AN
INAUGURAL DISSERTATION
ON THE
Suffocatio Stridula, or Croup,
WHICH, UNDER THE DIRECTION OF THE
Reverend JOHN EWING, D. D.
PROVOST OF THE UNIVERSITY OF PENNSYLVANIA;
BY THE AUTHORITY OF THE
HONOURABLE BOARD OF TRUSTEES,
AND WITH THE APROBATION OF THE
RESPECTABLE FACULTY;
IS SUBMITTED TO THEIR SUPERIOR JUDGMENTS, AND TO THE
CANDID EXAMINATION OF THE LEARNED,
FOR A
DEGREE OF DOCTOR OF MEDICINE.
BY ROBERT G. W. DAVIDSON, A. M. OF PHILADELPHIA
Honorary Member of the Philadelphia Medical Society,
19th MAY, 1794.
Nic Via Martis simplex-
Nec proli medicas adhibere manus abneget parens,
Aut sedeat posoens meliora deos. VIRGIL.
PHILADELPHIA:
PRINTED BY WRIGLEY & BERRIMAN, No. 149, Chesnut street,
M,DCC,XCIV.



TO
ADAM KUHN, M. D.
PROFESSOR OF THE PRACTICE OF PHYSIC
IN THE
UNIVERSITY OF PENNSYLVANIA,
THIS DISSERTATION
IS INSCRIBED,
AS A SMALL MARK OF
RESPECT and AFFECTION
FOR THE 
MANY BENEFITS RECEIVED FROM HIS INSTRUCTIONS,
DURING THE STUDIES
OF HIS
FRIEND and PUPIL,
THE AUTHOR.
19th May, 1794.



A
DISSERTATION, &c.
AMONGST the disorders to which the human race are lia-
ble, there are few that require the attention of the medical
world more than the subject of this dissertation. And, although
it be a disease which is not so commonly under the notice of the
Practitioner, yet it frequently occurs, and is then so deceitful in
its approach, so quick and terrifying in its progress, and so very
fatal in its termination, that it generally proves fatal before there
is any suspicion of its nature or danger ; and is usually so far ad-
vanced when discovered, as to be beyond the reach of medical as-
sistance.
Of late years, Physicians have paid particular attention to this
subject, but they differ widely with respect to its nature and treat-
ment. I have, with diffidence, undertaken this subject, not with
an expectation of offering any thing new, or making proselytes to
the opinions that have been advanced respecting it ; but rather
with a desire of being useful, which I hope will fully compensate
for the want of novelty.
Impressed with these sentiments, I have chosen a disease, upon
which there are few accurate observations to be read, and con-
cerning the nature of which, and its treatment, Physicians every
where materially differ. I also hope, that by giving the generally
received opinion of the Physicians in this place, and also the me-
thod of cure which is at present adopted by them, it will not
be unworthy the perusal of the American reader : And, as it is
absolutely necessary that a Thesis, on some medical subject, should
be written by the Candidate for a degree in medicine in this Uni-
versity ; these considerations taken together, but especially the
last, will, I hope, sufficiently excuse my coming forward thus
publicly, as an author, and, I presume, dispose the candid reader
to overlook the many imperfections of this juvenile performance.
B

6
DIFINITION OF THE DISEASE.
THE SUFFOCATIO STRIDULA, the disease which is the subject
of the present Thesis, may be defined, to consist in a difficult re-
spiration, and peculiar shrill noise in inspiration, without any ap-
pearance of inflammation or swelling in the fauces, and with a
perfectly natural and easy deglutition.
Many, and very different have been the names assigned to this
disease, by the different writers who have treated of it, and by
the people in general in different parts of the world. Most of the
writers have given it that name which they thought most express-
ive of their ideas, or that would comprise in it the most characte-
ristic signs of the disease. Doctor Cullen, who considers it as an
inflammatory affection of the trachea, calls it the CYNANCHE
TRACHEALIS ; by others it is called the ANGINA SUFFOCATORIA
and CYNANCHE STRIDULA, including in these names, not only
the idea they held of the nature of the disease, but likewise some
symptoms, which they supposed highly characteristic of its effects.
Doctor Michaelis, from the idea which he entertains of the disease
being a true polypous concretion in the trachea, has given it the
name of ANGINA POLYPOSA. Other writers on this subject have
described it under other names. We have adopted the name giv-
en to it by Dr. Home, as being more expressive of its characteris-
tic symptoms, and not immediately supporting any theory. Per-
haps it would be more proper to call it the SUFFOCATIO TRACHE-
ALIS - by this name we distinguish its seat particularly, and we
omit the expression STRIDULA, which is not constant through the
disease, for as we shall say hereafter the voice is sometimes entirely
lost. The propriety or impropriety of these different names will
appear hereafter, when we consider the different theories of Phy-
sicians.
In Scotland it is commonly known by the names of the Croup,
CHOCK or STUFFING ; and in this city it is called the HIVES.
HISTORY OF THE DISEASE.
IT has been generally supposed that this disease was unknown
among the ancients. Dr. Home observes, that "there is little
to be learned from enquiry, and still less from books." It is true,
that before he favoured the world with his most excellent treatise
on this disease, and his dissections of those who had died of it,
Physicians were ignorant of its nature ; but that the disease was
till then unknown, seems very improbable. Many circumstances
in early times prevented its discovery. The age of the patient,
from whom little could be learned—the slow and unalarming ap-
proach of the disease, from which circumstance the Physician was
seldom called to visit the patient till it was too late ; and, above
all, the great aversion that people had to dissections, which alone

