(j) The submaxillary glands situated behind the chin.
All these nodes (f—j) communicate directly or indirectly not only among each other but also with the true bronchial nodes.
[This important fact is not definitely established. Recent experi mentors have been unable to demonstrate by' means of the injection of colored fluid into the cervical lymph-channels any connection between the cervical and bronchial lymph-nodes. Again clinical experience shows that we may frequently meet with tuberculosis of the cervical lymph-nodes without a secondary involvement of the bronchial lymph nodes or lungs. It also shows that of the many cases of pulmonary tuberculosis in which the bronchial lymph-nodes are affected, few are complicated by a tuberculosis of the cervical lymph-nodes. These cir cumstances, experimental as well as clinical, must be weighed when we judge of the existence and importance of the anastomosis between the cervical and thoracic lymph systems.—A. F. H.] The question as to how the tubercle bacilli gain admission to the bronchial lymph-nodes allows of two answers: either they gain entry to the lungs by means of the venous blood current or by the air and are carried thence to the lymph-nodes by the interlacing lymph capillaries, or they follow the direct path from lymph-nodes outside the thorax, more especially the cervical chain. We must also not overlook the fact that following a tuberculosis of the bronchial lymph-nodes a retrograde current may be set in motion which will bring about the involvement of nodes situated external to the thoracic cavity.
Symptoms.—The clinical picture of tuberculosis of the bronchial lymph-nodes is by no means clear if we except those rare cases where the entire symptom-complex points to the diagnosis.
The onset of the disease is generally insidious. The condition of the child passes almost imperceptibly from one of health to that of disease. The appetite becomes poor, the cheeks lose their color, the child soon grows thin although it continues to grow in length, which makes its loss of flesh appear more marked. Irregular pyrexia at this
time points to some systemic affection, but examination generally dis closes nothing. In fact the lack of cause for the change in the general con dition of the child is truly characteristic of tuberculosis of the bronchial lymph-nodes.
In other cases the course may be a different one. After a short preliminary stage, high fever may set in, the temperature remaining at 40° C. (104° F.) for weeks and gradually falling by lysis.
The fever curve is atypical, it may be broken by marked remis sions or it may be continuously high. We meet with all the manifes tations which accompany prolonged fever in children: loss of weight and strength, lack of appetite, apathy, etc.
In those cases where the nodes are much enlarged and form a large cheesy mass, we may be able to diagnose the condition by the physical signs, however, in this regard I am somewhat sceptical, as are also Widerhofer and llenoch. Dulness can hardly ever be absolutely deter mined as due to enlargement of bronchial nodes. Even large tumors may not cause dulness, owing to the resonance of the pulmonary tissue.
Two areas are especially accessible for percussion, the interscapu lar space at the level of the 2nd and 3rd dorsal vertebra, and anteriorly over the manubrium sterni. In these locations an increased sense of resistance may also aid us in the diagnosis.
Auscultation generally reveals nothing on account of the excellent conductivity of the neighboring pulmonary tissue. In the interscapular space according to Seitz, rough harsh respiration, especially in expiration may be heard: Widerhofer states that this is more marked on the left side.
We should always try to feel a resistance deep down in the supra sternal space. sometimes a mass of nodes may be palpated. Palpa tion of the cervical and submaxillary nodes may also be of aid in the diagnosis. However these nodes may not be enlarged in spite of, or notwithstanding, tuberculosis of the bronchial nodes.