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.
Osteopathic Etiology and Pathology.—An important predisposing cause of emphysema is often found to be due to derangements of the tissues, usually vertebræ and ribs, which affect the innervation to the lung tissues. Such lesions are found in the vagi and spinal dorsal nerves. The atlas may be involved, but it is generally the ribs and dorsal vertebræ. Distinction should be made between cause and effect in the skeletal changes. No doubt in many instances a vicious circle is thus established. Congenital weakness of the lung tissues, probably due to non-development of the elastic tissue, is a predisposing factor. This disease has a markedly hereditary character and frequently starts early in life. The heightened pressure within the air cells upon an already weakened lung tissue produces emphysema. Hence, the obstinate cough of chronic bronchitis and expiratory straining of asthma are sometimes the immediate cause. In all attacks of severe coughing or straining efforts, the glottis is closed and the air is forced into the upper part of the lungs, forcibly expanding them, and here is where emphysema is found to be most advanced. This disease is also found in players of wind instruments, in glass blowers and in those whose occupation necessitates heavy lifting or straining.
Pathologically, the thorax is barrel-shaped. The lungs are enlarged and do not collapse when the thorax is opened, as they have lost their elasticity. The organs are pale, soft and downy to the feeling and pit on pressure. Enlarged air vesicles may readily be seen beneath the pleura. Microscopically, there are seen atrophy of the vesicular walls and a diminished amount of elastic tissue. There is more or less obliteration of the capillaries, and the epithelium of the air cells undergoes a fatty change. There is usually chronic inflammation of the bronchial tubes, which may be roughened and thickened. The diaphragm is lowered and the subjacent viscera are displaced. The most important morbid changes are found in the heart, the right chamber being dilated and hypertrophied. This is caused by the increased tension in the pulmonary artery, which is enlarged and the seat of atheromatous degeneration. In long standing cases the hypertrophy is general. Changes in the liver, kidneys and other viscera are those associated with prolonged venous engorgement.
Symptoms.—The onset of the disease is usually gradual. The first symptom to be noticed is the shortness of breath. In rare cases it may exhibit a more acute development, as after whooping cough, and then the first symptom will be dyspnea. In some cases this persists all the time, while in moderate emphysema the dyspnea is noticed only on slight exertion, such as going up-stairs, running or walking rapidly. The lungs are always filled with air which is charged with carbon dioxid and does not change, as the patient is constantly making ineffectual efforts to draw in air. The inspiration is shortened and the expiration is greatly prolonged and is often harsh and wheezy. The pulse-rate is accelerated; the temperature is usually normal. Cyanosis is a characteristic symptom in well established cases and is of an extreme grade not seen in any other affection. Bronchitis is frequently found in combination, especially in winter. In this case there will be the symptoms of the associated bronchitis, cough, expectoration and sometimes oppression. As the patient advances in age and there are successive attacks of bronchitis, the condition gets worse. In advanced cases, the result of cardiac failures, there may be venous engorgement, dropsy and effusions into the serous sacs.
Physical Signs.—Inspection.—There is a marked change in the shape of the thorax. The chest is rounded with increased circumference, giving the characteristic barrel-shaped chest. The sternum bulges, as do also the costal cartilages. The intercostal spaces are wide, especially in the hypochondriac region, and narrow above. The clavicles and muscles of the neck stand out with great prominence and the neck itself seems to be shortened on account of the elevation of the thorax and sternum. The curve of the spine is increased and there is a winged condition of the scapulæ. These changes give the patient a stooping posture. The chest does not expand, but is raised up by the scaleni and sternocleidomastoid muscles which stand out prominently and are hypertrophied. The heart’s apex beat is invisible and there is usually marked epigastric pulsation. On palpation, vocal fremitus is found diminished, but not absent; the apex beat is rarely felt. There is distinct shock over the ensiform cartilage. This is due to the displacement of the heart and engorgement of the right ventricle. There is marked pulsation in the epigastrium. On percussion there is sometimes increased resonance, almost amounting to tympany. The upper level of hepatic dullness is depressed. The heart dullness may be obliterated and the upper limit of splenic dullness may also be lowered. The percussion note is greatly extended. Auscultation reveals that the inspiration is short and feeble while there is prolonged expiration, the normal ratio being reversed. In associated bronchitis rales are frequently heard.
Diagnosis.—Unless complicated the diagnosis is generally easily made. The enlargement of the thorax, with dyspnea and hyperresonance and a prolonged expiration will differentiate emphysema from chronic bronchitis. Pneumothorax is of sudden development while emphysema is of slow development. Pneumothorax is usually unilateral, and it gives a tympanitic percussion note. In auscultation there is amphoric breathing and metallic tinkling and absence of any vesicular murmur.
