seems to be more beneficial than any other systemic treatment.
Destruction of the nodules and ulcerated tissues is indicated when the
diseased structures are sufficiently circumscribed and accessible. This
may be done with the sharp spoon or with the electric cautery. Silver
nitrate and iodine have been lauded as topical remedies.
Lepra of the Larynx.
Lepra is rare in the larynx.
ETIOLOGY.--Its cause seems to be climatic. In Europe it is most
frequent in Norway and Sweden, and in America in Cuba and the West
Indies.
PATHOLOGY AND MORBID ANATOMY.--It is always associated with cutaneous
lepra, and usually with lepra of the nasal passages and the pharynx.
According to Schroetter's observations, laryngeal lepra occurs as small
connective-tissue nodules on the epiglottis or in the interior of the
larynx, or as uniform thickenings, general or circumscribed. These may
lead to stricture. Extensive ulceration may ensue.
SYMPTOMS.--Dysphonia, aphonia, dyspnoea, cough, and local anæsthesia
are the main symptoms. Pain is infrequent.
DIAGNOSIS.--This depends upon the external manifestations of lepra and
the laryngoscopic detection of the characteristic thickenings and
nodulations.
PROGNOSIS.--This is unfavorable.
TREATMENT.--This must be conducted on general principles. Elsberg
commended iodoform topically and gurgun oil internally.
{133}
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. (See
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
membrane.
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 {134} 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, semi-transparent, and abundant. The
separation by forcible paroxysmal 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 mucorrhrea 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 situated 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 râles 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.
{135} [Illustration: FIG. 25. Acute Tracheitis: anterior wall.]
[Illustration: FIG. 26. Same case as Fig. 25: posterior wall.]
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 nitre-paper, 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, 1/16-1/8 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 {136}
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.[1] Tracheal oedema is
extremely rare even when the larynx is oedematous. 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.
[Footnote 1: _Transactions of the Edinburgh Medico-Chirurgical
Society_, vol. iii., 1828.]
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, {137} 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 epithelium 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.
[Illustration: FIG. 27. Tuberculous Ulceration of the Trachea, as seen
during life.]
[Illustration: FIG. 28. Same case as Fig. 27: post-mortem appearance.]
[Illustration: FIG. 29. Syphilitic Ulceration of Trachea, as seen
during life.]
{138} [Illustration: FIG. 30. Same case as Fig. 29: post-mortem
appearance.]
The seat of tracheal ulcers is usually the posterior wall and the lower
portion, unless the upper portion is affected by extension from the
larynx or by pressure from a tracheotomy-tube. They are found also in
other portions, and sometimes are so numerous that they give to the
membrane a sieve-like appearance. Occasionally they denude some of the
tracheal rings. In shape they vary, being mostly irregularly circular
or oval, and excavated or scooped out; in size they vary from that of a
pin's head to that of a marble. In tuberculosis they are generally
small and numerous, have a pale background, and are occasionally
confluent, while in syphilis they are usually isolated and large, very
destructive, and apt to cause contractions or other deformities by
{139} partial or extensive cicatrization. Such contracting ray-like
cicatrices have more than once produced fatal stenosis.
The SYMPTOMS are frequently obscure, but local pain and irritation are
usually, purulent or muco-purulent sputa are sometimes, present. The
diagnosis is difficult unless tracheoscopic examination reveals the
condition. Fig. 27 shows the tracheoscopical image, and Fig. 28 the
post-mortem appearance, of a case of tuberculous tracheal ulceration on
the upper portion of the front wall, while Figs. 29 and 30 show the
image during life and the appearance after death of a case of
syphilitic ulceration. In Fig. 30 the posterior wall is seen with the
ulcers, and below them a star-shaped cicatrix.
The PROGNOSIS generally depends upon the underlying disease, and is
grave because the latter is. Perforation may take place, as well as
cicatrization and hypertrophy, and either process may lead to a fatal
issue. In a number of instances post-mortem examination has shown that
tracheal ulceration may produce surprisingly great ravages before
destroying life.
TREATMENT, like the prognosis, depends somewhat upon the disease
underlying the ulceration. Pain is relieved by anodyne, and
cicatrization promoted by alterative inhalations, as of nebulized
glycerated solutions of morphine, ethereal solution of iodoform,
iodinic preparations, oil of solidago, citronella oil, etc. Catarrhal
ulcers heal without special treatment with the subsidence of the
catarrhal inflammation. In syphilitic ulceration, stenosis from
cicatrization is to be dreaded, and specific constitutional treatment
is the main reliance. The internal administration of cod-liver oil has
been found of service in nearly all cases of tracheal ulceration,
especially in phthisis, lupus, etc. Appropriate general treatment must
be combined with the local.
