(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.