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\0X^ We must remember that the bronchial breathing we hear in pneumonia is really the tracheal tubular breathing Generic Oxybutynin produced in the larynx and trachea transmitted unchanged, as far as pitch is concerned, through a consolidated area of uniform medium, but to produce this physical possibility the consoli- dation must extend down to the hilum of the lung or be at least in connection with a fair sized bron- chus so that the tubular breathing can go through unchanged. If the Purchase Ditropan Online note first enters the lung and becomes vesicular, it remains vesicular even though it may later impinge upon a consolidated area, for the consolidated area has no physical means of re- changing Buy Oxybutynin the pitch. This law of sound explains the Order Oxybutynin Online many varying physical signs of pneumonia, and also explains why the bronchial breathing is delayed or even absent in some cases. Another point it is well to emphasize is that pneumonia begins with a wedgeshaped triangular patch with base at surface of hmg and apex pointing inward, and whether bronchial breathing will Generic Ditropan or will not be heard depends upon whether the consolidated area is in communi- cation with a bronchus or has reached the hilum of the lung. Buy Ditropan Online These assertions are Ditropan Online not merely theoretical ; they are very practical, and our success in finding a pneumonia patch will depend on our knowledge of these two facts, for otherwise, expect- ing some change in the auscultatory note, we will overlook a slight grade of dullness indicating a pneumonic area. As an instance of the difficulty of diagnosis we may cite the case of a child treated by Dr. H., who for three weeks had had a cough and a temperature with wide variations. Several con- sultants expressed various opinions, and it was finally thought that the case was one of malaria, as the child came from a malarial district and the ijlood examination revealed suspicious bodies. I was Order Ditropan Online a.sked to see the child. I discovered a dull patch in the left subclavicular region, but normal vesicular breathing was present. Diagnosis of pneumonia was Purchase Ditropan confirmed by radiographic findings. Similarly in Dr. A's case a right apical dullness developed, lasting ten weeks, but at no time was bronchial breathing to be heard. This was also confirmed by radiographic findings. With these facts in mind Order Oxybutynin I may say that in the diagnosis of early pneumonia the percussion note is the most important sign to Buy Oxybutynin Online be depended on. We must remember, too, that a child's chest is very resilient and its lungs highly elastic, and a slight change in percussion note will often be overlooked unless we use the lightest stroke so as to throw as little of the surrounding chest into vibration as ]iossible. The child must be placed in Purchase Oxybutynin a position, ijreferably supine, so as to relax the entire muscu- lature of the chest thoroughly, otherwise tension of the muscles on one side will give a higher note, with the possibility of a mistake in diagnosis. In the early diagnosis we must not Order Ditropan depend on Buy Ditropan any auscultatory assistance for even rales in the pneu- monias of childhood are as often absent as present. A child may go through a pneumonia without a rale and even in the stage of resolution none or very few rales may be heard. Because of this marked variation of the presence of rales I teach my interns not to place too much interpretative value on rales in a chest. They indicate a pathological process, but the exact nature of this process it would be difficult to state because of this Buy Cheap Ditropan variation. As the process continues the auscultatory changes begin to come to the fore. The breathing becomes high pitched, bronchovesicular, and then bronchial, with or without rales. All that has been said above holds true for the lobar type of pneumonia and not for the broncho- pneumonia type. Because of its different pathology and the usually accompanying bronchitis the patches are frequently too small to be detected by percussion note, and, for that matter, even for the radiograph. Frequently, with otherwise positive sig^s of bron- chopneumonia, a radiograph will often be Buy Cheap Oxybutynin negative, and we, therefore, have learned to expect little confirmation from the x ray findings, and unless the patches become confluent and more or less Oxybutynin Online massive we can find few signs except those of a fine bron- chitis. Because of this bronchitis with tenacious mucus in the finer bronchioles, unaffected lung vesi- cles about the Purchase Oxybutynin Online bronchopneumonic patches may Cheap Ditropan be put in a state of atalectasis or high tension and. therefore, either apparently extending the consoli- dated area, enabling us to obtain a dull note, or o\'ershading the bronchopneumonic patch, giving a hyperresonant note. Aside from these slight per- cussion changes in nonconfluent bronchopneimionia we have little to expect in the way of physical signs except those of a bronchitis. As far as bronchial breathing is concerned it is most frequently absent for the very reasons I have explained that the

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