An essay on laryngismus stridulus, or croup-like inspiration on infants

Front matter

Google to make the world's books discoverable online.

It has survived long enough for the copyright to expire and the book to enter the public domain. A public domain book is one that was never subject

to copyright or whose legal copyright term has expired. Whether a book is in the public domain may vary country to country. Public domain books

Chap. 1. History of the Disease

Of the Causes

Sect. 1. Predisposing Causes

. 50

Sect. 2; Exciting Causes

. 60

Sect. 3. Causes of the Paroxysm

. 85

Of the Pathology of the Disease

. 104

Of the Diagnosis .....

. 156

Of the Prognosis

. 177

Of the Treatment

. 191

Appendix

I. Illustrations of the General Principles of the Pa-

thology of Nerves 283

II. Of the Functions and Attributes, in their natural

and diseased conditions, of the Pneumo-gastric

or Eighth Pair of Nerves, as illustrative of the

General Principles of the Pathology of Nerves 407

a 2

PREFACE.

The very peculiar disease, which it is the object of the following Essay to investigate, has been long known ; and its dangerous tendency has been, perhaps, rather exaggerated than under-rated.

Its existence, indeed^ as a complaint separate and distinct from croup, has been a fruitful source of controversy upon the continent, where it is much less frequent than in this country : — but, even "here, constantly as we have opportunities of observing it, the opinions of the profession are still unsettled as to its pathology and treatment.

The views hitherto entertained by those, who have either written expressly on this malady, or noticed it incidentally in their writings, have been much wanting in precision, perspicuity, and accuracy. They have differed also greatly from each other, and hence not only dissimilar, but even contrary, modes of treatment have been adopted; some speaking in terms of the greatest confidence of the successful results of copious blood-letting, large and reiterated doses of calomel, active purgatives, and very slender diet, whilst others denounce these remedies as useless or pernicious, and advocate the employment of a totally opposite practice, recommending

VI PKEFACK.

strongly a tonic regimen, including quinine, nutritive food and country air.

My opportunities, both in public and private practice, of tracing this disease from its commencement to either its favourable or its fatal termination, have been numerous. These have, I would fain hope, enabled me to clear up some of the obscurities, to reconcile the discrepancies, and to discover and correct some of the practical errors, which are so manifest in the very brief accounts of this disease which have hitherto been presented to the professional public ; and if, by tracing the morbid changes upon which, in at least a very large numerical majority of instances, the disease depends, I shall be able to explain more satisfactorily the phenomena, or establish more definite rules for the management of the complaint, my time and labour will not have been misapplied, and my purpose will have been attained.

The work, composed at different times, often at somewhat distant intervals, and under the pressure of severe indisposition and laborious professional occupations, has, I am abundantly aware, numerous imperfections and occasional repetitions ; and it has grown under my hands until a few brief communications to a periodical medical journal, in which I sketched an outline of my views, have become a portly volume. I have found it difficult, however, or rather impracticable, to compress within a narrower compass the numerous facts and observations which the illustration of my subject required, and I was much influenced by the opinion of a distinguished French physiologist, that ** il vaut mieux p6cher par exc^s que par d6faut de preuves, quand il s^agit d'6tablir une th^orie nouvelle, d*ajouter une v^rit6 aux verites d^J£L connues : on ne dit jamais tmp alors, tant il est difficile de convaincre." 1 At all events, since the time of Millar,*

* Brachet.

' Observatioiis on the Asthma and on Uie Hooping Cough, by John Millar, JM,D. 1769.

PREFACE. Vll

there has been no monograph of this disease, and it appeared to me to be well worthy of a detailed consideration.

Most of the cases which I have related occurred within my own observation and I can vouch, therefore, for their autb^aticity and accuracy. I have, however, had occasion also to refer to instances recorded by other individuals equally entitled to professional confidence, and these have forced conviction upon my mind, that the general opinion with regard to the pathological essence of this complaint is in most instances erroneous. With regard to the conclusions to which I have been led, the result, I trust, of no hasty generalization or illogical induction, I have little expectation and less desire that they should be adopted without a searching examination of the proofs upon which they rest. I know how difficult it is to eradicate the impressions of early education and to combat the influence of habitual trains of thought ; and it will, probably, be with others as it has been with myself. I entered upon the investigation of this disease much biassed by the, all but, universal belief, that it was essentially a convulsive malady ; and it was only in the progress of my observations and inquiries that I could disabuse my mind of this very common opinion, which I found to have, instead of evidence, little better than the dicta of the profession in its support, to be consistent with very few of the phenomena, to afford no satisfactory explanation of the symptoms, and to be totally irreconcilable with a large proportion of the facts.