Prognosis.—The disease is rarely fatal, although death may result from heart failure, dropsy or pneumonia. Thorough and persistent treatment will generally relieve the primary condition. The disease, as a rule, runs a long course but does not necessarily shorten life.
Atrophic emphysema is a senile change.
Treatment.—In cases of recent occurrence one may be able to build up the altered lung tissue by treatment of the innervation to the lung structure, viz.: the vasomotor nerves from the second to the seventh dorsal, the vagi, and the cervical and dorsal sympathetics. When a number of air vesicles have been converted into one sac, it is impossible to restore the altered lung structure and a treatment to relieve the symptoms and to prevent the further progress of the disease is indicated. In all cases treatment should be applied to correct any vertebræ or ribs of the upper dorsal region that may be displaced, and to raise and spread the ribs so that the lung structure may be better nourished and strengthened and that the aeration of the blood will be more perfect. Treatment of the vagi nerves is important, as their physiological action on the lungs is to increase their movement.
The general health of the patient is an important consideration and everything should be done to promote as healthy a condition as possible. The digestion should be carefully looked after and everything done to restore a normal state of the blood. A change of climate may prove beneficial.
Strengthening the cardiac action will be of service in relieving any dropsical tendency that might occur on account of obstruction to the pulmonary circulation. If bronchitis or asthma occurs, their respective treatments are indicated. A general treatment of the splanchnic and lung vascular areas should be given to prevent any disturbance in the circulation which might cause congestion of the liver, congestion of the hemorrhoidal veins, or catarrh of the stomach and bowels.
“Free evacuation of the bowels and measures to relieve any flatulent distention are very needful in cases of emphysema to take off from the diaphragm any pressure from below, and to allow it to descend as freely as possible. With this view also the food should be concentrated, nourishing, and not bulky.”[95]
It is a good plan to instruct the nurse or attendant to aid inspiration by raising the arms strongly above the head during inspiration and to compress the chest during expiration so as to coincide with natural breathing, which will render the aeration of the blood greater and increase the elasticity of the vesicles.
Acute Lobar Pneumonia
(Croupous Pneumonia)
This is an acute, infectious disease wherein various vertebral, rib and muscular lesions predispose to a lowered nutritive state of the parenchyma of the lung, permitting the invasion of the diplococcus pneumoniæ, with consequent local inflammation and pronounced constitutional disturbances, chill, extreme prostration and fever, which terminates abruptly by crisis. Secondary infective processes are frequent.
In describing a typical case of pneumonia it is considered as a self-limiting disease. By osteopathic treatment it is often aborted or, at least, its course much shortened. In such a case it is not typical pneumonia and could not be described as such.
Osteopathic Etiology and Pathology.—Pneumonia occurs more often in the young up to the sixth year and in the aged. It is more frequent during the winter and spring months. “Colds,” exposure and wetting are predisposing influences that lower resistance. Climate exerts little predisposing influence. Males are, on the whole, more frequently attacked. Pneumonia may follow injuries of the chest. Various derangements of the ribs and vertebræ are always found in pneumonia; such derangements correspond with the regions of vasomotor, motor and trophic fibers of the lungs, viz., second to seventh dorsal, inclusive, and the upper cervical vertebræ, the latter region affecting the vagi. The muscles of the chest region are always severed contracted. These various disorders produce a lowered vitality of the bronchial and lung tissues, thus favoring the existence of the micrococcus lanceolatus. Unhygienic surroundings, alcoholism, any or all habits that tend to depress the nervous system, or lowered vitality from some pre-existent disease, like diabetes, Bright’s disease, organic heart affection or one of the infectious fevers, favor its development. One attack undoubtedly predisposes to another and repeated attacks may occur in the same individual. The exciting cause is the invasion of the lung by pathogenic bacteria, especially by diplococcus pneumoniæ. Pneumococci are frequently found in the throat and mouth of the healthy.
Pathologically, the lung in croupous pneumonia exhibits three distinct stages—congestion, red hepatization and gray hepatization. In the stage of engorgement the tissue is red in color, firm and solid and less crepitant than the healthy lung. The cut surface is bathed in blood and stained serum. Microscopic examination shows the capillaries to be dilated and tortuous. The alveolar epithelium is swollen and the air cells filled with a variable number of red corpuscles, detached alveolar cells and a few leucocytes. During the stage of red hepatization the tissue is solid. It is reddish brown in color and of a dry, mottled appearance. It is very friable and does not crepitate, as the affected portion is airless. Its weight and specific gravity are increased so that it sinks in water. The torn surface presents a granular appearance, there being fibrinous plugs in the air cells. On microscopic examination the air spaces are found filled with coagulated fibrin. The tissue contains red blood-corpuscles and pus cells and the walls of the air cells are infiltrated. In sections properly treated the diplococcus is detected, and in some cases also the streptococcus and staphylococcus. In the stage of gray hepatization, the lung is still dense and heavy, but the surface is moister and softer, while the lung tissue is even more friable and the red color gives place to a mottled gray. The exudate loses its granular character and a yellowish white purulent liquid flows from a cut surface. Microscopically, the air cells are filled with leucocytes, while the red corpuscles and fibrin filaments have disappeared. The stage of gray hepatization is the stage of beginning resolution. The exudate is softened. The cell elements are disintegrated and absorbed by the lymphatics and largely eliminated through the kidneys. In unfavorable cases the consolidated lung may become infiltrated with pus, and abscesses occur. In some instances the tissue is gangrenous, or it may become the seat of fibroid induration. These, however, are rare.
