SYMPTOMATOLOGY - CHYLURIA.
"The course of the disorder," says Roberts, "is marked by an irregularity and capriciousness which baffle explanation." The on set may be sudden, following a nervous shock or a fall, or after par turition; but usually it appears spontaneously.
Once the effection is established, the chylous urine may appear intermittently or be continuous. The interruptions are, I suspect, due to temporary blockages of the minute openings into the urinary channel, and the grounds for this belief are the following : The appearance of chylous calculi in Mackenzie's case showed that the stream through the terminal intercommunicating channels had slackened and stagnated, and that inflammation had occurred to block one or more at least of the channels altogether. By this means the flow would cease until the back-pressure had opened up a fresh channel or set of channels, which would finally become thinned and would burst. In those cases in which the intermission extends over years, it is probable that other channels are opened up which allow of the chyle finding its way into the thoracic duct by a circuitous route of absorbents.
2. It will be noticed that in two of the post-mortems recorded, Mackenzie's and Havelard's, the lymphatic varicosities extended along the ureter from the kidney to the bladder, as if the pressure which first found an outlet at the pelvis of the kidney was forced subse quently along the lymphatics which accompany the ureter and its surroundings. An analogue to this is the ordinary varicocele. Pressure abruptly checked in one vein by a valve passes off into an adjoining vessel. * The intermissions in the appearance of chylous urine are very irregular. The chylous flow may cease for ten or more years and be again renewed. During the remissions the urine regains its normal character. Sometimes the attacks assume a certain periodicity. Thus in one case the urine was always chylous for eight days previous to menstruation; in another chyluria preceded or accompanied attacks of epilepsy or erysipelas. In Mr. Pearse's case it occurred when the patient was suckling her children and ceased on her weaning them.
There are also diurnal variations having a relation to meals, exer cise, rest, and posture. Dr. Mackenzie observed in his case that al terations in the meal-times produced changes in the character of the urine. Thus the clay urine almost completely coagulated and con tained a considerable amount of blood, while the night urine did not form so large a coagulum and contained less blood, and was much more milky. An alteration of a few hours in the meal-times caused
the characters of the day and night urine to approximate, and when the habits of day and night were completely reversed the conditions of the urine were similarly reversed.
Posture.—In Ackerman's case f normal urine was passed if the patient lay on his right side. Perhaps the opening in this case was into the left renal pelvis draining into the prevertebral lymphatics. This would expain the fact noticed that when the patient stood up the urine at once became chylous./ Intercurrent disease, such as an attack of gout, carbuncle or pneu monia, temporarily suspends the chylous discharge. Should the chylous urine clot, renal or vesical colic is noticed, and if renal colic is present it is absolute evidence of a renal source.
The course of the disorder is very irregular, and it may be of indefinite duration. The general health nearly always suffers more or less, there being marked general debility, lassitude, and depres sion, and often gradual emaciation. Beyond the chylous character of the urine there are generally no distinguishing symptoms, and the constitutional results are probably entirely due to the waste of nutri tive material.
Filaria in the Blood. —Manson, in a systematic research at Amoy, found that one in every ten Chinamen had filarim in his blood, but most of the men were in perfect health. He thinks that probably so long as the parent parasite is healthy it is innocuous ; should it, however, die, it acts as a foreign body and sets up irritation around it; this causes great obstruction of the duct in which it is lying, and an abscess may result.
Dr. Manson discovered the most remarkable feature of the entire subject in noting that the parasite is found only at night. "Un less," he says, "there is some disturbance such as fever, interfering with the regular physiological rhythm of the body, filaria embryos invariably begin to appear in the circulation at sunset; their num bers gradually increase till midnight; during the early morning their numbers become fewer by degrees, and by nine or ten o'clock in the forenoon it is a very rare thing to find one in the blood." Dr. Cobbohl not inaptly designated the phenomenon filarial periodicity. Dr. Myers of Formosa, Dr. Rennie, Dr. Adams, and Dr. Mackenzie not only confirmed this, but the latter also acutely showed that by making the patient change his hours of sleeping and waking, thus turning night into day, the filaria followed suit. The important fact of inversion of filarial periodicity was thus established.