How far I may have succeeded in establishing the startling proposition that this complaint is, generally, more allied to partial or local paralysis than to convulsive movement, it is not for me to determine. But multiplied experience, observation, and reasoning, confirmed by physiological experiments and pathological inquiries, have convinced me of its truth ; and each succeeding instance of the malady which has presented itself to my notice, has but tended still more to

• • •

VIU PREFACE.

fortify my opinions. The facts, by which they are supported, have addressed themselves so forcibly to the eye of reason as well as of observation, that their influence has been irresistible. I felt with Galen, that " si quis non credit iis quae per sensum et intellectionem evidenter patent vanum erit constitutioni alicujus artis operam navare,"" or as Brassavolius compresses the same sentiment in his reference to this passage, " Sensui qui non credit explodendus est."

Some apology may, perhaps, be requisite for entering so largely, as I have done in the Appendix, upon the subject of the general principles of the pathology of nerves. Without reference to these I found it impracticable to proceed with any explanation or illustration of the complaint so aptly, though quaintly, designated " child- crowing**' by my lamented friend and colleague, the late Dr. Gooch. It appeared, upon examination of the subject, that although a mass of valuable materials might be collected from the writings of those, who had directed their attention to the diseases of these all-pervading instruments of sense and motion, no very perspicuous attempt had been made to bring together the numerous and instructive observations, to arrange and generalize the facts, and to deduce such general inferences, as might be useful to future inquirers. I was forcibly struck, when consulting the best authorities upon the subject, with the truth of a remark by Dr. Alison, that " there is in many medical writings an indifference to the establishment of such general principles, both in physiology and pathology, as the information we already possess sufficiently warrants, which argues inattention to the value and importance of these principles not only for the gratification of the desire of knowledge, but for securing the recollection and useful application of individual facts.*"*

It was this deficiency which obliged me to investigate the subject for myself ; and in collecting the requisite materials

3 Outlines of I'bysiolog^y and Patliologry, Preface, vi.

PREFACE. IX

I have endeavoured to exclude all such recorded instances of diseased conditions of individual nerves, as appeared to be stated upon insufficient testimony, or were not minutely exa* mined. The labour of the research has, I trust, not been altogether unproductive. The results are« at all events, not without interest ; and if they should tempt others, who have more leisure and less limited opportunities, to pursue a similar train of investigation, or should they afford any assistance in such inquiries, I shall not regret the time I have devoted to the elucidation and illustration of a subject so comprehensive, obscure, and intricate.

But it was not enough thus to attempt the establishment of general principles connected with the pathology of nerves, without tracing at the same time their application to the par vagum, with the diseased conditions, structural or functional, of which, and more particularly of its recurrent branches, the phenomena of the laryngismus stridulus have the most intimate connexion. It was necessary, for this purpose, to follow the course of the nerve to its ultimate distribution, to ascertain, by the positive and negative results of physiological experiments, the functions to which its various ramifications minister, and to adduce illustrative examples of the changes in its attributes and offices produced by disease. In this part of my inquiry I have availed myself largely of the physiological labours of British and continental writers, and of such pathological observations as fell within my reach. These have in a striking manner corroborated my views as to the essential nature — the proximate cause as it is generally" termed, though it is the disease itself— of the crowing or croup-like inspiration of infants, and have convinced me, in opposition to the prevailing doctrine, that in the distressed and stridulous breathing, which attends the laryngismus stridulus, the respiratory nerves, to the entire exclusion of all morbid condition within the cranium, may he in fault. — Saepe nervorum culpa.

X PREFACE.

* Morgagni, Epist. Anat. Med. xv, art. 10.