Symptoms.—The disease begins abruptly, usually with a severe chill, lasting from half an hour to an hour, the fever rising rapidly. There is a sharp pain in the side, the skin becomes harsh and dry, the face is flushed, the eyes are bright and the expression anxious. A short, dry, painful cough soon develops. The expectoration presents a characteristic, rusty or blood tinged appearance and is extremely tenacious. The temperature rises rapidly, frequently to 104 or 105 degrees F., and continues high for from five to ten days and generally terminates by crisis. The pulse is full, but the pulse-respiration ratio is not maintained. There is marked dyspnea, the respirations ranging from forty to fifty per minute. There are many fine rales. Headache, gastro-intestinal disturbances, sleeplessness, epistaxis, rarely delirium except in drunkards, may also be present.
The symptoms given are those of a typical case of pneumonia, but all are subject to modification. The onset may be gradual and the chill absent. In all cases, and especially drunkards, the temperature may not be high, while the pulse is often feeble and rapid instead of full and strong, and the physical signs may not make their appearance until the second or third day.
Special Symptoms.—The fever rises abruptly in the initial chill, the temperature reaching 104 or 105 degrees F., and is continuous with a variation of a degree or two. The fever terminates by crisis after having continued from five to nine days. The temperature commonly falls during the night and is accompanied by a profuse perspiration. The temperature may fall from five to eight degrees in eight to twelve hours. There is a wide range here depending upon promptness and skillfulness of treatment, the reaction of the tissues, and previous health. Early treatment is invaluable in modifying the course of the disease.
The sputum at first is mucoid and frothy. About the second day it becomes of a characteristic color, quite copious and consisting of a frothy, fluid mucus, containing small viscid masses. It is very viscid and glutinous, in some cases almost from the onset. In old and previously weak persons, there may be no expectoration. Under the microscope the sputum is seen to contain red blood-corpuscles, leucocytes, alveolar epithelium, the micrococcus lanceolatus as well as other micro-organisms, pus corpuscles and small fibrinous casts. A stabbing pain is a common early symptom, as well as a dry, short cough. The urine is febrile, scanty and high colored. Urea and uric acid are increased. A trace of albumin is often present, and there may be symptoms of acute nephritis. Herpes is common. The nasolabial herpes appear from the second to the fifth day, and they may occur upon the cheek, genitals and also upon mucosa of the tongue. It is supposed to indicate a favorable prognosis. There is redness of the cheek, usually on the affected side. The mucous membrane of the mouth is dry. The tongue is white and furred. Anorexia and thirst are present. The patient is usually constipated, but diarrhea may occur. Vomiting is common. The spleen is usually enlarged, but the liver is not perceptibly increased in size, unless there is extreme engorgement of the right heart. The pulse is bounding. The average pulse-rate is from 100 to 108 per minute. In consolidation the left ventricle receives a lessened amount of blood and the pulse may become small. In the aged and debilitated, a small, weak and rapid pulse may be present. The heart sounds are loud and clear, and in favorable cases the pulmonary second sound is accentuated, owing to the increased tension in the pulmonary vessels. Upon distension of the right side of the heart and partial failure of the right ventricle, the second sound becomes less distinct which is a very unfavorable symptom, for very much depends upon the strength of the right ventricle in pneumonia. The blood usually exhibits leucocytosis which disappears with the crisis. In malignant pneumonia this is absent and its continued absence is an unfavorable sign. The proportion of fibrin is also greatly increased. The diplococci can rarely be seen. Headache is common as an initial symptom and may be persistent. The disease is often ushered in by convulsions, especially in children; consciousness is usually retained throughout the whole attack, even in severe cases, though in some cases there is delirium. In drunkards delirium tremens may be present from the onset. In these cases the patient often wanders about until the preliminary excitement gives way to coma.
Physical Signs.—Stage of Congestion.—Diminished expansion, the movements of the affected side are defective, the face is flushed and the patient lies on the affected side. Tactile fremitus is slightly increased. There may be tympany over the involved area from diminished intrapulmonary tension. In the latter part of this stage there is impairment of resonance. Fine crepitant rales are heard at the end of forced inspiration. Great care has to be taken in examination when there is deep seated consolidation.
