The cough is an important symptom and may be characteristic. It occurs in prolonged attacks, occurring perhaps at intervals of hours, and frequently resembles the paroxysms of pertussis. However there is no mucous, no vomiting, no regular nightly exacerbations. The attacks of coughing are probably caused by pressure of the enlarged nodes upon the vagi nerves.
We must now consider what may be designated as the indirect consequences of tuberculosis of the bronchial lymph-nodes caused by compression on the important organs in their immediate vicinity (see Plate 34, Fig. c). In the first place the trachea is exposed and may be almost flattened out by pressure. The result is a disturbance of res piration, dyspncea, cyanosis and finally suffocation. If the nodes press upon only one bronchus, more or less of the lung may cease to func tionate. Again, the (esophagus may be entirely occluded by pressure from without, resulting in pain, difficulty in deglutition, leading even to starvation. The blood vessels, more especially the large veins may be compressed, thus giving rise to all the symptoms of venous stasis (see Plate 34 c).
Course.—The course of tuberculosis of the bronchial lymph-nodes is variable. The disease may remain stationary; the cheesy nodes may become encapsulated or calcified. Nevertheless such a tuberculous node existing in the human body cannot be disregarded, especially if the affected individual be a child. For at any time an accident or an inter current disease, especially measles or whooping-cough, but also scarlet fever or diphtheria, may light up the latent focus and endanger the entire body. The bacilli may be transmitted to the lungs, to the meninges, or throughout the body.
In other cases, tuberculosis of the bronchial lymph-nodes may lead by continuity or by a retrograde current to pulmonary infection, resulting in a tuberculous peribronchitis, a diffuse tuberculous pneu monia, or in a local process in the neighborhood of the cheesy nodes, especially those at the hilus of the lungs (see Plate 34, Fig. a).
The nodes may break into the surrounding organs. I have seen a sudden rupture into the trachea lead to the expectoration of masses of cheesy material; a rupture into the bronchi cause an aspiration pneumonia; a rupture into the vessels lead to a miliary tuberculosis of the lungs or entire body. The oesophagus, pericardium, or pleural cavity may likewise be penetrated. Sooner or later in almost all these cases death ensues.
diagnosis in the early stages is difficult. If, after many thorough examinations of a child, we are unable to find the seat of the disease, we may suspect the bronchial lymph-nodes to be the source of the trouble. Radioscopy sometimes enables the diagnosis in advanced cases. Tuberculin may be tried in some cases when there is no fever.
The typical paroxysms of cough are of diagnostic value where per tussis can be excluded. In advanced cases with stenosis of the trachea, where no history of the slow onset is obtainable, it may be difficult to differentiate the disease from diphtheria or even from a foreign body in the bronchus. Sudden onset of the disease with high fever may cause it to be mistaken for miliary tuberculosis.
Prognosis.—The prognosis is not bad so long as the focus is not too large and there is no caseation. Where cheesy degeneration has taken place, we generally have an unfavorable outcome, due to involvement of other organs.
prophylaxis of tuberculosis of the bronchial" lymph-nodes is that of tuberculosis in general. The treatment consists in improving the general condition of the child, which at times accomplishes a great deal. A diet rich in fat, varied in nature, containing a large quantity of fruits and vegetables, is to be recommended, and its results tested by regular weighing of the patient. The appetite may he stimu lated by giving spicy articles of diet, or by arsenic, especially in the form of the natural arsenical waters.
Mud baths are to be recommended. Some recommend giving sium iodide or inunctions of iodine-vasogen. A careful tuberculin cure in the case of patients with normal temperature is by no means futile. In addition, we should resort to symptomatic treatment. tinued fever may sometimes be held in check for a long while by means of hydrotherapy, lactophenin, pyramidon or aspirin. When the nodes compress the oesophagus we should be most careful in the use of the stomach tube. At times the symptoms improve following rupture of the glands. Where a marked dyspncea results, resort to a low tracheotomy and to the removal of the glands from the trachea may be indicated. A few words may be added in this connection concerning culosis of the cervical lymph-nodes. This is of frequent occurrence, at times following involvement of the bronchial nodes, but far oftener through infection from the mouth, from carious teeth, from scrofulous eruptions about the mouth and nose, etc. Compared to the ment of these nodes through pyogenic processes, the tuberculous ments progress slowly. They may be merely as large as a kernel of rice or a cherry but may also reach the size of a plum or become even larger. If these nodes tend to infect those more centrally situated, early operative removal should be considered. As long as the affected nodes remain isolated, only dietetic measures should be resorted to. At times these nodes reach such a stage of caseation, that the neck becomes virtually imbedded in cheesy masses. The reproduction in Plate 34 conveys an idea of this condition.