(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.