MULTILOCULAR HYDAT1DS. 703 



is usually very decided ; fluctuation was only noticed in one of the cases 

 observed by Griesinger. 



When the disease commences and runs its course with the above 

 symptoms, it can never be recognized with certainty, or absolutely dis- 

 tinguished from other diseases of the liver, particularly carcinomatous 

 or syphilitic. In the first case I saw, death was caused by apoplexy ; 

 the preparation was presented to me as an immense suppurating cancer 

 of the liver. The attending physician had not made out the nature of 

 the nodular, stony tumor of the liver, whose gradual growth he had 

 watcl ed for years. The patient had no icterus during the latter years 

 of his life ; he only had a slight jaundice, of short duration, about ten 

 years before his death. In a second case, carefully observed for several 

 months, at my clinic, besides the above symptoms, there were albumi- 

 nuria and general dropsy ; the case was diagnosed as syphiloma of the 

 liver and amyloid degeneration of the kidneys. Only the second half 

 of the diagnosis was confirmed by the autopsy. Instead of a syphi- 

 loma, the liver contained a multilocular hydatid tumor, as large as the 

 head. This patient was never jaundiced. In both patients the pas- 

 sages and excretory bile-ducts were entirely pervious. 



These observations not only disprove Friedreicffs assertion, that 

 marked icterus is among the most constant symptoms of multilocular 

 hydatid, but they also prove that, in cases where there is no obstruction 

 of the bile-ducts by echinococci, and, consequently, where there is no 

 obstruction and reabsorption of bile, the patient's state may long re- 

 main as endurable as in the ordinary form of hydatid. After a long 

 time, the advancing suppuration of the tumor and the fever accompa- 

 nying it appear to impair the nutrition, and to develop a cachexia, 

 which finally carries off the patient, if he does not die of some inter- 

 current disease. In my second case, death was hastened by the second- 

 ary disease of the kidneys (whose occurrence, in multilocular hydatids, 

 Friedreich expressly denies). 



The symptoms and course of the disease are entirely different when 

 the bile-ducts are obstructed by echinococci locating in them, or break- 

 ing into them from without. In these cases, at least in their later 

 stages, the disease is not unfrequently so characteristic that an approxi- 

 mate, or even an absolute, diagnosis may be made. The series of 

 symptoms is opened by an apparently inoffensive icterus, but this 

 steadily increases ; all remedies used for it prove unavailing, and it 

 gradually becomes excessive. The faeces usually soon lose their color 5 

 a proof that all the gall-ducts or the excretory ducts are closed. As 

 there are no dyspeptic symptoms, and as the occurrence of the icterus 

 is preceded by no severe paroxysms of pain, we may, with great proba- 

 bility, exclude catarrh of the excretory bile-ducts and their obstruction 



