58 FISTULA AND POLL-EVIL 



In rare cases both sides bulge simultaneously. 

 The bulging may take the form of a circum- 

 scribed spherical protrusion or it may be dif- 

 fuse, extending evenly forward over the base of 

 the neck and backward over the withers with 

 its crest opposite the cephalic angle of the 

 scajiula or slightly forward from that point= 

 When both sides bulge from a diffuse enlarge- 

 ment, the withers may appear enormous in 

 width and elevation, sometimes to the extent 

 of making the patient seem top-heavy. If the 

 cavity is not artificially evacuated, nor other- 

 wise molested, the enlargement may remain un- 

 changed indefinitely. We have in mind cases 

 remaining in the saccular stage for more than 

 two years with no other changes pathologically 

 than that of becoming less fluctuant from the 

 development of its fibrous encapsulation, and 

 not infrequently we have seen them disappear 

 entirely. There is no way to predict accurately 

 when any given case will suppurate. 



Finally, the great majority of cases pass into 

 the phlegmonous stage ; that is, they become in- 

 flamed from the invasion of microorganisms. 

 This event is announced by local pain, radiating 

 lines extending from the crest of the enlarge- 

 ment, indisposition to move, grunting, fever 

 and general depression. Cases that become in- 

 fected before the cyst is large enough to bulge 