MORBID GROWTHS.
DEFINITION.--Tumors, benign or malignant, growing from the wall and
projecting into the interior of the windpipe. Inversion of the mucous
membrane forming a protrusion into the interior will be spoken of under
the head of Stenosis; and tumors of other organs extending into the
trachea, such as cancer of the oesophagus, lymphatic glands, thyroid
body, etc., are excluded from consideration under the present head.
FREQUENCY OF OCCURRENCE.--Aside from post-tracheotomic
granulation-tumors, which with careless tracheotomy or after-treatment
occur often, the disproportion in the frequency of laryngeal and
tracheal morbid growths is even greater than that of other laryngeal
and tracheal affections. I have met with only eight instances of
tracheal morbid growths, strictly so called, in a special practice
during more than twenty-five years. This is exclusive of
post-tracheotomic vegetations and tumors from contiguity.
ETIOLOGY.--Local irritations and chronic inflammatory conditions seem
often, if not always, to be the forerunners of tracheal tumors, but the
real cause of the latter is unknown. Recently it has been suggested
(see the article on LARYNGEAL TUMORS) that the ever-present bacilli
play a rôle in the production of morbid growths as well as in that of
other diseases. As it is known that some parasitical organisms on
plants use up their nidus very slowly, with the formation of peculiar
excrescences, while others very rapidly destroy the tissue of their
host, it would be easy to suppose that some such difference in the
micro-organism causing the tumor determines its benign or malignant
character.
Post-tracheotomic vegetations may arise from the irritating pressure of
a {140} tracheotomy-tube, especially from the use of a fenestrated tube
or a tube ill fitted to the patient. Some observers are of opinion that
such tumors existed before the performance of the operation, and,
indeed, led to it, even though the supposed reason may have been
laryngeal or some other tracheal disease. While it cannot be denied
that such may have been the case sometimes, there is no doubt that in
other instances--and not only in those in which the vegetations "always
grow from the cicatrix" (Petel)--they are truly caused by the
operation, or by the wearing of the tube, especially if it be in any
way unsuitable as to size, form, etc.
SYMPTOMATOLOGY.--The symptoms of tracheal tumors are local irritation;
tickling or other morbid sensation, sometimes inducing and sometimes
not inducing cough; and encroachment upon the
breathing-space--dyspnoea--depending on their precise seat, size, and
rapidity of growth. It is usually difficult for the patient to specify
the beginning of his trouble, because, on account of the large size of
the windpipe, dyspnoea generally comes on very gradually. An accidental
catarrhal condition of the tracheal mucous membrane from a cold usually
first arrests the patient's attention. The very great diminution of the
calibre of the tube that the patient can bear when the tumor enlarges
slowly is sometimes astonishing. Unless the tumor is pedunculated (so
that expiratory efforts can throw it up into the larynx), which is
generally not the case, expiration and inspiration are equally
affected, both becoming gradually more and more labored and noisy.
Sometimes the act of swallowing large morsels brings on an increased
dyspnoea; sometimes respiration is accompanied by a sort of valvular
sound. Cough is frequently, but not always, present, and depends,
together with expectoration, upon either coincidental catarrhal
condition or irritation from the tumor: in the latter case it is
essential, dry, and persistent, and may vary with the position of the
patient. Sputum may be bloody and even contain shreds of the tumor, as
in similar cases of laryngeal growth. With increase of the tumor the
voice becomes weak and suffers in extent of range, as in other cases of
tracheal stenosis; the same is true of the diminished rising and
falling of the larynx. The course and duration of the disease vary
considerably with its nature. I have observed a tracheal fibroma to
remain stationary for eight years, when the patient died from other
causes and the diagnosis was confirmed post-mortem; and, on the other
hand, a cancer to grow so rapidly that the patient died from
suffocation within five months of its first causing the slightest
symptom. If not relieved, suffocatory paroxysms, with or without
consequent bronchitis and pneumonia, lead to a fatal termination.
PATHOLOGY.--As in the larynx, so in the trachea, the pathological
character of neoplasmata is generally that of papilloma. Of my eight
cases, all observed during life, four were papillomatous (two examined
microscopically after successful extirpation, one post-mortem, and one
in situ macroscopically only), one was a fibroma, microscopically
examined, one an osteo-chondroma, one a sarcoma, and one a carcinoma,
the three last having been examined post-mortem.