640 THE ANIMAL PARASITES OF MAN 



are seen which have grown almost without symptoms. They finally, however, 

 lead to displacement of adjacent organs, particularly of the lung and the 

 heart, and a prominence appears in the hepatic region and in the lower parts 

 of the thorax. Protuberances from the size of an apple to that of a child's 

 head are not rare, and they may be recognized by inspection and palpation. 

 Palpation is almost always painless. Hydatid thrill, a symptom which has 

 been mentioned so often, is occasionally present. I have only rarely been 

 able to elicit it. Jaundice is by no means frequent. As the size of the tumor 

 increases it gives rise particularly to gastric difficulty : disturbance of appetite, 

 nausea, a tendency to vomit, constipation. Dyspnea, cough, attacks of fear, 

 cardiac palpitation, etc., also occur. 



While the course has previously been afebrile, when suppuration of the 

 cyst occurs high fever, chills, and great pain appear, and, if suppuration be 

 long-continued, pyemic phenomena in the lungs, spleen and kidneys may briag 

 a threatening change. Eupture into the pleural cavity, into the lungs, and 

 into the abdominal cavity may also give rise to a condition of collapse, pyo- 

 pneumothorax, peritonitis, etc., and may seriously endanger the life of the 

 patientj Or perforation into the stomach or intestine may lead to vomiting 

 or discharge of the characteristic contents of the cyst. Eupture into the 

 biliary passages we have several times known to cause the discharge of bile- 

 stained cysts or shreds of membrane with the symptoms of a colitis hepatica. 



In rare cases the echinococcus is felt beneath the abdominal walls far 

 removed from its original seat, and here finally leads to rupture. 



The course described is not invariable in echinococcus disease. Fortu- 

 nately, the echinococcus not seldom develops to only moderate size. It dies, 

 the sac contracts, and the contents are absorbed. Calcareous nodes and broken 

 cheesy masses in which portions of the echinococcus may be recognized are 

 occasional autopsy findings. In the Pomeranian report, compiled by Wiede- 

 mann at my instigation, and including more than 153 cases, echinococcus 

 of the liver occurred 34 times = 33.01 per cent, as an accidental autopsy 

 finding. 



The same compilation gives data concerning the prognosis of echinococcus 

 cases. In 28 instances there was no operative treatment. Twelve patients 

 died of chronic invalidism. Spontaneous recovery by perforation into the 

 lung and intestine occurred in 8 patients. In 8 other cases the further course 

 was unknown. In 41 operative cases recovery followed in 34 = 82.93 per 

 cent. Improvement occurred in 4 = 9.75 per cent; 3 died = 7.31 per cent. 



In the difEerential diagnosis, besides amyloid fatty liver and hypertrophic 

 cirrhosis — diseases which are sufiiciently characterized by the accompanying 

 symptoms — we must consider: Hepatic abscess, cancer of the liver, syphilis 

 of the liver, dropsy of the gall-bladder, hydronephrosis, etc. 



Lennhof calls attention to a symptom he observed in cysts of the lower 

 part of the liver — an " inspiratory furrow." Upon deep inspiration, accord- 

 ing to his observation, the prominence of the abdomen due to the tumor moves 

 downward while the skin retracts above this, and between the arch of the 

 ribs and the prominence a fiat furrow is formed. 



Abscess of the liver usually develops acutely, and is accompanied by a chill, 



