FibroCystic Tumor of the Neck, 
BY 
Robert Battev, M. D., 
ROME, Ga. 
Mr. Colman Keen, of Walnut Hills, LaFayette County, Arkansas; 
a native of Washington County, Ga., aet. 43; weight 145 pounds; 
race, Caucasian; occupation, farmer; physique, tough and wirey; tis- 
sues like good old bacon, firm and dry; married, father of seven 
children; always enjoyed good health, and still able to do effective 
labor on the farm, notwithstanding his grievous burden, of which he 
seeks relief. His father died at the age of 45, of typhoid fever; his 
mother at 40, with general dropsy. 
Sixteen years ago, he observed a small tumor developing beneath 
the jaw, in the region of the left submaxillary gland. It gave him 
no pain, grew slowly, and did not command much of his attention 
for some years. It was hard, and quite movable. As the tumor en- 
larged, it progressed both upwards towards the ear, and downwards 
along the anterior margin of the sterno-cleido muscle. For several 
years past it has increased in a much more rapid way, and has become 
soft at a number of points upon its surface. During the past twelve 
months,' the augmentation in bulk had become so rapid as to alarm his 
fears, and add seriously to his burden. 
On examination, I found the large irregular tumor, illustrated in 
Cut I. It was moderately movable in a direction upwards and 
downwards, and much more freely so in the direction forwards and 
backwards. Above, it had involved the lobule of the left ear, and 
completely closed the external meatus, depriving him for the time of 
the sense of hearing upon the left side. In a forward and upward 
direction it had surmounted the lower jaw, and formed a broad and 
firm attachment to the zygomatic arch and superior maxillary bone, 
by which the weight of the tumor was chiefly supported. Below, it had 
burrowed its way downwards and forwards, until it passed the median 
line and rested upon the trachea and sternum. Behind and below, the 
base of the tumor reached to the clavicle, and the pendulous portion 2 
ROBERT BATTEY, 
hung down upon the chest, as shown in the cut. Its surface throughout 
was irregular and nodular, soft and elastic rather than fluctuating in 
some of its parts; in others, quite hard and resisting to the touch. So 
completely were the carotid vessels covered in by the tumor, it was im- 
practicable to feel the arterial pulsation at any point. The superficial 
veins were not enlarged; the course of the external jugular could not be 
traced at all. The skin was not actually adherent at any point, and yet 
it did not move with freedom over the tumor. From the history and 
external characteristics of the growth, a diagnosis of fibro-cystic tumor 
Cut 1. 
of the neck was unhesitatingly made, without resort to the exploring 
needle, which was deemed unneccessary. 
With a rest of but a single day from his journey, and without any 
attempt at systemic preparation, he was subjected to operation on the 
eleventh of November last, my partner, Dr. G. W. Holmes, and Drs. T. 
J. Word, and A. P. Richardson kindly assisting me. The patient hav- 
ing been fully etherized, a large anterior flap (see Cut II) was re- 
flected upwards upon the face and anterior surface of the neck, and a 
correspondingly large posterior flap was turned down over the chest 
and shoulder. These flaps were purposely left of ample size, to pro- 
vide for much shrinkage, and to avoid any tension in the sub-max- FIBROCYSTIC TUMOR OF THE NECK. 
illary fossa. The formation of the flaps required slow and tedious 
work, as the connections between the tumor and the adjacent tissues 
were very firm and intimate, and the vessels, though for the most part 
of small calibre, were quite numerous, ten or twelve ligatures being 
required, besides torsion of a number of others. Each vessel was 
dealt with in turn as it was severed. The external jugular was 
found to pass through the centre of the tumor, and it was ligatured 
and divided upon either side, a double ligature being used in each 
case. Care was used in the dissection to keep fully down upon the 
tumor, and to follow closely the line of demarcation between it and 
the surrounding textures, thus avoiding confusion and uncertainty, 
and enabling me to enucleate the tumor cleanly and completely, 
as will be seen in the photograph from which Cut II is taken. 
Fortunately, the deeper portions of the growth which lay upon the 
Cut 11. 
parotid gland and dipped down rather deeply in the carotid space, did 
not involve either of those'large vessels, the internal jugular vein, nor 
the pneumogastric, phrenic, or other important nerve. Notwithstand- 
ing the great taken to avoid any unneccessary hemorrhage, 
the operation was a bloody one, as such operations upon the neck 
usually are. That it should have been so, is not surprising, when it is 
stated that the raw surface exposed on lifting out the tumor could not 
have been fully covered by a dinner-plate. Upon the completion of 
the operation, the still fairly good, notwithstanding the very 
considerable loss by oozing of the surfaces. The flaps, with a single 
slight trimming at the upper angle, were brought together in a line 
connecting the ear with the top of the sternum, in such manner as 
to hide the cicatrix in the cervico-maxillary fossa, and were united by 4 
ROBERT IiATTEV, 
numerous points of silk suture. At the upper angle, the loose skin was 
utilized, by folding in such manner as to reproduce the lobule of the 
left ear very perfectly. The submaxillary space was well filled up with 
soft sponges, as recommended by Gross, surmounted by compress and 
bandage, to keep the flaps well in contact with the subjacent tissues. 
This arrangement was found to work admirably, and as I think the 
event showed, with great advantage to the patient. 
The patient rallied well from the operation, was cheerful and com- 
fortable, requiring no morphine until night, when a single dose se- 
cured good rest. At 6P. M., the pulse was 120, the temperature 
99.70; at 9P. M. the figures fell to 96 for the pulse, and 990 lor the 
temperature. On the morning of the second day, the pulse was izo. 
Cut 111. 
temperature ioi°, and in the evening, pulse 130, temperature 103 . 