could have unfolded the nature of the disorder, were insurmounta-
ble difficulties. However, of late years, parents have been appris-
ed of the danger of neglecting the complaints of children, and
have applied to the Physician much sooner.
Their willingness also to submit to the opening of dead bodies,
which shews their progress from the superstitious notions of the
ancients to a more enlightened æra, have furnished opportunities
to the modern Physician for obtaining that knowledge of the dis-
ease by dissections, which was much wanted, and which it is hop-
ed will one day put a stop to its dreadful ravages by eftablishing a
sure and certain method of cure.
In support of the opinion I have advanced, I beg leave to quote
two or three passages from the ancients. Hippocrates in his A-
phorisms, speaking of the diseases of the throat and fauces, has the
following words ; "Ex anginis, gravissimae sunt, et celerrime interimunt,
quæ neque in faucibus, neque in cervice quidquam con-
spicuum faciunt." Galen in his commentary on the Aphorisms of
Hippocrates, where he is speaking of the Asthma, as a disease
particularly incident to children, has an observation so applicable
to the Suffocatio Stridula, that I am induced to believe he must
have confounded the two together. His words are, "Jam vero
sit ob angustiam eorum quæ sunt in pulmone ventriculorum. Hæc
vero angustia sit, repleto viscere ab iis quæ desuper veniunt defluxionbus.
Nam et ex utero ad aerem ambientem transitus, & alimenti muta-
tio eos omnes imbecilles reddit, si ad hæc etiam fluxiones ad pulmo-
nem accesserint nequaquam sustinêre possint."
That the Suffocatio Stridula has been often confounded with
the Asthma Infantum, will not appear strange, when it is observed,
that Dr. Millar expressly says, that the disease described by Dr.
Home is exactly like the second stage of the disease which he calls
the spasmodic Asthma of children, and therefore it is probable,
that other writers may have fallen into the same mistake.
Michaelis insists upon it, that no cases of this disease are to be
found earlier than the time of Tulpius, who, he says, has described
one case of it in a taylor, who threw up, by coughing, pieces of a
white thick smooth membrane. This case, however, is so very
short and imperfect, that it is impossible to determine upon it.
Besides, the ejecting of pieces of a membrane, cannot be said to
be a proof of the presence of the disease ; because this takes place
in other disorders of the mouth and fauces, and also in cases of a
Polypus in the Trachea*.
Michaelis dates the first-account we have of this disease from the
case mentioned by Tulpius; and then mentions several Physici-
ans who have seen and described it before Dr. Home published his
treatise. He particularly notices an Italian Physician by name
* See Medical Transactions, Vol. I. and Michaelis, page 116.

8
Ghisi, who saw the disease prevailing as an epidemic, and described
it very accurately. At Upsal, in the year 1764, a graduate, by
name Wilcke, published a dissertation, in which he gives one or two
cases of this disease, but confounds it very much with the Scarla-
tina. About the same time, a piece on the disease appeared in the
Act. N. Nat. Curios, by Dr. a Bergen; and in the year following
Dr. Home published his Enquiry*.
I have mentioned the account given by Michaelis, and traced
what could be known of it down to Dr. Home, not only to shew
how wrong some people have been in calling it a new disease ; but
also to shew, that from its being known so much earlier than was
generally thought, there is reason to suppose that no fixed period
can be assigned to Its existence.
The Suffocatio Stridula is frequently an epidemic disease. It is
peculiar to no country, and is generally met with in low wet and
marshy places ; and those near the sea, or other large bodies of
water. Dr. Crawford mentions a very particular fact, respecting
a place in which it prevailed. He says it was very common in a
wide plain, called the Carse of Gowrie, which is stretched along the
river Tay, in Scotland. This plain has lately been dried up, since
which time the disease is rarely met with in that place.
It is not, however, confined to these places, for Dr's. Cullen
and Rosen von Rosenstein mention its appearing in midland coun-
tries, and those far distant from the sea. It appears, generally, in
Autumn, especially if the weather be moist, in the Spring, Sum-
mer and Winter, only when the weather is damp.
Dr. Rosen von Rosenstein is the only writer who considers this
disease as contagious. Of this, however, he can produce but a solitary
instance, and, as he has evidently confounded the disease
with the ulcerous sore throat, we cannot from thence deduce its
contagious nature. Besides, there are instances of children living
codem hypocausto, with a child sick in the disease, without their being
affected by it.
Children are generally the subjects of this malady. Grown
persons are, however, sometimes attacked by it. Dr. Kuhn, in
his lectures, mentions an instance of a person upwards of 40 years
of age, being attacked with all the symptoms of the disease, and
cured by the usual remedies†.
With a few exceptions of its attacking grown persons, the dis-
ease is said to be peculiar to children from the time they leave the
breast till the twelfth year of their age, though it seldom attacks 
those above seven or eight years old. I can, for my own part, see
no reason why it should not attack at any period during infancy,
* See Michaelis de Angina Polyposa five membranacea, page 5.
† See also Ghisi, and if the case mentioned by Tulpius is to be considered as an
instance of the disorder, it will further support the truth of this observation.

79
and I entertain no doubt but that it does. Children's complaints
are not easily known, and it would be almost impossible to discover
this disease in an infant, when there is so little pain or difficulty of
swallowing, unless the symptoms were very strongly marked. If
children were able to make known their complaints at so early an
age, I have no doubt, we would meet with many cases of the dis-
ease during the first year of their existence.
Dr. Sauer, in a letter to Dr. Michaelis, giving an account of
the disease as it appeared epidemic at Wertheim, has the follow-
ing words in support of what has just been said. " Infantes pluri-
mos hoc morbo correptos vidi, qui materno adhuc alebantur lacte."
Children of a full and gross habit of body, who are of a lively
disposition, and apparently enjoy the best health, are particularly li-
able to the disease. In general, it is slow in its attack, though it
sometimes comes on suddenly. The child appears languid, droops,
and becomes drowsy and heavy, refuses to join in any of its usual
amusements, and becomes sad and peevish. There is a slight de-
gree of hoarseness, the presence of which symptom frequently
misleads parents into the opinion that the child has only caught
cold, and, on this account, they seldom apply for assistance at that
period. This is one reason why the disease proves so fatal. There
is, however, very little or no cough, and when present, it is short
and stifling, and less convulsive than the catarrhal cough, and is
attended with little or no expectoration. Deglutition is never
affected.
The child grows warmer than usual, the tongue is covered with
a white mucus, the pulse is quick and hard, and if the child is able
to express its feelings, it presently complains of a dull sensation
(seldom, if ever, of an acute pain) at the head of the trachea. The
anterior part of the neck,answering to the upper part of the trachea,
swells a little, and is painful when pressed ; but this pain is never
acute. The disease makes its appearance in this way, for the first
two or three days, gradually becoming more alarming. The face
is sometimes red and swelled, though it is more frequently over-
spread with a deadly paleness, or is of a livid colour. At times,
the patient is thirsty, and affected with sickness at stomach and
headach ; and the urine is with or without sediment. These four
last symptoms are adventitious circumstances, and by no means con-
stant attendants.
The breathing, though but little impaired in the beginning,
soon becomes more quick, difficult and laborious, seeming to
threaten instant suffocation. To prevent this, the shoulders are
raised, and the muscles of the abdomen contracted with great
force, in order to dilate the thorax. There is no apparent cause
for this difficult respiration, or the other symptoms. On looking
into the fauces, we observe nothing worthy of remark, or different
from what is natural, except, that in some cases they have appear-

