ECHINOCOCCUS DISEASE 537 



placed downward and the heart to the left. Left-sided echinococci lead to 

 dislocation of the spleen and kidney. In bilateral echinococcus the heart is 

 forced into the mediastinal space. If the echinococcus has a tendency to grow 

 outwardly it forces its way through the intercostal spaces, leads to erosion of 

 the ribs, and appears as a semiglobular tumor beneath the skin. The skin is 

 usually movable over the tumor, but occasionally adheres to it, and shows 

 decided inflammation. Secondary pleurisy is said to be invariably absent. 

 In the main, the echinococcus shows but slight tendency to perforation. If 

 rupture occurs, it usually takes place through the bronchi. 



The diagnosis is mostly difficult. Differentiation from solid tumor is, how- 

 ever, generally possible. If a collection of fluid can be detected, the question 

 arises whether this is situated above or below the diaphragm. In favor of a 

 subdiaphragmatic seat is the bell-shaped prominence of the lower parts of the 

 thorax, and the absence of the respiratory displacement of the liver downward. 

 On account of atrophic paralysis of the diaphragm the upper bow-shaped 

 line of dulness prevents the recognition of respiratory displacement. Besides, 

 the history usually points to a disease of the liver. Yet in many cases a 

 positive diagnosis is almost impossible. To distinguish echinococcus from 

 pleurisy with effusion is important. The latter is -accompanied by more 

 marked constitutional and local phenomena, chills, fever, cough, stitch in the 

 side and dyspnea. Later the dyspnea is less marked, while in the case of 

 echinococcus it is one of the most prominent and troublesome symptoms. 

 Pleural exudates lead to a uniform bulging, pleural echinococcus to a pro- 

 tuberance, of the lower aperture of the thorax. In pleurisy the line of dulness 

 follows the well-known characteristics, while in echinococcus the line of dul- 

 ness shows irregularities. The demonstration of another tumor in the liver 

 is not without importance. The course of pleurisy is much more rapid than 

 that of the slowly growing echinococcus. Exploratory puncture is not advis- 

 able on account of the danger associated with it, unless an immediate opera- 

 tion is to follow. 



Echinococcus of the lung is next in frequency to that of the liver. Ac- 

 cording to Madelung 11.9 per cent, of all cases occurred in the lungs, and 

 according to the Pomeranian statistics, 10.6 per cent. The parasite may de- 

 velop in any part of the lung; most frequently, however, it is met with in the 

 right lower lobe. The latter circumstance is explained by the frequent simul- 

 taneous affection of the liver. The thinness of the walls of its capsule, as 

 elsewhere, and the yielding of the pulmonary tissue make the decided growth 

 of the echinococcus possible, and it not rarely fills the pleural cavity, leading 

 to displacement of the heart, of the diaphragm, the liver and the spleen. Symp- 

 toms of chronic inflammation, of hepatization, of atrophy, or of gangrene, may 

 develop and complicate the pathology. Erosion of the bronchi and of the 

 pulmonary vessels, and rupture into the pleural cavity, are not infrequent. As 

 the result of destruction of larger blood-vessels, severe, often fatal, attacks of 

 hemoptysis occur. 



The passage of daughter-cysts into the blood-vessels with the formation of 

 emboli has been observed. Upon opening into the bronchi, gangrenous sputum 

 appears in which daughter-cysts, scolices or shreds of membrane are found. 



