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No 294 hos already been mentioned as a case of either primary intestinal origin with a lưng fosus,or,possibly, the lung focus was the original site, the alimentary
secondary to it, and from thence the lungs may have been infecte d with miliary tub-
75 eroles via the thoracis duct and the pulmonary circulation.
Kos 217 and 239 have already been spoken of in sufficient detail,when the remark
was made that the alimentary condition appeared to be of the longest standing. In the former was a diseʊus mass in the right upper lobe as large as a filbert,in Me
latter a foeus the size of a bean in the left upper lobe.
It has been stated by MacƐallım that in shildren one may find, instead of the apical lesion po common in adults, a casecus softening of bronchial lymphatio glands and erosion through a bronchus to produce wholesale tuberculosis of a ling or a large section of it. Several of the ouses in this series might be looked upon as examples of this; we must bear in mind,however, that though this may explain gener- alised infection of part or even the whole of a lung, we still leave unaccounted for the sourde hence the gland became involved. In those instances in which we find a focal lesion the subsequent more generalised condition in that lung or part of it may be ascribed to reinfection from the gland, which itself was due to the primary focal lesion, as in Hos 46,64,98,99,186 and 249,
In cases wiera no focal lesion is found to which the affected mediastinal gland conlé bạ traceable, and especially in cases where both lungs are attacked by miliary or grey tuberoles,the spread may have occurred by the bloodfatrem,if general by the pulmonery circulation,if localised either by a branch of this or of a bronchial art- ery. In No 141 the gland me probably secondary to the spine and pleural condition and the widespread affection of the right lung may then have arism as described by
MacCallum,
In No 181 na focal lesion was found to account for the fasested mediastinal glands on the right side and the universal distribution of miliary tubercles in both lunge; the extensive meningeal involvement would be in favour of hamatogenous method of
269
spread. Nos 160,173,áš, and 283 are similar,but in 178 the hamatogenesus route is still more probable because the left lung showed miliary tubercles although there
was no enlargement or sign of infection of the left mediastinal glands.
Nos 79,154 and 163 may be examples of both methods combined, Thus, to speak only the last, the focus in the left lower lobe we may suppose gave rise to the casentad mediastinal gland, and the latter by erosion may have affected the remainder of that || lung, and also by conveyance to the opposite side have spread in a similar way tɔ