10
ed somewhat shining, or covered with a tough white mucus. Join-
ed with, and accompanying this difficult, and, for the most part,
deep respiration, there is a change or total loss of the voice, at-
tended with a peculiar shrill noise on inspiration, which has been
likened to the crowing of a young cock*. It is difficult to de-
scribe it, though easily known by a person who has has once heard it.
Sometimes this noise attends each inspiration—at other times, it is
only perceived when the child cries, coughs or calls out. The
skin becomes dry, the body is costive, and the belly swelled. In
some patients, the hands and feet swell, the tonsils sometimes,
though seldom, and even then not to any high degree.
In some cases these symptoms encrease very fast, and often to
such a height, that a disease, which, a few hours before, seemed
to require no medicine, is now frequently beyond all means of re-
lief. The difficult breathing and anxiety are so great, that suffo-
cation is expected every moment. The pulse becomes quick, small
and irregular, and sometimes intermitting ; a cold sweat breaks
out upon the face and neck, and often over the whole body.
This period of the disease is frequently attended with a vomit-
ing and a violent coughing ; both of which have sometimes thrown
up a large quantity of a tough white mucus, or pieces of a hollow
membranous concretion exactly resembling the figure of the tra-
chea or bronchiæ. In consequence of this evacuation, the respi-
ration is very much relieved, all the symptoms seem to be chang-
ed for the better, and frequently, if all, or a large portion of the
membrane is ejected, the patient is relieved of all his complaints,
and regains his former health ; but the natural tone of the voice is
seldom recovered for many months†. If, however, a great part of
the tough mucus or membrane remains, or when ejected is very
soon reproduced, all the symptoms grow worse, and the patient,
who, a short time before, was thought out of danger, is suddenly
carried off in a fit of suffocation, or quietly sinks into the arms
of death.
During all this time, the child appears easy, owing, probably, to
the absence of pain ; and retains its senses and reason to the last.
It has even been supposed, that the strength of the mind is in-
creased, and that a preternatural judgment has been discovered
before death.
I should also observe, that, very often, all the symptoms sudden-
ly remit, and put on a more favorable appearance, without any
evident cause, or even the evacuation of the mucus or membrane,
* Michaelis says it resembles the noise made by a young hen more than any
thing he knows. Other writers compare it to the noise of a hen when frightened ;
and others to the barking of a dog or fox.
† I had an opportunity, not long since, of seeing a very striking instance of a
recovery of this sort, and had part of the membrane in my possession for some
days.

11
which we have just mentioned ; and which we shall say hereafter, 
has been found in the trachea, by dissection after death. When
this remission happens, the respiration is freer, and becomes in a
manner natural; and the child is able to rise out of bed and walk
about the room. These remissions, however, continue but a short
time ; the disease receives, as it were, a new spring ; the symp-
toms return with redoubled violence, and the child is suddenly 
suffocated. Others are taken off in a flower manner—the symp
toms gradually increasing, respiration becoming difficult and labo-
rious, the pulse weaker, more freqnent, intermitting and tremulous.
This last termination of the disease is rare. Other symptoms may
occasionally attend ; but then they are by no means fixed, or cer-
tain. The disease may likewise be combined with other disor-
ders, particularly a catarrh, when the symptoms of each will be
blended together.
There is no fixed time for the disease to finish its course, whe-
ther the patient dies or is cured - many have died on the third or
fourth day, and not a few on the second. The succeeding days
however, are by no means without danger. An instance is men-
tioned by Hallenius, of its proving fatal on the eighteenth day.
Many are saved after the third or fourth day, and even longer pe-
riods— in adults the disease lasts much longer; and in the Act.
Nat. Curios. there is an account of a boy, twelve years of age, who
recovered, by throwing up the membrane, after the disease had
continued five weeks. A child that has once had the disease, is,
nevertheless, liable to future attacks of it.
To compleat the history of the disease, which has just been giv-
en, we shall give an acccount of what has appeared in those who
have died of the disease, on
DISSECTION.
THE external appearance of the body resembles that of per-
sons who have died of suffocation. The face is swelled and livid,
the eyes are prominent and turgid with blood, the veins of the
neck are swelled, and sometimes the anterior part of the neck is
tumid with blood. The fauces are free from every ap-
pearance of inflammation or other affection according to most au-
thors. Sometimes the glands at the root of the tongue are swell-
ed ; the mouths of their excretory ducts are much distended, and
the parts surrounding the glottis are covered with a white tough
mucus.
In the thorax the lungs were, In most cases found of an healthy
appearance and found : In some, they were tinged with a red co-
lour and turgid with a great quantity of blood.
On laying open the trachea, we discover a great quantity of a
tough white mucus, or a hollow membrane with similar qualities
putting on the appearance of the internal surface of the trachea.

