By means of light clips with broad points and a constant stream of oil and water faintly colored with blue, each section of the vari cosed lymphatics can be rendered tense for cleaning, and their inter communicating channels dissected out without rupture of their walls.
In Dr. Mackenzie's case the dissection was carried out piece by piece, starting from the orifice of communication of the thoracic duct with the left internal jugular and subclavian veins. Unfortunately circumstances prevented me from describing the dissection, but my late colleague, Dr. Anderson, undertook to do so, partly from the specimen and partly from the drawing which had been carefully done under my direction by Mr. Burgess. Dr. Anderson describes the dissection as follows : "The thoracic duct commences in a dense mass of lymphatic tissue and glands which extends from the bifurcation of the aorta below to the level of the aortic opening of the diaphragm above. Looked at from behind, this mass occupies the whole of the space between the kidneys, and is continuous below with the chains of lymphatic tissue on the iliac arteries. The mass consists very largely of enormous dilated lymph sinuses, which can here and there be inflated. The receptaculum cliyli commences by two large lymph sinuses about the size of a pencil, one from each side of the aorta, and is joined opposite the aortic opening of the diaphragm by a third large sinus about the same size. The duct now ascends, sinuous and much pouched, for three to four inches, varying in diameter from three-eighths to half an inch, pervious for the first inch and a half above the aortic opening of the diaphragm, then filled with a loose clot for an inch and a half, after which it is lost in a tough, thick mass (query, inflammatory?). (The occluded point in the thoracic duct when opened was found to contain a very long, twisted clot, tapering at the end.) About four inches above this point, when it can again be traced, although still involved in dense tissue, it is now the size of a small crow-quill, impervious, and tend ing to the left side behind the aorta. At its termination in the angle between the left subclavian and internal jugular veins it passes through a mass of lymphatic tissue, is pervious, and about the size of a goose-quill. As stated, the iliac, the lumbar, and the renal lymphatics are very much enlarged, and the enlargement is specially marked in the left iliac and left renal lymphatics. Scattered through out the left renal lymphatics are numerous hard, round masses, some the size of a pea, but mostly smaller. These masses manifestly oc cupy the lymph sinuses." To this I may add, the calculi found in the lymphatics of the left renal pelvis were the size of small shot. They were composed appar ently of layers of fatty material and were all adherent to the walls of the dilated lymphatics and usually behind the atrophic remains of valves. They were, in my opinion, the evidence of a slackening stream of chyle and were analogous to the small phleboliths which are found in the prostatic plexuses of veins, each phlebolith being situ ated in this portion behind a diseased valve, and marking usually the partial or complete obliteration of the trunklet in which the phlebo lith is found (" Venous System of the Bladder and Prostate," Journal of Anatomy and Physiology, 1892).
The actual site of communication between the lymphatics of the left renal pelvis and these extraordinarily dilated intercommunicating lymphatic chambers was not discovered, probably because the work was suddenly interrupted, but as there had been a history of left renal colic, and as the channels were not enlarged much beyond the edge of the pelvic brim, and as the bladder surroundings were not matted or thickened, the orifice of communication was probably in the left renal pelvis.
In a examination of a case of chyluria, Dr. Lewis found vast numbers of fllarife in the kidneys. There were also " numerous translucent oil-like tubules of a somewhat varicose appear ance running alongside the uriniferous tubes, as if the lymphatics or minute blood-vessels of the part had been plugged." (Roberts, op. cit.) Lastly, I was able to demonstrate by means of the cystoscope a renal source in one chylurie patient under Mr. Clement Lucas, who kindly permitted me to examine the patient and relate the facts of the case. It was apparently of non-parasitic origin and occurred in a woman aged twenty-four. * A small swelling had been noticed at birth in the lumbar region, but this had since increased in size to that of a child's head. When she was seven years old the urine be came thick and milky. Associated with the tumor was an extensive noevus invading the posterior aspect of the thigh. The swelling had a distinct limit, and appeared to be also naavoid in character. There was probably some communication between the swelling and the lymphatics around the kidney. Seen through the cystoscope the bladder was healthy, but the surface was blurred with milky de posit. Jets of milky fluid were distinctly seen to issue from the right ureter, and to mix rapidly with the surrounding medium.
Non-Parasitic Cases.—In almost all cases of chyluria, Manson says, when the parasite is properly looked for the filaria will be found in the urine and usually in the blood also. He thinks that the absence of fllarim does not always indicate that the case is not of parasitic origin, as there may be only one parent worm present, or all present may be of the same sex, and thus there are only sufficient for obstruction and not for the propagation of embryos.
This view, though taken by one who has been foremost in eluci dating this interesting and obscure disease, is not yet assented to. It is thought by many that the chyluria is in rare instances caused by some pressure such as that produced by a tumor, or constriction formed of inflammatory thickening, in or about the walls of the tho racic duct, but this condition has apparently not been proved to exist. Osler records a case of chyluria, which lasted thirteen years, in which filarice were never found. Post-mortem examination showed that the abdominal lymph vessels were perfectly normal, that no parasites were present in any part of the lymphatic system, and that the urinary system was quite normal. He accordingly believes that there is a non-parasitic chyluria, but can offer no explanation of it.