Part I

.

[75] The student will receive many helpful suggestions by reading Macleod, Physiology and Biochemistry in Modern Medicine; Cannon, The Mechanical Factors of Digestion; Carlson, The Control of Hunger in Health and Disease; Gaskell, The Involuntary Nervous System; Pottenger, Symptoms of Nervous Disease.

[76] Von Noorden, Colitis, 1904.

[77] See Philosophy and Mechanical Principles of Osteopathy, p. 190.

[78] There are several possible suggestions. (1) Developmental (See Mayo, Relation of the Development of the Gastro-intestinal Tract to Abdominal Surgery. Jour. A. M. A. Feb. 7, 1920). (2) Owing to the appendix, cecum, ascending colon, duodenum, and biliary tract being frequently disordered. (3) Imbalance of muscular tension, owing to the muscles of the right side being often the better developed. Muscular lesions and lymphatic involvement of the cervical region seem to occur oftener on the right side than on the left.

[79] Journal of Osteopathy, May, 1900.

[80] For points on enema, see treatment under Intestinal Obstruction.

[81] Diseases of the Intestines, Vol. I, p. 240.

[82] The Lancet, (London,) Oct., 1904.

[83] Philosophy of Osteopathy, p. 226.

[84] Medical Record.

[85] The Vermiform Appendix and Its Diseases, p. 711.

[86] Dr. Chauvel, 1902.

[87] Rose and Carless.

[88] Clinical Osteopathy.

[89] Journal of the American Osteopathic Association, Dec, 1902.

[90] Journal of American Osteopathic Association, March, 1905.

[91] Journal of American Osteopathic Association, March, 1905.

DISEASES OF THE RESPIRATORY SYSTEM

DISEASES OF THE LARYNX[92]

Acute Catarrhal Laryngitis

=Definition.=—An acute, catarrhal inflammation of the mucous membrane of the larynx. This may be ushered in as an independent disease or it may be associated with inflammation of the upper respiratory passages.

=Osteopathic Etiology= and =Pathology.=—One of the principal causes of acute catarrhal laryngitis is exposure to cold and dampness, which contracts the muscles of the neck region, especially about the larynx. Lesions in the upper and middle cervical vertebræ are important predisposing causes. Occasionally the first rib becomes luxated, causing a greater or less congestion of the laryngeal mucous membrane by contracting the lower antero-lateral muscles of the neck, and affecting lymphatic drainage. Improper placing of tone, as well as too constant use of the voice in speaking and singing, are common causes. Inhalation of irritating gases or dust, and mechanical injuries to the larynx are occasional causes. The disease may be associated with certain infectious diseases, as measles, diphtheria, influenza and whooping cough.

=Pathologically=, the mucous membrane is intensely reddened and inflamed; this inflammation involves both the true and false vocal cords and may extend into the trachea and about the epiglottis. The membrane is covered slightly with mucous secretion. In rare instances edema of the glottis may occur. The muscular contraction about the larynx impedes blood and lymphatic drainage and thus induces congestion. The contraction may be so severe as to slightly prolapse the organ. The vertebral lesions impinge upon or affect vasomotor fibers and thus bring about congestion.

=Symptoms=.—There is hoarseness and cough with a sensation of tickling in the larynx; these are the most constant symptoms. The cough is dry and the voice altered. At first the voice is husky, but some attempts at speaking are attended with more or less pain and finally the voice may be entirely lost. Deglutition is painful. At first the expectoration is scanty, but later it becomes mucopurulent. There is rarely much fever. When there is considerable edema, dyspnea and asphyxia are prominent features.

=Prognosis.=—Simple catarrhal laryngitis never terminates fatally. When there is dyspnea or asphyxia indicating edema of the larynx, the prognosis is grave. The attack usually lasts from one week to ten days, but this can be materially shortened by careful osteopathic treatment. In severe infections it may be two or three weeks before the larynx returns to its former condition.

=Treatment.=—In a few cases confinement of the patient to his room, and possibly the bed, will be necessary; especially should the larynx have rest from phonation, and the taking of food of an irritating character should be avoided. Smoking is to be prohibited. The room should be at an even temperature, from 70 to 75 degrees F., and the atmosphere saturated with moisture by the generation of steam.