12
When the membrane is found, there is always a quantity of mucus
lying between it and the trachea, which prevents it from adhering
to the inner membrane. Sometimes it has been found fixed to the
lower part of the trachea, and in attempting to take it out has
been lacerated—Ghisi says that in one instance it resisted even the
knife. Dr. Home has kept it macerating in water for many days
without dissolving it. This membrane has been found so long as to
stretch down from the top of the larynx into the small ramifications
of the bronchiæ ; sometimes it extends no farther than the bron-
chiæ ; and frequently only two or three inches from the upper
part of the trachea. In some cases, it is not thicker than writing
paper ; in others, it is so thick as nearly to stop up the wind-pipe.
The mucus is found in the trachea and bronchiæ and may be
squeezed out in great quantity from the lungs, by pressure.
The inner surface of the trachea, in general, shews no signs of in-
flammation. In most of the dissections made by the physicians
in this place, no marks of inflammation were discovered*. Dr.
Home frequently observes that "no signs of inflamation" were to
be seen.
In addition to what has just been said, I beg leave to give the
following quotation from Dr. Home. " The seat of this disease
appears to be the cavity of the wind-pipe. The place first and
most particularly affected is the upper part of the trachea about an
inch below the glottis ; for, in that part, they complain of a dull
pain ; the external swelling has been observed there ; and the mor-
bid membrane we have found stretching from that place downwards.
The back part of the trachea, where there are no cartilages, seems
from the inspection of those that die of this disease, to be its first
and principal seat, as this morbid membrane is often found there,
when it is in no other part. No wonder that the morbid appear-
ances are chiefly found there ; for there are lodged the greatest num-
ber of glands, designed for the secretion of mucus."
DIAGNOSIS.
IN the beginning of this dissertation we took notice of the fre-
quent mistakes committed by parents in supposing that the first ap-
pearance of this disease is a simple CATARRH or COLD ; physicians
unfortunately fall into the same error ; and it will be found very
difficult, in the beginning, to make a distinction. However, in the
Suffocatio Stridula, there is frequently no cough, and when it is
present, it is short and stifled ; and not so convulsive as the catarrhal.
* See Dr. Kuhn's lectures.
Dr. B. Duffield, a practitioner of eminence in physick, and lecturer on mid-
wifery, in Philadelphia, informs me, that he has made many dissections, all of
which bear testimony to the absence of inflammation. See also Sparman's trans-
lation of Rosen Von Rosenstine, on the Diseases of Children.

13
When the peculiar shrill voice, and laborious respiration take
place, the difficulty of distinguishing vanishes. Extraneous bo-
dies falling into the trachea, have produced symptoms exactly
similar to those of this disease. In such cases the pain at the head
of the trachea will be acute and not a dull sensation as in the hives.
If the pain changes its place in coughing, it will assist in forming
a diagnosis. We should enquire too, whether the child has been
in a situation to get any thing into its trachea that might stick
there and give the symptoms peculiar to this disease.
Another disorder with which this has been confounded is a spas-
modic disease of the lungs, to which children are liable and which
is totally different from the disorder under consideration. As this
has given rise to various disputes among physicians, I shall beg
leave to spend some time upon it, and endeavour to prove from
the symptoms, treatment and termination of this disease, that it
is not of a spasmodic nature.
Spasmodic disorders of the lungs come on suddenly and ge-
nerally at night; they go off quickly and are attended with considerable
remissions or intermissions, which leave the patient free from
all complaints. The suffocatio stridula or hives comes on gradual-
ly, and is two or three days before it arrives to any considerable
height. It is attended with very little remission or intermission and
even then, the patient is not entirely freed from the shrill noise,
difficult respiration, &c. until all the obstruction in the trachea is
removed. The voice suffers no change in spasmodic diseases: in
the hives it is considered as the Pathognomonic symptom. Spasmo-
dic disorders are periodical in their attacks, and are accompanied
with an evacuation of pale limpid urine : circumstances which do
not take place in the hives. In the spasmodic asthma, the pulse is
quick, small, irregular, and contracted. In the hives it is hard and
quick in the beginning, and becomes weak, feeble and Irregular
towards the close. Dr. Millar says, that the spasmodic asthma is
sometimes attended with a train of nervous symptoms ; such as in
voluntary crying and laughing, delirium, subsultus tendinum, &c.
and that a flight delirium was observed in most cases. These symp-
toms never appear in the hives.
During the paroxysm of a spasmodic constriction of the lungs,
there is no secretion of mucus, but as soon as this takes place, the
constriction is removed. In the suffocatio stridula, there is a dis-
charge of mucus from the trachea, which may be distinctly heard
rattling in it. When part of the membrane is thrown up there
can be no doubt of the nature of the disease ; as no membrane has
ever been discovered in those who died of the spasmodic asthma.
The want of irritability in the inner membrane of the trachea
seems to oppose the idea of its being owing to spasm. Bleeding,
blistering, and antispasmodics are the remedies most successful in
spasmodic diseases; but are useless, and rather hurtful in the hives.
C

14
Spasmodic disorders seldom prove fatal on the first attack ;
whereas the hives are generally so.
Michaelis has confounded this disease with a true POLYPOUS CON-
CRETION in the trachea. It is therefore necessary that we should
know how to distinguish such affections. These may be known
by their coming on very gradually, and being generally attended
with a slight cough, and sense of irritation in the trachea, many
months before they shew signs of any great obstruction to the res-
piration : or when they come on quicker, they are preceded by in
flammation of the parts, and the effusion of serum, or of blood into
the bronchiæ or air vessels of the lungs.*
REMOTE CAUSES.
These are generally divided into predisposing and exciting or
occasional ; according to which division we shall consider them.
From what has been already delivered on the history of the disease,
it appears that its predisposing causes are a certain period of life,
viz. INFANCY; a particular habit of body, namely, A GROSS AND
FULL HABIT ; and lastly, a peculiar state of the weather, such as A
WET AND MOIST ATMOSPHERE, attended with cold.
The reason why children are most liable to the hives seems to be
owing to the redundancy of fluids, with which they are furnished,
in order to supply the necessary nourishment to their growing solids;
This redundancy of humours is found in every young animal, and
is demonstrated from the gelatinous state of all their solids. Chil-
dren, moreover, are in general the subjects of several diseases, which
have a great effect in weakening the organs of respiration, and to
which grown persons are less obnoxious ; viz. measles, catarrh,
chin-cough, &c. Children of a gross full habit of body, as abound
ing more in this redundancy of humours, must be the particular
subjects of this complaint. Another reason may be, that children
are more apt to neglect, or are less able to throw up this tough
mucus, when secreted in a large quantity, than adults.
A wet and moist atmosphere produces a general relaxation of the
whole system, and is universally observed to have a great effect in
producing affections of the breast. In the present case we suppose
its effects to be particularly exerted on the organs of respiration
and adjacent parts. And that this cause conduces to the forma-
tion of the disease, appears from the time in which it is most pre-
valent, and the places where it is most commonly met with ; in
some of which it is said to be almost endemic.†
A situation near the sea is also considered as favourable to attacks
of this disease. This may act in two ways ; first, by the moisture
which is imparted to the air by the exhalations from the sea.
* Nee raro post Hæmoptyses observantur, unde eos ex sanguine conflari verosimil-
limum evadit. P. 29.
† See the fact mentioned by Dr. Crawford respecting the plain called the Carse
of Gowrie, and quoted above.

