other affairs, as to his children, &c. About twenty-four hours after he had another attack of convulsions, but his brother forbade a repetition of the bleeding, and he died.

Case IX.-A similar case, with recovery.

A woman, aged forty-five, similarly affected, only with great anasarca, was bled to twelve ounces by me, in 1867, and is alive now, and in fair health, although of course her damaged kidneys remain to her.

Cases X & XI.-Puerperal convulsions. Bleeding. Recovery.

I could mention some sixteen or eighteen cases in which I saw this treatment adopted by the late Dr. Ramsbotham with complete success, but I will note only two, in which I myself used it. One was a stout primipara, aged nineteen, and the convulsions were I believe, uræmic, and did not cease with the birth of the child. Bleeding to twenty ounces: recovery. The other a pluripara, aged forty-two, convulsions also of renal origin, I believe.

to sixteen ounces: recovery.

Bleeding

ON CROUP AND DIPHTHERIA.

BY ROBERT HUNTER SEMPLE, M.D., M.R.C.P. LOND., PHYSICIAN TO THE HOSPITAL FOR DISEASES OF THE THROAT.

THE word " Croup," as applied in a medical sense, is very vague, but is employed by the public to express any kind of cough attended with stridulous inspiration. It is not to be found in Johnson's Dictionary as indicating a form of disease, and the only information we have as to its etymology is that it was employed as a provincial term, in the last century, in some parts of Scotland, to indicate the cough just referred to. It was adopted, however, by some Scotch physicians as a medical term, and the disease it represented was first distinctly described, as will be presently shown, by Dr. Francis Home, of Edinburgh. Since his time the word has become acclimatized in our language, and has been used also on the Continent and in America; and the French writers, in particular, have adopted it as being synonymous with that form of Diphtheria which attacks the larynx and trachea. This view, after much consideration, I have been induced also to adopt, and the reasons for my doing so I shall endeavour to develope in the present paper.

The word Croup really means nothing, and conveys no definite idea to the mind, but the word Diphtherite, or Diphtheria, being derived from the Greek Aplepa, a skin, at once presents an image which may be seized by the understanding. The difference in the terminations, diphtherite and diphtheria, is caused by the doubt as to the inflammatory or non-inflammatory nature of the affection, and as the preponderance of evidence shows that the disease is not really inflammatory, the latter name is now almost universally employed in this country.

In the early half of the present century the word Croup was used, by British medical writers, to indicate what I consider to be several different diseases: namely, one which is purely spasmodic, another

which is characterized by the presence of a false membrane, and a third which is distinctly inflammatory, but which presents no false membrane. While this confused notion of what was called croup prevailed in this country, the throat affections of a similar nature occurring in some parts of France attracted the attention of French practitioners, and were at first either confounded with one another or were made the subject of false pathological analogies. But in process of time Bretonneau and his followers discovered that his diphtherite of the trachea was the croup of Francis Home, and the claim of diphtherite to the title of a new disease was disavowed.

I have a full recollection of the impression made upon the medical profession in this country by the news of the arrival of a throat epidemic in 1857, and I can assert that the general feeling at first was one of disbelief in the existence of any such disease as that which was described. While admitting that several persons had died of some throat affection in a very rapid manner, most practitioners regarded the disease as nothing more than either an exaggerated form of sore-throat, or a peculiar and abnormal development of scarlatina. It was not considered as croup, for croup was said to be a disease of infancy and childhood, whereas the disease in question attacked all ages indiscriminately.

But the French practitioners at once recognized the unwelcome visitor as the disease which had often been observed in various parts of France, and had been especially described by Bretonneau, under the name of Diphtherite. The history of the malady, how

ever, did not extend, even in France, to a very remote antiquity, for the first recorded epidemic occurred at Tours, from the years 1818 to 1821, and Bretonneau's first memoirs on the subject were published in the year 1826. The pupils and friends of Bretonneau, among whom was Trousseau, and a few English physicians, including the late Dr. Conolly, who happened to visit Tours at the time of the epidemic, were well acquainted with its features; and a few systematic writers on the Practice of Medicine in England, among whom was the late Dr. Copland, were also well acquainted with the literature of the subject, although none of them described the disease as a special malady. Dr. Copland, in fact, does not describe diphthérite under a separate heading, but all his information upon its features as defined by Bretonneau is included in his article on Croup.