Stage of Red Hepatization.—The breathing is markedly abnormal. Very little or no expansive motion of the chest over the affected region. Vocal fremitus is markedly exaggerated. The skin is hot and dry and the pulse frequent. Dullness over the affected parts with an increased sense of resistance is present. There is high-pitched, prolonged, bronchial breathing when the lung becomes solidified. When the larger bronchi are completely filled with exudate, tubular breathing is absent. Crepitant rales may also be heard.
Stage of Gray Hepatization.—Largely the same physical signs are repeated in this stage as in the second. The normal manner of breathing returns, as does also the normal expansive movement of the affected side. Crepitant rales reappear. The temperature of the skin is lessened, breathing changes from bronchial to vesicular and bronchial resonance continues for some time.
Complications.—Pleurisy is the most frequent complication. Pneumonia on one side and pleurisy on the other is possible. The pain is more acute and localized. The respiration is greatly affected and the usual signs of effusion are present. Empyema may be a complication. Pericarditis is more common in the pneumonia of children. Though usually plastic it may be serofibrinous, but rarely the fluid is purulent. There is increased dyspnea, the pulse becomes weaker, and the heart sounds are gradually suppressed. Endocarditis is a comparatively frequent complication. It is more liable to attack patients with old valvular disease and to affect the left heart. The physical signs are sometimes absent and even when present are liable to be very deceptive. It may, however, be suspected in cases where the fever is protracted; when septic manifestations, such as chills, sweats or irregular temperature, develop; when embolic symptoms appear, or when a rough, diastolic murmur develops. Meningitis is a complication that comes on at the height of the fever. This complication is rarely recognized unless the basilar meninges are involved. It is frequently associated with ulcerated endocarditis. Cerebral embolism causing hemiplegia has been observed. Other possible complications are neuritis, arthritis, nephritis, parotitis and various digestive disorders.
Diagnosis.—A typical case of pneumonia is easily recognized. The abrupt onset with rigor, the rapidly developed fever, the sputum, physical signs and abnormal pulse-respiration ratio, as a rule make the diagnosis easy. Frequent examination of the lungs should be made in Bright’s disease, diabetes, organic affections of the heart, cancer and alcoholism, as all these affections are liable to become complicated with acute pneumonia. Pleurisy is often confounded with pneumonia. The resemblance between friction sounds and crepitant rales is often very close. In pleurisy vocal resonance and vocal fremitus are diminished; there is no “rusty” sputum; the percussion dullness may change with the posture of the patient, and the breathing is distant and weak. A typhoid state may be mistaken for typhoid fever. Hypostasis occurs late in typhoid fever while dullness sets in early in pneumonia. The history of the onset will be of aid, as pneumonia as a complication sets in late in the disease. The Widal test will be of value. Acute phthisis may begin with a chill and may resemble pneumonia very closely, especially the physical signs. Examination of the sputum will show the bacilli of tuberculosis. The X-ray will often be of aid as a diagnostic measure.
Prognosis.—This largely depends upon the previous health of the patient. At the extremes of life the prognosis is much more unfavorable. It is especially fatal in drunkards. By competent osteopathic treatment the mortality rate may be materially lessened and this disease, dreaded by both physician and patient, need not seem so fearful. The death rate from pneumonia during the past few years has been appalling. In New York and Chicago nearly one-eighth of the deaths the year around are due to pneumonia, and during certain months of the year twenty-seven or eight per cent. of all deaths are due to this disease. Drug medication is notoriously unreliable, the most competent physicians freely admitting that they are practically powerless to stay the ravages. Given a patient with a fair constitution, osteopathic treatment will offer reasonable hope to the sufferer. There is no question that osteopathy merits much commendation in the treatment of pneumonia. Many severe cases have been cured and many more have undoubtedly been aborted. The treatment is directly applicable and specifically indicated, and coupled with good nursing and hygiene, the mortality rate of the old schools is being markedly lessened.
Treatment.—The treatment of pneumonia must be both constitutional and local. By this is meant that the systemic strength and vigor must be maintained in addition to treatment of the chief lesion of the disease, which is located in the lungs.