15
2dly. By the saline impregnations* which it derives from the
same source, stimulating the glands of the trachea, and causing
them to secrete a greater quantity of mucus than usual.
The occasional causes are whatever debilitates and relaxes or sti-
mulates the mouths of the glands in the trachea, and causes them to
secrete a greater quantity than usual of that mucus which is con-
stantly secreted to moisten it in health. Hence this disease is fre-
quently seen to come on after those diseases which have a tendency
to weaken those parts, e. g. measles, chin-cough, catarrh, &c.
This is also proved by analogy. A Lucorrhœa is produced from
a relaxation of the glands of the vagina, and a gleet is. the conse-
quence of a relaxation of those of the urethra. And even when
the stomach is weak or relaxed, a quantity of tough mucus is pour-
ed forth from its glands.
Another exciting cause is cold, which, by suppressing the perspi-
ration, determines the fluids to the internal parts. When this
takes place, different parts are affected by the determination ; but
why one part should be affected in preference to another we are
Unable to conjecture. In the present case, we suppose the fluids to
be determined to the glands of the trachea, in consequence of which,
a greater secretion of mucus takes place. Perhaps cold may act
by stimulating the glands, and thus produce the disease.
PROXIMATE CAUSE.
WHILE physicians were unacquainted with the appearances on
dissection, they had no idea of what was going forward in the tra-
chea ; nor could they form a just idea of the disease. But when
Dr. Home favoured the world with his very valuable dissections ;
the nature of the disease was evident, and its cause clearly discovered.
By the information we have derived from dissections and from
the history of the disease and its causes as treated of above ; we
shall endeavour to lay down a Proximate cause, which it is pre-
sumed will be perfectly satisfactory. This we suppose to consist in
a preternatural secretion of a tough, white and thick mucus from
the glands in the trachea. To this some have added the presence
of the membrane before mentioned, but this is an effect and de-
pends upon the duration of the disease. Children that have died
suddenly, and have been opened after death, shewed no appearance
of membrane, but the trachea and bronchiæ were full of mucus.
When a child is exposed to the remote causes, they produce a
preternatural secretion of that mucus, which is designed by nature
to line the trachea, and defend its tender coats from irritation ;
and if the patient is unable from age, or weakness of the parts,
to spit it up, the disease is produced. While the mucus is poured
* It is a fact generally received, that the air on the sea shore imparts an evident
saline taste to the tongue. This is accounted for, from the common salt in the
sea being swept along with the moisture and mixed with the air. See Home's
enquiry into the croup. - Page 40.

16
out from the glands, its thinner and more aqueous parts are car-
ried off partly by absorption,* and partly by the air in respiration,
and its remaining parts are formed into a thick tough membranous
substance. While these circumstances take place, the secretion is
still going on and increases the thickness of the membrane at the
same time that it prevents it from adhering to the trachea.
This account of the production of the membrane is plausible
and I expect, on examination will be found to be the true one.
But as Michaelis entertains a different idea, supposing it to be a
true polypus of the trachea† ; it will be proper to take some notice
of his opinion. The matter discharged from the trachea and
lungs by coughing or hawking, during the whole course of this
disease has all the properties of mucus. " This fluid is separated
from glandular bodies, deposited betwixt the different membranes,
which are perforated by an Infinite number of almost imperceptible
holes, that give a passage to the excretory ducts of those glands‡."
The membrane, as was before observed, is generally found at the
upper and back part of the trachea where the glands are numerous,
and no where else. The glands too at the root of the tongue and
their excretory duds have been found enlarged : all which clearly
shew, that the glands are principally affected and that the secre-
tion of mucus from them must have a great share in producing the
disease. The appearance of the membrane does not oppose this
opinion, as all writers agree, that mucus is capable by stagnation
of becoming hardened into a tough membranous or crust like ap-
perance§. Dr. Rush observes, "that were the passages of the
nose less in our reach, it is probable, that a membrane resembling
that found in the trachea would be found in it every 24 hours¶." 
Polypous concretions of the trachea are generally solid: but the
membrane in those who died of this disease was always found
tubular.
Michaelis says polypous concretions of the trachea putrify very
easily, but that mucus does not. Dr. Home says, that this pre-
ternatural membrane did not dissolve, though purposely kept for
many days, in warm water ; now this we know is one of the first
appearances of putrefaction, laying aside the probability that so
accurate an observer as Dr. Home would have taken notice of any
appearance of putrefaction had it been discovered.
If this membrane was formed, as he supposes, entirely from the
coagulable lymph, we should have stronger marks of inflammation
attending the disease - or, even granting that inflammation is an
* See Haller's physiology, vol. I. chap. vii. sec. 229.
† Mihi singulare illud respirationis impedimentum, verus asperae arteriae poly-
pus esse videtur." Page 23.
‡ Home. Page 35.
§ Haller's Physiology. Chap. VIII. sect. 190.
¶ Letter to Dr. Millar. Page 16.

