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 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.
| FIG. 25. |
| Acute Tracheitis: anterior wall. |
| 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 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.
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, 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.
| FIG. 27. |
| Tuberculous Ulceration of the Trachea, as seen during life. |
| FIG. 28. |
| Same case as Fig. 27: post-mortem appearance. |
| FIG. 29. |
| Syphilitic Ulceration of Trachea, as seen during life. |
| 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 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 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.
Of non-malignant tracheal tumors observed by others, the large majority were papillomata; next in number come fibromata. Aside from these two kinds of tracheal tumor, the cases recorded in literature are the following: Rokitansky more than thirty years ago described tracheal enchondromata found after death; and Cohen discovered in the corpse of a phthisical patient a number of small enchondromata on the central portions of the tracheal cartilages. Steudener, Demme, Wilks, Chiara, and Eppinger have observed, post-mortem, tracheal osteomata. Gibbs has described a tracheal cystic tumor2 seen with the laryngoscope; Müller, under the guidance of Gerhardt, a myxo-adenoma observed tracheoscopically and carefully studied during life and after death; and Eppinger has recorded a case of post-mortem tracheal adenomata and cysts, Simon having previously found three similar tumors on dissecting a new-born tigress. Virchow speaks of the occurrence of retro-tracheal retention-cysts, and Gruber has observed several; but there can be no doubt that at least some of the tumors thus described are nothing but circumscribed dilatations of the tracheal mucous membrane—practically, dilated mucous glands. As to malignant tumors, in addition to my two cases Schrötter has reported two cases of sarcoma, and Labus one of fibro-sarcoma, while Rokitansky, Klebs, Koch, Schrötter, Langhans, and Mackenzie have described cases of carcinoma.
2 Cohen questions whether this was a cyst or an abscess. It burst spontaneously.
Cases of cancer of the oesophagus, which involve the trachea—excluded, as before stated, from present consideration—are, comparatively speaking, by no means rare, and are apt to establish a fistulous communication between the two tubes.
DIAGNOSIS.—The symptoms mentioned are those common to nearly all cases of tracheal stenosis, and will be referred to again under that head. Tracheoscopy alone makes the diagnosis certain; unless when the seat of the disease is ascertainable without, its nature is shown by the expectoration of portions of the tumor. The first case of tracheal tumor ever diagnosed during the patient's life was observed by means of the mirror by Tuerck in 1861; but it is very difficult in the mirror to estimate distances as to depth, and unless the number of tracheal rings above a tumor can distinctly be counted, a growth in the lower cavity of the larynx may readily be mistaken for one in the trachea, and vice versâ. Catheterism of the trachea shows the distance at which the tumor is situated, sometimes very accurately, but it is dangerous unless performed under the guidance of the mirror, and even then requires great care. The introduction without the mirror of a probe or sound for the same purpose is still more dangerous and unjustifiable, while with the mirror it is perfectly safe in proper hands. Localized protrusion of the mucous membrane into the interior is the condition which most simulates tracheal tumor. (Compare [Fig. 32].)
| FIG. 31. |
| Papilloma of Trachea. |
The pathological nature of a tracheal tumor can sometimes be determined in situ with more or less probability. Without microscopical examination it is not always possible to say whether a growth is benign or malignant unless the mass has advanced to ulceration, and then specific disease must be excluded by the history and concomitant symptoms. Papillomata have a peculiarly uneven surface; fibromata are usually more smooth. With equally good illumination, tumors of the trachea resemble tumors of the larynx, and may be similarly differentiated. The former are almost always non-pedunculated, or at least none of those hitherto observed have had a long pedicle. Their seat is generally the posterior wall, or the cicatrix of the anterior wall after tracheotomy. In Fig. 31 is seen the tracheoscopic appearance of one of my cases of tracheal papilloma.
PROGNOSIS.—The prognosis is always unfavorable in malignant cases, and also in non-malignant when the tumor grows rapidly or has already attained a large size. The introduction of the laryngoscope has bettered the prognosis, inasmuch as in many cases early recognition enables us, by performing tracheotomy, to prevent sudden death from suffocation, and also because by the aid of the mirror removal has been accomplished through the natural passages.