Introduction

A B&iEF sketch of the literary history, which is somewhat curious, of the Laryogismus Stridulus may, perhaps, codstitute no uninteresting or useless introduction to the investigation of its medical history. We are assured by one original writer upon the subject, that " though no complete history has ever been given of the disease, yet there are several observations concerning it scattered through the writings of practical physicians." ^ A second mentions it as " a disease conceived by some gentlemen of great respectability and experience, as generally fatal.'' « A third states, that *' it is a complaint of such rare occurrence that it has been little attended to by practitioners, and has not been described by any author." ^ A fourth alleges ^^ that it is often mistaken and treated as some other disease even by medical men ; and the true nature of it has been little known even to practitioners generally conversant with children's diseases ;" and that ** it is therefore less likely to be detected by those, who have bestowed little or no attention upon them."* A fifth gives it as a reason for " dwelling on the characteristic features of the disease," that he does " not find it described in any systematic work in the English or French language." ^ And, lastly, a sixth " believes it has never been regularly described." ^

Notwithstanding, however, these illustrations of the little attention this disease is said to have attracted, it appeared to

» Millar, 1769. « Underwood, 1789. » Hamilton, 1813.

* Clarke, 1815. « Marsh, 1830. « Goocb,by Skinner, 1831.

Xll IXTllODUCTION.

nie extremely improbable that a complaint, which is dependant upon the physical agency of causes which have been always in operation, could have altogether escaped the observation of practical writers upon medicine. I concluded, therefore, that it must have been with this disease as Royer CoUard alleges with regard to croup, that " les causes qui concourent a la production de la maladie ont existe de tout tems, et il serai t bien extraordinaire qu*elles fussent rest^es inactives, et, pour ainsi dire, silencieuses pendant une longue suite de si&cles, poui* se reveiller avec une energie aussi feroce que subite.''^ Accordingly, although it is unquestionably true that to the late Dr. John Clarke is due the merit of having first succeeded in fixing strongly the attention of the profession upon this interesting, • distressing, and sometimes mortal malady, I still found, as I had anticipated, that long previously to his time, and even from the earliest ages, to which the records of our art extend, very distinct and unequivocal notices of its occurrence were to be found in the writings of medical authors. M. Double thinks that he finds a trace of croup as early as the Rabbinical writings ; but it seems more probable, that the complaint noticed by Elias the Levite, in his Thisbi^ was the laryngismus, since he describes it as destroying in an instant by closing the entrance to the windpipe.

Whatsoever difference of opinion, as to the causes and intimate nature of this complaint, may have existed amongst those who have noticed it in their writings, or howsoever numerous and various the denominations under which they have described it, there has still been that uniformity in the accounts of its characteristic features, which enables us at once to identify the disease as similar or the same in all. The phenomena, almost invariably observed, have been severe, but paroxysmal, distress in breathing, threatening and sometimes producing irrecoverable suffocation, and, in cases of recovery, accompanied or immediately succeeded by, and terminating in, a lengthened sonorous inspiration like that which occurs in croup and hooping-cough. These are mentioned as the leading and pathognomonic signs of the disorder by almost

^ Diet, des Sc. MM. Art. Croup.

INTRODUCTION. Xlll

all modern writers including Millar, Rush, Underwood, Burns, Hamilton, Capuron, Clarke, Cheyne, Pretty, Davies, Norths Golis, Gooch, Marsh, Joy, and Roberton.

Other phenomena have been enumerated by some amongst the symptoms, but they are merely accidental associations or consequences, and are not essential to the complaint. Some, again, and especially amongst the earlier writers, have omitted the croup-like inspiration^ but the other circumstances are so analogous to those of the laryngismus stridulus, that I cannot divest my mind of the belief that the complaint described by them is no other than that disorder. But these incidental combinations and occasional omissions do not affect the essence of the disease ; at most they can only constitute varieties, and are not sufficient to justify our founding upon them even a specific^ and certainly not a generic distinction.

Until the beginning of the present century this complaint appears to have been commonly described under the very general and somewhat vague title of " asthma," which, together with struma and several other complaints, Hippocrates enumerates amongst the diseases of children advanced somewhat beyond the time of life when the first teeth begin to appear ; 8 a period more minutely, if not more accurately, defined by Galen to extend from the first appearance of these teeth to the age qf twelve or thirteen. ^ In another part, also, of his voluminous writings, Hippocrates mentions the " asthma^ as a disease of childhood, as particularly apt to occur ^^ during winter, in cities whose confined situation precludes them from due exposure to the evaporating influence of the sun and winds, where the inhabitants are subject to the violent alternations of hot summers and cold winters, and where the only water they have is from marshes or standing pools ;"" and, further, as connected, or confounded with or constituting an attack of epilepsy. ^ Some indeed have expressed their

" Hipp. Apb. sect. 3, aph. 26. ' Galen Comm. 3. in Aph. Hipp.

