Chapter XXIX: Introduction (14)

=Aphonia= is commonly caused by a dislocated atlas. The aphonia may also be caused by swelling of the vocal cords and tissues about them and by serous effusions of the laryngeal muscles. The larynx may be prolapsed slightly and if raised quickly relieved. Difficult breathing and hoarseness are occasionally very troublesome symptoms. The former is due to an inability of the glottis to dilate, on account of swelling of the mucous membrane of the diseased parts and from drying of the secretions on them, thus increasing the obstruction (this is sometimes termed pseudocroup) but expiration is easy, the stridor is from the inspiration; the latter is due to a collection of mucus on the vocal cords or the cords may become relaxed, swollen or roughened.

Another annoying symptom sometimes presented is pain on deglutition, which is due to swelling of the mucous membrane of the upper laryngeal passages and the epiglottis. In all of these annoying symptoms, persistent, thorough, direct treatment of the larynx is of value. On the whole, careful, continued treatment of the cervical innervation and vascular supply of the larynx, as in the acute form, is indicated.

In all laryngeal disorders, if condition permits, hyperextend the neck while the patient is lying supine and thoroughly relax the soft tissues about the organ and then carefully raise it.

Laryngismus Stridulus

(Spasm of the Glottis)

=Definition.=—A spasm of the muscles of the larynx that are supplied by the inferior or recurrent laryngeal nerves. This is commonly not excited by an inflammatory condition, but it is usually a purely nervous condition.

=Osteopathic Etiology= and =Pathology=.—Spasm of the glottis is usually found in children with =enlarged tonsils and adenoids=. It has been observed that rickets and syphilis are probably frequent underlying causes. The spasm is occasionally associated with tetany. The nervous factor is the immediate and important consideration. Cervical lesions, both vertebral and muscular, are invariably found. Then nasopharyngeal and tracheal disorders and reflex digestive disturbance are exciting causes. An elongated uvula or a deranged hyoid bone will occasionally be exciting factors. Subluxation of the upper two or three ribs and of the clavicle may also be exciting factors.

The affection is usually found in children under five years of age. All cases are not of a distinct nervous type, for slight acute catarrhal laryngitis may be present.

=Symptoms.=—There is a sudden onset and the spasm may occur on waking from sleep, but it may come on either in the night or day. The disease starts with a sudden arrest of breathing, the child struggles for breath; there are tonic muscular spasms and the face becomes congested in a few seconds. This is followed by sudden relaxation of the spasm and the air is drawn through the glottis with a shrill, crowing sound. Several spasms may occur in a day or they may be weeks apart. Death rarely occurs.

=Diagnosis.=—The absence of fever, cough and hoarseness and its distinctly intermittent nature will differentiate it from croup. Should there be any question of diagnosis a bacteriological examination is advisable.

=Prognosis.=—The prognosis is almost always favorable. In very young children death from suffocation may occur, but rarely.

=Treatment.=—The treatment should be applied either centrally or peripherally, depending altogether upon the location of the irritation. If the irritation is of central origin, that is, through the innervation from the brain and spine, a correction of the superior and inferior laryngeal nerves is necessary; if the stridor is due to peripherial irritations, a correction of the end-plates (muscles) over and about the larynx is required in order that the spasms be relieved.

Thorough treatment should be applied to the upper part of the chest and diaphragm, chiefly the phrenic nerves at the third, fourth and fifth cervicals and over the eighth, ninth and tenth ribs anteriorly, in order that the spasms may be prevented from extending to the intercostal muscles and the diaphragm.

Placing the patient in a hot bath will be of service in some cases when the spasms are severe. Alternating hot and cold packs about the throat are of service. The air of the room should always be kept moist. Care should be taken that the trouble is not due to gastro-intestinal disorders or to dentition. Keep the child upon a fluid diet of milk, meat broths and egg albumin.

In the more severe cases the well known osteopathic method of relaxing and inhibiting the soft palate and contiguous tissues will stop the spasm.

Spasmodic Laryngitis

(False Croup)

=Definition.=—A catarrhal inflammation of the mucous membrane of the larynx with spasm of the glottis.

=Osteopathic Etiology= and =Pathology=.—This affection is practically the same as laryngismus stridulus associated with catarrhal inflammation of the mucous membrane. It is a disease of young children. Derangements of the innervation and blood supply to the laryngeal mucous membrane and muscles of the larynx are found in the same locality as noted under acute catarrhal laryngitis and laryngismus stridulus. There is acute catarrh causing a croupy cough, and difficult breathing due to spasm of the glottis.

=Symptoms.=—These attacks generally occur during the night, the child being suddenly awakened by severe paroxysms of suffocating and a dry, hard cough, associated with evidences of dyspnea. In half an hour or an hour or two the coughing ceases, perspiration follows and the child falls asleep. If proper treatment is not given, these attacks may occur for several successive nights, the child appearing almost or quite well during the day.

=Diagnosis.=—The symptoms are so characteristic that the diagnosis is easy. In all instances the prognosis is favorable.

=Treatment.=—The catarrhal inflammation of the mucous membrane of the larynx should be treated in the same manner as simple inflammation of the laryngeal mucosa, i. e., thorough treatment of the cervical spine and direct treatment over the larynx.

During the paroxysm, if the patient cannot be relieved very shortly by the cervical treatment, he should be placed in a hot bath of a temperature from 98 to 110 degrees F. This will, in the majority of cases, relieve the attack. In addition a hot compress may be placed about the throat. Producing emesis by irritating the fauces with the finger is necessary in a number of cases in order that the secretions in the laryngeal region may be ejected, thus relieving suffocation and labored breathing. Also, an overloaded stomach which is causing an irritation, should be emptied at once by vomiting. The bowels should be kept well open in all cases. Occasionally the epiglottis becomes wedged in the chink of the glottis. Such a condition requires an introduction of a finger into the fauces to release the disorder.

