As these signs develop, indicating ex tension of the local morbid processes, the symptoms become correspondingly se vere. Dyspncca increases and the respira tion-rate rises, with children reaching sixty or seventy, with adults rarely ex ceeding fifty, and usually remaining be low that number. Cyanosis now becomes manifest. There may be suprasternal and infrasternal retraction. At first, in severe cases, the children exhibit great restlessness and anxiety, obtunding of sensation takes place, drowsiness in creases, and, while the breath becomes more gasping, the efforts to obtain air diminish. The heart becomes weaker, the right ventricle is evidently distended; the pulse is small, feeble, and fluttering; and death may occur from cardiac paral ysis or from exhaustion. Sometimes there is delirium, cephalalgia, retraction of the head, and tenderness of the scalp and neck, apparently indicating menin geal complications, and convulsions may occur; at other times there is constant or intermittent delirium, with jactitation, and this seems to be rather toxaemic than due to cerebral inflammation.
Two forms of laryngeal spasms ob served complicating eases of broncho pneumonia: one in which the medias tinal lymph-nodes were large enough to compress the recurrent laryngeal nerve; the other in which the lymph-nodes were not enlarged. The spasm can only be explained as reflex, due to the lesion in the lung-parenchyma. Variot (Jour. de Clin. et de Th6r. Infant., vol. iv, No. 32, '96).
Catarrhal pneumonia may be divided into three groups: 1. A primary one in older children not suffering from any exanthematous disease. 2. That follow ing infectious diseases accompanied by inflammation of mucous membranes. 3. That met with in cachectic children, due to bad air, poor food, and in rachitis of the thorax.
In the first group we encounter high fever, in the second a long-continued fever, and in the third no fever. We occasionally elicit dullness over both lower lobes of the lungs in pneumonia, accompanied by bronchial breathing in the upper lobe, and this happens in catarrhal -pneumonia, which might, therefore, easily be taken for tuberculo sis. In severe disease of the lower lobes
the upper do not expand well, so that quiescent air-columns are formed. Au frecht (Der Kinderarzt, viii, p. 220, '97).
Four clinical types of infantile pneu monia recognized: (a) complete consoli dation of lobar distribution, without signs of bronchial catarrh; (b) with no sign of consolidation, bronchial catarrh being generally distributed over one or, frequently, both lungs; (c) with bron chial catarrh and some areas of incom plete consolidation of lobular distribu tion; (d) with bronchial catarrh and larger areas of incomplete consolidation of lobar distribution. The differentia tion of the last three types depends to a greater or less extent upon the degree of accompanying consolidation. The acute pneumonia of infancy and early childhood is a bronchial pneumonia in the majority of cases. James Car michael (Brit. Med. Jour., Oct. 15, '98).
Recovery may take place even in ap parently desperate cases, and the symp tomatic changes may be as sudden as in lobar pneumonia, though usually the process is gradual, but rapid. The dura tion varies from about ten days to about three weeks. In cases delayed beyond this the suspicion of tuberculosis or local ized empyema becomes strong. Some cases, however, which are not clearly tuberculous, run a remittent or subacute course, and others gradually take on, a chronic type.
Diagnosis. — There used to be much written concerning the differential diag nosis of capillary bronchitis.and broncho pneumonia. Post-mortem investigation has shown that the differentiation is im possible, for the two conditions usually co-exist. The difference is symptomatic only, and affects treatment only as this is guided by symptoms. The chief dif ficulties in diagnosis are to determine whether or not lobar pneumonia exists in a case presenting massive areas of dull ness and to determine whether or not a case of recognized bronchopneumonia is tuberculous. The recognition of influ enza as the general condition is also im portant.