BRONCHIECTASIS Occurrence and tilight dilatations of the finer bron chi may rapidly occur even in acute bronchial catarrh, especially' in the course of whooping-cough, but they may also disappear very rapidly. Chronic bronchiectasis, which may be clinically diagnosticated, occurs congenitally in rare instances, and at times develops very slowly in older children, mostly- following acute diseases of the pleura and lungs, and typical pneumonias terminating in chronic induration, bronchopneu monia of measles, whooping-cough, or influenza. It also follows pleurisy which has led to thickening and adhesions, and stenoses (foreign bodies, syphilis). The dilatation of the bronchi develops from expiratory pres sure (in bronchitis), or front inspiratory efforts (pulmonary and pleuritic shrinkings).
Pathological dilatations are cylindrical, spindle shaped or sacculated, diffuse or circumscribed. Clinically, the circum scribed, sacculated dilatations, which are chiefly found in one of the lower lobes and proceed front a medium sized bronchus, are prin cipally to be considered. Beside these smaller cavities are often found. The mucous membrane is atrophic in advanced cases, elastic fibres, muscles, and even cartilage, having disappeared. The cylindrical epi thelium is replaced by pavement epithelium, or is even destroyed by granulations and ulcerations. The mucopurulent contents of cavities which may be as large as hen's eggs, show an enormous number of bacteria (strepto- staphylo- pneutuococci, and many anaerobia).
obstinate ronchi always in the same situ ation (usually in the lower lobe) in the course of a chronic bronchitis lead us to surmise the pre.sence of a larger dilatation; and this is strength ened by the offensive odor of the abundant expectoration. Frequently, months and years elapse until the manifestations become plainer, espe cially as long as the patients .swallow the expectoration.
The cough is often characteristic in so far as the general bronchitis which usually accompanies it does not influence it to any material degree. Frequently, the patients do not cough for hours and are then harassed by violent paroxysms of coughing which occur after a change of posi tion, such as lying over on the sound side on awakening in the morning.
They- then cough up a very abundant secretion which is thin, liquid, grayish yellow, mucopurulent and which in standing separates into the well known three layers. The expectoration is often somewhat offen sive, though usually not so strong as in fetid bronchitis, at any rate not so stinking as in gangrene of the lungs. The expectoration occurring in gushes and "mouthfuls" is a striking condition, which occurs only in rupture of an empyerna into the bronchi. The expectoration is fre quently bloody, and severe hremoptysis may also occur.
Only in larger cavities and peripheral situations are the local symp toms unequivocal. Numerous coarse Hiles are then heard over a circum scribed spot, which at times, especially after coughing, produce a gurg ling sound. In the same situation there is often bronchial breathing and bronchophony. The percussion note is tympanitic, sometimes also diminished because the bronchiectasis is frequently surrounded by thickened lung tissue which causes the rAles to be heard more distinctly. True cavernous signs are rare in children. The change in the symp toms according to whether the cavity is filled with secretion or is empty is pathognomonic, as are also the disappearance and the reappearance of the tympanitic sound and dulness, bronchial breathing, etc. The accumulation and stagnation of the secretion often cause irregular ele vations of temperature and fetid breath. Repeated occurrence of small pneumonic areas always in the same spot often indicates a bronchiec tasis. In addition to the commonly accompanying diffuse bronchitis, a pleurisy, generally purulent, often occurs. Additional symptoms, such as dyspnosa, clubbed fingers, pulmonary- emphysema, pleuritic thickening, chronic pneumonia, displacement, of the heart, etc., are often connected with the primary disease. The course frequently extends over many years with varying improvements and relapses. Adclitional complications of pulmonary gangrene, bronchopneumonia, metastatic abscesses, amy loid degeneration, tuberculosis, which may furnish the cause of death, may be mentioned, besides amemia and exhaustion with hectic fever.