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.

_Diagnosis._--The chief importance lies in differentiating tuberculous
disease from lympho-sarcoma and from lymphadenoma, and this is usually
possible from the history and from the nature of the enlargement. Signs
of liquefaction and suppuration support the diagnosis of tubercle. If
any doubt remains, one of the glands should be removed and submitted to
microscopical examination. Other forms of sarcoma, and the enlargement
of an acce