[From the American Practitioner and News, August 26, 1893.] 
THE DIFFERENTIATION OF ACUTE BRONCHO=PNEUMONIA AND 
BRONCHITIS IN CHILDREN.* 
HENRY E. TULEY, M. D. 
In the writings of most of the older diagnosticians, and in many 
of the more recent ones, bronchitis and acnte broncho-pnenmonia have 
been confounded, bnt it is the belief of the writer that many cases of bron- 
chitis so diagnosticated are in truth cases of acute broncho-pneumonia. 
My attention to this point was first aroused while resident at the 
New York Infant Asylum during the service of Dr. L. Emmett Holt, 
and later by a comprehensive and thorough paper on this subject, by 
Dr. Holt, published in the Archives of Pediatrics in December, 1891. 
The object of this short paper, for the facts of which I am indebted 
to the above-mentioned article, is to second Dr. Holt in his efforts, 
hoping to make plain the identity of many cases of bronchitis and 
acute broncho-pneumonia, especially that large class of cases termed 
" capillary bronchitis." 
A glance at our city death-returns will show how prevalent among 
our medical brethren is the use of this term " capillary bronchitis." 
It is evident without demonstration that it is impossible for an inflam- 
mation to occur in the smaller bronchi and their terminal branches, in an 
infant, without spreading to and involving the surrounding structures. 
'Tis true that there are cases where it may be impossible, clinically, 
to make a differentiation, but I believe the number of such is small. 
There is little or no difficulty in making out a bronchitis of the 
larger bronchi, both from the physical signs, the character of the rales, 
etc., and the general symptoms, absence of great prostration, little 
fever, etc. It is rare that we find a unilateral bronchitis. 
The temperature in bronchitis is usually high during the first day- 
reaching its maximum then, 102° or 103°-which lasts twenty-four 
or thirty-six hours ; a fall to ioo° or normal then occurs, fluctuating 
for a degree or so for several days, with a subsidence coincident with 
the cessation of the local trouble. 
There is little or no prostration and the symptoms of a severe lesion 
are absent. 
But how different the clinical aspect of a broncho-pneumonia: Given 
a case with an initial temperature of ioi°, or thereabouts, and the sub- 
Read before the Jefferson County (Ky.) Medical Society, June 6, 1893. 2 
sequent history shows a rise on successive days to 102° or 103°, with the 
general symptoms, prostration, cyanosis, etc., present, we are sure of 
having a serious disease of the lung to deal with, though the physical 
signs may not present themselves until later. 
As to the importance of a diagnosis in these cases, I quote from Dr. 
Holt's article: 
" It may be urged that as there is no difference in the manage- 
ment of a case of severe bronchitis and one of broncho-pneumonia, a 
diagnosis is of no practical importance. This may be admitted from 
the standpoint of a therapeutist in the acute attack. It is, however, 
essential to a correct understanding of what so often follows such an 
attack-relapses, recurrences, or chronic pneumonia-to know from the 
beginning there existed not only a bronchitis but broncho-pneumonia." 
Our diagnosis, then, is to be largely made up from the " severity of 
all the general symptoms, cough, prostration, restlessness, dyspnea, and 
cyanosis." 
If the physical signs of pneumonia be present, bronchial breathing, 
dullness, etc., there is no doubt about the diagnosis; but I have often 
seen cases in which at the autopsy disseminated patches of broncho- 
pneumonia were found, but in which there had not been present dull- 
ness on bronchial breathing at careful physical examinations made 
before death. 
The temperature in broncho-pneumonia is variable, no typical 
courses being followed. In the majority of cases it is high and remit- 
tent, in others it is 103° and below, but it is not infrequent that we 
have temperatures running below ioi°, sometimes even sub-normal; 
the latter occurring more frequently in children who are very delicate 
than among those of robust condition. There is generally a morn- 
ing remission and an evening exacerbation, but it is not unusual to 
meet with the opposite condition, a higher morning temperature, last- 
ing for several days, the resulting chart being very characteristic. The 
temperature may reach as high as 107° or 1080, and is generally fatal. 
The highest temperature recorded in Dr. Holt's series of cases with 
recovery was 1060 of twenty cases, seventy-five per cent proving fatal. 
The duration of the temperature is, of course, very varied. Cases 
are reported as lasting from a few days to fifty-one days or more, the 
greatest mortality in the cases above referred to being one hundred per 
cent in those cases lasting four days or less. 
Of the physical signs which we may expect in pneumonia, are dull- 3 
ness, bronchial breathing, or change in the respiratory note, rales, and 
pleuritic friction sounds. 
The absence of dullness and bronchial breathing, as before stated, 
does not by any means preclude the presence of pneumonia; the patches 
of consolidation maybe so disseminated, with normal pulmonary tissue 
intermixed, as to cause no deviation from the normal pulmonary reso- 
nance or change in the respiratory note, except perhaps a slight weaken- 
ing of the latter. Time and again I have seen cases throughout have 
no dullness, on superficial or deep percussion, with the other pathog- 
nomonic signs of pneumonia present. 
The presence and the character of the rales, and particularly their 
location, is of importance. Finding a localized area of rales, either on 
one or both sides, should cause pneumonia to be suspected, especially 
if over one or both lower behind. 
Of pleuritic sounds, Dr. Holt says: " They may be looked for in 
broncho-pneumonia whenever we have large areas of consolidation pres- 
ent, but in my experience, based upon post-mortem investigation, and it 
has not been small, almost never under other circumstances. In the 
cases under discussion they are so rarely heard that they may then be 
dropped from our thought altogether." 
The general aspect of the child when afflicted with pneumonia is 
characteristic ; the prostration is generally severe, the cyanosis more or 
less marked, dilatation of the alae nasi present, increase in the pulse and 
respiration in the proper ratio, and we nearly always hear the " pneu- 
monic sigh " caused by the short, sharp expiration. 
It is the combination of these general symptoms which in the 
absence of pathognomonic signs would cause us to class these cases 
as broncho-pneumonia, and not "capillary bronchitis," especially those 
cases which only give signs of generally distributed rales with few other 
definite signs. The diagnosis can well be verified by an autopsy, if it 
may come to that. 
Broncho-pneumonia may always be considered a dangerous disease. 
The percentage of mortality has been variously stated. Holt gives it as 
sixty-eight per cent in his 156 cases recorded, while the mortality from 
acute bronchitis is practically nil. 
In conclusion I would state that in the opinion of the writer the 
term capillary bronchitis can not properly be used, for pathologically, 
and in the great majority of cases clinically, these are cases of acute 
broncho-pneumonia and not " capillary bronchitis." 
Louisville.