=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.