U€pi dffxay, Mr»y, r&jrtw, Hippoc. Focsii. Francof. 1621, p. ^81.

XIV TNTHODUCTION.

doubts whether Hippocrates meant, by the expression employ- €!^ — '* iepTJv vovffov" — more than a very severe disease or a visitation of the gods ; but it is well known that the ancient writers commonly used this expression to designate the disease called the falling sickness or epilepsy and Galen, in another part of his works* quoting this passage of Hippocrates, expressly identifies it as the " rd rjc cViXiyif^iac irddo^,*'

The sense, in which the terms asthma and struma were used by Hippocrates, must be gathered from writers, who may be supposed to be the most conversant with the meaning of these expressions, because least remote from the time of the author himself, and because abundantly familiar with the language in which he wrote. So Galen tells us, that by the term asthma is meant that kind of difficulty of breathing, which occurs in those who have been running violently, or have been agitated by any other kind of vehement exercise ; « and a similar explanation is given by Aretaeus^ and Paulus of iEgina. * Celsus defines the word " asthma" with even still more exactness, and distinguishes it from dyspnoea; restricting the latter to those more moderate cases of difficult breathing which are without a sense of strangulation, and applying the former to those in which the difficulty is extreme and the respiration sonorous.^ Coelius Aurelianus also alludes to asthma, as a disease afflicting men more frequently than women, old people and children more frequently than . those of youthful age, the delicate rather than the strong, as attended with a sense of stiffbcation^ sonorous wheeling respiration and enfeebled voice, and in its very severe forms with lividity of lips, and as liable to occur in winter more frequently than in summer, in the night rather than by day. ^

Such being the acceptation in which the word asthma was used by the ancients, and it being notorious that spasmodic asthma^ in the more restricted sense in which the name is now

^ Com. 1 in lib. 6. Hipp. sect. 1. de Morb. Vulgaribus. ' Galen Comm. 3 in Apb. Hipp.

• ^ginet. lib. 3, cap. 29.

' Celsi de re Medica, lib. 4, cap. S.

^ Ccel. Aareliani Morb. Cbron. lib. 3, cap. 1.

INTRODCCTIOK. XV

applied^ is an extremely rare disease amongst infants and children, it is highly probable that when Hippocrates and Galen mention asthma unconnected with cough, as a disease of childhood, they must have meant that peculiar malady which it is my purpose to investigate : and this probability is reduced almost to certainty when we find that, in the enume* ration by Hippocrates of diseases thus incident to the age of childhood, he has also comprehended struma, which Galen ^ and all the ancient writers agree in describing as *^ indolent glandular tumours, particularly apt to affect the neck ;" thus associating, as Millar, Molloy, and perhaps, in our own time. Marsh have done, these two affections which so constantly coexist in the same individual.

There can be little doubt that a case, described in the seventeenth century by Felix Plater, was an interesting and fatal example of this disease. A boy five months old, of sound habit of body, and free from previous disease, was seized with sonorous and difficult breathing, and died suddenly. The father, anxious to ascertain the nature of a disease, which had already deprived him of two of his children, was desirous that the body should be opened, when the only morbid change of importance, which could be detected, was a large strumous gland, weighing an ounce and a half, having a membranous adhesion to the great vessels of the neck, the compression of which, it was thought, must have occasioned the suffocation. The facts thus briefly recorded possess great interest, but the explanation offered, although in consonance with the views generally entertained in the time of Plater, is little satisfactory. Pressure upon the great vessels of the neck, it is now well known, produces no such symptoms as those described ; and it can scarcely admit of question, as the tumour was placed immediately over the course of the respiratory nerves, that it was to compression either of the

* Stroma caro est sicca quae nee facile soWitur. Galen. Finit. Medic.