Care should be taken, especially following an attack, that the child is not exposed to cold or rapid changes of temperature, so as to avoid repetition of the spasms.

=Coughing.=—Coughing, not only in spasmodic laryngitis, but also in various diseases where coughing is a prominent symptom, is a most irritating and annoying feature. The osteopath is many times called upon to relieve the cough, whether it is due to slight irritation of a nerve fiber alone or is a symptom of a serious chronic disease. The coughing center is located in the medulla oblongata; the afferent nerves are sensory branches of the vagus; the efferent nerve fibers are found in the nerves of expiration and in those that close the glottis. Consequently, coughing may be caused by stimuli to various sensory nerves, various cutaneous areas (chiefly the upper part of the body), mucous membrane of the respiratory and digestive tracts, the mammae, liver, spleen, ovaries, uterus, kidneys, etc. Perhaps the most common cause of cough is contraction of some of the muscles of the neck, irritating sensory fibers. Contraction of the omo-hyoid muscle may produce an irritating cough by causing traction on the hyoid bone. In a few cases the larynx may prolapse to some extent and thus be a source of irritation. Lesions of the spinal cord between the seventh and eighth dorsal, also at various points above in the dorsal vertebræ and in the ribs (especially at the second and third ribs), are very apt to produce a cough. Impaction of the sigmoid flexure is oftentimes accompanied by coughing. Enlargement of the heart may cause pressure upon the respiratory tract directly and cause a deep, dull cough. Foreign bodies in the external meatus of the ear are occasionally a source of irritation which is accompanied by coughing. Thus there are innumerable sources of stimuli that may produce coughing. In all cases it is necessary to make a careful diagnosis as to whether it is an irritation to some fiber that can be corrected at once or whether it is a symptom of a disease that can only be relieved by the cure of the disease. In local congestions the cold pack will often be of service.

Tuberculous Laryngitis

=Definition.=—An inflammation of the laryngeal tissues of tuberculous origin.

=Osteopathic Etiology= and =Pathology=.—Tuberculosis of the larynx is commonly secondary to pulmonary tuberculosis. In a few cases the laryngeal invasion may be of primary origin. In either instance there will be found a disturbed innervation or altered blood supply of the larynx that predisposes to the multiplication and growth of the bacilli. The osteopathic lesions are similar to those found in other involvements of the larynx.

=Pathologically=, the mucous membrane is inflamed and swollen, and exhibits scattered tubercles, which are usually about the blood-vessels. The tubercles cluster, caseate and leave shallow, irregular ulcers. There is thickening of the mucosa about the ulcer, and the ulcer is generally covered by a grayish exudate. They may erode the true vocal cords, often destroying them completely. The ulcers slowly involve the tissues in all directions, causing perichondritis with necrosis of the cartilages. The mucous membrane of the pharynx, esophagus, fauces, and tonsils may be involved, and the epiglottis may be completely destroyed.

This disorder, strictly, should be discussed under pulmonary tuberculosis for, as heretofore stated, it is generally a secondary affection; the larynx being invaded by the tubercular bacilli in the sputum arising from the bronchial tubes and lungs. The bacilli in inspired air may primarily invade the laryngeal mucosa. However, in either case the circulation of the mucosa is not normal and osteopathic correction of the same is effective.

=Symptoms.=—Huskiness of the voice, followed by hoarseness, and in advanced stages aphonia, are prominent symptoms. A hacking cough is usually present and the patient complains of pain in the throat, particularly on coughing, swallowing or speaking. The loss of voice, painful speaking or whispering are quite characteristic. When the ulceration of the tissues of the larynx has progressed to a later stage, dysphagia, suffocation and distressing paroxysms of cough occur.

=Diagnosis.=—Is not difficult, as pulmonary phthisis is usually associated with it. Examination of the sputum for the specific bacilli will be conclusive.

=Prognosis.=—The prognosis is not of the best at any time. On the whole, it is unfavorable.

=Treatment.=—In this disease osteopathic treatment has been quite effectual. Cases of primary origin are more successfully treated than when of secondary cause, although one will be surprised many times at the results obtained when the disorder is not primary. The treatment must necessarily be both constitutional and local. Care of the general health as to hygiene and diet is absolutely necessary. The food must be nutritious and non-irritating. Scraped beef, raw oysters, raw eggs, soups and gruel are required. In cases where difficulty of deglutition occurs, it may be largely overcome if the patient hangs his head over the side of the bed and sucks through a tube liquid nourishment placed in a dish upon the floor.

The local treatment required is careful, persistent work over the larynx and adjacent tissues. The treatment is given to increase the blood supply to the diseased tissues so that healing may take place, and that the bacteria may be deprived of the conditions favorable to their activity. Treatment along the cervical spine and upper dorsal will aid in correcting the vasomotor disorders that exist. Local application of hot water will assist in relieving the pain. When pulmonary phthisis exists, attention and correction of it is important; in fact, is of primary consideration in laryngeal affection.

Syphilitic Laryngitis

=Etiology.=—This disease is of frequent occurrence, due to inherited syphilis, or to the secondary or tertiary stages of the acquired form.

=Symptoms.=—There is a hoarseness of the voice, a hacking cough, difficulty in swallowing and the various symptoms of catarrhal laryngitis. The secondary form may present superficial, whitish ulcers on the cords or ventricular bands, while in a tertiary stage the lesions are extensive and serious. Deep ulcers with raised edges are present, gummata develop on the submucous coat of the epiglottis and there may be necrosis and exfoliation of the cartilages. Deformity is produced by the cicatrices following the healing of the ulcers and sclerosis of the gummata. Edema of the larynx may suddenly prove fatal.

=Diagnosis.=—The history of the case, the presence of other symptoms of the disease, the deep, symmetrical ulcers, the absence of tuberculosis elsewhere and the absence of marked pain, will usually make a diagnosis easy.

=Prognosis.=—Is somewhat favorable, more so at least than the tubercular form of laryngitis. There is great danger of deformity and permanent impairment of the voice.

