From what has been mentioned, bronchopneumonia is not a dis ease svi genesis, like croupous pneumonia, but is a secondary manifes tation which, like the causative bronchiolitis, may occur in connection with different kinds of affections.
General Course of the most frequently develops in connection with a catarrh of the median bronchi. Its onset is announced by elevation of temperature, by severe coughing, and especially by dyspnata. The respiration is increased and becomes la bored, the number of respirations reaches 50-60 in younger and 60—S0 in rachitic children. The nostrils and auxiliary muscles are brought into action during inspiration. Inspiratory recessions appear in the sternal notch and at the lower portion of the thorax, especially along the attachment of the diaphragm (peripneumonic fissure), an important sign showing that the access of air to the lungs through the diminished or obliterated bronchioles is rendered very difficult. The cry is short and suppressed, the pulse is much increased, 120-180, and small. The inadequate supply of oxygen soon leads to cyanosis (most plainly visi ble at the lips and finger-nails), and to serious disturbance of the appe tite and general health. All smiles fade from the pale anxious face. The little patient restlessly throws himself from one side to the other. At a glance the experienced observer recognizes a serious disease of the or gans of respiration. The phy-sical examination reveals, besides medium rifles which have probably already been present for many days, scattered fine subcrepitant rftles most frequently in the lower inferior portions of the lungs. Percussion shows a normal condition or emphysema of the anterior portions of the lungs. The acute emphysema of the anterior por tions of the lungs particularly of the upper lobes is a special peculiarity during early years (Gregor). The ronchi are not so uniform as the crepitant tines, are chiefly inspiratory, but are also often heard in the beginning of expiration. The vesicular murmur is often diminished almost to the point of disappearance. Bronchiolitis subsides after a period of several days or weeks (mostly after one or two weeks), with gradual abatement of fever and dyspiava, the fine rales becoming less and less distinct. Very frequently, however, it leads to a fatal termination by the increas ing occlusion of the bronchioles, sometimes without the presence of a bronchopneumonia, but mostly only after the development of the same.
There is no sharp distinction, and often where a capillary bronchitis could be diagnosticated during life, on post-mortem examination nu merous scattered bronchopneumonie areas are to be found. An exten sive bronchiolitis is frequently a more serious disease than a broncho pneumonia of limited area. The existence of a bronchopneumonia in bronchiolitis, occurring simultaneously with it or usually after some time, seems probable by the increase of the existing fever, dyspneea, and especially from the fact that the cough is painful and suppressed and expiration moaning and interrupted. Usually, however, one or two days elapse from the time when it is accepted that a pneunionia has set in until the corresponding physical signs appear in the lungs. At first fine metallic rAles are heard in some particular spot, usually low down posteriorly, or the percussion note slio-s a slightly tyinpanitic accessory note. Soon, or perhaps only after some days, bronchophony, bronchial breathing, and dulness (on light percussion), make their appearance. These signs, however, may also remain absent.
If the bronchiofitis becomes more and more general, or larger and inore numerous, pneumonic areas develop, and a grave clinical picture is presented either very quickly or after one or two weeks. The fre quency of respiration rises to 70-100; the respirations are superficial; and at times somewhat irregular. All accessory muscles assist labori ously during inspiration, even the lower jaw being drawn downwards. The inspiratory recessions of the thorax are of a high grade; the cyano sis increases in an alarming manner; and cold perspiration and apathy appear. The dyspncea causes all efforts to take nourishment to be a torment. The infants lies with lustreless, half-closed eyes, and the sad look seeking for aid is directed towards the mother with head frequently drawn backwards. The pulse becomes very small, scarcely perceptible, 200-210 per minute, and the extremities become cold and swollen. ()ff and on, the infant still attempts to sit up only to fall back again into the pillow's, exhausted. The previously harassing cough ceases, and the suppressed crying gives place to strengthless moaning. The apathy gradually develops into stupor and the increased cyanosis gives place to an ominous pallor. With increasing hyper-accumulations of MUCUS even in the larger air-passages, the little sufferer slumbers to a death that may often be preceded by slight convulsions.