During the various stages of the disease, the treatment should be directed to the nerves of direct innervation that control the capillaries, and to the vasomotor nerves of the pulmonary circulation, in order that the hyperemic and inflamed state of the pulmonary capillaries and adjacent tissues may be lessened and the circulatory system equalized. The disordered tissues that should be corrected in order that the centers of the spinal cord and the nerves that influence the function and structure of the lungs may be relieved, are: contraction of the thoracic and dorsal muscles, subluxations of the ribs and dorsal vertebræ from the second to the seventh, inclusive, and the upper cervical vertebræ that may become disordered and impinge upon the vagi nerves. However, owing to the fact that the vasomotors are not especially abundant here, all increased chest mobility and deep breathing and abdominal aid will materially assist the circulation. Also, carefully treat the middle and inferior cervical regions for the lymphatics of the lungs. Each of these regions should be carefully examined and thoroughly treated whenever found involved. The specific micro-organisms that influence the course of pneumonia are naturally very important factors; but observing and improving the general health, and establishing an unobstructed circulation through the diseased lung tissues will hasten the crisis by favoring a rapid formation of antidotal substances to neutralize the poisonous substance produced by the micrococcus lanceolatus. Healthy tissues, which occur only where there is uninterrupted freedom of vascular supply and nerve force, are obtained by correction of any and all anatomical disorders. This will rapidly decrease any lethal tendency in the patient and often abort the disorder so that all that is needed is sufficient time for nature to heal the diseased tissues. The principal predisposing cause of many specific diseases, is some disorder of the anatomical tissues that interferes with normal physiological functions; and the determining of the different types of disease is often due to the location of the lesion and the character of the micro-organism involved in each disease. What is necessary in many cases is a correction of the mechanical predisposing condition and the exciting and determining influences will be rendered inactive.
The importance of close attention to both vagi can not be overestimated. Any obstruction above or below the origin of the superior laryngeal nerve is followed by loss of motor power of the lungs, thus causing difficult and labored breathing. The lungs become surcharged with blood, because the air pressure in the lungs is low and the thorax is distended. This condition is followed by serous exudation. Thus obstruction of the vagi may be one factor in the cause of pneumonia. Obstruction of the vagi below the origin of the recurrent laryngeal nerves affects the lower and middle lobes of the lungs, and produces also a catarrhal inflammation of the upper lobes. The recurrent laryngeal nerves may be obstructed by dilatation of the aorta or subclavian artery as they wind about them; also by dislocations of the first and second ribs, which may affect the nerves not only directly, but by causing an obstruction to the subclavian vessels with a consequent disturbance of the aorta and the heart. The recurrent laryngeal nerves may be treated directly at the inner lower part of the sternomastoid.
One of the chief objects of the treatment should be to prevent heart failure and to lessen the pulse-respiration ratio. The average pulse-rate in typical cases is from 100 to 110 per minute and when it exceeds this to any extent, say 120, there is cause for alarm. At first the pulse is full and bounding, later it is small on account of a lessened amount of blood reaching the left ventricle and systemic circulation, owing to the extensive consolidation. In treating heart failure particular attention should be paid to the condition of the ribs on the left side over the region of the heart, the second to the fifth, inclusive. A correction of any disturbance to the inhibitory nerves of the heart, (the vagi) and the accelerator fibers of the heart (the cervical sympathetic) should be made. This means close attention to probable derangements of the vertebræ from atlas to first dorsal. General treatment of the entire system will relieve the heart of some work and favor an equalization of the vascular system. Also by the use of hydrotherapy the maintenance of the heart’s action may be accomplished. Cold compresses, and not warm ones, should be used, as the latter relax the vessel walls, producing more or less paresis of the vessels, while the former stimulate the vaso-dilators, producing dilatation and tone of the vessels, thereby causing a vigorous increase in the flow of blood. This relieves the heart by increasing the cutaneous circulation, besides increasing arterial tension. The right heart is indirectly aided by the increase of the tension in the general vascular system, and the vessels of the pulmonary circulation have more force expended upon them and a greater contraction of their vessels occurs on account of the dilatation of the cutaneous vessels. The temperature of the water used should be 60 degrees F., and the compress applied for thirty minutes or as long as necessary.
Attention to the abdominal area and diaphragm will have a definite effect upon the circulation and elimination. It is beneficial in its influence upon lungs and heart and in combatting toxemia. Carefully graduated deep breathing is of distinct benefit.
In addition to the fever treatment in the cervical and dorsal regions, the gradually cooled tub-bath will be of aid. The temperature at first should be ninety degrees F. and then gradually cooled to eighty degrees F. The duration should not be over ten or fifteen minutes. Care should be taken that the patient does not exert himself. He should be lifted in and out of the baths. These baths also have a marked effect upon the respiratory and nervous centers. The ice-bag over the chest and spine has a beneficial influence; still, with feeble children be exceedingly careful when applying or using cold methods.
During all stages of the disease, the best possible care should be taken of the patient. See the patient frequently, probably twice a day or oftener. Each time thoroughly relax the dorsal muscles and readjust the ribs, for as every osteopath of experience will note (and Dr. Still particularly emphasizes) the contracted muscles frequently and continually displace the ribs. The treatment should not be prolonged to a point of overfatigue, but a definite reaction of tissues should be secured but no further.
Carefully raise all the ribs and moderately hyperextend the spine. Release the cervical, pectoral and axillary lymphatics, and stimulate spleen and liver.