=Treatment.=—The treatment should be both constitutional and local. Active measures must be taken to rid the system of the virus of syphilis, and thorough, direct treatment should be applied to the larynx and to its innervation. If the cicatricial stenosis has progressed so far that there is little hope from manipulative treatment, tracheotomy or gradual dilatation should be performed. The ulcerated portion is always to be kept clean.

Edematous Laryngitis

=Definition.=—An acute inflammation of the mucous membrane of the larynx with infiltration of serous fluid into the submucous tissue.

=Etiology.=—This is a very serious affection. It may occur in connection with acute laryngitis, though rarely, and occasionally with chronic diseases of the larynx, as tuberculosis and syphilis. It may be a complication of some acute infectious disease like diphtheria, scarlet fever, or erysipelas of the face. It sometimes occurs suddenly in the course of Bright’s disease. Lesions as in acute laryngitis are predisposing factors.

=Pathologically=, there is marked swelling of the epiglottis. The swelling can very easily be felt with the fingers. The mucous membrane is tense and changed in color. There is infiltration of a serous or sero-purulent fluid into the loose connective tissue of the larynx. The arytenoepiglottic folds are greatly involved, and they may be swollen to such a degree that they almost meet.

=Symptoms.=—Extreme dyspnea and stridulous respiration. Hoarseness of the voice and later aphonia. There is a feeling of intense oppression or suffocation. Evidence of dyspnea, anxious face, blue lips, protruding eyes and retraction of the base of the chest occur. The sternocleidomastoid muscle is very prominent.

=Diagnosis.=—This is not difficult. The history of the case, laryngoscopic examination, and the swollen epiglottis which can be easily felt with the fingers make diagnosis easy.

=Prognosis.=—Generally unfavorable. At any time it is extremely grave, but with prompt and vigorous treatment recovery is possible.

The duration varies from a few hours to several days.

=Treatment.=—One must attend strictly and carefully to the laryngeal innervation, as in acute catarrhal laryngitis. Obstruction to the superior or inferior thyroid, facial, internal jugular or innominata will cause tumefaction and edema of the larynx and adjacent tissues. Also, enlargement of the lymphatics about the larynx and salivary glands may produce edema of the laryngeal region; consequently, particular care should be taken of the various tissues about these vessels and of the innervation from the cervical spine, so the veins are not obstructed or the lymphatic channels disordered, so that infiltration of the tissues may be further prevented.

The most prominent symptom is laryngeal dyspnea and this depends altogether upon the swelling of the soft parts. If the swelling is great and the disorder cannot be removed, suffocation will follow. In such cases, besides giving direct treatment over the larynx, introducing a finger into the mouth, and reaching clear back under the roof of the soft palate, with a firm, downward, outward and sweeping movement on either side, relax the soft tissues. The persistent use of small pellets of ice, held far back in the mouth, will be found very beneficial; also, application of the ice-bag, provided the edema is of inflammatory origin.

If one is not able to control the rapid infiltration of the larynx and glottis when such cases arise, tracheotomy or intubation should be performed at once. When edematous laryngitis is due to diseases of the heart, lungs and kidneys, treatment of the primary disease should be given in addition to the local treatment.

FOOTNOTES:

[92] For diseases of the nose see Deason, Part 1, Page 257.

DISEASES OF THE BRONCHI

Acute Bronchitis

=Definition.=—A catarrhal inflammation of part or whole of the mucous membrane of the larynx, trachea and bronchial tubes, or it may extend into the capillary tubes. This is bilateral, affecting more or less the bronchial tree in both lungs.

=Osteopathic Etiology= and =Pathology=.—The most common cause of acute bronchitis is “catching cold.” It is more prevalent in the winter, and it often succeeds an ordinary cold in the head, coryza or laryngitis, the inflammation extending downward from the upper air passages. A case of acute bronchitis always presents a contracted condition of the muscles on either side of the spine in the upper dorsal region. The contracted muscles may extend as far down as the middle dorsal or as high as the entire cervical. Occasionally, the ribs posteriorly are drawn downward by the extreme contraction of the muscles, and the upper anterior part of the chest may be somewhat constricted and limited in its movements by the tensed muscles. Thus, in a few cases the ribs and upper dorsal vertebræ are actually subdislocated by the extreme contraction of the muscles. The principal points affected are the second, third, fourth and fifth dorsal regions. In a few instances cervical lesions disturbing the vagus and resulting in motor weakness of the tubes, will be noted. The osteopathic control of the bronchial vasomotor nerves is in this region (dorsal).

The disease is also associated with measles and it is usually a symptom of influenza. One attack predisposes to another. It affects either sex and especially children and the old, in whom it most frequently involves the smaller bronchi. In adult life it involves the larger bronchi. Micro-organisms, particularly the pneumococcus, influenza bacillus, and micrococcus catarrhalis, act as exciting causes.

=Pathologically=, the mucous membrane of the portion of the trachea and bronchi that are implicated become reddened, congested and more or less covered with a tough mucus mingled with epithelial cells. The hyperemia is most marked about the mucous glands. Some of the smaller bronchial tubes are dilated. In severe cases there is desquamation of the ciliated epithelium, swelling and edema of the submucosa, and infiltration of the tissues with leucocytes. The affection involves chiefly the vasomotor nerves. In cases on the verge of chronicity, look well to the diet; especially lessen in amount the starchy and saccharine foods.

=Symptoms.=—The onset of acute bronchitis is accompanied by the symptoms of a common “cold.” In the beginning the cough is hard and dry without expectoration; but later it is looser, the secretion becoming mucopurulent and abundant and finally purulent. The scanty sputum is at first glairy and mucoid, while later it becomes more abundant and mucopurulent and contains pus cells and desquamated epithelium. When the bronchial inflammation becomes fully established, there is a feeling of tightness and rawness beneath the sternum and a sensation of oppression in the chest, due to swelling of the mucous membrane and the presence of secretions which cause stenosis of the bronchial lumina. There is a slight fever, rarely exceeding 101 degrees F. The disease lasts from four or five days to three weeks. There is either a complete recovery or chronic bronchitis is developed.