TREATMENT.—Removal of a tracheal tumor through the natural passages by means of either cutting or cautery instruments requires so much special ability on the part of the operator that it need not be described in detail in a work designed for general medical practitioners. When the tumor is situated above a point at which tracheotomy can be judiciously performed, no physician worthy of the name should hesitate to lay open the trachea in any case in which suffocation is impending. Removal of the tumor by surgical operation after opening the windpipe may be attempted or not according to circumstances, but in all cases palliative measures by sedative inhalation and otherwise may be resorted to, and the patient's general health, especially in malignant cases, must be kept up as much and as long as possible.
STENOSIS.
DEFINITION AND PROXIMATE ETIOLOGY.—Stenosis is narrowing or more or less occlusion of the windpipe. It is either stricture or constriction from within, or compression from without, or both combined. Constriction within the trachea is due to swelling or thickening or cicatricial displacement of the mucous membrane or other tissue, inversion of its walls, or morbid growth or foreign body in its interior. Compression from without is due to goitre (which has in some cases prevented viability) or other disease of the thyroid body; aneurism; abscess; enlarged bronchial glands or cervical lymphatics; disease of the sternum, clavicle, or vertebræ; mediastinal tumor; cystic, emphysematous, or other tumor of neighboring tissue; or foreign body. According to Rose's observations of goitre,3 compression of the trachea leads to fatty degeneration of the cartilages and their subsequent softening and absorption; after which, the windpipe having become membranous throughout and no longer patulous, death can easily—in some positions or flexion of the body, etc.—take place.
3 Der Kropftod und die Radicalcur der Kröpfe, Berlin, 1878.
In acute tracheitis, though there is swelling of the mucous membrane, the large size of the tube usually obviates stenotic symptoms, while chronic tracheitis does occasionally lead to sufficient contraction to interfere with respiration; but generally stenosis is the result of syphilis, and frequently follows ulceration and cicatrization. In a case recorded in the Bullétin des Sciences médicales for January, 1829, the lumen of the trachea was reduced to two lines.
| FIG. 32. |
| Involution of Trachea, due to aneurism. |
SYMPTOMS AND DIAGNOSIS.—The main symptom is the peculiar, gradually increasing dyspnoea; once observed, it is recognized without much difficulty. There may also be mucous râles; cough rough and sibilant; attempts at clearing the throat without expectoration, or occasionally with some expectoration, which is at first light-colored, then streaked with blood, and at last purulent, but never abundant (unless accidentally complicated by catarrh), and always difficult to eject; perhaps occasional pain, but constant disagreeable sensation (tightness) in the trachea just above the sternum. Tracheoscopy settles the diagnosis. The tracheal rings are seen either as diminished circles or arcs—sometimes concentrically placed, sometimes in two different directions, as shown in a case of tracheal stenosis from compression causing protrusion of the mucous membrane into the interior, represented in Fig. 32, or else constricting bands are visible.
As to the dyspnoea, both inspiration and expiration are affected—frequently, however, the former more than the latter, as is shown by pneumatometry. The head is thrown forward and the chin up; the larynx moves up and down less energetically than in health (while the respiratory movements of the larynx are abnormally increased in laryngeal dyspnoea); the thorax is less expanded than normally, especially its upper portions.
As to catheterization and probing, see the remarks under the head of Morbid Growths.
PATHOLOGY.—The pathological changes in cases of stenosis vary with its cause. In the great majority of cases of stricture from within, syphilis—antecedent ulceration followed by cicatrization—has produced the stenosis; in compression thyroid disease, and next often aneurism, is the cause. The stenosis is most frequently situated in the lower, next in the upper, and least in the middle, portion; more often than the latter alone the whole tube is affected.
PROGNOSIS.—This is rather favorable with timely and proper treatment unless a continuing active cause be irremovable; without treatment, however, the cases almost invariably terminate fatally from pneumonia, tracheal spasm, apnoea as before explained, etc.
TREATMENT.—When the symptoms are urgent and the stenosis is not too low down, tracheotomy must be performed. Sometimes a very long and flexible tube may be introduced with success in case of very low stenosis, but more often tracheotomy is disappointing on account of the stenosis extending too low down even when its beginning is higher up.