The tissues in the cervical region about the cervical sympathetic and vagi nerves should be carefully adjusted. The deep posterior muscles of the cervical spine are to be relaxed and direct treatment given over and about the larynx. Relaxing tissues and raising the larynx will be very effectual in relieving the =huskiness= of the voice and in controlling the congestion and inflammation of the laryngeal mucosa. Besides the treatment of the vagi nerves at the atlas and their course down the lateral and anterior portion of the neck, the superior laryngeal may be treated at the upper portion of the great cornu of the hyoid bone and the inferior laryngeal at the inner side of the cleido muscle near its sternal attachment. Adjust the tissues along the course of the external carotid and subclavian arteries, chiefly the first rib for the latter. Give careful treatment to the internal jugular and innominate veins. Correct any tissues that may impinge upon the lymphatics of the mucous and submucous coats of the larynx where they are drained into the deep cervical glands. Release any immobility of the upper chest, relax the pectoral, auxiliary and upper dorsal muscles, and adjust the first four or five dorsal vertebræ.

Prompt action of the skin, freedom of the bowels, placing the feet in a hot bath and continued local hot packs, or even an ice-bag in severe cases, will be of special value at the onset; but due attention should be given these throughout the entire course. The fever is easily aborted by the cervical treatment and proper attention to the bowels and sweat glands.

Chronic Catarrhal Laryngitis

=Definition.=—A chronic, catarrhal inflammation of the mucous membrane of the larynx.

=Osteopathic Etiology= and =Pathology=.—The causes of chronic laryngitis may be numerous, but lesions of the cervical vertebræ are the most common. The contractured cervical muscles, especially the deep vertebral ones, are usually the result of corresponding osseous deviations.

Other causes given under the acute form, as overuse and abuse of the voice, inhalation of irritating substances, excessive use of tobacco and alcoholic drinks, tumors, etc., are important etiological factors. Thus irritations inducing acute attacks, if repeated, will result in chronic catarrh.

The =pathological= changes as revealed by the laryngoscope are swelling of the mucous membrane, occasional superficial erosions, and rarely ulceration.

=Symptoms.=—The voice is usually hoarse and rough, being due to a thickening of the vocal organs. In severe cases the voice may be lost. There is fatigue and pain after slight use of the voice, a sense of tickling in the larynx which produces a desire to cough, and expectorations of viscid mucus and mucopus.

=Prognosis.=—The prognosis is sometimes unfavorable, although many cases are cured.

=Treatment.=—The patient must learn to take care of himself properly. He should avoid overheated rooms and the use of tobacco and alcohol, and the throat should not be protected too much. It is a good plan to bathe the neck every morning and night with cold water. He should avoid loud speaking; the sound should be expelled by the abdominal muscles and diaphragm and not by the muscles of the throat. Examine the upper air passages carefully for any obstructions and infections that might exist which are a source of irritation to the larynx.

Special attention should be given to the atlas, axis and third cervical. Lesions lower down the spine may be found, for other laryngeal nerve fibers, other than those from the superior cervical ganglion, may be at fault. Palpate the =hyoid= to see if it is tilted by contracted muscles, as will often be the case.

=Aphonia= is commonly caused by a dislocated atlas. The aphonia may also be caused by swelling of the vocal cords and tissues about them and by serous effusions of the laryngeal muscles. The larynx may be prolapsed slightly and if raised quickly relieved. Difficult breathing and hoarseness are occasionally very troublesome symptoms. The former is due to an inability of the glottis to dilate, on account of swelling of the mucous membrane of the diseased parts and from drying of the secretions on them, thus increasing the obstruction (this is sometimes termed pseudocroup) but expiration is easy, the stridor is from the inspiration; the latter is due to a collection of mucus on the vocal cords or the cords may become relaxed, swollen or roughened.

Another annoying symptom sometimes presented is pain on deglutition, which is due to swelling of the mucous membrane of the upper laryngeal passages and the epiglottis. In all of these annoying symptoms, persistent, thorough, direct treatment of the larynx is of value. On the whole, careful, continued treatment of the cervical innervation and vascular supply of the larynx, as in the acute form, is indicated.

In all laryngeal disorders, if condition permits, hyperextend the neck while the patient is lying supine and thoroughly relax the soft tissues about the organ and then carefully raise it.

Laryngismus Stridulus

(Spasm of the Glottis)

=Definition.=—A spasm of the muscles of the larynx that are supplied by the inferior or recurrent laryngeal nerves. This is commonly not excited by an inflammatory condition, but it is usually a purely nervous condition.

