, however.

Still under treatment, of the number referred to, are eighteen. On the average, these have a better prospect than those who came under treatment at an earlier date.

In the case of those who have been treated as above the average time of confinement to the cot described has been between six and seven months. The shortest period of time was one month, employed for the purpose of correcting deformity. The average time during which they have worn the extension brace is thirteen months. One patient, after having a brace for nearly a year, had to be placed upon the cot in order to overcome the needless shortening which in his case could not "e corrected by the brace. He was kept upon the cot for three nonths, then returned to his brace,

which he used now with more care and intelligence. His recovery has been an excellent one, with nearly two inches of shortening. but with such an amount of abduction as permits him to walk very well without the use of any cork.

Briefly, the treatment may be summarized as follows:

1. Hip disease, as ordinarily spoken of, implies tuberculosis at the hip joint.

2. Constitutional treatment comprises:

(a) The suitable use of drugs.

(b) A skillfully arranged dietary, in which fats should hold a prominent place.

(c) Direct solar therapy has proved the most important agent. It should be continued throughout the whole day every day and for many months. The affected parts, and as much of the body as possible, should, in the nude state, be exposed directly to the sun's rays.

3. Local treatment comprises recumbency upon the Bradford frame, affording an opportunity to secure:

(a) Efficient rest.

(b) Traction to correct deformity, to prevent adduction and flexion, and to bring down the femur to a correct relationship with the pelvis.

4. A brace which will serve both as a crutch and as a means of preventing the recurrence of adduction and flexion, the brace to be worn until complete convalescence has resulted.

THE VALUE OF THE REFLEXES IN DIAGNOSIS.*

BY J. S. RISIEN RUSSELL, M.D., LONDON, ENG.

Mr. President, Ladies and Gentlemen:-It has been my good fortune to receive many kindnesses from our profession, and it has been my privilege to address distinguished audiences. Fully as I appreciate the honors I have enjoyed, and grateful as I am of the consideration that has been extended to me in the past, I feel that the honor your Council has done me far exceeds anything that I have hitherto experienced.

I can imagine no greater compliment than to be entrusted with the delivery of the Address in Medicine at so important a meeting. as the Canadian Medical Association is holding in Ottawa to-day, and I am confident that those who have been good enough to honor me in the past would be the first to admit that the position in which your Council has now placed me is the most honored I have ever filled.

There are, Sir, some moments that cannot find adequate expression in words. My gratitude is very sincere, but I am too conscious of my inability to find a portal sufficiently wide to convey the full depth of my feelings, to make me risk the attempt that would be sure to end in failure.

No words of mine can ever thank you enough for the great honor which you have done me.

When attempting to decide upon what subject to address you it naturally occurred to me that it must be on something of neurological interest, as it was improbable that any general survey of medicine would be expected from one who had devoted so much time to a special department.

On reviewing the neurological subjects that seemed most suitable, the usual difficulty was experienced in deciding which to select. It was not without many misgivings that the value of the reflexes in diagnosis was finally chosen as likely to be the most profitable, for I am very conscious of the large amount of work of the greatest possible excellence that has been done on this side of the Atlantic. Three considerations mainly encouraged me to adhere to my decision. One was that the same objection could be urged in regard to any subject I might choose. Another was that so much work has been done on the reflexes during recent years, and so much that is contradictory has been written about them, that there is a danger that the profession may become skeptical as to their value. The third consideration that influenced me was that *A'd ess in Medicine at the me ting of the Canadian Medical Association, Ottawa June, 1908.