If, on the other hand, improvement takes place, the respirations gradually become slower and deeper, and inspiratory recessions and cyanosis abate with gradual disappearance of dulness, bronchial breath ing, and rales. Sleep and appetite are itnproved, and the pale, but no longer cyanotic features are once more enlivened by- a smile. Recovery in bronchopneumonia takes place, on the average, after the second or fourth week, but frequently, when there are many improvements and relapses, only after some months. Even then relapses, diarrhma, exhaustion, and other complications, may bring about a fatal termination.
Individual Symptoms. Seat and Spread of the chiolitis usually attacks both lungs simultaneously in larger areas, chiefly the posterior lower portions. Consequently, bronchopneumonia occurs bilaterally, and with predilection first or, indeed, only for the posterior inferior parts. Front here the infiltration gradually spreads upwards as far as the middle of the scapula, becoming more and more distinct, but always remaining most distinct below, forming in this manner a stripelike zone which is therefore designated "Stripe" pneu monia, or more aptly paravertebral pneumonia (Gregor). The disease is usually more pronounced on one side than on the other, but may also remain unilateral. The paravertebral type is found as SL rule in infants during the first year in tho.se who constantly lie on their backs, or at least the greater part of the time, a significant reason why broncho pneumonia favors so much the dependent and illy ventilated portion of the lungs. Laterally, the consolidation does not usually extend beyond the axillary line. Bronchopneumonia may, however, appear in any of the other portions of the lungs, in the upper lobes, and is very apt indeed to affect the small portion of the left upper lobe covering the pericardium.
Considerable experience in physical examination is required to dem onstrate a beginning bronchopneumonia, and even in its subsequent stages well-marked symptoms of consolidation are usually shown much earlier by auscultation than by percussion. As an early sign of broncho pneumonia, in addition to medium and fine ronchi, there may be heard over a cireumscribed area, usually- below and behind, aggregated, fine, metallic rriles. Some time later, or perhaps at the same time, the per
cussion note over this region becomes tympanitic. This is a very impor tant sign, and is produced from the fact that the areas being about the size of hazel-nuts are not sufficient to diminish the resonance but may, however, produce a retraction of the intervening parts. It is charac teristic to have the metallic rates first disappear again in one situation in order to reappear in another. If consolidation spreads and the areas become larger and more confluent, distinct bronehophony is heard on crying or speaking. Bronchial breathing and dulness appear. Should the left lower lobe eontain larger areas, the heart's action niay be heard through them more distinctly than normally,. -Whenever respiration is superficial, in young children the respiratory murmur is either dimin ished or increased with ronchi; while during speech, and especially w-hile crying, distinct bronchophony and bronchial breathing are present. For this reason, auscultation of the infant while crying is always of espe cial value; and it is justifialule in doubtful cases to cause the infant to cry, during which bronchophony may be looked for. This has the same significance as bronchial breathing, ancl 'may be heard more frequently in children. Percussion must be very light, otherwise the loud reso nance of the sound lung tissue will not permit dulness to become percept ible which is produced by smaller areas. Should extensive continuous consolidation occur, the percussion note i.s very much diminished and no longer yields the tympanitic accessory- note; the finger receives the sensation of marked resistance while percussing, which is, however, not so great as in pleuritic exudates. Frequently, in bronchiolitis and espe cially, in bronchopneumonia, characteristic distention of the uninvolved anterior portions of the lungs occurs (acute emphysema), especially along the borders of the same. This manifests itself by the depth of the lower pulmonary border on the right side anteriorly, and by- dimin ution of the area of carcliac dulness. As recovery takes place the acute pulmonary distention subsides again. Vocal frernitus, which may also be tested with the ear during crying, is frequently somewhat increased in extensive consolidation.