17
attendant on it, why don't we meet with large quantities of pus
and a fetor of the breath, for, as Dr. Home has justly observed,
there cannot be a fitter situation for its formation ?— See also the
diagnosis.
In the last paragraph we hinted at an opinion that prevails, re-
specting the disease being of an inflammatory nature ; and, though
the contrary seems from the history of the disease, and the dissec-
tions to be clearly proved, we will trespass a little longer on the
patience of the reader, particularly as Dr. Cullen and most of the
European authors are of a different way of thinking. To consti-
tute this, an inflammatory disease, the usual phænomena of infla-
mation should present themselves. On looking into the fauces, how-
ever, there is no appearance of inflammation or other affection : The
sensation at the head of the trachea is a dull, not an acute pain ;
and the external swelling corresponding to it, is not inflamed, but
appears from a dissection made by Mr. Wardrobe and communica-
ted to Dr. Home to be rather œdematous than inflammatory. The
deglutition is not affected ; and though they consider it as an in-
flammation of the inner membrane of the larynx and trachea,
there is no cough, acute pain, very strong pulse, or feverish
symptoms : Nor is the disease followed by the usual terminations
of inflammation. In support of some of these assertions, I shall
beg leave to quote some authorities. The history of the disease,
as given by writers to which I refer the reader, will prove many of
them. Dr. Home, speaking of the opinions of physicians on this
disease, says, "Had these muscles, (viz. of the glottis) or any of
the coats of the trachea been inflamed, or mortified, as others
have thought, the pain would have been greater than it is before
the mortification, and the pulse would have been stronger than it
generally is, as the parts are membranous*." Dr. Home has been
quoted as saying, that the trachea appears inflamed on dissec-
tion, but this quotation conveys a different opinion : Besides, in
most of his dissections, he says there was no inflammation of the
trachea to be seen, nor any disorder of the lungs. And we have
the authority of Michaelis to say, that the buffy appearance of the
blood is very rarely to be met with. 
With regard to the disease being attended with fever. In addi-
tion to what was said in the history of the symptoms, we observe,
that Dr. Sauer, in his account of the disease as it prevailed at Wer-
theim, says, "Febris initio nulla." Michaelis observes, that the
disease was seldom attended with fever, and that when it was pre-
sent, at the beginning, it was so slight as to be perceived with dif-
ficulty†.
If what has been said is not alone sufficient to prove the ab-
sence of inflammation in the hives, the appearances on dissection
* Home, page 37.
† Michaelis, page 88.

18
should place the matter beyond a doubt ; In confirmation of what
was said on that subject, we will add the following authorities :
Dr. Rosen von Rosenstein takes notice of the case of one child
opened by a Professor Martin, and of three others, communicated
to him by a surgeon at Fahlun, by name Shulz; in all the four
cases the membrane was found, but there was no appearance of in-
flammation in the lungs or trachea, they being quite found. And
Dr. Kuhn, who was present at the dissection of several persons
who had died of the disease in this city, declares that he never
saw the least appearance of inflammation in the trachea*. A very
strong argument in favour of the proximate cause we have adopted
and very much against Dr. Cullen's theory of the disease is, that
upon the ejection of the mucus or membrane, the disease is remov-
ed, and the patient recovers†. This would not be the case if the
disease depended on inflammation. The method of cure which is
found to be most successful in this disease, will likewise be a means
of proving that it does not depend on inflammation.
RATIO SYMPTOMATUM.
HAVING thus endeavoured to establish a proximate cause, we
are next to see if it will account for the symptoms. The hoarse-
ness and change of the voice depend upon the presence of the mu-
cus in the trachea obstructing the glottis. As the secretion in-
creases, it becomes more obstructed, and the voice is shrill. When
the trachea is filled with mucus, and the glottis totally obstructed,
the voice is entirely lost, and the intermediate changes will depend
on the greater or less obstruction given to the passage of the air
through the glottis. In the case described by Mr. Balfour, and
communicated to Dr. Home, of a child who had died of all the
symptoms of this disease, which was occasioned by a piece of a
shell lodged in the trachea ; the shrillness of the voice was particu-
larly noticed.
The following case, in many respects similar to the foregoing,
is mentioned from its being attended with a favourable termination.
In the month of March 1785, Hartman Kuhn, the eldest son of
the Professor of that name, when between thirteen and fourteen
months old, put an English six-pence into his mouth, in the pre-
sence of his mother, who concluded he had swallowed it. Some
time after, he was frequently attacked with a wheezing and diffi-
culty of breathing exactly resembling the symptoms of the suffo-
catio stridula, but as they generally continued only a short time,
and came on when he was heated by exercise, or other causes, less
attention was paid than the immediate symptoms appeared to re
quire and it was conjectured they were occasioned by teething, as
* Dr. Kuhn's manuscript lectures.
† A case of this kind is related by Dr, Shippen.

19
he was then cutting his dentes canini. In the month of August he
was attacked with a regular intermittent fever, in the course of
which he took several antimonial emetics, some laxatives and the
Peruvian bark which removed his fever, but the wheezing and diffi-
culty of breathing continued as usual. In the month of September
he was unexpectedly attacked with a most violent fit of coughing,
which terminated in great exertions to vomit, and in one of these
violent efforts of coughing and retching at the same time, he threw
up a large quantity of mucus accompanied with some blood and
the English six-pence which he had put into his mouth upwards
of six months before, and which during that period, must have been
lodged in the upper part of the trachea. His voice was not affect-
ed with hoarseness or any alteration ; which circumstance was the
principal reason that the wheezing and difficulty of breathing did
not excite any apprehensions of immediate danger from those symp-
toms ; although at one time the child was supposed by an experi-
enced physician to labour under the croup.—The subject of the fore-
going case is now a fine hearty boy and free from every complaint.
On this case I cannot help remarking, how fortunate it was for
the child that his parents had no suspicion of the presence or situ-
ation of the piece of money ; as it is more than probable such ef-
forts would have been made for its removal as of themselves might
have proved fatal. And we may conclude, that it is very possible
a physician's ignorance of the cause of a complaint may in some
instances be the fortunate means of his patient's safety. The fa-
vourable termination of this case will, at least, point out the impro-
priety of a too quick recourse to violent measures in similar circum-
stances.
The total absence of pain is owing to the presence of mucus lin-
ing the trachea, and defending it from irritation—When the mem-
brane is present, there is always a quantity of mucus found be-
tween it and the trachea, which prevents its causing any irrita-
tion—besides, as the membrane is formed from the mucus, and
very gradually, the trachea will become used to any irritating
quality it may be supposed to possess ; and, in a short time will be
quite insensible to it. The laborious breathing is a necessary con-
sequence of the obstruction in the trachea ; and the difficult passage
of the air through it. The increased respiration and change of
colour which take place in the face, are owing to the difficult
passage of the blood through the lungs, occasioned by the same
cause, preventing the necessary quantity of air from being taken
into them.
PROGNOSIS.
THIS disease comes on with symptoms so trifling in appearance,
and so much resembling the attack of a slight cold, that it is sel-
dom discovered in time. It is also so quick in its termination,

