58 FISTULA AND POLL-EVIL 
Tn 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 
scapula 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 microdrganisms. 
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 
