4. A protracted and chronic form with a tendency to induration, pulmonary atrophy, and the formation of bronchiectasis.
Aspiration or deglutition pneumonia cannot be clinically separated from bronchopneumonia if abscess or gangrene of the lungs does not occur. Frequently pieces of food gain £1CCCSS to the lungs in feeble, stuporous individuals (meningitis), following tracheotomy in diph theria of the pharynx and larynx, and acting as irritants set up an inflam mation which may often lead to abscess or gangrene according to the bacteria which may be present. Henoch regards most pneumonias occur ring in diphtheria as aspiration pneumonias. The septic pneumonias of the newborn result from aspiration of decomposed amniotic fluid (Silbermann). Probably, also the pneumonias of infants suffeiing from gastro-intestinal diseases are often aspiration pneumonias (Spiegel berg). The inflammatory changes affect the alveoli (necrosis of epithe lium, distention with pus corpuscles) and inter-alveolar tissue (Plate 47). Small, gray, lobular areas are formed which often becotne necrotic. The enormous engorgement of the vessels of the bronchioles, charac teristic of bronchopneumonia is absent (Aufrecht).
Secondary Pneumonia in Various Diseases. — Bronchopneu monia is the most frequent cause of death in whooping-cough and measles. In whooping-cough it is often dragging and more dangerous than in measles. In the latter instance, it often appears even during the stage of eruption, and ruay present great similarity with croupous pneumonia. It frequently progresses with a continuous high temperature, but does not terminate with the typical decline (Ziernssen). Bronchopneumonia occurring before the appearance of the exanthem is often rapidly fatal.
In epidemic grippe a genuine croupous pneumonia frequently occurs, often also a bronchopneumonia of the disseminated or pseudolobar variety, and sometimes even a tnixed variety. In scarlet fever broncho pneumonia is not very frequent, but runs a severe course, and is apt to be followed by purulent pleuritis. Typhoid fever may be masked by an early bronchopneumonia. In rachitis it usually runs a very pro tracted course. In the newborn and during the first months of life the disease frequently produces neither fever nor marked cough and ' very little cyanosis and dyspnma, and is frequently recognized only- after death (Miller).
Complications.— Mild clry pleurisy is frequently found, more rarely exudative, and then mostly purulent. Purulent arthritis and meningitis are rare. Of frequent occurrence and debilitating is the ad vent of acute otitis media (unnoticed in the beginning) which frequently. leads to perforation and may be the cau.se of high temperature. Teich mann found otitis in 50 per cent. of his cases of bronchitis and pneu monia. Diarrluva and intestinal catarrhs are apt to supervene, especially during the summer. Occasionally, during the course of a protracted bronchopneumonia, miliary tuberculosis is apt to occur. Formerly, a transition of bronchopneumonia to miliary tuberculosis MIS regarded as frequent. It is however decidedly rare (Ziemssen, Aufrecht), The prognosis is always doubtful. The younger the ehild, the less is the chance for recovery. Dining the first year, more than one-half of the cases die. The prognosis is rendered decidedly more unfavorable by an active rachitis, general debility, gastro-intestinal disturbance, and insufficient care. Even iu the course of the disease itself, rapid changes for better or worse occur. Capillary bronchitis may even on the first or second day, before the parents think of sending for a physician, lead to sudden death from suffocation. In ordinary cases the prognosis de pends on the degree of dyspncea, the inspiratory recessions, the cy-anosis, and the quality of the pulse.
The diagnosis of capillary bronchitis is made from the scattered medium and fine subcrepitant rides; that of bronchopneumonia front appearance of smaller or larger areas of consolidation which lead to diminution of the percussion note, to bronchial breathing and also to cir cumscribed metallic titles, undetermined breathing, and slight tynipan itic pulmonary resonance. Mostly, there is doubt whether a capillary bronchitis or a bronchopneumonia is present. Frequent careful exam ination and observation of the above-described symptoms usually lead to a proper differentiation in the course of a few days.