=Physical Signs.=—There may be no physical signs in slight attacks of acute bronchitis of the larger tubes. In severer cases the physical signs are well marked. =Inspection= may recognize increased frequency of breathing, and when the smaller tubes are involved there is dyspnea. =Palpation.=—The bronchial fremitus may often be felt, providing there is sufficient narrowing of the breathing tubes. =Percussion.=—Sounds are normal as long as the bronchitis is uncomplicated. =Auscultation.=—In the early stage piping, sibilant rales may be heard on both sides. These rales are inconstant and appear and disappear with coughing. There may be harshness of breathing added to these. When resolution sets in, the rales change and become mucous and bubbling in quality. Vocal resonance in bronchitis is normal, unless complications occur.

=Diagnosis.=—This is generally easy. The absence of dullness and blowing breathing and the bronchial character of the cough and expectoration are usually sufficient to distinguish it from pneumonia and pleurisy. If the physical signs are noticed carefully, the diagnosis is rendered easy and positive in all cases.

=Prognosis.=—In the very young and the very old, the prognosis is unfavorable, but in a previously healthy adult the most that can happen to a case of acute bronchitis is to become chronic. Recovery is the rule; even in the aged and feeble death is rare. If osteopathic treatment can be instituted from the inception, the disease will probably be aborted. The treatment almost invariably lessens the severity and duration of an attack. For capillary bronchitis see Bronchopneumonia.

=Treatment.=—Complete rest in a warm bed, and a hot foot bath would cure a large majority of cases in a day or two if the patient would only submit to such treatment. Most of them wish to be around and out doors and very likely attending to their usual work, so that a cure in some cases is hard to perform. They are very liable to take more “cold” and in a few cases it will take great effort to prevent the bronchitis from becoming chronic. One thorough treatment per day will usually be sufficient.

The hyperemic condition of the bronchial tubes is due to a vasomotor disturbance, generally caused by a severe contraction of the muscles of the back in the region of the first to fourth dorsal; although the vasomotor nerves to the mucous membrane of the bronchial tubes may be affected anywhere from the first to the seventh dorsal inclusive. Contraction of the muscles over the anterior part of the chest corresponding to these regions and caused by the same influences (chiefly atmospherical changes) is of quite common occurrence. In the majority of cases the contraction of the chest and back muscles is so severe that the ribs are partly displaced by the tension and thus is added a complication to the disorder, and from this complication chronic bronchitis is liable to occur. The ribs or even vertebræ to the corresponding region oftentimes remain partly dislocated and are a source of continued and permanent irritation to the innervation of the bronchial tubes. So it is always necessary in treating any form of bronchitis to see at each treatment that the ribs and vertebræ from the first dorsal to the seventh dorsal, inclusive, are anatomically correct.

As has been stated, the disordered muscles or ribs may be affected anteriorly as well as posteriorly; consequently, the treatment applied is a thorough relaxation of the chest and back muscles and the correction of the ribs and vertebræ in order that the vasomotor disturbance of the bronchial mucosa may be corrected and the inflammation relieved. An excellent method to release the immobilized anterior upper chest is to place patient flat upon his back with pillow beneath upper dorsal. This hyperextends spine, enlarges spinal foramina, and tends to elevate ribs. Then by use of arms as levers, moderate inspiration, and employment of one hand over anterior end of ribs they may be easily released and raised. This treatment effects circulation, innervation, lymph tissue, and rib bone marrow.

In addition to the dorsal spinal nerves, and the sympathetic, the vagi are to be considered in the treatment of bronchitis, as all of these nerves, sympathetic, spinal, and vagi, go to make up the anterior and posterior pulmonary plexuses from which the bronchial mucosa receives its innervation. The veins particularly involved in passive hyperemia of the bronchial tubes are the superior intercostal and azygos major; so raise and spread the ribs to give greater freedom to these blood-vessels.

“The blood flow may be diverted from the bronchi to the abdomen by a slow, deep, inhibitive treatment over it, including pressure over the solar and hypogastric plexuses.” (Hazzard).

The excretory organs and the diet of the patient should be attended to. Especially in children, the diet had best be a fluid one, as milk, egg albumin, meat broths and meat juice. For those who are subject to the disease an outdoor life is best.

Chronic Bronchitis

=Definition.=—A chronic inflammation of the mucous membrane of the large and middle sized bronchial tubes.

=Osteopathic Etiology= and =Pathology=.—Chronic bronchitis may be either primary or secondary. The primary form is the result of exposure to wet and cold or to the daily inhalation of irritating vapors or dust. This form is rare, the affection being almost always a secondary one, and is most commonly met with in chronic lung affections, heart disease, gout or renal disease. It may be caused by any disease which favors congestion of the air tubes by obstruction of the circulation; especially mitral diseases and Bright’s disease. It is also caused by chronic alcoholism and may be the result of repeated attacks of the acute form. Chronic vertebral and rib lesions are found from the first to the seventh dorsal, inclusive. Elderly people are often subject to the disorder.

=Pathologically=, the lesions of chronic bronchitis present great variation, as to both their nature and extent. In some cases the mucous membrane is atrophied, so that some of the elastic fibers are noticeable. The epithelial layer is in great part missing. The muscular coat and mucous glands are atrophied.

In certain cases the mucous membrane of the bronchi is thickened, and there may be ulceration. In long standing bronchitis, there is frequently dilation of the tubes (bronchiectasis) and emphysema.