20
that it frequently proves fatal, before we are aware of the danger.
For these reasons, it has justly been considered as a very fatal dis-
ease. The younger the patient, the greater is the danger, and
the longer the disease has continued, before assistance has been
procured, the less chance of a recovery.
Physicians have considered the disease as being divided into two
stages. The first is reckoned from the beginning of the disease, to
the formation of the membrane ; the period after this is called the
second stage ; and is considered as extremely dangerous.
If we are called to the patient in the course of the first twenty-
four hours, and find the breathing not very laborious, the anxiety
not very great, the pulse firm and hard, the face but little chang-
ed, and the voice altered only in crying, coughing or hallooing ;
we may entertain hopes of a favourable termination. On the other
hand, if we do not see the patient before the third or fourth day,
at which time the membrane is supposed to be formed ; and the
reverse of the favourable symptoms has taken place ; such as a la-
borious, difficult respiration, soft, quick and irregular pulse, the
face swelled, and of a livid or leaden colour, great restlessness and
anxiety, the voice low and scarcely to be perceived, attended with
the shrill noise which is peculiar to the disease ; the worst conse-
quences are to be expected. Desperate however as this latter case
may appear, some have recovered from it ; by a critical cough or
vomiting supervening, and ejecting the mucus or membrane.
The first signs of a favourable event are the cough becoming
stronger and moist, accompanied with the symptoms that attend
moist lungs.
METHOD of CURE.
THIS, it is plain, must be adapted to the two different stages
of the disease which we have just mentioned. Before we lay down
the Indications to be pursued in the treatment of the suffocatio
stridula we will spend a few minutes in the consideration of a re-
medy that has been and is still used in the cure of it, namely BLOOD-
LETTING. This remedy must have been recommended from the
idea generally entertained of the disease being of an inflammatory
nature, and in this intention would have been very proper; but if
the theory of the disease and the proximate cause we have endea-
voured to establish is a just one; this remedy must certainly be im-
proper and will prove injurious by the debility it induces in the
system.
In many of the cases related by authors, bleeding was used and
yet many of the patients died ; although in some cases blood was
taken away on the first day. Bleeding will always relieve the
symptoms for the present, and it is probable that this effect has in
some degree led to a freer use of it ; but the symptoms are apt to
return soon after and with greater violence than before ; and the

21
pulse instead of being hard, becomes small, quick and weak. The
pulse will sometimes sink immediately after bleeding ; we should
therefore be always on our guard in ordering it. Sometimes the
disease is combined with symptoms of catarrh or the angina in-
flammatoria, in which cases, bleeding may be of service; but even
in these, it may be omitted and give place to other evacuations,
particularly Purging.
In a plethoric habit, however, it may be proper to take away a
small quantity, to relieve the difficulty of breathing and favour
the transmission of the blood through the lungs, and so prevent a
sudden suffocation ; but that it has any effect in removing the
proximate cause or curing the disease we utterly deny.
The method of cure we will consider under the three following
Indications.
I. To prevent a too great secretion of mucus into the trachea.
2. To remove the mucus when in a very large quantity or when
it has been formed into a membrane, and
3. To guard against a return of the disease
The first indication is chiefly suited to its beginning or forming
state. To answer this indication BLEEDING, BLISTERING, DIA-
PHORETICS, PURGATIVES, &c. have been recommended. Of
BLEEDING we have already spoken. 
BLISETRS are another remedy. They should always be used in
the first stage and are to be applied round neck. By the evacu-
ation they produce, they relieve the congestion in the trachea-
they give a new determination to the flux of the humours, and by
emptying the absorbent vessels they increase their power, and there-
by cause a greater absorption of the mucus.
The STEAMS of hot water and vinegar drawn in with the breath
are highly recommended by Dr. Home in this stage ; he supposes
they act by dissolving the mucus and preventing its concretion ;
and observes that the patient always spat a great deal after it, and
that the lungs appeared moister.- Another remedy recommend-
ed with a view of evacuating the mucus lodged in the trachea, is
VOMITING.- In the beginning of the disease it is certainly hurtful ;
for besides the debilitating effect it has on the system, it determines
the fluids upwards and will encrease the secretion it was meant to
remove. Besides they seldom answer the intention for which they
are given. But, should they have the intended effect, and the
mucus be ejected, the determination of the fluids upwards and the
debility induced, will encrease the secretion of mucus nearly as
fast as it is evacuated.—From which it appears that in the beginning
of the disease they are far from being useful and can never be con-
sidered as a certain cure.
DIAPHORETICS, as they determine the fluids from the internal
parts to the superficies, are very useful; they are particularly indica-
ted in those cases where the perforation is suppressed. Dr. Brown,
D