=Osteopathic Etiology= and =Pathology=.—Spasm of the glottis is usually found in children with =enlarged tonsils and adenoids=. It has been observed that rickets and syphilis are probably frequent underlying causes. The spasm is occasionally associated with tetany. The nervous factor is the immediate and important consideration. Cervical lesions, both vertebral and muscular, are invariably found. Then nasopharyngeal and tracheal disorders and reflex digestive disturbance are exciting causes. An elongated uvula or a deranged hyoid bone will occasionally be exciting factors. Subluxation of the upper two or three ribs and of the clavicle may also be exciting factors.

The affection is usually found in children under five years of age. All cases are not of a distinct nervous type, for slight acute catarrhal laryngitis may be present.

=Symptoms.=—There is a sudden onset and the spasm may occur on waking from sleep, but it may come on either in the night or day. The disease starts with a sudden arrest of breathing, the child struggles for breath; there are tonic muscular spasms and the face becomes congested in a few seconds. This is followed by sudden relaxation of the spasm and the air is drawn through the glottis with a shrill, crowing sound. Several spasms may occur in a day or they may be weeks apart. Death rarely occurs.

=Diagnosis.=—The absence of fever, cough and hoarseness and its distinctly intermittent nature will differentiate it from croup. Should there be any question of diagnosis a bacteriological examination is advisable.

=Prognosis.=—The prognosis is almost always favorable. In very young children death from suffocation may occur, but rarely.

=Treatment.=—The treatment should be applied either centrally or peripherally, depending altogether upon the location of the irritation. If the irritation is of central origin, that is, through the innervation from the brain and spine, a correction of the superior and inferior laryngeal nerves is necessary; if the stridor is due to peripherial irritations, a correction of the end-plates (muscles) over and about the larynx is required in order that the spasms be relieved.

Thorough treatment should be applied to the upper part of the chest and diaphragm, chiefly the phrenic nerves at the third, fourth and fifth cervicals and over the eighth, ninth and tenth ribs anteriorly, in order that the spasms may be prevented from extending to the intercostal muscles and the diaphragm.

Placing the patient in a hot bath will be of service in some cases when the spasms are severe. Alternating hot and cold packs about the throat are of service. The air of the room should always be kept moist. Care should be taken that the trouble is not due to gastro-intestinal disorders or to dentition. Keep the child upon a fluid diet of milk, meat broths and egg albumin.

In the more severe cases the well known osteopathic method of relaxing and inhibiting the soft palate and contiguous tissues will stop the spasm.

Spasmodic Laryngitis

(False Croup)

=Definition.=—A catarrhal inflammation of the mucous membrane of the larynx with spasm of the glottis.

=Osteopathic Etiology= and =Pathology=.—This affection is practically the same as laryngismus stridulus associated with catarrhal inflammation of the mucous membrane. It is a disease of young children. Derangements of the innervation and blood supply to the laryngeal mucous membrane and muscles of the larynx are found in the same locality as noted under acute catarrhal laryngitis and laryngismus stridulus. There is acute catarrh causing a croupy cough, and difficult breathing due to spasm of the glottis.

=Symptoms.=—These attacks generally occur during the night, the child being suddenly awakened by severe paroxysms of suffocating and a dry, hard cough, associated with evidences of dyspnea. In half an hour or an hour or two the coughing ceases, perspiration follows and the child falls asleep. If proper treatment is not given, these attacks may occur for several successive nights, the child appearing almost or quite well during the day.

=Diagnosis.=—The symptoms are so characteristic that the diagnosis is easy. In all instances the prognosis is favorable.

=Treatment.=—The catarrhal inflammation of the mucous membrane of the larynx should be treated in the same manner as simple inflammation of the laryngeal mucosa, i. e., thorough treatment of the cervical spine and direct treatment over the larynx.

During the paroxysm, if the patient cannot be relieved very shortly by the cervical treatment, he should be placed in a hot bath of a temperature from 98 to 110 degrees F. This will, in the majority of cases, relieve the attack. In addition a hot compress may be placed about the throat. Producing emesis by irritating the fauces with the finger is necessary in a number of cases in order that the secretions in the laryngeal region may be ejected, thus relieving suffocation and labored breathing. Also, an overloaded stomach which is causing an irritation, should be emptied at once by vomiting. The bowels should be kept well open in all cases. Occasionally the epiglottis becomes wedged in the chink of the glottis. Such a condition requires an introduction of a finger into the fauces to release the disorder.

Care should be taken, especially following an attack, that the child is not exposed to cold or rapid changes of temperature, so as to avoid repetition of the spasms.