Experience has shown that the first treatment is of the greatest importance and if the osteopath will control the predominant symptoms at that time the result will be much simplified. For that reason it is best not to leave the patient until the chest pain, fever, high pulse or whatever may be present, are well in hand, although it may mean a long visit with fairly frequent treatments. Treat the conditions existing and wait; then treat again and the result will more than repay. There is always more than a chance of aborting the disease, but the first treatment is often the crucial test. F. E. Moore and many others report numerous cases treated without a fatality and the average duration of the disease not exceeding five days. The apartment should be well aired and a temperature of 65 degrees F. maintained. In the very young the temperature should be higher. The diet is exceedingly important. Give a liquid, light and nutritious one, a milk diet being preferable. Otherwise give meat juice, broths, egg albumin and whey. Avoid starchy and saccharine foods, and give plenty of water. Good nursing and complete rest of body and mind, with careful attention to the activity of the bowels, kidneys and skin, will indirectly aid the clogged up lung fascia to perform its function and hasten an early recovery from the disease. In epidemic forms be particularly vigilant in the employment of antiseptics.
Bronchopneumonia
(Catarrhal Pneumonia)
Definition.—An inflammation of the minute bronchi and air vesicles. The affection begins with an inflammation of the capillary bronchi, which extends to the air vesicles. The micrococcus lanceolatus, streptococcus pyogenes, influenza bacillus, and staphylococcus aureus et albus are the principal exciting micro-organisms.
Osteopathic Etiology and Pathology.—The disease is most prevalent among the very young and the old, and may be either primary or secondary. It may occur as a sequence or in association with measles, diphtheria, whooping cough and scarlet fever. Exposure to cold, impure air, rickets and diarrhea are marked predisposing causes in children. In the old, debilitating affections and chronic diseases are predisposing causes. Bronchopneumonia occurs sometimes as a complication in smallpox, erysipelas, typhoid fever and influenza. The principal lesions found upon examination are subdislocated ribs affecting the pulmonary vasomotor nerves. The third, fourth and fifth ribs are especially apt to be subdislocated. The muscles throughout the thoracic region are generally severely contracted.
Another group of cases, the so-called aspiration or deglutition pneumonia, are caused by the inhalation of food particles or other substances. A lessened sensitiveness of the larynx (as in comatose states) may allow small particles of food to reach the smaller bronchi and produce inflammation, which may even cause suppuration and sometimes gangrene. Cases are liable to occur after operations about the nose and mouth. It is often secondary to carcinoma of the larynx and esophagus and after tracheotomy and glosso-pharyngeal palsy. A serious form of bronchopneumonia is caused by the tubercle bacillus.
Pathologically, both lungs are usually involved and become heavy. On the pleural surfaces, especially at the base, sunken purplish or slaty patches are noticed, representing collapsed lung tissue. On section small, projecting portions of consolidation are seen, separated from each other by uninflamed and collapsed tissue. The section of lung tissue is of a dark reddish color. The terminal bronchi are filled with tenacious, purulent material. Microscopically, the terminal bronchi and air cells are filled with a plug of exudation composed of leucocytes and desquamated epithelium. The walls of the bronchi are swollen and contain many leucocytes.
Symptoms.—The symptoms are frequently marked by those of the primary affection. The onset may be either abrupt or gradual. The child becomes feverish; there is increased frequency in respiration and there is an aggravated cough. The temperature rises to 102 or 104 degrees F.; respiration may rise as high as 60 or 80. The cough is hard, distressing, frequently painful and accompanied by a mucopurulent expectoration. The pulse is greatly accelerated—120 to 180 per minute. As the disease advances, signs of deficient aeration of the blood are noticed. At first there is a pale and anxious expression of the face, the lips are blue and the child makes strenuous efforts to breathe. The blood soon becomes highly charged with carbon dioxide and, by its benumbing influence upon the nerve centers, sensibility is reduced and the cough and suffering subside. The face becomes livid and death may occur within twenty-four hours from paralysis of the heart.
At the beginning of the attack dullness is absent and subcrepitant and sibilant rales are present. Areas of consolidation soon become manifested. There is slight impairment of resonance and the breathing is harsh. Upon inspection there is, in grave cases, retraction of the sternum due to defective expansion.
Diagnosis.—This is usually easy, developing as it generally does in the course or at the conclusion of another disease, with a gradual onset as a rule, and irregular fever and a long duration, besides usually occurring in children under five. If the areas of consolidation are large, involving the greater part of a lobe, it is sometimes very difficult to distinguish bronchial pneumonia from lobar pneumonia. Lobar pneumonia, when occurring in children, is usually between the ages of five and fifteen. The onset is abrupt in a child of good health; it resolves rapidly; there is rusty colored sputum and continued fever falling by crisis. Tuberculous bronchopneumonia is very hard to differentiate from simple bronchopneumonia. A great many cases can be correctly diagnosed only after the lapse of considerable time. The presence of signs of softening, considerable disease of the apices, and examination of the sputum, or in the case of a child, of the vomited matter, would diagnose this form. If elastic fibers and tubercle bacilli are found in the sputum or vomited matter, the diagnosis is at once decided in favor of tuberculous bronchopneumonia. X-ray diagnosis should be considered.
