DISEASES OF THE TRACHEA.

BY LOUIS ELSBERG, A. M., M. D.

DISEASE originating in or confined to the trachea is rare. It hardly ever follows tracheotomy unless the shape of the canula or its relation to the windpipe be improper; the normal tracheal mucous membrane probably resists cadaveric disintegration longer than any other mucous membrane of the body. But morbid processes of the larynx often extend downward, and those of the bronchial tubes still more frequently upward, so that the trachea is found affected in connection with both. Indeed, in what is ordinarily simply called bronchitis (see article on BRONCHITIS) the windpipe is seldom free from the inflammatory condition.

We shall here consider Inflammation, Ulceration, Morbid Growths, Stenosis, and Dilatation (hernia, fistula). Tracheotomy may have to be performed in any of these diseases to prevent impending suffocation, and in some to gain access to the part for further treatment. (Sce article on TRACHEOTOMY.)

INFLAMMATION.

TRACHEITIS is either simple or complicated, and acute or chronic.

Simple Tracheitis.

DEFINITION.-Inflammation of the windpipe limited to the mucous mem

brane.

SYNONYMS. Catarrhal tracheitis, Tracheal catarrh.

Its ETIOLOGY may be gathered from the corresponding sections on Catarrhal Laryngitis and Bronchitis.

SYMPTOMATOLOGY.-In acute catarrhal tracheitis local irritation is complained of, varying according to the severity of the case from a mere tickling sensation to soreness and pain. This morbid sensation is increased by pressure on the part, and with it there is cough and expectoration-the former either brassy and hacking, or paroxysmal and violent; the latter at first scanty, but very soon more copious than when the larynx alone is affected, although much less so than when the inflammation involves the bronchial tubes at the same time. The sero-mucous secretion gradually becomes muco-purulent or even purulent. When inflammation is confined to the trachea there is no alteration of the voice, and, except in children, in whom the calibre of the windpipe is proportionately small, usually no or only very slight dyspnoea. In mild cases there are no constitutional disturbances. Severe cases are accompanied by

the febrile symptoms of a bad cold. The disease runs its course in from a few days to a week or two.

Uncured or too frequently repeated attacks of acute catarrh of the windpipe lead to chronic tracheitis, occasionally with considerable hypertrophy of the mucous membrane. In mild cases the cough and expectoration are less than in the acute disease, but persist, with exacerbations in cold, damp weather; in other cases the cough is more frequent, and the expectoration either thick, glutinous, and scanty, or else thin, frothy, or glairy, semitransparent, and abundant. The separation by forcible paroxysmial coughing of accumulated adherent tough secretion from the tracheal mucous membrane has been observed to cause not only slight dyspnoea, but even the dangerous suffocating attacks of foreign bodies in the larynx. In color the sputa vary from gray to green and yellow; occasionally they are streaked with blood; sometimes they are without taste or odor; sometimes they are nauseous and fetid. Frequently patients with chronic tracheitis complain of "a sort of tightness at the root of the neck." In some cases a sense of dryness in the region of the trachea is the principal or the only symptom complained of, and this may alternate with, or even actually coexist with, occasional hypersecretion of tracheal or bronchial mucus.

In chronic bronchitis and senile pulmonary emphysema mucorrhoea and cough usually depend to some extent upon the chronic tracheitis that is present.

PATHOLOGY AND MORBID ANATOMY.-The pathological characteristics of simple tracheitis are hyperæmia, active or passive, swelling, and increased secretion of mucus. There is no fibrinous exudation.

Acute inflammation causes the mucous membrane to become softened, swollen and red, either uniformly or in points or patches, frequently with ecchymoses and catarrhal erosions, more perceptible in the lower than in the upper portions of the trachea. Scanty secretion sometimes lies upon the surface in pearl like drops, which might be mistaken for solid elevations only that they can be wiped off.

In chronic inflammation the redness is more dull, reddish-blue or grayish; the secretion, sometimes more scanty and sometimes more abundant, is puriform and usually spread out over larger portions of the surface; and the glands are enlarged and prominent, with their ducts so dilated that their mouths are readily visible, sometimes, to the naked eye, and always with a low-power lens, and the rest of the tissue is hypertrophied, especially at the back wall of the trachea. Catarrhal tracheal ulcers are exceedingly rare, superficial, and of but slight extent, but they do occur, and are usually situ ated on the intercartilaginous membrane.

