CHRONIC INFANTILE STRIDOR.

This is the place to mention an affection of the larynx which occurs in infants from birth up to the age of one or two years. It consists of a peculiar croaking sound, which is generally first heard soon after birth, and is continuous for long periods, perhaps all day and night, but may be absent for a few hours. The croaking takes place with inspiration, and is either a rough rhonchal sound, or more clear and musical; expiration is either quite normal, or rattling as if from accumulated mucus; the cough and cry are, as a rule, normal. There may be a little sucking-in of intercostal spaces, but there is rarely any lividity. In some cases the noise is constant during sleep, in others it is absent; it is generally worse when the child is lively or excited. It subsides as the child grows older, but I have known it still present at two and a half years. The child is in other respects quite healthy. Dr. Lees had the opportunity of examining the larynx in one of these children who died of diphtheria, and found the epiglottis folded on itself, and the aryepiglottic folds in contact. From this it would appear that the stridulous noise is due to the obstruction which the folded epiglottis presents to the entrance of air, whereas the expired air passes through it with comparative ease. It does not itself appear dangerous to the infant's life, and I know of no treatment which has any influence upon it.

ANESTHESIA OF THE LARYNX.

This occurs in diphtheria, and in bulbar paralysis. It is recognized by the insensibility of the laryngeal mucous membrane when touched with a probe, introduced with the help of the laryngoscope. It is often accompanied by dysphagia from particles of food entering the larynx. This is, according to Mackenzie, from paralysis of muscles supplied by the superior laryngeal nerve, and not because of the insensitiveness of the mucous membrane. The muscles which fail, under these circumstances, are those which depress the epiglottis and close the upper aperture of the glottis during swallowing. Anæsthesia from diphtheria generally recovers; prognosis is naturally bad in progressive bulbar paralysis.

The Treatment should be by galvanic and faradic applications; strychnia may be given internally; and feeding with the oesophageal tube may be necessary if dysphagia is serious.

DISEASES OF THE TRACHEA.

TRACHEITIS.

Inflammation of the trachea arises from circumstances similar to those producing laryngitis. Acute catarrhal tracheitis frequently accompanies laryngitis and bronchitis, but is masked by the symptoms which they produce. Occasionally it exists alone. It then produces cough, often hacking, perhaps violent or paroxysmal, with some amount of expectoration. With the laryngoscope, the mucous membrane may be seen to be congested, and ulcers are sometimes observed. With the stethoscope, mucous râles may be heard in the trachea; but the swelling of the mucous membrane and the mucous accumulation are not generally sufficient to cause much dyspnoea. The patient requires treatment similar to that used in bronchitis-warm temperature, and avoidance of exposure. Troublesome cough may be relieved by insufflations of morphia ( to gr.) or bismuth nitrate (to gr.); and expectorants, such as squills and ipecacuanha, steam or benzoin inhalations, and the application of mustard to the upper part of the sternum, are of service.

The trachea is attacked by diphtheria, spreading from the larynx. Croup was at one time supposed to be mainly a tracheitis (cynanche trachealis), but it is now recognized that membranous inflammation of the trachea descends from the larynx.

Tubercle of the trachea occurs occasionally in association with tubercle of the larynx; ulceration follows the deposit of tubercle in the mucous membrane or submucous tissue. The ulcers are more common on the posterior wall, and commonly measure from two to four millimetres, but may reach ten millimetres in diameter. The symptoms due to tracheal tubercle are generally masked by those to which simultaneous disease of the larynx or the lung gives rise.

Syphilis, in its secondary and tertiary stages, also affects the trachea, producing in different cases, according to Mackenzie, congestion, condylomata (rarely), and superficial ulcers. The most important change, however, is stricture. This affects both the trachea and one or other bronchus. The trachea is affected most often at its lower end, less commonly at its upper end; and the stricture may consist simply of a narrowing at one spot, or a considerable length of the trachea may be reduced in calibre. The mucous membrane is raised into bands and ridges, which have been regarded as cicatrices of former ulcers, possibly preceded by gummata; but German pathologists look upon the thickening as a direct result of the syphilis, and any ulceration which may occur as secondary. In late stages the cartilaginous rings have been exposed, necrosed, and expectorated or absorbed. The stricture can be sometimes seen below the glottis by means of the laryngoscope.

NEW GROWTHS IN THE TRACHEA.