Prognosis.—The prognosis depends on the cause. In children that are previously weak and debilitated the disease is very fatal. When the disease follows measles and whooping cough, the fatality is not so great. In adults the prognosis is about the same as in the croupous form. The deglutition variety is apt to be fatal.
Treatment.—A great deal can be done to prevent the disease, by careful attention to debilitated children in keeping them warm and protected at all times. There is usually a preexisting bronchitis. In measles and whooping cough and during convalescence, the child should be well taken care of.
A thorough, persistent treatment, but not to a point of overfatigue, of the dorsal vasomotor nerves posteriorly should be given. Gentle work over the cervical and axillary lymphatics to free the edematous barrier, correction of the tensed scaleni and deranged first ribs and clavicles, and stimulation of spleen and liver, with sufficient general treatment to start reaction, will be effective. Derangements to the third, fourth and fifth dorsal nerves are most likely to be found; the principal vasomotor innervation to the bronchials and air vesicles is from this region. Treatment over the chest anteriorly is of great aid, especially an upward and outward manipulation to release the ribs should be given. Attention should be given the vagi nerves to increase the activity of the lungs as well as for the effect gained upon the circular fibers of the bronchi. Care should be taken, that the first rib is not impinging upon the first thoracic ganglion, or interfering with lymphatic drainage.
Ice-bags over the chest are helpful. The chest should be protected from changes in temperature by a jacket of cotton batting. The diet should consist of milk, egg albumin and broths. Keep the temperature at about 70 degrees F. and the air of the room moist and free from draughts. When the fever is high, sponging or the wet pack is helpful. The bowels from the beginning of the attack should be carefully watched.
There is danger of a failing heart; this is generally associated with mucous rales and cyanosis. Douching alternately with hot and cold water will usually excite coughing and overcome the difficulty. The gradually cooled bath will have a marked effect in reducing the temperature, quieting the nervous symptoms, increasing the respiratory power and promoting sleep.
Raise and carefully stimulate the abdominal viscera, and elevate the diaphragm. This is effective in both cyanosis and toxemia.
In the first stage of pneumonia, Hazzard[96] says, “There is better opportunity to correct the specific lesion, as the patient’s strength will allow of such treatment. The work is also aided by the fact that the alveoli are still open, and lung action, stimulated by treatment, may become a valuable aid in dispelling the engorgement.” This is a most valuable suggestion, but be exceedingly careful in subsequent treatments not to treat too hard and thus lame and bruise the patient.
Series I, II, III, and V of the American Osteopathic Association Case Reports present several interesting cases of pneumonia which typify the importance of immediate and direct correction of the osteopathic lesions.
Herman[97] cites an interesting case of delayed resolution, due to a depressed condition of all the ribs on the affected side with marked luxation of the eighth. The lesion at the eighth was the cause of a prolonged attack of hiccoughs which prevented resolution. It is pointed out that there is an abundant intercostal nerve supply to the diaphragm from the eighth and ninth intercostals. C. E. Achorn instances an autopsy of patient dying of pneumonia, where a bony ankylosis was found at the second dorsal; this lesion was probably an important predisposing factor.
Broadly speaking, one should keep in mind the following: First, early treatment will frequently abort what would ultimately be pneumonia—still, in the preceding it is not these cases that are especially referred to, but those following the course of a typical pneumonic process; second, both specific and general treatment prior to the crisis will materially lessen the severity of the disease; third, the crisis corresponds to beginning resolution (during resolution expectoration and liquefaction and absorption of the exudate are paramount features) and must be met promptly and vigorously, special attention being paid to the heart; and, fourth, during convalescence, good, general attention and care of patient as to treatment, hygiene, diet, and climate, are important.
Chronic Interstitial Pneumonia
(Fibroid Induration)
Definition.—A chronic, inflammatory disease of the lungs, characterized by an overgrowth of fibrous or connective tissue.
Etiology.—With few exceptions chronic affections of the lungs cause more or less fibroid overgrowth. This is especially frequent after bronchial pneumonia and pulmonary tuberculosis. It is also excited by abscesses, hydatids, syphilis, emphysema, sarcoma and old fibrinous pleurisy. It may also be caused by compression, by aneurism or neoplasms. It may arise as a primary affection, due to the inhalation of irritating dusts (stone dust, coal dust and metal dust). There will be found deeply seated osseous lesions of the upper and middle dorsal region and corresponding ribs, and frequently of the cervical vertebræ.