=Symptoms.=—Pain is rarely present; there is merely a feeling of constriction beneath the sternum. The cough varies with the weather and season and there is often an absence of the cough during the summer. It is apt to be worse at night than in the morning, and is frequently paroxysmal. There is rarely any fever. As a rule, there is free expectoration of mucopurulent or distinctly purulent matter. Sometimes it is abundant, seromucous in character, and again there are severe cases of dry cough in which there is almost no expectoration. Unless associated with other diseases, the general health suffers but little, if at all. The appetite, as a rule, is good and the body weight is well maintained.

=Physical Signs.=—=Inspection.=—There is considerable immobility of the chest and if emphysema is present there is distension. =Percussion= is clear, and hyperresonant in emphysema. =Auscultation.=—The expiration is prolonged and forcible. This is associated with sonorous and sibilant rales and moist rales of all sizes.

=Special Varieties.=—Bronchorrhea, dry catarrh, putrid bronchitis or fetid bronchitis.

=Bronchorrhea.=—In this form there may be an excessive bronchial secretion. This may be liquid and watery, but more frequently it is purulent, thin and containing greenish masses; or again it may be thick. Dilation of the tubes and fetid bronchitis may be developed.

=Fetid Bronchitis.=—Fetid expectoration is associated with gangrene of the lungs, abscesses, bronchiectasis, decomposition of matter within phthisical cavities, or empyema with perforation of the lungs; or it may occur independently. There is considerable expectoration that is thin and offensive. When =putrefactive changes= take place during the course of chronic bronchitis, as a rule, the following symptoms immediately appear: fever, which may be septic; increase of cough; pain in the side, and sometimes a chill. There is increased prostration. The symptoms may abate followed by the usual course of bronchitis.

=Dry Catarrh.=—The cough is distressing and paroxysmal. It is usually associated with emphysema and is a very troublesome form.

=Diagnosis.=—This is not usually difficult. Phthisis—the absence of fever, of hemorrhage, of tubercle bacillus and the signs of localized consolidation (usually at one or other apex) will serve to distinguish between the two.

=Prognosis.=—Recovery is not always accomplished. The diseases being generally a secondary affection, the prognosis must depend upon the primary condition. The danger from development of emphysema, bronchiectasis and dilatation of the right ventricle must be thought of. Frequently cures will be obtained, even in old persons. Care must be taken that there are no serious organic lesions. Deep treatment to readjust the upper and middle dorsals is most essential.

=Treatment.=—In the first place there must be a careful regulation of the hygiene of the patient. The diet should be a nutritious one, care being taken to give food that is easily digested. A liberal diet can easily be selected from the various meats, vegetables, cereals, fruits, soups, broths, eggs and milk. The clothing should be carefully selected. Flannel should be worn next the skin the year around, care being taken that the sufferer is not too warmly clad. Due attention should be given to bathing, exercising, etc. The patient should be out in the open air a great deal, but be careful that it is not too stormy. The air of the room should be kept at an even temperature and not subject to abrupt changes. Two or three treatments per week will be required, and when the condition is considerably aggravated, do not hesitate to treat oftener, but be careful not to unduly irritate the lesions.

Lesions will be found to the ribs and vertebræ from the first to the seventh dorsal inclusive. Many cases present lesions in the vertebræ from the second to fourth, usually of a lateral nature. Other lesions of frequent occurrence are displacements of both vertebræ and ribs. Correcting these deviations relieves the chronic inflammation of the tubes. Also in those cases where dilatation of the bronchial tubes occurs, the obstruction to the motor fibers is to be removed by the correction of the vertebræ and by removing obstruction to fibers of the pneumogastric; the fibers of the latter supplying the transverse muscles of the bronchial tubes.

It generally requires a considerable course of treatment for the cure of chronic bronchitis, and one of the hardest things to contend with in the treatment is the likelihood of the patient “catching cold.” When a fresh cold gets thoroughly started, it is almost impossible to prevent the disease from extending down the bronchial tubes, as the innervation is less rich in the smaller tubes.

Hazzard says: “The obese should be taught the habit of deep respiration, as should all persons subject to the attacks of the disease. This measure, together with the daily cold sponge or shower bath, is a great aid in overcoming the chronic tendency.”

Those cases that are due to cardiac or nephritic diseases require the treatment of the primary disease in addition to a light bronchial treatment.

A lesion between the gladiolus and manubrium of the sternum may be found, but it is of rare occurrence in these cases. The upper portion of the sternum may be held very rigidly and slightly underneath the middle portion of the sternum; or at the point of articulation of the two portions a distinct ridge may be found, caused by the articular ends being pushed anteriorly. Probably such lesions affect the innervation to the bronchial tubes and lung tissues. Associated with this condition the upper chest is considerably immobilized, affecting the lymph and rib bone marrow function. Examine the first ribs and clavicles carefully. Changes of climate are often beneficial.

Fibrinous Bronchitis

=Definition.=—A rare, acute or chronic inflammatory disease of the bronchi, in which a fibrinous mould of the bronchus and its branches is formed. These are expelled in paroxysms of cough and dyspnea. The casts block the bronchial tubes. When these moulds are large or medium sized, they are generally hollow, while those of the smaller bronchi are solid.

=Etiology= and =Pathology=.—The causes are unknown. Young men, between the twentieth and fortieth years, are the usual subjects; but the disease may occur at any period of life. Lesions occur as in other forms of bronchitis. The attack occurs most frequently in the spring months. In some cases there seems to be some hereditary influence. Chronic pulmonary diseases, like phthisis, emphysema and pleurisy, are occasionally predisposing causes. It is sometimes associated with skin diseases, such as herpes, impetigo and pemphigus.

The =pathology= is not known. The masses that are expelled are usually round and mixed with blood and mucus. The casts are more dense, but the membrane is identical with that of croupous exudates. This affection, however, is limited to certain bronchial tubes and recurs at stated or irregular intervals, sometimes for a period of several years. There is loss of epithelium in the affected bronchi and the submucous tissue is often swollen and infiltrated with serum.

