The enlargement may affect only one gland, usually below the angle of the mandible, and remain confined to it, the gland reaching the size of a hazel-nut, and being ovoid, firm, and painless.  More commonly the disease affects several glands, on one or on both sides of the neck.  When the disease commences in the pre-auricular or submaxillary glands, it tends to spread to those along the carotid sheath:  when the posterior auricular and occipital glands are first involved, the spread is to those along the posterior border of the sterno-mastoid.  In many cases all the chains in front of, beneath, and behind this muscle are involved, the enlarged glands extending from the mastoid to the clavicle.  They are at first discrete and movable, and may even vary in size from time to time; but with the addition of peri-adenitis they become fixed and matted together, forming lobulated or nodular masses (Fig. 78).  They become adherent not only to one another, but also to the structures in their vicinity,—­and notably to the internal jugular vein,—­a point of importance in regard to their removal by operation.

At any stage the disease may be arrested and the glands remain for long periods without further change.  It is possible that the tuberculous tissue may undergo cicatrisation.  More commonly suppuration ensues, and a cold abscess forms, but if there is a mixed infection, the pyogenic factor being usually derived from the throat, it may take on active features.

[Illustration:  FIG. 78.—­Mass of Tuberculous Glands removed from Axilla (cf.  Fig. 79).]

The transition from the solid to the liquefied stage is attended with pain and tenderness in the gland, which at the same time becomes fixed and globular, and finally fluctuation can be elicited.

If left to itself, the softened tubercle erupts through the capsule of the gland and infects the cellular tissue.  The cervical fascia is perforated and a cold abscess, often much larger than the gland from which it took origin, forms between the fascia and the overlying skin.  The further stages—­reddening, undermining of skin and external rupture, with the formation of ulcers and sinuses—­have been described with tuberculous abscess.  The ulcers and sinuses persist indefinitely, or they heal and then break out again; sometimes the skin becomes infected, and a condition like lupus spreads over a considerable area.  Spontaneous healing finally takes place after the caseous tubercle has been extruded; the resulting scars are extremely unsightly, being puckered or bridled, or hypertrophied like keloid.

While the disease is most common in childhood and youth, it may be met with even in advanced life; and although often associated with impaired health and unhealthy surroundings, it may affect those who are apparently robust and are in affluent circumstances.