Now this article, "Croup," in Dr. Copland's Dictionary, most

clearly and indisputably describes two different diseases, which, although they are both very often fatal, and both affect the larynx, have no pathological relation to one another. One of these diseases is the affection now known as laryngismus stridulus, and which, in point of fact, is not a special disease at all, but a spasmodic malady due to causes remote from the actual structures involved, and affording an instance of reflex nervous action. That Dr. Copland really included this affection under the head of " Croup," there can be no doubt whatever, for he defines it as croup with predominance of spasmodic and nervous symptoms," and he gives as its synonyms "the larygismus stridulus of Good; the spasmodic croup of Wichmann, Michaelis, Double, &c.; and the acute asthma of infants of Simpson and Miller; and he goes on to describe it as a purely nervous affection, unattended with any marked premonitory symptoms or with fever.

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It is clear, therefore, that laryngismus stridulus, although it is sometimes called popularly false croup, has no relationship whatever with croup, in which there is evidence of distinct structural changes. But having thus eliminated laryngismus stridulus from croup, I contend that Dr. Copland and other writers have confounded two other diseases under the same head as croup, namely, tracheal diphtheria, and laryngitis stridulosa. Tracheal diphtheria, as at present known to medical practitioners, is distinctly and characteristically marked by the exudation of a false membrane upon the larynx and the trachea; laryngitis stridulosa is distinguished from tracheal diphtheria by the absence of false membrane. Tracheal diphtheria is a disease in which the symptoms of inflammation are, to say the least, very obscure; laryngitis stridulosa is a distinctly inflammatory affection.

I am fully aware that many modern English writers on medicine consider croup and tracheal diphtheria as distinct diseases, and yet there is not one of them, so far as I know, who, in describing the pathology of the one, does not, while denying the identity, include in it the pathology of the other. Dr. Copland, for instance, in his very able article on Croup, in the Dictionary, says, under the head "Pathology of Croup," that in the complicated cases, and in those of an apparently epidemic and infectious nature, the throat is equally affected, constituting the diphthérite, or the inflammation pelliculaire of M. Bretonneau; and in the bibliography and references at the end of the article he adduces the writings of Bretonneau, Trousseau, Guersant, and Bricheteau,

as authorities on croup, although every one of those authors regards croup only as a form of diphtherite.

The French writers are, in fact, and long have been, almost unanimous in considering that croup, as distinguished by British authors, is a form of diphtheria, and, according to them, "croup" is synonymous with tracheal and laryngeal diphtheria.

I think it is necessary, in the first place, to determine, if possible, what is meant by Croup, as the term is used by British authors. The first account of croup in the English language occurs in a letter written by Dr. Blair, of Cupar Angus, to Dr. Mead, of London, in 1713; but a distinct description of the disease is contained in An Inquiry into the Nature, Cause, and Cure of Croup, by Dr. Francis Home, published in Edinburgh in 1765. This treatise is a small one, but it contains a great amount of valuable information on the malady in question. The author, while wondering that the disease had not been described before his time, accounts for the fact by the local nature of its outbreaks, the infrequency of its attacks, its prevalence among children who are unable to give an account of their complaints, and the rapidity of its course and the apparent easiness, as the author terms it, of the symptoms. Croup, he says, happened, or at least was observed, very seldom in Edinburgh, but he himself, by putting his mind in the way of intelligence, had an opportunity of attending several cases, especially upon the coast of Scotland. He was struck by the danger of the symptoms, under apparent ease; by which expression Dr. Home evidently means that the indications presented were not apparently of an alarming nature; and the singularity of the postmortem conditions excited his curiosity. He laments his inability to point out a certain cure, and he excuses his shortcomings as to the description of the entire features of the malady on the pleas of the rarity of its occurrence, and of his own previous inexperience of its visitations. He thought that the croup was local in its attacks, and that it was seldom found at any great distance from the sea-shore. Notwithstanding Dr. Home's reputation as a physician, and his evident anxiety to collect together the history of all the cases possible, he gives only twelve instances of the disease, and of these the first three are rather doubtful as really being cases of croup, and the last four were communicated to him by brother practitioners. The circumstances just alluded to seem to confirm the opinion that the disease was comparatively rare. But the five fatal cases attended by Dr. Home himself leave no doubt as to the