The trachea is remarkably little subject to primary new growths, whether benign or malignant. When present, they give rise to dyspnoea, and may be recognized, possibly, by the use of the laryngoscope. More frequently cancer of the œsophagus or of the mediastinum grows into the adjacent trachea, narrowing its channel and producing symptoms of stricture. Where it spreads from the oesophagus, it is preceded by dysphagia; but tracheal symptoms may be the first indication of cancer of the mediastinum. Another way in which the tumors affect the trachea is by simply compressing it from outside.

As the chief symptoms in all these cases depend on the reduction of the calibre of the trachea, and as this may be due to other causes besides such tumors, it will be well to consider separately the pathology and clinical features of tracheal obstruction.

TRACHEAL OBSTRUCTION.

This arises in three ways: (1) From compression from without; (2) from changes in the walls of the trachea itself (stricture); (3) from foreign bodies within it.

Compression of the Trachea.-The most common causes are mediastinal new growths, aneurism of the aorta or large vessels, enlargement of the thyroid body, and malignant tumors in the neck. Cancer of the oesophagus may also compress the trachea, but soon invades it, so that perforation takes place between the two tubes. Less commonly, caseation and suppuration of the bronchial glands may lead to their enlargement, by which the trachea is compressed. This is more common in children. The abscess may burst into the trachea, and pus or portions of caseous glands be expectorated. A case of compression by mediastinal abscess from caries of the spine is quoted by Fagge from Schnitzler. And, lastly, the trachea is sometimes pressed upon by the dilated left auricle in cases of mitral constriction.

Stricture. The chief cause is syphilis, which has been already considered. Foreign bodies are rarely retained in the trachea, but commonly fall into one or other bronchus, though they may be driven up and down the trachea by the respiratory currents.

Symptoms.-The most important are dyspnoea and stridulous breathing; they are often accompanied by cough, and the expectoration of thin frothy mucus. The voice is unaffected, or simply feeble from the obstruction weakening the current of expired air. The chest is resonant, but vesicular murmur is faint, or drowned by the noise of the stridor. Other symptoms accompanying tracheal stenosis are due to the lesion which causes it, and these may be entirely absent at first in a case of aortic aneurism or deeplyseated mediastinal tumor.

Diagnosis. This has to be made (1) between obstruction in the trachea and obstruction in the larynx; (2) between the different causes of tracheal obstruction.

The first may be determined at once by the laryngoscope, by which the absence of laryngeal disease may be proved, and even the presence of tracheal stricture, or of tumor or aneurism compressing this tube, may be observed; but there are other points of distinction that are of value, espe cially as patients with severe dyspnoea do not always readily submit to laryngoscopic examination. One is the fact noticed by Gerhardt, that in laryngeal obstruction the larynx is moved extensively up and down in the neck during respiratory movements, whereas in tracheal obstruction it moves but slightly. In laryngeal obstruction the head is thrown back; in tracheal obstruction it is often bent forward. The stridulous breathing does not always offer points for distinction. Dr. Fagge says it is mainly inspiratory in tracheal as it is in laryngeal obstruction; but the expiratory stridor in the former is certainly louder than commonly occurs in double abductor paralysis, and this is a form of laryngeal stenosis from which tracheal obstruction has often to be diagnosed: for instance, where symptoms point to aneurism or mediastinal growth, and the question is whether the dyspnoea is due to compression of the trachea, or of the recurrent laryngeal nerves. Under these circumstances, the growth may press both on the nerves and the trachea, and a double cause for dyspnoea exists, when even the laryngoscope will not help us to a knowledge of the condition of the trachea. Auscultation of the trachea is deceptive, as the loudest stridor is heard over the larynx even when the stenosis is in the trachea. This I have verified on more than one occasion. The point is of practical importance because laryngeal obstruction may be relieved by tracheotomy, but tracheal obstruction rarely so; and it is desirable to spare the patient an operation of this nature when it can do no possible good.

The recognition of the cause of tracheal obstruction depends upon collateral symptoms, which in cases of compression would reveal the presence of something involving other organs, and causing dysphagia, compression of the veins of the head, neck, or arm, or of corresponding nerves, dullness under the sternum, or at the upper part of one or other chest. On the other hand, stricture due, as already stated, to syphilis must be free from such symptoms; but an aneurism of the aorta may compress the trachea without, at first, any other symptom by which it can be recognized. For the diagnosis of mediastinal growth from aneurism, the reader is referred to those subjects.

Much that has been said of tracheal obstruction may be said of obstruction of a main bronchus. Aneurisms and mediastinal growths are the chief causes of compression; syphilis leads to stricture; and foreign bodies become lodged in it. The lower end of the trachea and one or both bronchi may

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