TTJBEKCtrLOSIS. 518 TUBERCULOSIS. be involved, become consolidated, and, undergoing necrosis, result in the I'urmation of large cavities. In the chronic form there is a slower involvement of the lung tissues, and there is apt to be more fibrous tissue, especially in the walls of cavities. These cavities may be small or large ; are usually at first devoid of any wall, but soon acquire a wall of fibrous tissue, often lined with new tu- bercle tissue or with granulation tissue. This lining tissue often contains enormous numbers of tubercle bacilli, which are cast oti' in the sputum. It also furnishes a lodging place for pyogenic cocci, which cause suppuration of the membrane, and it is not at all improbable that these pyo- genic cocci are very largely concerned in the for- mation of the cavities themselves. This secondary or concurrent infection, as it is called, is also largely responsible for the bronchitis and yellow or greenish expectoration which so usually ac- companies phthisis. Blood vessels stretch across these cavities or lie exposed in their walls, to be broken either by an extension of the disease itself or from a strain too sudden for their weakened walls. In this way may be caused the hemor- rhages so frequently associated with phthisis. The most frequent site of tubercles in the adult lung is the apex, although the initial lesion may occur in any part of the organ. In children the broncliial lymph nodes are usually first affected. 'Healed tubercles' of the apex are found in a large proportion of autopsies. Associated with the lesions in the lungs may be lesions in other parts of the body. These may be secondary to the pulmonary infection or the lung lesion may be secondary to other lesions. Acute or chronic inflammation of the pleura com- monly accompanies the disease of the lung tissue proper. This inflammation may be simply exu- dative or may be tuberculous. Infection with the pyogenic cocci sometimes results in an empyoema (purulent pleurisy) ; or the opening up of bronchi or air spaces into the pleura may result in a pneumothorax. Tuberculosis of Sekous Meiibr.^nes. That of the pleura has been mentioned. Tubercular pleu- risy maj', however, occur independently of any lesion in the lung proper. Tubercular peritonitis may be primary^ but is more frequently associ- ated with tuberculous disease of some adjacent organs. Thus in women nearly half the cases are due to extension from the Fallopian tubes. In man the initial lesion may be in the seminal vesi- cles or prostate. It may be part of a general miliary tuberculosis. In the tubercular peritoni- tis of pulmonary phthisis the infection seems to reach the peritoneum through the intestines. In some cases minute tubercles are scattered over a part or all of the peritoneum and are usually ac- companied by a serous or sero-fibrinous exudate. There may be larger areas of tubercular tissue which undergo necrosis. Secondary infection by the pyogenic cocci may occur, resulting in a purulent exudate. In what is known as chronic fibroid tuberculosis of the peritoneum there is little exudation, the tubercles are firm and pig- mented, and the peritoneal surfaces matted to- gether by fibrous adhesions. It is not uncommon to have tumor-like formations. Tliese may be due to sacculated exudations, to matting together of omentum or intestinal coils, or to enlargement of mesenteric glands. Tubercular pericarditis may be primary or secondary, acute or chronic. In the acute miliary form the membrane is studded with tubercles and there is usually some serofibrinous exudate. In rare cases the exudate is large, ilusser in one ease rcjiorting 34 ounces of fluid in the pericardial sac. In chronic cases the membrane is thickened, adherent, and usually shows several cheesy tubercular masses. The bronchial and mediastinal lJ^nph nodes are regu- larly involved. Tuberculosis occurs in bones, periosteum, and joints. In tuberculous osteitis the tubercles may be small and scattered, or less in number and of considerable size. Abscesses are sometimes formed. The adjacent joints are frequently in- volved. The spongy parts of the bone are more susceptible than the hard parts. The vertebra, carpal and tarsal bones are most commonly all'ected. The chronic, purulent periostitis of poorl_v nourished children is frequently tubercu- lar. For description of the lesion in tubercular arthritis, see Synovitis. Genito-Urinary System. Tuberculosis of the kidney may be primary, a part of a general miliary tuberculosis, or, as is most commonly the case, secondary to lesions in other organs. There may be small nodules in the kidney proper, or in the pelvis; or there may be quite large areas of tubercular tissue with necrosis. These may occur in only one kidney or in both kidneys. With much destruction of kidney tissue, cavities or cysts are formed, in some cases the kidney being almost wholly replaced by cysts of various size. There is apt to be thickening of the pelvis and tubercle tissue in its walls. Tuberculosis of the ureter and bladder is almost always secondary, especially to disease of the kidney pelvis. Small tubercles or patches of tubercle tissue are present in the ureter or bladder walls. Tuberculosis of the testes occurs as a primaiy lesion or, more fre- quently, as secondary to lesions elsewhere. In tuberculosis of the Fallopian tubes, the tubes are enlarged, their walls thickened, and the lumen usually filled with cheesy matter. Both tubes are frequently involved. Adhesions and the for- mation of abscesses are common results. Liver. Jliliary tubercles of the liver are quite common as a part of a general miliary tuberculo- sis. Wany of these tubercles are microscopic in size. Sometimes the tubercles are in among the liver cells, in other cases they develop in the walls of the smaller bile vessels, forming ab- scesses. Large tubercular patches having a diam- eter of an inch or more are sometimes found. In connection with the tubercular process there may be a marked increase in the connective tissue of the liver, constituting what is known as a tuber- culous cirrhosis. Lips, JIouth, etc. In tuberculosis of the lips, which is a rare disease, there develops on the lip an extremely sensitive ulcer. This ulcer has much the appearance of an epithelioma or a chan- cre. Tubercular laryngitis is most frequently secondary to tuberculosis of the lungs. Miliary tubercles form in the submucosa and are accom- panied by a catarrlial inflammation of the mucous membrane. With necrosis of the tubercles, ulcers are formed. These ulcers often run together, involve adjacent parts, and determine extensive destruction of tissue. Tuberculosis of the tongue is marked by the appearance of small nodules on the upper surface or edge of the organ. These open on the surface and become ulcers. It is a