Stricture, especially when the symptoms are not very urgent, may be relieved by dilatation through the natural passages, with, or if possible without, previous tracheotomy. The cure of compression implies removal of the compressing tumor or disease. Soothing inhalations, such as of hops, benzoin, etc., diminish irritation and give temporary relief.
DILATATION (HERNIA, FISTULE).
Dilatation of the trachea is either confined to the tube (when the synonym tracheaectasy is applied to it) or is diverticular. In the former case it may involve only a part or else the whole extent of the windpipe. Whenever free respiration, especially expiration, is chronically impeded, some portion of the air-tract below the obstruction is apt to become dilated; thus, a bottle-shaped dilatation is sometimes found immediately below an annular contraction. On the other hand, tracheaectasy may extend upward from bronchiectasy. It has been observed post-mortem to a slight extent in public criers, trumpeters, etc., and in old coughers from laryngeal disease, chronic bronchitis, pulmonary emphysema, etc., but without giving rise to distinct symptoms during life.
Diverticular dilatation forms an air-containing tumor which either looks into the oesophagus or is discernible on the outside of the neck. Though rarely met with, it ought to be thought of in all appropriate cases, and when pointing externally ought always to be recognized by the careful practitioner. It is either hernial, glandular, or fistular—three pathological conditions which have hitherto been confounded. On account of the construction and position of the trachea there can be but little protrusion outward without previous dilatation. Unless there be a deficiency of the cartilaginous rings, only the posterior wall, which is always unsupported, and to a slight extent also the intercartilaginous membranous portions, are liable to tracheal hernia. This is properly called tracheocele; but the various terms aërial goitre, aërial bronchocele, pneumatocele, tracheal air-cyst, tracheal retention-cyst, internal tracheal fistule, subcutaneous or incomplete fistule of the trachea, have been indiscriminately used as synonyms of tracheocele, and have added all the more to the confusion, as some of them originated, no doubt, as correct appellations of the particular cases to which they were applied. Aside from the occasional occurrence, both congenital and acquired, of tracheo-cutaneous fistule, complete and incomplete, and the still more rare occurrence of hernia of entire portions of the mucous membrane, the cases of diverticular dilatation of the trachea—or saccular tracheaectasy, as it may be called—are glandular, as found by Rokitansky more than fifty years ago. Virchow seems to regard all such glandular dilatations as retention-cysts (see Morbid Growths), but although retro-tracheal retention-cysts doubtless do occur (Gruber has reported two unquestionable instances), and although the tumors now under consideration do in fact sometimes contain a little mucus in addition to air, they do not constitute cysts or adenomatous new growths, but are simply distended portions of the tracheal mucous membrane, respiratory glands, whether the dilatation be caused, as Rokitansky thought, by traction (Zerrung) and hypertrophy of the mucous glands, or, as Eppinger suggests—and which is more likely—mainly by increased intra-tracheal air-pressure. There must, however, I think, coexist some deficiency or weakness of the cartilaginous or other tissue, either congenital or acquired.
When the dilatation is retro-tracheal only, the symptoms are very obscure, and diagnosis during life is at best uncertain. In one such case under my care, confirmed (death having occurred from another cause) by post-mortem examination, there was some dysphagia and slight alteration of the voice. In all other cases the characteristic and unmistakable sign of the disease is the peculiar intermittent, or, at all events variable, aërial cervical tumor. It increases and diminishes with forcible expiration and inspiration, and attains its largest size during violent coughing, hawking, blowing of the nose, or other expiratory effort. Occasionally the voice is considerably affected. The tumor, especially by the manner in which it can be made to temporarily disappear and reappear, can usually be easily differentiated from subcutaneous emphysema and goitre, the only two conditions with which it might be confounded. In the fistular variety the opening into the trachea can sometimes be seen by means of tracheoscopy.
Aside from the deformity which the tumor may cause, it sometimes induces laryngeal spasm and dyspnoea; otherwise it is of no gravity.
As to TREATMENT, methodical and continued compression by applications of astringent collodion or by mechanical means is the only palliative measure applicable; when suffocatory attacks call for it, tracheotomy must be performed.