of those who were suspected of having typhoid and doubtful fever cases.

My list of thirty-six cases, compiled with the assistance of Dr. Rowley of the house staff of the hospital, includes hospital cases, those referred to me by other physicians, and cases in my own private practice, from the middle of August to the first day of October. Cases as a rule

do not come into the hospital until the second week and in the other cases it was not possible for me to examine the blood as a rule before the tenth day. In one case the reaction was present in the first week and before the sure diagnosis had been made from the clinical evidence. This case, in a child, terminated fatally from hemorrhage.

Of the thirty-six cases, twenty-eight were typhoid beyond any doubt, and twenty-five of them gave a positive reaction. The others were malaria, pleurisy, phthisis and one of multiple abscess of the liver, which were negative as regards the reaction. In the case of abscess of the liver the blood was examined five times with negative result, except once the bacilli were motionless but did not form into groups at all. For a long time it was considered a sure case of typhoid, but the autopsy confirmed the reliability of the test.

Some of the cases were very interesting from the fact that they occurred in families. One member would sicken and have all the clinical symptoms of typhoid, including the serum reaction. Another would soon be taken sick and we were sure typhoid was present, but for several days the reaction was positively negative. On the other hand, one mother died of typhoid. Her child was brought in with a high fever, delirium, sordes on tongue, everybody said typhoid. Reaction was absolutely negative and the next day the temperature was normal. Quinine relieved every symptom.

In only a few of our cases did the grouping take place

instantly, but we had to wait some time before we were satisfied.

None of our cases gave the true reaction except the typhoid. Two cases reacted in a measure. In both the bacilli became entirely stationary, but did not form into groups even after waiting an hour. These two cases were of doubtful character, but have proved clinically not to have been typhoid fever. One of these cases, multiple abscess of the liver, has been referred to previously.

The blood from two typhoid cases, although examined twice failed to react. One of the patients died the day following the last examination.

There is considerable personal equation in reports on this subject and that is why reports vary so much. It cannot be disputed that a certain number of cases not typhoid will give an absolutely typical reaction. One observer says three per cent. of all cases not typhoid will give a typical reaction. It has been observed in certain cases of valvular disease of the heart and in pneumonia.

Dr. Park of the New York Health-Board claims that if the serum is diluted one-twentieth with water, typhoid fever alone will produce the reaction but if no such dilution is used, various diseases will give it at times.

VALUE OF THE TEST.

As ninety per cent. of typhoid cases in one thousand give a positive reaction, it stands to reason that a positive reaction is fairly conclusive that the case is typhoid if we get a typical reaction. If, however, the serum does not react we must not declare that the disease is not typhoid, for the reaction may be delayed. We must use the test as an accessory to the other means at hand for determining the true nature of the disease. We must not reject the test because it is not absolutely perfect, for the most skeptical observer must confess that it is present in the great majority of cases of typhoid.

Nobody was more skeptical than myself when I first began the work, but the more I use the test the more I am convinced that it is of decided value. But it would be utter folly to say that a case that did not react was not a true case of typhoid, especially if all the usual clinical symptoms were present. Let us, then, estimate the test at its true value and not condemn it utterly because it is not perfect.

USE OF DIPHTHERIA ANTITOXIN.

COUNTY REPORT.

OLIVER C. SMITH, M.D.,

HARTFORD.

In submitting to you a report on the use of diphtheria antitoxin in this County, I should perhaps apologize for bringing to your notice a subject upon which most of you are so well agreed. It is a fact, however, that antitoxin still has some opponents. The secular press has occasionally noted deaths due to its use, it is still attacked by some writers in the medical journals, and at times we are hampered in our work by the reluctance of the patient at having the remedy employed. It is my hope that the statistics compiled from the reports of the members of this Society will establish the value of the antitoxin treatment of diphtheria beyond the possibility of doubt.

Fifty-six physicians have replied to the circular letter, twenty-eight of whom have not used the serum; twentyeght report having used it in a total of four hundred and three cases, including twelve cases kindly given us by the Hartford City Hospital. The Klebs-Loeffler bacilli were found in two hundred and sixty of these cases, in one hundred and seventeen of the cases no cultures were made; one hundred and sixty-nine were laryngeal or croup cases of these one hundred and seven recovered, a percentage of 60.3; of the two hundred and thirty-four non-laryngeal cases, one hundred and ninety recovered, a percentage of eighty-one. Results were observed in nearly all cases, in from two to twenty-four hours. The majority favored repeating the injection in from twelve to twenty-four hours, unless a marked improvement had

taken place. Three only observed urticaria, in a small percentage of cases; no other unfavorable results were reported. Six have reported using antitoxin for immunizing purposes; ninety per cent. of those treated escaped the disease after having been exposed.

The report of the Nursery and Child's Hospital in New York is interesting in this connection. "In the three weeks preceding April, 1895, there were fifteen cases of diphtheria. Upon that day one hundred and thirtysix children, varying in age from three weeks to four years, were immunized by receiving from fifty to one hundred units each. The children showed no bad effects from the injections. The temporary rise in temperature occurred in one-quarter of them, which lasted from six to twelve hours. From the day of the injections to the present time, no diphtheria has developed in the Hospital, with two very interesting exceptions, the physician and a nurse who had not been immunized; since then the Hospital has been free from diphtheria."

The majority favor the antitoxin made by the New York Health-Board, or Mulford. From two hundred to one thousand units have been given for immunization, and one thousand five hundred to two thousand five hundred in treating the disease. Two are in favor of tracheotomy where an operation is required, and sixteen are in favor of intubation.

We find by comparison of these statistics with those gathered by Dr. Guerard from Berlin, Paris and New York, that our statistics are not unlike those from all parts of the world. In 1893 in Berlin the 'death-rate per one hundred thousand of population was 100.8; in 1896 it was reduced to 30.9. In Paris in 1893, 51.4; in 1896, 17.5. In New York in 1893, 145.5; in 1896, 91.3. The mean death-rate from diphtheria in the three cities in 1893 was 99.2; in 1896, 46.5, or a reduction of over fifty per cent.