TUBERCULOSIS OF THE BRONCHIA I. LYMPH-NODES The bronchial glands in children are certainly a locus minoris resist The bacilli must here gain an easy entrance and furthermore must flourish at this site. We find the bronchial lymph-nodes almost without exception inrolred in every tuberculous child. In very many eases we can easily demonstrate that these areas are the oldest in point of origin, and that the spread of the disease throughout the system or to the lungs or meninges originated from this focus.
It is questionable whether isolated bronchial lymph-node tuber culosis is as common as one would imagine from a superficial post-mor tem examination. A more careful examination will often disclose small areas in the lungs which are easily overlooked. However, the main feature, from an anatomical as well as from a clinical point of view, is the tuberculosis of the bronchial lymph-nodes, as the small pulmonary foci, even if primary, are frequently completely healed.
On the other hand we have unquestionable cases of isolated tuberculosis of the bronchial lymph-nodes, indeed Weleminsky has lately expressed the opinion that glandular involvement always precedes involvement of the organ itself, even in the case of the lung and its lymph-nodes.
A careful consideration of the anatomical relationship is necessary in order to understand this question. The bronchial lymph-nodes com prise those lymphatic glands in the thorax which receive the lymph stream from the lungs and the bronchial system. As these nodes, how ever, are closely connected with other lymphatic glands of the thorax and the neck, we must consider them as well. There are three sets of bronchial lymph-nodes: (a) The tracheobronchial lymph-nodes situated at the bifurcation of the trachea, one of which is situated in the angle formed by the sepa ration of the main bronchi.
(b) The bronchial lymph-nodes situated along the main bronchi.
(c) The pulmonary lymph-nodes situated at the hilus of the lungs, also peribronchial in their arrangement, and extending to or into the parenchyma.
All three groups receive their lymph from the lungs, the bronchi and, in part, from the posterior aspect of the heart. Their enlarge ment leads most especially to pressure upon the trachea, the larger and middle sized bronchi, as well as upon the recurrent laryngeal nerve.
Other lymph-nodes to be considered are: (d) The anterior mediastinal, about 12 in number, situated pos terior to the sternum and around the large vessels, e.g., in the space between the right innominate artery, in the concavity below the right subelavian artery, and in the concavity formed by the arch of the aorta.
According to Friedleben, the nodes lying below the concavity of the right subelavian arc very frequently affected. The lymph enter ing these nodes comes from the anterior portion of the diaphragm and from the upper surface of the liver, as well as from the pericardium, the heart and the thymus. Their enlargement leads to compression of the great vessels.
(c) The posterior mediastinal lymph-nodes situated along the aorta and oesophagus and receiving the lymph from the (esophagus, poste rior part of the diaphragm, pericardium and the liver. Enlargement produces compression of the oesophagus, or even of the aorta. All these nodes (a—e) are connected by anastomosis, so that disease of one set may be transmitted to another. They also connect with nodes lying outside of the thoracic cavity, of which the most important groups are: (I) The tracheal and oesophageal lymph-nodes. These are covered by the sternothyroid muscle, and extend from the isthmus of the thy roid gland, down along the anterior aspect of the trachea, two or three being situated somewhat to the left on the oesophagus.
(g) The jugular lymph-nodes lying beside the internal jugular veins.
(h) The supraclavicular lymph-nodes lying above the clavicle and between the borders of the trapezius and the sternomastoid muscles.
(i) The superficial cervical lymph-nodes lying on the upper half of the sternomastoid muscle and below and behind the external ear.