=Symptoms.=—Acute cases are rare. The attacks may set in with rigor, high fever, pain in the side, soreness, severe paroxysms of cough and sometimes a slight hemoptysis. The symptoms are those of an ordinary acute bronchitis, but of severer character; aggravated cough and dyspnea and fatal termination are not uncommon. Death occasionally results from suffocation. There may be but one attack without any recurrence, but in the chronic form the paroxysms recur at irregular intervals, though they are less severe than in the acute form.

The disease may last for ten or even twenty years, the attacks recurring weekly, or a period of a year or more may intervene. The onset is marked by bronchial symptoms with or without fever. The cough soon becomes distressing and paroxysmal in character. The sputum may be blood-stained and occasionally there is profuse hemorrhage. The expectoration is in the form of ball-like masses which, when unraveled are found to be moulds of the bronchi. They may be hollow and laminated or quite solid. When examined under the microscope they are seen to consist of a fibrillated membrane in which are imbedded leucocytes, mucus, corpuscles, fat drops and epithelial cells. Leyden’s crystals and Curschmann’s spirals are occasionally found.

=Physical signs= are usually those of bronchitis. The weakened or suppressed breath sounds in the affected territory may occasionally be determined. There is sometimes a diminished expansion or even retraction of the chest wall over the affected area. There is no dullness on percussion, unless the portions of the lung supplied by the affected tubes collapse. After dislodgement of the casts, the normal respiratory murmur returns.

=Diagnosis.=—The fibrinous casts alone are sufficient for a positive diagnosis.

=Prognosis.=—Generally favorable. In uncomplicated cases there is rarely any danger, even though there may be severe paroxysms of cough and dyspnea. In fatal cases the lesions of associated or preceding affections have been found, such as chronic pleurisy, pneumonia and phthisis. Although this is a rare disease, cases have been treated with success by osteopathic means. If uncomplicated there should be a fair chance for a cure, depending, of course, upon the constitutional condition and the permanency of the lesions.

=Treatment.=—The treatment is largely that of acute bronchitis. The disorder is more extensive than in acute bronchitis, consequently severe subluxations of the ribs and vertebræ of the upper and middle dorsals occur, besides extensive muscular contractions of the chest and neck. The fibrinous casts are somewhat of the same nature of membranous exudates elsewhere, therefore the treatment should be directed to a correction of the hyperemia of the mucous membrane of the bronchial tubes, thus loosening and disorganizing the exudate. The vagi nerves supply a part of the innervation to the bronchial tubes and lungs. Any disorder to them should be corrected when diseases of the bronchial tubes and lungs exist. They contain motor fibers to these organs, and to the bronchial tubes they supply, principally the transverse fibers. In bronchitis of various forms, marked effect can be secured by close attention and treatment to the inferior laryngeal nerve. This is best treated at the inner side of the lower portion of the sternocleido muscle.

The different forms of bronchitis illustrate the point so often noted in osteopathic etiology and pathology, that the various affections of the same region should not be studied so much as types of several diseases or disease entities as different degrees of involvement, depending on the severity of the causative lesion, the function of the nerves disturbed, and the character of the tissues. It is straining a point to diagnose and classify many diseases according to signs and symptoms instead of studying the process from central causes, for, at best, peripheral manifestations, micro-organisms, etc., are really incidental to the importance of the primary source of disturbed nutrition. Consequently, the same treatment, if scientific, is frequently indicated for all of the disorders that may affect a given locality. After all has been said and done, the therapy as well as the pathology, must hinge upon the fundamental—uninterrupted blood channels and nerve courses are essential to health. Whether a disease is of primary or secondary origin, or whether or not it presents different symptoms in various types, the above basic principle is invariably applicable. This simplifies etiology, pathology and treatment and furnishes a backbone to theory and practice, and some day rational medicine will adopt it.

Bronchiectasis

=Bronchiectasis= is a dilatation of a part or the whole of the bronchial tube. As a rule this affection is a secondary one, the most common cause being chronic bronchitis. The inflammation weakens the bronchial walls so that they are unable to resist the strain that is put upon them during violent paroxysms of coughing. After dilatation has once commenced, the weight of the secretion which accumulates tends to further distend the weakened walls and the elasticity, becoming impaired, is finally lost. Dilatation of the bronchi is also associated with emphysema, compression of a bronchus, aneurism or mediastinal tumor, bronchopneumonia, measles and whooping cough in children, and also traction associated with fibroid induration. Hence the bronchial dilatation is especially associated with bronchitis, interstitial pneumonia, and sometimes chronic pleurisy. It is rarely a congenital effect in such cases. It is commonly unilateral. The lesions presented to the osteopath are largely like those found in chronic bronchitis, i. e., derangement of the upper four or five dorsal vertebræ and ribs, and lesions of the cervical vertebræ involving the vagi. These lesions obstruct the nerve force to the bronchial tubes and thus cause the dilatation.

=Pathologically=, the dilatation is usually either cylindrical or saccular, which may occur in the same lung. The entire bronchial tree may be converted into a series of sacs opening into each other. These have smooth, shining walls in the most dependent parts which are sometimes ulcerated. In extreme conditions the dilatations may form large cysts immediately beneath the pleura; as a rule, the lung tissue lying between the sacculi becomes cirrhotic. =Partial dilatation= is more common. The bronchial mucous membrane is involved with an occasional narrowing of the lumen. The narrowings are most commonly cylindrical, sometimes saccular.

In all forms there is decided change in the bronchial wall. In the large dilatations, the epithelium is changed. The elastic and muscular layers are thin and atrophied. These dilatations frequently contain fetid secretions and when these secretions are retained, the lining membrane becomes ulcerated.

