When softening begins the general symptoms become more pro nounced. There is fever, the evening temperature rising to 102° or there is marked pallor, although the cheeks become flushed towards night ; and the expression is distressed. Often the child sweats towards the morning. These symptoms indicate an infection of the system by absorption from the softening area. The disease from being local is becoming general ; and the consequences are quickly seen in the inter ference with nutrition which never fails to ensue. The child begins to lose flesh and strength ; his spirits fail ; his appetite and digestion become poor, and he shows all the symptoms of suffering. The course of the disease is almost always unequal. Every now and again an improvement is seen to take place. By careful nursing and treatment the fever dimin ishes or subsides ; the nutrition improves ; and flesh and strength are regained. It is not uncommon to see a child fairly plump and to all appearance in tolerable health, who yet has a cavity in one lung and signs of consolidation at the opposite apex.
During this stage pains are often complained of in the shoukler of the affected side. They come and go, and seldom continue for long together. The respirations are usually more hurried than in health, but when the child is quiet are not necessarily much exaggerated. The increased fre quency of breathing is a cause of no inconvenience to the patient, and unless after exertion does not give rise to a feeling of dyspncea. The cough is frequent and fairly loose. If expectoration occur, the sputum consists of yellowish or greenish muco-purulent matter which under the microscope is found to contain fragments of yellow elastic tissue and often bacilli, the latter perhaps in large quantities. Hmoptysis is rare, but does occur in exceptional cases. Children accustomed to a sufficiency of good food seldom have much appetite, and often show a complete dis gust for food. In hospital patients, however, the appetite may remain keen ; and a child with cavities in his lungs and a high temperature may be seen to enjoy his meals almost as if he were well. The digestion is usually impaired, and, probably from the quantity of acrid mucus which is swallowed, vomiting is not uncommon. Diarrhoea, too, is a familiar symp tom. In cases where the appetite is preserved nutrition may seem for a time to go on fairly well in spite of the pyrexia. Hospital patients often gain weight after admission, although the evening temperature may stand every night at 102° or 103°.
The physical signs in the stage of softening consist of an increase in the dulness, for the irritation set up by the changes occurring at the diseased spot induces an extension of the catarrhal process ; and an alteration in the quality of the breathing, which becomes blowing or even cavernous. It is accompanied by a moist crackling rhonchus which, as a cavity forms, becomes very metallic and ringing. At this time the apex of the opposite lung should always be carefully examined. In many cases slight loss of re sonance with high-pitched or faintly bronchial breathing will be found at the supra-spinous fossa, and a click or dry crackle can be heard at the end of inspiration. It is at this period of the illness that diarrhoea is especially
frequent ; and if caseation and softening occur in the solitary follicles of the intestine and the glands of Peyer's patches, the stools may soon begin to present the characters peculiar to ulceration of the mucous membrane (see page 662). If this complication occur, the child wastes rapidly and be comes haggard and hollow-eyed. He sweats profusely at night ; is rest less ; refuses food ; and quickly dies with all the symptoms of prostration. The temperature in these cases seldom reaches a high elevation. It is usually between 101° and 102° in the evening.
Children who are the subjects of a chronic caseous consolidation of the lung often suffer from attacks of secondary catarrhal pneumonia. In these attacks the boundaries of the original mischief are not always extended. It is common to find the chief force of the complication expended upon a different part of the lung. Thus, a child with signs of consolidation at the apex of the right lung is attacked with catarrhal pneumonia. A loud crep itating rhonchus is heard all over both sides of the chest, and at the right posterior base there is some dulness with tubular breathing and a metallic quality of the rhonchus. The basic dulness becomes gradually more pro nounced, and at this spot the respiration gets to be cavernous or even am phonic, and the rhonchus'to be excessively metallic and ringing. The vocal resonance is bronchophonic. The temperature rises to 103° or 104° in the evening. After two or three weeks the temperature begins to fall and the dulness to diminish ; the hard metallic rhonchus becomes looser and more bubbling ; the cavernous breathing is less intense at the base, and the gur gling is less large and metallic. The child begins to regain flesh, and when lost sight of, although looking plump and well, has still the old mischief at the apex, and the signs of consolidation with cavernous breathing still per sist at the base of the lung. In such a case, which is no imaginary one, the child recovers from his intercurrent attack with two consolidations instead of one. The catarrhal pneumonia has given rise to a cheesy deposit at the base of the lung and dilatation of the bronchi. This, of course, if the patient be placed under favourable conditions, may possibly be recovered from ; but the probable consequence of such a condition, if time be allowed for the change, is the development of a fibroid overgrowth at the spot and permanent bronchiectasis.
An attack of bronchopneumonia is often a cause of death, or the patient dies worn out with fever, diarrhoea, cough, and want of sleep. In not a few cases a secondary tuberculosis supervenes, or the case may be compli cated by a more chronic and less general formation of miliary tubercle confined to the lungs. These are called cases of tuberculo-pneunionic phthisis.