SLRGICAL COMPLICATIONS AND SEQUELS OF FEVEKS. 25 



an altered voice. I have only found it distinctly stated as 

 unaltered in three cases. Generally it is hoarse, sometimes 

 higher, but usually lower in tone, probabl}" from involvement 

 of the crico-thyroid muscle. Sometimes complete aphonia sets 

 in. Stokes' has supposed the hoarseness and deafness both to 

 be due to the muscular degeneration, to which I shall allude 

 hereafter; but it is more likely to be due here, at least, to 

 tedema and inflammatory swelling, and, at a later period, to 

 the mechanical destruction of the parts involved. 



Soon after this hoarseness is observed, the dyspnoea sets in. 

 This is paroxysmal, the attacks being generally at night. 

 With each succeeding attack the severity increases, until life 

 is destroyed ; but even the very first attack may be unexpected, 

 sudden, and fatal. Especially does this seem to be the case in 

 tj'phus, and in supra-glottic oedema. Emmet and others have 

 recorded a number of cases, in which, even witliout the least 

 previous d^^spnoea, on simply assuming the erect ])osture sud- 

 den suffocation came on, and life w^as only saved by instanta- 

 neous lar^-ngotomy. The delay of ''a few minutes" caused 

 death in one case which otherwise would probabl}^ have re- 

 covered. Most frequently- the dyspnoea is inspiratorj-, but I 

 cannot find that this is of an3' decided diagnostic value. 



The expectoration, curiously enough, aids us but little ; in 

 but few cases did it attract sufficient attention even to be 

 named ; but if it be purulent or gangrenous, it should arouse 

 instant attention. Pain and tenderness, though often masked 

 by the mental condition, are generally present, especiall}' in 

 perichondritis. As we have the resisting verteljral column 

 behind the cricoid, I would strongly urge that both by direct 

 and lateral pressure on the cricoid, and also by sliding it side- 

 wise, we may often elicit pain which might otherwise be over- 

 looked. Lateral pressure will also often produce dyspnQ?a, or 



' On Fevers, riiila., 1876, p. 105. 

 42 