	22
a physician in the late Continental Army, a man of respectability
and eminence in his profession, placed his whole dependance for a
cure, in exciting and supporting a gentle diaphoresis by Antimonials,
and confining his patients during the course of the disease to a
close room, to prevent any bad effects from exposure to the exter-
nal air. The removal of the patient from the operation of remote
causes is always desirable, and it is probable, that confinement to 
close room might have some effect this way, and that dry, warm
air, may act in some peculiar manner on the secretion of mucus in
the trachea. With the same view, the WARM BATH is recom-
mended and used with very beneficial effect. Diaphoretics are
best given combined with PURGATIVES.
Keeping the bowels constantly open Is generally recommended,
and for this purpose, gentle laxatives of the cooling neutral salts
have been admnistered: but the stimulating cathartics seem to be
more proper, as our intention is not merely to evacuate the intestines,
but to produce a greater secretion from the glands of the bowels,
into their cavity. For this purpose, no medicine seems to have a
better effect than CALOMEL, which is now considered as the only
radical cure (if we may be allowed the expression) and on which
we place our principal dependance. When this medicine can be
had, it will almost supercede the use of any other remedy in
the first stage of the disorder. Calomel is suited to every stage of
the disease but it is most effectual in the first. In what manner
this medicine produces its good effects is now to be considered—
It possesses a purgative quality, is very insoluble, an universal stimu-
lus and has a peculiar action on the glandular system, in preference
to any other. It's use as a purgative we have mentioned ; from
it's insolubility, stimulus and peculiar action on the glandular sys-
tem, it will stimulate the glands through the whole tract of the
primæ viæ, ab ore ad anum and produce a very plentiful secretion of
mucus into the fauces, æsophagus, stomach and intestines : in con-
sequence of which the secretion of the mucus in the trachea will be
lessened, and the humours determined to the cavities just mention-
ed.
Calomel to be of service must be given in very large doses, and
these frequently repeated. The following case taken from Dr.
Kuhn's lectures on the practice of physic, will point out its efficacy,
and shew in what quantities it maybe given, "On the third day of
the disease he was called to visit a child, the only one of a gentleman
in this city, to whom a variety of medicines had been given to no
effect ; vomits, pediluvia, blisters and bleeding, had by no means
been neglected. Calomel was then proposed and given, and though
the child was about ten months old, it took twenty grains of calo-
mel in sixteen hours, and, by this means, was snatched from the
jaws of death—In all human probability it must have been suffoca-
ted in twenty-four hours, had not this method been pursued." In

23
addition to this he observes, "That when called in at an earlier
period he has in several cases given it with equal success ; though
the disease had not arrived at it's second stage and the membrane
was not formed." I shall dismiss the subject of calomel with the
following expression of another professor. "The bark is scarcely
a more certain remedy for intermittents, than calomel, when thus
administered, is, in this species of cynanche*.
The only remedies, besides the one last mentioned, suited to the
second indication are the exciting of VOMITING or COUGHING,
although we do not approve of vomiting in the beginning of the
disease, yet when the mucus is in great quantity in the trachea and
seems to threaten suffocation, or when the membrane is formed, vo-
miting may be very useful ; accordingly we have instances of it's
evacuating the mucus or membrane and thereby compleating a
cure or else by exciting a cough which has had the same effect.†
Although vomiting has sometimes produced this desirable effect,
yet it seldom succeeds and at best is but a doubtful remedy. But as
it is incumbent on us to do all in our power for the recovery of our
patient, we should neglect nothing that has ever been serviceable or
that might possibly relieve him. To excite vomiting, tartar eme-
tic, in large doses, is recommended.
It has frequently happened that a spontaneous COUGHING com-
ing on, has ejected the membrane and removed the disease. Se-
veral cases of this kind are related by authors, and one, not long
since fell under my own notice. But unfortunately, we are seldom
able to copy nature in this salutary exertion—The trachea is so in-
sensible, in this disease, that nothing seems capable of exciting it
into action. Steams received into the mouth are recommended,
and fumes have been tried, but without effect.
The fumes of the capsicum or piper guineensis may be tried, as
they are found to excite a cough sooner than any thing else.
When every thing that has been recommended fails, and there
are no hopes of the patient's recovery; the last and only remedy we
can have recourse to is TRACHEOTOMY. This will not afford relief
unless the membrane is extracted ; but when we reflect that this
lies loose and floating as it were in the trachea, it seems probable
that it would be no difficult task.— The operation was performed
once in this city, by a gentleman eminent in physic and surgery,
but without success ; this solitary instance should not deter us from
other trials and while there is the least probability of its being suc-
cessful, we ought to attempt it. The operation is seldom re-
commended before every other remedy has been tried in vain and
the patient is supposed to be incurable. In such a case the hazard
of the operation is much more commendable, than consigning the pa-
tient to his fate, without this last though doubtful chance. When-
* Dr. Rush's Observations and Enquiries, Vol. I. page 124.
† See the case related by Dr. Shippen in his Lectures.

24
ever the membrane is evacuated, no matter by what means, it will
be proper to continue the Calomel for some time or until the pa-
tient is perfectly recovered.
To answer our third indication or to prevent a return of the dis-
ease, the remote causes must be carefully avoided or guarded against—
For this purpose, the patient should be removed into a warmer
and drier situation, where he can have the advantages of a pure,
dry and temperate air ; and perhaps the method practised by Dr.
Brown would be serviceable in this case : He should avoid wet and
cold, and should guard against the effects of sudden changes of the
weather, by good warm cloathing. But if any symptoms of the
disease should return, we must have immediate recourse to the re-
medies mentioned in the first indication, particularly diaphoretics
and purgatives—above all, calomel : To this we may add a small
quantity of tartar emetic, in order to produce a gentle determination
to the surface. The calomel must be given in doses to move the
bowels and is to be continued until all the symptoms vanish. TO-
NICS will likewise be of service, particularly in those cases where
the disease has been preceded by the chincough, measles, &c. which
were observed to have a great influence in promoting the disease.
The preparations of steel, peruvian bark and the cold bath, are
remedies which should not be omitted.
Where the disease seems disposed to return frequently, a SETON,
OR ISSUE, in the neck, and continued for some time, seems like-
ly, to be of service.
" I shall only add, upon the subject of this disorder, that in-
stances of its mortality have been very rare, in Philadelphia, since
the general use of the remedies which have been mentioned*."
† Dr. Ruth's Observations and Enquiries, Vol. 1. page 125.