=Symptoms.=—There is always cough, which occurs in severe paroxysms. In some cases a change of position will cause a paroxysm of coughing—very likely due to the emptying of the contents of a dilated tube into a normal one. The sputum is mucopurulent and is greenish brown in color, is fluid, and has a sour, or more frequently, a fetid odor. On standing, it separates into three layers; the upper is frothy and thin, the middle mucoid, and the lower is a thick sediment of cells and granular debris. Microscopically, the sediment consists of pus corpuscles, fatty acid crystals which are arranged in the form of bundles, and sometimes red blood discs and hematoidin crystals. Elastic fibers may be found if ulcers are present.

=Physical Signs.=—When distinctly present, they are those of a cavity in the lungs. When chronic pleurisy and interstitial pneumonia are associated, there may be retraction of the chest wall. The percussion resonance is impaired. On auscultation, bronchial, or even amphoric, breathing is heard occasionally with metallic rales.

=Diagnosis.=—In a number of cases this was formerly impossible, where the X-ray is now proving of great assistance. History, paroxysmal cough, characteristic copious sputum and an absence of tubercle bacilli with little impairment of the general health will serve to distinguish bronchiectasis from pulmonary tuberculosis. Circumscribed empyema which has ruptured into the lung may simulate bronchiectasis. This is of a much more sudden onset, has a history of previous pleurisy, the health is gradually impaired, and there is thoracic oppression and dyspnea on the slightest exertion.

=Prognosis.=—Is generally unfavorable. However this largely depends upon the cause.

=Treatment.=—Largely the same as in chronic bronchitis. Severe lesions are found in the dorsal vertebræ about the region of the third, fourth and fifth, and many times lesions of the pneumogastric at the upper cervical vertebræ are also found. The lesions are much of the same nature as those of bronchitis, but, as a rule, there is a much deeper or more extensive lesion. These lesions weaken the motor innervation to the muscular coats of the bronchial tubes, and in many instances the extensive lesions involve the vasomotor nerves controlling the blood supply to the bronchial tubes. In most cases marked lesions of the ribs on either side will be found, usually in the region corresponding to the affected vertebræ.

The position of the patient is important; the head should be low in sleeping. In certain fetid cases surgery should be considered.

Care should be taken as to the hygienic surroundings of the patient. The diet should be carefully regulated and nutritious, as in chronic bronchitis.

Bronchial Asthma

=Bronchial= or =spasmodic asthma= is a chronic affection, characterized by a paroxysmal dyspnea due to a spasmodic contraction of the muscles of the bronchial tubes or to swelling of their mucous membrane.

=Osteopathic Etiology= and =Pathology.=—The majority of lesions causing bronchial asthma are from the second to the seventh dorsal region, inclusive, either in the ribs posteriorly or anteriorly, or in the vertebræ. These lesions involve vasomotor nerves to the bronchioles which produce the narrowing of the tubes and thus cause the dyspnea. Usually the lesion is at the third, fourth or fifth rib on the right side, although, as stated, a lesion may be found above or below this point at the anterior or posterior ends of the ribs or in the vertebræ corresponding to the same region. Probably lesions are found more on the right side, because most people are right-handed; these muscles being better developed would tend, when contracted, to draw the ribs from their articulation. The third, fourth and fifth ribs are usually found involved because it is the region of greatest vasomotor innervation to the bronchial tubes.

In a number of cases there will be found a posterior curvature of the dorso-lumbar region; and accompanying this condition will be catarrh and dilatation of the stomach, congestion of the liver, and, perhaps, intestinal indigestion and constipation. Careful attention should be given to the digestive organs.

Lesions involving the pneumogastric at the atlas and axis are fairly frequent. These irritate fibers of the pneumogastric to the muscles of the bronchioles and thus produce narrowing of the tubes and consequently the paroxysms. Other points to note are the costal cartilages and hyoid bone, and probably, in a few instances, lesions to the phrenic.

Attacks may be induced reflexly by various excitants, as dust, diseases of the upper respiratory tract, etc., but the lesions to the vasomotor and motor nerves are the predisposing causes. Laughlin[93] says: “It is questionable whether reflex causes alone are sufficient to produce genuine asthma without the existence of specific lesions affecting the direct nerve connections of the part involved.” No doubt a neurotic tendency is often a predisposing factor. Overeating, and particularly certain foods will frequently excite an attack.

=Pathologically=, true asthma is a pure neurosis. There is more or less chronic inflammation of the bronchial tubes, shown by injection and thickening of the bronchial mucosa in the majority of cases. There may be found the morbid states peculiar to chronic bronchitis and emphysema. Whether the constriction of the tubes is due to spasms of the bronchial muscles or to swelling of the mucosa, or to both, the primary, predisposing and irritating influences are common to both. These are vertebral and rib lesions affecting the spinal nerves at their exit and the sympathetic chain along the head of the ribs; irritating lesions to the vagi, constricting pulmonary vessels, and to the cervical sympathetics, causing disturbance of the same, would be factors in the pathological chain. Reflex irritations may be found in various regions, but the principal osseous lesions, according to Dr. Still, are on the right side from the second to the sixth dorsal.

=Symptoms.=—The attack may come on at any time, but usually it comes on in the night during sleep. The onset may be sudden or the attack may be preceded by premonitory sensations, such as tightness in the chest, flatulence, sneezing, chilliness and a copious discharge of pale urine. Nervous symptoms, headache, vertigo, neuralgia, and an anxious, nervous, restless feeling may precede the attack. There is a sense of oppression and anxiety, followed by dyspnea. Soon the respiratory efforts become violent, the patient is obliged to sit up or runs to the window for air. The shoulders are raised, the hands are placed upon something firm to keep the shoulders fixed so that the accessory muscles of respiration can be brought into play. The contracted tubes resist the entrance of air. Expiration is prolonged and wheezy. In severe cases the face becomes pale, the skin is covered with perspiration, the extremities are cold, the lips, finger tips and eyelids are livid, owing to defective oxygenation of the blood. The pulse is small and quick and the temperature is normal or subnormal. The attack may terminate suddenly, sometimes with a spell of coughing; this is especially so of severe cases, as the cough is generally absent in brief paroxysms.