XVI INTRODUCTION.

par vagum, or, more probably, its recurrent branch, that the difScult and stridulous breathing was owing; and that the sudden death was attributable to some sudden and accidental aggravation of that pressure. 9

Primerosius, * in the middle of the same century, describes the asthma amongst the diseases of children, and Etmuller,^ who wrote towards the conclusion of the same century, confirms by adoption his statement, defines more accurately what was meant by the term, mentions it as one of the ailments connected with dentition, and as only occasionally associated with cough ; notices the difficulty of breathing attended with sonorous respiration, which he denominates "stertor,^ and which he expressly identifies as the same sound with that which occurs in the hooping cough, traces it to acidity, or acrid secretions, or a loaded stomach, and whilst he inveighs against checking a spontaneous, recommends strenuously artificial vomiting for the cure of the disease .^ In his chapter, also, " de catarrho sufFocativo,'' he still more plainly alludes to it, for, ** to this head," he says, " should be referred the suffocative catarrh, apt to be followed by convulsions, of infants, in which the alternate actions of inspiration and expiration, exceedingly hurried and with little or no cough, are attended with the frequent appearance of suffocation ;"* and this he believes to be essentially an affection of the larynx.^

* De puerorum morbis, p. 73.

* Pertinere hue videtur infantum quorundam plus minus robustorum catarrhus suffbcativus cum epilepsias metu junctus, dum v. g. simpUciter creberrima thoracis sjstole et diastole cum levi vel nulla tussi continue suffocari videntur. — Op. Omn. 1697, vol. ii. p. 273.

INTRODUCTIOV. XV11

It is also very far from improbable, that the complaint, which he elsewhere describes under the title of the ** suflbcatio convulsiva,^ is of the same kind ; and it is a curious and interesting fact, connected with his account of this peculiar form of disease, that he should distinctly allege that it may occur from paralysis, as well as from spasm of the muscles of the glottis,^ the symptoms of both being similar or identical.

A contemporary and friend of Sydenham, Dr. Walter Harris, whose little work upon the acute diseases of infants gave the first impulse, in this country, to the investigation of the ailments of children, was probably not unacquainted with this laryngeal affection. Speaking of the complaints arising from excess of acidity in the primae viae, to which it was his habit to ascribe most of the maladies of infantile life, after enumerating amongst them nausea, vomiting, acid eructations, a pallid, sallow, or even greenish tinge of complexion, reddish pustules (the strongest evidence according to him of redundant acid) upon the cheek, chin, forehead, neck, or sometimes the lower parts of the body, he adds, of such patient, " Sed et idem anhelat et cum stertore aures astantium feriente nonnunquam spiritum ducit."^ That the word "anhelat," here employed, ineans not merely panting or difficulty of breathing, is more than probable from the literary habits and pursuits of Harris, who would naturally apply the term in the sense, in which it was commonly employed by the ancient medical writers ; and upon this point it may suffice to quote a single passage to show that the expression was considered as equivalent to being seized with asthma, for we find the terms •* asthmatici," and " anhelosi,'' used even by Galen, as synonymous or convertible.® As to the term " stertor," which is not sanctioned by any classical authority, it is perhaps equivalent to stridulous breathing, Cornarius, in his translation of Galen's book, " De difficultate respirationis,'' lib. iii. cap. 7,

* Ibid. p. 226. Quoted at large in the Essay, p. 129. "^ De Morbis A cutis Infantum, p. 36.

h ^

XVin INTRODUCTION.

rendering the Greek expression irepx^w^ecc, (which has reference to a harsh grating and probably acute sound, rather than snoring,) by what he considers the parallel phrase in the Latin ** stertorosi ;*" a phrase used, as we have already seen, by Etmuller, who was nearly contemporaneous with Harris, in the same sense, as implying the stridulous inspiration which is characteristic of hooping cough.

Hoffman notices asthma amongst the diseases which result from inflammation of the gums in painful dentition,^ and in a subsequent chapter, ^^ de aliis infantum morbis,^ he alludes to coughs of a strangling character with excessive difliculty of breathing and fear of suffocation, and occasionally epidemic. This might indeed be supposed to be merely the hooping cough, were it not that he has devoted a separate dissertation to the latter disease, and refers to Willis and EtmuUer, ^ as his authority for applying to it the name of tussis convulsiva, which, according to him, may occur at any period of life, although it is more common during the tender age of infancy or childhood. But to the strangling cough, before alluded to as a disease exclusively of infantile life, (often mistaken for hooping cough, and confounded with croup,) he gives the very appropriate designation of "tussis ferina vel furibunda.*" * Hoffman is, moreover, the first writer, as far as I have been able to ascertain, who has mentioned a connexion, of which I have given more than one instance, and have seen several, between the "asthma suffocativum**^ of children and certain eruptions upon the surface, amongst which he particularizes tinea capitis, and crusta lactea.^ ^

' Tussis saepe ferina et sicca infantes exercet, cum magna respirandidifficultate et suffocationis metu, et epidemice ssepe grassatur. — Prax. Clin. Morb, Infant, cap. 6. De aliis Infantum Morbis, §. 2.

