The usual termination of scrofulous glands in the abdomen is that by shrinking and petrifaction. They rarely soften, although cases are re corded in which suppurating glands have become adherent to a coil of intestine and have discharged their contents into the bowel.
From the preceding description it will be seen that the phenomena produced by the development of the scrofulous cachexia are very numer ous. The manifestations of the diathesis must therefore vary greatly in different cases, the constitutional tendency expressing itself now in one way, now in another ; for in addition to the general predisposition, the child seems also to inherit a special weakness of particular tissues. Thus, in one family we see child after child suffer from scrofulous inflammation of the eye ; in another there is equal susceptibility of the pharyngeal or the nasal mucous membranes ; in a third we detect a special proneness to disease of the bones or of the joints. All these disorders are apt to run a tedious course and to resist treatment with singular obstinacy. They can only be attacked successfully by using means which improve nutrition, and weaken the morbid tendency on which the lesion depends. Until this be done mere local applications will be of small value.
Diagnosis.—It has been said that scrofulous lesions have no special characters which indicate their constitutional origin. Their real nature must therefore be inferred from their lingering course, their tendency to recur, the frequent absence of any discoverable local cause to account for them, and the coexistence of other disorders of a like nature, espe cially of glandular enlargements.
The subcutaneous abscesses may be, and often are, mistaken for syph ilitic gummata. They must be distinguished by the history of the case, noting the complete absence from it of any syphilitic symptoms.
The diagnosis of the early stage of spinal caries has been already indi cated in the description of that disease. Remembering how the pain radi ates in this affection to distant parts, we should always look with suspicion upon pain in the chest or stomach in a child of scrofulous tendencies until the spine has been tested for the effect of sudden jars or shocks, and the child's attitudes as he walks or plays have been inquired into. Persistent
pain in the occipital region, if combined with any stiffness in the neck or any altered manner of holding the head, is always suspicious of caries of the cervical vertebrae. Pain in the chest or stomach, unaffected by food but increased by movement and relieved by lying down, is highly sugges tive of dorsal caries. In all cases where spinal disease is suspected the child should be made to raise himself from a recumbent position, to pick up a small object from the floor, or to climb on to a chair or table, and his manner of performing these acts should be carefully observed, noting the degree of movability of the spine, and whether any part of it is held rigid.
In the case of enlarged glands we may consider that a gland has be come cheesy if it have enlarged without evident cause, and if it persist for a long time as a painless indolent tumour showing no tendency to subside.
Caseation of the bronchial glands may be detected in their early stage by the experiment of listening over the upper bone of the sternum while the child's head is retracted, as already described. Dulness at the upper part of the sternum, if combined with any sign of pressure, is very sus picious, especially if there be fulness of the superficial veins of the neck, side of the head, and temples. Spasmodic breathing and paroxysmal cough are also characteristic symptoms—the more so if they are combined with any altered quality of voice. In all cases where children have attacks of so called " asthma," attention should be always directed to the bronchial glands (see page 182).
In the case of the mesenteric glands the only satisfactory proof of their enlargement is them between the fingers. Even in these cases, however, we have to satisfy ourselves that the substance is really a gland, and not a cheesy mass attached to the omentum, or a lump of hardened feces. Cheesy omental masses are much more superficial, and consequently more easily felt than enlarged glands. They are also more freely mova ble. In feeling for mesenteric glands the fingers have to be pressed down firmly towards the spine, and the glands, if enlarged, can be detected as slightly movable lumps with ill-defined margin.