DIAGNOSIS.-Tracheoscopy, a modification of laryngoscopy, can alone determine with certainty whether, and to what extent, the trachea is inflamed. Unfortunately, very few practitioners have as yet mastered this method of examination, which, though really not more difficult than laryngoscopy, requires greater illumination (necessitating under some circumstances a mirror of longer focal distance) and different relative position of patient and operator. (See article by Seiler.) Figs. 25 and 26 show the tracheoscopical images of a case in which there was intense acute tracheitis. The anterior wall is seen in Fig. 25, and the posterior in Fig. 26; on both, but especially the latter, clumps of phlegm and ramifying injected blood-vessels. are distinctly seen. In many cases, by means of the stethoscope, either dry sonorous or mucous rales may be heard over the windpipe; at other times we may be aided in coming to a conclusion by the presence of dysphagia-increased when the chin is raised and diminished when the chin is pressed on the chest, as pointed out by Hyde Salter-and by the morbid sensations, increased by pressure, in the region of the windpipe when there is cough and expectoration.

PROGNOSIS.-Simple tracheitis, though occasionally not without danger in extremely young and very old patients, rarely if ever destroys life. Under good hygienic circumstances it frequently gets well of itself, and it does not

usually produce sufficient swelling or hypertrophy to cause stenosis. It is, however, when severe, an annoying disease, apt to recur, and, unless properly managed, difficult to eradicate."

TREATMENT.-Tracheitis is treated very much like bronchitis confined to the larger tubes, only that local measures are more prominently applicable, especially in chronic cases. Frequently, when acute, the disease may be arrested by a Dover's powder, a warm bath, and a diaphoretic drink at night, with hygienic attention, regulation of systemic functions, and soothing applications, such as inhaling simply vapor of water or medicated water, or using warm-water poultices externally. Expectorant mixtures, containing ipecacuanha, sanguinaria, squills, or senega, may be given, according to the age and condition of the patient, with matico and the like, when the secretion is abundant, and with ammonium acetate or sodium bromide (potassium carbonate or ammonium carbonate where there is depression) or tincture of aconite (especially when fever is present), or a very minute quantity of tincture of veratrum viride, when there is much dryness. Inhaling the steam arising from a pint of hot water (160-170° F.) containing 10 grs. of extract of conium, 1 drachm of compound tincture of benzoin, and half a drachm of ammonium sesquicarbonate, or inhaling nebulized solution of potassium bromide, 10 to 20 grains to the ounce, or fumes of evolving ammonium chloride or of nitrepaper, is very serviceable, as well as placing a mustard plaster or a hot poultice on the upper part of the chest (not directly over the windpipe) and on the back of the neck or between the shoulders. Some patients require for several days to take daily from 8 to 10 grains of quinia sulphate, then a smaller quantity, care being taken not to discontinue the remedy suddenly. Smoking eucalyptus-leaves, with much inhalation of the smoke, is useful in protracted cases. In chronic as well as acute tracheitis not only balsamic, anodyne, and astringent inhalations either of vapors, or of liquids nebulized by the various spray-producers are in vogue, but also insufflations of powders, injections of liquids, and touchings with the sponge or cotton-wad probang or tracheal applicator. Powders should never or only rarely (as, e. g., morphia,

of a grain, when the cough is troublesome, etc.) be blown into the trachea; injections and touchings should be made use of only after the operator has acquired the necessary skill to apply them by means of the mirror. A few drops of a solution of silver nitrate, varying in strength inversely as the chronicity of the case from 5 grains to 60 to the ounce of water, thus accurately applied at proper intervals of time, have proved successful in otherwise intractable cases. In chronic tracheitis general tonic treatment must be combined with the local, and attention be paid to possible coexistent cardiac and

broncho-pulmonary affections or other morbid conditions. In some cases it is advisable to administer potassium iodide; in rheumatism, sodium salicylate; in gout, colchicum. The utility of producing alkalinity of the blood (as by giving alkaline mineral waters to drink, etc.) has received a new and direct support by Rossbach's recent observations of diminution of the blood-supply and of the secretion in the tracheal mucous membrane of cats whose blood was made alkaline by injecting sodium carbonate into the femoral vein.

