Enlarged cervical glands do not always suppurate. Sometimes, after remaining a variable time as a chain of indolent swellings, they begin gradually to diminish in size and return slowly to their normal dimensions.
Caseation of the bronchial glands is little less common than the same condition in those of the neck. The effect, however, of such disease is very different. Swelling of the superficial glands of the neck, although unsightly enough, is yet in itself a complaint of comparatively little moment. But when the glands of the mecliastinum become enlarged, the consequences may be serious. The glands are seated at the bifurcation of the trachea, behind the upper bone of the sternum, and a little below it. They also accompany the bronchi into the interior of the lung. When swollen, they must therefore encroach upon neighbouring parts, and may produce considerable disturbance by pressing upon the blood-vessels, the air-passages, and the nerves of the chest.
Before describing the symptoms produced by this means, it may be remarked that enlargement of the bronchial glands does not necessarily imply the existence of chronic lung disease. A child is not to be con sidered consumptive because his mediastinal glands are bigger than they ought to be. The term " bronchial phthisis," which has been applied to this condition, is very misleading, and was given at a time when all chronic changes in the glands were attributed to tubercle. Scrofulous children, who are so prone to suffer from pulmonary catarrh, will generally be found, on careful examination, to have some swellings of the glands be hind the sternum ; but if no dulness or bronchial breathing can be de tected over either lung, we have no reason to infer the existence of pulmonary disease. Like the same affection in the neck, caseation of the glands below the trachea is often a purely local process, induced in a scrof ulous child by some passing irritation. It is more serious than a similar condition in other parts only because the glands are shut up in a closed cavity, in the immediate neighbourhood of large vessels and vital organs, which may be affected injuriously by their pressure, or by pathological changes occurring in them.
It is possible that the bronchial glands may be, as most authorities hold, occasionally the seat of tubercle, although arguments in favour of this view, drawn exclusively from morbid anatomy, are of only secondary value. But there is little doubt that the ordinary form of glandular en largement is due to a very different cause. It is true that children who suffer from this form of scrofula are frequently feverish, and that they are often thin and under-nourished ; but these phenomena are not necessarily the result of tubercle. It will be generally found that the pyrexia is not a constant feature in the case. It occurs now and again, the child's tem perature in the interval being normal, and lasts on each occasion for a week or ten days. While the feverishness continues, the child is languid and moues, eats little or nothing, and is generally troubled with cough. The explanation is that a child suffering from this cachexia is excessively sensitive to changes of temperature and readily takes cold. While the catarrh lasts he is feverish ; and as all the mucous membranes are equally sensitive, the stomach sympathizes in the general derangement. For the time, then, nutrition is in abeyance, and he loses flesh. Even when the attack is at an end, and appetite returns, the stomach does not all at once recover its power. The patient's digestion continues weak and cannot fully satisfy the requirements of his system, so that he regains flesh but slowly. If the catarrhs recur at short intervals, the child is kept thin and weak ; but he is not therefore tubercular, and if he die, he dies usually from a simple bronchitis or pneumonia, and not from any tubercular com plaint. But such children, if in a position to receive all the care they re quire, seldom do die. In my experience such a termination is rare in cases where the lungs are unaffected. When due precautions are taken, they often become fat and strong, and the signs of glandular enlargement dis appear.