648 OCCURRENCE AND MEDICAL IMPORTANCE. 



also the ureters and bile-ducts (though less frequently, because of 

 their smaller size), are also occasionally the seat of the rupture. In 

 some cases, a twofold rupture is observed in the same Echinococcus, 

 usually into intestine and lungs, or more rarely into the intestine 

 and ureter. 



Such a rupture is more frequent in the Echinococci of the lungs 

 than in those of the liver, so that evacuation often takes place through 

 the bronchial tubes. Among the sixty-eight cases enumerated by 

 Neisser, no fewer than thirty-one had this issue, nine led into the 

 pleural cavity, while the rupture took place into the pulmonary veins, 

 intestine, and through the umbilicus once in the case of each. 



Here and there a rupture has been observed in the Echinococci of 

 the pelvis, leading either into the body-cavity or to the exterior 

 through the female generative passages, and once (in Sibille's case) 

 through the perinseum. 



The prognosis varies in all these cases according to circumstances. 

 First we must take into consideration, besides the intensity and extent 

 of the ulcerative inflammation caused by the rupture, the nature of 

 the affected organ. The more sensitive it is to external influence 

 the more unfavourable is the situation ; in many instances, e.g., where 

 the contents are poured into the pleural or abdominal cavities, the 

 case is almost hopeless. 



In these cases the evacuation is followed by a violent inflam- 

 mation of the peritoneum or of the pleura, and this is usually rapidly 

 succeeded by death. Where the inflammation has a less serious 

 character this is probably due to the small quantity of the emptied 

 matter, and to its condition. Of importance, therefore, in this con- 

 nection are the differences in the number, size, &c. of the daughter- 

 bladders. 



The state of the case is much more favourable when the rupture 

 has been effected directly to the exterior through the abdominal walls 

 or the intercostal spaces. This is especially the case when the 

 fistula is short, and when the emptying of the daughter-bladders 

 presents little difficulty. Under such circumstances the rupture 

 leads not unfrcquently to a perfect recovery, so that of late years 

 it has been sometimes artificially produced (by caustic paste according 

 to Re'camier) in order to effect a radical cure. Of course there are 

 also cases in which the rupture, whether natural or artificial, may prove 

 fatal in consequence of peritonitis, or of long-continued suppuration 

 and exhaustion ensuing. 



When the Echinococci (even if E. hydatidosus) open into the 

 bronchise, or the intestine, recovery is usually only a question of time. 

 This is specially true in the case of rupture into the intestine, for 