INTRODUCTION. XIX

Some have supposed that Dr. Starr, a Cornish practitioner of consiclerable eminence, described the laryngismus stridulus of infants under the formidable designation of the " morbus strangulatorius.'*^ A perusal, however, of his paper in the Philosophical Transactions can scarcely fail to leave the impression, that he has confounded several diseases of very severe character, the result of atmospheric influence upon unhealthy subjects or individuals weakened by the peculiarity of the season. Amongst these complaints, there are distinct traces of cynanche tonsillaris, parotidsea, and trachealis, of enlargement of the other salivary glands — the submaxillary and sublingual — ^and such obstruction of the absorbent glands of the neck as to cause, by the " internal tumour,'' a " large (edematous swelling of the subcutaneous and cellular tissue from the chin down to the thyroid gland, and up the side of the jaw." Amongst the symptoms he enumerates *' a short, low, becking, hoarse cough, producing, sooner or later, a diiBcult, noisy, and strangulating respiration ,'' and these last he ** esteems as the pathognomonic symptoms of the real morbus strangulatorius.'' From the respiration, " howsoever agonissing" having remissions and exacerbations, he infers that " its cause cannot of course be permanent,**** and he refers it therefore to an occasional " lodgement of some matter in or about the larynx and glottis, through which the inspired air is obliged to pass ;" and he adds, that " while this matter is capable of being expectorated, and happens to be coughed off, the breathing for a time becomes free, and the patient is delivered from the utmost seeming distress; but upon its recurrence, which usually takes place, the patient either dies suddenly, or sinks gradually, or expires in convulsions." That some of the cases recorded by Dr. Starr were unequivocal instances of cynanche trachealis or croup, admits not of question ; — this was proved by the portions of membrane in one case, believed by him to be the lining membrane of the

etiam hoc asthma spasmodicum est et ab repulsa e peripberia corporis ad interiora materia excrementitia acri in purpura, tinea capitis, erysipelate, vel crusta lactea fit, vel etiam ex eo habet quod respirationis nervi tenduntur per consensum in dolorific^ dentitione. — Ibid. ^.3.

XX INTRODUCTION.

whole trachea and bifurcation of the bronchi, which the patient expectorated ; but that the whole of his description of the symptoms is applicable to that disease is extremely doubtful, for ^^ pustules in the groins and about the anus, eating quick and deep and threatening mortification,'' t}ie occurrence of ** petechiae,'' " swellings of the tonsils, parotids, submaxillary and sublingual glands," " internal tumours'" producing " oedematous swelling of the neck," and " gangrenous sloughs of the mouth,'' all which are enumerated as the symptoms of the disease, have clearly no essential connexion with croup ; and it appears to me no great stretch of imagination to suppose that in this prevalence of glandular disease or of ailments likely to influence injuriously the cervical absorbent glands, these may have become enlarged and produced the laryngismus stridulus, as the sole original affection in some instances, and in others accompanying and modifying the symptoms of some other disease so as to produce the " pathognomonic symptoms, ^' a difficult, noisy, and strangulating respiration ;"* — a conclusion which derives further countenance from the occurrence of occasional attacks of agonizing respiration, with exacerbations and remissions, (like that which is the result of the lodgment of a foreign body in the larynx or glottis,) as well as from the " sudden death," with or without " convulsions," by which the children attacked were often carried off upon the recurrence of the fits of difficult breathing.

To Dr. Russell, also, has been ascribed a knowledge of the acute asthma, which h^ is represented to have described under the denomination of the angina inflammatoria of infants. Such at least was the opinion of Dr. Haygarth. * In some particulars there is great resemblance, and, were it not for the " redness at the back of the palate and of the epiglottis," the affection of the tonsils in some cases," " the little creeping ulcers which spread about the larynx and alter the voice," and " the occurrence of fever," I should have little hesitation