=Coughing.=—Coughing, not only in spasmodic laryngitis, but also in various diseases where coughing is a prominent symptom, is a most irritating and annoying feature. The osteopath is many times called upon to relieve the cough, whether it is due to slight irritation of a nerve fiber alone or is a symptom of a serious chronic disease. The coughing center is located in the medulla oblongata; the afferent nerves are sensory branches of the vagus; the efferent nerve fibers are found in the nerves of expiration and in those that close the glottis. Consequently, coughing may be caused by stimuli to various sensory nerves, various cutaneous areas (chiefly the upper part of the body), mucous membrane of the respiratory and digestive tracts, the mammae, liver, spleen, ovaries, uterus, kidneys, etc. Perhaps the most common cause of cough is contraction of some of the muscles of the neck, irritating sensory fibers. Contraction of the omo-hyoid muscle may produce an irritating cough by causing traction on the hyoid bone. In a few cases the larynx may prolapse to some extent and thus be a source of irritation. Lesions of the spinal cord between the seventh and eighth dorsal, also at various points above in the dorsal vertebræ and in the ribs (especially at the second and third ribs), are very apt to produce a cough. Impaction of the sigmoid flexure is oftentimes accompanied by coughing. Enlargement of the heart may cause pressure upon the respiratory tract directly and cause a deep, dull cough. Foreign bodies in the external meatus of the ear are occasionally a source of irritation which is accompanied by coughing. Thus there are innumerable sources of stimuli that may produce coughing. In all cases it is necessary to make a careful diagnosis as to whether it is an irritation to some fiber that can be corrected at once or whether it is a symptom of a disease that can only be relieved by the cure of the disease. In local congestions the cold pack will often be of service.

Tuberculous Laryngitis

=Definition.=—An inflammation of the laryngeal tissues of tuberculous origin.

=Osteopathic Etiology= and =Pathology=.—Tuberculosis of the larynx is commonly secondary to pulmonary tuberculosis. In a few cases the laryngeal invasion may be of primary origin. In either instance there will be found a disturbed innervation or altered blood supply of the larynx that predisposes to the multiplication and growth of the bacilli. The osteopathic lesions are similar to those found in other involvements of the larynx.

=Pathologically=, the mucous membrane is inflamed and swollen, and exhibits scattered tubercles, which are usually about the blood-vessels. The tubercles cluster, caseate and leave shallow, irregular ulcers. There is thickening of the mucosa about the ulcer, and the ulcer is generally covered by a grayish exudate. They may erode the true vocal cords, often destroying them completely. The ulcers slowly involve the tissues in all directions, causing perichondritis with necrosis of the cartilages. The mucous membrane of the pharynx, esophagus, fauces, and tonsils may be involved, and the epiglottis may be completely destroyed.

This disorder, strictly, should be discussed under pulmonary tuberculosis for, as heretofore stated, it is generally a secondary affection; the larynx being invaded by the tubercular bacilli in the sputum arising from the bronchial tubes and lungs. The bacilli in inspired air may primarily invade the laryngeal mucosa. However, in either case the circulation of the mucosa is not normal and osteopathic correction of the same is effective.

=Symptoms.=—Huskiness of the voice, followed by hoarseness, and in advanced stages aphonia, are prominent symptoms. A hacking cough is usually present and the patient complains of pain in the throat, particularly on coughing, swallowing or speaking. The loss of voice, painful speaking or whispering are quite characteristic. When the ulceration of the tissues of the larynx has progressed to a later stage, dysphagia, suffocation and distressing paroxysms of cough occur.

=Diagnosis.=—Is not difficult, as pulmonary phthisis is usually associated with it. Examination of the sputum for the specific bacilli will be conclusive.

=Prognosis.=—The prognosis is not of the best at any time. On the whole, it is unfavorable.

=Treatment.=—In this disease osteopathic treatment has been quite effectual. Cases of primary origin are more successfully treated than when of secondary cause, although one will be surprised many times at the results obtained when the disorder is not primary. The treatment must necessarily be both constitutional and local. Care of the general health as to hygiene and diet is absolutely necessary. The food must be nutritious and non-irritating. Scraped beef, raw oysters, raw eggs, soups and gruel are required. In cases where difficulty of deglutition occurs, it may be largely overcome if the patient hangs his head over the side of the bed and sucks through a tube liquid nourishment placed in a dish upon the floor.

The local treatment required is careful, persistent work over the larynx and adjacent tissues. The treatment is given to increase the blood supply to the diseased tissues so that healing may take place, and that the bacteria may be deprived of the conditions favorable to their activity. Treatment along the cervical spine and upper dorsal will aid in correcting the vasomotor disorders that exist. Local application of hot water will assist in relieving the pain. When pulmonary phthisis exists, attention and correction of it is important; in fact, is of primary consideration in laryngeal affection.