At night, twelve grains of quinine were given, but, as the stomach re- 
jected it, no more was attempted. On the third day morning, the 
pulse®and temperature had dropped to 96 and ico.s respectively. 
The dressings were now removed for the first time, and the lips ol the 
long wound appeared well adherent throughout. A grain and a-half 
of saccharine calomel* was placed upon the tongue, with a view to 
* See Atlanta\Medical and Surgical Journal for August, 1873, p. 261. FIBROCYSTIC TUMOR OK THE MFC SC. 
move the bowels. From this time forwards, there was no consider- 
able rise in either pulse or temperature, and everything progressed 
as favorably as could be asked. The bowels moved satisfactorily on 
the fourth day. Upon the fifth day, he called for food and sat up in a 
chair. On the seventh day he got on his clothes, and sat up most of 
the day. He was on his usual diet, and the appetite was sharp. On 
the twelfth day, most of the ligatures came away, and he was out upon 
the street. Thirteenth day the last ligature came away; upon the 
street several hours. Fifteenth day, photograph taken, (see Cut III,) 
discharged to visit friends in Alabama. The wound was now 
healed, excepting at two points, either of which might be covered by 
the tip of the finger. In three days more I saw him upon the cars, 
■en route for his home in Arkansas, in fine health and spirits, duly 
thankful for his riddance from the burdensome load which had 
c aused him to take so long a journey. On the twenty-sixth of Decem- 
ber he writes, that soon after his return home, a small abcess formed 
behind the angle of the jaw, which discharged itself, since which he 
has been entirely well. 
The tumor removed (Cut ll,} weighed four and a-half pounds. 
In general appearance it reminded me strikingly of afibro-cyst of the 
ovary which I had formerly removed from the abdomen, with the sin- 
gle exception that the cyst walls were very much more thin and deli- 
cate, in the case under consideration. It consisted of a dense, fibrous 
portion, in which were bedded numerous small cysts, and which was 
surrounded by quite a number of larger cysts, varying in size from 
that of a hickory nut to the dimensions of a large orange. Like the 
ovarian tumor, the contents of the cyst varied from the color of light 
yellow serum to the brown color of coffee decoction, and like the ova- 
rian tumor, the consistency of the liquid was somewhat mucilaginous or 
viscid. In the cut, the arrows (d. d.) point to the fibrous portions of 
the tumor; a. a. to the larger cysts; h. b. to large cysts emptied and 
tied; and c. c. to some of the cysts of smaller size. 
In connection with this case, a few thoughts present themselves 
which may not be un worthy of mention. Why should a tumor of the 
neck be allowed to grow to such enormous proportions, as in this case, 
when the dangers and difficulties of its extirpation are constantly aug- 
menting ? Doubtless in some instances, want of proper knowledge 
on the part of medical counsellors, leads them to advise delay, because 
of an exaggerated estimate of the dangers of surgery of the neck. In 
other instances there is reason to fear a want of confidence in himself ROBERT BATTEY, 
to give the proper remedy, is coupled with an unwillingness in the 
family attendant that his patient shall have relief at the hands of an- 
other. When it is considered that these tumors ordinarily are some- 
what superficial in their early stages, and prone, as they advance, to 
strike deeply down amongst important nerves and vessels, it seems 
scarcely probable that a patient before whom the facts were fairly put, 
would deliberately carry, month by month, and year by year, a tumor 
which must eventually be extirpated, and this at a constantly increas- 
ing hazard. Next to the skilled physician who cures his malady, a 
grateful patient will always hold in kindly remembrance the faithful 
monitor who points out his danger, and directs him to the competent 
specialist who removes it. 
I have designated this tumor fibro-cystic, for such it seems to me to 
be, although it is certainly very closely allied to the “congenital cys- 
tic tumor’ ’ of Gross, and is probably identical with the rare form of 
admixture of fluid and solid material, which he mentions as character- 
izing a case of his own, and one reported by Otto. In this instance, 
however, I have, on careful inquiry, failed to elicit any information 
which would lead to the belief that the tumor was congenital. The 
patient asserts unequivocally that he was twenty-seven years old 
when he first noticed the growth, and that it was then but a mere 
marble in size. And more than this, by one of those very common 
but nevertheless strange coincidences which are so frequently observed 
in medicine as well as in surgery, scarce a month elapsed from the 
discharge of Mr. Keen when another man of middle age, from the 
State of Alabama, presents himself for operation, with a large tumor of 
the neck, differing apparently from the former one only in the two 
points of its somewhat smaller size and its situation upon the opposite 
side of the neck. So clear do I esteem the case, Ido not hesitate to 
pronounce it to be a fibro-cystic growth of the same character as the 
other. The history given is that it first appeared at about forty years 
of age, and upon the lower jaw instead of under it. It seems to me 
that it may be fairly asserted in these two cases, that the disease is not 
congenital. 
An attempt was made in the operation to expedite matters by using 
the handle of a scalpel to enucleate the tumor, it, however, proved to 
be wholly unavailing, as the attachments were so intimate and so firm 
everywhere that perseverance with this instrument would quickly have 
resulted in a general rupture of the cyst walls, and such inextricable 
confusion as must have ended in humiliating defeat. By raising the FIBRO-CYSTIC TUMOR OF THE NECK. 
tissues upon a grooved director in small portions at a time, and sever- 
ing them with scissors close down to the boundaries of the tumor, the 
latter was kept in full view throughout, and the whole operation pro- 
ceeded with system and satisfaction. Care was used in the formation 
of the flaps to place the line of union as accurately as possible in the 
cervico-maxillary groove so as to hide the cicatrix from front view. 
The success of this is well shown by the photograph from which cut 
111 is taken.