In many cases the disease in the glands is associated with pulmonary phthisis ; but this is more often than not of the non-tubercular variety. When death takes place in such cases it results from the lung disease, and the glandular swelling contributes little, if at all, to the fatal issue. Death, however, does sometimes occur as a consequence of the scrofulous swell ing. The mass may cause such disturbance by pressure upon neighbour ing parts that inflammation and ulceration are set up, and the child sinks from exhaustion. Thus the oesophagus or an air-tube may be perforated, as in a case published by Dr. Gee, without any softening having occurred in the gland. In other cases the gland softens and becomes converted into a mass of pus. Here there is hectic fever, general and persistent wast ing, and loss of strength. Eventually the abscess discharges itself into the pleural cavity, into a bronchus, or into a large vessel, causing fatal haemor rhage. A common termination when softening takes place in the gland is by acute tuberculosis. This, however, may occur in the case of any other softening cheesy mass wherever situated. It is no proof that the gland was originally the seat of tubercle.
The special symptoms produced by enlargement of the mediastinal glands are the consequence of pressure—the glands by their unwonted size encroaching upon the parts around.
Pressure upon the superior vents cava, or either innominate vein, inter feres with the return of blood to the heart. There is a certain degree of lividity of the face, the skin around the mouth has a bluish tint, and the lips look puffy and dark. The superficial veins also are unusually visible in the temples, the neck, and over the front of the chest and shoulders. A small amount of pressure is sufficient in children to cause dilatation of the venous radicles of the chest, and the symptom is one of the earliest indi cations that the bronchial glands are larger than they ought to be. If there be great obstruction to the return of blood from the head, oedema of the face and puffiness of the eyelids may be seen ; and this, when one innominate vein only is pressed upon, is limited to one side of the face. On account of the congestion of the venous system, epistaxis is common, and hemorrhage may even occur from the lungs. But limmoptysis in chil dren is difficult to detect, for blood coming up from the air-tubes is al most invariably swallowed, while a discharge of blood from the mouth is usually the consequence of epistaxis, the blood escaping backwards into the throat from the posterior naves.
Pressure on the nerves of the chest causes hoarseness of the voice and paroxysmal cough which may be mistaken for whooping-cough. It occurs in violent fits, and sometimes ends in a crowing inspiration. It is, how ever, seldom followed by vomiting. When the pressure affects also the lower end of the trachea at its bifurcation there may be, in addition, attacks of dyspncea. These are the ordinary " asthmatic attacks" of young children. Sometimes laryngeal spasm is induced, and long-continued spasm may so interfere with the entrance of air into the lungs that the antero-posterior diameter of the chest becomes diminished, the weight of the atmosphere forcing the sternum backwards below the level of the ribs. All these press
ure symptoms become greatly aggravated by an attack of pulmonary ca tarrh. In ordinary cases severe symptoms are only seen when the child catches cold. If this happen, the condition of the patient becomes alarm ing. His face is livid ; his dyspncea distressing ; his voice hoarse ; his cough violent and spasmodic. Even then the attack is often not continu ous. It occurs in sudden seizures which come on once, or more often, in the day, or only at night. The attacks last a variable time and create much alarm. In most instances their violence abates after a few clays, and in the course of a week or so the child seems restored to his ordinary health, although he is left languid and more feeble than before his illness. In other cases the symptoms increase in severity instead of diminishing. The child starts up suddenly in his bed with staring eyes and a dusky, frightened face ; his respiratory muscles work violently, and his agitation. and distress are painful to see. After several repetitions of these attacks death may take place either suddenly, or after a fit of convulsions.
The physical signs afforded by examination of the chest are of impor tance. In marked cases we find dulness on the first bone of the sternum, which may extend for some distance on each side and below. Sometimes it is found to reach As far downwards as the base of the heart. I have never succeeded in detecting any dulness in the back between the Indeed, the results of percussion even in front are often misleading. There may be very considerable and extensive disease in the glands, and unless the mass is in actual contact with the wall of the chest no dulness may be discovered at the spot. The signs afforded by the stethoscope are much more trustworthy. Pressure upon the lower part of the trachea produces a respiratory stridor which is sometimes so loud as to be heard at a distance from the chest. It is generally intermittent. In either bronchus marked pressure may interfere with the entrance of air into the corresponding lung, and lead to a certain amount of collapse at the base. Pressure such as-this, however, is exceptional, and is only seen in cases where the enlargement is great. The most common auscultatory sign connected with the breathing is produced by conduction, the glands forming an artificial medium of communication by which sound is conveyed from the air-tubes to the chest wall. This gives to the breathing a loud blowing character which is very characteristic. It is less high pitched and metallic than the ordinary blow ing and cavernous breathing heard in cases of pulmonary consolidation and excavation ; and is most marked at the apices of the lung, especially at the supra-spinous foss. Sometimes it is heard loudly over the whole of one or both sides of the chest. Opening the mouth generally modifies consid erably the intensity of this blowing quality, and may even make it cease altogether.