Patients subject to tracheitis should observe all the precautionary measures of so-called bronchitics as to sponging, bathing, and friction of the body, wearing a respirator, clothing, exercise, habits, etc.

Complicated Tracheitis.

Under this heading are here classed together all inflammatory conditions of the windpipe differing from simple or catarrhal tracheitis. In these, other tissues may be affected as well as the mucous membrane. In exanthematous, erysipelatous, and exudative tracheitis the mucous membrane is prominently involved; in oedematous and phlegmonous tracheitis, the submucous connective tissue; and in perichondritic and chondritic tracheitis, the cartilages and their investing membrane. The latter forms are connected with suppurative and ulcerative processes, and, unless traumatic, almost never occur, except in phthisical and syphilitic tracheitis. I shall speak of them under the head of Ulceration.

The tracheitis of measles and scarlatina consists in an acute catarrh, with sometimes considerable desquamation of epithelium, erosion, and capillary hemorrhage. In cases of small-pox in which the larynx is affected, the same disease may extend into the trachea, varying in severity from a congestion of the mucous membrane to an intense pustular process. Erysipelas of the larynx may also involve the windpipe, and when it does is exceedingly dangerous. More than half a century ago Gibson observed in an epidemic of erysipelas that when it spread to the trachea it generally proved fatal.' Tracheal oedema is extremely rare even when the larynx is ædematous. Phlegmonous inflammation and abscess have been observed in a few instances. Tracheal diphtheria is usually an extension of diphtherial disease of the larynx. Without entering into a discussion of the nature and cause of diphtheria, as either a local or general disease, it is here sufficient to refer to the fact that while in simple inflammation of mucous membrane no fibrinous exudation takes place, certain poisonous irritations lead to the exudation of lymph which infiltrates the tissue and may form a pseudo-membranous deposit upon it: experiments have proved that ammonia, chlorine, and, certainly, bacteria, are able to produce this. In laryngo-tracheal diphtheria or croup the disease most frequently commences in the pharynx, occasionally in the larynx, and much more rarely in the trachea.

The treatment of each of these forms of complicated tracheitis is the same as the treatment of the corresponding form of laryngitis.

ULCERATION.

TRACHEAL ULCERS are just as multiform as laryngeal ulcers, but far more rare. Like inflammation, they may occur by extension from above or below, 1 Transactions of the Edinburgh Medico-Chirurgical Society, vol. iii., 1828.

and only those following localized morbid conditions are certain to have arisen in the trachea. Under the head of Inflammation it has been stated that simple catarrhal ulceration does occasionally occur; of this there is really no doubt, but some writers have denied it and thrown the whole subject into great confusion. It is true, however, that a tracheal ulcer has usually a so-called dyscratic base, and either is diphtherial or phthisical (tuberculous) or syphilitic or lupoid or leprous or carcinomatous, or else comes from extraneous causes; as, for instance, from traumatic ulceration or extension or perforation from neighboring abscess, etc. There are two kinds of ulcers-viz. one in which the molecular death of tissue proceeds from the surface inward, and another in which it proceeds from within to the surface. Catarrhal ulcers, as well as ulcers from decubitus after tracheotomy, from pressure of the canula, belong to the first kind; when involving only the epithelium or the epithelium and the layer immediately underneath it the name erosions is given them; and if it were true that catarrhal erosions never penetrate to the deeper structures, it would be justifiable to say that there are no catarrhal ulcers, but only erosions: they do, however, penetrate, and sometimes to great depths. In the second kind of ulcers the epithelium is at first normal or intact, and the loss of substance of underlying tissue in consequence of inflammatory processes in the mucosa, submucosa, or perichondrium affects the epi

thelium secondarily. This occurs whenever, from any cause, there is primarily caries of cartilage or suppuration of submucous tissue, especially in typhoid conditions, in phthisis, and in syphilis.