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.