Pathologically, as it involves limited or extensive areas, it is recognized as local or diffuse. It is a unilateral affection. The involved portion is shrunken and on section it is found to be tough, firm, of a greenish color and containing an overgrowth of fibrous tissue. If it affects the left side the heart may be displaced. The unaffected lung is usually enlarged (compensatory emphysema). There is hypertrophy of the right ventricle of the heart.
Symptoms.—There is a chronic cough, which varies greatly in its severity; moderate dyspnea, and a variable expectoration. There is no fever and the general health of the patient may be preserved for a number of years. The expectoration is generally copious, muco- or sero-purulent, rarely fetid. There is retraction of the affected side, displacement of the apex beat and lateral curvature of the spinal column. The unaffected side is enlarged. The intercostal spaces disappear, the ribs sometimes even overlapping. The tactile fremitus is generally increased, but if the pleural membrane is thickened the fremitus may be decreased. There is generally impairment of resonance. A tympanitic or amphoric note may be heard over a dilated bronchus. On the sound side the percussion note is generally hyperresonant. The breathing sounds may be feeble. They may be bronchial or cavernous, but rather amphoric. Late in the disease cardiac murmurs are not uncommon.
Diagnosis.—This is never difficult. It is mainly to be distinguished from fibroid phthisis. In the latter both lungs are involved and there is fever and bacilli are found in the sputum. An X-ray examination should be made.
Prognosis.—The disease is exceedingly chronic and may last for many years. Death may result from gradual failure of the right heart, hemorrhage or from intercurrent attacks of acute pneumonia involving the other lung.
Treatment.—Little can be done for this condition. Intercurrent bronchitis may be somewhat relieved by the treatment for chronic bronchitis. The patient should dwell in a mild climate. Hygienic surroundings and nutritious food are indicated. Something can be done by attempting to correct the condition of the ribs and vertebræ, but this measure, from the nature of the disease, is generally palliative at best.
Congestion of the Lungs
Congestion of the lungs may be active, passive or hypostatic. The two former have particular osteopathic significance, owing to the lesions involved.
Active congestion may result from violent physical exertion, excessive alcoholic indulgence, inhalation of hot air or as a symptom in pneumonia and other pulmonary affections. There is dyspnea and cough with rusty expectoration of a frothy nature. There may be absence of fever. But generally a slight chill followed by moderate fever, pain in side, and cough are the principal symptoms. On percussion, the note is dull with increased tactile fremitus and bilateral involvement.
Prognosis is good under osteopathic treatment, but it must be promptly met as it is usually a symptom of another disease.
Treatment is the same as in the beginning of pneumonia.
Passive congestion, when not hypostatic, is mechanical and due to an impeded return of blood to the left heart from mitral stenosis, or regurgitation, dilatation of the right ventricle and cerebral disease. The lungs are large with distended pulmonary vessels with venous blood in the air spaces. There is dyspnea and cough, with blood-streaked, frothy expectorations.
The treatment is primarily of the condition causing the congestion, but in addition the upper ribs should be raised and thorough treatment of the abdomen and elevating the diaphragm are beneficial.
Hypostatic congestion results from a weakened heart in exhaustion, infection or old age; also from continued dorsal decubitus. Rheumatic fever, tuberculosis and other constitutional diseases, as well as organic growths, may predispose. The condition gives rise to a mild form of lobar pneumonia. Symptoms are not well defined and often are not recognized. There may be slight dullness, increased fremitus, moist rales and other signs of a venous engorgement.
In treatment the first move is to change position of the patient and then look after any underlying cause. Osteopathically, follow treatment of pneumonia. In all cases of circulatory involvement of the lungs, treatment to relax muscles or to adjust vertebræ and rib lesions to the vasomotor nerves of the lungs is very efficacious. Landois (1904) says: “Irritation of sensory nerves, particularly if intense and long continued, causes a dilatation of the vessels in the areas innervated by them.”
Edema of the Lungs
There are two forms of edema, collateral and general, which follow an intense congestion with transudation of serum into the air vesicles and interstitial tissue. The collateral form is localized and usually appears in connection with pneumonia, pulmonary infarction or abscess. In general edema the base of the lung is involved to a greater extent, but the whole structure is affected and hydrothorax is generally present. The cause of edema is not well understood, but may result from a long line of constitutional diseases. The symptoms are dyspnea, cough with copious, blood-streaked sputum which is expelled with difficulty. There may be fever in the inflammatory type with weak, increased pulse. Dullness over the affected area, broncho-vesicular breathing and small liquid rales are audible. The diagnosis must largely be made upon the bilateral dullness at the base of each lung and physical signs noted above. X-ray examination will usually be of value. Prognosis depends on the condition causing the edema and treatment should be directed to correcting it. Frequently edema is a terminal affection. This should be followed by osteopathic treatment to free the lungs of the effusion as outlined under pneumonia, especially relaxation of the upper dorsal and cervical muscles, separation of the upper ribs and stimulation of the heart.