Syphilitic Laryngitis

=Etiology.=—This disease is of frequent occurrence, due to inherited syphilis, or to the secondary or tertiary stages of the acquired form.

=Symptoms.=—There is a hoarseness of the voice, a hacking cough, difficulty in swallowing and the various symptoms of catarrhal laryngitis. The secondary form may present superficial, whitish ulcers on the cords or ventricular bands, while in a tertiary stage the lesions are extensive and serious. Deep ulcers with raised edges are present, gummata develop on the submucous coat of the epiglottis and there may be necrosis and exfoliation of the cartilages. Deformity is produced by the cicatrices following the healing of the ulcers and sclerosis of the gummata. Edema of the larynx may suddenly prove fatal.

=Diagnosis.=—The history of the case, the presence of other symptoms of the disease, the deep, symmetrical ulcers, the absence of tuberculosis elsewhere and the absence of marked pain, will usually make a diagnosis easy.

=Prognosis.=—Is somewhat favorable, more so at least than the tubercular form of laryngitis. There is great danger of deformity and permanent impairment of the voice.

=Treatment.=—The treatment should be both constitutional and local. Active measures must be taken to rid the system of the virus of syphilis, and thorough, direct treatment should be applied to the larynx and to its innervation. If the cicatricial stenosis has progressed so far that there is little hope from manipulative treatment, tracheotomy or gradual dilatation should be performed. The ulcerated portion is always to be kept clean.

Edematous Laryngitis

=Definition.=—An acute inflammation of the mucous membrane of the larynx with infiltration of serous fluid into the submucous tissue.

=Etiology.=—This is a very serious affection. It may occur in connection with acute laryngitis, though rarely, and occasionally with chronic diseases of the larynx, as tuberculosis and syphilis. It may be a complication of some acute infectious disease like diphtheria, scarlet fever, or erysipelas of the face. It sometimes occurs suddenly in the course of Bright’s disease. Lesions as in acute laryngitis are predisposing factors.

=Pathologically=, there is marked swelling of the epiglottis. The swelling can very easily be felt with the fingers. The mucous membrane is tense and changed in color. There is infiltration of a serous or sero-purulent fluid into the loose connective tissue of the larynx. The arytenoepiglottic folds are greatly involved, and they may be swollen to such a degree that they almost meet.

=Symptoms.=—Extreme dyspnea and stridulous respiration. Hoarseness of the voice and later aphonia. There is a feeling of intense oppression or suffocation. Evidence of dyspnea, anxious face, blue lips, protruding eyes and retraction of the base of the chest occur. The sternocleidomastoid muscle is very prominent.

=Diagnosis.=—This is not difficult. The history of the case, laryngoscopic examination, and the swollen epiglottis which can be easily felt with the fingers make diagnosis easy.

=Prognosis.=—Generally unfavorable. At any time it is extremely grave, but with prompt and vigorous treatment recovery is possible.

The duration varies from a few hours to several days.

=Treatment.=—One must attend strictly and carefully to the laryngeal innervation, as in acute catarrhal laryngitis. Obstruction to the superior or inferior thyroid, facial, internal jugular or innominata will cause tumefaction and edema of the larynx and adjacent tissues. Also, enlargement of the lymphatics about the larynx and salivary glands may produce edema of the laryngeal region; consequently, particular care should be taken of the various tissues about these vessels and of the innervation from the cervical spine, so the veins are not obstructed or the lymphatic channels disordered, so that infiltration of the tissues may be further prevented.

The most prominent symptom is laryngeal dyspnea and this depends altogether upon the swelling of the soft parts. If the swelling is great and the disorder cannot be removed, suffocation will follow. In such cases, besides giving direct treatment over the larynx, introducing a finger into the mouth, and reaching clear back under the roof of the soft palate, with a firm, downward, outward and sweeping movement on either side, relax the soft tissues. The persistent use of small pellets of ice, held far back in the mouth, will be found very beneficial; also, application of the ice-bag, provided the edema is of inflammatory origin.

If one is not able to control the rapid infiltration of the larynx and glottis when such cases arise, tracheotomy or intubation should be performed at once. When edematous laryngitis is due to diseases of the heart, lungs and kidneys, treatment of the primary disease should be given in addition to the local treatment.

FOOTNOTES:

[92] For diseases of the nose see Deason,