The =cough= is at first very tight and dry and accompanied by a tough, scanty expectoration which is expelled with great difficulty. The =sputum= contains rounded masses of matter, the so-called “pearls” of Lænnec. Microscopically, they are found to be of a spiral structure, containing cells derived from the bronchial mucous membrane and fatty degenerated pus cells. A second form is contained in the inside of the coiled spiral of mucin, a filament of great clearness and translucency, that is most probably composed of transformed mucin. Curschmann’s spirals are found in the early stages of the attack and for a time these were supposed, by their irritation, to excite the paroxysms. Their spiral form is unexplained. Curschmann believes that these spirals are found in the finer bronchioles and to be a product of bronchiolitis.

=Physical Signs.=—=Inspection= shows enlargement of the chest which is fixed and barrel-shaped. The breathing is labored and the chest moves but slightly. The diaphragm is lowered and fixed. =Percussion= yields hyperresonance, especially in cases which have had repeated attacks or when the asthma is associated with emphysema. =Auscultation.=—With inspiration and expiration are heard sonorous sibilant rales which are more marked on expiration. As the secretion increases, which is later in the attack, the rale becomes moist. The attack lasts for a variable period, rarely less than an hour. In severe attacks the paroxysms recur for three or four nights or more with spontaneous remissions during the day. In some cases the relief seems to be absolute, but in the majority of cases there is more or less oppression and cough for a day or two, sometimes for many days.

=Diagnosis.=—The physical signs, examination of the sputum and the history of the case makes the diagnosis easy.

=Prognosis.=—It is not a fatal disease and only dangerous when complications arise. Under osteopathic treatment the prognosis is usually favorable, unless there are serious complications, as this is a disease that osteopathy has treated with signal success. In long standing cases emphysema invariably develops.

=Treatment.=—Asthma, unless complicated with bronchial and lung diseases, is usually readily relieved during the paroxysms. Cases of many years’ standing have been cured in a few treatments. It should be borne in mind that asthma is a respiratory neurosis.

To relieve an attack the osteopath should locate the lesion and, if possible, correct it. Oium[94], in the acute attack, standing at the head of his patient inserts the tips of both thumbs well under the angles of the jaw and then brings direct pressure on both vagi as they pass over the transverse processes of the axis. Pressure must be brief and let up to be applied again. Immediate relief is given in many cases. Adjust upper three cervicals if found deranged.

If the muscles are so severely contracted that it is impossible to make out the nature of the lesion, then strong inhibition, with an upward, outward movement over the angles of the ribs involved, will be sufficient. The object to be gained in every case is to relieve pressure or irritation to the vasomotor or motor nerves, so that the narrowed tubes may be relaxed. Strong inhibition, such as placing the knee in the patient’s back, at the same time pulling on the shoulders, will have temporary effect, but it is always best to reduce the lesion if possible. In severe cases dilatation of the rectum may relieve the paroxysm, and in a few instances it will be necessary to treat the uterus locally.

During the interval between the attacks is the time to remedy the disease. Then one is able to locate exactly the position of the disturbed tissues that are causing the paroxysms and apply treatment in the regions given under etiology. Many cases of asthma are cured in from one to three months’ treatment. One treatment a week is sufficient, provided one is able each time to accomplish something toward a correction of the lesion and that the patient does not suffer during the meantime. Too frequent treatments may simply act as an irritant to the nervous lesions.

Attention should always be given to the diet and hygiene. Gastric digestion should be complete before retiring or it may induce an attack. Complications are treated according to the disease. Examine the upper respiratory tract, the digestive tract, and the pelvic organs when there is reason to believe the paroxysm may be induced reflexly. Laughlin sums up the treatment as follows: (1) Removal of specific lesion; (2) removal of exciting causes; (3) removal of reflex causes; and, (4) treatment of the patient to improve the condition of the general nervous system.

FOOTNOTES:

[93] Laughlin—Asthma—Journal of the American Osteopathic Association, Oct., 1914.

[94] Journal A. O. A. 1918.

DISEASES OF THE LUNGS

Emphysema

Used in a general way, emphysema is a term which implies the presence of air in the interstitial tissue, but when applied to the lungs there are two applications of the term, having widely different significations, viz: Interlobular or interstitial emphysema and vesicular emphysema.

=Interlobular Emphysema.=—This is caused by rupture of air vesicles, deep in the lung structure, the air escaping into the interlobular connective tissue. It is not a very serious condition, rarely produces symptoms and affords no physical signs. It usually results from violent acts of coughing in which the expiratory strain is very great, as in whooping cough and in bronchial asthma; also, from wounds of the lung.

The air bubbles escape into the interlobular septa and are sometimes seen like little rows of beads outlining the lobules. The pleura may become detached and larger vesicles may form. In rare cases the rupture may take place at the root of the lung and the air passes along the trachea into the subcutaneous tissue of the neck and chest wall, which gives rise to a very peculiar and distinctive crepitation upon palpation. Rarely there is rupture of the superficial vesicles, producing pneumothorax.

=Vesicular Emphysema.=—Dilatation of the infundibular passages and alveoli or an increase in their size either symmetrical, involving both lungs, or localized. Vesicular emphysema is divided into compensatory, hypertrophic and atrophic forms.

=Compensatory.=—This occurs when a region of the lung has been disabled from any cause and does not expand fully during inspiration; the healthy portion of the lung must then distend and do vicarious work or the chest wall will sink in to occupy the space. This happens with portions of healthy lungs in the neighborhood of tubercular areas and cicatrices, areas of collapsed lung or parts prevented from expansion by pleuritic adhesions (in this case the compensatory emphysema is chiefly at the anterior margins of the lungs). As a rule this distention is physiologic and beneficial, the alveolar walls being simply stretched. Later they may atrophy, the air cells becoming fused.

=Hypertrophic Emphysema.=—This is enlargement of the lung, due to dilatation of the air vesicles and atrophy of the walls.